BACKGROUND:Transplantation is the treatment of choice for end-stage renal disease; it increases survival and quality of life, while being more cost-effective than dialysis. It is, however, limited by the scarcity of kidneys. The aim of this paper is to investigate the fairness of the priority setting process underpinning Swedish kidney transplantation in reference to the Accountability for Reasonableness (A4R) framework.METHODS:Fifteen semi-structured interviews were carried out with transplant surgeons (7), nephrologists (6) and coordinators (2) representing centers nationwide. Collected data was analysed using thematic analysis. To assess fairness in the priority setting process, identified factors were assessed in the reference to the four conditions (publicity, relevance, revision and appeal, enforcement) forming the accountability for reasonableness framework.RESULTS:Decision-making in assessment and allocation is based on clusters of factors. The factors appeal to various values, which are balanced against each other throughout the kidney allocation process: maximizing benefit, priority to the worst off and equality. The factors described by subjects and the values on which they rest satisfy the relevance condition of the accountability for reasonableness framework. However, two potential sources for unfair inequalities in access to treatment are identified: clinical judgment and institutional policies.CONCLUSIONS:The development of national guidelines both for assessing transplant candidacy, and for the allocation of kidneys from deceased donors, would contribute to standardize practices across centres; it will also help to better meet the conditions of fairness in reference to Accountability for Reasonableness. The benefits of this policy proposal in Swedish kidney transplantation merits consideration.

In Sweden "anonymous living donation'' (ALD) has recently been performed but is still under evaluation. We considered it important to learn more about the thoughts of the volunteers for such a donation. Five persons out of ten people who had volunteered to donate anonymously at the transplant unit at Malmo University Hospital were interviewed. The main reason for the wish to donate was the possibility to help another person. One informant thought it was logical and the one who had donated said he wanted to make someone really happy. When asked about possible consequences of the donation the spontaneous answers were related to medical risks and none mentioned psychological risks. The informants in this study, although only five, did not tell us anything that, in our opinion, would contradict ALD but these interviews highlight some points of view regarding anonymous living donation that deserve further discussion.

A complete registration of all deceased patients at intensive care units in the Southern Health region of Sweden has shown that 3,114 patients died during the five years from 1999 to 2003. Only 174 cases (5.6 per cent) were classified as potential organ donors according to the definition of total brain infarction (brain death) without medical contra-indications against organ donation. Consent for organ donation was given in slightly more than half of these cases. In 42 per cent of the cases relatives were not aware of the attitude of the deceased, and in 40 per cent of these cases they used their right of veto against organ donation. Corresponding registration, as part of the computerised system for quality assurance for intensive care (PASIVA), may become a national and complete quality assurance for organ donation in Sweden.

The aim of this study was to survey attitudes toward xenotransplantation and to investigate whether there is a difference in attitudes between patients awaiting a kidney transplantation and the general public. A questionnaire was sent to randomly selected members of the public aged 18–75 (n= 1000) and to all patients of the same age group waiting for kidney transplants in Sweden in 1998 (n= 460). Among the public, 60% expressed a positive attitude toward receiving an animal kidney graft with the same degree of risk as a human kidney graft, compared with 66% for the patients. The proportion in favour of receiving a heart remained 60% for the public, but rose to 70% for the patients. If a human heart was not available, 61% of the public were for the use of an animal heart, compared with 73% in the patient group. A majority of the respondents would accept a transplant from an animal, provided the result and risk of infection were the same as with a human transplant. A greater proportion of patients had a positive attitude to receiving a xenotransplant than did the general public. A life threatening situation marginally increased the positive proportions.