Living donors should be used more often

EDITOR,—Celia Wight and Bernard Cohen's editorial discusses the report by the British Transplantation Society's working party on organ donation.1 2 In addition to trying to increase the donation of cadaver organs we should give much more attention to the use of living donors. The survival rates of grafts from living unrelated donors are equivalent to those of grafts of mismatched haplotype from living related donors and are superior to those of cadaver grafts in the short term.

Only 8.5% of grafts currently transplanted in Britain are from living donors (2.6 per million population); this compares unfavourably with figures from the United States (20%) and continental Europe (10%). If we were to increase live donation to the level in Norway (40%, or 17 per million population)3 the accrued overall increase in the half life of a transplanted kidney would probably be considerably higher than currently seems possible with all other procurement procedures. The use of living related donors has been an integral part of the Norwegian programme since 1969 and has increased since the introduction of cyclosporin in 1983.

The Norwegians base their policy on the principle that unilateral nephrectomy is not harmful to a healthy person. They have performed over 1200 living nephrectomies, and no donor has died. Two donors have developed uraemia requiring a transplant; this occurred 12 and 15 years after nephrectomy. The programme accepts healthy elderly donors, and, though it accepts all relatives (and, since 1985, spouses), it does not accept altruistic donations that it believes are beyond the fringe of medical ethics.

Britain has always concentrated heavily on cadaver transplantation, and it is interesting that the big transplant units have the lowest rates of live donation. I suspect that having a busy cadaver programme leads to complacency about accepting living donors.

Donation from living unrelated donors is more contentious. In Britain it is prohibited except by special permission. An acceptable example would be donation from a husband to his wife, where the motive is based on the emotional ties of both parties.

Transplantation of organs from living related donors is one of the few ways in which we have an opportunity to increase the number of transplants. The message is clear: such transplantation is achievable, is socially acceptable, and has minimum morbidity. Furthermore, it provides an opportunity to bridge the gap between the increasing waiting list and the number of grafts currently available.