Good afternoon. I'm delighted to welcome you to today's seminar on ethical issues and organ transplantation. We're delighted and honored that Dick Thistlethwaite will present the talk today on a more equitable and efficient system for kidney allocation.  We worked on some projects together in the 1980s when Dick performed the first pancreatic transplant in Illinois and was a member of the team that performed the first liver transplant in Illinois. He also was a member of the team that did the first living donor transplant in the program here at the University of Chicago. Dick is a professor of surgery, a professor in the committee on immunology who received his MD and PhD from Duke and then did his residency in fellowship training at the Mass General and the NIH. Dick has performed more than 1500 transplants, kidneys, pancreas, livers, and conducts research on T-cell receptors and co-receptors to develop biological reagents that can prevent transplant rejection. He and I also worked together for six years in the Immune Tolerance Project, something that came out of the University of Chicago. Dick has had many positions of distinction. I'll just mention a few. He's been president of the International Pediatric Transplant Association and the Illinois Transplant Society. He has been the board chair for the regional organ bank of Illinois and has served as a governor of the American College of Physicians. Please join me in welcoming Dick Thistle-Tway. That was American College of Surgeons. I don't qualify for this. All right, so what I'm going to do is talking about a, in part at least, about a way of allocating organs based on donor and recipient age that we call age mapping, that I've been very fortunate to work with Lainey to develop. But a large part of the talk is going to be about sort of, about current algorithms of allocation of disease donor kidneys and an attempt that's been ongoing for several years by UNOS to create new algorithms that will be more efficient. And I hope I can convince you that both equity and efficiency considerations are compatible, at least with age mapping, although I think somewhat questionable with the proposals that have been made through the kidney transplant committee of UNOS recently. This is not just an ethics issue. It's an issue of law that the National Organ Transplant Act, which is actually a law passed by Congress, demands equitable access to patients to organ transplantation and equitable allocation of organs. So trying to figure out ways to get equal access is very important. Now, more recently by government regulation, federal regulation, not only has equitable allocation been restressed, but notice at the bottom in red, the issue of proficiency, the best use to donated organs has also been raised. And this has been really a decade-long struggle for UNOS, the group that oversees organ allocation in the United States, to try to come up with ways to do this. I might add that in different organs, this has been approached differently. How we do things in kidney is different from life-saving organs because of the alternative of dialysis. But still, since we are talking about a shortage of organs, an important way to figure out how to ration organs in the best possible fashion. My collaborators, Lanie I mentioned already, Will Parker, who is a first-year intern in medicine here during an elective period as a fourth-year student here, did a lot of the mathematical work of the model I'll show you. Bob Beach is an ethicist and a longtime friend of Lanie's from Georgetown, who helped us with the ethical considerations for age mapping. Summer Gentry is a mathematician, statistician and modeler from the Naval Academy, who I had heard give a talk several years ago that I was impressed with, and that Lanie said, well, let's call her, and we got her involved without ever having met her to help Will with the mathematical modeling. And then Ben Hippen is an aphrologist from the Carolina's Medical Center in North Carolina, Charlotte, North Carolina, who actually, in the early part of the project, worked with us and did a lot of the statistical analysis in terms of looking at the UNO's proposal and critiquing it. Well, if you haven't gotten, if you've gotten anything out of the seminar series, it's there aren't enough organs. And if there were, no one would argue about allocation at all, we'd all be happy and we'd be transplanting. And there wouldn't be federal laws or regulations governing transplantation, that is over and above what we're all facing now in the rest of medicine. But it's been a fact of life for us for a long time. This demonstrates graphically that the waiting list keeps growing, the number of kidney transplants remains stagnant. And the only real point to make from this is actually how good the nephrologists are of keeping people's renal failure alive now. Because despite the increasing disparity, you notice the death rate on dialysis has not changed. Well, just some general things. There are multiple approaches to trying to increase the supply of organ donors. Non-heart beating donors now, which we refer to as DCD. These are people that don't quite meet brain death criteria, but whose families have determined they want to withdraw active treatment for supportive care now make up about 10% of all organ donors. Excuse me, yes, 10% of all organ donors. In this hospital, I want to mention that Tracy Kugler was instrumental in developing our DCD policy here. First person consent remains controversial if you sign and get on a registry in your state for to be an organ donor. That now legally takes precedent over the wishes of your families after your death. It's a mixed blessing. Yes, we can force one more donor, but to the news media loves to publicize these events, which probably then prevents several more people or families from donating. Presume consent is more of a European model, which is an opt out. In other words, you're presumed to be a donor unless you have stated beforehand you don't want to be. And in Spain, where it's most successful, it's combined with actually having in each hospital in Spain a paid employee whose job is to identify donors and help have potential donors actually become donors. Spain, because of this, is the most successful country in the world. In terms of donors per million, with about 45 donors per million population, the U.S. is somewhere around 30. So in other words, they do about 50% better than we do. Something that actually just this week was introduced as a bill to Congress is the to try to reverse a law which prevents HIV positive people from being organ donors. The concept here would be to allow HIV positive donors to give to HIV positive recipients, which now at least for our program is about 5% of our kidney transplants are in HIV positive patients. So this would again increase the availability of organs for everyone. I think it's conceivable with the improved retrovirals, by the way, that in the future you could envision giving HIV positive organs to individuals who were HIV negative and treating them prophylactically. And that probably even today would work, I think, intellectually and emotionally. It's probably not an acceptable thing right now, but theoretically it could be. And in fact, as I talked some about older donors, I suspect an older recipient, I suspect a lot of older recipients would do better with that sort of donor from a young person than with an old donor because of the efficacy of current treatment. Economic incentives, I might mention that Frank Delmonico, the keynote speaker of this series, about ten years ago proposed that there be a donation made to families of deceased donors for funeral expenses as a thank you, in other words as a payment, didn't go very far. And finally, Lanie has mentioned the possibility of revising the brain death criteria to that of cortical brain activity. I'm not sure how many new donors this would bring because this would just convert what we now do as DCD donors basically into a redefined brain death donor status. Living donors, although it's still a very small number, the non-directed donor altruistic donor has become increasingly a donor source. And as we heard Garrett Hill talk about in his business model of donor chains earlier in this series can be magnified many times over in terms of one donation starting a whole chain of exchanging of donors among living donors who are incompatible with their emotionally related recipient. And finally the whole, the big elephant in this refrigerator is the idea of paying for donors themselves. It's a very emotional argument on both sides. Those four can see how we would have enough donors to to transplant everyone needed at least for kidneys. I don't think we're talking about heart donors here or lung donors but and note that we do have hazard pay for several other risky things that we allow individuals to undertake. Those opposed to it talk about the privilege praying on the underprivileged because certainly the people who would volunteer to give up their organs for money for the amounts of money likely to be offered at least because I suspect we all have our price. But the price that would probably be given would be those of the poor. Just as a side Lady now has a journal book club I guess that has met twice trying to look into the underpinnings of payment and the possibility of this or the ethics of why it shouldn't be done to try to get a more reasoned approach than what we've heard publicly. I'm going to probably skip this slide because I have a lot of slides other than the very bottom which says actually and what we're going to talk about is one of the ways to help not resolve but help with the organ donor shortage is to change the allocation algorithm to favor optimal candidates. And I think this slide this next slide will help you understand that if you look at the most frequent cause of failure of kidney transplants and this comes from an article very good article actually out of the Mayo Clinic where they had biopsy data on failing kidneys. But you can see by far and away the most common cause of a kidney of a kidney failure is death with a functional kidney. That means that the kidney could have worked longer. Now I can quibble with some of their percentages they have a different patient population than us and they take different risks because we don't have 11 or 12 percent of our patients have no primary non-functional with disease donor kidney transplants. I think we would find that unacceptable and I believe if I ask Michelle who oversees our transplant follow-up Michelle Josephson I believe we probably have more than 11 percent of our patients with chronic rejection also. So there are some differences in populations and how you approach but the astounding factor is that a lot of kidneys go into the ground into the grave they could still be working for someone else if they were put into a more appropriately matched recipient. Let's just review kidney allocation now. Since 2002 there have been two types of donors primarily standard criteria donors that's the majority and about 16 percent of donors called extended criteria donors. That's all donors greater than 60 year old or greater than 50 with the caveats noted. It requires an opt-in by sign consent to get a expanded criteria donor. This is because statistically and they were chosen as an expanded criteria donor they have a relative risk of graft failure at least 1.7 times that of an ideal donor. Now that statistic is not limited to expanded criteria donors. If you look at standard criteria donors about 30 percent of them also hit that level of a relative risk of graft loss of 1.7 percent but virtually all expanded criteria donors hit that and have that risk or higher. The distribution algorithm which is the baseline financial move is a point system where waiting time is the most important gets you the most points. The longer you waited the more likely you are to be offered a transplant. Queuing waiting is an equity way of doing it. Everybody gets their chance you get in line and you take your chance of getting to the end of the line and getting a transplant. There are some points given for efficacy and that's HLA matching primarily. That used to be a big deal as immunosuppression has gotten better it's not nearly as much of a deal as it is now in fact only HLA DR matching not AB or DQDP or others are used in the algorithm and also and this is probably a good thing within each category there is varying quality so when I get offered a kidney in the middle of the night it may be a standard criteria donor kidney from a 20 year old who has no cool mobilities other than having been in a traumatic accident or it may be from a 65 year old who's had a stroke had hypertension may have diabetes so there is a varying quality and that again is sort of a lottery which is another equity measure but equity drives pretty much the current system rather than efficiency. So in 2011 the kidney committee KTC kidney transplant committee of UNOS presented a concept paper with a proposal to totally change how we distribute kidneys. So first the top 20 percent of kidneys by what's called a kidney donor profile index and I'll explain these terms would be given to the top 20 percent of recipients best as determined by their estimated post-transplant survival. So just take the best and give to the best in other words off the top. This remaining 80 percent of kidneys would be distributed by age matching with a range on either side of 15 years which would give younger kidneys to younger recipients and hopefully improve efficiency. So this raised the two questions because it's a two different scheme for a lay side by side is giving the best kidney to the best candidate ethically justifiable and is giving the younger kidneys to younger donors ethically justifiable. This is each of these is a question in two parts because one is a general question and the other is looking at the specific criteria that UNOS set to try to incorporate these. Now for me I have trouble with the first one best to best is not sort of how we do medicine it's sort of the neediest first. The second I would argue that in theory there is not a problem with giving younger kidneys to younger recipients indeed that's the age mapping proposal that I'll talk to you about. It makes it easier because I think the specifics of how UNOS has done each of these or proposed to do each of these is flawed. So let's talk about longevity matching. The kidney donor profile index is to be an estimate of donor kidney not survival not the recipient survival in terms of longevity but just the kidney survival has 10 different factors that are only donor based and you can argue with the individual factors but if you plot the relative risk of graft failure versus the percentile by this KDPI index and it's an index over 100 percent so if someone's at 80 percent it means 80 percent of the kidneys or kidneys at 80 percent 80 percent of the kidneys are estimated to perform better predicted to perform better than that kidney. Now you can see the real problem of this as far as I'm concerned is actually out at the tail where the among the worst kidneys and you can read from that the kidneys that older people are going to get meaning people like me and what they want to do is limit at least distribution to the bottom 20 percent best to best but since the KDPI we will talk a little bit about the upper end as we move along as well now the estimated post transplant survival is only based on four factors age time of dialysis prior transplant and diabetes and obviously each of these factors make post transplant survival worse and we'll talk about that as well now if you look at this in terms of median estimated post transplant lifespan you can see that indeed some kidneys excuse me some kidneys are estimated to work much better I would argue that the top 10 percent is looks different than the top 20 percent because the second decile it looks pretty much on a linear curve with the others the justification given interesting and this is this is actually a quote is the reason they the top 20 percent was selected was for no other reason that it was determined to be the most discernibly different from the rest of the kidneys and I think as we'll talk about that is an issue a busy slide I've just talked about the arbitrary dichotomous division between 20 and 80 percent is having no justification ethically about why the it is a 20 percent having virtually no justification other reasons is methodologically the statistical evaluation is lacking this is a test to remember to determine who gets a kidney so a medical test that can pick out the top quintile from the bottom quintile but not people in two successive quintiles so in other words you're going to treat similar people differently based on a measure that cannot make that distinction I put this bottom paraphrase actually here because Alan Lightman who talked to us a few weeks ago was a member of the group that helped develop the precursors for both EPTS and KDPI and is an author on this critique stating essentially what I have already so one of the things that I wanted to point out about the upper end of that curve is that KDPI is calculated without consideration for candidate factors that decrease graph survival from the earlier slide where I talked about death with a functioning kidney which is what we're trying to overcome that's mostly older people who basically their kidney could outlive that's a recipient factor so this formula that ignores that makes it look like the worst kidneys which by our current system which is where this is modeled from meaning the expanded criteria donor kidneys are the ones that fit into that category and we're digging them even excessively by the formula because we don't take into account that many of those kidneys would actually last longer if put into people who would live longer and I think I showed that slide again one and concentrate up here that certainly it is going to keep going up but I don't think it's going to go up so expeditious what's the difference try convincing a kidney recipient they want one of these kidneys and we're going to discard kidneys because of the way we're presenting the data to them and I don't think adequately analyzing it for the patients the bottom point even the kidney committee of UNOS admits that they have not really vetted or validated the estimated post transplant survival this is their quote and I think again having ideas presenting them is great but not saying this is how we want to distribute kidneys when it's not actually been a validated measure diabetes remember one of the four things that go into estimated post transplant survival how can you pick the most prevalent disease that causes kidney failure and make that as a discriminating factor it actually isn't the discriminating factor is cardiovascular disease that's what causes people to die before whether kidney is still working not diabetes yes diabetes have a lot of cardiovascular disease but so do other people the problem is that UNOS doesn't collect data on cardiovascular disease to be able to use it as a discriminating factor and this is the closest they get so that they will pick to discriminate against a disease people with a certain disease in order to try to have it as a surrogate for another model because the diabetes if you look at the multiplication factors it's not just 25 percent of its time on dialysis and 25 percent of its age etc age and diabetes are the two strongest drivers of EPTS and it will disqualify even young diabetics from being in that top 20 percent it will also along with the age plus minus 15 age discrimination when they looked at what's going to happen to various diseases and who will get transplanted diabetes is the only disease among the major diseases that cause kidney failure that will be discriminated that's because it's primarily type 2 diabetes which far out numbers type one is primarily an older population so that's as much age matching it as it is the 20 percent now they really unfortunate thing is that they have chosen in this to look at survival from time of transplant if you look at earlier data looked at survival from time of starting dialysis of development of end stage renal disease transplant makes a tremendous difference to people with diabetes if you look at lifespan from listing with no transplant these are people who are highly sensitized have hard time getting a recipient you can see that in young people their time that they would live just on dialysis is less than half of that of someone who doesn't have diabetes it's reduced in middle age people and really only starts to almost become the same in old people but still a decrease if you look at life years gained with transplant it's the diabetics who gained more life years with transplant again until you get to the very old so that it's actually imperative that we try to get your diabetics transplanted because they benefit so much from it and this is totally ignored by simply looking at time from transplant rather than the time of development of renal disease the final thing that's just I think probably for lady more than anything else is they actually present this data in their proposal and that is the improvement of their hybrid proposal over baseline meaning what the current way kidneys are distributed there are life years gained there's no doubt about that compared to baseline but if you look on a per patient basis relatively small gains if you look at life span benefit of transplant versus dialysis for example it's a half year that's gained that would be 5.4 versus 4.9 but the most amazing thing is if you said let's do away with this 20 percent of giving best to best because of all the concerns I mentioned and just did age matching you would see absolutely no difference and if you compare those two columns you can see there's virtually no difference between the two so in in the concept proposal the justification they are having presented this data that they gave for the hybrid proposal was that it gave them increased flexibility I don't know what that means but that was the only stated benefit and and actually there is none so let's talk about age matching I can trash that too if you are going to age match you have to consider what are the age distributions of your donors and recipients because and actually the one of the first papers Mark and I worked on had to do with age matching of liver pediatric liver transplant recipients and brain death donors of pediatric age and there was a great mismatch here there's a great mismatch also if you look at donors first thing I want to point out is that this is not the number of donors this is 10 times the number of donors so when you see this peak at 3000 and this one almost is 3000 think of it actually being down here at 300 okay so in other words there are far more recipients than donors but in order to show the peaks and they're actually three there's a small peak due to unfortunately due to infant death there is a large peak due to trauma among young people and there's a large peak due to cerebral vascular accidents among old people now obviously 50 is not the and I'm looking from the side is not the peak of that disease but there tend to be core mobilities in people with cerebral vascular accidents from older age that make them disqualify them as donors both these peaks are younger than the peak of recipients so if you did strict age matching year for year here and you were say 20 years old you'd have enough donors so because this is really remember 300 not 3000 you'd have about the same number each year of 20 year olds who needed transplants and donors who were 20 years old if you go out let's say to 65 where donors here that read 500 would be really 50 and you by comparison have 2000 recipients vying for those 50 transplants so very inequitable hence the plus minus 15 years to try to smooth that out it doesn't really smooth that it out however because even with the plus minus 15 years if you look at the number of transplants per the number of candidates and these age ranges were chosen by unison will continue to use those further so we can do comparisons it looks like the youngest age range 18 30 to 34 year old candidate would have an over three times chance of getting transplanted than someone who is in the highest age range of over 65 so this is just age discrimination so not only is it because of the mismatch in ages of donors and recipients preferentially giving more kidneys to younger as age discrimination but there's another unintended consequence here and I bring these up because Laney loves unintended consequences and that that is that if you give fewer kidneys to older people their weights will be longer these are the people who are most likely to die while waiting and therefore you're going to increase your death on the waste list that statistic that's remained relatively stable for a long time so this is not a good thing to do now in the public comment period which the way Unis does is they put out these proposals they allow public comment in the public comment period the office of general counsel in the office of civil rights of HHS commented and you can read their comment saying this is it does not meet with the requirements of the age discrimination act of 1979 and likely to bring lawsuits and that killed this proposal I'm sure they didn't listen to Laney in my comments but they listened to to the government's the government gave them an out and actually stated that stipulations in the age discrimination act allowed that age can be employed if it's used as a proxy for medical variables it was like a lifeline being thrown out to them they didn't take it but nonetheless it was there well Laney and I looked at this and as you can see I've been very critical if she were giving this talk I think it'd probably be up a notch or two it's easy to pick out flaws and other people's ideas it's much harder to be constructive about how you might be able to help them improve on it and we looked at the two parts of the proposal and neither of us saw a way that we could clearly ethically justify best to best people may agree with that certainly the creators of that algorithm disagree with that but at least with our feet being soundly based in equity that didn't seem to be the right thing so we asked each other and both of us sort of came up with this idea at the same time what can we do because age is very appealing number one as I say here we all age is something that happens to everybody it's not taking diabetics versus non-diabetics tomorrow we're all going to be a day older but two and we had realized this actually and begun an opinion piece actually we're on about its 20th version by the time the the government statement came out that it is a good surrogate for both donor graft survival and candidate lifespan and it should even though I don't think I had any idea it was in the age discrimination act of 1979 it should meet those requirements so this is actually a graft of hazard ratio of donor age and graft survival in the paper that first proposed the precursor to KDPI and they even admitted in that paper and this is again the the Michigan group that there was a great relationship indeed you saw from about 10 to 40 or 10 to 35 years of age that there was about the same hazard ratio there wasn't a difference but above that almost a linear relationship with age and the then the graft survival of that transplant when it was transplanted Laney presented this slide two weeks ago and I presented it only because she couldn't find the 18 to 34 year old donors I don't know if you remember that but she was searching around for this dotted purple line and the reason she couldn't find it is it's because it's hidden by the solid purple line which is the 10 to 17 year old donors there is just no difference in survival when you plot out this was 10 years of the UNOS database that we plotted out ourselves successively older groups of donors have successively worse survival much consistent with the hazards ratio that I just showed you but it really is equivalent a donor who's 18 and a don't up to 34 that it's even if you plot that out by smaller increments there's very little change as the hazard ratios would suggest UNOS actually looked at age as a similar variable and compared it to KDPI forget the kids they did this wrong they're this is all mild remember so if you don't have a good model their model doesn't work for children and indeed one of the things as well as subsequently done is gone and looked at kids and with more granularity you can pick out even some people from donors from zero to four years of age that if you do dual transplants or unblocked transplants do just as well as the 11 to 35 year old but look at the adults and you can see again there's a linear relationship between donor quality as measured by their KDPI and age itself so that KDPI adds very little to age now they want us to see that there's a substantial overlap as a negative advantage I see it as a positive advantage and again I go back to my statement we want to treat similar people in a similar fashion and by having that wiggle room and I think they didn't describe it but I believe these are the lines are outliers the bars are probably 70 and 25th percentile and the middle line is median by having that variation in quality it makes one group closer to the next and so there's not as much discrimination because of that sort of lottery effect that we even talked about earlier with the current system what about lifetime this is another slide from UNOS they shoot themselves in the foot a lot and that is looking and expected remaining lifetimes from people starting dialysis from people getting transplanted and age match normal controls now I want to focus primarily on the green line obviously to again point out that there with age there is a incremental decrement in lifespan so this is the EPTS which age is a good surrogate for this is not all that accurate for comparison because this is all people on dialysis not all people on dialysis are healthy enough to get a transplant so it's not a good comparator but it does worse obviously and again the focus for patients is when I show them this graph they're not going to be as good as if they had their own kidneys working normally for them but still age is a good surrogate for outcome in terms of post-transplant survival so the development of age mapping for us was really a two-step process the first was to create an ethical framework that would say that it's okay to use age as a discriminating factor without it being discriminating to use the word two different ways and the second when Will came as a fourth year student during his elective period to work with us with a lot of math mathematical expertise that we claimed we had forgotten but probably actually never really had we were able to actually generate a model for this perhaps it should say oversimplified rather than simplified there so one of the things you have to know about Laney is when she gets into something she takes a mini sabbatical so one weekend Laney came to me and said I need to read about rationing of scarce resources and I have this mental image of her locking herself up in a room at home and ignoring her kids and her husband and and reading about rationing of scarce medical resources one of the things she came back with after that weekend was this article by Prasad at all which was essentially about how you allocate scarce medical resources not necessarily transplant organs although that was one of the examples he used and although he didn't agree with all the principles he enumerated I think this statement is very true to achieve just allocation of scarce medical intervention society must embrace the challenges of implementing coherent multi-principle framework rather than relying on simple principles or retreating into the status quo we do a lot of retreating into the status quo I think if you look at the argument about kidney allocation there are those who want better efficacy and there are those who want to maintain equity and if you're going to just use those two principles you're never going to get any place so we said okay we we like this and we're going to run with it so the way we ran with it is course equity-based because that's where we come from and we set us our first principle that we needed to maintain as demanded by NODA equitable access and equitable allocation which is really equal opportunity and what does equal opportunity do it respects the worth importance and dignity of all individuals so if you're going to have a first principle that's not a bad one to start with in terms of transplant of course that means everybody should have an equal chance of getting a transplant that's mandated by law but mathematically we could express that and we already started to do that when we were looking at the number of transplants per candidate age group but rather than letting that fluctuate we'd say what we ought to do is first principle is set that at a constant value so whether you're 65 or whether you're 20 you have an equal chance of getting a transplant and I had to include this last line because it's philosophy speak that I don't understand that that means it lexically constrains subsequent principles which might justify age mapping there's nothing about dictionaries in this so I just don't understand that so on the first principle also that helps us out I don't oh so here's the mathematical or the graph of what this would be mathematically rather than having different numbers of kidneys given to different age groups we'd start from the premise that we had to have each age group that get exactly the same number of kidneys the ratio number there is not important that just happened to be what it was in 2010 2011 is actually 0.9 because we get more people on the list and don't have any more transplants but it's across the board everybody has the same chance so the first there are the second principle we used in our step two is called prudential lifespan also philosophy speak because it has nothing to do with prudence but what it is is the principle at least applied to medicine that treating all persons the same over the lifespan is equitable not that people need to be treated the same throughout their lifespan but equal to other people at the same stage of life we do this all the time you don't get your driver's license until you're 16 we set an age at which you can vote we set an age at which you can qualify for social security might change in fact some of the previous ones have changed but but everybody's treated the same at the stage of life so this justifies giving older kidneys to older candidates now i look at this a little bit differently and again i'll use myself as an example i'm in my 60s i had good kidneys when i was in my 20s i had good kidneys when i was in my 30s and 40s and 50s thank goodness i still have good kidneys now but if i didn't what i had the same claim on a 20 year old kidney as someone who developed kidney failure at 18 and never had good kidneys when they were 20 never got that chance that i've already had and enjoyed and that to me is what prudential lifespan equity means now on the other end of this is a principle of fair innings which bob veach our collaborator championed uh you know i'm a south sider i like the white sox i know what an ending is but this this is not a baseball ending this is actually a cricket ending which i know less about but i assume everybody has to have the same number innings when you play cricket you get your fair innings but as a principal harris defines this as an equity principle that each person should be given an equal chance of a reasonable length of life and derived from that it directs health resources preferentially to those who are worst off by means of being furthest from obtaining this normal lifespan applied to kidney transplantation it's used uses being a younger candidate as proxy for medically worse off think back to the discrimination act this is sort of the phraseology they use also the same that harris used in the sense of having fewer healthy life years and less chance of reaching a normal lifespan and it justifies giving younger kidneys using younger kidneys as a proxy for better kidneys as i've shown graphically on a couple of graphs previously therefore it seems to us that it would be very consistent with the requirements of the age discrimination act so our conclusion from the ethical portion of this is that using age and allocation of these donor kidneys this is ethically permissible and does not constitute discrimination what's wrong is discriminating by limiting equal access to transplant for all patients as originally stated in nota now well comes in and summer gentry comes in because we were trying to push will to do this great continuous variable thing that everybody would proportionally listen that and he was getting frustrated with us and we actually had a conference called summer gentle gentry and she has simply said keep it simple stupid although she said it much more nicely than that and that she said you can achieve the same thing as a prototype by simply sitting up age group candidate age groups and donor age ranges and if you want to keep the proportion constant you can do that so you will have an allotment of the let's say the 18 to 34 year old kidneys the optimal kidneys and you will a lot a certain proportion of those because they're again they're disproportionate younger kidneys are disproportionately in a ratio fashion plentiful even though numerically they're not for younger donors now we didn't know how to treat the kids so we use the literature of the time that said kidneys from 0 to 10 year olds actually perform about like a 50 year old kidney so we placed them in the 50 year old pot but that's neither here nor there that can be done better and what we did is we started and we said okay we'll take all the young kidneys and our youngest candidate age group range we set it 18 to 34 because we knew those had essentially the same performance and we put a proportion of those into the youngest recipient group or a candidate group up to the quota that they would get and then those less over we put in the next group and by doing that successively we created an allotment allotment matrix which is here so if you look at the donor ages only to provide the appropriate allotment for the 18 to 34 year old only takes 30 percent of the 18 11 to 34 year old kidneys so the other 70 percent goes to the next recipient age candidate age group that pretty much fills that up 94 percent but you need some more so 6 percent out of the next age group also goes that and that fills that allotment up so most of the 35 to 49 year old kidneys actually go to the 50 to 64 age group so how does this work with this work in real time you would take a donor kidney and let's take a 20 year old as an example and that that would fit in the youngest or the optimal age range 11 to 34 and then it's allocated to a weighted probability of 29 point 29 percent going to the youngest age range and 71 percent going to the to the next youngest candidate age range and you just work that on through basically so how does that end up distributing kidneys if you look over here the answer is by mapping not matching ages you actually do very well because you give most people a kidney younger than their age so that you look at the 18 to 33 year old 18 to 34 year olds they're all going to receive kidneys from the 11 to 34 year old group and as I said if you do this on a percent basis remember there are a lot more people 50 to 64 year needing kidneys but on a percent this is totally filled up this is 94 percent filled up and you only need 4 percent of the kidneys to come from the 35 or 6 percent to come from the 35 to 49 age range on up if you look at the 50 to 64 year olds most of our kidneys are going to come from the 35 to 49 year old age range in other words still younger than I am that we put the pediatric kidneys here a few are going to get age match kidneys 50 to 59 year olds and even in the plus 65 year olds half come from 50 to 59 year old younger than they are half from 60 plus now I could go back to the graph of the age distribution of donors but most of these 60 plus are actually less than 65 because as you go over 65 they're fewer and fewer so this is actually an equitable way of giving younger kidneys to younger recipients by mapping rather than matching just look at the baseline system and its lack of efficacy because you have younger kidneys going to older recipients about a quarter of them 20 year old kidneys 30 year old kidneys you have older kidneys 50 59 year olds still going to even the younger recipients because this was a time period when we were doing the scd ecd the expanded excuse me extended criteria donors most of the older kidneys above 60 ended up with older recipients but that's a function of how kidneys are distributed currently so how did you know respond to this the office of civil rights as I said Laney and I had already stalkered our work on this but we certainly let me put it in a first person I certainly felt vindicated by the government probably the only time that I can remember I suspect she did also that they actually thought that it was as discriminatory as we did well you must respond to not by taking their hint but by saying okay we're not going to do age matching or age allocation in any form instead they devised and presented in September a new protocol which would maintain the top 20 percent into the top 20 percent by giving them preference but what it also did in which also I think is the main reason for the benefits that I'll show you is they gave the top 20 percent recipients equal access to all other kidneys now I don't think they'd want equal access to a 90 percent KDPI kidney but I think they would want access to that access to that 20 to 35 or maybe 20 to 40 percent kidney but what that does is by allowing them to double dip and this is all models by a UNOS model that is not freely available to the rest of us is it still gives a preference to younger donors in terms of the numbers of kidneys the ratio their chance of getting a kidney and I think it drives most of its benefit from that factor and not by the 20 percent into 20 percent this is a more refined picture a larger database so to speak of of looking in 2012 rather than 2011 of estimated graph survival by KDPI you can notice a couple things indeed as your KDPI index gets higher it gets lower and there's still this drop-off at the end this is one-year survival this is two-year survival and clearly there's a decrement over time which we all know that's magnified with the poor grade kidneys but if you look and they also provided us a table and I wanted to specifically compare with the question of what is a top 20 percent recipient to take if they take a 10 percent kidney it's one-year survival is 93 percent that's only one and a half percent better if they get offered a 30 percent kidney I would advise them to take it first that would be their choice and if you look even at it five years the difference between a 10 percent and a 30 percent kidney is projected to be only 4 percent now not every 10 percent kidney necessarily is better than a 30 percent kidney because they're factors that don't go into KDPI that affect graph survival that we know about but they are not that frequently involved but for example if someone had bad DIC from a gunshot wound to the head and had micro thrombi in their kidney that kidney might still qualify as a 10 percent kidney by other things but it might not be as good as a 30 percent kidney so with the overlaps here I would have no problem saying to someone you're offered a kidney that with a KDPI 30 percent you could wait and get perhaps a better one but I think you ought to take this kidney now because by waiting even someone in their 20s has a two to three percent chance of dying within the next year of complication of the renal failure so it's not without risk to wait longer here here is the outcome based on the baseline versus now their new proposal and notice that the advantage gained is cut is extensively if you look for example just lifespan lifespan benefit uh transplant versus dialysis a quarter year is all that is gained now with the new proposal so I maintain they need to go back to the drawing board once again whether they will or not I don't know and finally my conclusions age mapping doesn't raise ethical issues that still exist in the new proposal it's likely that age mapping would produce better results in the current proposal remember the current proposal only affects the top 20 percent uh not everybody and age mapping does affect everybody uh in in all the outcome measurements that they have looked at and when we presented this to the kidney transplant committee our proposal this summer and asked them to at least run it or a form of it in in their model modeling system to be able to see how much benefit it gave their response was basically they wanted to wait and see what the units board decided about their new proposal which will happen in a meeting this June so thank you very much thanks very much so um I think that to me that the crux of the argument uh and the proposal that you make is is that um the chance of getting a kidney is equal across all ages yes right um and I don't know where that lands ethically but um as I was sitting there and I was thinking okay my son is 23 or whatever four if both he and I had kidney failure and we both needed a kidney therefore I'd want him to have a higher chance of getting that kidney than me and I don't know where that lands in terms of ethics and and I suspect that it doesn't um work with the equitable things that the nota and all that stuff and the final rule set rule says but to me it just seems right that my son would get have a better chance of getting a kidney than I would would he say the same yes you don't think he's I don't believe so I believe he'd say that you ought to have an equal chance with him 20 year olds so so so I believe he ought to have a chance at a better kidney I'm not sure he should have a chance of no you you should you should you you're saying he should have equal chance of a better kidney yes and that's not only legally correct as far as I'm concerned but I also think ethically correct you're valuing his lifespan differently than you and you personalize it and it's very hard when we do with our kids but when I am talking to a 60 year old who's on dialysis not tolerating dialysis life is miserable I believe that person values whatever five or seven years he'll get out of a kidney transplant perhaps more than a 20 year old who won't take his medicines and lose it okay so that it's very hard to project our own feelings on others and I think that honestly I think people have an equal claim to getting a transplant which is exactly what notice was all about to start with but but I really I really resent the fact that we are now giving 20 year old kidneys to 65 year old recipients and and that's that's what we're trying to correct I agree that that's not right just the chance dick you showed us nota and then you showed us the final rule and the final rule said that the equitable allocation of cadaveric organs should be attitude the best use of the donated organ and you indicated that you and Laney for ethical reasons elected to go with the equitable allocation of the cadaveric organ as your starting point let's say rather than the best use of the donated organ as someone who trained for a while in England where you remember they had that informal convention never a rule never written down that organs would not go to people above the age of 55 you're showing your age mark because they no longer have that in England no I know you know it took a generation and a gradually since it was never written down it was just a matter of enough people changing the convention but maybe maybe that's it yeah but but if you start I mean if you start not with the I think the politically correct move that you made to start with equity rather than with efficiency and best use but if you start with best use which I think was behind the the English 55 rule went when they adopted it but if you start with best use could you not come up with an entirely different allocation system and then then you'd have to find the ethical justification for it but we could do that I mean we could work down on Mark I'm sure you could I guess let me give you the bottom line of my question because if I didn't know Mike was gonna ask his bottom line of my question is why don't we transplant everybody under the age of 50 before we transplant anybody above the age of well you know it's it's interesting that if you look at fair innings and don't constrain it by equal opportunity you run out of kidneys at 39 because if you say you should give it to the youngest person first because they have least chance of having a normal lifespan and you just go into your run out of kidneys at least for 2010 it was 39 I don't think anyone would say no one above 39 deserves a chance at a kidney and therefore it has to be constrained in some fashion we start with equity because I think both of us think it's important it also happens to be the law the final rule is a regulation I mean they can throw us in jail and find our hospital and other things but it actually isn't a law and I do think what they were getting at in between 1984 and 2000 was the idea that we weren't using kidneys in a prudential fashion there I used it the way it should be used Laney in other words we weren't using them in a smart fashion because it's not going to make a world of differences I showed these differences are a half year or a quarter year increased advantage over staying on dialysis incremental increase that is but that's a difference and it's especially a difference for the young person so I think our age mapping actually gets that that it actually gives young people kidneys that are equal at their age or younger and it does that for everybody so I think we actually got to a very good place we weren't sure we were going to get there when we started out add on to what Vic just said because I do love unintended consequences the other thing we have to remember is that when you look at the young people they get about seven currently they get about 75 percent of their organs from living donors whereas somebody over 40 has about a 25 percent chance of getting a living donor and I mentioned that because if you gave all the deceased owners to those under 39 two things either happened one nobody serves as a living donor because their loved ones got the kidney they wanted or we're going to start having the 30 year olds giving to the 60 year olds and living kidneys are even better than even the best deceased on the kidney and so if you want to talk about an inefficient system is to increase the number of living donors going to older people so you need to have some way of still encouraging the young person for seeking out a living donor otherwise you're going to decrease the whole pot and remember you know only gets to control 60 percent of that high because they don't control the living donors I would argue a little bit against Laney it's that the benefit level given here is not enough to convince anybody to wait to get a deceased donor kidney if they have a living donor and like Mike most most fairings would but moments proposing that except it's a straw thing to knock down I think Mike's question says what's going to happen with the 20 year olds is those of us that are still healthy enough to give our kidneys to them will right so it's already 10 plus after the after the hour and so obviously a very interesting and controversial area that still hasn't been solved congratulate dick and Laney for trying to to get something better and thank you dick very much for presenting


The various sources of international law that were surveyed in the preceding weeks do not live in isolation from each other, but they very often interact with each other. And for instance, a state may accept, by a unilateral undertaking, an obligation which is contained in a treaty to which it is not a party, or a customary rules, as you will see assist in the interpretation of treaties. Or again, customary international law may also arise out of the practice stemming from identical treaties or from multilateral treaties. But what the sources of international law have in common is that they are all formal processes by which international obligations are created. In other words, the origin of any international obligation and of any corresponding right is to be found in one or several of those processes. But things are a little bit complicated because the interaction between the sources is such that the same obligation may exist for a state or an international organization under a treaty and under a rule of customary international law or under a treaty and a unilateral act of that state or organization or a general principle and a treaty. Sources are grounds for international obligations and several different sources can each be ground of an identical obligation which will simply have different origins. Origins that remain legally distinct and independent from each other in terms of validity and in terms of scope. And conversely, and because the production of international law is, as you remember, decentralized, the same state or the same international organization will sometimes not be bound by the same international obligation through different sources but will be facing obligations that contradict each other. Those obligations will contradict each other because it is impossible to reconcile them and to perform each of them at the same time. And those irreconcilable obligations can be found in sources of the same nature, for instance in two treaties, or in sources having different nature, for instance a treaty and a unilateral act of an international organization. In light of this, when it comes to the application rather than to the making of international obligations, a few elementary questions arise. Who is bound by the obligation at stake and is it always owed by those who are bound? What does the obligation actually mean and what must be done in order to comply with the obligation? Which obligation should be preferred in case several obligations conflict with each other? Those are the questions that we will address this week and that we shall try to answer. But let me turn first to the first question that is the personal scope of what can also be called the rationer personer scope of the various sources of international law we have surveyed. Who is bound by the obligation at stake? That question is indeed a question that must be answered in light of the sources where the obligation is grounded. And let me recall some of the answers that you know already. On customary international law you may recall two important things. First, the fact that customary international law provides for rules that are binding on all states. And also all international organizations which are by their very object concerned by the rule at stake. That is customary international law is general international law. The exceptions to such generality in terms of the rationer personer scope of customary international law, the exceptions is the situation of the persistent objector you may remember and also the possibility for certain customs to be regional or local and therefore to be only binding on a few states. Secondly you may recall also that customary international law is use disposable and that it can be displaced derogated from by treaty. In such a case and as long as the treaty is binding on the parties to it, the parties to the treaty will have to respect between them the obligations contained in the treaty rather than the obligations existing under the customary rule at stake. But of course that customary rule continues to be binding on the parties to the treaty in their relations with states and organizations that are not party to that treaty. You also remember that when the customary obligation is not of a use dispositive nature but of a use co-gain nature it must be respected by all, irrespective of any contrary obligation contained in a treaty and such treaty is void. Let me turn now to the same question but in relation to general principles of law within the specific meaning of article 38 paragraph 1c of the ICJ statute and not general principles as synonymous to customary rules of international law. And as their name indicates and as the comparative law process forming them requires, general principles of law are general in personal scope. They are binding on all states but because general principles within the meaning of article 38 are filling the gaps as it were in the absence of a customary rule or an applicable treaty they are also of a use dispositive nature and they can be derogated from by custom or by treaty. As far as unilateral acts of states are concerned the answer to their rationer-personer scope is quite straightforward. Unilateral undertakings are binding on their authors only. The same is true as far as unilateral acts of international organizations are concerned. Being part of the rules of the organization, unilateral acts of international organizations are binding on the organization and on its members according to the conditions set forth in the basic instrument establishing the organization and as long as they have as they have not been changed or repaired by a subsequent act of the organization adopted under the same procedure. Unilateral acts of organizations may also be binding on individuals and on corporations again according to the conditions set forth in the basic instrument and this can notably be the case of some EU secondary legislation or some United Nations Security Council resolutions as we shall see at the end of the course. Treaties deserve a separate and more elaborate answer and this is what the next video will be about.


this constant declaration of victory on the behalf of the government and also a sense of arrogance on the behalf of the government. So it is the nature of this government, the way of their action that is causing this problem. They have basically taken off all our warning systems and shut them down and we are in the middle of the ocean in a storm and now the ship has no idea where to go.


You're still watching Waze. National Monday also known as Space Exploration Day is observed on July 20 every year to commemorate the anniversary of the United States' first crewed mission to the moon and the landing of astronaut Neil Armstrong and Buzz Aldrin on July 20, 1969. Phone Facts here, when I was a child. I always imagined myself in a space, something that I've always wanted to do But since I heard about that... This is a good one That case is still very funny for me We did that just another day but it's just funny But some other day I want to travel to a different planet I think it would be a good experience Without gravity and all that Let me see how it would be floating and moving around But it's National Monday Right? But here it's $450,000 So you can start saving Maybe now that's Okay I'm proud of myself You haven't even started Okay, not gonna say anything I'm not saying anything Let's just move on from it Okay Jenny, what did you find in the news? Antrax Outbreak Stop eating more Make it stay government, caution residents So basically they've noticed that there is an outbreak And they've been cautioning everyone in the agricultural sector People who have been around dead meat Butchers, farmers People who kill meat Or people who have gone to countries where they were exposed to antrax So what the government is saying is That there has been an exposure And it looks like we're having an outbreak here in Nigeria So everyone just has to be very careful Maybe stay away from pommos Stay away from bushmeats From smoked meat I mean it seems like a joke right Because I mean Pommos is really sweet It's really nice And I love pommos right Every time right Health is wealth and it's important I think we can't claim ignorance Once you've heard of information like this You've been told and you've been warned So it's just nice to stay away from it Until you get further information That the outbreak is normal Or it has been taken care of So just to be on the safe side Just stay away from dead meat Stay away from pommos If you work in abatio and all of that Just try and make sure that you're safe When you get home your hygiene is stopped Priority You're taking care of yourself Your skin and your health Very important Although this one that the hotel doesn't eat pommos They don't eat rice Next one we don't drink water I feel like at some point we'll be eating Just grass alone I know right With anything Because almost everything You know every day they tell you Pepper does this This does that You know they tell you This is dangerous to your health And these are things that we've been eating For a long time So giving up certain things Or more now It's like a major part of A subo So telling Nigerians Not to eat that It's going to take a lot of Apart from that You know that it's a cheaper option Of putting That meat And all that meat So Quite helpless in this country Noma what did you find for us In the news today Staying away from all Right so I have this Unfortunate news From Punch newspaper About Tobi Amoson And it's about The fact that five days before Her women's Hundred meters HODL's Title And world record clock Her world record Noma are you there Okay I think we lost Noma Okay NJ What did you find for us And hopefully she comes back To take that story Okay My story is a very Very interesting one So while You know glancing through the news This caught me my attention And it's funny because It's something that is quite abnormal To most people But it's strangely very Comes naturally to this young lady So there's a Woman who is addicted to eating Toilet paper And she reveals that she Eats up to about four rolls a day And spends nearly two thousand seven hundred Dollars a year buying it I don't know I know that there's a video I don't know if they're going to show the video about You will clearly if you watch the video You will clearly see this woman You know she goes around just eating toilet paper And you know there's this recording Of her saying how It tastes so much like How it tastes so much like Like a meal Like she eats it as a meal She doesn't eat food She just sits around She just sits around with A long roll of toilet paper And she's just nibbling on it Like a safe is You know like eating Like dry wafers without taste So she's just eating it And then there are videos of her Going to the salon She eats it everywhere in the office And everyone around her thinks She's Luna obviously But she claims that you know This gives her so much joy And that it puts her in a very good place And she eats The record says that she eats About four toilet papers a day So when you calculate that She does about fourteen thousand pounds Over the course of twenty years And she's been eating that For a couple of years And she has been surviving Yes she just eats it She says it just comes naturally to her Like literally Having a conversation with her She's just eating toilet paper And she even goes through the motion Of telling you how the difference Between the different types of toilet paper That her best is the one with the single sheets So she's like oh it's so crunchy And you know it gives her body this You know feeling And it tastes good So over time she has done that And I guess she has gotten used to it But what I would have loved to know Because everyone even her ex fiance Is mental He says how do you go around Eating toilet paper You know if someone wants to get married to you You have to introduce you to his parents You come to their house And you don't understand And even the toilet paper won't survive the day You just say one second Can I use your bathroom And then Someone sees you coming out of the bathroom And you're just chewing on toilet paper Like oh my So it's quite weird Her workers see it as really weird But she doesn't care She has gotten to the point where she doesn't care She literally goes around She doesn't care if people laugh at her And I think for me What bothers me is the health implication of this I don't know what it is But I'm sure there's a health implication Because I know toilet paper is soft And everything is mushy When it dissolves But I'm just wondering When there's a pile of that in your system And it's not giving nutrients Or the normal natural nutrients That you need to survive I can only wonder How someone can add weight with that And you're just stuffed up with toilet paper Well they said If they gave the record that she eats She has eaten about 14,000 pounds Over the course In the past 20 years So I want I choose to believe that She has been at Maybe not 20 years But she has been at this for a while And it's quite strange But strange things happen every day We see these things There's more to it Guys this is not spiritual It's not spiritual The moment I saw the story If it was in Nigeria I would say They've done Juju for this person But this guy is living abroad So it's weird To have that kind of an I know Is it normal back? There's Juju everywhere There's Juju everywhere There's Juju everywhere Let's take your story quickly Alright So my story Is on Tobi And Musan Who has been banned For For some Who has You know Has been given a ban And this is coming five days before Her women's 100 meters Hordles world title And world record As it clocks one year And then exactly one month To 2023 World Athletics Championships That will hold between August 19th To 2017 Budapest Hungary And She has been handed This Ban By the Athletics Integrity Unit And this is because She has missed three Out of competition Tests in 12 months And I'm not sure This was confirmed yesterday actually And they charged her Provisionally And have suspended her And I'm one Oh no, since I've lost Noma again I mean, but then this is very sad Because I was actually looking forward to To Musan's That was called a To Musan Yeah, to be honest Breaking another record at the Women's Race that she was going to go for But then I wonder why I want to hear what Noma has to say The major reason For the ban is Oh so the ban is so Can you hear me? Yeah, yeah, yeah Can hear you now Oh, I'm sorry So I don't I'll just To Pay back from what Chinelo was saying I was just going to say that I was wondering why she Missed three Tests And she claims That she is Clean Right, because these tests are supposed to Determine whether You were doing Your championships with Integrity And all of that And having celebrated her Having Captured the essence of what She represents both in Nigeria And across the athletics World And wondering what Could the reasons have been For her to miss not one Not two Not three But three tests So this is already Questionable You know that countries like this They do not take this for granted I don't know if it's as important About Nigerian way of doing things Or that she had Doing reasons to miss Three tests But it's something that we probably Would prove further Because we weren't giving the details But she claims that she is clean And they claim that she has missed three So if you're clean Why did you miss three tests? These are the questions That need answers We'll continue to follow the story Hopefully because this is so painful Especially having After we had celebrated The fact that What our own is breaking World record Making history In terms of athletics and all So that there are questions to be answered Definitely It's quite unfortunate When it's almost like When we're just bringing out our head out of water Something just happens Because for me initially I would have said These people just don't want this girl to break another record They just want to kill her career But really there's a valid reason If you're not doping Why miss the test The test is to prove It's like a pass mark It's like missing an exam and expecting a result It's education Yeah it's education, thank you People almost said it's juju everywhere It's juju everywhere Okay so my story I saw this and I just Could not stop laughing I had so many questions I don't even read the comments on that Somebody said this one is worry titanic For the moment a ship Almost destroyed the Udu bridge In delta if you have the picture Can we just have that Up on the screen because it just explains What I'm talking about First things first, how did this ship Even get here How did this ship sail to the How did this ship think it was going to pass the bridge That's the first question What were they thinking So they got to the foot of the bridge Before they realized I don't even understand I honestly don't understand I think crazy things are happening in this country For real for real because Apparently almost collapsed the bridge Or did they think it was there What's that bridge in the UK London Suspension Bridge It thought it was going to open for them to pass But how did they get there Did they lose on the road Maybe they lost that way That's the only explanation They should retry Because a ship this size There must have been calculations You know there are calculations As you approach a bridge You can almost tell Okay no we're not going to make it Especially you already know We don't even have that high bridges In the whole entire country But you know in England Almost always big jokes out of everything You should check to say that there can't be no I know Okay We're going to go on a short break And when we come back we'll be discussing Balancing work and life See you after the break


Lignin is an abundant and complex plant polymer that can slow down the decomposition of litter, but it is often a minor component of soil organic carbon, SOC. Different soil conditions can account for this apparent contradiction. In laboratory experiments, lignin decomposition varied greatly among soils, while SOC decomposition was less affected by soil type. This suggests that lignin decomposition is more dependent on local environmental factors than SOC decomposition. Furthermore, climate history appears to be the main driver of lignin decomposition, while nutrients and microbes have only a small effect. These findings suggest that lignin is not necessarily a barrier to SOC decomposition and can help explain why lignin content varies widely among ecosystems. This article was authored by Wen Huan Huang, Wen Huan Yu, Bo Yi, and others.


Hi, I'm Owen Honey and you're watching Ready to Renovate for Builders and Private Property. I'm at the now fully renovated apartment here in the northern suburbs of Johannesburg. It has taken six weeks from start to finish. You have seen how the contracting team renovated each room, the garden and even the garage. It is now ready for the final test. While the renovation impressed the property experts and more importantly increased the value of the property. The appraiser Khoshi Sasa from Mochalakwena Valuers and media personality and realtor Tito Titianba were invited to review the final reveal of the apartment. Hi guys, my name is Khoshi Sasa, property valuer. I've been brought in to come and put value on the property at the end here. I've been sent lips of the property look like before. Just going to see how it looks like and take it from there. Realtor Titianba then arrived to review the apartment. Hello, my name is Titianba, I'm a master practitioner in real estate and I've just been called to have a look at this apartment and I've actually just been sent a video of what it looked like before. We sent each other gents an identical clip of what the apartment looked like before the renovation. Here, that's the entrance there, got an old tub kitchen there. The kitchen looks a bit dated with those old wooden cupboards. Bathroom there, whoa okay, the shower. The shower looks a bit small and squashed for someone my size, it looks like I'll never fit in there. The bathroom reminds me of my grandmother's bathroom, old taps. There are some chips in those tiles as one can see there. Wow, look at that shower, shower curtains. In 2021. The bathtub has got some issues there, there's definitely need for some general maintenance. No curtains or blinds. The walls ever look quite dated, I definitely want to see what the walls are going to look like after. Even the bedroom cupboards and the skirting as well. Even the lighting and the lounge, the lighting features could do a bit of an upgrade. The lights look like original lights. Looking at the fittings, one can say it looks about between 15 and 20 years old. The garden looks like it needs to be greatly in the upgrade list. Interesting that they've got a price stand feature but there's no price stand there. So they've used the same tiles on the picture as inside. Yeah, no, no, no, no, I can't wait to see what this is going to look like after. I've really got ideas of what I would do. It looks like it needs some upkeep of sort and general maintenance. Let's go see how it looks like. Let's go check it out. Then with those images fresh in their memories, we invited the two to meet at the apartment and see the final presentation of the renovation themselves. Hi man, my name is Khoshi, property valour. Hi, my name is Titia, my realtor. Shall we go in? Nice to meet you. Nice to meet you, my brother. So Khoshi, what are your thoughts, my brother? I like the paint right, man. Smells fresh here. It does, right? It's nicely done, yeah. It really does. And it's got that scent. Yeah. It's newness. Yes, it says, come home. Yeah. And then you notice the lighting pictures. Yeah, it looks like they changed everything here. Got everything on the walls there. I love those shanty hair features. And did you notice that the plug points? Wow. Yeah, man. It looks nice. The sushi scent. Can you see the skettings as well? The skettings, yeah. The skettings there as well. The tiles. Wow. That's the first thing that I wanted to actually see when I was walking in. It bothered me earlier on because they had those small lines. They had chips all over. Yeah. But those old tiles. Yeah, the very small squared ones. Look at the wallpaper. The wallpaper changes everything. And I was worried about the fact that there were actually no curtains. I love the fact that they put in some nice railings. Nice railings. I noticed that the plants are quite a feature everywhere. They are quite well spaced out. Man, this is very inviting. Wow. Tropical bedroom. Wow. I feel like I'm somewhere on the seaside. Wow. Even the covered doors, remember they were quite woody. Yeah, they were woody. And they were all over. Lighting feature again. Gives you the tropical outdoor feel. Yeah. The plants again, I can see that they've really done a good job in terms of bringing in the nature into the space, eh? The rails again. Wow. There were no rails on the before, remember? Yes. They've done a great job, man. So this is the office. Look at the chandeliers, man. Wow. It's got a beautiful feel. Yeah, it's well done. You can tell that this is work, work, work. I'm assuming this is an office for someone who's living alone or a couple. And they've converted this into an office space. Especially because everyone is working from home. Yeah. It's actually quite smart of them to use the space productively so that you actually feel like you're walking into an office. Yeah, it's well thought. Love it. Yeah. Let's check out the bathroom. Your, your, your. My first impression is the shower door. I'm very impressed. Remember they had the curtain shower thing going. Yes. And the taps. Remember the taps were old and separated. Now they've got black taps. I think it's a trend these days with these black taps. Black taps, yeah. I've seen them. And the shower head. Ah. Thank goodness. And the shower is tight. But with the, with the, with the new shower head, you are in and out of time. Yeah. And I like, I like the, the way the tiling is done. Yeah. Yeah. Very pristine. The design of the tiles also creates an illusion of space.  Yeah. And they created the ceiling as well. Nice and big. Whoever's going to, whoever's going to shower here first is going to be great. Good luck to them. Hoshi. Your thoughts? You know Artiti. Elia, I saw the stove. I can't tell but, but, but Marvel at this. This is nice. The countertops for me is something that stands out because I saw the old countertops and not the best. Do you see your favorite tap? Yeah. Black. Black, black. And then put the blinds as well. And now you can actually appreciate the, the space because now you've got space for microwave, washing machine. Yes. And then the fridge looks nice. And I love the fact that they've chosen silver as a theme here. Yes. Gray. Well, different shades of gray. And look at this. Very impressive. It's getting on the side here. It is told to avoid chips on the, on the, on the tiles. But there's also an illusion of space. Yeah. So you can actually prepare meals while having a conversation with your guests. Now the kitchen is really neutralized. It is. It's functional and beautiful. There's a lot of space here as well. Yeah. You can do a lot with this. Finally, outdoors, my brother. Outdoors, outdoors, outdoors. So beautiful. Wow. Okay. Hmm. You see this for me is a win. You can't have a space for a bride, not have a bride stand. Yeah. Now you can always find something. Ah. When you say come over the bride, you mean, look, look at the plants to tea. Earlier they had one little tree that I saw that didn't quite impress me. Yeah. But now no, this is nicely done. And I noticed the tiles have been carried out throughout as well. All the way through. Yes. And earlier what I saw as well. A lot of cute here. Yes. I've done a good job with that. Yeah. I didn't even notice this. Look at the garden. Look at that. Oh. It's nicely done, man. Finally, this garden actually looks like a decent garden, eh? And, and it being a ground floor, you need to imagine, garden is supposed to be pristine. Absolutely. Lovely. And you can see they put your lights as well. Even on the, on the, on the boundary wall. This is the garage. What are your impressions, my brother? I like it. Look at the paint work, man. They painted. Very neat, eh? And the storage as well. Exceptional neat. For a handy man like myself, this would be a lovely hobby. Yeah. The woodwork. Yeah. It's beautiful. So the theme is, is carried on, even with the light. Yes. So black. And they are black. Yeah. And look at the floor as well. Nicely done. You know where to place what. And when it is dead, you can easily pick it up as well. Yeah. Very impressive. Ah, I don't know. I like it. No, man. This is a beautiful place. Yes. It's a job well done. Definitely a job well done. So my immediate first impression when I walked in was the towels. That's the first thing that I actually noticed. The fact that they were grey and it was a beautiful shade of grey that was used. And the second thing that I noticed was the walls. The smoothness of the walls was something that was quite impressive for me. The lighting fixtures, the chandeliers stood out. The rest, this just made sense for me. So as a realtor, the first things that we look at in any, any home is the kitchen, the bathroom and of course the bedroom. Those are the main areas that most buyers actually look out for. And I was quite impressed with the level of detail that each space actually offered. In my opinion, the value of this apartment has definitely increased by probably 30 to 40 percent because a lot of work has gone into it. You can see that a lot of stuff was ripped away and replaced with new and modern finishes. That does have a great impact or a positive impact on the value of the apartment itself. So the other owners can be proud to ask for the price that they actually want. My first impression when I walked in with TT's, I liked the paintwork is beautiful. The tiling as well. Just the workmanship because for property value as well, we look at the workmanship more than anything when you walk in. My impression of the garden is they did very well because they save you water. There's artificial turf there. Based on what I've seen before on the previous pictures as now, I can almost confirm that the value of this apartment will go up in about, say, about 20 to 35 percent or so. It's very well done. From what I can see, they got everything out, started holding up from scratch. Everything is redone. It's just beautiful. The fittings are new. They did well. The tiling, the wallpaper, the painting, the light switches, the plugs. It's all modernized. It's just beautiful. They did a very good job. You get a feel that you're in an apartment. It's very well done. If you enjoyed the final reveal of Ready to Renovate with builders and private property, you can go and watch the transformation of the individual rooms and areas again on the builders and private property websites. All the products and materials that were used are available from builders online or in store. Until the next renovation, it's goodbye from me, Owen Honey. Get to builders. Get it done.