Compassionately Logical: Part I

There are a couple of lively debates over organ trading, as suggested by an Assoc. Prof. Lee Wei Ling from the National Neuroscience Institute in a letter to the Straits Times forum, at the Kway Teow Man and nofearSingapore, where the majority of opinions have been against the sale of human organs. There seems to be some sort of instinctive revulsion towards the idea of trading human organs. The idea of regulated organ trade is fairly interesting and since I know next to nothing about the issue, so I decided to dig a little deeper. It turns out that there has been a flurry of discussion over the regulated trade of human organs.

Organ tranplant is a fairly complex issue so I decided to just look into kidney transplant since there seems to be much more information on it in general; also, there is some information on the regulated kidney trade in Iran which has been going on for some years. The following articles are quite informative, especially no. 7 to 10 which describe how the 'trade' in kidney transplants is managed in Iran.

1. Iran's market in human organs which was published on Nov 16 in the US print edition of The Economist. Sorry, it is available online only to subscribers of Economist.com and I don't want to violate copyrights on this website.
   
2. Organ transplant? which was also published in the same issue of The Economist.
3. Call to allow body organ selling, published in BBC online.
   
4. Experts warn against organ trade, published in BBC online.
5. What is a kidney worth? published in The Christian Science Monitor.
   
6. Kidney market, anyone? by Tan Hui Leng, published on Nov 24 in Today.
   
7. An organ is no different from a life-saving drug by Assoc. Prof. Lee Wei Ling, published on Feb 6 in the Straits Times forum. You can find the letter in the post by the Kway Teow Man.
   
8. Renal transplantation from living related and unrelated donors by I.Fazel ,MD, FACS.
9. Iranian Model of Paid and Regulated Living-Unrelated Kidney Donation, by Ahad J. Ghods, and Shekoufeh Savaj, published in Clin J Am Soc Nephrol 1: 1136-1145, 2006.
10. About kidney transplants in Iran, by Firooz Fassihi M.D.
11. Iran's desperate kidney traders, by Nima Sarvestani, published in BBC online.
12. Iran kidney sale, published in BBC online.
13. Organ sales 'thriving' in China, published in BBC online.
14. Flesh trade, by Stephen J. Dubner and Steven D. Levitt, published in the N.Y.Times.
    
15. Living kidney donor FAQ from the University of Maryland Medical Center.
    
16. Living donor kidney donation from the University of Pittsburgh Medical Center.
    
17. Living with one kidney from the National Kidney Foundation, Inc in the United States of America.
18. Kidney transplant from Medline Plus.
    

With all due respect to Assoc. Prof. Lee, I will like to state that she did a rather poor job of selling the case for regulated human organ trade. Then again, the thrust of her letter was not that why we should have a regulated human organ trade but how we should approach the issue ("compassionately logical" in her own words).

What is a kidney?

It's more than an ingredient in kway chap, lah. According to the Wikipedia article on the kidneys,

In anatomy, the kidneys are bean-shaped excretory organs in vertebrates. Part of the urinary system, the kidneys filter wastes (such as urea) from the blood and excrete them, along with water, as urine. The medical field that studies the kidneys and diseases affecting the kidney is called nephrology, from the Ancient Greek name for kidney; the adjective meaning "kidney-related" is renal, from Latin.

In humans, the kidneys are located in the posterior part of the abdomen. There is one on each side of the spine; the right kidney sits just below the liver, the left below the diaphragm and adjacent to the spleen. Above each kidney is an adrenal gland (also called the suprarenal gland). The asymmetry within the abdominal cavity caused by the liver results in the right kidney being slightly lower than the left one.

...

In order not to bore people with the technical detail, our kidneys are our body's built-in sewage treatment plants which clean our blood, remove its waste and send it off as urine. In our daily lives, we produce a fairly large amount of metabolic waste and they are removed from our blood by our kidneys. Generally, the greater your muscle mass and the more protein you eat, the harder your kidneys have to work to remove the nitrogeneous waste.

Most humans have two kidneys (although it should be noted that 1 in 750 individuals is born with only one) which give us a high level of redundancy. Furthermore, modern humans generally have a far more sedentary lifestyle and consume less protein compared to our hunter-gatherer ancestors, which increases the level of redundancy. It must be noted that healthy kidneys can handle a very high level of nitrogeneous waste over prolonged periods; drug-free bodybuilders have a far higher level of muscle mass, exercise more and consume much more protein but don't have a higher incidence of renal failure than the general population. Also, there are no restrictions on healthy individuals with only one kidney from doing vigorous physical sports although they are usually advised not to take part in contact sports like rugby, football, boxing, etc since there is a chance that the kidney might get physically injured. They are more vulnerable to physical injury to the kidney since the one kidney usually grows bigger to deal with its increased workload.

On the other hand, if we are on medication - a benefit of modern civilization - our kidneys have to work harder to remove it from our blood and that is a problem that our hunter-gatherer ancestors didn't have. Having two kidneys in this case is an advantage in case you ingest something you're not suppose to. For example, in the rare case, some individuals can get renal failure from just ingesting aspirin.

Renal failure

There are many causes of renal failure. I am not a medical doctor and have the vaguest knowledge of nephrology. But in general, from what I know, renal failure can result from problems in your blood circulation (like getting hypotension), damage to your kidneys (like ingesting some kind of toxins or medication that you are allergic to) and/or problems with your urinary tract (e.g. kidney stones). If you are interested, see http://en.wikipedia.org/wiki/Renal_failure.

There are several stages of renal failure, which progresses with the level of loss of function of your kidneys and increasing use of hemodialysis (aka dialysis). End-Stage Renal Failure (ESRF) is the term doctors use to mean that the kidneys are gone-case. At that stage, the patient has to be hooked up to a dialysis machine until he/she has a renal transplant. Hemodialysis is only a stop-gap measure and is also expensive. Very expensive if you have to keep having it non-stop. Once the patient has ESRF, he/she is put on a waiting list for renal transplant until he/she finds a suitable donor or dies. There are others who do not have ESRF but can receive a renal transplant provided that they have a willing donor (who is usually a family member). It should be noted that not everyone with ESRF gets to be on the waiting list. There are age limits and some health restrictions. Basically, the qualifying condition is that the transplant procedure will not endanger you and getting the transplant will significantly improve your chances of survival. The medical authorities do not see any point in giving a kidney to a 90 year-old individual with ESRF and terminal lung cancer.

Kidney transplant

There's a relevant Wikipedia article here. I am not going to reproduce the article here in any form but will mention a few points that I think are rather salient.

1. Basically, there are two types of kidney donors - living and cadavers. In any case, donors and recipients are screened for compatibility before the operation. Studies seem to indicate that "overall, recipients of kidneys from live donors do exceedingly well in comparison to deceased donors".
   
2. Transplant patients should be under 69 and have no other other conditions apart from kidney disease. Obviously, the recipient and the donor have to be evaluated to ensure that they are fit for surgery.
   
3. "Some studies seem to suggest that the longer a patient is on dialysis before the transplant, the less time the kidney will last. It is not clear why this occurs, but it underscores the need for rapid referral to a transplant program. Ideally, a kidney transplant should take place before the patient starts on dialysis (pre-emptive.)"
4. "Recent studies have indicated that kidney transplantation is a life-extending procedure. The typical patient will live 10-15 years longer with a kidney transplant than if they stay on dialysis. The years of life gained is greater for younger patients, but even 75 year-olds (the oldest group for which there is data) gain an average of 4 years of life with a kidney transplant. People generally have more energy, a less restricted diet, and fewer complications with a kidney transplant than if they stay on dialysis."
5. Acute rejection occurs in 10% to 25% of people after transplant during the first 60 days. Rejection does not mean loss of the organ, but may require additional treatment.
   
6. Recipients have to take immunosuppressants for the rest of their lives to prevent rejection, unless the kidney is from a genetic twin (or clone if you've watched the movie The Island).
   

From the University of Maryland Medical Center's FAQ, I quote:

Death from kidney donation is extremely rare (about 3 in 10,000). Donating a kidney does not change your life expectancy nor does it increase your chance of kidney failure. The health effects of kidney donation have been and continue to be carefully studied by several research groups in the United States. This research has shown that kidney donation does not appear to put donors at any increased risk for future health problems.

Illegal kidney trade in India

Illegal kidney trade is a thriving unregulated business in India. Kidney transplants from living donors are illegal if they involve any kind of commercial transactions but not much has been done by the authorities. Kidneys are mostly obtained from poor people, who are usually impoverished rural villagers and paid a sum of money, and then transplanted into rich recipients. The transaction usually involves a middleman and the entire business is carried out with the connivance of doctors in India. There is minimal or no post-operative care for the donors and some of them seem to suffer from health problems following the operation but there has been no actual study on the extent of the problem. Most of the recipients are actually locals although India is regarded as an international centre for kidney trade. Many foreigners in need of renal transplant go to India to get their kidneys.

There are several factors contributing to the growth of the illegal kidney business in India. Firstly, dialysis is expensive and the country does not have enough dialysis facilities. It is much cheaper to get a kidney transplant than go on dialysis. Secondly, enforcement is weak and the punishment for selling an organ is rather light; it is punishable by up to seven years in prison and provides a fine of Rupees 10,000, about 300 U.S. dollars. Also, there is a loophole in the law that allows donors not related to the patient to donate in extreme circumstances on "compassionate" grounds. Thirdly, there is a ready supply of of willing sellers from the impoverished rural areas. Fourthly, the supply of kidneys from cadavers is too low and the country lacks the medical expertise to perform cadaveric kidney transplants. There is no law regulating the harvesting of kidneys from brain-dead patients which further restricts the supply of kidneys from deceased donors. Fifthly, kidney transplants have a higher rate of success given the availability of more effective immunosuppressants in recent years.

For further information, see:

1. Nepal's trade of doom.
2. India Kidney trade.
3. India: A Pound of Flesh. Selling kidneys to survive.