The Living Donor Lost Wages Trial: Study Rationale and Protocol

Why Do They Persist? Understanding Living Kidney Donors and Persistence

Many participants persist through the living kidney donation process, although it is challenging, multifaceted, and burdensome, particularly during the predonation evaluation (PDE) phase. This study uses a constructivist grounded theory approach to analyze the experiences of living kidney donors (LKDs) undergoing evaluation who shared their perspectives in blog reflections. One hundred five (105) blog posts met the inclusion criteria. They generated three overarching themes: (1) Facilitators to completing the PDE qualification process, (2) Burdens experienced during the PDE qualification process, and (3) Tools to mitigate burdens or enhance facilitators. Internal facilitators, such as the desire to help and other motivating emotions, emerged as key drivers for LKDs to persist through the donation process. Religious belief or faith, an external facilitator, is also crucial in motivating donors. Conversely, internal burdens, such as doubts, fears, financial concerns, and health risks, posed challenges to the donation process. External burdens also included recipient relationship management, delays and setbacks, poor communication, qualification testing, lack of support, and being denied as a donor. This study's findings shed light on the complex interplay between burdens, facilitators, and tools in shaping the experiences of LKDs during the PDE, which enabled their persistence through the process and highlights a potential persistence spectrum. The insights gained from this research can inform interventions to better support living kidney donors throughout their donation journey, enhancing the overall donor experience and potentially increasing the number of living kidney donations.

Distinct clinical profiles and post-transplant outcomes among kidney transplant recipients with lower education levels: uncovering patterns through machine learning clustering

BACKGROUND

Educational attainment significantly influences post-transplant outcomes in kidney transplant patients. However, research on specific attributes of lower-educated subgroups remains underexplored. This study utilized unsupervised machine learning to segment kidney transplant recipients based on education, further analyzing the relationship between these segments and post-transplant results.

METHODS

Using the OPTN/UNOS 2017-2019 data, consensus clustering was applied to 20,474 kidney transplant recipients, all below a college/university educational threshold. The analysis concentrated on recipient, donor, and transplant features, aiming to discern pivotal attributes for each cluster and compare post-transplant results.

RESULTS

Four distinct clusters emerged. Cluster 1 comprised younger, non-diabetic, first-time recipients from non-hypertensive younger donors. Cluster 2 predominantly included white patients receiving their first-time kidney transplant either preemptively or within three years, mainly from living donors. Cluster 3 included younger re-transplant recipients, marked by elevated PRA, fewer HLA mismatches. In contrast, Cluster 4 captured older, diabetic patients transplanted after prolonged dialysis duration, primarily from lower-grade donors. Interestingly, Cluster 2 showcased the most favorable post-transplant outcomes. Conversely, Clusters 1, 3, and 4 revealed heightened risks for graft failure and mortality in comparison.

CONCLUSIONS

Through unsupervised machine learning, this study proficiently categorized kidney recipients with lesser education into four distinct clusters. Notably, the standout performance of Cluster 2 provides invaluable insights, underscoring the necessity for adept risk assessment and tailored transplant strategies, potentially elevating care standards for this patient cohort.

Wages, Travel, and Lodging Reimbursement by the National Kidney Registry: An Important Step Toward Financial Neutrality for Living Kidney Donors in the United States

BACKGROUND

Since 2007, the National Living Donor Assistance Center has provided the most financial support to US living donors meeting specific income criteria by reimbursing travel, meal, and lodging expenses. In 2019, the National Kidney Registry started providing lost wages, travel, and lodging reimbursement via their Donor Shield program. Donor Shield is automatically provided to donors who participate in kidney paired donation through the National Kidney Registry or who donate at a Donor Shield Direct center, without any income restrictions.

METHODS

The support donors across the United States received from the Donor Shield program between January 2019 and February 2020 was studied.

RESULTS

During the study period, 326 (25.9%) of the 1260 donors covered by Donor Shield, from 46 programs received reimbursements amounting to a total of $647 384.45, with $472 389.97 (73.0%) covering lost wages. Median reimbursement per donor was $1813.80 (range, $44.0-$165.63). Eighty-one percent of 108 reimbursed donors who were surveyed reported that the lack of these reimbursements would have posed a financial hardship, and 4% said they would have been unable to donate without this support.

CONCLUSIONS

Expansion of lost wages reimbursement programs to all donors in the United States would be an important step toward achieving financial neutrality for this unique population and could also help meet the growing demand for transplantable organs by increasing living donation rates.

The need for a living donor wellness program

PURPOSE OF REVIEW

Living donation has a tremendous impact in bridging the gap between the shortage of organs and the growing list of transplant candidates but remains underutilized as a percentage of total transplants performed. This review focuses on obesity and social determinants of health as potential barriers to the expansion of living kidney donation.

RECENT FINDINGS

The growing rate of obesity and associated metabolic syndrome make many potential donors unacceptable as donor candidates because of the future risk for developing chronic health conditions, such as hypertension and diabetes. There is also increasing evidence demonstrating socioeconomic differences and racial disparities potentially limit access to living donation in certain populations. These potentially modifiable factors are not exclusive of each other and together serve as significant contributing factors to lower rates of living donation.

SUMMARY

Living donors make sacrifices to provide the gift of life to transplant recipients, despite the potential risks to their own health. Studies describing risk factors to living donation call attention to the overall need for more action to prioritize and promote the health and well being of living donors.

Nonreimbursed Costs Incurred by Living Kidney Donors: A Case Study From Ontario, Canada

BACKGROUND

Living donors may incur out-of-pocket costs during the donation process. While many jurisdictions have programs to reimburse living kidney donors for expenses, few programs have been evaluated.

METHODS

The Program for Reimbursing Expenses of Living Organ Donors was launched in the province of Ontario, Canada in 2008 and reimburses travel, parking, accommodation, meals, and loss of income; each category has a limit and the maximum total reimbursement is $5500 CAD. We conducted a case study to compare donors' incurred costs (out-of-pocket and lost income) with amounts reimbursed by Program for Reimbursing Expenses of Living Organ Donors. Donors with complete or partial cost data from a large prospective cohort study were linked to Ontario's reimbursement program to determine the gap between incurred and reimbursed costs (n = 159).

RESULTS

The mean gap between costs incurred and costs reimbursed to the donors was $1313 CAD for out-of-pocket costs and $1802 CAD for lost income, representing a mean reimbursement gap of $3115 CAD. Nondirected donors had the highest mean loss for out-of-pocket costs ($2691 CAD) and kidney paired donors had the highest mean loss for lost income ($4084 CAD). There were no significant differences in the mean gap across exploratory subgroups.

CONCLUSIONS

Reimbursement programs minimize some of the financial loss for living kidney donors. Opportunities remain to remove the financial burden of living kidney donors.

Risks of Living Kidney Donation: Current State of Knowledge on Outcomes Important to Donors

In the past decade, there have been increasing efforts to better define and quantify the short- and long-term risks of living kidney donation. Recent studies have expanded upon the previous literature by focusing on outcomes that are important to potential and previous donors, applying unique databases and/or registries to follow large cohorts of donors for longer periods of time, and comparing outcomes with healthy nondonor controls to estimate attributable risks of donation. Leading outcomes important to living kidney donors include kidney health, surgical risks, and psychosocial effects of donation. Recent data support that living donors may experience a small increased risk of severe CKD and ESKD compared with healthy nondonors. For most donors, the 15-year risk of kidney failure is <1%, but for certain populations, such as young, black men, this risk may be higher. New risk prediction tools that combine the effects of demographic and health factors, and innovations in genetic risk markers are improving kidney risk stratification. Minor perioperative complications occur in 10%-20% of donor nephrectomy cases, but major complications occur in <3%, and the risk of perioperative death is <0.03%. Generally, living kidney donors have similar or improved psychosocial outcomes, such as quality of life, after donation compared with before donation and compared with nondonors. Although the donation process should be financially neutral, living kidney donors may experience out-of-pocket expenses and lost wages that may or may not be completely covered through regional or national reimbursement programs, and may face difficulties arranging subsequent life and health insurance. Living kidney donors should be fully informed of the perioperative and long-term risks before making their decision to donate. Follow-up care allows for preventative care measures to mitigate risk and ongoing surveillance and reporting of donor outcomes to inform prior and future living kidney donors.