This is a modified version of a correspondence I sent to my medical school in order to try and get the nephrology curriculum altered, emphasizing the role of living donation.
Over the weekend I attended the annual meeting for Give a Kidney, a charity for the promotion of living directed and non-directed kidney donation in the UK. Donors, recipients, and healthcare professionals discussed the role living donation plays in the therapeutic landscape, and how best to support it in the future. The meeting identified the occasionally harmful culture in transplant units and the treatment of prospective and past donors. I believe that the lack of teaching medical students receive about living donation is at least partially responsible, so I have outlined some reasons why it should play a larger role in our education than it does at present.
Firstly, transplantation from living donors is already a mainstay in renal replacement therapy. Currently a third of all renal transplants come from living donors 1, this equates to around 1000 operations a year, being carried out across the country. Non-directed donation is also no longer exceedingly rare, accounting for just under 10% of living donors.
Furthermore, grafts from living donors have been found to have a longer survival than deceased donor kidneys 2, and higher one-year survival rates. This not only leads to increased QALYs, but represents a significant cost-saving to the NHS. In the decades since the first living kidney donation, thousands of these procedures have been performed, so that the number of people walking around with a kidney from a living donor is in the 5-figure range.
Despite the efficacy of living donation, positive attitudes among healthcare staff are not universally shared. BOUnD 3, an as yet unpublished trial looking into patient and professional perspectives surrounding non-directed donation, is finding that donors are treated with a degree of suspicion, with many facing an uphill struggle to be treated in accordance to NHS Blood and Transplant guidelines. Whether from lack of exposure or from lack of knowledge, these attitudes do nothing to support a valuable option to end years on dialysis.
I had the pleasure to listen to Dr Aisling Courtney talk about the efforts in Northern Ireland to increase the rates of living donation. Key in these efforts were to move the assessment of donors to a single day, as well as leading a cultural shift in her department, emphasizing that living-donor kidneys are preferable. These efforts took Belfast from the bottom of the pack in donation rates to higher than any other country in Europe, effectively quadrupling living donor rates in the space of 2 years 4, resulting in the first net decrease in the dialysis list in decades.
Regrettably teaching surrounding living donation remains thin on the ground, and any discussion is almost exclusively focussed on the recipient’s process and health, with very little information regarding donation screening or donor health. An informal canvas of my peers confirmed my own recollections about the lack of teaching surrounding living donation, at least at my own medical school.
Our other ever-present source of information, the Oxford Handbook of Clinical Medicine (basically the bible for clinical students), has two relevant sections; the first is the sentence “Living Donor: Best graft function and survival, especially if HLA matched” followed by a paragraph about deceased donation, and the second is a section on organ donation exclusively based on talking to patient’s families after they have died, helpfully at the bottom of a double page spread entitled “Death”.
Polls carried out by Give a Kidney found that only 50% of the public know about living donation, and knowledge about non-directed donation is in the single digits. While we can naturally assume medical students and doctors to be better informed than the general public, from personal experience I can say that many are still in the dark.
We should be taught about donor health if no other reason than there are now thousands of people walking around having donated, a prevalence orders of magnitudes higher than those of some conditions we routinely learn about. We are also likely to meet and counsel prospective donors and should be competent discussing organ donation in our future practice.
Medical schools seem ideally placed to tackle unhelpful attitudes. We already have lectures and clinics about renal replacement therapies, and small modifications would go far to correct the lack of knowledge. Living donors are also well placed to aid educators as they’re medically stable and often keep in tight association with their transplant centres. The transplantation centres themselves are also often already aligned with universities.
We will probably never have enough kidneys to reduce the transplant list to 0, and there are some for whom transplantation is not an option. However, the idea that there are people being kept on dialysis in part due to the negative attitudes of healthcare professionals should be challenged.