The Psychosocial and Independent Living Donor Advocate Evaluation and Post-surgery Care of Living Donors

Psychosocial Evaluation of Living Kidney Donors: A Survey of Current Practices in the United States

BACKGROUND

Best practices in psychosocial evaluation and care of living donor candidates and donors are not well established.

METHODS

We surveyed 195 living kidney donor (LKD) transplant centers in United States from October 2021 to April 2022 querying (1) composition of psychosocial teams, (2) evaluation processes including clinical tools and domains assessed, (3) selection criteria, and (4) psychosocial follow-up post-donation.

RESULTS

We received 161 responses from 104 programs, representing 53% of active LKD programs and 67% of LKD transplant volume in 2019. Most respondents (63%) were social workers/independent living donor advocates. Over 90% of respondents indicated donor candidates with known mental health or substance use disorders were initially evaluated by the psychosocial team. Validated psychometric or transplant-specific tools were rarely utilized but domains assessed were consistent. Active suicidality, self-harm, and psychosis were considered absolute contraindications in >90% of programs. Active depression was absolute contraindication in 50% of programs; active anxiety disorder was excluded 27%. Conditions not contraindicated to donation include those in remission: anxiety (56%), depression (53%), and posttraumatic stress disorder (41%). There was acceptance of donor candidates using alcohol, tobacco, or cannabis recreationally, but not if pattern met criteria for active use disorder. Seventy-one percent of programs conducted post-donation psychosocial assessment and use local resources to support donors.

CONCLUSIONS

There was variation in acceptance of donor candidates with mental health or substance use disorders. Although most programs conducted psychosocial screening post-donation, support is not standardized and unclear if adequate. Future studies are needed for consensus building among transplant centers to form guidelines for donor evaluation, acceptance, and support.

The psychology, legality, ethics and medical aspects of organ donation by minors

Any individual who has not attained the chronological age of legal majority as per national law is termed a minor. The concept of living donation (LD) has always been a subject of ethical debate and further compounding the controversy is the question of LD by minors. The decision for a minor to donate poses a special challenge as it involves a close family unit of parent-child relationship. Such an emotionally loaded situation wherein questions of attachment, perceived duties, moral obligation are likely to cloud a truly informed consent on the part of the minor to donation, who may find themselves in a vulnerable position. Furthermore, a minor's cognitive ability to comprehend the gravity of LD and when required defy parental coercion need to be elucidates before a minor is accepted for LD. Experts have set out stringent conditions which need to be met prior to the exceptional circumstance that a minor is considered for organ donation. Such donations should require parental permission, child's assent and the involvement of a paediatric-trained donor advocacy team. This article debates the question of minors acting as live donors from ethical, medical, psychosocial and legal viewpoints with an aim to present internationally defined circumstances when a minor may morally participate as a LD, thereby laying the foundation for future deliberations in this regard using traditional metrics to juxtapose divergent courses of action.

Assessment of the Desire and Readiness of Taif Residents for Heart Donation After Death

Background/aim Heart transplantation is often the only preferable treatment for end-stage heart failure (HF); however, there are insufficient organ donors in Saudi Arabia. In this study, we aimed to understand the desire and readiness of Taif populations for heart donation after death. Methods We carried out a descriptive cross-sectional study among Taif residents in November 2022. A questionnaire designed from a previous survey was distributed among the participants. The questionnaire included sociodemographic data and questions assessing their desire for heart donation. Results The study included 405 subjects who have accepted to participate in the study. About half of the participants were aged 18 to 32 years (43.5%), most were females, were non-employed, and had a university degree. Of them, 86.2% accepted the concept of organ transplantation, 81% accepted the concept of heart transplantation, and one-third of the participants desired to donate their hearts. The participants with a university degree reported significantly less acceptance of the concept of heart transplantation (p-value=0.026), and those employed showed a significantly stronger desire for organ donation to a relative after death (p-value=0.049). In addition, younger participants showed a significantly higher willingness for organ donation to a relative or non-relative after death (p-value=0.017 and 0.009, respectively). Employed participants were significantly more willing to undergo heart transplantation surgery if needed (p-value=0.044). Conclusion Awareness campaigns could be established in the community and popularized during contact with the health system to build trust in the organ donation system, stress the importance of heart donation in saving the lives of more patients, and reduce the shortage of organ transplantation.

Taming Wickedness: Towards an Implementation Framework for Medical Ethics

"Wicked" problems are characterized by intractable complexity, uncertainty, and conflict between individuals or institutions, and they inhabit almost every corner of medical ethics. Despite wide acceptance of the same ethical principles, we nevertheless disagree about how to formulate such problems, how to solve them, what would count as solving them, or even what the possible solutions are. That is, we don't always know how best to implement ethical ideals in messy real-world contexts. I sketch an implementation framework for medical ethics that can help clarify wicked problems and organize further ethics research toward their resolutions. This framework describes the procedural variables that work alongside substantive ethical ideals to deliver ethical decisions in complex real-world situations. Using controversial GM mosquito research as an example, I illustrate how the generalizable relationships between the variables clarify emerging ethical guidelines of research governance and provide a pathway to extend these guidelines in a way consistent with our ethical intuitions across a wide range of research and public health ethics.

Low Rates of Preemptive Kidney Transplantation: A Root Cause Analysis to Identify Opportunities for Improvement

Background

Kidney transplantation success can help improve the quality of life substantially and alleviate much of the physical, social and psychological stress that comes with dialysis lifestyle. Preemptive kidney transplantation has been established to be superior with more success rates than other means of transplantation types. However, low rates of this method need more attention to address the reason and tackle the root causes affecting low preemptive kidney transplantation.

Methods

This study was undertaken at a tertiary care academic hospital. We conducted a retrospective chart review of 50 living donor kidney transplants (recipient and donor charts) between January 1, 2017 and September 30, 2018 and performed a root cause analysis on the module. A three-step algorithm was developed to divide the root cause of all preemptive kidney transplantation.

Results

Out of 50 patients included, only 11 (22%) achieved a successful preemptive kidney transplantation. Furthermore, an estimated glomerular filtration rate (eGFR) of 15 - 20 was a significant factor in achieving preemptive kidney transplantation (P = 0.042). Meanwhile, 22 recipients started dialysis before transplant and was a major cause of not achieving the preemptive transplantation despite them achieving the status. Moreover, the most common recipient root cause was incidental medical issues in 10 cases (20%) while in donor factors, the most common root cause was the delay in evaluating multiple donors to achieve the preemptive status (20%).

Conclusion

Even though preemptive kidney transplantation is superior when compared to other modalities, achieving such a milestone is still considered very challenging. An eGFR of 15 - 20 was a significant factor in achieving preemptive kidney transplantation, while pre-transplant dialysis was a major cause of not achieving it. Further large-scale studies are needed to identify new factors as well as validate our findings.

Care of international living kidney donor candidates in the United States: A survey of contemporary experience, practice, and challenges

The evaluation and care of non-US citizen, non-US residents who wish to come to the United States to serve as international living kidney donors (ILKDs) can pose unique challenges. We surveyed US transplant programs to better understand practices related to ILKD care. We distributed the survey by email and professional society list-servs (Fall 2018, assessing 2017 experience). Eighty-five programs responded (36.8% program response rate), of which 80 considered ILKD candidates. Only 18 programs had written protocols for ILKD evaluation. Programs had a median of 3 (range: 0,75) ILKD candidates who initiated contact during the year, from origin countries spanning 6 continents. Fewer (median: 1, range: 0,25) were approved for donation. Program-reported reasons for not completing ILKD evaluations included visa barriers (58.6%), inability to complete evaluation (34.3%), concerns regarding follow-up (31.4%) or other healthcare access (28.6%), and financial impacts (21.4%). Programs that did not evaluate ILKDs reported similar concerns. Staff time required to evaluate ILKDs was estimated as 1.5-to-3-times (47.9%) or >3-times (32.9%) that needed for domestic candidates. Among programs accepting ILKDs, on average 55% reported successful completion of 1-year follow-up. ILKD evaluation is a resource-intensive process with variable outcomes. Planning and commitment are necessary to care for this unique candidate group.

Validation of the american quality assessment model and performance improvement to the brazilian transplant

Objective:

To validate the quality assessment and performance improvement instrument of US transplant programs to the Brazilian reality.

Method:

Methodological study developed for semantic validation and cultural adaptation of the Quality assessment and Performance Improvement instrument in the following steps: 1) translation; 2) synthesis; 3) back translation; 4) review by expert committee; 5) pretest and 6) content validation. To evaluate the agreement between the five judges, the Kappa coefficient was used and for content validation, the content validation index.

Results:

Kappa coefficient showed the agreement of the judges for semantic, idiomatic, cultural and conceptual equivalences. Content validation index values for relevance and item sequence of at least 0.80 for all blocks.

Conclusion:

The instrument of Quality Evaluation and Performance Improvement of Transplantation Programs proved to be valid and reliable. This instrument will contribute to the development of quality assurance programs for transplant teams in Brazil.

Impact of the OPTN transmissible diseases policy and US PHS increased risk donor guidelines on living donor candidates

Donor-derived human immunodeficiency virus (HIV), hepatitis C virus (HCV), and hepatitis B virus (HBV) transmissions in transplantation have led to policies mandating assessment of donor behavioral history, and disclosure of donor increased risk (IR) status to recipients. Organ Procurement Transplantation Network (OPTN) policy safeguards were promulgated in the context of deceased donation, with its narrow time window for organ utilization and uncertainty about donor history. These policies have been applied to living donation without substantive data on risk of disease transmission in living donor transplantation. Unlike for deceased donors, the OPTN does not collect data on living donor IR status. Given the feasibility of thorough living donor evaluation via already-mandated lab tests and clinical assessments, living donor IR assessment and associated disclosures may have limited benefit in improving recipient informed consent. Applying the current IR policy to living donors may also introduce unintended consequences to donors and recipients, causing donors psychological harm, delays in donation to avoid IR status disclosure, and potential withdrawal from donation. We suggest strategies that reduce risk of harm to donor candidates while maintaining policy compliance, and review additional approaches for evaluating risk of disease transmission in living donor candidates. Data on the risk of disease transmission by living donors are needed to inform policy modification.

Donor outcomes in anonymous live liver donation

BACKGROUND & AIMS

Death rates on liver transplant waiting lists range from 5%-25%. Herein, we report a unique experience with 50 anonymous individuals who volunteered to address this gap by offering to donate part of their liver to a recipient with whom they had no biological connection or prior relationship, so called anonymous live liver donation (A-LLD).

METHODS

Candidates were screened to confirm excellent physical, mental, social, and financial health. Demographics and surgical outcomes were analyzed. Qualitative interviews after donation examined motivation and experiences. Validated self-reported questionnaires assessed personality traits and psychological impact.

RESULTS

A total of 50 A-LLD liver transplants were performed between 2005 and 2017. Most donors had a university education, a middle-class income, and a history of prior altruism. Half were women. Median age was 38.5 years (range 20-59). Thirty-three (70%) learned about this opportunity through public or social media. Saving a life, helping others, generativity, and reciprocity for past generosity were motivators. Social, financial, healthcare, and legal support in Canada were identified as facilitators. A-LLD identified most with the personality traits of agreeableness and conscientiousness. The median hospital stay was 6 days. One donor experienced a Dindo-Clavien Grade 3 complication that completely resolved. One-year recipient survival was 91% in 22 adults and 97% in 28 children. No A-LLD reported regretting their decision.

CONCLUSIONS

This is the first and only report of the characteristics, motivations and facilitators of A-LLD in a large cohort. With rigorous protocols, outcomes are excellent. A-LLD has significant potential to reduce the gap between transplant organ demand and availability.

LAY SUMMARY

We report a unique experience with 50 living donors who volunteered to donate to a recipient with whom they had no biological connection or prior relationship (anonymous living donors). This report is the first to discuss motivations, strategies and facilitators that may mitigate physical, social and ethical risk factors in this patient population. With rigorous protocols, anonymous liver donation and recipient outcomes are excellent; with appropriate clinical expertise and system facilitators in place, our experience suggests that other centers may consider the procedure for its significant potential to reduce the gap between transplant organ demand and availability.

Transplant advocacy in the era of the human immunodeficiency virus organ policy equity act

In 2013, the Human Immunodeficiency Virus Organ Policy Equity (HOPE) Act was passed to permit the conduct of research on the transplantation of organs from donors infected with human immunodeficiency virus (HIV) into recipients who are HIV-positive. The HOPE Act workshop had many objectives including the discussion of the ethical issues involved in HIV-positive to HIV-positive transplantation, the informed consent process, and the role of independent advocates in the context of HIV to HIV transplantation. As of 2018, 22 transplant hospitals are approved, or undergoing approval, to perform HIV-positive to HIV-positive transplant surgeries, and this number is expected to grow. This study aims to: (i) briefly review the history and research of HIV+ transplantation prior to the HOPE Act, (ii) describe the ethical principles supporting the HOPE Act, (iii) characterize the informed consent process, and (iv) provide guidance regarding the role of independent advocates in the context of HIV-positive to HIV-positive transplantation.