ABSTRACT
Organ shortage is the major limitation to kidney transplantation in the developed world. Conversely, millions of patients in the developing world with end-stage renal disease die because they cannot afford renal replacement therapy-even when willing living kidney donors exist. This juxtaposition between countries with funds but no available kidneys and those with available kidneys but no funds prompts us to propose an exchange program using each nation's unique assets. Our proposal leverages the cost savings achieved through earlier transplantation over dialysis to fund the cost of kidney exchange between developed-world patient-donor pairs with immunological barriers and developing-world patient-donor pairs with financial barriers. By making developed-world health care available to impoverished patients in the developing world, we replace unethical transplant tourism with global kidney exchange-a modality equally benefitting rich and poor. We report the 1-year experience of an initial Filipino pair, whose recipient was transplanted in the United states with an American donor's kidney at no cost to him. The Filipino donor donated to an American in the United States through a kidney exchange chain. Follow-up care and medications in the Philippines were supported by funds from the United States. We show that the logistical obstacles in this approach, although considerable, are surmountable.
Subject(s)
Cost-Benefit Analysis , Directed Tissue Donation , Health Care Costs/legislation & jurisprudence , Kidney Failure, Chronic/economics , Kidney Transplantation/economics , Living Donors/supply & distribution , Tissue and Organ Procurement/economics , Developing Countries , Glomerular Filtration Rate , Graft Survival , Health Resources , Health Services Accessibility , Humans , Kidney Failure, Chronic/surgery , Kidney Function Tests , Kidney Transplantation/legislation & jurisprudence , Kidney Transplantation/methods , Philippines , Policy Making , Prognosis , Risk Factors , Tissue and Organ Procurement/methods , United StatesABSTRACT
Failure to convert computer-identified possible kidney paired donation (KPD) exchanges into transplants has prohibited KPD from reaching its full potential. This study analyzes the progress of exchanges in moving from "offers" to completed transplants. Offers were divided into individual segments called 1-way transplants in order to calculate success rates. From 2007 to 2014, the Alliance for Paired Donation performed 243 transplants, 31 in collaboration with other KPD registries and 194 independently. Sixty-one of 194 independent transplants (31.4%) occurred via cycles, while the remaining 133 (68.6%) resulted from nonsimultaneous extended altruistic donor (NEAD) chains. Thirteen of 35 (37.1%) NEAD chains with at least three NEAD segments accounted for 68% of chain transplants (8.6 tx/chain). The "offer" and 1-way success rates were 21.9 and 15.5%, respectively. Three reasons for failure were found that could be prospectively prevented by changes in protocol or software: positive laboratory crossmatch (28%), transplant center declined donor (17%) and pair transplanted outside APD (14%). Performing a root cause analysis on failures in moving from offer to transplant has allowed the APD to improve protocols and software. These changes have improved the success rate and the number of transplants performed per year.
Subject(s)
Internet , Kidney Transplantation , Tissue and Organ Procurement/methods , Algorithms , Decision Support Techniques , Donor Selection/methods , Donor Selection/organization & administration , Donor Selection/trends , Humans , Living Donors , Models, Statistical , Tissue and Organ Procurement/organization & administration , Tissue and Organ Procurement/trends , United StatesABSTRACT
Previous studies reported that some children who survive acute lead encephalopathy suffer from ataxia and have difficulties maintaining postural equilibrium. More recent studies have failed to quantify postural imbalance in association with lower levels of lead exposures, perhaps due to the insensitivity of the clinical measure. In our study, we noninvasively measured postural disequilibrium with a microprocessor-based force platform. The test provides a real time quantification of the body's center of gravity movement pattern. Measurements were made in a cohort of 33 inner city children (mean age: six years +/- 0.4 SD) with well documented blood lead histories. The average maximum blood lead of these children during their first six years of life was 23.5 micrograms/dl (range = 8.5 to 49.4). The children performed four postural tests [i.e., standing eyes open (EO) and closed (EC), on firm surface and standing on a compliant foam surface with eyes open (FO) and closed (FC)]. The results indicated that the maximum blood lead incurred during the second year of life was significantly positively related to postural sway, and the body balance was most affected in the EC test where visual cues were eliminated and proprioceptive feedback was not modified. Fetal Pb exposure levels as well as Pb exposures during the first year of life were not correlated with postural sway of six year olds. However, the maximum blood lead concentration beyond two years of life was significantly associated with the postural sway at six years of age.
