I had the opportunity to watch a live donor kidney transplant – live! From the first incision in the donor to the last suture in the recipient, I was standing there, granted the privilege to observe after spending the summer as a kidney transplant research trainee at the University Health Network in Toronto. Throughout the day, I reflected on how so many others would be desperate to be in my position: in an operating room with a ready-to-transplant kidney. In the United States there are approximately 500,000 people living with end-stage renal disease (ESRD) in need of a kidney transplant. There are not 500,000 kidneys ready for donation, at least not for free.
The kidneys are an underrated organ. They form urine; excreting waste is just as important as ingesting nutrients. Blood pressure – the silent killer – is regulated by your kidneys. What tells your body to make more red blood cells? Your kidneys. They release the hormone erythropoietin, which signals their production. The kidneys even produce the active form of vitamin D needed by the body to increase blood calcium levels. Calcium is important for bone formation, but also for cell signaling in nerves, skeletal muscle, and the heart.
When the kidneys fail, it’s dire. Luckily, you only need one kidney, and everyone is born with two. That’s why kidney transplants from live donors are such a miraculous possibility.
Just like the organ, the transplantation itself is quite amazing, as I saw first-hand. Organ extraction for a living donor has shifted towards using a minimally invasive laparoscopic technique. I watched as the kidney was separated from donor tissues internally and pulled out through a small incision, the precious organ enclosed in a retrieval bag analogous to a fishing net. After the harvested kidney was placed on ice, we went for lunch.
Then came the recipient surgery. In the recipient, the failed kidneys typically are not removed. Native kidney removal is difficult, so it’s easier to keep them in place where they aren’t posing any problems. But if the diseased kidneys stay put, where does the new kidney go? It gets inserted in the lower abdomen, in front of the pelvis, also known as the iliac fossa. A transplanted kidney gets surgically attached to the iliac vessels, which vascularize the pelvis, reproductive organs, and part of the thigh. Of course, the kidney must also be attached to the bladder via a tube called the ureter. The bladder is located in the pelvic cavity – convenient!
How do surgeons decide which of the two donors’ kidneys to remove and transplant? In the surgery I observed, they flipped a coin. Just kidding! The left kidney is usually preferred because it has a longer renal vein.
The recipient surgery typically takes approximately three hours, but the transplant journey is far from over even after everyone is sutured-up. Our immune systems attack anything foreign introduced inside our bodies – including donated organs. Transplant recipients must take medications indefinitely to supress their immune systems. By telling the guards defending their bodies to step down, they also open the gates to cancers and infections. Even by taking this risk, there is still ample possibility their bodyguards will start a coup and reject their transplanted organs.
While this transplantation is a fascinating procedure, not everyone is willing to donate a kidney, and those who are willing aren’t always a match. Kidney transplant candidates who don’t have living donor offers can be stuck for years on a deceased donor wait-list. High demand, low supply… you can see in which direction the market for kidneys equilibrates. Many consider turning to illegal organ trade and even travelling out of country – transplant tourism – as a shortcut. For donors struggling to make ends meet, transplantation is an opportunity: a one-time surgery, a few weeks of recovery, and a few thousand dollars.
If you spent years dealing with the side-effects of kidney failure with no donors in sight, what would you do?
Approximately ten percent of transplants are estimated to be purchased, and kidneys are the most commonly trafficked organs. Buying a kidney costs approximately $94,000 to $216,000 CAD. In impoverished countries such as the Philippines, after the medical professionals and brokers get a cut, the donor receives about $5000 USD, though it can be as little as $1000.
Because these procedures are illegal, they are often performed in unlicensed clinics that do not meet Canada’s surgical standards and have higher risks of complications. Pre-transplant donor evaluations can be unreliable. Desperate sellers may lie about personal information and may not be properly screened for kidney health. It is devastating for both donor and recipient if the donated kidneys develop ESRD as well. Donors aren’t provided with adequate follow-up and recipients may not be given adequate anti-rejection medications. But the moral implications of organ trafficking are much more complicated.
Still, someone needs a kidney, and someone needs money. There have been various efforts to encourage regulated financial incentives to increase organ supply legally. Iran is the only country that has legalized organ commercialization. However, there is no transplant registry in Iran so it is difficult to determine the success of this policy.
There is also an ongoing debate about opt-in versus opt-out programs. In most of Canada, you must actively opt-in to become a deceased organ donor. Nova Scotia has a presumed consent system, where you must opt-out of deceased donation of your organs.
These conversations are riddled with ethical dilemmas. Unlike the distinct surgical scars that trace the abdomens of many legal and illegal kidney donors and recipients, the line between what is right and wrong can seem blurry.
Haleh Cohn is studying Anatomy and Cell Biology at McGill University with a minor in Economics.
