Now, before you make a formal complaint, you’re absolutely right: this question would not hold water as a standardized board-level MCQ! There’s more than one correct answer. It’s controversial. And it’s perhaps not a direct test of the knowledge you’ve worked to acquire over the course of Living Kidney Donor Case Challenge.
However, every response from A through D is a real-life comment from a real-life nephrologist in an equivalent clinical scenario. So the range of responses from our #LKDCC community is not at all surprising. And if you chose E, don’t worry!
By following the whole week of #LKDCC, you’ve gained an insight into the available evidence regarding risks to kidney donor candidates. You’ve learnt about the risks of ESKD, proteinuria and pre-eclampsia. You’ve pondered the potential contribution of body composition, ethnic background, family history, dysglycaemia and age to these risks. You can confidently explain the ‘known knowns’ to would-be kidney donors. And hopefully you recognise the ‘known unknowns’ as well: the current gaps in evidence that are equally important to discuss with donors, but partly explain why there is such diversity between nephrologist attitudes in this field. We all - doctors and patients - weigh unquantifiable risk differently: some are more conservative, others more adventurous.
So what does this mean for Helen? Helen is a motivated donor candidate with some risk factors for future metabolic and cardiovascular disease, including elevated BMI and family history. It’s essential that these are addressed in the informed consent process as we counsel Helen. We should explain to Helen how lifestyle choices could reduce her future risk of diabetes, discussing the benefits of weight loss and physical activity. She is of childbearing age, and therefore our consultation should also take into account her reproductive history and the potential impact of donation on any future pregnancy.
Is it important to us, as Helen’s medical advocate, who the intended recipient is? Arguably, it is not, except perhaps to establish that Helen’s relationship with the recipient is not complicated by coercion or exploitation. Our role is to assess Helen’s medical suitability as a donor, and to ensure she understands the implications of donation. As a mother who performs peritoneal dialysis for her son every day, and wishes for a long healthy life for him, Helen brings an understandably strong motivation for donation. As a donor to her father, Helen may be aware of the potentially shorter lifespan of the donated organ, but remain motivated to relieve her father of the burden of haemodialysis, thereby improving his survival and quality of life, and, by extension, her quality of life as a daughter and carer. Given the choice, as resource allocators, we would prefer to see Helen's kidney give benefit to a younger recipient - perhaps that explains why 43.5% of the #LKDCC team chose Option A. Similarly, if there were an alternative choice of donor, such as Helen's mother, whose lifetime risk may be lower than 37 year-old Helen, that risk differential should be clearly outlined in counselling Helen and her family. Ultimately, when it comes to risk-benefit analysis in living kidney donation, there are no measurable medical benefits. The potential benefits are all psychosocial, and therefore only truly definable by each individual donor, after thorough counselling.
Living kidney donors don’t need paternalistic protection from unquantifiable long-term risks. They need our guidance, in providing them with all the available information to make a reasoned decision, while continuing the research required to expand the evidence base. They need our advocacy, firmly representing their individual needs in the multi-pronged transplant process. And they need our support to undertake a risk-benefit analysis that is truly unique across all of medicine.
