Guide Ethical problems in dialysis and transplantation

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These opportunities for disparities should be eliminated. The Society is grateful for the development of this white paper and supports the concept of standardization criteria for exemptions and a transparent central review committee process of these requests. We recommend that the criteria be stringent and standardized across all organs to limit the opportunity for inequity. We agree with a balance between equity and utility. The Pediatric Transplantation Committee Pediatric Committee commends the Ethics Committee for their effort in creating the white paper and thanks them for their presentation on the document.

A Pediatric Committee member asked what data the Ethics Committee considered in creating their recommendations, specifically if the waitlist outcomes of the pediatric population were considered independently. The Pediatric Committee was concerned that the white paper does not do enough to address the pediatric population, especially regarding their prioritization within kidney allocation. The Pediatric Committee noted that many high-quality kidneys are allocated to adult kidney-pancreas candidates instead of pediatric candidates.

The Pediatric Committee suggested that the Ethics Committee discuss this issue in this paper or a separate paper, instead of leaving it for the individual committees to decide. A Pediatric Committee member suggested that the Ethics Committee provide recommendations on how to address disparities in multi-organ transplantation for vulnerable populations.

While ASTS supports this as a white paper, that support would not necessarily extend to policy derived from its contents.


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  8. We strongly believe that all policy development should undergo public comment regardless of its origins as white papers or guidance documents. After hearing a presentation on the white paper, the Liver Committee had no further comments. The white paper asks the question on whether it is ethical to give more than one organ to one patient when two patients could have benefited from those organs. The member urged that the committee not discount those patients that cannot survive without a multi-organ transplant.

    Two members voiced praise for the white paper, stating that this is a good first step in trying to tackle a very complicated aspect of organ donation and transplant. The purpose of my comment is to make sure multi-organ transplants, such as SKP, are given their full weight during all of the discussion of eliminating DSA and Region. In the case of SKP, there is ample evidence that the kidney should follow the pancreas in this case to get better surgical and long-term medical outcomes. The shorter ischemic time of the pancreas should make it necessary that the kidney is given to the candidate and goes along to surgical completion.

    There are ample situations where multi-organ transplants that include the kidney should be considered as one transplantable unit and the sickest patient should be the primary concern given the complications that occur from staying on a waitlist until a simultaneous multi-organ transplant can be done. The American Society for Histocompatibility and Immunogenetics ASHI strongly supports this white paper and believes that it can serve as a guide for alleviating disparities in multi-organ transplants.

    In tangent with these concerns was how certain MOT combinations prevent the use of the pancreas. This comment is the opinion of the Houston Methodist Hospital. As MOT becomes more prevalent it will become increasingly important to consider whether existing allocation policies for MOT are ethically justifiable.

    The dual aims of bringing about the most benefit and distributing benefit fairly, when understood correctly, provide a helpful framework for determining whether allocation policies are ethically justifiable. Differences in organ allocation rates among various populations may, but do not necessarily, indicate inequitable distribution of these scarce resources.

    Whether these differences are ethically problematic turns on whether there are morally salient differences among the populations themselves. If there are not, unequal distribution of organs may be unethical. Our group believes that there are explanations for the observed MOT-driven differences that suggest the practice of MOT is not exacerbating inequitable distribution of organs.

    In contrast, The suggestion that there is an ethnicity inequality is not accurate. Data indicates black recipients receiving MOT are equal or actually higher when compared to those receiving a specific organ. See Table 2 below. The SOT performed for liver, black percentage is 9. These data suggest that racial differences in organ transplants come not from allocation policies but from variations in disease and waiting list demographics that are likely explained by the prevalence of different conditions is different populations.

    Similarly, differences socioeconomic status among MOT and IK transplant recipients might simply reflect the fact that MOT is typically performed at high-volume medical institutions that draw geographically from a more urban population than centers performing IK transplantation. Therefore, the differences identified are likely to be the result of variations in the populations these types of interventions target rather than by inequities in organ allocation policies. Percent White 1, Even in IK transplants the system finds it ethical to distribute the best kidney to highly sensitized patients and Zero mismatched recipients in an attempt to improve outcome.

    One additional concern is that withholding MOT from these potential candidates, mortality will significantly increase. While specific data is not as readily available in other organ systems, ongoing renal dysfunction following transplant is a well-known risk factor for patient mortality. Thus, policy changes which prevent MOT have the potential to significantly increase the number of futile transplants, which violates the Final Rule.

    Furthermore, analysis of data from patients at our center demonstrates that despite a significantly higher medical acuity among recipients of SLKT compared to KTA, KTA and SLKT recipients matched based on recipient age, gender, race, and KDRI exhibit equivalent mortality and death-censored kidney allograft survival at 5 years following transplantation Lunsford et al.

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    Thus, when comparing equivalent patient populations, long-term outcomes for SOT compared with MOT do not differ significantly. We also suggest that creating a national review board Recommendation 3 for MOT would create an additional and unnecessary step in the already extensive process for patients being listed for transplant. We reject the assessment there is an ethnicity inequality Recommendation 7. There is actually a higher percentage of blacks in the MOT candidates and recipients for SLK vs LTA and the differences identified are likely to be the result of variations in the populations these types of interventions target rather than by inequities in organ allocation policies.

    Finally, we believe that establishing additional standards for centers performing MOT Recommendation 10 is likely to exacerbate inequities in access, likely making it more difficult for those who live in medically underserved areas to take advantage of this innovation. We appreciate the opportunity to submit our concerns on behalf of Houston and South Texas patients to the committee and look forward to solutions that to maintain an equitable and fair system for transplantation.

    References Lunsford, K. Transplantation, 5. Reece, P. American Journal of Transplantation, 14 1. Disparity in selecting patients based on employment status has been previously reported in South Africa. This is no longer a discriminatory factor in the current Western Cape guidelines. Despite this, the guidelines may still negatively affect unemployed candidates.

    Acceptance onto the program requires evidence of financial means to regularly arrange for transport to the renal unit, which is part of the criteria. Other socio-demographic factors such as gender, marital status, nationality and area of residence were not predictors of acceptance among presented patients. This adds strengths to the use of current guidelines which do not discriminate against these groups. Inadequate access to health care probably explains another finding in our audit.


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    Patients who are socioeconomically disadvantaged tend to present late to a nephrologist[ 18 , 19 ] and have less than optimal outcome on treatment. This work indirectly reveals the challenges in the current health system of the Western Cape. The difficulty in early diagnosis was also seen in HIV positive patients. In our cohort, HIV positive patients were under-represented. Early diagnosis and management of HIV would allow more HIV positive candidates to be considered for dialysis and transplantation, and, notably, HIV status was not a predictor of acceptance onto the program among new patients presented.

    The retrospective study design depended on available reports which had some missing data. These results may not be generalized to the whole South African population because there is a significant dialysis population in the private sector. Twenty years after the end of apartheid, South Africa has made improvements in disparities to access of dialysis despite resource challenges. In the setting of resource limitation, rationing of dialysis becomes unavoidable in running a sustainable program.

    Efforts to allocate more resources should continue in view of the loss of young and potentially productive life. Advanced presentation of patients with ESKD represents challenges in early diagnosis and referral in the current system. Data curation: KGK. Formal analysis: KGK. Software: KGK. Supervision: BR KY. Browse Subject Areas?

    Click through the PLOS taxonomy to find articles in your field. Competing interests: All authors have no competing interests to declare. Introduction Chronic kidney disease CKD is a global public health problem. Materials and methods This was a retrospective analytic study in which characteristics and allocation outcomes of patients assessed by the renal replacement therapy RRT committee at Groote Schuur.

    Download: PPT. Table 1.

    Ethical Problems in Dialysis and Transplantation

    Data analysis and statistical considerations Data cleaning was performed by two methods. Results Between January 1 st , and December 31 st , there were new assessments of which Table 2. Baseline demographics of Blacks vs. Socio-demographic and clinical characteristics The socio-demographic, and clinical characteristics of patients are described in Tables 3 and 4. Table 3. Socio-demographic characteristics of new patients presented to the renal assessment committee in Groote Schuur from — Table 4. Clinical characteristics of new patients presented for the renal replacement program in Groote Schuur hospital from — Predicting acceptance into the renal replacement program In multivariate analysis Table 5 , race, compliance to treatment, dependents, paying patients and co-morbid diseases were not predictors.

    Table 5. Multivariate analysis of predictors of acceptance by the Renal Replacement committee among new patients presented in Groote Schuur Hospital from — Effect of prioritization criteria The introduction of prioritization criteria has not led to changes in outcomes of the assessments Table 6. Table 6. Discussion This study describes the allocation outcome of patients assessed for the RRT program and explores the extent to which equity in selection is achieved.

    Study limitations The retrospective study design depended on available reports which had some missing data. Conclusion Twenty years after the end of apartheid, South Africa has made improvements in disparities to access of dialysis despite resource challenges. References 1.

    Background

    Chronic kidney disease: global dimension and perspective. Outcomes of rationing dialysis therapy in biopsy-proven end-stage renal disease in South Africa. J Nephrol. View Article Google Scholar 3. Naicker S.