Book Review

Living Donor Organ Transplantation

N Engl J Med 2008; 359:324-325July 17, 2008

Article

Living Donor Organ Transplantation
Edited by Rainer W.G. Gruessner and Enrico Benedetti. 791 pp., illustrated. New York, McGraw-Hill, 2008. $205. ISBN: 978-0-07-145549-7

As one who works in the field of transplantation, I find it hard not to be positively predisposed to a book that begins with the dedication, “To all living donors for their vision and courage.” Living donors have always been crucial to transplantation. In the beginning, they were vital because preventing rejection depended on immunologic relatedness rather than pharmacologic firepower. Today, our immunosuppression armamentarium is much more powerful than it was at the beginning, and we regularly perform transplants between complete immunologic strangers. And yet, living donation not only persists but is growing in popularity, currently fueled by the success of organ transplantation and its superiority over other therapies for end-stage organ failure. In Europe and North America, two regions with sophisticated organ-exchange systems, the number of transplantable organs needed far exceeds the number available from deceased donors; for most of the world, living donation remains the only option. The editors of this book, Rainer Gruessner and Enrico Benedetti, recognize this reality.

The book addresses the use of living donors in the transplantation of the kidney, pancreas, islets, liver, and intestine. The content in the sections on each of these organs is similar, beginning with an introductory historical perspective by a pioneer in the field and followed by contributions on concerns relevant to the donor and to the recipient and a cost analysis. Within each chapter on the donor, there are subsections on donor selection and on operative considerations, including perioperative care, donor morbidity and mortality, long-term outcome, and psychological considerations. There are similar subsections within each recipient chapter, as well as several organ-specific discussions, such as a subsection addressing “small-for-size grafts” in the section on the liver. The book is extremely well organized, and there is remarkably little redundancy. The operative descriptions are clear enough to allow a nonsurgeon to follow them.

It is worth noting that within each organ section, there is just as much — or in the cases of the sections on the liver and intestine, three times as much — content devoted to the recipient as there is to the donor. This would seem to confirm my belief that the information we currently use to reassure donors about the consequences of their donation is not only incomplete but at times irrelevant — such as quoting survival data from living kidney donors of the 1980s (who were usually between 20 and 40 years of age) to the 60-year-old living donor of today. The United Network for Organ Sharing (UNOS) — the U.S. transplant network — does not maintain data in its follow-up registry for living donors beyond 2 years. Many transplant centers do not see the donor after an initial postoperative visit. Therefore, the remarkably candid and honest subsections that discuss donor morbidity and mortality and the long-term outcomes for transplantation of each organ are a real strength of this book; for the purpose of enhancing informed consent, they should be required reading for all potential living donors.

This book also contains a discussion of future alternatives to transplantation from living donors as well as an outstanding two-part societal discourse, which is my favorite part. Part 1 discusses the ethical and legal issues of using living donors, including the effects of various religions and cultures on donation rates, written by members of those cultures. Part 2 deals with paid legal and illegal organ donation and explores aspects of financial incentives in a point–counterpoint fashion, including an assessment of the impact of the Internet. Especially thought provoking is Mark Cherry's consideration of the implications of adopting paid organ donation as public health policy.

Living Donor Organ Transplantation has much to recommend it. Its publication is timely, since the bylaws regulating UNOS living donation, requested by the Department of Health and Human Services, were adopted in September 2007. An excellent compendium of the state of transplantation from living donors, this book will be a valuable resource for the national network, transplant centers, referring physicians, and potential living donors. The composite bibliography from many noted transplant professionals is a treasure. Readers will save a lot of time searching in PubMed with this reference on their shelves.

Patricia L. Adams, M.D.
Wake Forest University School of Medicine, Winston-Salem, NC 27157
padams@wfubmc.edu