Wall Anji E, Veale Jeffrey L, Melcher Marc L
Department of Surgery, Stanford University, Palo Alto, CA.
Department of Urology, University of California, Los Angeles, CA.
Transplantation. 2017 Dec;101(12):2818-2824. doi: 10.1097/TP.0000000000001838.
Kidney paired donation (KPD) strategies have facilitated compatible living-donor kidney transplants for end-stage renal disease patients with willing but incompatible living donors. Success has inspired further innovations that expand opportunities for kidney-paired donation. Two such innovations are the advanced donation strategy in which a donor provides a kidney before their recipient is matched, or even in need of, a kidney transplant, and deceased donor initiated chains in which chains are started with deceased donors rather than altruistic living donors. Although these innovations may expand KPD, they raise several ethical issues. Specific concerns raised by advanced donation include the management of uncertainty, the extent of donor and recipient consent, the scope of the obligation that the organization has to the kidney exchange paired recipient, the naming of alternative recipients, and the potential to unfairly advantage the recipient. Use of deceased donors for chain-initiating kidneys raises ethical issues concerning the consent process for each involved party, the prioritization of deceased donor kidneys, the allocation of chain ending kidneys, and the value of a living donor kidney versus a deceased donor kidney. We outline each ethical issue and discuss how it can be conceptualized and managed so that these KPD innovations programs are ultimately successful.
肾对肾捐赠（KPD）策略为患有晚期肾病且有意愿但不匹配的活体供体的患者促成了匹配的活体供肾移植。这一成功激发了进一步的创新，扩大了肾对肾捐赠的机会。其中两项创新是：提前捐赠策略，即捐赠者在其受者匹配到或甚至需要肾移植之前就提供肾脏；以及由已故供体启动的链式捐赠，即链式捐赠由已故供体而非利他性活体供体启动。尽管这些创新可能会扩大肾对肾捐赠，但也引发了一些伦理问题。提前捐赠引发的具体担忧包括不确定性的管理、供体和受者同意的程度、组织对肾交换配对受者的义务范围、替代受者的指定以及可能对受者不公平地给予优待。将已故供体用于启动链式捐赠的肾脏引发了关于每个参与方同意过程、已故供体肾脏的优先排序、链式捐赠结束时肾脏的分配以及活体供体肾脏与已故供体肾脏的价值等伦理问题。我们概述了每个伦理问题，并讨论了如何对其进行概念化和管理，以使这些肾对肾捐赠创新项目最终取得成功。
