Jul 17, 2008

Old Kidneys and Young Kidneys

Recently I discussed the topic of organ trading. The ST article below raises an interesting point not previously mentioned in my old blog post nor by the readers who had commented.
ST July 17, 2008
Short queues for kidneys in Spain and Norway: Here's why
Kidneys from the elderly are accepted and more people are willing to be donors
By Salma Khalik

BEFORE considering organ trading, Singapore can increase its supply of kidneys by learning from Spain and Norway, says a top kidney specialist here.

The two European countries have short waiting lists for kidney transplants - unlike Singapore, where the average wait is nine years for the 560 people on the list.

Both countries accept kidneys from the elderly, whereas in Singapore, kidneys are taken only from people 60 years old and younger.

This immediately cuts off the supply of many kidneys every year. In Spain, a third of the cadaveric kidneys are from people over 60 years old.

Spain and Norway stand out in the world for their short list of patients waiting for kidney transplants. Their success has been cited in the current debate raging over whether Singapore should consider legalising the organ trade to meet the high demand here.

Organ trading is a criminal offence here and, in the last month, five men were charged in connection with the offence, the first such cases here.

The cases have resulted in some people calling on the Health Ministry to reconsider the ban on organ trading.

But before going down that route, Professor A. Vathsala, director of the kidney transplant programme at the National University Hospital, said Singapore should expand its organ donation programme first.

She has visited Norway and Spain and believes that some of their practices, such as removing the age restriction on cadaveric donation, could be adopted here.

Spain transplants both kidneys from an older donor - even someone in his or her 80s - into an elderly recipient.

'No organ goes 'wasted' to be buried needlessly when it can save the lives of so many others with organ failure,' she said.
The obvious question that comes to mind is whether older cadaveric kidneys and younger cadaveric kidneys yield equally good transplant results. (Strangely, the Straits Times article did not discuss this at all).

I did a quick Google search. The answer seems to be that younger cadaveric kidneys deliver better transplant results than older ones. How significant that difference is, I must leave to the experts to comment (a fair number of doctors regularly read my blog).

The next point to consider is whether the kidney patient would be better off with a transplanted old kidney, or with no kidney transplant at all. This could be a "beggars can't be choosers" situation. Your best bet might be with the old kidney, since a young kidney might never become available before you die.

Finally, back to the question of whether organ trading should be legalised. The way I see it, there are many ways to skin a cat, and they don't have to be mutually exclusive. For example, we could legalise organ trading and at the same time, accept the use of older cadaveric kidneys. At the same time, we could continue to encourage "altruistic" donations from living donors etc.

The goal is to save lives. We can simultaneously pursue different paths to that goal.

30 comments:

Anonymous said...

In your humble opinion, what is the recomended list price for 1 unit of older cadaveric kidney and younger cadaveric kidney should organ trading be legalised by the Gahmen?

Sorry, my comment is a bit crude or offensive or unsophisticated to some but I always call a spade a spade unlike the Gahmen who likes to say nice words pleasing to the common peasants' ears e.g. GST increase to helps the poor. The poor include our "Super Talent" Ministers, ERP increase to help the business in time of rising inflation. More $$$ for Auntie Ho Ching spending spree.





Finally, back to the question of whether

Mr Wang Says So said...

Your comment is neither crude nor offensive but it does show that you have misunderstood the matter quite a lot.

The recent discussion of the legalisation of organ trading was not in relation to cadaveric organs. Therefore there is no need to talk about the price of older or younger cadaveric kidneys.

Anonymous said...

To be more precise, there is no need to talk about price ... YET.

If Ministar Khaw gets to regulate organ trading, I wouldn't be so sure that cadaveric kidneys would be FOC.

Running costs ya know. The Ministry has to show a profit else singapore will fall into chaos and the world as we know will end.

Can we just decriminalise(?) organ trading so that we can "win-win" the body parts from our friendly neighbours insteads of the rich and powerful "win win" our "high quality" organs?

NoName

Charles said...

I am really sorry, but I do not see how organ trading would work in the World we live in.

Singapore, for sure, could start by buying a few kidneys, corneas from its neighbours; in fact it could, like it did for water; negotiate a 100 year price per ton of kidneys.

Then, as more and more Singaporean are found to be out job, and more and more wealthy people are attracted to Singapore's wealth management and medical hubs, Singaporean could re-train into organ sellers, or better organ providers.

Lelong Lelong

Mr Wang Says So said...

"If Ministar Khaw gets to regulate organ trading, I wouldn't be so sure that cadaveric kidneys would be FOC."

Then you are imagining a scenario beyond the scope of the current discussion.

The topic is the possibility of legalising organ sale-&-purchase trading between individuals. However, dead individuals are not able to sell/purchase organs any more than they are able to sell/purchase shares, bonds or real estate.

Mr Wang Says So said...

"Singapore, for sure, could start by buying a few kidneys, corneas from its neighbours; in fact it could, like it did for water; negotiate a 100 year price per ton of kidneys."

Please refer to Point 1 of my earlier post on 29 June.

Anonymous said...

Um, the problem with this entry is... you are actually kind of right.

It's a little premature and ill-informed to discuss in too much detail right now without knowing that much about old and young kidneys. It's just kind of blind speculation and guesswork without the info, no?

Anonymous said...

Obviously the dead cant buy or sell. I meant it will not be FOC .. for the recipient.

Sorry, u are the zen guy while i am highly cynical. With your exp as DPP, u may have greater confidence in our various regulators. you may well be correct.

And yes it would be great if the Gahmen increase the availability by accepting old donors (live or otherwise).

But I much prefer they get out of the way of organ trading, until they show that they are capable of transparency.

Sorry for deviating from your article but my experiences with public healthcare under Ministar Khaw's leadership have been singularly bad. Its not something elites like urself will ever understand.

NoName

Anonymous said...

Dear Mr Wang

It is admirable that you have a working moral compass. Unlike me. But you are obviously using a yardstick which is greatly different from many. your point 1 currently irrelevant. There will be no major dispute if they(officials) are adequately compensated. Even if they make some noise (and there will be many excuses) there will be no repercussion. Unless we decide to rub them the wrong way from our high horses.

Just using a random number .. say S$50k is not a big sum in SG but will be more $ than many families will ever see (in Thailand\Indonesia). $50k will still be exploiting your poor fellow singaporeans but will be manna for thais\indonesians.

NoName

Anonymous said...

"...there are many ways to skin a cat, and they don't have to be mutually exclusive."

"We can simultaneously pursue different paths to that goal."

I beg to differ. As you have mentioned, the paths are not mutually exclusive but your last point does not take that into account. Each path has the potential to affect the effectiveness of other paths, directly or indirectly. We do not have unlimited resources and donors.

Mr Wang Says So said...

I don't agree with your view, except that yes, the biggest limit is the number of available kidneys.

What I'm interested is finding different ways to increase that number, as opposed to finding one way to increase that number.

Mr Wang Says So said...

"I meant it will not be FOC .. for the recipient."

You might be right. However, getting a Panadol is also not FOC in Singapore. So I am not too sure what your exact in-principle difficulty is.

Mr Wang Says So said...

"$50k will still be exploiting your poor fellow singaporeans"

True, if we were abducting them in the night and forcibly removing their organs. However, I was referring to legalised organ trading predicated on willing buyers and sellers.

Anonymous said...

Onlooker: "remember there is also the risk of post transplant diabetes"

Fox said...

Every year, on average, about 600 patients, poor and rich, suffer kidney failure. About half of them (-300) will join the waiting list for kidney transplant.

Every year, 55 to 60 kidney transplant operations take place, of which about half the donated kidneys are from cadavers. So, we get about 30 kidneys from cadavers. Meanwhile, 240 patients on the waiting list will just have to die.

According to the ST article, in Spain, a third of the cadaveric kidneys are from people over 60 years old. Suppose we use kidneys from older cadavers in Singapore, that will increase the supply of cadaveric kidneys by 15 to 20, assuming the Spanish model holds in Singapore.

The additional 15 to 20 kidneys are welcomed but no way will they meet the needs of the other 240 patients on the waiting list.

Fox said...

I should add that my previous post was not written to disparage over-60 cadaveric kidneys but to demonstrate numerically its inadequacy in meeting the needs of the kidney waiting list.

Anonymous said...

This discussion about legalising organ sales is important, but I think that a larger issue that has been overlooked is the holistic care of our citizens with chronic illnesses, which includes renal (kidney) failure patients.

Those who work the wards will tell you that based on anecdoctal evidence, renal (kidney) failure patients with poor health are largely from a disadvantaged socioeconomic background. They usually have high blood pressure or diabetes, but could not afford the intensive medical care required to delay the onset of complications (ie medications and regular medical checkups). As a result, they progress to renal failure much earlier, which needs to be treated with dialysis.

Dialysis alone may buy the patient a good 10-15 years. However, it is very expensive, and again, many of these patients cannot afford the cost, and worse, do not have the health to work to pay for their treatment. It ends up as a chicken-and-egg situation resulting in a downward spiral, leading to the patient's death.

How then do we avoid this whole mess? Prevention is really better than 'cure', as in this case, kidney transplants are so limited, and essentially priceless. But the prevention is also expensive.

The question really then, is how much is the government willing to step in to provide cheap healthcare to the people who need it, but are not able to afford it. Based on our national healthcare budget, it doesn't seem to be a lot, compared to other areas such as defence.

If there's only one advice I can give, it would be: buy all the healthcare insurance you can comfortably afford. Healthcare costs WILL go up, and your CPF will NOT be enough.

Ammar said...

The issue of organ trading aside, you do mention allowing older people's kidneys to be used for transplants. I reckon that we will (in more countries than just those) have to take those steps as a large part of the western population ages (baby boom generation) and as average life spans increase. There may just be too few people available for transplants like that. Of course, in the coming years, odds are that more older people will require kidneys, so perhaps getting a 75 year old's kidney(or hell, a 68 year old's) when you're 70 may actually work out in your favour. I don't know the relative betterness of a younger person's kidney, but it seems logical to me that the ages will be moved upwards.

Peesai chow chow said...

Mr Wang, the other question not asked is, can older donors recover from the lost of 1 kidney as well or fast as young patients?

If they need extra care or have higher risk of infections etc, then it adds on to the equation.

Mr Wang Says So said...

I suspect some readers are misunderstanding my main post (and the ST article).

Look at this again:

"Professor A. Vathsala, director of the kidney transplant programme at the National University Hospital, said Singapore should expand its organ donation programme first.

She has visited Norway and Spain and believes that some of their practices, such as removing the age restriction on cadaveric donation , could be adopted here."

Cadaveric means that the person is already dead.

Example 1: A 59-year-old man dies in a road accident. Under the HOTA rules, his kidney may be used for transplantng into a kidney patient.

Example 2: A 61-year-old man dies in a road accident. Under the HOTA rules, his kidney may NOT be used for transplanting into a kidney patient.

What Prof Vathsala is saying is that we could raise the 60-year-old limit for cadaveric kidneys. For example, it could be raised to, say, 75 years. Then more kidneys would be available.

Anonymous said...
This comment has been removed by a blog administrator.
Mr Wang Says So said...

The above comment has been deleted for making unnecessary aspersions about me.

Do not be ridiculous. I have no need of an extra kidney and I have nothing to gain by the legalisation of the sale of kidneys.

Anonymous said...

"What I'm interested is finding different ways to increase that number, as opposed to finding one way to increase that number."

I don't think anyone has objections to finding ways to increase the number of kidneys available for transplant. More so, no one had insisted on only one way.

The key is to find the optimal combination, taking into account all that has been discussed - pros, cons, concerns etc. New and even innovative ideas may crop up but that does not mean they are good.

Compared to organ trading, the Spanish model is more attractive and acceptable even though it is much simpler than the Iranian model to administer.

This talk about old and young kidneys is a luxury. Those who get one should count their blessings instead of being choosy about the age of the organ.

Anonymous said...

The goal is to save lives. We can simultaneously pursue different paths to that goal.

How altruistic! What a refreshing breath of idealism in the land of economic pragmatism!

Saving lives is an outcome that may contribute positively to economic imperatives.

In the words of some famous person, "It's not that simple."

Anonymous said...

If organ trading is legalised in Singapore, I will withdraw from HOTA. I will not trust the government with my organ, not even after death. If they choose to solve problems with money, with no regard to ethics, I will not want to be exploited.

Fox said...

If you withdraw from HOTA, it doesn't make a difference to the rest of us who are in HOTA. By withdrawing from HOTA, although you reduce the potential availability of a cadaveric organ, you are also excluding yourself from the waiting list for cadaveric kidneys (which means one more kidney for the rest of us in HOTA).

On the other hand, you better count on having relatives with a good match since you are, presumably, believe it to be unethical to pay for a donated kidney.

By the way, in the unforeseeable future, you might also need a heart, a pancreas, etc, which are NOT available from live donors or relatives.

lobo said...

"Compared to organ trading, the Spanish model is more attractive and acceptable even though it is much simpler than the Iranian model to administer."

I am just curious if you DO know what the Spanish model is?

As far as I know, there is NO Norway model. Only that there are many willing live donors, but how they 'created' that many live donors was never fully explained.

Our HOTA without age limit would supersede the Spain model, which is still an opt in model. As mentioned by fox in a previous post, it is still short on the number that is needed.

To add on to fox's statistics, each year, 20-30 go overseas to do transplants. They do follow ups in Singapore, hence they is how the figure is derived.

Fox said...

As for kidneys from over-60 cadavers, I should add, as a point of interest, that over-60 people are currently not allowed to be on the waiting list for cadaveric kidneys. In a sense, it is a little unfair to people who are over 60.

Anonymous said...

BBC's Visions of the Future (2 of 3) The Biotech Revolution. Regeneration of organs is a question of when.
http://video.google.com/videoplay?docid=-5040988246744133463

madz said...

I know this may sound out of topic but i need someone to buy my kidney for me to be able to pay some unwanted debts. hope u can help me. contact me at madz_nov@yahoo.com. thanks