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Monday, July 06, 2020

So, about that whole kidney donation thing... (Part 3)

[Read Part 1 and Part 2 first for context]

If you've finished reading the two previous installments, you now have a vague understanding of what put the idea into my head.  But everyone who donates a kidney comes to the decision by a different road.  Always keep that in mind.

Today's installment is about that critical stage where thoughts are translated into actions.  And here, pretty much everyone travels the same road.  

To be clear, one doesn't go from idly thinking that kidney donation might be a neat idea, to checking into the hospital and letting the surgeons remove the organ. 

Oh my, no... that's how altruistic financial donations work.   In fact, most charities count on hooking you with a compelling pitch at an impulsive moment, so that you'll whip out your credit card before you have a chance to think about all the other things you could do with the money you're about to hand over.  After all, you can always make more money.

That is the very antithesis of the process of considering living organ donation!  You have only two kidneys, and even under ideal conditions you can only give one away.

Obviously the the organizations that manage the stream of potential kidney donors (not to mention the potential recipients), are very anxious for as many people as possible to sign up for altruistic donation.  But there are two main hurdles that must be cleared in order for the donation to go ahead: 

1. Medical

2. Psychological / ethical 

Today I'll be discussing both. 

As an aside, for many people, there is a step before this which deals with the question of who you actually want to receive your kidney.  But I'll leave that for the next chapter. 

The Medical Hurdle:

In order to be able to donate a kidney, a person must be healthy enough that the surgery to remove the organ, and the future lived (to 120!), with only one kidney, do not present unreasonable medical risks.  After all, aside from the whole 'do no harm' thing that the transplant surgeons are bound by, the math falls apart if by removing one person from the list of sick people waiting for kidneys, they end up adding someone new to the list by allowing an unsuitable candidate to go under the knife.

Not only that, but there are a bunch of medical conditions ranging from weight to cardio fitness that can influence your chances of tolerating/surviving the surgery and loss of a kidney  

The kidneys are responsible for a whole range of essential functions in the human body.  The most obvious is removing waste and excess fluid from the body.  That's why people in kidney failure are dependent on ongoing dialysis to stay alive. 

But the kidneys are also responsible for regulating blood pressure, making red blood cells, keeping bones healthy, and controlling the body's PH levels.  If your body is struggling with any of these things with two kidneys, chances are you aren't a good candidate to give one away.

[More about what kidneys do here

That means that the first thing you are going to be asked to do when you make contact with a kidney donation organization or hospital transplant center, is to go to your family doc and get a complete physical exam (including a bunch of basic blood tests).  If you're a grown-up, you should be getting an annual physical anyway, so this might be just the kick-in-the-pants you needed to get into the habit.  

Bottom line, in order to be considered seriously - from a medical standpoint - as a potential donor, you need to make sure your body can survive the surgery and carry on comfortably with only one kidney.

Once you pass that hurdle, buckle up for a long journey of self-discovery.  You are going to find out more about your physical health than most people care to know.  I personally found this process reassuring.  But others take an 'ignorance is bliss' approach to knowing what is going on under the hood. 

I would also add that it is really important to have access to one or more people who have already donated a kidney.  Hearing the perspective of a layman is incredibly helpful to sort the wheat from the chaff.  I was blessed to have several friends who had previously donated, offer insight, advice and guidance during my journey.  If you don't know someone, the hospital and/or donation organization will certainly have a list of people who have offered to have potential donors contact them.

The actual time-frame for this screening process is not set in stone.  If, G-d forbid, you have a critically ill family member waiting for your organ, that might fast-track the screening process to a couple of months or even weeks.  But for most people, you're looking at a minimum of 6-8 months of testing before you get the 'Good Housekeeping Seal of Approval' to don the backless gown and surf into an OR on a gurney.

The Psychological / Ethical Hurdles:

Once you've gotten acceptable results from your basic blood work and physical exam, you will begin a long, two-pronged, path of testing designed to establish your suitability for living organ donation.  I've already talked a bit about the medical side.  Now for the psychological and ethical side.  Even though these two criteria are mostly unrelated, I've decided to address them together since neither can be determined using blood tests or other 'hard' medical exams.

From an ethical standpoint, they are going to want to make sure you aren't being pressured, or paid, to donate a kidney.  As hard as it is to imagine, there are deals being made with the devil every day where the imbalance of wealth is leveraged to essentially extort a kidney from someone in financial need.

I'm not talking about someone waking up in a bathtub full of ice in Tijuana after being rolled in some back-alley cantina. That kind of thing may happen occasionally in the third world... but is mostly the stuff of fiction.

But if someone has a pressing financial need (say, a wedding, college tuition or an expensive medical procedure in the family), 'selling' a kidney might seem like a quick and viable solution.  Sadly, there are doctors and middle-men around the world who profit from this imbalance of organs and resources... and it is as unethical as it is dangerous.  The screening process you are about to undergo is designed to prevent even the appearance of anything of the kind.

You will also be screened several times by a psychologist and/or social worker to determine if you are mentally fit to undergo the organ donation process, as well as to make sure you aren't volunteering to give away a healthy organ for unhealthy reasons (feelings of guilt, inadequacy, desire for accolades, extreme risk-taking behavior, surgery-fetish, etc.).   They will also ask a question that caught me off-guard:  How will you feel if the transplant is unsuccessful (meaning you gave away a kidney for nothing)?  It gets kinda real when you think about such things.

Many potential donors are focused solely on the act of donating.  But they aren't prepared for the day after, and the return to normalcy (and relative obscurity), that invariably occurs weeks, months and years after they've recovered.  That's a topic for another day, but it is worth mentioning that the psychological screening is meant to force a potential donor to take a brutally hard look at what is driving the decision process, and how it might all play out before, during and especially after the kidney donation is completed.

I'll be happy to answer any specific questions about MY screening process (your mileage may vary), in the comments or private email.  But assuming you successfully pass all the screening hurdles, you will find yourself with an appointment to sit before a multi-disciplinary committee tasked with giving final approval to you as a potential donor.  At least this is how it is done in Israel... I assume most developed countries have similar approval committees in place.

The committee is made up of medical doctors, mental health workers, attorneys and a civilian advocate.  They will be given your entire file of screening tests / reports to review in advance.  Their job is to determine - objectively - if you are a suitable candidate for living kidney donation.

What does 'objectivity' have to do with anything'?  Isn't the hospital that did all the tests objective?  Aren't they staffed by physicians bound by the Hippocratic oath to 'do no harm'? 

Yes.  But they are also an interested party.  In fact they are one of many interested parties involved in the process!

Your motivations may be ethically and psychologically correct/healthy, but the fact that you want to donate a kidney makes you an interested party.

The recipient needs a new kidney.  They would never want to do anyone else harm, but the fact that they have a need colors their objectivity.  So they too, are an interested party.

Even the hospital doing the transplant is an interested party, albeit their interests are confusing and often conflicting: 

On the one hand, they genuinely want to 'do no harm'.  Add to that, they are like a baseball player whose future prospects depend heavily on maintaining good 'stats'.  A ball player needs to keep their batting average or ERA at optimal levels.  A hospital has its own set of stats by which it is ranked locally and internationally; particularly in the realm of transplant surgeries.  A hospital with a strong transplant program wants to have a statistically 'all-star' success rate (for both surgical outcomes and long-term donor and recipient health).  Accepting bad candidates means increased risks... which translate into bad 'stats'. 

On the other hand, there are far fewer potential kidney donors than there are people waiting (desperately), for viable transplant organs.  Even if everyone signed their donor cards, and every fatal accident and illness ended with two viable kidneys entering the transplant pool, cadaver kidneys don't last nearly as long as organs taken from a living donor.  The difference can be the difference between a donor kidney lasting 5-8 years in the recipient's body... and lasting 15-20 years! 

So hospitals have an interest/stake in qualifying as many living donors as possible.  I don't believe they would deliberately qualify an unsuitable candidate for kidney donation.  But I could certainly see how they might qualify a borderline candidate with rationalizations and statistics to back up their decision.

So, standing in the way of all these interested parties is this final committee whose job it is to objectively determine if the person in front of them is medically, ethically, and psychologically suited to take the fairly drastic step of allowing the removal of a healthy organ from their body.

This committee is not a rubber stamp.  They will ask hard questions, And as adversarial as they may seem during what may feel like an interrogation... they are actually the only party in the entire process that is completely uninterested.  Their interest is protecting the health and welfare of the donor, and ensuring that the entire process is transparent and adheres to international medical and ethical standards.

If / when you receive the formal approval of this committee, you are free to commit to donate your kidney and schedule the transplantation surgery with your hospital team.

But (and this is a huuuuge but), at any point up to the point when you are rolled into the OR and put under general anesthesia, you can change your mind and decide not to go through with it.  The recipient will only be told that it turned out you weren't a suitable donor, and nobody will hold it against you.  At every stage of the process it is important to keep this in mind.  At no point while you are still conscious are you committed to the point where you can't change your mind.  This harks back to the previous installment when I explained why its best not to tell too many people in advance.  Leaving yourself the ability to back out gracefully is important to decision-making process and your long-term mental health.

Stay tuned for the next installment which will deal with the issue of who actually winds up with your kidney, should you decide to give one away.

As always, if you want to be informed of new posts, follow me in twitter @treppenwitz

Posted by David Bogner on July 6, 2020 | Permalink

Comments

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Thank you for sharing this with us.

Posted by: Ilana-Davita | Jul 6, 2020 9:27:23 PM

Ilana-Davita... You're very welcome. Thank you for being my sounding board.

Posted by: treppenwitz | Jul 7, 2020 7:53:18 AM

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