Thirty years ago, Dr. Francis Moore, a pioneering leader in organ transplantation, was prescient when he noted that the dictum to “do no harm” (by removing an organ from a healthy living donor) would be overcome by the demand for successful transplantation.1 Dr. Moore suggested that the ethos in the field of transplantation would change from not doing harm to a healthy organ donor to the notion of an acceptable donor risk as an offset to the life-saving benefit to the recipient. Despite the admonition from the Declaration of Istanbul and several other international forums (among them the World Health Organization [WHO], Council of Europe, and the Pontifical Academy of Sciences) that governments are responsible to ensure donor safety, it is important to reflect on whether we as professionals and health ministries have fulfilled our obligation to minimize risk to the live donor.2-5
The success of transplantation is widely understood to be limited by the lack of donor organs. The current global activity of 130 000 yearly transplants is thought to represent <10% of the total potential transplants worldwide.6 Although the Guiding Principles of the WHO urge Member States to implement programs of deceased donation “to avoid the inherent risks to live donors,” the number of deceased donors is inadequate to meet the transplant needs. As a consequence, live donors are carrying a large burden of the global liver and kidney transplant activity without proper accountability of their well-being.
The practice of donation and transplantation requires oversight by health authorities in each country to ensure transparency and safety; it is necessary to record all deceased and living donor transplants in a national registry that identifies the relationship of every living donor to the recipient. The registry should also record live donor deaths and donor complications that result in hospitalization. Instead, we see a current reality that the future of the live donor is jeopardized by continued commercialism with some transplant professionals as the agents (knowingly or unknowingly) exploiting vulnerable individuals in need of money. Procedures should be developed for the evaluation and selection of living donors with a review by an independent donor advocate.
There is no annual compilation of living donor complications either nationally or globally, nor is the outcome/well-being of the living donor known by transplant centers beyond the first few months after transplantation. Nevertheless, kidney donors are now known to undergo kidney transplantation more than a decade after donation, and that risk has yet to be comprehensively described in the informed consent process.7 The most complete data are limited only to the first 15 years after donation.8 Short-term mortality statistics exist for live donors, but there is no information as to the long-term morbidity and mortality.9
Transplant centers should not be authorized by governmental agencies without a mandatory requirement to record through an annual report, the identity of the donor and recipient, assessment and deliberation by an ethics committee whose task is to ascertain ethical relatedness, complications that occur after live donation or without measures of annual follow-up for the live donor included in the cost of transplantation. The criteria for centers to be authorized to perform living donor transplantation should be established by the national agency. National and regional professional societies should embrace the prohibition of organ sales as promulgated by the Declaration of Istanbul, WHO, and Council of Europe Convention against Organ Trafficking.2-5 The national agency should develop a system of reporting for suspicious or confirmed cases of organ trafficking by professionals to the relevant authorities. Professionals should also promote programs of deceased donation, making certain that patients with a devastating brain injury and fulfilling the criteria of brain death are identified and referred to the appropriate agency to facilitate organ recovery.
The noble individuals who are prepared to be living donors rely upon society and government oversight which authorize transplantation centers to living donors from harm and exploitation; and that responsibility is not being accomplished worldwide by either ministries of health or transplant professionals.
1. Moore FD. Three ethical revolutions: ancient assumptions remodeled under pressure of transplantation. Transplant Proc. 1988;20:1061–1067.
3. Sixty-Third World Health Assembly. WHO guiding principles on human cell, tissue and organ transplantation. Cell Tissue Bank. 2010;11:413–419.
7. Gill JS. New evidence of the need for living kidney donor follow-up. Am J Transplant. 2018;18:1041–1042.
8. Grams ME, Garg AX, Lentine KL. Kidney-failure risk projection for the living kidney-donor candidate. N Engl J Med. 2016;374:2094–2095.
9. Steiner RW. The risks of living kidney donation. N Engl J Med. 2016;374:479–480.