Strangers Donating Kidneys: 'Important Contributions'

Divyanshu Malhotra, MD

News stories abound of altruistic individuals donating their kidneys to strangers. These donations are based on the principle that a person should be willing to donate a kidney with no knowledge of the recipient's identity or medical or personal circumstances, and with agreement that the outcome of the transplantation may not be known.

Kidney transplantation remains the ideal form of renal replacement therapy and has shown consistently superior trends in mortality, cardiovascular outcomes, quality of life indices, and healthcare cost compared with all forms of dialysis.

Kidney allografts are categorized based on the source of the organ into deceased and living donor transplants.

Living donor transplants offer better long-term graft outcomes along with optimal donor workup, thus reducing the risk for disease transmission, minimizing wait times, and optimizing recipients for the surgical procedure.

According to the latest annual data report from the Scientific Registry of Transplant Recipients (SRTR), 22% of kidney transplants performed in the United States in 2020 were procured from living donors.

After a consistent upward trend since 2014, there was a slight decrease compared with 2019, primarily owing to the COVID pandemic, when most living donor programs in the country were on hold for variable periods during the year. Globally in 2019, 36% of all kidney donors were from living donors.

"Unspecified," "Anonymous," and "Good Samaritan" Donations

Within the living donor cohort, an important contribution is made by kidney donation from a living person to a stranger, and the terms "unspecified," "anonymous'," "nondirected," "altruistic" and "Good Samaritan" are used interchangeably in the medical literature.

The history of this form of donation in the United States dates to the 1970s, when the initial reports of unspecified or nondirected kidney donation were published. A decline in interest followed until the early 21st century, when a National Conference was convened leading to an increase in unspecified donation in different transplant centers in the country.

Use of Nondirected Kidney Donors Evolves

The use of nondirected kidney donors has evolved over time, such that nondirected donors were 1.5% of the total and more than 6.5% of living donor kidney transplants in the US, according to the latest SRTR report.

Nondirected donors are used in innovative ways to trigger paired donations and altruistic donor chains which increases the probability of transplanting more patients. Although this remains a controversial topic, altruistic donation plays an important role in bridging the gap between patients on the waitlist and the number of patients receiving transplant.

Evaluating Altruistic Donors

The evaluation of potential altruistic donors involves a thorough medical, surgical and psychosocial work up by a multidisciplinary team. Over time, there has been debate in the transplant community about the extent of evaluation of motivations and understanding of such donors and whether they should be held to a higher medical standard compared with directed living donors.

Some clinical guidelines explicitly support the principle that the donor-recipient relationship is irrelevant to the acceptable risk and thus nondirected donors should be evaluated with same benchmarks.

Without reaching a consensus for the adoption of different assessment tools for psychosocial assessment, there is a significant dropout of potential unspecified donors from initial evaluation to eventual donation. Therefore, caution must be exercised to ensure that the workup of such donors is robust but not overwhelming.

We as a transplant community need to ensure that these potential donors clearly understand the risk and benefits of donation as well as balancing the ethical principles of autonomy, beneficence. and nonmaleficence.

The outcomes of living donors are favorable. Overall mortality from donor nephrectomy is very low, at 0.03% — similar to appendicectomy.

Current evidence suggests that morbidity from live kidney donation is also low, with a less than 1% chance of developing end-stage kidney disease over 15 years and with outcomes similar to those of directed donors.

However, we must recognize the limitations of these studies when discussing risks and benefits with our potential donors. Emphasis must be laid on the psychosocial outcomes of nondirected kidney donation.

Qualitative studies confirm that donation is a largely positive experience, with evidence of an increased sense of well-being after donation and few lasting adverse psychological outcomes (Massey et al; Rodrigue et al).

Negative outcomes, including donor regret, temporary psychological stress, familial opposition, and feelings of disappointment when the donation does not get recognition from the recipient, have been described in the literature (Massey et al; Lennerling et al; Gare et al). Careful assessments of donor and family, as well as community education and outreach, remain key ingredients of a successful altruistic donation.

There has been a steady increase in altruistic donation over the past few years. However, many uncertainties remain, and thus multiple pathways can be utilized to pave the way for more such noble acts.

Transplant professionals and leaders of national and international committees should make every effort to have clear guidelines for evaluation and acceptability criteria for potential nondirected donors.

Widespread education is needed to dispel myths about living donation and highlight the potential positive impacts on both donor and recipient lives.

Media platforms, including social media, can be used to disseminate information on living donation, generate discussion, and engage potential altruistic donors. However, this requires careful scrutiny and an ethical framework, particularly when transplant professionals are involved, to avoid conflicts of interest and erosion of public trust (Massey et al; Henderson et al: Allen and Reese).

Collaboration between previous unspecified kidney donors, healthcare professionals and procurement organizations is seen as the most effective model for engaging with target audiences.

Personalized home education initiatives; reimbursement of expenses, including donors' lost income; and recognition of altruistic donation at the level of the transplant center are some other potential areas of innovation (Rodrigue et al; Wu et al; LaPointe Rudow et al).

Altruistic or nondirected donation is a steadily expanding area of living donor kidney transplantation that can contribute toward the multifaceted fight against kidney disease worldwide.

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