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Purpose of Review: Living donation has a tremendous impact in bridging the gap between the shortage of organs and the growing list of transplant candidates but remains underutilized as a percentage of total transplants performed. This review focuses on obesity and social determinants of health as potential barriers to the expansion of living kidney donation., Recent Findings: The growing rate of obesity and associated metabolic syndrome make many potential donors unacceptable as donor candidates because of the future risk for developing chronic health conditions, such as hypertension and diabetes. There is also increasing evidence demonstrating socioeconomic differences and racial disparities potentially limit access to living donation in certain populations. These potentially modifiable factors are not exclusive of each other and together serve as significant contributing factors to lower rates of living donation., Summary: Living donors make sacrifices to provide the gift of life to transplant recipients, despite the potential risks to their own health. Studies describing risk factors to living donation call attention to the overall need for more action to prioritize and promote the health and well being of living donors.

Purpose of Review: As experience grows, living donor liver transplantation (LDLT) has become an effective treatment option to overcome the deceased donor organ shortage., Recent Findings: Donor safety is the highest priority in LDLT. Strict donor selection according to structured protocols and center experience are the main factors that determine donor safety. However, with increased experience, many centers have explored increasing organ availability within living donation by means of ABO incompatible LDLT, dual graft LDLT, and anonymous living donation. Also, this growing experience in LDLT has allowed the transplant community to cautiously explore the role of liver transplantation for hepatocellular carcinoma outside of Milan criteria and patients with unresectable colorectal liver metastases., Summary: LDLT has become established as a viable strategy to ameliorate the organ shortage experienced by centers around the world. Improved understanding of this technique has allowed the improved utilization of live donor graft resources, without compromising donor safety. Moreover, LDLT may offer some advantages over deceased donor liver transplantation and a unique opportunity to assess the broader applicability of liver transplantation.

Purpose of Review: Many institutions have started or are planning to start a purely laparoscopic right hepatectomy (PLRH) for adult living donor recipients but the experience is relatively very limited. The present review will look at the current status of PLRH and go over some of the technical details important for a safe operation. Necessary elements and different strategies to start a safe and reproducible PLRH program will be discussed., Recent Findings: Several publications with a relatively large number of cases have been published in the last few years. The initial results of PLRH seem to be comparable to open donor hepatectomy when performed by surgeons with sufficient expertise laparoscopic and donor hepatectomy., Summary: With the ongoing accumulation of experience in laparoscopic liver surgery and living donor liver transplantation, it is most likely that PLRH will be performed more widely than the present time. Institutions should implement a step-by-step approach with proctorship, standardization of surgical procedures and a balanced selection criterion for donors for a safe transition from open method to a PLRH program.

Purpose of Review: With an increasing demand for donor organs, strategies to increase the number of available donor organs have become more focused. Compensating donors for donation is one strategy proposed to increase the availability of organs for transplant. This has been implemented in several systems internationally, but debate continues in the United States with respect to appropriate strategies. The National Organ Transplant Act (NOTA) currently prohibits the transfer of any human organ 'for valuable consideration' for transplantation, but allows for the removal of financial disincentives., Recent Findings: Several proposals currently exist for compensating patients for living donation. Recent data have focused on studying and creating mechanisms for reimbursement of costs incurred as part of the donation process, which is related to the removal of disincentives to living donation. Others have advocated for the provision of actual incentives to patients for the act of donating, in an attempt to further expand living donation. The current debate focuses on what measures can reasonably be taken to increase donation, and whether additional incentives will encourage more donation or reduce the motivation for altruistic donation., Summary: Currently, the transplant community broadly supports the removal of disincentives for living donors, including reimbursement of expenses for travel, housing and lost wages incurred during evaluation, surgery and after care. Others have advocated for financial incentives to further increase the number of donor organs available for transplant. Although the removal of disincentives is currently allowed under the existing legal structure of NOTA, providing financial incentives for living donation would require further evaluation of the economics, law, ethics and public readiness for a significant policy shift.

Purpose of Review: This article reviews current strategies for living-donor organ procurement in liver, kidney, pancreas, and intestinal transplant., Recent Findings: Here we summarize current open and laparoscopic approaches to living donation of abdominal organs., Summary: Living donation strategies expand the organ pool in the setting of a significant organ shortage.

Purpose of Review: Recipient sensitization to a wide variety of human leukocyte antigens (HLA) represents a major barrier to transplantation. We discuss the options for the challenging group of broadly sensitized kidney transplant candidates., Recent Findings: Transplantation by way of kidney-paired donation (KPD) represents a preferable way to bypass immunological barriers. Recent data suggest that KPD programs can be optimized by the use of innovative serological techniques to define unacceptable HLA antigens, inclusion of altruistic donors or altruistic balanced paired kidney exchange, and complementary recipient desensitization. It has become evident that plasmapheresis and/or intravenous immunoglobulin (IVIG)-based crossmatch conversion may not completely prevent rejection and chronic injury. However, recent evidence suggests major improvements by sophisticated serological risk stratification and new innovative treatment principles. Wait-listed broadly sensitized patients were shown to benefit from specific allocation programs, such as priority allocation of organs via the Eurotransplant acceptable mismatch program. Recent studies have suggested a benefit from IVIG/rituximab-based desensitization on the waitlist, or apheresis-based protocols for rapid antibody removal immediately before transplantation., Summary: A multifaceted repertoire of complementary strategies was shown to facilitate successful live and deceased donor kidney transplantation in high-risk patients. Recent promising developments can be expected to significantly improve outcomes.

Purpose of Review: Kidney paired donation (KPD) has become a viable option for patients in need of a kidney transplant who have a willing, but incompatible living donor. The purpose of this review is to highlight the recent advances in KPD including shipping live-donor kidneys to their intended recipient, enrolling compatible pairs, and combining KPD with desensitization., Recent Findings: KPD has been expanded and facilitated by multiple organizations. KPD chains have been extended from single-center two-way 'swaps' to transcontinental KPD chains in which living-donor organs have been shipped without compromising outcomes. Living-donor kidneys have been shipped transcontinentally on commercial airlines with great success. Enrollment of compatible donor--recipient pairs, particularly those with blood group O donors, is one strategy that has been employed to extend KPD to even more patients. It has also become more apparent that KPD can be successfully combined with desensitization in order to transplant our most immunologically challenging patients., Summary: KPD is becoming an established method of transplantation at transplant centers throughout the world. Advancements have been made through shipping living-donor kidneys, combining KPD with desensitization, and enrolling compatible pairs.

Purpose of Review: Many sensitized patients have willing live donors but are unable to use them because of a human leukocyte antigen (HLA) incompatibility. The options for these patients include: remaining on the deceased-donor list, entering a kidney-paired donation scheme, or undergoing desensitization with high-dose IVIg or plasmapheresis and low-dose IVIg., Recent Findings: Mathematical simulations verified by actual data from several national kidney-paired donation (KPD) programs has shed light on which donor/recipient phenotypes are likely to benefit from each transplant modality. Pairs that are easy to match are likely to receive compatible kidneys in a KPD. Those who are hard to match may be better served by desensitization. The phenotype which is both hard to match and hard to desensitize due to board and strong HLA reactivity are most likely to be transplanted by a hybrid modality utilizing desensitization after identifying a more immunologically favorable donor in a KPD., Summary: Recent outcomes from desensitization in which starting donor-specific antibody strength is low have been very good. For broadly sensitized patients with a high-strength cross-match, searching for a better donor in a KPD pool can facilitate a safer, less expensive, and more successful desensitization treatment course.

Purpose of Review: The current era of organ shortage has necessitated expansion of the currently available organ donor pool, to increase the number of pancreases available for transplant. This review summarizes the cumulative efforts of various centers in making this possible., Recent Findings: Various centers are consistently reporting their experience with marginal donors; recent additions to the cohort have been increase in pancreases from donors after cardiac death (controlled and uncontrolled), update on long-term outcomes of live pancreas donors, as well as efforts at objectively assessing donor risk., Summary: It has become important for the transplanting surgeon to make difficult decisions on organ suitability and appropriateness depending upon the recipient's status. Further more, limiting further damage to these vulnerable grafts is important in improving utilization as well as successful transplantation.

Purpose of Review: The widening gap between the growing number of liver transplant candidates and the supply of deceased donor organs became a strong motivation for the development of living donor liver transplantation (LDLT). LDLT has gone through its developmental phase and become an established life-saving procedure., Recent Findings: Despite the challenging nature of the technique of LDLT, there have been continuous innovations. A better understanding of complex surgical anatomy and physiologic differences of partial hepatic allografts has helped to avoid graft congestion, small-for-size syndrome, or graft hypoperfusion from portal flow steal. LDLT for patients with high Model for End-Stage Liver Disease score can achieve comparable results with deceased donor liver transplantation (DDLT). Size limitation of partial grafts can be overcome with dual grafts. The extended application of LDLT for hepatocellular carcinoma beyond Milan criteria seems feasible but at the cost of slightly compromised survival. More information has become available for prospective donors about the consequences of living liver donation in terms of psychosocial impact., Summary: Although LDLT is still evolving, it has become the most effective alternative to DDLT. Proven or potential benefit of LDLT include the superior quality of the allograft despite the smaller size, selection of proper timing for transplantation and a reduced waiting time, which prevents waiting list mortality.

Purpose of Review: To analyze the current status of living donor intestinal transplantation (LDIT) as a treatment option for intestinal failure., Recent Findings: Long-term outcomes from LDIT and combined living donor intestinal/liver transplantation (CLDILT) are comparable with those from transplantation using deceased donors. In certain life-threatening situations, especially in pediatric patients, this strategy may offer potential advantages., Summary: According United Network for Organ Sharing (UNOS) data children with intestinal failure affected by liver disease secondary to parenteral nutrition have the highest mortality on a waiting list compared with all candidates for solid organ transplantation. Elective nature of CLDILT offers multiple advantages for this patient population. LDIT also could be life-saving option for patients with intestinal failure who run out of venous access. Optimal timing, short ischemia time and good human leukocyte antigen (HLA) matching may contribute to lower postoperative complications. Current literature suggests that living intestinal donors experience very low morbidity and high level of satisfaction.

Purpose of Review: To summarize recent practices and views regarding children as living organ donors in the USA., Recent Findings: Living donors have become an increasingly important source of organs for transplantation. Concern for the rights of donors has resulted in reconsideration of the use of minors as living organ donors. Most commentators have voiced concerns that minors deserve extraordinary protection, but are unwilling to ban the practice of living donation by minors outright. Instead, factors to be considered in individual situations have been enumerated, and safeguards recommended. These same safeguards have also been recommended to be extended to adults, as attainment of legal age does not in itself confer immunity from exploitation. Developmental factors of importance include brain maturation affecting decision making, executive function and impulse control; the dependent status of minors, usually on the persons who may most want them to be donors; youthful idealism and sense of invulnerability; and incomplete identity formation., Summary: Fewer children in the USA have become living donors in the past decade. Preadolescent children in particular should probably be considered as potential donors only in extraordinary circumstances. Safeguards protect not only children, but transplant physicians, programs and the image of the transplant endeavor.

Purpose of Review: The scarcity of suitable donor organs continues to limit lung transplantation, resulting in long waiting times and significant mortality for those patients listed for transplant. Strategies to expand the donor pool can substantially lift donor lung utilization rates from historically low levels of less than 20% to rates greater than 50%. This article reviews recent developments in the selection, assessment and management of the potential lung donor that aim to increase donor organ use., Recent Findings: Close adherence to the originally published lung transplant donor acceptability criteria has historically restricted the number of donor lungs available for transplant. Important advances that aim to increase donor lung utilization include the use of donation after cardiac death lungs, cut-down lungs and expanded criteria lungs. Emerging diagnostic tools that predict how donor lungs will function after transplant are likely to facilitate selection of appropriate donor lungs significantly in the future., Summary: Optimal donor management should aim to maximize lung donation through aggressive donor management and consideration of the complete and expanded donor pool. However, long-term studies are required to validate such an approach and to confirm that long-term outcomes are not being compromised by the use of both traditional and nontraditional organ donors.

Purpose of Review: The number of organs available for the patients on the transplant waitlist remains at a disproportionate low. All possible methods to curtail this shortage, including providing donors with incentives, have been proposed. This article reviews recent publications addressing the benefits and risks involved in incentivizing living donation., Recent Findings: The debate about the ethics, feasibility, and possible models for compensating organ donors has been prominent in recent literature. As certain countries take lead on this initiative, others are cautiously weighing in on the impact implementations of such policies may have on the society, especially on the underprivileged., Summary: The shortage of organs has resulted in proposal of strategies that encroach on certain moral and ethical principles. Providing incentives to donors is one such strategy that is likely to receive a lot of attention in the next few years.

Purpose of Review: The purpose of this review is to discuss the recent events and experiences in the Philippines related to compensated kidney donation., Recent Findings: Between 2002 and 2008, the Philippine government, through the Department of Health, administered a program called the Philippine Organ Donation Program that allowed prospective kidney providers to sign up, be allocated to prospective recipients and receive gratuities for their kidney. Transplant tourism flourished during this period because of rampant disregard for the regulation limiting foreign recipients to 10% of total kidney transplants. There is evidence of inadequate donor care. Efforts to curb the problem included a ban on foreigners coming to the Philippines to have kidney transplants with Filipinos as donors as well as strengthening of the implementing rules and regulations of both the antihuman trafficking law and the organ donation law that allowed donation after brain death., Summary: The experience in the Philippines mirrored those in India and Pakistan where paid donors reported poor outcomes. An effective national kidney disease prevention program and the deceased donor program for transplantation should be aggressively promoted. Legislation against transplant commercialism is needed.

Purpose of Review: Several factors have generated interest in proposals to offer incentives in exchange for kidneys from living donors, including the growing shortage of available organs, the apparent asymptote of traditional means of organ procurement, and the intimate link between the inadequacies of organ procurement policies in developed countries with the flourishing of underground organ trafficking in developing countries., Recent Findings: Herein, we review the scope and dimensions of the growing shortage of organs in the United States, with attention to how each of the proposed solutions to same has proven insufficient. With special attention to the concerns leveled by Gabriel Danovitch in his 'Open Letter,' we conclude that each of his concerns are unfounded, and offer a prospectus on how a trial of such systems might be pursued in the United States., Summary: The failure of current approaches to organ procurement in the United States and other developed countries has led to unnecessary suffering and death, with morally unacceptable consequences for developing countries. For these reasons, a structured trial of incentives for organ procurement in the United States is a moral imperative.

Purpose of Review: 'Global transplant commercialism' (practices and policies involving international trade in organs from living vendors, e.g., 'transplant tourism') is currently subjected to unprecedented criticism. In parallel, the debate around 'local transplant commercialism' (practices and policies that confine trade in organs from living vendors to national markets or economic unions) is heating up. In an attempt to assess the potential outcomes of these trends, this article reviews and discusses some sociological and ethical issues, ending with a proposal for a reinvigorated anticommercialist strategy., Recent Findings: The current international campaign against global transplant commercialism is conducted by an ad hoc alliance between strange bedfellows, proponents of local transplant commercialism on the one hand and opponents of any transplant commercialism on the other. Disparities in the rigor of the respective ethical discourses, the expanding list of precedents of legitimized commerce in the human body, and the political economy of transplantation, all suggest that the former have the upper hand., Summary: Recent achievements in the struggle against international organ trafficking may not herald the abolition of transplant commercialism but rather presage its reconfiguration in deglobalized forms. In light of such a prospect, those who wish to prevent the pervasive commodification of the human body from entering the gates of transplant medicine should consider devising a new, perhaps more radical, strategy.

Purpose of Review: Organ trafficking, transplant tourism and transplant commercialism are now defined by the Declaration of Istanbul; the Declaration provides principles of practice based on those definitions. Organ trafficking and transplant tourism should be prohibited because they violate the principles of equity, justice and respect for human dignity., Recent Findings: This report provides a country-by-country description of current events that may effect the practice of transplantation internationally for the foreseeable future., Summary: The implications of the Istanbul Declaration are profound. It calls for a legal and professional framework in each country to govern organ donation and transplantation activities. It calls for a transparent regulatory oversight system that ensures donor and recipient safety and enforces the prohibitions of unethical practices. Governments should ensure the provision of care and follow-up of living donors be no less than the care and attention provided for transplants recipients.

Purpose of Review: Paid living unrelated kidney donor transplantation has flourished in Pakistan and Iran. This review discusses the dynamics and consequences of organ trade in Pakistan and of a regulated paid donor model in Iran on transplant activities in these countries., Recent Findings: In 2007, over 2500 renal transplants were performed in Pakistan, where more than 70% were from socioeconomic disadvantaged kidney vendors. More than half of recipients were foreigners who paid US$20,000-30,000. Recipients of vendor kidneys had poor outcome and high infectious complications. Regulated paid donor kidney transplant in Iran number around 1500 per year and constitute 70% of the total transplants. Graft survival rates are similar to those for living related donors. The donors are paid US$1200 and additional monies are negotiated between the recipient-donor pair. This model claims to have abolished waiting lists, although many poor patients wait for deceased donors. In both countries, recipients are relatively rich and vendors are the poor of the society who sell kidneys for quick money or to repay debts., Summary: Paid donation, regulated or commercial, leads to coercion and exploitation of the poor and benefits the rich. This situation has forestalled deceased donor program and hence other solid-organ transplants. The way forward is to promote deceased donors by making transplant available to all who need it.

Purpose of Review: To consider proposals to use financial incentives for organ donors that have become a subject of intense controversy in both lay and medical press (in contradistinction to the removal of financial disincentives, which is essentially noncontroversial although typically not practiced)., Recent Findings: In a concerned response to the shortage of organs the office of Senator Specter of Pennsylvania has been the source of a proposal to amend the 1984 United States National Organ Transplant Act, which has been interpreted to prohibit such incentives. The proposal would permit various forms of financial incentives for donation to no longer be prohibited., Summary: The amendment would have unintentional negative consequences that could undermine, rather than strengthen, the national and international organ transplant endeavor. These concerns are considered in my personal correspondence to Senator Specter's office on which the text is based.

Purpose of Review: To explore the scope and implications of emerging global problem of transplant tourism, a practice in which patients seek transplant services (most commonly kidney allografts) in countries other than their permanent residence. Potential remedies that must be implemented if abuses are to be curbed are also offered., Recent Findings: Although traveling abroad for medical services may not be problematic from a number of perspectives, what makes transplant tourism so troubling is its link with organ trafficking and transplant commercialism. Unlike many illegal markets, however, this one is driven by the need of patients with irreversible kidney failure, who, along with kidney vendors, are the most vulnerable participants in the process in terms of medical and financial outcomes., Summary: This review explores the scope and implications of transplant tourism, and offers potential remedies that must be implemented if abuses are to be curbed.

Purpose of Review: The organ shortage is the major problem in kidney transplantation today. Despite aggressive organ procurement efforts, the supply of donated kidneys, living and deceased, has not matched the growing demand; as a consequence, more and more qualified candidates are suffering on dialysis and then dying before being transplanted. Herein, we provide justification for a regulated system of compensation for donation., Recent Findings: The main argument in favor of compensation is simple-financial incentives will increase donation, so fewer transplant candidates will suffer and die while waiting. In addition, development of a regulated system of compensation is the most effective means of crippling the core economic support for transplant tourism. Because dialysis is so much more expensive than a transplant, compensated donation could be cost-neutral to the healthcare system. Importantly, opinion polls suggest that the public would support compensation. As uncompensated kidney donation is widely accepted, persuasive arguments against compensation must explain why such a system would be morally distinguishable from uncompensated donation., Summary: We suggest that the potential advantages of a regulated system of compensation for donation far outweigh any potential disadvantages. It is time to advocate for a change in the law so that trials can be done.

Purpose of Review: There is an ongoing vigorous debate regarding the wisdom of the current prohibition of organ sales in the United States. We argue that this prohibition must remain in place. We discuss the current international realities regarding organ vending in order to show that even a so-called 'regulated' market brings with it danger to the welfare of transplant donors, their recipients, and potential recipients of nonrenal organs. We counter the specific arguments made in favor of organ sales while recommending multiple measures that can serve to remove disincentives to noncommercial organ donation. We encourage the investment in innovative healthy transplant practice for the benefit of all., Recent Findings: In 'natural experiments' performed in developing countries the outcome for kidney vendors, in terms of both their medical and psychosocial health, has been shown to be poor. A high incidence of serious infections has been reported in recipients of vended organs., Summary: Commercialization of living kidney donation does not serve the interests of the donors, endangers the health of recipients, and undermines the healthy development of the international transplant endeavor.