Demystifying Medicine One Month at a Time

Tag: living donors

The Gift that Kept Giving

Old guy, generous young guy and his even more generous sister. (Photo: AP)

In case you missed it, there was a heartwarming story in the news about two kidney transplant recipients.

One, a young man with an autoimmune disease that destroyed his kidneys, was lucky enough to receive the gift of a kidney from his sister.

When the new kidney started to fail from the same disease process, he was offered the chance to have it removed so that another, older patient (who did not suffer from the same disease process ) could try to benefit from it.

Charitably, both he and his sister (the original donor) accepted this plan.

It worked!

The older gentleman (who happens to be a retired surgeon) is now in good condition, off of dialysis, and feeling better than he has in years.

According to news reports, this is the first documented U.S. case of ‘kidney recycling.’

For you medical buffs, the disease in question is focal segmental glomerulosclerosis (“FSGS“). And it’s not unusual that it would harm the donated kidney-the disease process occurs independent of the origin of the kidney (i.e. even if the donated kidney had come from an unrelated donor, his FSGS would have started going to town on that one as well). According to the literature, this happens ~40% of the time.

Yet when removed from the FSGS environment, the kidney recovered function and now works well in a new recipient.

Weird science!

Xmas Spirit….or Bah! Humbug?

Are you a yoda or a grinch?

You’re in your 30s. You work hard. You strive to master your craft. You support your extended family. You are liked by both your co-workers and boss.

Problem: You unexpectedly become unhealthy–you find out your kidneys are failing.

Solution: Regular kidney dialysis can keep you alive, by filtering toxins out of your blood.

Problem: Dialysis is time consuming (>3 hours/session, 3 sessions/week) and leaves you feeling tired and weak.

Solution: Your brother, who is a tissue match, offers you the gift of a lifetime–one of his kidneys.

Problem: Because you don’t have health insurance (you are covered under the Medicaid program for your ’emergency’ dialysis only) you are deemed ineligible for the transplant surgery.

Fact: The estimated cost of dialysis is $75,000 per year. The cost of the transplant surgery and care is $100,000, with an additional $10,000/year in anti-rejection medication costs.

Fact: Research shows that transplant pays for itself vs. the cost of dialysis at four years. Beyond that point, transplant is a tremendous cost saver overall. Patients feel better and live longer with transplant, too.

Solution: Surgeons at a medical center agree to waive their fees to perform the transplant.

Problem: The hospital still won’t allow the transplant to go forward.

Solution: Your kind boss offers to pitch in for health insurance.

Problem: You are denied because your kidney disease is a ‘pre-existing’ condition.

Solution: Raise $200,000 to pay the hospital up front for the cost of the operation and any potential complications.

Any readers out there willing to step up?

You can read the full story of this patient’s plight here. Pay attention to the comments below the article to see the extremes of opinion.

The patient in question is an undocumented immigrant. His children were born here and are citizens. He meaningfully contributes to the community.

But because of his status, he’s out of luck in the sweepstakes world of health care.

I welcome your opinions on how this situation should be handled. Comment on the post or send an email.

Happy Holidays. Thanks for reading and sharing GlassHospital.

Mississippi Learning

Governor Haley Barbour of Mississippi recently suspended the life sentences of sisters Gladys and Jamie Scott on the condition that Gladys donate a kidney to her older sister Jamie, who has end-stage kidney failure and is dependent on dialysis treatment three times per week.

Gladys (36) and Jamie (38) Scott (photo: Guardian, UK)

The sisters served sixteen years of their life sentences, and had become a cause celebre in social justice circles (both the NAACP and the ACLU were involved in their petitions to overturn the sentences) for the harshness of their punishments. Their crime?

In 1994 they were convicted of being accomplices to an armed robbery that netted the main bandits $11 in cash, according to press reports.

Barbour is on record stating that he no longer felt the sisters were a danger to society. That and Jamie’s dialysis is costing the state prison system on the order of $200k per year.

In her petition for pardon, younger sister Gladys came up with the idea to donate one of her kidneys to her big sister. She was quoted as saying that she made the decision herself and would go through with it, pardon or no pardon. [The sisters were pointedly not pardoned; they merely had their sentences suspended. Their petition to seek pardons continues, with or without a transplant.]

The conditional release set off a furor in parts of the medical community, particularly the transplant and medical ethics sectors. The President of the American Society of Transplantation wrote a letter to Governor Barbour “respectfully requesting” him to de-link the kidney donation from the suspension of their sentences. The linkage gives the impression of a quid-pro-quo: “You donate your kidney, we’ll let you out of jail.” Such coercive tactics are not morally, ethically, or legally permitted in the United States, where the law of the land (NOTA, 1984) forbids commerce (or even ‘objects of value’) in exchange for organs.

I’ve thought about this story a lot; I concluded it would be fun and interesting to break down the plot and its meanings from all of the players’ perspectives:

Jamie Scott: I’m sick: Sick of being in jail for a pretty small crime, and sick from kidney disease. Did I mention sick of dialysis treatments? Verdict: Win-win: out of jail, and possibly a kidney which will be better treatment.

Gladys Scott: I’m happy to help my sister, jail or no jail. Governor wants me to donate as a condition of getting out, then so be it. I’d do it anyway. Verdict: win-win, doing a mitzvah, getting out of jail. Potential cost: donor surgery. Also, potential for re-incarceration if she doesn’t wind up donating, though pundits think that’s unlikely.

Governor Barbour: I’m letting these sisters out, which seems like the right thing. But I’m extracting the promise that one sister will donate to the other. This pleases my conservative constituencies. Verdict: win-win, he gets to placate both sides by his actions, and look fiscally prudent as well (the state will save the estimated $200k per year). The sisters promptly moved to Florida after their release, which will invoke federal and Florida money for their future health care needs.

Other patients awaiting kidney transplants: There’s hope that one day our country will increase the likelihood of someone donating to me by offering incentives to do so. Verdict: hung jury.

Other potential kidney donors: This lady got something in return for her kidney (her freedom). What will I get other than gratitude? Surely my kidney must have some market value? Maybe at least if I go through with this I could get my health care for life paid for? Verdict: double jeopardy.

The hospital where the proposed transplant may happen in the future: We’ll benefit from the media attention; we must be careful not to look like we condone the Governor’s quid-pro-quo appearing deal, and say the ‘right’ things. Verdict: win, with some downside potential.

Medical ethicists: This trade defies our current norms; there is a lot of debate in our community about compensating donors; most stakeholders remain resolutely opposed to compensating donors, though there seems to be a rising chorus of critics interested in changing these norms. Verdict: lose-lose, looking like sticks in the mud (implying that for principle Gladys should stay in jail), and having our values trampled by political (and medical/economic) opportunism.

What are your opinions on this story?


Gift of Life?

One of the joys of practicing at an academic center is that I get to do many different things in my job.

The foundation of my work is seeing my own patients in a large group (more than thirty doctors!) primary care practice.

Two months a year, I take my turn rotating on the hospital inpatient services, supervising teams of residents and students who are the primary caregivers for patients with illnesses serious enough to merit hospitalization.

I also am a classroom teacher, team-teaching the Medical Ethics course taught to all first year medical students.

My work in ethics has afforded me another interesting opportunity, one that combines teaching with medical practice:  For the past two years, I’ve been serving as our medical center’s living donor advocate physician.

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