Consensus statement on the live organ donor

[Autoaggressive donation motives in the context of living kidney donation]

BACKGROUND

Which psychodiagnostic criteria indicate artificial donation motives at work in living organ donation?

METHODOLOGY

Using a casuistic we investigated self-harmful behaviour with regard to peculiarities in transference as well as countertransference.

RESULTS

Diagnostically of great important is the discrepancy between the difficulty of the examiner to understand the donation request in its psychosocial context and the vehemence with which the donor insists on going through with the transplantation. At the same time, one may notice a lack of reflective ability impeding an ambivalent attitude toward the donation. The doctor/patient relationship is restricted by aggressive affects, and the body of the donor is reduced to an object with exchangeable organs.

DISCUSSION

When evaluating donor-recipient pairs who belong into the group of pairs with particular emotional investment according to Article 8.1 of the German Organ Transplantation Law, one should consider the possibility of autoaggressive motives as a background to a living organ donation. Also, when discussing the extension of anonymous and predominantly altruistically motivated living organ donation one should consider the exclusion of autoaggressive motives.

Stranger Donors: A Key Link in Transplant Chains

Living donation to strangers is a complex issue that has caused some transplant centers to ban the practice altogether. Most prominent of the troublesome issues is the common source of these donors; namely, the Internet. These “stranger donors,” however, are critical to both paired kidney transplants and chain kidney transplants. This article presents the ethical complexities of donors in these transplant arrangements and offers 2 case examples from our facility. Rigorous donor screening and informed consent processes are crucial, and together they help make transplant pairs and chains ethically feasible.

Transplant center provision of education and culturally and linguistically competent care: a national study

Although transplant centers are required to educate patients about kidney transplantation (KT) and living donation (LD), little is known about the educational format, and cultural and linguistic competence necessary for patients to make informed treatment decisions. This study surveyed US transplant administrators about education provided concerning KT and LD and culturally and linguistically competent care. Transplant administrators were invited to participate in an anonymous Internet-based survey about education format, education providers, promoting LD, culturally and linguistically competent care and center characteristics. Most (61%) transplant administrators contacted (N = 280/461) completed the survey. Most administrators (91%) reported that their center provides any type of formal education in their pre-KT evaluation. Education was mostly provided by: nurses (97%), social workers (72%) and surgeons (55%), and predominantly as one-on-one (80%) versus group discussions (60%). Education was primarily delivered through written materials (93%). Written educational materials in Spanish (86%) and the provision of interpreters (82%) were emphasized over educational sessions in Spanish (39%), or employing bilingual (51%) and bicultural staff (39%). Half (55%) promoted LD as the best option. Transplant centers need to take greater efforts to consistently provide appropriate education, promote LD, and provide culturally and linguistically competent care to ensure effective communication with all patients.

Attitudes of medical professionals and transplantation facilities toward living-donor liver transplantation in Japan

The Japan Society for Transplantation (JST) revised their guidelines in 2003 to specify that a living donor must be "a relative by blood within the sixth degree or an in-law within the third degree." Although several criticisms have been raised on this issue, these criteria have persisted without any empirical data showing the opinions and attitudes of people who are affected by the revision. Therefore, we performed a questionnaire survey to determine what Japanese medical professionals involved with living-donor liver transplantation (LDLT) regarded as eligible relationships for donation, as well as the kind of relationship for which they would be willing to donate their liver, and what donor eligibility criteria was currently used by their institutions. Among the 71 representatives of the Japanese Liver Transplantation Society, >90% answered that liver donations to emotionally close parents, siblings, children, or spouses were acceptable. However, the numbers were considerably lower for donation to emotionally close blood relatives, in-laws, friends, and strangers (78.2%, 52.1%, 18.6%, and 5.9%, respectively). This gap was more prominent when participants were questioned about their own willingness to donate. More than two-thirds of facilities that perform LDLTs have independent regulations for donor eligibility that are more conservative than the JST guidelines. No facility accepted friends or strangers as donors. When introducing policies or guidelines, it is important to carefully investigate the views of the people who are affected. The data obtained in this study should serve as a resource for ongoing discussions about the JST revised guidelines.

Barriers to living donor kidney transplantation among black or older transplant candidates

BACKGROUND AND OBJECTIVES

Lower rates of living donor kidney transplant (LDKT) among transplant candidates who are black or older may stem from lower likelihoods of (1) recruiting potential living donors or (2) potential donors actually donating (donor "conversion").

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A single-center, retrospective cohort study was performed to determine race, age, and gender differences in LDKT, donor recruitment, and donor conversion.

RESULTS

Of 1617 kidney transplant candidates, 791 (48.9%) recruited at least one potential living donor, and 452 (28.0%) received LDKTs. Black transplant candidates, versus non-blacks, were less likely to receive LDKTs (20.5% versus 30.6%, relative risk [RR] = 0.67), recruit potential living donors (43.9% versus 50.7%, RR = 0.86), and receive LDKTs if they had potential donors (46.8% versus 60.3%, RR = 0.78). Transplant candidates ≥60 years, versus candidates 18 to <40 years old, were less likely to receive LDKTs (15.1% versus 43.2%, RR = 0.35), recruit potential living donors (34.0% versus 64.6%, RR = 0.53), and receive LDKTs if they had potential donors (44.5% versus 66.8%, RR = 0.67). LDKT and donor recruitment did not differ by gender. Race and age differences persisted in multivariable logistic regression models. Among 339 candidates who recruited potential donors but did not receive LDKTs, blacks (versus non-blacks) were more likely to have potential donors who failed to donate because of a donor-related reason (86.9% versus 72.5%).

CONCLUSIONS

Black or older kidney transplant candidates were less likely to receive LDKTs because of lower likelihoods of donor recruitment and donor conversion.

64-channel multi-detector row CT angiographic evaluation of the micropigs for potential living donor lung transplantation

Micropigs are the most likely source animals for xenotransplantation. However, an appropriate method for evaluating the lung of micropigs had not been established. Therefore, this study was performed to evaluate the feasibility of 64-channel multi-detector row computed tomography (MDCT) to measure the diameter of the pulmonary arteries and the lung volume in micropigs. The mean diameters of the trachea, and left and right bronchi were 1.6 ± 0.17, 1.18 ± 0.14, and 1.1 ± 0.11 cm, respectively. The mean diameters of the main, right, and left pulmonary arteries were 1.38 ± 0.09, 1.07 ± 0.26, and 0.98 ± 0.13 cm and the diameters of right, left, and common inferior pulmonary veins were 0.97 ± 0.20, 0.76 ± 0.20, and 1.99 ± 0.26 cm, respectively. The mean lung volume was 820.3 ± 77.11 mL. The data presented in this study suggest that the MDCT may be a noninvasive, rapid, and accurate investigational method for pulmonary anatomy in living lung donors.

Practice patterns for evaluation, consent, and care of related donors and recipients at hematopoietic cell transplantation centers in the United States

Conflict of interest may arise when 1 physician serves 2 persons whose medical care is interdependent. In hematopoietic cell transplantation (HCT) from unrelated donors and in the setting of solid organ transplantation from living donors, the standard of care is for donors and recipients to be managed by separate physicians to provide unbiased care. However, the practice patterns of evaluation and care of related donors and recipients are not well described. A survey of HCT centers in the United States was conducted by the Donor Health and Safety Working Committee of the Center for International Blood and Marrow Transplant Research to determine the type of provider involved in medical clearance, informed consent, and medical management of hematopoietic cell collection and the relationship of that provider to the HC transplant recipient. The response rate was 40%. In greater than 70% of centers, transplantation physicians were involved or potentially involved in overlapping care of the HC transplant donor and the recipient. These patterns were similar between transplantation teams caring for adult or pediatric donors and recipients. Among responding centers, medical management of recipients and their related donors by the same provider is common, a practice that has the potential for conflict of interest.

Addressing racial and ethnic disparities in live donor kidney transplantation: priorities for research and intervention

One potential mechanism for reducing racial/ethnic disparities in the receipt of kidney transplants is to enhance minorities' pursuit of living donor kidney transplantation (LDKT). Pursuit of LDKT is influenced by patients' personal values, their extended social networks, the health care system, and the community at large. This review discusses research and interventions promoting LDKT, especially for minorities, including improving education for patients, donors, and providers, using LDKT kidneys more efficiently, and reducing surgical and financial barriers to transplant. Future directions to increase awareness of LDKT for more racial/ethnic minorities also are discussed including developing culturally tailored transplant education, clarifying transplant-eligibility practice guidelines, strengthening partnerships between community kidney providers and transplant centers, and conducting general media campaigns and community outreach.

Kidney transplantation and HIV: does recipient privacy outweigh the donor's right to information?

BACKGROUND AND OBJECTIVES

There exists an inherent conflict between a kidney donor's right to know key aspects of a recipient's medical history and specific disease, such as HIV, where federal and state statues protect this information. The authors of the live organ donor consensus group expressly stated the principal of a donor's right to recipient information. This information includes the risks and benefits of not only the donation procedure, but also the risks, benefits, and alternative treatment options of the recipient. In this paper, a case will be presented highlighting this conflict and the ethical and legal reasoning used to resolve it.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A 22-year-old woman came forward as a directed kidney donor for an HIV-positive individual. The donor and recipient were medically appropriate for kidney donation and transplantation. During the donor advocacy panel review, there was disagreement regarding whether or not the potential donor had the right to know about the HIV status of the potential recipient.

RESULTS

In living kidney transplantation to HIV-positive individuals, the recipient's right to privacy of information outweighs the donor's right to know.

CONCLUSIONS

Although protecting the recipient's right to privacy is paramount, the donor is still entitled to consider factors a priori that could alter their decision to donate. This can be accomplished by informing the donor that they are not entitled to protected health information of the recipient and that their decision to donate should be based on knowing the recipient is medically appropriate for kidney transplantation.

Practices and barriers in long-term living kidney donor follow-up: a survey of U.S. transplant centers

BACKGROUND

Many have called for more comprehensive follow-up of living kidney donors, both for the donor's benefit and to establish a high-quality database of donor outcomes. United Network for Organ Sharing currently requires transplant centers to report donor follow-up information at several time points after donation, but little is known about how frequently this information is obtained, or which barriers exist to compliance with United Network for Organ Sharing requirements.

METHODS

To assess practices and barriers in providing follow-up care to living donors, we sent a questionnaire to all program directors at U.S. transplant centers.

RESULTS

Few transplant centers are currently seeing donors for long-term follow-up. Many centers recommend that donor follow-up care be provided by primary care physicians, but follow-up information is rarely received from primary care physicians. The main barriers to collecting more complete information are donor inconvenience, costs, and lack of reimbursement to the transplant center for providing follow-up care.

CONCLUSIONS

Significant changes are required to improve long-term donor follow-up by U.S. transplant centers.

Medical follow-up of living kidney donors by 1 year after nephrectomy

BACKGROUND

Concerns have been raised that many kidney donors do not receive adequate medical care after nephrectomy. In 2003, our program developed a policy recommending that donors receive medical follow-up by 12 months postnephrectomy. We hypothesized that medically complex donors would have a higher rate of follow-up than other donors.

METHODS

A retrospective cohort study of 137 live kidney donors from a single center was performed. Donors were considered medically complex if they had hypertension, body mass index of 30 or greater, nephrolithiasis, age 65 years or older, creatinine clearance less than 80 mL/min/1.73 m(2), or had a first-degree relative with diabetes mellitus. Adequate follow-up was defined as one visit with a nephrologist at our center, or blood pressure, serum creatinine, and urinalysis checked elsewhere.

RESULTS

Eighty-three donors (61%) had adequate follow-up, 42 did not, and 12 could not be contacted. At multivariate logistic regression, donors with adequate follow-up were more likely to be medically complex (odds ratio, 2.48; 95% confidence interval 1.18-5.23; P = .02) and older than donors with inadequate follow-up (odds ratio, 1.46 per 10 years of age; 95% confidence interval, 1.01-2.10; P = .04).

CONCLUSION

A substantial minority of donors do not receive recommended care by 1 year after nephrectomy.

Transplant tourism to China: the impact on domestic patient-care decisions

Organ procurement in China has been criticized because of its reliance on executed prisoners as donors. We aimed to assess the influence of perceptions about organ procurement practices in China on domestic patient-care decisions.

METHODS

An anonymous internet administered case-based questionnaire was used to survey a sample of healthcare professionals with affiliations to hepatology and transplantation professional societies.

RESULTS

Of 674 completed surveys, the vast majority (93%) of the respondents were physicians, surgeons or allied transplant professionals actively caring for liver transplant patients and 81% practiced in the US. A strong majority believed procurement practices were ethically sound in the US and Europe (87% and 73%) but fare fewer believed that procurement practices were ethically sound in China (4%, p < 0.001). In case-based questions, lack of confidence in the ethical standards of organ procurement in China predicted patient-care decisions. The majority would provide post-transplantation care for patients who underwent liver transplantation at another domestic center, in a foreign country and in China (90%, 78%, and 63%, respectively, p < 0.001) yet respondents who suspected unethical procurement practices in China were more reluctant to do so (p < 0.001).

CONCLUSIONS

Transplant professionals expressed concern about organ procurement practices in China which influenced their patient-care decision-making.

Liver transplantation

Liver transplantation has become a lifesaving procedure for patients who have chronic end-stage liver disease and acute liver failure. The satisfactory outcome of liver transplantation has led to insufficient supplies of deceased donor organs, particularly in East Asia. Hence, East Asian surgeons are concentrating on developing and performing living-donor liver transplantation (LDLT). This review article describes an update on the present status of liver transplantation, mainly in adults, and highlights some recent developments on indications for transplantation, patient selection, donor and recipient operation between LDLT and deceased-donor liver transplantation (DDLT), immunosuppression, and long-term management of liver transplant recipients. Currently, the same indication criteria that exist for DDLT are applied to LDLT, with technical refinements for LDLT. In highly experienced centers, LDLT for high-scoring (>30 points) Model of End-Stage Liver Disease (MELD) patients and acute-on-chronic liver-failure patients yields comparably good outcomes to DDLT, because timely liver transplantation with good-quality grafting is possible. With increasing numbers of liver transplantations and long-term survivors, specialized attention should be paid to complications that develop in the long term, such as chronic renal failure, hypertension, diabetes mellitus, dyslipidemia, obesity, bone or neurological complications, and development of de novo tumors, which are highly related to the immunosuppressive treatment.

The living donor advocate: a team approach to educate, evaluate, and manage donors across the continuum

Living donor transplant has developed as a direct result of the critical shortage of deceased donors. Federal regulations require transplant programs to appoint an independent donor advocate to ensure safe evaluation and care of live donors. Ethical and pragmatic issues surround the donor advocate. These issues include the composition of a team versus an individual advocate, who appoints them, and the role that the advocate(s) play in the process. A team approach to donor advocacy is recommended. Common goals of the independent donor advocacy team should be protocol development, education, medical and psychosocial evaluation, advocacy, support, and documentation throughout the donation process. The team's involvement should not end with consent and donation but should continue through short- and long-term follow-up and management. Ultimately it is the goal of the independent donor advocacy team to assist donors to advocate for themselves. Once deemed medically and psychologically suitable, donors must determine for themselves what they wish to do and must be free to vocalize this to their team. The decision to donate or not affects the donor first. Optimal outcomes begin with prepared, educated, uncoerced, and motivated donors, and it is the team's goal to help donors reach this point.

Psychiatric Disorders: Are They an Absolute Contraindication to Living Donation?

Little information has been published about the suitability of candidates for living organ donation who have a past or current psychiatric diagnosis. A retrospective review of 445 living donor kidney transplants performed at Barnes-Jewish Hospital's transplant center from 1995 to 2005 disclosed 42 donor candidates with such a history, prompting detailed psychological evaluation. Although 41 candidates (10% of the donor pool) met criteria for 1 or more psychiatric diagnoses, none were considered psychologically unfit for donation. Of these, 22 candidates underwent kidney donation without medical or surgical complications and without development of subsequent active psychological problems. Several donors maintained long-term contact up to 12 years to report good health and a high degree of satisfaction with the decision to donate. This experience suggests that for donor candidates with a psychiatric diagnosis, formal psychiatric evaluation to evaluate current mental health stability is warranted. Stable individuals, on or off therapy, can be considered fit to donate with expected short- and long-term outcome prognoses similar to those for the general population.

The Living Donor Advocate: A Team Approach to Educate, Evaluate, and Manage Donors across the Continuum

Living donor transplant has developed as a direct result of the critical shortage of deceased donors. Federal regulations require transplant programs to appoint an independent donor advocate to ensure safe evaluation and care of live donors. Ethical and pragmatic issues surround the donor advocate. These issues include the composition of a team versus an individual advocate, who appoints them, and the role that the advocate(s) play in the process. A team approach to donor advocacy is recommended. Common goals of the independent donor advocacy team should be protocol development, education, medical and psychosocial evaluation, advocacy, support, and documentation throughout the donation process. The team's involvement should not end with consent and donation but should continue through short- and long-term follow-up and management. Ultimately it is the goal of the independent donor advocacy team to assist donors to advocate for themselves. Once deemed medically and psychologically suitable, donors must determine for themselves what they wish to do and must be free to vocalize this to their team. The decision to donate or not affects the donor first. Optimal outcomes begin with prepared, educated, uncoerced, and motivated donors, and it is the team's goal to help donors reach this point.

The evolution and direction of OPTN oversight of live organ donation and transplantation in the United States

For more than 20 years, the Organ Procurement and Transplantation Network (OPTN) has developed policies and bylaws relating to equitable allocation of deceased donor organs for transplantation. United Network for Organ Sharing (UNOS) operates the OPTN under contract with the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS). Until recent years, the OPTN had little defined authority regarding living donor organ for transplantation except for the collection of data relating to living donor transplants. Beginning with the implementation of the OPTN Final Rule in 2000, and continuing with more recent announcements, the OPTN's role in living donation has grown. Its responsibilities now include monitoring of living donor outcomes, promoting equity in nondirected living donor transplantation and ensuring that transplant programs have expertise and established protocols to promote the safety of living donors and recipients. The purpose of this article is to describe the evolving mandates for the OPTN in living donation, as well as the network's recent activities and ongoing efforts.

Laparoscopic donor nephrectomy

Since it first was performed in 1995, laparoscopic donor nephrectomy (LDN) has grown to be the standard of care in most transplant centers in the United States. This article reviews the current indications, selection criteria, surgical approaches, outcomes, and complications of LDN.

[Living donor liver transplantation]

Sixteen years after its first successful application, living donor liver transplantation now has a small but well-established role in treatment for liver failure in Germany. It remains problematic in both child and adult patients concerning effort, expected results, and assessment of risks to the donor. Therefore the method shall remain limited to more research-oriented institutions for the time being before it can be established more broadly as an alternative to postmortal donation. In Germany it presents generally the same limitations as living donor kidney transplantation.

Substantial variation in the acceptance of medically complex live kidney donors across US renal transplant centers

Concern exists about accepting live kidney donation from 'medically complex donors'--those with risk factors for future kidney disease. This study's aim was to examine variation in complex kidney donor use across US transplant centers. We conducted a retrospective cohort study of live kidney donors using organ procurement and transplantation network data. Donors with hypertension, obesity or estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m(2) were considered medically complex. Among 9319 donors, 2254 (24.2%) were complex: 1194 (12.8%) were obese, 956 (10.3%) hypertensive and 392 (4.2%) had low eGFR. The mean proportion of medically complex donors at a center was 24% (range 0-65%). In multivariate analysis, donor characteristics associated with medical complexity included spousal relationship to the recipient (OR 1.29, CI 1.06-1.56, p < 0.01), low education (OR 1.19, CI 1.04-1.37, p = 0.01), older age (OR 1.01 per year, CI 1.01-1.02, p < 0.01) and non-US citizenship (OR 0.70, CI 0.51-0.97, p = 0.03). Renal transplant centers with the highest transplant volume (OR 1.26, CI 1.02-1.57, p = 0.03), and with a higher proportion of (living donation)/(all kidney transplants) (OR 1.97, CI 1.23-3.16, p < 0.01) were more likely to use medically complex donors. Though controversial, the use of medically complex donors is widespread and varies widely across centers.

Substantial variation in the acceptance of medically complex live kidney donors across US renal transplant centers

Concern exists about accepting live kidney donation from 'medically complex donors'--those with risk factors for future kidney disease. This study's aim was to examine variation in complex kidney donor use across US transplant centers. We conducted a retrospective cohort study of live kidney donors using organ procurement and transplantation network data. Donors with hypertension, obesity or estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m(2) were considered medically complex. Among 9319 donors, 2254 (24.2%) were complex: 1194 (12.8%) were obese, 956 (10.3%) hypertensive and 392 (4.2%) had low eGFR. The mean proportion of medically complex donors at a center was 24% (range 0-65%). In multivariate analysis, donor characteristics associated with medical complexity included spousal relationship to the recipient (OR 1.29, CI 1.06-1.56, p < 0.01), low education (OR 1.19, CI 1.04-1.37, p = 0.01), older age (OR 1.01 per year, CI 1.01-1.02, p < 0.01) and non-US citizenship (OR 0.70, CI 0.51-0.97, p = 0.03). Renal transplant centers with the highest transplant volume (OR 1.26, CI 1.02-1.57, p = 0.03), and with a higher proportion of (living donation)/(all kidney transplants) (OR 1.97, CI 1.23-3.16, p < 0.01) were more likely to use medically complex donors. Though controversial, the use of medically complex donors is widespread and varies widely across centers.

Minors as living solid-organ donors

In the past half-century, solid-organ transplantation has become standard treatment for a variety of diseases in children and adults. The major limitation for all transplantation is the availability of donors, and the gap between demand and supply continues to grow despite the increase in living donors. Although rare, children do serve as living donors, and these donations raise serious ethical issues. This clinical report includes a discussion of the ethical considerations regarding minors serving as living donors, using the traditional benefit/burden calculus from the perspectives of both the donor and the recipient. The report also includes an examination of the circumstances under which a minor may morally participate as a living donor, how to minimize risks, and what the informed-consent process should entail. The American Academy of Pediatrics holds that minors can morally serve as living organ donors but only in exceptional circumstances when specific criteria are fulfilled.

Living kidney donor informed consent practices vary between US and non-US centers

BACKGROUND

Living kidney donation rates are increasing in the United States and internationally. Major consensus statements on the care of living kidney donors recommend communicating all potential health and psychosocial risks to donors. We evaluated the degree of international variation in the process of informed consent of potential donors during their evaluation.

METHODS

Transplant professionals attending the 2006 World Transplant Congress responded to a survey assessing their process of informed consent, evaluation and communication of living donor risk. US-based respondents were compared to non-US respondents.

RESULTS

There were 221 respondents from 177 transplant centers and 40 countries (48% US respondents). Across US and non-US transplant centers, potential donors were most likely to receive written material about living donor risk by mail prior to evaluation, receive risk information in person during evaluation, have a psychosocial evaluation, which usually lasted longer than 30 min and sign an official donation consent form presented to them by a surgeon or nephrologist. Although over 75% of respondents stated that donors received information about medical risks such as hypertension, chronic kidney disease and potential need for dialysis, there was less consistency regarding whether or not respondents conveyed an increased risk of these medical complications to donors. Additionally, the financial and psychosocial costs associated with being a living donor were inconsistently communicated to donors during the informed consent process. Compared to non-US respondents, US respondents were more likely to use written material and visual aids to convey risks to donors, have mandatory psychosocial evaluations and provide access to donor support groups. US transplant centers were also more likely to discuss the possibility of the donors needing dialysis or a transplant if their remaining kidney fails in the future, possible travel expenses and loss of work income due to donation recovery. Conversely, the US respondents were less likely to offer long-term follow-up and to utilize nephrologists to obtain written donor consent for donation.

CONCLUSIONS

As dependence on living organ donation increases best practices for informed consent, donor evaluation and uniform risk conveyance need to be established. This may be accomplished by using a model informed consent template to ensure that informed consent from donors is consistently obtained.

Kidney transplantation as primary therapy for end-stage renal disease: a National Kidney Foundation/Kidney Disease Outcomes Quality Initiative (NKF/KDOQITM) conference

BACKGROUND AND OBJECTIVES

Kidney transplantation is the most desired and cost-effective modality of renal replacement therapy for patients with irreversible chronic kidney failure (end-stage renal disease, stage 5 chronic kidney disease). Despite emerging evidence that the best outcomes accrue to patients who receive a transplant early in the course of renal replacement therapy, only 2.5% of incident patients with end-stage renal disease undergo transplantation as their initial modality of treatment, a figure largely unchanged for at least a decade.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The National Kidney Foundation convened a Kidney Disease Outcomes Quality Initiative (KDOQI) conference in Washington, DC, March 19 through 20, 2007, to examine the issue. Fifty-two participants representing transplant centers, dialysis providers, and payers were divided into three work groups to address the impact of early transplantation on the chronic kidney disease paradigm, educational needs of patients and professionals, and finances of renal replacement therapy.

RESULTS

Participants explored the benefits of early transplantation on costs and outcomes, identified current barriers (at multiple levels) that impede access to early transplantation, and recommended specific interventions to overcome those barriers.

CONCLUSIONS

With implementation of early education, referral to a transplant center coincident with creation of vascular access, timely transplant evaluation, and identification of potential living donors, early transplantation can be an option for substantially more patients with chronic kidney disease.

Consideration of Psychosocial Factors in the Evaluation of Living Donors

Results of donor outcome studies indicate that most living donors report a positive psychosocial response to donation. However, negative psychosocial outcomes have also been reported. Evaluation guidelines have been proposed, although a standardized evaluation specific to living donors is not yet available. In an effort to determine what psychosocial factors should be considered in a comprehensive evaluation of living donors, an extensive literature review was undertaken that was focused on previously proposed guidelines for the psychosocial evaluation of living donors, research on outcomes among living donors, and other relevant psychosocial data.

Optimal Transplant Education for Recipients to Increase Pursuit of Living Donation

Context

Inadequate transplant education may stop kidney patients from beginning or completing evaluation or limit recipients from considering living donation.

Objective

To learn about recipients' decision making about living donation and preferred transplant education resources.

Design

Retrospective, cross-sectional survey. Patients—304 kidney recipients.

Main Outcome Measures

Living donation comfort, concerns, education preferences.

Results

Recipients spent 10 median hours learning about transplant, primarily by speaking to medical staff (2–3 hours) and reading transplant brochures (0–1 hour). Twelve percent had not received any education before coming to the transplant center. At least 75% wanted education discussing the evaluation, surgery, and medical tests required of recipients and donors, as well as common transplant-related fears. Recipients who received living donor transplants were more interested in information about donors' evaluation ( P< .001), surgery ( P< .001), medical tests ( P< .001), and donation concerns ( P= .004) than were other recipients. Recipients who had living donors evaluated were more comfortable accepting family members or friends who volunteered rather than asking potential donors because of concerns about pressuring donors (85%), harming their health (83%), or causing them pain or inconvenience (76%). Besides providing accurate medical information, education that addresses recipients' fears about transplantation, explains living donors' donation experiences, and teaches patients how to pursue living donation may increase recipients' pursuit of living donation.

Minimizing morbidity of organ donation: analysis of factors for perioperative complications after living-donor nephrectomy in the United States

BACKGROUND

Expansion of living kidney donation through liberalizing acceptance criteria invites a renewed focus on safety and outcomes. Wide variability exists in reported donor complications, and associated risk factors are ill defined. Use of administrative data can overcome the bias of single-center studies and identify variables associated with untoward events.

METHODS

The study population consisted of 3074 living kidney donors from 28 centers during 2004 and 2005. Data from a large healthcare registry were used to retrospectively identify the study cohort. Perioperative complications were identified using ICD-9-CM coding and classified according to the Clavien system. Logistic regression models were constructed to identify donor and center factors associated with complications.

RESULTS

There were no perioperative deaths. The overall complication rate was 10.6% and major complications defined by Clavien grade >or=3 was 4.2%. The prevalence of tobacco use, obesity, and hypertension, was 7.8%, 2.4%, and 2.3%, respectively. Age >50 (odds ratio [OR]=1.81, 95% confidence interval [95% CI]=1.25-2.61), tobacco use (OR=1.41, 95% CI=1.02-1.94), obesity (OR=1.92, 95% CI=1.06-3.46), and annual center volume

CONCLUSIONS

The inclusion of donors with tobacco abuse, obesity, and age >50 increases complications; however, the risk of major morbidity is small. Use of administrative data represents an important tool to facilitate the reconciliation of an increased need for organ donors with the concern for donor safety.

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MESH Headings

• Adult
• Cohort Studies
• Female
• Humans
• Intraoperative Complications/epidemiology
• Living Donors/statistics & numerical data
• Male
• Middle Aged
• Morbidity
• Nephrectomy
• Odds Ratio
• Postoperative Complications/epidemiology
• Racial Groups
• Retrospective Studies
• Risk Factors
• United States

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Affiliation(s)

Siddharth Patel Division of Transplantation, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
James Cassuto
Mark Orloff
Georgios Tsoulfas
Martin Zand
Randeep Kashyap
Ashok Jain
Adel Bozorgzadeh
Peter Abt

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Follow-up interviews of 12 living kidney donors one yr after open donor nephrectomy

Very few studies have prospectively followed living kidney donors the first year after donor surgery. In 2003, we in-depth interviewed living kidney donors one wk after donation to explore their immediate experiences of going through nephrectomy. The aim of the current investigation was to explore experiences regarding physical and psychosocial health during the first year after donor surgery. Twelve donors going through open donor nephrectomy were interviewed by telephone at one yr after donation. The analysis was carried out with an empirical phenomenological method. All participants expressed an overall positive experience about being a donor a year after transplantation. However, several participants experienced physical disincentives longer than expected post-donation. Emotional distress, such as mild depression and a feeling of loss, was also part of the donor experiences. Donors experiencing unsuccessful recipient outcome reported severe physical and mental reactions. This study provides insights on the physical and mental cost to living kidney donation. Awareness of how donors may experience their situations can help transplantation professionals in their efforts to understand and provide support.