Question index:
Questions received during this symposium have been paraphrased
and the answers submitted by the panelists are presented.

Does transplantation from an old donor to a young recipient work well?
Is a related donor better than an unrelated donor?
Are there any repercussions on the kidney donor?
What medical conditions might eliminate somebody who wants to be a living donor?
What about pancreas-kidney transplant?
To what extent is a diabetic who suffers other complications eliminated or considered for successful transplantation of the kidney? For sake of argument, I have both a son and a daughter who are both willing to donate a kidney to me.

Dr. Peters' answers
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Does transplantation from an old donor to a young recipient work well?
Dr. Peters:
The oldest donor we have done, living-donor--that's your question, living-donor? The oldest living- donor we've done is a very healthy 72-year old who actually was a physician's wife and gave a kidney to their daughter. She was in very good health, wanted to do this. There was actually some urgency to the transplant, and she did fine. And we showed, of course beforehand that she really didn't have the kidney function of most 72-year old women. She had excellent kidney function, more like a 35- or 40-year old woman. So, yes, older people can be donors. Older people can be recipients. It is unusual to find a 70-year old, however, even in good health who could be a kidney donor. There are some though.

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Is a related donor better than an unrelated donor?
Dr. Peters:
Five years ago, almost everybody doing transplantation in Canada and the States would have said yes. Today we know the answer is they are the same. Whether you are related by blood or whether it is an unrelated-living donor, the results in large populations of both kinds of kidney transplantation are essentially the same. The only difference is if you have a brother or a sister who happens to share almost all the same genes that you do, then that is just a little bit better. But in point of fact, spousal donation and transplantation in most centers today is as good as any other living-donor kind of kidney transplant.

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Are there any repercussions on the kidney donor?
Dr. Peters:
The donors generally do well. There have been rarely, thankfully, reported deaths from organ donation. They are almost always flukes of anesthetic reaction, unforseen blood clots or bleeding--things that just don't happen. I don't know how many hundreds of living donors I have done without a death, without long- term disability. In fact, as I showed you, donors and recipients in our centers now are out of the hospital in two or three days usually.

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What medical conditions might eliminate somebody who wants to be a living donor?


Dr. Peters:
I think the principle medical condition that would eliminate a person from being a living donor is any compromise of kidney function. We cannot have a living donor who has that 50 percent or 30 percent of kidney function that ultimately will go down to no kidney function. We must have living donors who have the expectation of normal kidney function all of their life.

We cannot have living donors who have had recent active cancer. We cannot have living donors who have significant high blood pressure or diabetes. Remember, most patients with high blood pressure, most patients with diabetes who are well controlled don't go on to have kidney failure. And so donors who have mild high blood pressure or donors who have mild diabetes will be accepted in many centers, but not in all. Not in all--I want to emphasize. Many centers will absolutely put the kibosh on anybody whose got even an abnormal glucose tolerance test or slightly elevated high blood pressure. We just have not because in the States there are millions of diabetics in the United States and hundreds of thousands of diabetics on dialysis. The vast majority of people with high blood pressure don't get kidney failure. Why couldn't we consider some of those as possible kidney donors?

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What about pancreas-kidney transplant?
Dr. Peters:
I believe that the majority of diabetics who have kidney failure probably do very well with a kidney transplant if the transplant option is elected. Their diabetes certainly isn't cured, and there are long-term effects of the diabetes. But in getting the kidney transplant only, they are not subjected to the potential complications of pancreas transplantation, which can be significant. Just the surgical complications are considerably greater with pancreas transplantation along with kidney than they are with kidney alone.

So it is a trade-off. There are some diabetics, a small number of them on dialysis, who really need to be considered for kidney/pancreas transplantation. Probably in my practice, that is about 5 percent of the diabetics who walk in the door. Pancreas transplantation is not just to get off insulin. Pancreas transplantation is to save vision, save extremities, and to save patients who have wide swings in their glucose. A well-controlled diabetic with stable retinal disease, stable vascular disease may be taking more of a chance with a pancreas transplant than with a kidney transplant alone.

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To what extent is a diabetic who suffers other complications eliminated or considered for successful transplantation of the kidney? For sake of argument, I have both a son and a daughter who are both willing to donate a kidney to me.
Dr. Peters:
Your question is an excellent one. It gets in to, I am sorry to say--it gets into the elements of indications for transplantation that vary from center to center. What I told you about patients with mild hypertension and diabetes as living donors is not something that is practiced worldwide. Many of my colleagues would suggest to me that we should never, ever use a person who has even the mildest form of diabetes as a kidney donor.

Most diabetics don't get renal failure. In addition, I tend to be less paternalistic in some of these decisions than others do. And so in some centers, that lady I showed you first who was a blind diabetic, would not even have gotten through the transplant door I am sorry to say. I think that we have an obligation to serve patients, not to deny service because they are blind or their diabetes is severe or other circumstances obtain. Now would we have transplanted that patient had we known she had cancer? No, we would not have done that. Would we have transplanted that patient were she to have been otherwise ill and we were certain that this transplant one way or the other would not have worked? No, we would not have done that. But we would not deny her just because she was blind.

Whether you should receive a kidney transplant from your spouse because you have children who have diabetes and they may someday need your spouses kidney is a question that might be broached at some centers. It is a question that would not be broached at our center because I would simply say, $quot;You've got renal failure. You've got a wife who has two normal kidneys. We'll fix your kidney failure with a new kidney. And I hope by the time your daughters are affected by diabetes, there is a new cure.$quot; Just like Dr. Friedman said.

One cannot impugn one's colleagues for thinking differently. I am not suggesting that I am right because I have a more liberal approach to these things than my colleagues who do not have such an approach. In fact, they may be right; I may be wrong. It is a matter of how one approaches the management of a complex disease where there is a limited resource, and that is organs.