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March 1, 2013 Volume 77, Number 3
Living-Related Transplantation of a Kidney With a Mass Barbara G. Jericho, M.D.

Jeffrey Jacobs, M.D., Chair

ASA Committee on Ethics



A 40-year-old male with no significant past medical history wants to donate his kidney to his father who was diagnosed with end-stage renal disease six months ago. The father is 61 years old and wishes to avoid dialysis. During the preoperative evaluation of the son, the son was found to have a 1.8 cm renal mass.*

More than 90,000 individuals are waiting for a renal transplant in the United States as of June 22, 2012.1 Despite the lower long-term mortality risk of transplantation compared to dialysis2, there is a discrepancy between the number of individuals awaiting transplantation and the availability of organs. To address the shortage of organs available for transplant, various approaches to the shortage of organs are being utilized, including the transplant of organs with a mass. However, the concerns of tumor recurrence and the respect for patient autonomy and autonomous choice are reasons given by some clinicians expressing reluctance to advocate for the transplant of organs with a mass.

Several studies have reported experiences with tumor recurrence in patients who have had the transplant of kidneys that had undergone resection of small renal masses prior to being transplanted. Nicol et al. reported that 43 donor kidneys with incidental < 3 cm masses were transplanted into recipients who were elderly or had significant comorbidities.3 Back-table resection of the tumor was performed prior to the renal transplant.3 While the mean follow-up for this study was 32 months, only one of these cases showed tumor recurrence by X-ray and renal ultrasound nine years after the transplant.3

Nicol et al. state the estimate of tumor recurrence after transplant of a kidney after back-table resection of a renal mass is approximately 5 percent.3 In a matched cohort analysis by Brook et al., the authors showed that there was no observable difference in patient and graft survival of recipients between kidneys that had masses excised prior to transplant and living unrelated renal transplant recipients.4 Patient survival of recipients of kidneys that had masses excised prior to renal transplant was improved compared to dialysis patients awaiting renal transplantation.4

Prior to the consideration of transplanting a kidney with a mass, it is essential that informed consent be obtained from the recipient and donor. Informed consent involves the following components: competence and decision-making capacity, disclosure, understanding, recommendation of the plan, voluntariness, decision for or against a plan, and authorization.5 Implicit to the obtaining of informed consent is the patient’s autonomous choice to proceed with the operation without controlling influence. In the case of living-related kidney transplantation with the donor having a known renal mass, the patient should be referred to a urologist for a discussion of treatment options that reflect what would be best for the patient (the donor).4 The discussion should not include reference to possible use of the kidney for transplantation.4 If the patient and physician decide to proceed with a radical nephrectomy, the patient can then be approached to ask if the kidney could be used for transplant.4 For the recipient, the informed consent process should include a discussion of the possibilities of tumor recurrence, reduced renal mass and death due to metastatic disease as well as surgical complications related to the excision of the tumor.4

Therefore, there are three patient considerations in the presented case:
1. Has the potential donor decided with the urologist to have a nephrectomy?
2. Has the potential donor decided to donate his kidney with a mass to his father?
3. Does the father want to accept a kidney with a mass that has been excised?

The donor in this case met with a urologist and decided to proceed with a radical nephrectomy. Informed consent was obtained from the father and son individually. The kidney was transplanted into the father and the pathology report of the renal mass revealed that the mass was benign.



Barbara G. Jericho, M.D. is Associate Professor of Clinical Anesthesiology, University of Illinois Hospital and Health Sciences System, Chicago.

Jeffrey Jacobs, M.D. is a staff anesthesiologist, Cleveland Clinic Florida, Weston, Florida.


References:
1. U.S. Department of Health & Human Services. Organ Procurement and Transplantation Network. http://optn.transplant.hrsa.gov/latestData/rptData.asp. Accessed July 5, 2012.
2. Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med. 1999;341(23):1725-1730.
3. Nicol DL, Preston JM, Wall DR, et al. Kidneys from patients with small renal tumors: a novel source of kidneys for transplantation. BJU Int. 2008;102(2):188-193.
4. Brook NR, Gibbons N, Johnson DW, Nicol DL. Outcomes of transplants from patients with small renal tumours, live unrelated donors and dialysis wait-listed patients. Transpl Int. 2010;23(5):476-483.
5. Beauchamp TL, Childress JF. Respect for autonomy. In: Principles of Biomedical Ethics. 6th ed. New York: Oxford University Press; 2009:120-121.