Medical Files
Protecting the giver of the ultimate gift
By Rafael Castillo, MD
Philippine Daily Inquirer
First Posted 19:56:00 04/18/2008
Filed Under: Health, Diseases
MANILA, Philippines—In the early ‘70s, it would make the front page of major broadsheets if a kidney transplantation was done in any of our hospitals. Now, at least one, sometimes up to three or four kidney transplantations are being done daily in some of our hospitals which are well-equipped for this type of surgery. Our various transplantation teams have gained world-class expertise in doing this complicated surgical operation.
Now, with modern, more reliable tests to screen potential donors for compatibility, and more effective drugs to prevent organ rejection, even nonrelated donors can offer one of their kidneys for altruism or for a small bundle of money. Hence, the rate of transplantation has increased tremendously over the years, and the Philippines has emerged as one of the leading centers for this procedure.
But just when we thought we should be in high spirits for this distinction of being one of the top centers for kidney transplantation, the medical specialists involved in this and the officials of the Department of Health are now in a high-level conflict arising from the revised guidelines on kidney transplantation which the DOH has recently circulated for implementation.
Dr. Lynn Gomez, president of the Philippine Society of Nephrologists (PSN), called me up earlier this week expressing her board’s concern about the new DOH administrative order. The board assailed the new government policy on kidney donation, believing it will not solve the problem of rampant illegal sale of kidneys and other human organs mostly to rich foreigners. On the contrary, the new order is likely to aggravate it, according to Lynn.
More lax than old policy
While China, India and Pakistan have enforced new stricter rules to regulate illegal sale of organs, the new DOH policy seems to be more lax than the previous policy which limits transplantation in foreigners to not more than 10 percent of the total cases of procedures being done annually. It is the general perception that this previous policy, which gives priority to Filipino patients in need of kidney transplantation, is not being followed strictly in the medical centers doing kidney transplantation since close to 50 percent of cases are foreigners with Filipinos donating the kidneys for a measly sum of something like P150,000 (US$3,570).
What is sad is that most of these poor donors, blinded by the money they expect to receive, volunteer to donate their kidneys even if they’re advised that there are some risks involved if they have concomitant medical problems like preexisting high blood pressure, obesity or kidney problems. We don’t know if the screening personnel are at fault for being swayed by the overeager donors and the greedy brokers. We hate to think that many donors are not being screened properly and are generally not undergoing the prescribed postoperative follow-up care.
It is not unusual to see cases of kidney donors eventually developing hypertension, and kidney failure. And there’s simply no possibility they could afford the expensive procedure for which they have parted with one of their kidneys previously. That is why donating a kidney or any organ is really the “Ultimate Gift” and it is just proper that any policy governing the surgery must also protect the welfare of the live donor, from the screening phase to the regular follow-up even years after the donation. A kidney donation should never be allowed if the donor will be exposed to an undue risk of developing complications in the future.
Detailed analysis
An international forum on the care of the live kidney donor was held in Amsterdam in 2004; and the international consensus, participated in by more than 100 transplant experts from more than 40 countries around the world including the Philippines, made a detailed analysis of all relevant aspects of selection and long-term management of live kidney donors.
Many transplant doctors may disagree but worldwide, there is a problem of underreporting of donor complications since this could discourage potential future donors. It is the responsibility of transplant centers to assure donor protection, safety and welfare. According to the Amsterdam forum, the live kidney donor must receive a complete medical and psychosocial evaluation, and be capable of understanding the information presented in that process to make a voluntary decision.
It makes me wonder if this informed consent and voluntary decision are achievable if the donor does not even get to meet the person to whom he is donating one of his kidneys.
Well-screened donors generally show no increased risk after the donation; but those wherein some contraindications have been overlooked—hopefully unintentionally—during the screening, may subsequently develop serious problems later on.
Some guidelines
The following are some of the guidelines set during the Amsterdam forum for donors:
• BP should preferably be measured by ambulatory blood pressure monitoring (ABPM), particularly among older donors (50 years) and/or those with high office BP readings.
• Patients with a BP 140/90 or higher are not acceptable as donors.
• Some patients with easily controlled hypertension who meet other defined criteria (e.g., 50 years of age or younger, good kidney function, no protein spillage in the urine) may represent a low-risk group for development of kidney disease after donation and may be acceptable as kidney donors.
• Donors with hypertension should be regularly followed by a physician.
• Obese patients should be encouraged to lose weight prior to kidney donation and should be advised not to donate if they have other associated medical conditions.
• Obese hypertensives particularly are not suitable kidney donors.
• Healthy lifestyle education should be available to all living donors.
• Cholesterol problems alone does not exclude kidney donation.
• Smoking cessation at least 4 weeks prior to donation is advised.
• Abstinence from alcohol should be done for a minimum of 4 weeks prior to donation.
Protect donor’s welfare
There is now intense debating in the media, but there’s simply too much noise that has muffled and blurred the real issues. This issue carries a psychosocial context as equally important as its serious medical or health concerns, and emotions are expectedly running high in some interviews I’ve watched on television. This may be good for the media, but certainly not for the resolution of the conflict. It only distances all major stakeholders (patients, donors, government and doctors).
I support any move to protect the donor’s health and welfare and we should condemn, better yet penalize, any selfish exploitation of the donor, many of whom admittedly are financially motivated. The DOH should have made more exhaustive consultations and consensus generation before releasing the new administrative order, but it’s not yet too late to achieve that.
The old policy is still a relevant policy although it could stand a few amendments. What is obviously the problem is the lack of proper implementation of the policy, and this is where measures ensuring proper adherence to the policy by all transplant centers should be strictly enforced.
It would be a pity if the ultimate gift is made meaningless when we extend the life of the patient with the gift, but at the expense of the giver.
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