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Sunday, December 23, 2012

Pros and Cons of Monetary Compensation in Kidney Transplantation

Demand for organs has always exceeded supply. In order to resolve the shortage of donors, some have advocated financial payments being made to donors. Despite being illegal in most countries, the trade appears to be booming in nations such as Turkey, Russia, and South Africa

In 2008, the legislative branch of the Israeli government, approved a law that provides for various benefits to living organ donors, such as:

1. Reimbursement for medical expenses and lost work up to $5,000
2. Priority on the transplant list should they require a future organ donation
3. Waived self-participation fee for any medical service resulting from the donation
4. Attainment of a "chronic patient" status, which entitles the holder to additional medical benefits. 
5. If two patients have the same medical need, priority will now go to the patient who has signed an organ donor card, or whose family members have donated an organ (though medical necessity is still takes precedence).

One of the few countries that has legalised the sale of organs is Iran. A third-party independent association was set up to arrange contact between donors and recipients. This agency is staffed on a voluntary basis by end-stage renal failure patients. Within the first year of the establishment of this system, the number of transplants had almost doubled; nearly four fifths (80%) were from living unrelated sources. Donors receive:

1. A Payment from the government
2. Free health insurance 
3. Often payment from the recipient or a charity

The receiver of the ‘new’ kidney is provided with highly subsidized immunosuppression and charitable organizations allow those unable to pay for the transplant themselves to receive a new organ. Importantly, it is illegal for the medical and surgical teams involved or any ‘middleman’ to receive payment. A potential donor is also not allowed to contact anyone on the waiting list. Despite, this, anecdotal stories of young men touting their ‘spare’ kidney in dialysis clinics are common.

While still illegal in ‘Western’ nations, could the ‘Iranian model’ of payment for kidney donation be used in Unites States to solve the problems of kidney donor shortages? 

1. The advocates for legalization argue that each of us has autonomy over our own body in every aspect of our health and that from this stems the right to donate a kidney to a related or non-related patient. Payment for sperm and eggs is legal in many countries, even though they arguably have greater long-term implications due to the potential to create a whole new individual. Similarly to compensation received for participation in some clinical trials, the individual also gains no immediate benefit from putting themselves at risk.

2. After the initial peri-operative risk, the donor has no long term increased risk of mortality.

3. Most importantly, in the longer term, there is no significant acceleration in decrease in glomerular filtration rate (beyond that expected due to aging) in kidney donors fifteen years after transplantation. 

4. Charitable organizations allow those unable to pay for the transplant themselves to receive a new organ

5. Advocates of the Iranian model insist that where there was once a significant waiting time in excess of the length in ‘Western’ nations, there is now no waiting time. 

6. The Iranian system is known to have ethical and legal loopholes which have been exposed and exploited. 

7. There are “no significant differences” in groups of donors and recipients when compared in terms of socioeconomic background (wealth and education level). Thus significant social exploitation is not occurring. 

8. One of the earliest problems involved patients from abroad travelling to Iran to receive a kidney donation from an Iranian. This practice was outlawed to prevent the development of true ‘transplantation tourism’ and international exploitation of Iranian donors. In addition, refugee groups (such as those from Afghanistan) are offered transplants but are not allowed to donate to people outside of their ethnic groups, further decreasing potential exploitation of vulnerable groups.

9. As ESRD continues to grow in prevalence, the problem of unregulated organ markets and brokers is likely to become more severe. It is argued that the setting up of regulated markets would ‘cut out the middleman’ and reduce the exploitation of individuals and developing nations.

10. Inferior surgical and medical practice, common on the black market, leave both the donor and recipient at greater risk whilst the broker pockets a large cut of the proceeds.

11. The end-stage renal failure population continues to increase in most countries, putting an increasingly heavy load on medical infrastructure. Using economic cost-effectiveness analyses, a figure of approximately $90,000US has been proposed, much less than the estimated cost of dialysis of up to $70,000US per annum per patient. Government intervention would also guarantee adequate post-operative care and follow-up for the donor, something which is currently limited.

1. The downside of legalizing Kidney trade is that the majority of those selling kidneys in Iran are disproportionately poor. 
2. Opponents argue that the donation of a kidney is permanent.
3. Iranian system insist that the systemis not as perfect as it seems. 
4. There is evidence to suggest Iran’s system has not cleared its waiting list and that trading between socioeconomic classes is a substantial problem. 
5. Critics of the Iran model would argue that even this well developed system has major flaws and that a ban on payment to kidney donation should be maintained in other parts of the world.

A possible compromise
1. A non-monetary reward system. For instance, patients who have previously agreed to be on the transplant list could receive priority health care.

2. It has also been suggested that governments should control the monetary aspects of the transactions rather than payment passing directly from individual to individual. The donor would effectively sell their organ to the state which would then allocate it on the basis of clinical need. By making the process more medically transparent, it may placate to some degree those who accuse pro-monetary transplantation advocates of disregarding the exploitation of the poor by the rich. It is also likely that a ‘fair’ standard price could be set to prevent those in desperate financial need from being even further exploited. 

As the pressure of demand for organs continues to increase rapidly, the idea of financial compensation for kidney donation will continue to rise. 

Griffin A. Kidneys on Demand. BMJ. 2007;334:502–505.
Ghods AJ, Savaj S. Iranian Model of Paid and Regulated Living-Unrelated Kidney Donation. Clin J Am Soc Nephrol. 2006;1:1136–1145.

Ardavan Mashhadian D.O.
1400 S Grand Ave Suite 615, Los Angeles, CA 90015
(213) 537-0328

Sunday, December 16, 2012

Erectile Dysfunction in Chronic Kidney Disease Patients
Sexual dysfunction is very common in patients with chronic kidney disease. Kidney disease can cause chemical changes in the body affecting circulation, nerve function, hormones and energy level. The condition has been found to be significantly more common in men and women with chronic kidney disease (CKD) than in the general population. Approximately 50% of male predialysis CKD patients and 80% of male dialysis patients have erectile dysfunction. Multiple factors contribute to the frequent occurrence of sexual dysfunction in CKD patients, including hormonal disturbances such as hyperprolactinemia, hypogonadism in males.

Causes of erectile dysfunction in chronic kidney disease:
1. Diabetes 
2. High Blood pressure
3. Men with renal disease may find their hormone levels changing
4. Side effect of medicines, particularly those taken to control blood pressure
5. Symptoms such as breath and body odor, weight gain or unusual facial or body hair may be present
6. A man on hemodialysis may feel self conscious about how his vascular access site looks and feels
7. Men on peritoneal dialysis may worry about the size of their abdomens
8. Some men with kidney disease are afraid sexual activity may be harmful to their condition or harmful to their partners. 
9. Anemia due to kidney disease
10. Chronic kidney disease mineral and bone disorder

Treatment must start with determining and treating the underlying causes. Honest evaluation of alcohol, tobacco, and recreational drugs is essential. Assessment of emotional life, i.e. how well the patient gets along with his partner is vital. He may benefit from a referral to a psychotherapist, or the couple may be advised to seek marriage guidance. For men in whom vascular problem appears to predominate: Doppler studies, pharmacocavernosometry, pharmacocavernosography, dynamic infusion studies, and colour Doppler response studies may be helpful. 

Once erectile dysfunction is diagnosed and psychosexual component is ruled out a review of the drugs, haemoglobulin levels and dialysis adequacy should be corrected. They should have hormonal studies, including testosterone, LH, FSH, and prolactin. Correction of these hormones may not necessarily restore libido. The use of testosterone injections have shown only a small and variable response in erectile function. Using clomiphene in uraemic males may correct the androgen deficiency and increase the sense of well‐being, libido, and potency, similarly to testosterone administration; however, its long‐term use in uraemia is inconclusive.  To treat erectile dysfunction, bromocriptine in doses of 2.5–5 mg has been shown to improve libido and potency; the mechanism, however, remains unclear and it is possible that bromocriptine may influence potency directly as a result of its dopaminergic properties.

Treatment of erectile dysfunction in chronic kidney disease:
1. Your doctor can perform blood work to determine if your lack of interest in sex is due to your changing hormone levels. He may prescribe medicine to bring your levels to a normal range.
2. Talk to your doctor about the blood pressure medications you are taking if you are experiencing impotence. 
3. Phosphodiesterase-5 inhibitors (PDE5i) such as viagra compared with placebo significantly increases sexual performance.
4. Oral zinc supplementation results in a significant increase in plasma testosterone concentration along with an increase in the potency and frequency of intercourse. 
5. Only sparse data are available for vitamin E, bromocriptine, and dihydroxycholecalciferol in CKD patients and no trials assessed intracavernous injections, transurethral injections, mechanical devices, or behavioral therapy in CKD. 

Therapies that have been used to treat sexual dysfunction include phosphodiesterase-5 inhibitors (PDE5i), intracavernosal injections, intraurethral suppositories, hormonal therapy, mechanical devices, and psychotherapy.
Studies have also identified significant associations between sexual dysfunction in chronic kidney disease patients and depression, impaired quality of life, and adverse cardiovascular outcomes. Effective treatment of sexual dysfunction in CKD patients may therefore potentially lead to improvement in these patient-level outcome. There are now many new assessment techniques and treatments. There are encouraging reports in the use of phosphodiestrase 5‐inhibitors use in patients with CKD. A greater awareness of this common problem should be encouraged so that patients and their partners do not feel embarrassed about broaching this subject with their physicians. Although renal transplant may effectively reverse many of the hormonal and psychological changes of chronic renal failure, many patients will remain on a transplant waiting list for a considerable length of time. Patients who develop significant vascular disease may still remain impotent even after a successful transplant.


Ardavan Mashhadian D.O.
1400 S Grand Ave Suite 615, Los Angeles, CA 90015
(213) 537-0328