Thursday, January 28, 2010

Kidney Mitzvah

The following article is shown in it's entirety. It appeared in Slate Magazine.

I apologize for it's length, but felt that it was an important subject to cover.

Slate Magazine
medical examiner
Kidney Mitzvah
Israel's remarkable new steps to solve its organ shortage.
By Sally Satel
Updated Wednesday, Jan. 27, 2010, at 4:47 PM ET

This month, Israel launched a new policy to encourage organ donation: Anyone who registers to allow his organs to be taken posthumously gets slight priority if he needs one in the future. When two comparably ill patients are in need, the tie will go to the organ-donation cardholder. The new policy garnered publicity in the Australian, Canadian, South African, and British press.

Meanwhile, under the radar, another, more dramatic Israeli initiative took place: giving compensation to families of deceased organ donors.

On Jan. 20, the relatives of a 51-year-old deceased man named Nachis Yafim gathered to accept a check for 10,000 Israeli shekel (roughly $2,700) in recognition of his wife Clara's decision to allow his liver, kidneys, and lungs to be taken for transplantation. The funds will be used by Clara and their 10-year-old son to memorialize Nachis—by paying for his headstone, for example.

In legalizing such a "memorial," Israel thus becomes the first country in the world to reward deceased organ donors. The Organ Donation Law, passed by the Knesset in 2008, says that families who agree to donate the organs of deceased loved ones may accept money to "memorialize" the deceased. Currently, the Israeli Ministry of Health has allowed up to 50,000 shekel, or $13,400, to do so. The money—given by nonprofit groups and taken out of their own pool of charitable contributions—may be used in any way the families see fit to memorialize the deceased.

According to the law, the donor, while alive, must not have refused to become a posthumous donor. This quells anxiety about a family benefiting over the objections of the donor himself.

The money for Nachis Yafim's family was given by ADI, a nonprofit organization outside of Tel Aviv that was established to encourage organ donation. It is named for Adi Ben Dror, who died of complications of kidney disease.

In the ceremony held in honor of Yafim, who emigrated from Russia and worked as a security guard in Be'er Sheva, Gadi Ben Dror, the director of ADI, said, in handing the check to Clara, "In this country we always talk about military heroism. ... [T]his is clearly a case of civilian heroism. [His organs] saved four lives. ... [T]he family should be blessed."

Donation at death is a big deal in Israel because of its infrequency. The country is lodged far down on the list of developed countries regarding the availability of deceased organs for transplantation: Nine donors per 1 million people. In comparison, that number is 35 in Spain and 25 in the United States. As of last year, only 8 percent of adult Israelis held organ-donor cards. In Europe, the rates are between 30 percent and 40 percent. In the United States, about 38 percent of adults with a driver's license were registered organ donors in 2009. In addition, the "conversion rate"—that is, the percentage of times a death meeting eligible criteria for donation becomes an actual donor—is 60 percent to 70 percent in the United States. (The rate depends, in large part, on whether families of deceased people agree when asked to give permission to retrieve the organs of loved ones—yes, even if one signs a card, hospitals will allow families to override the deceased donor's indicated preference.) In Spain, the conversion rate is around 80 percent. Israel's conversion rate is 45 percent.

Why such low rates? "Most Jews are under the mistaken impression that traditional Jewish law requires a body be buried whole at all costs," according to Robby Berman, director of the Halachic Organ Donor Society, an organization that encourages Jews all over the world to donate organs to the general population.

Another barrier to deceased donation has been the definition of death. Some ultra-Orthodox rabbis reject brain death as the definition of death because the ventilator is providing oxygen that allows the heart to beat for a few more days after brain death. They insist that the heart must cease to beat before a person can be pronounced dead—a condition making it difficult to obtain suitable organs in a timely manner. To facilitate donation, Israel passed a law in 2008 establishing "brain death" as the definition of death relevant for all legal purposes, including organ donation.

Why is Israel working so hard to increase donation now? Because Israelis can no longer participate in transplant tourism—that is, go abroad to obtain organs.

In 2008, a new law mandated that the Israeli Ministry of Health stop paying for transplants that were obtained in countries that themselves outlaw organ sales. This brought a stop to a policy that was in effect since 1998, when the ministry began covering the cost of transplants obtained from foreign donors. Israelis seeking organs had traveled to places such as Turkey, China, Eastern Europe, and the Philippines, though the exact number of transplant "tourists" is not known. As more Israelis received transplants this way, rates of donation by living relatives went down, according to the Ministry of Health.

Israel should be commended for moving to solve its organ problem, and save lives, by making two moral choices: first, to reduce transplant tourism; second, to provide compensation for deceased donation and priority ranking to encourage donations. This symmetry is critical to reducing the organ shortage in Israel and all over the world. Incentives must be paired with efforts to combat trafficking.

Alas, the World Health Organization, the Council of Europe, the United Nations, and the International Transplantation Society fail to grasp the need for such a two-pronged strategy. Instead, these groups endorse a strictly unilateral policy that bans organ trafficking. At first blush, yes, this seems reasonable. After all, corrupt brokers deceive indigent donors about the nature of surgery, cheat them out of payment, and ignore their post-surgical needs.

But clamping down on unlawful organ sales without first expanding the organ pool means more patient deaths, not less criminal activity. It drives corruption rings further underground or causes markets to blossom elsewhere around the globe. This is happening now. As China, Pakistan, and the Philippines have begun to curb illicit organ sales, places like Egypt, Eastern Europe, and South and Central America are becoming popular "tourist" sites.

Indeed, the global transplant establishment is so leery of benefiting donors or families directly—as in, for example, allowing Clara to use the 10,000 shekel to pay bills now that her husband is gone—that Israel had to put limits on how the cash was spent. I think this is too bad. Yafim would surely want his family to have some short-term financial cushion. Moreover, freedom to use the benefit as the family decides might be an even better incentive to donate.

Nonetheless, the compensation-for-memorialization is an important development that more countries should adopt.

When Gadi Ben Dror presented the check to Yafim's family, he said, "[We] owe the family our appreciation [which] we express with a gift. It's important to publicize their courage to donate organs in order to encourage others to donate as well." Within those sentiments lies the solution to the organ shortage: expressions of gratitude for a life-saving act intended to encourage others to do the same.
Sally Satel, M.D., a resident scholar at the American Enterprise Institute, is editor of When Altruism Isn't Enough: The Case for Compensating Kidney Donors.

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Monday, January 18, 2010

Transplant Update: UNOS data shows largest drop in organ donations in 20 years

The following is reprinted from the January 2010 issue of Nephrology News & Issues.

As transplant programs get more creative on finding ways to match organ donors and recipients...the transplant community is looking for new approaches on slowing a downward trend in organ donation.

The United Network for Organ Sharing reports that 10,916 organs were donated in the United States in 2009 (as of Dec. 11). That is a drop from donations in 2008 of 13,156-the largest year-to-year drop recorded since 1988. The agency shows that organ donation increased steadily from 1988 until 2007, when there was a slight decline. That has continued to slide until the major drop in donations this year.

The drop in donation is highest among living donors, which is a major source of organs for kidney transplants. The number of living donors dropped from a high of 6,647 in 2004 to 4,727 in 2009. Deceased donors also dropped from 6,325 in 2004 to 5,481 in 2009

Year Living Deceased
2004 6647 6325
2005 6571 6700
2006 6435 7178
2007 6043 7240
2008 5968 7188
2009 4727 5481

That drop in donations has had an impact on organ transplants performed. "The total number of transplants in the United States increased on average by 872 transplants per year between 1998 and 2006. Thus, the decrease of 713 transplants in 2007 represents a substantial divergence from the longstanding trend," UNOS said in its 2008 annual report from the U.S. Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients." This drop was due largely to decreases in donation, particularly by living donors. There were 423 (6.3%) fewer living donors in 2007 than in 2006. Living donation has been decreasing since 2004."

There are 105,272 people on the national transplant waiting list as of December 2009; of this group, 82,956 are awaiting a kidney transplant.

The 2008 Annual Report of the OPTN and SRTR is based largely on data pertaining to the 10-year period from 1998 to 2007. The full report is available online at

Why do you think the number of kidney transplants are decreasing? Any ideas on how to reverse the trend? Please share your thoughts.

Harvey Mysel is a kidney transplant recipient and Founder of the Living Kidney Donors Network, a nonprofit organization that offers Workshops and Webinars to educate people in need of a kidney transplant about living kidney donation and help prepare them to effectively communicate their need to family members and friends. The Living Kidney Donors Network website is: and Harvey could be reached at: or follow him on Twitter

Thursday, January 7, 2010

What's my PRA? It's the first question you should ask when pursuing a Kidney Transplant

When it comes to needing a kidney transplant most people are thinking about finding a compatible donor. They don’t realize that there is a test you need to take that will determine how easy or difficult it will be to find that person. The test is called PRA.

PRA’s are "panel reactive antibodies.” A blood test measures the level of antibodies in your blood. The more antibiodies you have, the more difficult it will be to find a compatible donor. A person's PRA can be anywhere from 0% to 99%. Your PRA represents the percent of the U.S. population that the antibodies in your blood would react negatively to. For example, having a PRA of 25 means that about 25% of the population will not be able to donate a kidney to you. The antibodies present in your blood would attack the transplanted kidney and can cause immediate rejection. About 20% of the people who need a kidney transplant have high PRA’s. Simply stated, having a high PRA will significantly limit the number of people that will be able to donate to you.

You can develop high PRA’s from a blood transfusion, or an earlier transplant or from being pregnant.

There are ways of lowering PRA’s through a procedure called Plasmapheresis a blood-cleansing process that can eliminate the dangerous antibodies from the blood. Plasmapheresis is used only in cases in which the patient has a live donor.

Plasmapheresis can also been used to allow blood-type incompatible donor/recipients to proceed with the transplant. Plasmapheresis can cost tens of thousands of dollars more than conventional transplants and are complex to administer.

If you’ve been told by a transplant center that you are too highly sensitized, (another term used to describe high PRA's,) to receive a transplant ask about Plasmapheresis. If they don’t offer it there, speak to another transplant center.

Harvey Mysel is a kidney transplant recipient and Founder of the Living Kidney Donors Network, a nonprofit organization that offers Workshops and Get-Togethers to educate people in need of a kidney transplant about living kidney donation and helps prepare them to effectively communicate their need to family members and friends. The Living Kidney Donors Network website is: and Harvey could be reached at: or follow him on Twitter

Tuesday, January 5, 2010

"Matching" and Kidney Transplants - Myths and Misconceptions

The use of the terms “match”, “matching” or a “perfect match” are often misunderstood or misused when referring to a recipient and donor.

A more accurate way of describing the evaluation process is to use the terms, “suitable” and “compatible”. A suitable donor is someone that is healthy enough to donate. A donor is compatible when all the tests are finalized for the recipient and donor and it is shown that the prospective donor is able to donate to their recipient. When people say they are a "match", they usually mean that they are compatible to the recipient.

Generally, a recipient and donor aren't "matched" until they know that the donor is suitable and compatible.

The term “match” references the 6 HLA's (Human Leukcyte Antigens.) Before antirejection medications, 6 out of 6 antigens needed to match in order for the transplant to be successful. The new anti rejection drugs are so effective, that there isn’t a statistical difference in success rates between a zero match and a 5 out of 6 match. Therefore, HLA matching typically is not a factor that determines whether someone is compatible. There is however, a benefit to having a “perfect match,” 6 out of 6 antigens since the life of the transplanted kidney survives significantly longer. (On average, 28 years instead of 18 years for a 0 - 5 match,)

Donor and recipient matching is divided into three distinct areas: blood type matching, tissue type matching, (the HLA referenced above,) and cross matching.

Transplants are being done when donor and recipient have different blood types. A procedure called plasmapheresis on the recipient makes this possible. (Plasmapheresis will be a topic of another blog.)

Cross matching is a very sensitive and final test performed on a kidney donor and their recipient. The basic cross match test involves a mixing of the donors and recipients cells and serum to determine whether or not the recipient of a kidney will respond to the transplanted organ by attempting to reject it. A positive cross match means that the recipient has responded to the donor and that the transplant should not be carried out. A negative cross match means that the recipient has not responded to the donor and therefore transplantation should be safe.

While this language may appear a bit backwards, the cross match is the test indicating a “go” or” no go” for the transplant.

Either way hearing that there's a "match" is usually Great News!!

Harvey Mysel is a kidney transplant recipient and Founder of the Living Kidney Donors Network, a nonprofit organization that offers Workshops and Get-Togethers to educate people in need of a kidney transplant about living kidney donation and helps prepare them to effectively communicate their need to family members and friends. The Living Kidney Donors Network website is: and Harvey could be reached at: or follow him on Twitter

Is it Time to Consider Compensating Someone Who Donates a Kidney?

In sports and in business, when the chosen strategy isn't working, you make a change.

The current system for supplying kidneys to those in need was developed in 1983. It is not keeping up with the demand. You'd think we would change the system, especially when there is another option that has proved to be successful.

As strange as this may seem, we need to look to Iran who has overcome the kidney shortage with a fair solution. Iran has completely eliminated its kidney transplant waiting list, we should consider adopting the model they've developed.

In “Organ Sales and Moral Travails,” Benjamin E. Hippen, MD, transplant nephrologist, shows that Iran’s system of compensated donation has effectively provided the organs needed for transplant. “Iran is the only country that legally permits kidney vending,” he writes. “The waiting list for kidneys was eliminated in 1999, 11 years after the legalization of organ vending, and for the past 8 years, Iran has had no waiting list for kidneys.”

Concerns about the negative impacts of offering financial incentives for kidney donation naturally arise. Hippen reports that Iran has addressed this problem by putting a non-profit intermediary between potential kidney vendors and patients in need. “Separating the role of identifying vendors from the role of evaluating their medical, surgical, and psychological suitability permits transplant professionals to avoid confusing judgment on a vendor’s candidacy with various financial and professional incentives to perform more transplants,” Hippen writes.

Though the Iranian system is not perfect, it offers lessons that would be of value to American policy makers seeking to reduce the United States’ tragic organ shortage by setting up markets. “A review of 20 years of experience with a living organ vendor system in Iran reveals successes, deficiencies, and ambiguities,” Hippen concludes. “If the discussion of kidney markets in this country can progress beyond preconceptions as to what can and cannot work, in Iran or elsewhere, to an examination of the example of the Iran based on the evidence, that will be a significant step in the right direction.”

The above was taken from the blog, System Models.

For a full copy of the report by Dr. Hippen:

Harvey Mysel is a kidney transplant recipient and Founder of the Living Kidney Donors Network, a nonprofit organization that offers Workshops and Get-Togethers to educate people in need of a kidney transplant about living kidney donation and helps prepare them to effectively communicate their need to family members and friends. The Living Kidney Donors Network website is: and Harvey could be reached at: or follow him on Twitter