Kidneys wanted

The number of people around the world on renal replacement therapy is growing, fuelled by the rising tide of diabetes and hypertension. According to the authors of this week’s clinical review, the current global figure, 1.4 million, is increasing by 8% a year (doi:10.1136/bmj.d7300). Transplantation is the best option, they conclude, both for the patient and for healthcare budgets, and the good news is that rates of transplantation are going up and the number of people waiting for kidneys has fallen.

Still, about 7000 people are currently waiting for kidneys in the UK, and each year 300 of them will die waiting. As for the kidneys, not all are equal. As the clinical review explains, the best outcomes, in terms of how quickly a new kidney starts working and how long it lasts, are reported from pre-emptive transplantation (before dialysis becomes necessary) using a kidney from a living donor. These kidneys come mostly from donors who are either genetically or emotionally linked to the recipient. And because this link doesn’t guarantee that the kidney will be compatible, a range of creative schemes is now in place that brings together two or more donor-recipient pairs—the donor donates a kidney to the pool and their relative or friend receives a different, more compatible one.

The altruism of such an exchange is softened by the emotional ties of kinship or friendship. What, then, might prompt someone to a starker altruism: donation of a kidney to a stranger? The first such exchange in the UK took place in 2007, and “living non-directed altruistic kidney donation” now accounts for 3% of this country’s living donor kidney transplants. Last week saw the launch of a new charity campaign, Give a Kidney: One’s Enough (www.giveakidney.org), which aims to push this contribution up. The BMJ must declare an interest: the campaign has been chaired by our News editor, Annabel Ferriman, who wrote about her experience of donating a kidney to a friend (BMJ 2008;336:1374).

How should doctors respond to this small but growing trend? Should they actively encourage their patients to give a kidney, just as they might encourage them to give blood? Walter Glannon thinks not (doi:10.1136/bmj.d7179). It’s unethical, he says, because it contravenes the doctor’s primary obligation to protect their patients from harm. The risks are small compared with other surgical procedures, but they are not zero. One in 3000 donors will die, the figures suggest, and one in 10 will have some form of perioperative or postoperative complication. Antonia Cronin makes a good attempt at arguing the other side of this head to head debate (doi:10.1136/bmj.d7140). Who could disagree with her closing words: “if something is not wrong to do but actually a good thing, then it cannot be wrong to encourage the doing of it.” But I am with Glannon when he says that it would be “ethically objectionable,” or at the very least uncomfortable, for the doctor to initiate such a discussion. Tell us what you think on bmj.com.