Contents
1
Contents
1
INTRODUCTION ...............................................................................................................................3
2
AIMS ..................................................................................................................................................4
3
METHODOLOGY ..............................................................................................................................5
3.1 Clinical databases ....................................................................................................................5
3.1.1
3.1.2
CINAHL ......................................................................................................................................................5
PubMed .....................................................................................................................................................5
3.2 Other relevant databases .........................................................................................................5
3.3 Grey literature ...........................................................................................................................5
3.4 Snowballing ..............................................................................................................................5
4
RESULTS ..........................................................................................................................................6
4.1 Barriers to living organ donation ...............................................................................................6
4.1.1
4.1.2
4.1.3
4.1.4
Clinical contraindications ...........................................................................................................................6
Financial barriers .......................................................................................................................................6
Demographic and cultural barriers .............................................................................................................6
Societal attitudes .......................................................................................................................................7
4.2 Initiatives to improve rates of living kidney donation .................................................................8
4.2.1
4.2.2
4.2.3
4.2.4
Broadening the pool (overcoming clinical contraindications) .....................................................................8
Financial reimbursement programs ...........................................................................................................9
Improving cultural and socioeconomic disparities ...................................................................................10
Education and awareness-raising ............................................................................................................11
5
DISCUSSION ..................................................................................................................................13
6
REFERENCES ................................................................................................................................14
2
1. Introduction
1
INTRODUCTION
One in ten Australian deaths in 2007 were related to chronic kidney disease (CKD).1 This includes endstage kidney disease (ESKD), in which the function of the kidneys is not sufficient to sustain life, and
‘renal replacement therapy’ (renal dialysis or transplantation) is required.
In Australia, the number of individuals treated with dialysis or kidney transplantation for ESKD almost
tripled between 1991 and 20092 and, in 2010, almost 19,000 Australians received renal replacement
therapy for the condition (including 8,382 people living with a functioning kidney transplant, and the
remainder receiving dialysis).3 Significant further increases in demand for renal replacement therapy
are expected in the coming years driven primarily by an increase in new cases of ESKD in the older,
non-Indigenous population.
Renal transplantation (from a living or deceased donor) remains the optimal and most cost-effective
treatment for ESKD.4 In addition, ‘pre-emptive’ living donor kidney transplantation (LDKTx) – occurring
before a patient begins dialysis – is an increasingly common approach where a living donor is
available,5 because of the potential for better outcomes.6
The high prevalence of CKD and ESKD, as well as a chronic shortage of donor kidneys, are worldwide
phenomena,7 and there have been many varied attempts at increasing the available donor pool. Many
of these, including the National Reform Package introduced in Australia in 2008,8 primarily aim to
increase deceased organ donations and utilisation.
Since the introduction of this reform agenda in Australia, the number of kidney transplantations involving
deceased donations has increased. However, over the same period, the frequency of LDKTx (in terms
of both absolute numbers and proportion of total kidney transplantations) has decreased. 9
3
2. Aims
2
AIMS
This document reviews the Australian and international literature to identify and describe key barriers to
living organ donation and effective strategies for increasing living organ donation rates. Where
possible, these are compared and contrasted with the Australian context. While a very small number of
living donor liver transplantations are also performed in Australia, this review focuses exclusively on
LDKTx because it is a much more common procedure, and also because of the greater availability and
relevance of information to the Australian context.
The dynamics of organ donation vary greatly around the world, and are dependent on factors including
local legislation, clinical capabilities, health systems and the local supply of and demand for both
deceased and living organ donations. To highlight the information most pertinent to the Australian
context, this review will focus on documented barriers to living kidney donation, and initiatives to
increase LDKTx among countries with high-performing deceased donation rates (specifically Spain,
Belgium, France and the United States of America, which are the highest-performing countries in this
respect).10
This document does not represent a systematic review of the literature, but aims to inform
recommendations for improving LDKTx rates in the Australian context.
4
3. Methodology
3
METHODOLOGY
Relevant clinical databases and a generic search engine (google) were probed for information about
barriers to LDKTx and programs to address these, with a particular focus on countries with highperforming deceased donation rates (specifically Spain, Belgium, France and the United States of
America) as well as Australia for the purposes of contrast. Where relevant information was found,
evidence from other nations was also considered (e.g. Canada).
A broad review of the retrieved information was used to inform key issues and initiatives for discussion,
and these are presented and illustrated with appropriate reference to the literature. Additional
information about the search methodology is provided below.
3.1
Clinical databases
Two clinical databases were searched: CINAHL and PubMed (see below for specific details). Articles
more than ten years old were excluded from review, as were those in languages other than English.
Articles pertaining solely to deceased donation were not included.
3.1.1
CINAHL
This database has a nursing focus but also covers biomedicine, health sciences librarianship,
alternative/complementary medicine, consumer health and 17 allied health disciplines. The key term
‘living donor’ was used to search for relevant abstracts (and ‘transplant donors’ to uncover articles
published prior to 2007), further refined as required by the keywords ‘barriers’, ‘increase’, ‘improve’ and
‘facilitate’.
3.1.2
PubMed
The key term ‘living donation’ was used to search for relevant abstracts, again further refined as
required by the keywords ‘barriers’, ‘increase’, ‘improve’ and ‘attitudes’. In addition, these terms were
linked with ‘Australia’, ‘Spain’, ‘Belgium’ and ‘France’ to specifically search for information from these
nations of particular interest.
3.2
Other relevant databases
The list of publications from the Cochrane Renal Group was reviewed and the NHS Centre for Reviews
and Dissemination searched for relevant items.
3.3
Grey literature
A web search was also used to locate any relevant supporting documentation (with an emphasis on
living donor programs in the countries of focus). Relevant documents made directly available to the
project team were also considered.
3.4
Snowballing
Where relevant, additional articles were sought by reviewing the reference lists of key articles.
5
4. Results
4
RESULTS
4.1
Barriers to living organ donation
The search identified four key themes relating to barriers to living organ donation. These related to
clinical contraindications, financial considerations, demographic and cultural issues and societal
attitudes.
4.1.1
Clinical contraindications
There are a number of contraindications to both donating and receiving a living donor kidney, and the
clinical decision must consider the potential benefit against likely outcomes of LDKTx and alternative
options (e.g. need for dialysis, suitability and likely timing of a deceased donor transplantation). 11
Judgements regarding these contraindications vary significantly between health systems and services,12
and are evolving with the emergence of newer techniques and drug agents (e.g. to overcome antibody
incompatibility between donor and recipient or better manage a comorbidity) and the worsening
shortage of donor organs. However, some contraindications are becoming more, rather than less,
problematic. A prime example is the rising incidence of diabetes in Australia (and, in particular, the
increasing incidence of diabetes-related ESKD) that may mean LDKTx is less frequently appropriate. A
2006 survey found that Australian nephrologists are far less likely to recommend living kidney donation
to a potential related donor if the recipient’s ESKD is attributable to diabetes and there is a strong
history of diabetes in the family.13
4.1.2
Financial barriers
The financial effects and disincentives of living kidney donation are well-documented.14 The nonmedical costs – including unpaid leave, travel and accommodation – can be significant and prohibitive,
particularly for donors in non-metropolitan areas.15 The inherent costs involved may, in part, explain the
fact that, in a study of non-Indigenous patients who commenced renal replacement therapy between
2000 and 2010, individuals from the most socioeconomically advantaged areas were more likely to
receive a LDKTx and a pre-emptive transplantation than those in the most disadvantaged areas.16
Although differences in the prevalence of co-morbidities may be a key factor in this phenomenon (i.e. a
higher prevalence of multiple comorbidities, smoking and obesity in disadvantaged areas), financial
barriers (particularly for the potential donor) are likely to play a part. There was no such disparity in
rates of deceased donor transplantations in this analysis, suggesting that any effect of clinical
contraindications is likely to be related to potential donors, rather than recipients.
4.1.3
Demographic and cultural barriers
In addition to the documented financial barriers discussed above, there may be other barriers to LDKTx
related to socioeconomic status and ethnicity.
Of particular relevance to the Australian context is evidence that while Aboriginal and Torres Strait
Islander people are more likely to have ESKD than other Australians, they are far less likely to have a
kidney transplantation.17 The reasons for this are likely to be extremely complex: relating to
comorbidities, geography, other socioeconomic factors and clinicians’ views.18,19 In particular, there
may be a greater risk to Indigenous donors due to higher rates of kidney disease and other relevant comorbidities in these populations.20
6
4. Results
Older age has also been associated with a lower likelihood of having a potential donor among
transplantation-suitable patients, potentially related to the higher incidence of diabetes-related ESKD
(which may make relatives less suitable donors) and/or protective attitudes among older individuals for
younger relatives.21 A recent international multivariate analysis found that LDKTx rates in the countries
analysed correlated with the proportion of the population over 80, as well as the nation’s GDP.22
4.1.4
Societal attitudes
The attitudes of a society in general will affect the acceptability and therefore frequency of LDKTx.
Attitudes towards LDKTx may vary between potential donors, recipients and clinicians, and, in
particular, various concepts of risk are likely to shape groups’ and subgroups’ attitudes. While LDKTx
may result in superior outcomes for the recipient (compared with deceased donation transplantation), 23
the risks to the donor are difficult to determine, and will depend on the particular characteristics of the
individual donor. In particular, the CARI guidelines note the lack of data available to describe the longterm outcomes for donors who do not meet the strict criteria for suitability (e.g. those who are
overweight, mildly hypertensive, smokers and those with minor urinary abnormalities). 24 Some
estimates suggest LDKTx is associated with a perioperative risk of death to the donor of about one in
3,000, and a risk of perioperative complications of around 2-4%.25 However, a number of studies report
no significant disadvantage (in terms of morbidity or mortality) over the long term. 26,27 Psychological risk
is also an important consideration, although there may be psychological benefits inherent in living organ
donation and, conversely, psychological risk associated with failure to donate.28
A recent review suggests that general acceptability of the concept of living organ donation, particularly
for individuals related to an intended recipient, is high.29
Potential donors’ views
A Canadian study by Young and colleagues found that potential donors were significantly more willing
to accept greater long-term risks to themselves (as a donor) than were clinicians or intended transplant
recipients – with the last group appearing to be the most risk-averse.30 There is evidence that
Australian donors’ concerns primarily relate to psychosocial dynamics, psychosocial health, financial
and work issues, the benefits and costs associated with donation and physical health expectations.31
Potential recipients’ views
While general views towards living kidney donation may be favourable and donors may be willing (see
above), international studies suggest that a significant proportion of ESKD patients may not be prepared
to raise the subject or directly ask their relatives for a kidney donation. They may be unwilling to burden
a loved one with the request,32 or be fearful of resulting psychosocial issues such as feelings of guilt, the
potential for disappointment if the transplantation fails, and negative changes in their relationship with
the donor.33,34 Even when a relative offers to donate a kidney, ESKD patients may be reluctant to
accept.35,36
As previously outlined, there is evidence to suggest that potential LDKTx recipients are primarily
concerned about the potential risk to the donor – perhaps to an extreme degree. In the study by Young
et al, 22% of potential recipients would not allow a donor to undertake any risk to achieve the outcomes
presented. The authors speculate this may relate to having a more real and personal understanding of
the impact of chronic illness, guilt, feelings of unworthiness, or a lack of understanding of the
motivations of a living donor.37 Ultimately, the decision to seek a living donor may come down to the
individual recipient’s analysis of risk (to the donor) versus benefit (to him- or herself).38
7
4. Results
Clinicians’ views
As the ‘gatekeepers’ of relevant information and advice regarding living kidney donation, clinicians’
views and practices are vitally important influences on the LDKTx rate. While there is evidence to
suggest that the vast majority of Australian nephrologists and trainees are supportive of living kidney
donation and would recommend it to a suitable donor, key concerns remain around comorbidities,
particularly diabetes, and donor risk.39
The emergence of LDKTx has raised considerable ethical concerns arising from the introduced risk to
an otherwise healthy donor, running contrary to the ethical principle of ‘doing no harm’. The CARI
guidelines emphasise that, in order to justify LDKTx, “the risk of harm to the individual donor should be
very low and the potential benefit to the recipient should be significant, with a reasonable likelihood of
success”.40 The 2007 National Health and Medical Research Council (NHMRC) guidelines specifically
note that “the rapidly evolving culture of transplantation contributes to the complex ethics of living organ
donation. Living organ and tissue donation and transplantation are constantly changing, in both medical
and social terms. Ethical guidance needs to reflect long-standing principles, which have to be reexamined to encompass new technologies.”41
In Spain, the fact that clinicians were not informing patients of LDKTx as an option, let alone
recommending it, has been identified as a key barrier, although the extent to which this occurred varied
greatly between jurisdictions. A 2004 survey of dialysis patients found that 83.4% claimed they had not
been informed of LDKTx as an option.42 This situation may have changed significantly over time, and
the rate of LDKTx in Spain has risen substantially over the years since.43 However, a more recent
survey suggests that 87% of Spanish transplant hospital personnel are in favour of living kidney
donation,44 comparing unfavourably with data from other countries of interest. For example, Canadian 45
and UK46 surveys found that found 100% of medical and nursing staff in a transplant centre considered
LDKTx ethically acceptable between blood relatives. In a 2006 survey, 95% of Australian nephrologists
indicated they would recommend LDKTx to suitable donor, and 97% would be willing to become a living
kidney donor for an immediate family member.47
4.2
Initiatives to improve rates of living kidney donation
The search identified four broad categories for improving living kidney donation rates: broadening the
pool (overcoming clinical contraindications); financial reimbursement programs; strategies to address
cultural/demographic disparities; and education/awareness-raising initiatives. These are described in
the following sections.
4.2.1
Broadening the pool (overcoming clinical contraindications)
There are a number of common themes internationally that relate to ‘broadening the pool’ of potential
living donor kidneys.
Antibody-incompatible transplantation
Historically, some potential donor kidneys could not be used in a particular recipient because antibodies
present in the recipient’s bloodstream would cause rejection of the organ. New drugs and protocols
allow ‘desensitisation’ of the recipient in order to avoid this, resulting in ‘antibody-incompatible’
transplantation. Greater use of antibody-incompatible donations has the potential to increase the
number of LDKTx performed,48 and the UK has published specific guidelines to direct this practice.49
The guidelines state that the practice is cost-effective when compared with dialysis, but should be
performed as part of an ‘ongoing structured program’ within a transplant unit (rather than occasionally)
8
4. Results
to ensure appropriate support, expertise and protocols are in place. According to the guidelines,
antibody-incompatible transplantations may account for up to 20% of the total living donor
transplantation program in the UK.50
Expanding donor criteria
With both improved methods and available drugs and increasing demand for donor organs, many
transplant centres internationally are relaxing the criteria against which they assess a potential donor for
LDKTx. These ‘expanded criteria’ (e.g. acceptance of donors who are obese or have proteinuria) vary
widely between and even within countries and are not universally applied or accepted.51 While they
represent a relaxing of historical clinical contraindications and effectively increase the potential pool of
organs for transplantation, there is a lack of evidence for the comparative effectiveness of using such
donors52 as well as long-term donor outcomes.53
Paired kidney donation exchange programs
Paired kidney donor exchange programs now operate in a number of countries including the United
States, UK, Spain, Netherlands, Canada and, since 2010, Australia.54 As well as identifying appropriate
non-compatible pairs, these programs often enable donation chains to occur (in which a non-directed
donor sets off a chain of donations among pairs within the program), facilitating a number of LDKTx that
may otherwise not have been possible.
It is assumed that such programs increase the number of LDKTx occurring in the jurisdiction in which
the program operates, and there is some evidence to support this.55 However, experience from the US
(and early Australian experience – see below) suggest that such schemes may not have a significant
impact on LDKTx rates.56
The Australian Paired Kidney Exchange program (AKX) allows searching of registered donor/recipient
pairs for combinations in which the donor in an incompatible pair can be matched to a recipient in
another incompatible pair. The program commenced in late 2010 and was expanded in 2011, and
during that year the program resulted in an additional 23 transplantations that would not otherwise have
occurred.57 Although there is evidence that the program may significantly decrease time spent waiting
for a transplantation (compared with a deceased donor transplantation),58 the frequency of LDKTx in
Australia has continued to decline.59
Increasing altruistic (non-directed) living kidney donation
A survey of Australian nephrologists found that, while 97% would be a live kidney donor for an
immediate family member, only 4% would donate a kidney to a matched stranger.60 However, this type
of donation has become significantly more common in the United States over recent years.61 A recent
review that found a wide variation in acceptability of altruistic living kidney donation; however, overall,
33% of subjects in the four studies identified would consider living kidney donation to an unknown
recipient.62
In Australia, altruistic kidney donation is possible through the AKX program, and some information is
available online.63 However, it is not widely publicised on the websites of Australian transplant
hospitals.64
4.2.2
Financial reimbursement programs
Many countries have some type of government-funded expense reimbursement program for live donors;
including Belgium, Canada, France, New Zealand, the United Kingdom, the United States and
Australia.65 A selection of these are described below. While such initiatives presumably were
9
4. Results
introduced to overcome a perceived key barrier to living kidney donation (as described above) and are
thought to be likely to improve the mobility of potential donors (which may become increasingly
important with the Australian paired kidney exchange program), there is little empirical evidence
available to confirm that they do, in fact, increase rates of LDKTx.
Canada
Canada’s Living Organ Donor Expense Reimbursement Program (LODERP) allowed living donors for
potential recipients in British Columbia to access reimbursements for certain expenses relating to donor
assessment, surgery and recovery up to a maximum of CAD$5,500 per donor. The items covered by
the scheme are comprehensive, and include travel, accommodation, meals, parking, loss of income and
child- or elder-care. At the time of evaluation, the LODERP had disbursed CAD$282,557 to 269
applicants over three years – less than anticipated. While extremely well-received by both healthcare
professionals and living donors, the authors of the evaluation concede that it is difficult to ascertain
whether such a program improves donation rates, particularly in the short term.66
United Kingdom
While the UK guidelines recommend that reimbursement of expenses incurred by living donors occurs
through local jurisdictions,67 these principles may not be applied uniformly.68 The guidelines, published
in 2011, stated that a national reimbursement scheme for England was under development at that time.
USA
In the USA, a ‘National Living Organ Donor Assistance Package’ used both donor and recipient income
to determine eligibility, with preference given to low-income pairs.69 Tax deductions and credits have
also been made available in a number of states, but do not appear to have translated into an effect on
living kidney donation rates.70 It is worth noting that a lack of universal access to healthcare in the US
may mean that there are significant differences in the systems and barriers at play compared with the
Australian context.71
Europe
Sickland and colleagues outline a number of reimbursement schemes throughout Europe, including
those in France and Belgium.72 Of these, the French program is more comprehensive, incorporating
payment of non-medical expenses, while the Belgian initiative covers lost income only. Spain did not
have a reimbursement scheme in place at the time of publication of this article (2009).
Australia
There have been few, and isolated, schemes for compensating living donors in various parts of
Australia in the past such as travel assistance for donors in country areas of Western Australia. 73
Significant financial barriers remain, and generic state- and territory-administered patient
accommodation and travel schemes may not be sufficient to support LDKTx.74 A new national paid
leave scheme has been recently announced, which will be evaluated over the coming years.75
4.2.3
Improving cultural and socioeconomic disparities
Other than the new Australian paid leave scheme, this search retrieved no information about initiatives
that specifically aim to address disparities in LDKTx rates between different cultural and socioeconomic
groups in Australia. However, although its focus is more broadly on improving Indigenous Australians’
access to kidney transplantation in general (as opposed to LDKTx in particular), the IMPAKT study may
provide important insights to direct improvement initiatives.76 The study included analysis of
nephrologists’ attitudes and practices, patients’ knowledge, attitudes and decision-making processes
and transplantation ‘work-up’ requirements. The Royal Australian College of Surgeons has suggested
10
4. Results
further research and policy development to address the disparities in care of ESKD between Aboriginal
and Torres Strait Islander people and other Australians.77
In a significantly different context (improving LDKTx rates in African American patients), it has been
suggested that culturally-sensitive, home-based education may reduce racial disparities in terms of
living donor inquiries and donor suitability evaluations.78
4.2.4
Education and awareness-raising
A number of educational and awareness-raising campaigns aiming to increase rates of LDKTx have
been documented around the world. These may target health professionals, potential donors or
potential recipients: however, in many cases the nature of the relationship between clinician, patient and
donor in this context makes it difficult to determine whether any observed effect is due to changes in
any single group. For example, a Spanish ‘living kidney donor program’, aimed to increase the overall
donor pool by improving communication and education by clinicians for patients and their relatives.
While the program (run by dialysis nephrologists through chronic kidney failure clinics) was deemed
successful, with the LDKTx rate rising from 0.8% to 4.4%, 79 it is unclear whether the authors attribute
the success to changes in clinician behaviours or donor or recipient knowledge, awareness and
attitudes.
Donor education
Donor education is not only deemed essential from an ethical standpoint, but has been cited as a
potential intervention to improve LDKTx rates.
It has been postulated that, while it is theoretically possible to improve knowledge about living kidney
donation among relatives of patients with ESKD, there may be no effect on LDKTx rates. A Canadian
survey of previous donors and non-donor relatives of transplantation-waitlisted patients found that most
donors appeared not to deliberate extensively or research LDKTx before committing to donation.
Although only 20% of non-donors in the study felt well-informed about LDKTx, the authors concluded
that educational efforts should focus, at least initially, on the potential recipient because of the strong
relationship observed between the knowledge and beliefs of an ESKD patient regarding LDKT and
those of his/her family.80
For potential donors seeking knowledge on the internet, a 2007 study found 86 unique international
websites on living kidney donation; most created by transplantation programs and organisations.
Although the content of the sites was generally accurate, the vast majority were written above the
recommended patient reading level and covered, on average, just over one third of the recommended
information. Information regarding potential long-term risks, psychological risks, and expected benefits
to the donor were often absent, and the most popular websites were often not ranked among the best
sites to provide information.81 Although ten years old, an analysis of written information from around the
world identified similar issues, with five of 16 brochures reviewed considered to cover all essential
information. When donor risks were mentioned, interpretations of the risks and examples given were
dissimilar, potentially reflecting legislative and clinical practice differences.82 In Australia, there is a
distinct lack of information on living kidney donation available online.83
Recipient education
There are a number of published articles describing educational interventions to increase living kidney
donation that are aimed at potential recipients. One found that an educational intervention including a
specific discussion with a health educator (about LDKTx risks and benefits, how to identify a potential
donor and overcoming barriers in approaching potential donors) increased the proportion of patients
11
4. Results
considering LDKTx and asking a donor for a kidney in some (but not all) patient groups.84 Another
found evidence that interventions aimed at increasing the likelihood that patients will actively seek a
donation can facilitate discussion and increase patient ’pursuit behaviours’.85 However, it is unclear
whether these results are likely to translate to an increase in LDKTx. Another US study has suggested
that home-based education, involving the recipient and ‘guests’ (including potential donors) selected by
the recipient led to increases in the presentation of potential donors, evaluations for LDKTx and LDKTx
itself – although whether this is related to an effect on recipient attitudes, donor attitudes or both is
unclear.86
While greater ‘self-efficacy’ – a measure of a patient’s belief in his/her ability to attract a donor – may be
associated with a greater likelihood of a potential live donor presenting for assessment, a patient’s
knowledge about LDKTx may not.87
Education/awareness-raising among health care professionals
It is clear that the attitudes of health professionals play a vital role in the rate of LDKTx performed within
an institution, a jurisdiction, and a country. However, there are very few examples of initiatives (beyond
publication of clinical guidelines) that aim to alter these attitudes. Nevertheless, there may be some
scope to influence them, particularly at the early training stage: for example, in Canada, a 20-minute
PowerPoint presentation addressing statistics of organ and tissue need and donation and an
audiovisual presentation resulted in increased awareness of living kidney donation among health and
allied health students.88
While it has been suggested that the vast majority of Australian nephrologists do recommend LDKTx to
relevant patients,89 the variation in practice evidenced by state and territory LDKTx statistics90 suggests
there may be some scope to influence professionals’ attitudes and/or clinical practice to increase LDKTx
rates.
12
5. Discussion
5
DISCUSSION
This review illustrates the complexity of factors that are likely to influence LDKTx rates within a given
system. While there is a significant body of literature relating to observed or theoretical barriers to living
kidney donation, there is relatively little describing effective interventions to overcome these barriers.
What evidence exists may be strongly influenced by local legislation and guidelines, community
attitudes and demographics, limiting its interpretation in the Australian context.
Interestingly, a number of initiatives that would appear to logically lead to increased LDKTx rates have
not necessarily been shown to do so. Key examples include financial reimbursement schemes in the
US and Canada, and paired kidney exchange programs (including the Australian initiative).
Of the identified countries with high-performing deceased donation rates, the United States clearly leads
the way in terms of LDKTx. This may be, at least in part, due to the fact that altruistic (non-directed)
donation has become increasingly common in the US. However, it is worth noting that the US kidney
transplantation rates are higher across the board and, in fact, a similar proportion of living donor to
deceased donor kidney transplantations are performed when compared with Australia. 91
Altruistic donation may also be of most concern in terms of legal and ethical issues, as the psychosocial
wellbeing of potential donors and capacity to consent must be carefully considered. The low
‘acceptability’ of this approach among Australian nephrologists92 and current lack of information
provided by transplant hospitals93 suggests that a similar phenomenon may be difficult to replicate in
this country, at least in the short to medium term.
In contrast, while the rates of LDKTx in European countries with world-leading deceased organ donation
rates (Spain, Belgium, France) are increasing, they remain comparatively low.94 This review found no
clear explanation for this phenomenon, although the language bias in the methodology for this study
that means this analysis is incomplete. There is some evidence to suggest that clinicians’ attitudes in
these countries, though still favourable, may not be as positive as in other parts of the world. Although it
may be argued that a strong deceased donation record may lessen the need for LDKTx, an international
analysis has found no relationship between the two factors, and noted that the factors influencing
deceased donation are entirely different to those influencing living kidney donation.95
In principle, increases in LDKTx can be achieved by either:
 increasing the overall motivation of a society and health care system to use LDKTx as a
treatment option for ESKD and/or
 identifying and removing obstacles that prevent those who wish to proceed to LDKTx from
doing so (i.e. facilitating living kidney donation by those motivated and willing to donate).
While efforts to overcome known barriers continue to be important, the complexity of psychosocial,
ethical and communication issues that affect potential donors, potential recipients and clinicians (and
the interactions between these elements) are likely to provide the key challenges in increasing LDKTx
rates in Australia.
13
6. References
6
REFERENCES
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http://www.aihw.gov.au/chronic-kidney-disease. Accessed 22 May 2013.
2 Kidney Health Australia. CKD in Australia. Available at:
http://www.kidney.org.au/HealthProfessionals/CKDinAustralia/tabid/622/Default.aspx. Accessed 22 May 2013.
3 Australian Government Department of Health and Ageing. Chronic Kidney Disease (CKD) and End-Stage Kidney Disease
(ESKD). Available at: http://www.health.gov.au/internet/main/publishing.nsf/Content/pq-ckd-eskd. Accessed 22 May 2013.
4 Kidney Health Australia 2010. The Economic Impact of End-Stage Kidney Disease in Australia:
Projections to 2020. Available at:
http://www.kidney.org.au/LinkClick.aspx?fileticket=vave4WFH73U%3d&tabid=635&mid=1837. Accessed 22 May 2013.
5 National Clinical Taskforce on Organ and Tissue Donation, 2008, National Clinical Taskforce on Organ and Tissue
Donation Final Report: Think Nationally, Act Locally, Commonwealth of Australia, p. 51.
6 Milton CA, Russ GR, McDonald SP. Pre-emptive renal transplantation from living donors in Australia: Effect on allograft and
patient survival Nephrology 2008;13: 535–540.
7 Bendorf A, Pussell BA, Kelly PJ, Kerridge IH. Socioeconomic, Demographic and Policy Comparisons of Living and
Deceased Kidney Transplantation Rates Across 53 Countries. Nephrology 2013 (article accepted for publication) Available
at: http://onlinelibrary.wiley.com/doi/10.1111/nep.12101/abstract. Accessed 6 June 2013.
8 Donatelife. National Reform Agenda. Available at: http://www.donatelife.gov.au/the-authority/national-reform-agenda-.
Accessed 6 June 2013.
9 Australia & New Zealand Dialysis and Transplant Registry (ANZDATA). 2012 Annual Report. Available at:
http://www.anzdata.org.au/anzdata/AnzdataReport/35thReport/2012c08_transplants_v1.pdf. Accessed 22 May 2013.
10 Transplant Australia. Statistics. Available at: http://www.transplant.org.au/Statistic_s.html. Accessed 7 June 2013.
11 Kanellis J. Justification for living donor kidney transplantation. Nephrology 2010; 15: S72-S79.
12 Tong A, Chapman JR, Wong G, et al. Screening and follow-up of living kidney donors: a systematic review of clinical
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