 Juliano Testa, who you just heard from in his next question. Juliano is the surgical director of living donor liver transplantation at Baylor University Medical Center in Dallas. He graduated from the University of Kadova Medical School in Italy, completed a fellowship in abdominal organ transplantation at Baylor, additional surgical training in living donor liver transplantation under transplant pioneer Dr. Christoph Broch, who many of you may remember who was here for a number of years. Dr. Testa's research focuses on surgical and transplant ethics, and I have to say, you know, a few years ago Juliano left the University of Chicago to go to Baylor where I know he's doing great, but it was sad for those of us who remain here. We lost a great surgeon and a great colleague, so welcome back Juliano. Thank you. Well, it's a pleasure being here. This is really one of the things I like to do. When I get the invitation to come here, Mark, it's always, I'm kind of looking forward to it, so I'm very glad to be still part of this group that has influenced a lot of the things I do in surgery. My disclaimer is that I do have an Adam 1 and Adam 2 personality, so my Adam 2 is the one that I need to perform surgery every day, so I'm on the field and I work with transplant patients every day and I've invested practically the past 18 years of my life working living donation. That's really what I have done, so I'm very biased from their side. The other side of Adam is that I like to think about these things, and I know it may be strange to some of you, the surgeon thinks. I do really take a lot of pride in thinking that Mark and the McLean Center in general have helped me to get a better understanding of some things, and also have helped me to frame some of these discourse in a way that may seem a little mundane to some to you, simple, but in reality surgery is simple. Surgery is an act of simplicity in its conception. That's at least the way I see it, and so I like to bring things to a very simple basic principle. How do I advance there? As usual, my simplicity is this one. I'm so tired of seeing this. I think Mark has presented something in this at any time, and every time you talk about organ transplants, you heard from Elisa, you always hear of this. There is not much enough, how much is enough, and the bottom line is that after a while having a surgical personality, you end up saying, okay, if the pass is under the skin, let me cut and get the pass out, because that's really, you know, Bonhomme et laudable, I used to say in the old days, and that's really what the surgical personality does. Reality seems like even if we were pushing the disease donor supply to the extreme, we will never be able to fulfill demand. So that's the reality of what it is. And the problem, and Elisa had that on the side, I noticed, is that this is from Dr. Rodrigo from Boston, who has an incredible beautiful project called the House Project, where he goes to the house to the potential patients and tests them about living donation. But this is a slide, and he gave it to me, and you see there is a decline in living donors, which is tragic in a certain way, those are the numbers, by the way, because in reality, as Mark has been advocating for a while, and of course, being my mentor, I really follow him on this, is that if we were really making this living donation work properly, we will have maybe much less problem with transplant at large, and we know many other issues at large. The other incredible part of this conversation is that living donor kidneys work better, and there is no data in the world that will change this, no matter how beautiful the kidney you get from a diseased donor, it will never be as good as a living donor kidney. So there is really a point there that's strange enough, we are trying to push a lot this marginal donor donation from diseased donors, knowing that we're giving to our patients a product that is not as good as the one we've regularly available, which will be the living donor. The not-act was mentioned, of course, we cannot do any valuable exchange for this. So those are the issues and the children's in 1989, so in non-suspected time, I would say, because at that time we were still coming up with many of these issues, we're saying that, well, you know, if this donation thing doesn't work, probably it will not be a bad idea to go into a system or attribution. That was said in 1989. Now, the big issues that most of the opponent to live donation have is risk to the donor. Even this is becoming a little old. It's got a lot to do to autonomy, in my opinion. It's got a lot to do with many issues. And the bottom line is this, as somebody who does that every day, I can tell you that if you look at the data on immediate risk for donation, it's the same in Japan as it will be in Germany, as it will be in the United States. So we know exactly what we have to tell in terms of informed consent to all our donors when they come to see us. You're going to have x percent risk of having this, x percent risk of having that, because those data are the same no matter what. Where the problem becomes sticky, and I have to say that, for example, the work that Lenny Ross has ground, is that we have a problem with long-term data. And this is true. In our conference on living donation, where Mark was gracious enough to come, it was pointed out that the data showed that most of the problems we see in donors will come to surface about 7 to 10 years of donation. It's not an immediate problem that you find in the GFR, which means your kidney function, as a donor will go down immediately. It may continue to go down. And this is a huge issue because, of course, how will I know that the donor who donated 10 years ago is now at risk of developing chronic kidney disease if I have no way whatsoever to follow up on this donor? And so what do we have thus far is the following. There is this persistence scarcity. We have to acknowledge the fact that there is a great incredible opportunity of giving perfect kidneys to people who need it. We know what the immediate risk are. We know we have limited data on, especially in the United States, by the way, on long-term risk for the donors. Those leaders are all retrospective, and they're all limited. And when I say that, I can prove that to you because whatever you study today is after the fact. So you don't know what would have happened to that particular patient who donated 15 years ago and started to have a creeping up of the blood pressure seven, 10 years later, but nobody has intervened on it. Had somebody intervened on that increment of blood pressure or intervened on that decrement of GFR, probably that patient would not have developed chronic kidney disease. So that's my claim that there is something that could be done about that. And of course, on that, there is a legal problem with reimbursement. How do you put this together is that we always acknowledge the fact that the moment we say, okay, guys, this is not good. We are not going to do leave-in donation or allow leave-in donation because the risks are such and such and such. Then we have to leave the consequences with that. And if we are all ready to do that, I'm all for it. I don't need to do leave-in donation to make a living. I can continue to do what I do. I'm on a salary, whether I do this or that doesn't really change my life. So the bottom line is that I can continue to do disease donor transplantation and be fine with that. But then I have to leave with the fact that about 6,000 patients a year only in this country will not receive a kidney transplant. And then if that's the case, you read the New York Times articles about a month and a half ago. You see the number of... Why do I see that? I'm certain about that. You see the number of transplant tourism increasing because that's human nature. Nobody has asked, for example, to the recipient, I would like to see that if we did a survey of the recipients, all of them, how much would you pay for your kidney? That's the other side of the market. The market is always made by a seller and a buyer. So it would be intriguing to see that most of them say, if I had the money, any money would be necessary to me to get the kidney. So people would go out to do this. So there is also a problem with utility, right? We all know that the longer you are in dialysis, the greater is the chance that you're going to die. See, if you are less than 50 years of age, you have diabetes and renal failure in your dialysis, you have 20% mortality every year in your dialysis. That's a big number. So bottom line, there is a problem with that. And there is a fact that if you get transplanted early, you get off dialysis, then you have a longer survival, you can go return to the workforce. There are so many benefits. There is a really utilitarian approach to that that should be not forgotten. And of course, for us, the taxpayer, we're translating in a decreased amount of money that we have to give because taking people off dialysis saves money. Now, where is the problem? Why am I getting all this? This seems to confuse me. I'm trying to wrap it up to what I believe. Years ago, Mark and I, we wrote an article and we say, living don't should come first. And of course, many people say, this is absolutely not the way you're looking at things and there was a lot of criticism about that. And Mark pointed out, you know, the problem, Giuliano, is that you cannot do that unless you form some form of incentive by which the donor would be also incentivized to become a donor. And I've been thinking about that and that's why I really enjoy the talk that Lisa gave. And I try to put everything together because at the end of the day, there is an hypocrisy in some way we do. And as somebody who does it, I'm really, I'm culpable of that. I'm part of this hypocrisy. The donor most of the time is lost a follow-up. So if I lose the donor a follow-up, how I'm going to find out if the donor will develop something that will be detrimental to his own health after becoming such a great actor in making somebody better? I will never know. And so by the same time, you will say, what if I found a way to have the donor under control and at the same time give him something back for what he does? So I would say, that's a normal idea. I'm trying to give a justification why, in my opinion, give a lifelong medical coverage to every single donor, independently of how much money makes a year over these poor or rich will be a good way of going around it. In my opinion, we'll do this. We'll kind of address normal efficiencies. Normal efficiencies is the ethical principle that many transplants surgeons who are against living donation use to say that's why we shouldn't be doing it because you're now supposed to operate on people who are healthy and they don't need the operation per se. But, you know, if you are reinforcing your missing data, all of a sudden you make an argument to say, no, I know exactly what is going to happen. So you reinforce your informed consent because my way of fighting or contracting normal efficiencies is that I give informed consent. So I empower autonomy in the donor to make a decision regarding what is going to happen to him. And since I have a missing data, which is the long-term effect, if I have a way of getting the donor coming back to me for life, I will have data to tell to the other potential donor come to me because I know exactly not only what is going to happen to you in the short term, but also what is going to happen to you 25 years from now. And we will be able, as a community, to say if you are 35, you have this characteristic, you're not going to be a donor period and a discussion. I think it's going to be much more robust data to the people who, like me, think living donation is a good thing. It would enhance beneficence. And what I say with that is that what I do if I can follow you for life, the moment, as I said, that you go and gain 15 pounds, I'm going to tell you now, man, you almost kind of signed a contract with me by which I give you lifelong medical coverage. Now you're going to go into some prophylactic measures that allows me to control your weight, allows me to control your blood pressure, allows me to control some other lifestyle modification that needs to be done so that you remain healthy for life. So I think that, in my opinion, has some benefit. And this is justice. Because, you know, let's face it. This thank you note that we give to the donors is becoming a little old. A donation. Words are powerful. We have always framed this thing about donation, but there is a point in which you keep donating. You expect something back. You know, even when you donate your name to the University of Chicago, you expect something back because you want to have your name up there and people can see from a distance. So we need to be a little honest about this and I think justice is important in this. Let's have some form of fair trade in a certain way. Let's call it fair trade when we talk about these issues. And there is, of course, a moderate utility because if you think about the way that Obama carries being, for example, sold to us, to all of us, is that you need to have, and that's true for any insurance industry, the insurance industry survives for the simple reason that there are people who pay premium and you don't use it because if everybody who pays the premium would require incredible medical care, either the insurance industry goes bankrupt or the premium would be unbelievably high. So who are the living donors? The living donors are healthy people by definition. So it would be a really smart business choice that I enroll as many healthy people as I can in my health plan because they're not going to use it. And the only thing they're going to have for them is following up for life and we check up saying if something happens and give a little intervention and avoid them from going into dialysis, which will be a very costly intervention. So I see a big benefit in that, very smart in a certain way of using the utilitarian approach. There are other things that go into these things that I'm not going to go into it but I'm on time and I want to leave hopefully some questions with that. There are many things that we can see about reward for doing something risky should be there anyhow. There is a lot of autonomy and entitlement of the body part that we should respect when entering a large conversation regarding reimbursement or giving something back to the donors. And then this commodification of the human body, I find that a little bit academic because in reality it's a commodification no matter what you say it to me, in my opinion. But this is really a sticky point. Now I became a Texan, I say, and it's 26 million people. And interestingly enough, 39% of the population in Texas if needed a transplant today will not qualify. 39%. It's a huge number. So the other point is that the same 39% will not qualify to receive a kidney, a heart, a liver, or a pancreas is perfectly okay to donate it. Perfect. We will never question, do you have money to donate? No. We go there and we take their organs. So we need to be a little bit more, how do I say this in a nice way? Less hypocritical about this. A little more honest about this. And then I like, again, children, I read some of the stuff that I like what they say, what is the difference between buying an organ and buying the procedure to get an organ? There is a lot of depth into these kind of centers. So in conclusion, why do I think giving medical coverage lifelong to the donor is at the correct because of the reasons and the principle in a very simple way. I agree. I try to bring down to general comprehension. It's definitely financially sound. I think I give you an idea of that. Of course, there are a lot of issues. Like one of the hypocritical ways that the hospital decided not to cover for lifelong cover is that it costs money. Honestly, it costs very little to have somebody coming to you giving a CBC and a CMP and maybe a GFR calculated once a year. It's a joke in comparison of what it costs to keep somebody on dialysis or other intervention that we do. It will allow better donor selection for the reason that I told you. We will have healthier donors for life because we can do intervention with something that happens and I think there will be less patients on dialysis. That's my daughter. Thank you very much. If you have questions, please ask them. Thank you. No question. I'm a lucky. No questions. I find that hard to believe. Dan is on his way. You know, I wasn't going to, but... So, Juliana, I love your idea about following patients, you know, scrupulously after they transplant. And I think it's a wonderful idea and perhaps maybe we should just do that for everybody, you know? Just follow the patients and follow them scrupulously because I think we could do that in this country. No, hold on a second. But that's an answer. There is a guy here at the business school, Taylor. He wrote this book, It's Nudge. People don't do things unless you find a way of kind of pushing them to do things. Tell them they have to do it. It doesn't work. 50% of the people who don't need it follow up. So the ball line is you have to find a way of making sure that these donors have an incentive to come back. I think if we made it easier for people to come back. The book was mentioned yesterday things fast and things slow. It hurts when they take something away from you. So if you give them the lifelong medical coverage and they give them as part of their, you know, and then you say if you don't show up I'm going to take this away. All of a sudden people are nudge to do something good for themselves and the larger for the community. That's at least my opinion. Okay, we've got lots of people up to ask questions so make them short. Sure. Dr. Tessa, your first slide about how the rate of directed altruistic donation is going down I think is more shocking in the fact that the wait list is going up. People's family members are going into renal failure but less people are donating in light of that increased demand. What do you think is the possible explanation for this failure of the altruistic donated directed donation system? I think part of it is as it was pointed out today it's good to talk about this in a conference where everybody is very comfortable but I live with donors every day and a kidney donor practically loses a lot of work after donation. A liver donor takes about two months to recover and be able to go back to work. There is a lot of heart to donation that we practically do nothing. It's like when you're pregnant we all say the family is a great thing and we do everything for the family and then the surgical resident has got three weeks and has got to go back to work. So words are beautiful facts in life hurt. That's why. Herb Stone I'm a urologist I thank you for your excellent presentation. The question I ask is that everybody should be asking these questions. Who pays for this? Is it the person that receives the organ the government or philanthropic organizations and I think it would be I like the idea but I think it would be a good idea to put an addendum down there and to find out how to pay for it because this is almost like an annuity a lifetime annuity and it is costly regardless of what people may think. Yeah it's in any business you have to look at what is more costly and what at the end of the day that your bottom line will look like and it's much more costly to have people on dialysis than transplanting these people. Number one Number two is also the fact that the hypocrisy of the insurance industry on donation is is universal. That if a donor of mine has a keloid and there's 5,000 deductible in insurance plan and the recipient dies so the recipient the students cannot pay for that complication that donor doesn't know where to go so I think that everybody should put something in the game. The insurance companies because they benefit from having people transplanted and the government are largely because they benefit from people going off dialysis so a solution can be found. It's just a matter of finding common ground where you can initiate this conversation. Thank you. Juliana thank you I actually want to agree with you No way it's impossible but there's always a but so I want to agree with you that all donors should get lifetime health insurance I actually want to argue that everybody should have lifetime health insurance You just told me how expensive dialysis is wouldn't it be really important to do prevention so that we have less hypertension, less diabetes that leads to the dialysis and the leads to the chronic renal failure that needs dialysis in the first place I agree look I agree but this is a larger problem if we had more time I would ask you how come we list so many people for transplantation in this country when and if you ratio with population is the greater number on the list of the entire world because we list everybody and there is no control for that but try to tell people in a larger conversation of course that it's not probably the best idea to transplant somebody who is 80 years old there's going to be a riot for this so there are so many issues in this transplant that touch upon prevention how we do this I agree 100% but my talk was about donations so I have to go there but donations is only necessary because we didn't start with prevention and you know the chronic disease is increasing I mean this is not something that's going to end tomorrow unfortunately it's not like hepatitis C or which we will see probably an ending 20 years doesn't work this way last question so I have a question about there's been a lot of discussion about incentivizing the living and I've always been curious if there's been any thought about incentivizing the dead and that if patients were eligible to donate all organs this would also help in hearts and lungs that if there's any thought for incentivizing the patients that have already died paying their families or paying for funeral arrangements or paying for having some sort of incentive for those that have died do you think that one that would increase the number of organs enough that it could be beneficial is there less risk of exploitation especially from a socio-economic perspective if you're incentivizing the person that has already died so yeah there's been tried to pay for that to reimburse for that if you ask me I will be fully in favor absolutely and if you ask me why in certain areas the donation rate from diseases is still 50% it doesn't go higher than that is because people are getting tired they know there is an industry behind this and come on let's be a little more honest about that so if you tell me I'm going to give you an incentive for your funeral I would do what's wrong with that I really don't see anything wrong with that and I would be in favor of that and it would decrease the need absolutely thank you very much