Notes on the risks and benefits of kidney donation

post by Derek Shiller · 2021-11-26T15:02:57.540Z · EA · GW · 7 comments

Contents

      Summary: The possible risks of kidney donation to the donor seem somewhat greater and the benefits to the recipient somewhat lesser than is generally conveyed in donation literature.
  Risks
  Benefits
    References
None
7 comments

*edit: formatting changes for accessibility and added summary

Summary: The possible risks of kidney donation to the donor seem somewhat greater and the benefits to the recipient somewhat lesser than is generally conveyed in donation literature.

I considered donating a kidney two years ago. I went through the workup to get approval while simultaneously reading about it. Covid hit, and I put off a decision. I had some significant concerns which have prevented me from returning to the idea with enthusiasm. Since this is a decision others here have considered, I thought I'd share my takeaways here.

Donating a kidney is not a particularly effective compared with the other great opportunities available these days. Still, there may be good reasons to do it. It is helpful in a straightforward way; it isn't filtered through the administration of a charity or dependent on the speculative efficacy of an intervention. It is an option available to those who don't have good ways to use their time for other ends. It may serve as a lifelong reminder of one's commitment, perhaps solidifying one's identity as an altruist in a way that protects against value drift. Further, it is a signal of altruistic sincerity that most people will acknowledge. If you're into cause areas perceived as weird, like insect suffering or AI, making a transparently altruistic sacrifice might lead people to take your more eclectic interests more seriously.

These other considerations aside, the effectiveness of kidney donation turns on the value it provides the recipient and the cost to yourself. As far as I can tell (and I am no expert on these issues), the cost to yourself is not perfectly understood. The value to the recipient seems to be significant but not overwhelming in comparison to the risks. I suspect my comments come across as negative about donation. I think it is a net positive thing to do, but the risks and benefits should be acknowledged. Once I looked into it myself I felt misled by a lot of the pro-donation marketing.

Risks

Benefits

References

Bosch, Juan P, Anna Saccaggi, Allan Lauer, Claudio Ronco, Mario Belledonne, and Sheldon Glabman. 1983. “Renal Functional Reserve in Humans: Effect of Protein Intake on Glomerular Filtration Rate.” The American Journal of Medicine 75 (6). Elsevier: 943–50.

Boudville, Neil, GV Ramesh Prasad, Greg Knoll, Norman Muirhead, Heather Thiessen-Philbrook, Robert C Yang, M Patricia Rosas-Arellano, Abdulrahman Housawi, and Amit X Garg. 2006. “Meta-Analysis: Risk for Hypertension in Living Kidney Donors.” Annals of Internal Medicine 145 (3). American College of Physicians: 185–96.

Delanghe, J, JP De Slypere, M De Buyzere, J Robbrecht, R Wieme, and A Vermeulen. 1989. “Normal Reference Values for Creatine, Creatinine, and Carnitine Are Lower in Vegetarians.” Clinical Chemistry 35 (8). Oxford University Press: 1802–3.

Denic, Aleksandar, John C Lieske, Harini A Chakkera, Emilio D Poggio, Mariam P Alexander, Prince Singh, Walter K Kremers, Lilach O Lerman, and Andrew D Rule. 2017. “The Substantial Loss of Nephrons in Healthy Human Kidneys with Aging.” Journal of the American Society of Nephrology 28 (1). Am Soc Nephrol: 313–20.

Garg, Amit X, Aizhan Meirambayeva, Anjie Huang, Joseph Kim, GV Ramesh Prasad, Greg Knoll, Neil Boudville, et al. 2012. “Cardiovascular Disease in Kidney Donors: Matched Cohort Study.” Bmj 344. British Medical Journal Publishing Group: e1203.

Go, Alan S, Glenn M Chertow, Dongjie Fan, Charles E McCulloch, and Chi-yuan Hsu. 2004. “Chronic Kidney Disease and the Risks of Death, Cardiovascular Events, and Hospitalization.” New England Journal of Medicine 351 (13). Mass Medical Soc: 1296–1305.

Gorodetskaya, Irina, Stefanos Zenios, Charles E Mcculloch, Alan Bostrom, Chi-Yuan Hsu, Andrew B Bindman, Alan S Go, and Glenn M Chertow. 2005. “Health-Related Quality of Life and Estimates of Utility in Chronic Kidney Disease.” Kidney International 68 (6). Elsevier: 2801–8.

Ibrahim, Hassan N, Robert N Foley, Scott A Reule, Richard Spong, Aleksandra Kukla, Naim Issa, Danielle M Berglund, Gretchen K Sieger, and Arthur J Matas. 2016. “Renal Function Profile in White Kidney Donors: The First 4 Decades.” Journal of the American Society of Nephrology 27 (9). Am Soc Nephrol: 2885–93.

Kasiske, Bertram L, Jennie Z Ma, Thomas A Louis, and Suzanne K Swan. 1995. “Long-Term Effects of Reduced Renal Mass in Humans.” Kidney International 48 (3). Elsevier: 814–19.

Merzkani, Massini A., Aleksandar Denic, Ramya Narasimhan, Camden L. Lopez, Joseph J. Larson, Walter K. Kremers, Harini A. Chakkera, et al. 2021. “Kidney Microstructural Features at the Time of Donation Predict Long-Term Risk of Chronic Kidney Disease in Living Kidney Donors.” Mayo Clinic Proceedings 96 (1): 40–51.

Mjøen, Geir, Stein Hallan, Anders Hartmann, Aksel Foss, Karsten Midtvedt, Ole Øyen, Anna Reisæter, et al. 2014. “Long-Term Risks for Kidney Donors.” Kidney International 86 (1). Elsevier: 162–67.

Mjøen, Geir, Anna Reisaeter, Stein Hallan, Pål-Dag Line, Anders Hartmann, Karsten Midtvedt, Aksel Foss, Dag Olav Dahle, and Hallvard Holdaas. 2011. “Overall and Cardiovascular Mortality in Norwegian Kidney Donors Compared to the Background Population.” Nephrology Dialysis Transplantation 27 (1). Oxford University Press: 443–47.

Muzaale, Abimereki D, Allan B Massie, Mei-Cheng Wang, Robert A Montgomery, Maureen A McBride, Jennifer L Wainright, and Dorry L Segev. 2014. “Risk of End-Stage Renal Disease Following Live Kidney Donation.” Jama 311 (6). American Medical Association: 579–86.

Narkun-Burgess, Deborah M, Charles R Nolan, James E Norman, William F Page, Peter L Miller, and Timothy W Meyer. 1993. “Forty-Five Year Follow-up After Uninephrectomy.” Kidney International 43 (5). Elsevier: 1110–5.

  1. “Paired Exchange Results Quarterly Report.” https://www.kidneyregistry.org/pages/p508/NKR_Qtrly_RPt_Q4_2018.php.

Ramcharan, Thiagarajan, and Arthur J Matas. 2002. “Long-Term (20–37 Years) Follow-up of Living Kidney Donors.” American Journal of Transplantation 2 (10). Wiley Online Library: 959–64.

Rana A, O’Mahony C, Murthy B. 2018. “Waitlist Survival Is Approaching Survival After Kidney Transplantation.” https://atcmeetingabstracts.com/abstract/waitlist-survival-is-approaching-survival-after-kidney-transplantation/.

Shimamura, Tetsuo, and Ashton B Morrison. 1975. “A Progressive Glomerulosclerosis Occurring in Partial Five-Sixths Nephrectomized Rats.” The American Journal of Pathology 79 (1). American Society for Investigative Pathology: 95.

Von der Lippe, Nanna, Bård Waldum, Fredrik B Brekke, Amin AG Amro, Anna Varberg Reisæter, and Ingrid Os. 2014. “From Dialysis to Transplantation: A 5-Year Longitudinal Study on Self-Reported Quality of Life.” BMC Nephrology 15 (1). BioMed Central: 1–9.

Williams, Susan L, Jacqueline Oler, and Diane K Jorkasky. 1986. “Long-Term Renal Function in Kidney Donors: A Comparison of Donors and Their Siblings.” Annals of Internal Medicine 105 (1). Citeseer: 1–8.

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comment by david_reinstein · 2021-11-27T18:48:25.970Z · EA(p) · GW(p)

Maybe worth considering: would there be a way to donate a kidney in exchange for the recipient making a large donation to an effective charity?

Replies from: ElliotJDavies
comment by ElliotJDavies · 2021-11-28T15:40:41.185Z · EA(p) · GW(p)

I have started discussing with people the idea of having a "Sponsored" altruistic kidney donation. This would be much like a sponsored half-marathon or something, with money collected for AMF or another high impact charity. 

I brought the idea up at an event on fundraising we recently ran, in a room of 20+ people, 50/50 EA and non-EA, most seemed super sceptical about the idea. This could be down to how squeamish people are about the idea of kidney donations. 

I have also had people mention that this could present EA in a very extreme and unpalatable light, which is my main concern about actually doing this.

Replies from: david_reinstein
comment by david_reinstein · 2021-11-29T15:13:47.645Z · EA(p) · GW(p)

Interesting idea, I really like it. Who were going to be the donors for this event?

I really thought that the kidney recipient and their family and friends should be the ones making the donations though. The idea is to get around a gap in the market; you can't "buy a kidney".

But

  1. I don't know how legal "donate in anticipation of a kidney' is either
  2. Maybe this would squick people's 'unfairness' concerns anyway? (E.g., '1%-ers can now buy a kidney indirectly, middle class Americans cannot') ... the fact that the 1% would also be helping many more people with their donation gets lost in that conversation
Replies from: ElliotJDavies
comment by ElliotJDavies · 2021-12-01T11:10:45.193Z · EA(p) · GW(p)

Who were going to be the donors for this event?

I was mostly thinking friends and family, but I was hoping the novelty factor could spread it to local communities

I don't know how legal "donate in anticipation of a kidney' is either

Wow yeah I have  a feeling you'd get your name down in case-law either way. 

comment by ElliotJDavies · 2021-11-27T11:07:29.636Z · EA(p) · GW(p)

Interesting. Thanks for posting, as someone who has tried to research this quickly, I agree it's hard to get an accurate picture of the benefits and risks. I think the "self-signalling" is an important incentive for me to donate, but only if it's actually an action of large utility. 

Regarding the benefits of donating, I think you have probably under-sold them here. My logic is (deferring judgment to medical professions) just the amount of effort and money that is spent on facilitating kidney donations, despite the existence of dialysis, indicates that experts think the cost/benefit ration is a good one. One reason I feel safe in this deference is because the field of medicine seems to have strong "loss aversion". I.e. Doctors seem strongly concerned about direct actions that cause harm, even if it is for the greater good. 

Replies from: Derek Shiller
comment by Derek Shiller · 2021-11-27T12:53:53.704Z · EA(p) · GW(p)

My logic is (deferring judgment to medical professions) just the amount of effort and money that is spent on facilitating kidney donations, despite the existence of dialysis, indicates that experts think the cost/benefit ration is a good one. One reason I feel safe in this deference is because the field of medicine seems to have strong "loss aversion". I.e. Doctors seem strongly concerned about direct actions that cause harm, even if it is for the greater good.

The cynical story I've heard is that insurance providers cover it because it is cheaper than years of dialysis and doctors provide it because it pays well. Some doctors are hesitant about it, particularly for non-directed donors, but they aren't the ones performing it.

I do think that is overly cynical: there are clear advantages to the recipient that make transplantation very desirable. Dialysis is a pain, and not without its risks. Quality of life definitely goes up. Life expectancy probably goes up a fair bit too. If I had to make a guess, I'd guess donation produced something like 3-8 QALYs on average for the primary beneficiary, at a cost of about .5 QALYs for the donor. That is a pretty reasonable altruistic trade, but it isn't saving a life at the cost of a surgery and a few weeks recovery.

Replies from: ElliotJDavies
comment by ElliotJDavies · 2021-11-28T15:27:36.072Z · EA(p) · GW(p)

The cynical story I've heard is that insurance providers cover it because it is cheaper than years of dialysis and doctors provide it because it pays well. Some doctors are hesitant about it, particularly for non-directed donors, but they aren't the ones performing it.

While that's certainly a possibility, some evidence against that perspective is that many countries (UK, DK off the top of my head) have introduced altruistic/non-direct kidney donation in the last decade. 

Interestingly, I think the Danish Health-board may have a perspective closer to you, in that they have set the minimum age of altruistic kidney donation to 40 years old. I was a little bit frustrated when I discovered this. 

One thing I would say (again, without knowing much) in dialysis does sound intuitively a lot worse than having a transplanted kidney, because you have waste products building up in your body for days at a time.