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BOOK REVIEW

Living Donor Kidney Transplantation: Current Practices,Emerging Trends and Evolving Challenges

Editors: Robert S. Gaston and Jonas Wadström

Publisher: Taylor & Francis

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IVING DONOR kidney transplantation af-fords the patient with end-stage renal dis-

ase optimal survival and quality of life. Withach day, we increase our dependence on livingonors because of the limited number and chang-ng quality of deceased donors. Gaston and Wad-tröm have finally captured the importance of liv-ng donors and catapulted them to proper eminencey dedicating an entire book to their evaluation,election, and follow-up. Living Donor Kidneyransplantation not only provides an outline ofhe medical evaluation and immediate surgicalisks, but also discusses controversies surround-ng selected isolated medical characteristics andayment for donation. It provides a balancederspective for those taking care of living donorsnd food for thought for the general populationnterested in the ongoing dialogue about donorafety and reimbursement. This book is wortheading by medical ethicists, those determiningational policy, and medical professionals select-ng and operating on living donors.

The text begins by recapping the history ofiving kidney donation, followed by an outline ofhe data supporting the benefit of living transplan-ation and the immunologic basis of this success.hapter 3, Immunological Advantages of Livingonor Kidney Transplantation, provides one of

he most to-the-point and understandable expla-ations of the immune response to the trans-lanted organ that I have read. Chapter 4, onelection and evaluation of potential donors, is wellritten, well referenced, and complete. Chapter 5iscusses the outcomes of 171 Swiss donorstudied prospectively over 5 years. The authorsetail results in donors without and with suchsolated medical abnormalities as a marginallomerular filtration rate, hypertension, mi-roalbuminuria, dipstick hematuria, or obesity.he authors also propose a means to determine

he minimal acceptable donor creatinine clear-

nce. They propose that the clearance at donation

merican Journal of Kidney Diseases, Vol 47, No 1 (January), 200

hould leave the donor at age 80 with a creatininelearance of 40 mL/min/1.73 m2 (0.67 mL/s/1.732). One limit of this study is the use of a

alculated creatinine clearance as the measure ofenal function; it also lacks identification ofonor ethnicity. Creatinine-based measurementsre less accurate than formal glomerular filtra-ion measures. Ethnicity is associated with theisk to develop renal failure.

Living Donor Nephrectomy (chapter 6) details theurgical procedure and postoperative risks. Long-erm risks after kidney donation are described inhapter 7, with the emphasis on outcomes inonors of European heritage. Chapter 8 reviewshe psychosocial impact of donation, with adviceo improve psychosocial assessments, because ofhe distancing of familial relationships betweenonor and recipient (ie, increasing dependencen nonrelated donors). Chapters 9 and 10 discussvercoming blood group type and major histo-ompatibility complex incompatibility betweenonor and recipient. Chapter 11 outlines therchestration and success of paired-donor ex-hanges, while chapter 12 describes the perfor-ance of altruistic donor evaluation at the Uni-

ersity of Minnesota, where 24 of 397 inquiriesave resulted in live donation. Chapter 13 startshe discussion of legal and ethical dilemmas inive donor transplantation and is followed byhapter 14 (for) and chapter 15 (against) pay-ent for living donation.Overall, this is an excellent reference for the

valuation, selection, and discussion of the livingonor. Only a reconciliation of a few minorecommendation differences about renal func-ion measurements and protein and albumin ex-

Originally published online as doi:10.1053/j.ajkd.2005.10.002n December 6, 2005.

© 2005 by the National Kidney Foundation, Inc.0272-6386/05/4701-0024$30.00/0

doi:10.1053/j.ajkd.2005.10.002

6: pp 191-192 191

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BOOK REVIEW192

retion rates in chapters 4, 5, and 7 would haveade the book entirely cohesive. Last, in the

ealm of review, although this is a very thought-ul and thorough book, data are still missing.bsent is a report of survival and renal functionutcome in donors of color. However, this is nothe fault of the editors or authors because theseata have not yet been reported. Yet withouthese data, no book on living donation is trulyomplete.

Gaston and Wadström’s book serves the livingonor well, especially because it objectively dis-usses such societal issues as payment for dona-ion. However, it is time to take the donor discus-ion even further, to lifetime immunosuppressiveoverage for transplant recipients and donor healthare. Immunosuppressive coverage for recipients isot guaranteed for the life of the allograft. Afterhildren who undergo transplantation becomedults and if an adult recipient loses a job or iseyond the 3 years of posttransplantation medica-ion coverage from Medicare, it is not uncom-on for an allograft to be lost because of the lack

f immunosuppressive coverage. In our quest foriving donor transplantation, to improve recipi-nt outcome and decrease overall end-stage renalisease expenses, we have forgotten that we are

isking the live donor’s psychological state. This

isk is for grieving after the loss of their kidneyecause the recipient has lost immunosuppressiveedication coverage. We ask people to donate and

o put their lives at risk, but we do not providengoing support to maintain the transplant! Nowhat more than half the kidney donors are livingonors, it is time to address this issue head on. Ist ethical to perform living donor transplantationsf there is no funding to provide immunosuppres-ive medications and other support (eg, antihyper-ensive medications, dietary counseling) to maxi-

ize survival of the allograft? Or are we askingonors to make a futile sacrifice, especially at aime when our donors may have minor medicalbnormalities, such as hypertension and obesity?urthermore, is it appropriate to operate and runrom the responsibility to care for donor issueshat arise over time as a consequence of dona-ion, or are we asking donors to be altruistic withheir bodies, their futures, and their pocket-ooks?

Connie L. Davis, MDProfessor of Medicine

University of Washington School of MedicineMedical Director

Kidney and Pancreas Transplantation

Seattle, Washington