Instead of donating a kidney, why not just hang around hotel bars accepting drinks from strangers until you wake up in a bathtub full of ice. That way, the market decides where to allocate your kidney for the greatest efficiency.
Risk aversion makes me unlikely to do this, but the "it's easy and almost consequence-free!" suddenly fell flat when he got to "everyone who donates a kidney has to switch to acetaminophen (Tylenol) rather than aspirin or ibuprofen for over-the-counter pain relief for the rest of their lives". That's basically "you get no OTC pain relief for the rest of your life", as far as I can tell.
Instead of donating a kidney, why not just hang around hotel bars accepting drinks from strangers until you wake up in a bathtub full of ice.
Because that means forgoing the opportunity to multiple the impact of the donation (I'm being slightly sarcastic, but this is an interesting bit from the article).
Surgeons in Cincinnati then transplanted the kidney into a recipient I'd never met and whose name I didn't know; we didn't correspond until this past month. The only thing I knew about him at the time was that he needed my kidney more than I did. It would let him avoid the physically draining experience of dialysis and possibly live an extra nine to 10 years, maybe more.
It's not just him, though. We were part of a chain of donations that led to four people getting kidneys, all told. My recipient (let's call him Craig) had a relative who was willing to donate a kidney to him. Unfortunately, the two didn't match. So Craig and his relative agreed to a trade: If Craig got a kidney from somebody, his relative would still go forward and donate to someone else who needed a kidney.
So the very same day that I donated, Craig's relative had their kidney taken out as well and flown to the West Coast. This second recipient also had a friend or relative agreeing to an exchange; so did the third recipient, who got the second recipient's friend's kidney. Our chain will let people enjoy 36 to 40 years of life they would've otherwise been denied.
Hang on to those kidneys, people. That second one is a spare for you.
There's some neat math behind the donor-matching problem that I once saw a talk on. Basically you want to optimize people who have a smaller donor pool available to them, and if you're not thoughtful about it, you'll waste a specialized donor on a recipient who matches with a wider donor pool.
I found the "chain" thing a little weird, too. Be altruistic, to enable someone who is less altruistic? I suppose it makes sense, but I could also see an argument that you should try to hold out to get someone *else* downstream of you to be altruistic, to extend the chain....
4 gives every indication of being a message from the Almighty, and so the argument should end there.
Be altruistic, to enable someone who is less altruistic?
Yeah, essentially. You're helping somebody else who would be willing to donate to a relative but isn't quite prepared to donate to a strange to get over that hump.
I don't know that I'd do it. But it makes sense.
I have a friend who donated a kidney to a relative of one of her friends recently and another who did last year for someone else in her religious community I think. Both are also foster parents. I also know three recipients, I think. I probably wouldn't do it because I'm afraid of side effects and anything that would keep me from being a functional parent, but I'm thinking a lot these days about non-EA altruism and what I can and should be doing with my life.
Limiting this to altruism seems short-sighted. Why not harness vindictiveness? If you donate a kidney to a stranger, you can stop someone you hate from getting a kidney donated by another stranger.
2. Can you not buy Tylenoln over the counter in the land of the free? I too am limited to acetominophen, for different reasons, and I only get it on prescription because that way I can get a couple of hundred at a time for free on the NHS. I think you can even get Paracodol otc here. The main risk is if you're one of the small percentage for whom acetominophen doesn't work.
2 is saying that acetaminophen doesn't provide any pain relief (at least for said commenter).
That I can understand. I know a number of people in the same boat.
For run-of-the-mill headaches, I think it's mostly the placebo effect that helps the most.
Would it be terribly wrong to stipulate that the donated kidney not go to a Republican?
17. There was a case in Britain where somebody left their deceased loved one's organs to be used in transplants, but only for white people. The NHS rejected them.
Yeah, you can by Tylenol over the counter, in mass quantity - I hear on your side of the pond it's in blister packs or something, instead of jars of 500 1000mg pills?
I just find the stuff totally useless, and have been basically living on Advil for the past two weeks.
Not all Republicans are white people.
I've had good luck with Naproxen for chronic ankle pain
I use lots of Advil and the question of whether Naproxen would be okay is one that held me up while reading the article too. We see rheumatology again next week to decide whether to up that dosage or go with something else for the child in pain and it's scary to think of not having that. (Not that I'd trade my children's organs, mind you. This is mostly free-floating paranoia glomming onto whatever's nearby.)
I loved Naproxen in the days when I was allowed it. Magic stuff.
I assume if aspirin and ibuprofen are out that they really mean "all NSAIDs", including naproxen and ketoprofen.
24. Yeah, but racism, as opposed to hate crimes, isn't illegal in Britain (we couldn't build enough gaols). They rejected it on the pretext that they could not be bound by conditions on who they would treat and how. So, I guess, would the American health system.
26: But they specifically cited the Race Relations Act. Would there be a similar law binding governmental conduct in the case of political discrimination?
I think it would be covered, if nothing else, by civil law as malpractice. If I am a surgeon in possession of a life saving McGuffin and I am confronted with a dying patient who happens to be a LibDem and refuse to intervene on the grounds that the person who gave me the McGuffin stipulated that it should only be used for Kippers, I can expect to be sued for everything I have.
I'm thinking a lot these days about non-EA altruism and what I can and should be doing with my life.
Share thoughts? I am similarly reconsidering things after my employer's CEO made some pithy remarks yesterday about "how central the software [we] make is to capitalism." I'm also disinclined to complicity in the dumb-shittery of Wall Street just to donate my surplus, or anything similar.
I'm confused by 18: they rejected the organs, or rejected the conditions?
Both. the former because of the latter.
Rejected with, and because of, extreme prejudice.
The NHS doesn't actually have death panels, Mobes.
Wouldn't it have been a better idea to take the organs, and tell the donor's family they are welcome to file suit for breach of contract if they feel that strongly about it?
35. Probably, but the subtext was that the people who were confronted with the situation were spitting with rage and may not have thought it was worth their time working through a court case.
If it makes you feel good, donate. But to solve the systemic problem, work to change the laws to make organ donation opt-out by default.
Has anyone read the book _Against Purity: Living Ethically in Compromised Times_? I'm interested in how the author would address this issue. Here's a link to the book:
https://www.upress.umn.edu/book-division/books/against-purity
"opt-out by default" would be better worded as "opt-out, so that by default one is opted IN"
But to solve the systemic problem, work to change the laws to make organ donation opt-out by default.
This is the answer. In countries that are opt-out as opposed to opt-in the rate of donation is hugely higher than in the US. There's no sane reason not to make it opt-out but here we are.
The Race Relations Act has been rolled up in the newish, catch-all Equalities Act, which ought to cover political discrimination. But wait. Political discrimination is a thing; it's possible to ban an organisation (like the IRA) in which case membership in it becomes a crime. Further, that time when I had to apply for security clearance - I signed to say I had never attempted to overthrow Parliamentary democracy by political, industrial, or violent means.
There's probably an app now where you can check in and let them know if you start.
29: Sort of in the opposite direction. Since I'm not Catholic anymore, the idea that my suffering does anyone else any good is one I need to dispose of more than I have. I need to do the things I can and be fine with not doing other things and with doing more for myself. (My therapist wants me to work on being rather than being of service. Blech, but he's right.) I do feel that some of what I do outside of work is making up for being a tool of capitalism myself, but it's all pretty amorphous and dumb at this point.
Capitalism is always sort of amorphous and dumb.
The IRA was banned as a terrorist organisation under PoTA, 1974. Sinn Fein remained and remains legal and I think technically could only have been banned if it was shown to be carrying out shootings and bombings in its own name (or if the British government had been more than usually stupid). I'm not sure if any of the various Terrorism Acts permit the banning of organisations that just demonstrate noisily on those grounds alone.
What did you sign to say "I had never attempted to overthrow Parliamentary democracy by political, industrial, or violent means."? If you had been a member of the SWP in your misspent youth, would that have counted?
I once gave somebody some "pence" for one of their newspapers.
Hey guys, it's my 5 year appearance. Just a few notes on altruistic donors and chains. First of all, it appears there is a misconception about an altruistic donor enabling someone else who isn't willing to donate to anyone other than a family member to avoid donation. This is never (or almost never) true. An altruistic donor can donate to a recipient at the top of the list as a simple 1 to 1 match, but that is very uncommon. They are generally used as a starting point (or link) in a chain, in which every recipient has a donor. Those donors all give to someone who is not their originally intended recipient because they are not a match. There are donors who are only willing to give directly to their intended recipient, and if they are not a direct match the recipient has to wait in line like everyone else for a deceased donor. The altruistic donor allows a chain to end with an unused donor, rather than an untransplanted recipient, and can enable many more transplants.
Heebie is correct, the math for long chains is neat and way over my head, because optimizing a chain has to take into consideration multiple points of matching between blood types and HLA antigens, consideration for difficult to match patients who are highly sensitized, geographical distribution, age and size matching, and some other crap.
I am happy to talk more about this if anyone is interested, but I don't want to bore you all.
Hey guys, it's my 5 year appearance. Just a few notes on altruistic donors and chains. First of all, it appears there is a misconception about an altruistic donor enabling someone else who isn't willing to donate to anyone other than a family member to avoid donation. This is never (or almost never) true. An altruistic donor can donate to a recipient at the top of the list as a simple 1 to 1 match, but that is very uncommon. They are generally used as a starting point (or link) in a chain, in which every recipient has a donor. Those donors all give to someone who is not their originally intended recipient because they are not a match. There are donors who are only willing to give directly to their intended recipient, and if they are not a direct match the recipient has to wait in line like everyone else for a deceased donor. The altruistic donor allows a chain to end with an unused donor, rather than an untransplanted recipient, and can enable many more transplants.
Heebie is correct, the math for long chains is neat and way over my head, because optimizing a chain has to take into consideration multiple points of matching between blood types and HLA antigens, consideration for difficult to match patients who are highly sensitized, geographical distribution, age and size matching, and some other crap.
I am happy to talk more about this if anyone is interested, but I don't want to bore you all.
And I double posted - so, pretty boring after all. Also, it is all NSAIDS that we tell you to avoid, so no naproxen.
I signed to say I had never attempted to overthrow Parliamentary democracy by political, industrial, or violent means.
By being a worker in a capitalist society, I bring about resource starvation more quickly, which will inevitably lead to the demise of Parliament. Does that count as "industrial means"?
47.last: Not that this is at all on topic, but how did Duke put the wrong heart in that girl?
Also, do fewer patients have wristwatches sewn inside them now that everybody has a cellphone to tell them time?
30,35: yeah, there's some contorted "not cutting off your nose to spite your face" joke to be made here but, seriously, it seems like a fair call.
43: ah okay. Yeah, I think the trick is to convince yourself that self-abnegation is selfish, as it is excessively focused on the self! It... kind of... works.
it is all NSAIDS that we tell you to avoid, so no naproxen
But opiates are still OK, right?
So is the deal that acetaminophen works for pain relief on some people, but a smaller portion of the population than the NSAIDs? Does it help any of you?
It was a lung transplant, and they were actually doing 2 separate transplants and used the wrong organ.
I'm thinking of asking for physical therapy to see if I can exist without pain and Naproxen. On the one hand, I have good insurance and a family history of GI bleeding. On the other hand, PT sounds like effort.
54 - I find that heroin works wonders, as long as you get ahead of the constipation.
We have a bunch of morphine, but my sister threw it all away. She mixed it with old coffee grounds first.
60 is one of the saddest corrections ever.
Dr Oops! We found a subject which got you to comment.
it appears there is a misconception about an altruistic donor enabling someone else who isn't willing to donate to anyone other than a family member to avoid donation. This is never (or almost never) true. An altruistic donor can donate to a recipient at the top of the list as a simple 1 to 1 match, but that is very uncommon. They are generally used as a starting point (or link) in a chain, in which every recipient has a donor. Those donors all give to someone who is not their originally intended recipient because they are not a match.
If this was in response to me (at comment 8) my impression from the article wasn't that the members of the chain were unwilling to donate to a non-family member just that, their willingness hadn't extended to deciding, at some point in the past, to do as Dylan Mathews did and donate to a stranger.
Unless I'm misreading it, they were open to the idea of donating to a stranger but were only pushed to do so by participating in a chain which involved somebody they knew personally getting a kidney.
I find myself unwilling to give a kidney and am unable to give blood (my veins collapse, the Red Cross asked me not to try anymore), but I've been telling myself for 20 years that I should really donate bone marrow. Problem is that I've heard it hurts a whole hell of a lot and I guess I'm a wuss. I should probably get over that and just do it, huh?
On a related note, is it really true that I'm being a sucker by being a faithful blood donor? Especially as, nowadays, it's mostly plasma. I've skimmed the arguments, but they often smack of "in the coming utopia, blood banks will be cooperatively managed by the collective, so for right now they're basically evil." I mean, I get it: I donate blood product, and they sell it. But they're also, you know, serving a useful function as a middle man, so I don't get all righteous about them wetting their beak.
I should add that blood donation is basically the whole of my altruism: we continue not to have any money to spare (my leaky roof, let me show you it) and not a ton of time (I do community stuff--saving a park, serving on a nonprofit board--but not, like, soup kitchen stuff). My blood type is common, but not the universal donor, so I'm not providing any special value there. But I'm happy to show up 8-10 times/year.
I should really donate bone marrow
Plan Ossobuco.
I'm pretty sure blood banks are all non-profit in the U.S.
62 - Ahh, sorry I misunderstood your comment. Yeah, it is pretty rare to find an altruistic donor, and the majority of them are pretty wacky, to tell you the truth. I am the director of living donation at my institution (for the next week, until I am unemployed), and we reject virtually every altruistic donor for psychological reasons. 1 year mortality for the operation is generally quoted at about .03% all cause (including suicide, car accident, and the usual operative complications). Although the operation and testing is free to the donor, there is no compensation for lost wages, travel, or other expenses, and you can be out of work for 6 weeks if you do a physically demanding job. If you develop a condition like diabetes, you are more likely to end up on dialysis. All of this is very reasonable if you have a family member or friend who is suffering, as the health and longevity benefits for the recipient are tremendous (yuge?), but it is a real risk for someone who has no skin in the game otherwise. Many of the altruistic donors we see (not that there are that many) are unable to address the downsides in a realistic fashion, and we are reluctant to take their organs.
62 - Ahh, sorry I misunderstood your comment. Yeah, it is pretty rare to find an altruistic donor, and the majority of them are pretty wacky, to tell you the truth. I am the director of living donation at my institution (for the next week, until I am unemployed), and we reject virtually every altruistic donor for psychological reasons. 1 year mortality for the operation is generally quoted at about .03% all cause (including suicide, car accident, and the usual operative complications). Although the operation and testing is free to the donor, there is no compensation for lost wages, travel, or other expenses, and you can be out of work for 6 weeks if you do a physically demanding job. If you develop a condition like diabetes, you are more likely to end up on dialysis. All of this is very reasonable if you have a family member or friend who is suffering, as the health and longevity benefits for the recipient are tremendous (yuge?), but it is a real risk for someone who has no skin in the game otherwise. Many of the altruistic donors we see (not that there are that many) are unable to address the downsides in a realistic fashion, and we are reluctant to take their organs.
Dr Oops could definitely donate half his comments and survive on the other half.
this is why I don't comment here.... too embarrassing when I cant even manage to not double post.
66: Oh I know, but the CEOs are paid, so it's all a scam.
I can't tell if it's just purity policing or if it's runaway logic from "you'd have more donors if you paid them all" to "blood banks lobby against paid donors to maintain their lock on the market." Or if there's something legit even.
The thing is that the second one really does happen with for-profit companies, and many non-profits suck. I'm not convinced that any meaningful number of legit non-profits* operate that way, though. My general impression is that the whole concept of "poverty pimp" (and similar) just exists as a way to a. damage a political opponent, and b. make your supporters feel better about not trying to help anyone.
*as opposed to pure scams. Like, the Red Cross is crappy but legit.
we reject virtually every altruistic donor for psychological reasons.
Interesting. So how do you feel about the article? Do you think it does a decent job of demystifying a fairly unusual process or do you think it oversells the idea and may paint a misleading picture (or both)?
Wait, I have a question-- is somatic mosaicism an issue at all in assessing donor compatibility? I could try looking it up, but there's some controversy about how often it happens in people, and one place that it would show up is compatibility complications.
double answer is fine, I often need to reread passages anyway
Update: Bit the bullet and signed up at www.bethematch.org. It takes 10 minutes to sign up, should get a swab kit in about 2 weeks. Reading up on the procedure, it looks significantly less painful than I remember (I seem to recall that they used to take the donation from the femur under local, it's now from the pelvis under general--if they take marrow at all. There is also now an alternate procedure for harvesting stem cells from the blood.) So if I turn up as a match, my wussiness won't be nearly as much of a factor.
Regarding JRoth on beak wetting, there is a lot of that in transplant as well. There are 58 organ procurement organizations (OPO's) across the country that actually procure the organs from deceased donors and then sell them to the transplant centers. They provide the majority of the staffing, although most transplant centers provide the surgeons to do the procurements. Depending on various factors, a kidney can cost anywhere from $25-40,000, with the surgeons fee ranging from 625-1000, and the transplant centers have no negotiating power. The OPO's are tightly regulated by the federal government, and they are currently a necessary evil, but they do compete with each other and often obstruct transplantation due to their financial constraints.
with the surgeons fee ranging from 625-1000
That seems fairly low (1.5-4% of the total cost of the kidney?)
On the OP, this probably makes me a giant asshole, but I want to know who I'm keeping alive. I'd donate a kidney to Ruth Bader Ginsburg in a heartbeat. I'd probably not donate one to Steve Bannon.
75 - It is a pretty fair representation of the experience for most people, but I do think that he is a rather extraordinary person who is also in a financially secure situation with a great deal of support. The numbers he quotes are generally accurate, but would you take a 3 in 10000 chance of dying for someone you don't know? He is overstating the risk of kidney failure somewhat, but going to the top of the list for a kidney transplant as a perk still sucks. I do these operations and take care of these patients, and while I would give a kidney to a friend or loved one without blinking an eye, I have never considered being an altruistic donor.
I miss being able to give blood regularly as my "yes, I actually am a good person" reassurance, but they stopped taking me after I spent too much time in malarial countries.
but would you take a 3 in 10000 chance of dying for someone you don't know
If you asked me to make a snap decision I'd turn it down immediately. But, given time to think about it, and mull over the idea . . . . I don't know.
Laziness/wussiness would still win out without some prompting. But the thing that I find interesting about the article is that having a couple of examples of people who had done it and were glad to do so could make a real difference in how I would think about it. If the starting point wasn't, "I could do something that's completely out of the blue and has a 3 in 10000 chance of death" but was, "I could do something that's unusual but which plenty of people do and which only has a 3 in 10000 chance of death" it wouldn't (I think) be that hard to talk myself into it.
Shorter: it's easier to take a risk if you've had time to think it over and you're only assessing risk not risk + mystery & fear of the unknown.
81 - Those fees are controlled by CMS, as the great majority of kidney transplants are paid for by Medicare/Medicaid. It is accurate, as I invoice the OPO for my time when I do them, and it can take 8 hours of my time with travel, waiting around, and the operation. Deceased donors generally happen in the middle of the night, and I have to go back to work the next day to do my regular job. The OPO's often have trouble finding a surgeon who is willing to go out, as it is generally on short notice. It is a silly system, although some OPO's are starting to hire surgeons full time just to do donors.
I can't tell if it's just purity policing or if it's runaway logic from "you'd have more donors if you paid them all" to "blood banks lobby against paid donors to maintain their lock on the market." Or if there's something legit even.
There's evidence that paid donations compromises safety of the blood. Tests for blood-born diseases aren't 100% accurate and they don't want somebody with Hepatitis choosing between answering the question honestly or paying their rent.
There's also evidence that it doesn't compromise safety, but I think that evidence mostly comes from places with substantially lower levels of poverty than there.
with the surgeons fee ranging from 625-1000
No GroupOn?
I don't think there's a person in America that's currently better positioned to crowdfund her healthcare than Ruth Bader Ginsburg. She should take advantage of the opportunity.
And if she falls down a well, half of America will show up with shovels.
76 - The somatic mosaicism question is neat, and I don't know that I have a good answer. Matching is done using either virtual or real crossmatching, but is based on the Human Lymphocyte Antigen (HLA) markers found on lymphocytes of the donor and the recipient, as well as any anti-HLA antibodies found in the recipient. If the kidney in the donor expressed different markers than the donor lymphocytes, it would be possible to have a negative crossmatch but a higher risk for rejection. I don't know offhand of any studies that have looked at typing the kidney tissue itself to identify unexpected HLA expression, but that may just because I am a lazy surgeon who doesn't read enough. Let me do a bit of research and see if I can find anything.
I did a bit of research and didn't find anything. But I am pretty lazy...
I have been thinking about the sizes of various mammals and numbers of cells lately; a definite subset of animal model failures is due to rodents being a lot smaller than people. How much do we really know about whales and hippos and their health problems?
On hte other hand, greenland sharks. On the other other hand, sharks are pretty gosh-darned different from mammals.
93: Hippos are certainly getting attention now.
To the OP question of whether donating a kidney has enough bang for the buck to be a reasonable use for a person's altruistic desires - I think the answer is yes. The change in the health and well being of the majority of transplant patients is pretty amazing, and it is a financially sound decision as well. The break even point for transplant vs dialysis is at about 2 years - with an average graft-life expectancy of 9 years there is a dramatic cost savings to the Medicare budget. (Other transplants, like liver, lung, heart, are almost always more expensive, as the patient will die without the transplant. Death is pretty cheap). Kidney failure patients make up only about 1% of the Medicare population but take about 7% of the budget. Fun fact - while dialysis patients are the only patients under the age of 65 that are covered by Medicare, it will only cover the cost of medications for three years after transplantation. That means if a recipient under 65 cannot get adequate insurance from other source within 3 years after their transplant, they are on the hook for something like 25 grand/year in immunosuppression costs. A sizeable percentage of these patients don't get insurance in time and lose their kidneys to rejection, then go back on dialysis (and Medicare). Pretty stupid. Transplant physicians have been lobbying forever to get this changed, but haven't succeeded yet.
|| Wow, the spam bots are out in force right now. |>
96: Yeah, they're hitting at least 3 articles that I noticed. (Sports, Werner Forssmann, and My New Favorite Phrase).
If the starting point wasn't, "I could do something that's completely out of the blue and has a 3 in 10000 chance of death" but was, "I could do something that's unusual but which plenty of people do and which only has a 3 in 10000 chance of death" it wouldn't (I think) be that hard to talk myself into it.
I think that captures the dynamic well. I mean, we've repeatedly had the discussion about how much more dangerous driving is than practically anything else we do, and yet....
I don't think I'd seriously consider an altruistic donation, but I'm pretty sure I'd be (relatively) easily talked into it by anyone I have a connection with. That is, an acquaintance knows somebody? Quick, buy me some drinks and start loading the tub.
Meanwhile, I don't think I could ever foster.
Question for Dr. Oops: My girlfriend's father (mid 70s) is a lifelong Type 1 diabetic. He apparently is starting to experience renal failure. Does diabetes and/or his age make him ineligible for transplant? Just trying (lazily) to educate myself before I step in it in a conversation with her.
I love being able to do the Marshall McLuhan thing ("I happen to have a transplant surgeon right here...")
I'm assuming that 102 is in response to 79, not 100.
101 to "This guy wants to ride motorcycles without wearing helmets."
It doesn't rule him out absolutely, but there are a lot of variables to consider. Many transplant centers wont look at a candidate that age unless they have a living donor, as the waiting times are too long and the chances of him being in good enough condition to transplant 3-10 years down the road (depending on blood type and geographic location) are very small. Also, if he is just beginning to lose kidney function he still may have a long time before he actually needs a transplant. Transplantation before a patient actually starts dialysis is generally considered desirable, but there is no benefit to doing it too early, as the risks of surgery and complications of immunosuppression are considerable. Also, older diabetics with renal insufficiency often have many other comorbidities like heart disease and peripheral vascular disease that may make them poor candidates for surgery. Glomerulofiltration rate (GFR) is a measure of remaining kidney function - normal is about 90+, and most people go on dialysis when it is down to 8-12, depending on symptoms (fluid overload, nausea, confusion). The cutoff to be eligible for listing for a deceased donor is 20, but you also have to consider the rate of decline. A lot of older people can live and not need dialysis with a GFR between 12-20 for a number of years.
tl:dr - ask your doctor? If he is reasonably active and lively, dialysis is immanent, and he has a possible living donor, it may be a great option. If one center turns him down due to his age, find out the most aggressive center you can get to in your area.
Is the 1-year risk of dying the main appreciable risk? What about 10-year or 20-year?
Fun fact - while dialysis patients are the only patients under the age of 65 that are covered by Medicare
Not important to your point, but people with SSDI are also covered after a waiting period, and that will probably have many more sub-65s.
1 year mortality (mostly due to graft loss) is definitely where transplant has made many of its advances in recent years. We have pretty much beaten hyper-acute rejection (I have never seen a case), and most early rejections are treatable. People die perioperatively (heart attack, blood clots) and die when they lose the organ (congestive heart failure, heart attack, overwhelming infection if they are overimmunosuppressed). Because we are better at treating and preventing rejection, we run them on lower immunosuppression, which decreases the risk of fatal infections. We haven't done much to improve the graft survival presuming good graft function at 1 year, which is due to a combination of factors. Our best immunosuppressive drugs cause progressive fibrosis of the kidney, and we use many more marginal organs (older, sicker donors) because there are no where near enough kidneys to go around, so the kidneys were not going to last as long anyway.
I'm not sure that I answered your question, but I typed all these words, so here you go. I'll probably double post again now.
But graft loss and such wouldn't really apply to the donor, would it?
The problem with SSI or SSDI is that once you get the transplant, unless you have another disabling condition, you are no longer eligible. I think you can stay on SSI for about a year. It's a classic catch-22, because many of these patients have been out of work for years due to their renal failure, so they can't reasonably be expected to find a great job with good insurance. They lose their benefits, cant buy the immunosuppression, and end up back on the disability list and on dialysis.
They would have risks from the surgery plus longer term risks from some kind of renal issues, plus maybe castration anxiety if the scar was too close.
I can't find figures for mortality associated with iatrogenic castration anxiety.
Crap, I can't keep up. Yeah, I was talking about the recipient, not the donor. Almost all of the living donor mortality is front-loaded into the first year, really the first 30 days. Standard reporting for perioperative mortality for most surgeries is the 30 day mortality. They report 1 year mortality for donors because you are more likely to capture post-donation violent deaths (homicides and suicides), as well as deaths due to conditions not caught before the procedure. The violent deaths are important because it implies that there was an inadequate psychological evaluation, and deaths due to other medical conditions indicates that the medical evaluation was lacking.
There have been many studies that say that living donors live just as long as those who donate, but those studies looked at the general population as a control. Newer studies that use equally healthy people as a control do show slightly increased mortality among those who donate (about 5% increase over 25 years) as well as a 5% increase in pre-eclampsia, and some increase in premature births, although no increase in infant mortality or long term disability.
I had a patient lose a testicle once, but that was after a reoperation for a different complication. He already had a penile implant for ED, so interventionally speaking it was probably a wash.
I hope that's not where the pseud came in.
The problem with SSI or SSDI is that once you get the transplant, unless you have another disabling condition, you are no longer eligible. I think you can stay on SSI for about a year.
Interesting. I was just referring to those disabled without reference to any kidney issues - that's another group that gets Medicare regardless of age (they might have to be 18).
113: Thanks. If it's solid data, +5% donor mortality over 20 years makes me more trepidatious.
And I guess the pitfall is that's relative risk, so the absolute risk might be quite low.
Safer than boarding a plane at O'Hare.
A question for Dr. Oops. Someone I know had a cutting edge kidney transplant at a big teaching hospital, and she doesn't have to take immunosuppressive drugs.
See here.
Why aren't more transplants being done that way now?
See where? Did she have a combined bone marrow and kidney transplant? I cant get the link to work.
Yes. Weird. I don't know how I messed that up.
http://www.massgeneral.org/transplant/news/newsarticle.aspx?id=1437
The article in the OP was really good. Prior to cancer, I always felt really guilty about not giving blood. I'm a universal donor, but the couple of times I did give blood, it hurt like hell and I nearly passed out. Now it's not really an option. My compromise was that I am an organ donor (assuming any of them are still eligible).
Thanks to cancer camp, I know *a lot* of people who have received bone marrow transplants. Anyone willing to be a bone marrow donor is doing something incredible.
124 - Short answer - she got lucky. The bone marrow transplant works if you induced mixed chimerism, where you have a combination of donor cells and native cells in the bone marrow, both producing immune cells. If you induce full chimerism, where the bone marrow of the donor takes over completely, you still need immunosuppression because you are now at risk of graft vs host disease (the new immune system doesn't recognize the host as 'self', so it attacks its new host). Stable, or sometimes even temporary, mixed chimerism can induce tolerance, but so far this is far from a fail-safe response. When I was at UPMC we used a combination of a particularly strong induction protocol and administration of peripheral immune cells to try to do the same thing, and it worked well, right until it didn't. So far, that's what is happening at MGH as well. The only reason their numbers are as good as they are is because the surveillance of these patients is so tight. Your friend is in the perfect position, she had a living donor, she is well supported, and she is being watched incredibly closely so if she shows a sign of rejection they will jump all over her. A recent article that discusses a number of these trials at various centers shows that in their most recent cohort only 4/10 have remained off of immunosuppression long term.
UPMC may be able to make a chimera, but only Pitt employees get a free bus pass.
I'm signing off now - I have two more days of operating before I am gainfully unemployed, and I have to get up early tomorrow. This has been a lot of fun! If this is still going I'll chime in some more.
Lurkers unite! or don't, whatever.
This is the sort of thread that makes continuing to read Unfogged seem worthwhile regardless of how frustrating it can get.
"Switch to acetaminophen" is not really a thing at all. Acetaminophen is a DIFFERENT MEDICINE than NSAIDs, they work by very different mechanisms, you can max out on one from each category simultaneously, and if you're regularly in pain this is important. (I have close friends who are regularly in pain.) This is not a case of "you have to use X instead of Y," this is a case of "a common type of pain relief is now totally unavailable to you."
This seems overall consistent with a pattern in EA - and, to be fair, basically everything else in the world - of taking something that seems like a good idea, exaggerating the benefits, and understating the costs. The difference between EA and everything else is that EAs actually advocate taking cost-effectiveness numbers literally for decisionmaking, so the errors actually matter in a way they don't if you were operating under the assumption that marketing is largely bullshit. It would be really nice if there were accurate and unbiased sources of relevant information out there so that I could actually make this sort of decision based on data!
That said, some people I admire a lot have done this and I think it's often a good choice for people who feel comfortable doing it. Especially if you're not earning a high hourly rate and giving the money away to something you're sure is highly cost-effective, or doing work you think is especially high-impact, this seems like it's probably a pretty good way to have a clear positive impact.
93. I'd guess quite a lot is known about Asian elephants' health issues, given that they've been domesticated for thousands of years. I'd also guess that pretty much none of it transfers to humans.
I'd also guess that pretty much none of it transfers to humans.
Fortunately, this includes musth.
A couple of questions for the good Doctor. Okay, more than a couple. Answer any or none, as you see fit.
1) The lifetime ban on NSAIDs: where does this fall on the spectrum from "might be questionable, better safe" to "this will KILL YOU so DON'T DO IT"? Also, are there any other lifetime bans for donors?
2) What's the main reason for people to need kidney transplants? Diabetes? Something else?
3) I see the figure of "9 or 10 years" being thrown around. Presumably that's a mean, but what's the distribution? Does a 40 year old recipient have a chance at living to be 75, or is he almost certain to be dead by 60?
4) How are most recipients likely to die -- rejection, infection, general poor health, or what?
5) Finally, there's obviously a lot to learn about kidney transplants -- the system, the surgery, the immunology, the aftereffects. Are there any books or articles you might recommend?
Many thanks in advance,
Doug M.
On 5, one of the Crooked Timber bloggers wrote a book on transplant from the sociology end: Last Best Gifts. You could read that.
How does living donation work with health insurance in pre/post-ACA world? Are you going to be denied dialysis coverage or face much higher premiums?
On a similar note, how are the donor chains coordinated nationally, or even at a state level? Is it a government thing, or is there some voluntary information sharing network?
138: For some weird reason, from before the ACA, all dialysis patients are eligible for Medicare.
I will reveal all later - I am currently proctoring surgery and have to pay attention.
In the running for most unsettling comment ever.
105: thanks! LB, your job is now to bring in a diabetes specialist so I can understand the challenges my girlfriend is facing with her teenage son. (Or I can just go look at Wikipedia.)
141 is great.
Here's hoping Dr. Oops will stick around.
Don't worry, it's not a transplant, just a dialysis access procedure. I am proctoring a surgeon who is 8 years into his training and will be an independent surgeon in a few months. And wouldn't it be way more unsettling if I had told you I was proctoring after commenting for an hour?
True -- there are as yet unscaled heights of unsettlingness to reach.
I'm trying to think of the worst possible thing you could reveal that you were doing while commenting. Landing a plane? Driving a tractor-trailer? Or, actually, a bus would be better. Bomb disposal?
I'm trying to think of the worst possible thing you could reveal that you were doing while commenting
Donald J. Trump.
136. 1) The ban on NSAIDs is strongly recommended, but a little cheating wont do anyone any harm. As with all paternalism in medicine (see alcohol while pregnant, don't lift anything after surgery, drink 8 glasses of water a day, etc) The presumption is often that patients are not very good at moderation, so it is much easier to take certain options off the table completely. This of course leads to a profound distrust of doctor's instructions, because we all know that a large percentage of that advice is bullshit. Ask how much LB's mother drank while she was pregnant (on doctor's instructions!). We should all be grateful, as non-of us would be able to understand her if she had actually reached her full potential. I am forever thankful that she smoked while pregnant with me, because 6'1" is plenty tall.
NSAIDs cause interstitial inflammation in the kidney, and prolonged or excessive use can lead to fibrosis and even renal failure, so we discourage it as the go to drug for pain control. If you have a headache every few months that is helped by 400mg of ibuprofen, that really shouldn't be a problem.
(on doctor's instructions!)
True fact. The story as I recall it is that in relation to some difficulty Mom was having, her OB instructed her to go home, put her feet up, and have a drink of gin.
At her next appointment, Mom asked plaintively "Does it have to be gin? I don't like gin." The seventies were a different time.
Republican done for shagging a 17-year old boy within 1000 feet of a church is named Ralph Shortey. Because of course he is!
136. 2) Diabetics account for about 35% of the kidney transplant waiting list, with hypertension contributing about 25%. An unknown percentage of the HTN diagnoses are wrong, because everyone has HTN by the time their kidney has failed. Many people have no idea they have a problem until they have the catastrophic headache, show up in the ED, and need emergent dialysis. At that point, even biopsying the kidney wont give you a diagnosis because the damage is so bad. A huge percentage of these patients (both diabetics and hypertensives) could have avoided kidney failure completely if they had good primary care.
This conversation reminds me of a friend who had just given birth to twins and presented with some minor post-partum issue, to be told, "It'll clear up in a few weeks, but meanwhile avoid any heavy lifting."
Back to the OR, but stay tuned, because the first death panel was formed to pick dialysis candidates. Good story....
You all made me feel guilty, so I'm going to actually do this one. Poor patient....
136. 3) There is a pretty wide distribution for graft survival, with about 3-5% failing within the first year, and some that can last as long as 40 years. It depends on quality of the kidney and the recipient, how well matched the donor and recipient are (although this doesn't have a huge effect except in identical twin transplant where the risk of rejection is very low), and how well you take care of it. Survival benefit for a young diabetic cam be as much as an additional 10-20 years, but even a 70 year old can get an additional 3-5 years of life expectancy (on top of what they would normally be expected to have). You can get more than one kidney, the most I have seen is 5 transplants in one person.
4)The most common cause of death in kidney transplant recipients is cardiovascular. It used to be infection, but immunosuppression is better targeted and run at lower levels in the past. The trade off is that sub-clinical chronic rejection, as well as fibrosis induced by the preferred agents, leads to a slow but steady loss of function.
138 Its totally true! When dialysis was started (in Seattle in the 50's) there were only a couple of machines available and it was very expensive. A 'God Committee' was convened of about 7 volunteers from the community that decided who would get dialysis, based on education, moral fiber, contribution to the community, age, etc. The committee was exposed in Life magazine in '62, (They Decide Who Lives, Who Dies, Shana Alexander). 10 years later it was brought before the House Ways and Means Committee, because the treatment was still so expensive, and there were not enough dialysis machines to treat everyone. The solution was to allow these patients to go on Medicare even if they were under 65. You still have to qualify for Medicare by having paid into the system for a certain number of years or if you are a child. Those who don't qualify for Medicare will usually be covered by Medicaid and have the treatment covered. For those who don't qualify for either (the undocumented, for instance), they can usually get emergency Medicaid, which is only active on the days they get dialysis. They are basically going to the ER 3 times a week and getting 'emergency' dialysis, which can last for years. (If I have to operate on these patients, I can only do it on a day that they get dialysis, because there emergency Medicaid is only in effect on those days. Weird, right?)
"everyone who donates a kidney has to switch to acetaminophen (Tylenol) rather than aspirin or ibuprofen for over-the-counter pain relief for the rest of their lives".
Bull crap. I donated a kidney seven years ago and still use ibuprofen for otc pain relief without any pro
("They" being the NSAIDs, presumably.)
Yep, it's true. Docs make overly simplistic rules that assume the minimum of intelligence or insight in their patients. It is irritating, infantilizing, and backfires when someone realizes this and then decides that everything we say is a pack of lies. The flip side is, you cannot believe how goofy some people can be. The only solution is to have enough time for a physician to have a reasonable conversation with someone, gauge what they can and can't handle in terms of decision making (an extremely difficult and time consuming task), and then tailor instructions to the individual. This is actually not possible with the current structure of healthcare, and not because doctors are a bunch of lazy, entitled fuckheads. Sure, some of them are, but mostly they are struggling with not enough hours in the day to do all of this, code for their efforts so they get paid, call the insurance companies and wait on hold forever because they have denied coverage for a perfectly reasonable test or medication, etc, etc, etc. Dumbed down instructions are just one of the corner-cutting methods docs use to make it through the day.
Just wanted to chime in to say that I'm enjoying the Dr. Oops cameo immensely.
Also, people are really dumb. I don't blame docs for their stupid instructions.
Tailor Industries http://www.Tailorind.com Manufacturer of Mens Motorcycle Leather Jackets Womens Motorcycle Leather Jackets Men's Leather Motorcycle Vests Women's Leather Motorcycle Vests Motorcycle Leather Pants/Chaps Motorcycle Leather Racing Suits Motorcycle Bags Motorcycle Gloves Motorcycle Boots Motorcycle Textile Mens Textile Jackets Ladies Textile Jackets Textile Pants Off Road Gloves Winter Gloves Rain Suits Mens Motorcycle Jackets Ladies Motorcycle Jackets Motorcycle Vests Motorcycle Pants Motorcycle Gloves Motorcycle Rain Suits MotorBike Ware Fashion Garments Men Leather Jackets Men Leather Coats Men Leather Vest Men Leather Pants Women Leather Jackets Women Leather Coats Women Leather Vest Women Leather Pants Leather Vests Leather Jackets Trachten Garments Men Bavarian Garments Women Bavarian Garments Children Bavarian Garments Men Bavarian Garments Lederhosen Kniebundhosen Trachten Shirts Trachten Jackets Trachten Vests Trachten Socks Trachten Shoes Women Bavarian Garments Short Lederhosen Kniebund lederhosen Mini Dirndl Midi Dirndl Long Dirndl Dirndl Aprons Trachten Shirts Trachten Blouses Dirndl Blouses Trachten Bag Trachten Shoes Children Bavarian Garments Kinder Lederhosen Kinder Dirndl Trachten Shirts Trachten Socks Trachten Shoes Western Wears Garments Cowboy Jackets Cowboy Vests Cowgirl Jackets Cowgirl Vests Cowgirl Poncho Cowgirl Skirts Cowgirl Coats Cowgirl Bags Cowgirl Belts Western Hats . All Products are Made of Premier Quality Materials By Tailor Industries Sialkot Pakistan.
Tailor Industries
Haji Pura Bun Road,
Sialkot-51310 Pakistan.
http://www.Tailorind.com
WhatsApp: +92-311-7857727
Email: industriestailor@gmail.com
https://www.twitter.com/_TailorIND
https://www.facebook.com/TailorIndustries
https://www.pinterest.com/TailorIndustries
https://www.plus.google.com/+TailorIndustries
https://www.linkedin.com/company/Tailor_Industries