Allowing Altruistic Donors to be Altruistic

If you were embarking on a search to find and interview the healthiest individuals on the planet, speaking with kidney donors would be a great place to begin. People who have donated one of their kidneys share many traits in common. They have incredible compassion, mental strength, and are willing to undergo a major operation that carries a rare (but not zero percent) risk of complications to benefit a friend, a family member, or in some cases, a complete stranger. But even all these traits do not qualify a person to become a kidney donor.

As nephrologists, our duty in evaluating prospective kidney donors is to identify any potential health problems that may put the donor in harm's way. A prospective donor that is too young may not have accumulated the chance to develop certain diseases, making donation risky. A donor that is too old may carry excessive surgical risks, making the donation procedure unsafe. An intensive search for malignancy and transmissible diseases is required because of the risk to the donor and the potential recipient. Any history of kidney problems, including microalbuminuria, proteinura, a family history of kidney disease, and recurrent kidney stones, precludes kidney donation. A myriad of other considerations are also made by the transplant team, including a careful psychiatric evaluation of the donor and a number of blood tests, evaluating for ABO compatibility and HLA matching, which lead to possibilities of direct donation, paired exchange, or transplant chains outlined in this blog post.

Unfortunately, there is one risk whose occurrence is difficult to predict and whose impact is impossible to quantify: loss of health insurance. Described in this New York times article is the case of a father who donated his kidney to his daughter who had lost her renal function in the face of lupus nephritis. While he gained the chance to make an impact in his daughter's life, he lost his health and life insurance despite appeals from his nephrologist stating that his remaining kidney was healthy.

The Affordable Care Act recently upheld by the Supreme Court will protect people from being denied health insurance because of pre-existing conditions beginning in 2014. However, it will not prevent insurance companies from raising premiums on patients they consider higher risk, which may include kidney donors despite numerous prospective studies with long-term follow-up attesting to the safety of undergoing a uninephrectomy.

It is not clear how we can accurately assess the risk of insurance loss or rise in premiums for prospective donors, but one thing is clear. We need to allow altruistic donors to be altruistic.

Posted by Karandeep Singh