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Garg AX, Arnold JB, Cuerden MS, Dipchand C, Feldman LS, Gill JS, Karpinski M, Klarenbach S, Knoll G, Lok CE, Miller M, Monroy-Cuadros M, Nguan C, Prasad GVR, Sontrop JM, Storsley L, Boudville N. Hypertension and Kidney Function After Living Kidney Donation. JAMA 2024; 332:287-299. [PMID: 38780499 PMCID: PMC11117152 DOI: 10.1001/jama.2024.8523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 04/22/2024] [Indexed: 05/25/2024]
Abstract
Importance Recent guidelines call for better evidence on health outcomes after living kidney donation. Objective To determine the risk of hypertension in normotensive adults who donated a kidney compared with nondonors of similar baseline health. Their rates of estimated glomerular filtration rate (eGFR) decline and risk of albuminuria were also compared. Design, Setting, and Participants Prospective cohort study of 924 standard-criteria living kidney donors enrolled before surgery and a concurrent sample of 396 nondonors. Recruitment occurred from 2004 to 2014 from 17 transplant centers (12 in Canada and 5 in Australia); follow-up occurred until November 2021. Donors and nondonors had the same annual schedule of follow-up assessments. Inverse probability of treatment weighting on a propensity score was used to balance donors and nondonors on baseline characteristics. Exposure Living kidney donation. Main Outcomes and Measures Hypertension (systolic blood pressure [SBP] ≥140 mm Hg, diastolic blood pressure [DBP] ≥90 mm Hg, or antihypertensive medication), annualized change in eGFR (starting 12 months after donation/simulated donation date in nondonors), and albuminuria (albumin to creatinine ratio ≥3 mg/mmol [≥30 mg/g]). Results Among the 924 donors, 66% were female; they had a mean age of 47 years and a mean eGFR of 100 mL/min/1.73 m2. Donors were more likely than nondonors to have a family history of kidney failure (464/922 [50%] vs 89/394 [23%], respectively). After statistical weighting, the sample of nondonors increased to 928 and baseline characteristics were similar between the 2 groups. During a median follow-up of 7.3 years (IQR, 6.0-9.0), in weighted analysis, hypertension occurred in 161 of 924 donors (17%) and 158 of 928 nondonors (17%) (weighted hazard ratio, 1.11 [95% CI, 0.75-1.66]). The longitudinal change in mean blood pressure was similar in donors and nondonors. After the initial drop in donors' eGFR after nephrectomy (mean, 32 mL/min/1.73 m2), donors had a 1.4-mL/min/1.73 m2 (95% CI, 1.2-1.5) per year lesser decline in eGFR than nondonors. However, more donors than nondonors had an eGFR between 30 and 60 mL/min/1.73 m2 at least once in follow-up (438/924 [47%] vs 49/928 [5%]). Albuminuria occurred in 132 of 905 donors (15%) and 95 of 904 nondonors (11%) (weighted hazard ratio, 1.46 [95% CI, 0.97-2.21]); the weighted between-group difference in the albumin to creatinine ratio was 1.02 (95% CI, 0.88-1.19). Conclusions and Relevance In this cohort study of living kidney donors and nondonors with the same follow-up schedule, the risks of hypertension and albuminuria were not significantly different. After the initial drop in eGFR from nephrectomy, donors had a slower mean rate of eGFR decline than nondonors but were more likely to have an eGFR between 30 and 60 mL/min/1.73 m2 at least once in follow-up. Trial Registration ClinicalTrials.gov Identifier: NCT00936078.
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Affiliation(s)
- Amit X. Garg
- Lawson Health Research Institute and London Health Sciences, London, Ontario, Canada
- ICES, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Division of Nephrology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Department of Research Methods, Evidence and Uptake, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Ontario Renal Network, Ontario Health, Toronto, Ontario, Canada
| | - Jennifer B. Arnold
- Lawson Health Research Institute and London Health Sciences, London, Ontario, Canada
| | - Meaghan S. Cuerden
- Lawson Health Research Institute and London Health Sciences, London, Ontario, Canada
| | - Christine Dipchand
- Department of Medicine (Nephrology), Queen Elizabeth II Health Sciences Centre and Dalhousie University Halifax, Nova Scotia, Canada
| | - Liane S. Feldman
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - John S. Gill
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - Greg Knoll
- Department of Medicine (Nephrology), the Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | | | | | | | | | - G. V. Ramesh Prasad
- St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Jessica M. Sontrop
- Lawson Health Research Institute and London Health Sciences, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | | | - Neil Boudville
- Medical School, The University of Western Australia, Nedlands, Western Australia, Australia
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
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Vanterpool KB, Gacki-Smith J, Downey MC, Nordstrom M, Luken M, Riggleman T, Fichter S, Altema W, Jensen SE, Dumanian GA, Cooney CM, Levan ML, Tintle S, Brandacher G, Gordon EJ. Patient preferences of patient selection criteria for upper extremity vascularized composite allotransplantation: A qualitative study. SAGE Open Med 2023; 11:20503121231181236. [PMID: 37342616 PMCID: PMC10278401 DOI: 10.1177/20503121231181236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 05/25/2023] [Indexed: 06/23/2023] Open
Abstract
Background Upper extremity vascularized composite allotransplantation is a life-enhancing reconstructive treatment option that aims to improve recipients' quality of life and maximize function. This study assessed upper extremity vascularized composite allotransplantation patient selection criteria perceptions among individuals with upper extremity limb loss. The perceptions of individuals with upper extremity limb loss on patient selection criteria may enable vascularized composite allotransplantation centers to improve criteria to avoid mismatched expectations about the posttransplant vascularized composite allotransplantation experience and outcomes. Realistic patient expectations may increase patient adherence, improve outcomes, and reduce vascularized composite allotransplantation graft loss. Methods We conducted in-depth interviews with civilian and military service members with upper extremity limb loss and upper extremity vascularized composite allotransplantation candidates, participants, and recipients from three US institutions. Interviews assessed perceptions of patient selection criteria for suitability as a candidate for upper extremity vascularized composite allotransplantation. Thematic analysis was used to analyze qualitative data. Results A total of 50 individuals participated (66% participation rate). Most participants were male (78%), White (72%), with a unilateral limb loss (84%), and a mean age of 45 years. Six themes emerged regarding upper extremity vascularized composite allotransplantation patient selection criteria, including support for candidates who: (1) are of younger age, (2) are in good physical health, (3) have mental stability, (4) are willing to "put in the work," (5) have specific amputation characteristics, and (6) have sufficient social support. Patients had preferences about selecting candidates with unilateral versus bilateral limb loss. Conclusions Our findings suggest that numerous factors, including medical, social, and psychological characteristics, inform patients' perceptions of patient selection criteria for upper extremity vascularized composite allotransplantation. Patient perceptions of patient selection criteria should inform the development of validated screening measures that optimize patient outcomes.
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Affiliation(s)
| | - Jessica Gacki-Smith
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Max C. Downey
- Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | | | - Michelle Luken
- Walter Reed National Military Medical Center, Bethesda, MD, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Rockville, MD, USA
| | | | - Shannon Fichter
- Walter Reed National Military Medical Center, Bethesda, MD, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Rockville, MD, USA
| | - Withney Altema
- Walter Reed National Military Medical Center, Bethesda, MD, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Rockville, MD, USA
| | - Sally E. Jensen
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Carisa M. Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Macey L. Levan
- Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Scott Tintle
- Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elisa J. Gordon
- Department of Surgery and Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN, USA
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Lagging E, Wadström J, Krekula LG, Tibell A. Red Flags in the Living Kidney Donor Process. Transplant Proc 2023; 55:279-287. [PMID: 36797163 DOI: 10.1016/j.transproceed.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 01/06/2023] [Accepted: 01/24/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Ideally, no live kidney donor should regret their decision or feel they were not fully prepared for the process. Unfortunately, this is not a reality for all donors. The aim of our study is to identify areas for improvement, focusing on factors (red flags) that predict less favorable outcomes from a donor perspective. MATERIALS AND METHODS A total of 171 living kidney donors responded to a questionnaire with 24 multiple-choice questions and space for comments. Less favorable outcomes were defined as lower satisfaction, extended physical recovery period, long-term fatigue, and longer sick leave. RESULTS Ten red flags were identified. Of these factors, more fatigue (range, P = .000-0.040) or pain (range, P = .005-0.008) than expected while still in hospital, the actual experience being harder or different than expected (range, P = .001-0.010), and the donor wishing to have had but not having been offered a previous donor as mentor (range, P = .008-.040) correlated significantly with at least 3 of the 4 less favorable outcomes. Another significant red flag was keeping existential issues to oneself (P = .006). CONCLUSION We identified several factors indicating that a donor could be at an increased risk for a less favorable outcome after donation. Four of these factors have, to our knowledge, not been described earlier: more early fatigue than expected, more postoperative pain than anticipated, not having been offered a mentor at an early stage, and keeping existential issues to oneself. Attention to these red flags already during the donation process could help health care professionals to act early to avoid unfavorable outcomes.
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Affiliation(s)
- Eva Lagging
- Center for Health Care Ethics, LIME, Karolinska Institutet, Stockholm, Sweden; Regional Donation Center Stockholm-Gotland, Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.
| | - Jonas Wadström
- Department of Transplantation Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Linda Gyllström Krekula
- Center for Health Care Ethics, LIME, Karolinska Institutet, Stockholm, Sweden; Regional Donation Center Stockholm-Gotland, Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Annika Tibell
- Center for Health Care Ethics, LIME, Karolinska Institutet, Stockholm, Sweden; Department of Research, Education and Innovation, Karolinska University Hospital, Stockholm, Sweden
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Garg AX, Arnold JB, Cuerden M, Dipchand C, Feldman LS, Gill JS, Karpinski M, Klarenbach S, Knoll GA, Lok C, Miller M, Monroy-Cuadros M, Nguan C, Prasad GVR, Sontrop JM, Storsley L, Boudville N. The Living Kidney Donor Safety Study: Protocol of a Prospective Cohort Study. Can J Kidney Health Dis 2022; 9:20543581221129442. [PMID: 36325263 PMCID: PMC9619271 DOI: 10.1177/20543581221129442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 08/11/2022] [Indexed: 11/14/2022] Open
Abstract
Background Living kidney donation is considered generally safe in healthy individuals; however, there is a need to better understand the long-term effects of donation on blood pressure and kidney function. Objectives To determine the risk of hypertension in healthy, normotensive adults who donate a kidney compared with healthy, normotensive non-donors with similar indicators of baseline health. We will also compare the 2 groups on the rate of decline in kidney function, the risk of albuminuria, and changes in health-related quality of life. Design Participants and Setting Prospective cohort study of 1042 living kidney donors recruited before surgery from 17 transplant centers (12 in Canada and 5 in Australia) between 2004 and 2014. Non-donor participants (n = 396) included relatives or friends of the donor, or donor candidates who were ineligible to donate due to blood group or cross-match incompatibility. Follow-up will continue until 2021, and the main analysis will be performed in 2022. The anticipated median (25th, 75th percentile, maximum) follow-up time after donation is 7 years (6, 8, 15). Measurements Donors and non-donors completed the same schedule of measurements at baseline and follow-up (non-donors were assigned a simulated nephrectomy date). Annual measurements were obtained for blood pressure, estimated glomerular filtration rate (eGFR), albuminuria, patient-reported health-related quality of life, and general health. Outcomes Incident hypertension (a systolic/diastolic blood pressure ≥ 140/90 mm Hg or receipt of anti-hypertensive medication) will be adjudicated by a physician blinded to the participant's donation status. We will assess the rate of change in eGFR starting from 12 months after the nephrectomy date and the proportion who develop an albumin-to-creatinine ratio ≥3 mg/mmol (≥30 mg/g) in follow-up. Health-related quality of life will be assessed using the 36-item RAND health survey and the Beck Anxiety and Depression inventories. Limitations Donation-attributable hypertension may not manifest until decades after donation. Conclusion This prospective cohort study will estimate the attributable risk of hypertension and other health outcomes after living kidney donation.
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Affiliation(s)
- Amit X. Garg
- Victoria Hospital, London Health Sciences Centre, ON, Canada,Amit X. Garg, Victoria Hospital, London Health Sciences Centre, 800 Commissioners Road East, ELL-200, London, ON N6A 5W9, Canada.
| | | | - Meaghan Cuerden
- Victoria Hospital, London Health Sciences Centre, ON, Canada
| | | | | | - John S. Gill
- The University of British Columbia, Vancouver, Canada
| | | | | | - Greg A. Knoll
- Department of Nephrology, Department of Medicine, The Ottawa Hospital and University of Ottawa, ON, Canada
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5
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Thomas R, Consolo H, Oniscu GC. Have we reached the limits in altruistic kidney donation? Transpl Int 2021; 34:1187-1197. [PMID: 34008872 DOI: 10.1111/tri.13921] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 05/11/2021] [Accepted: 05/12/2021] [Indexed: 01/05/2023]
Abstract
Altruistic donation (unspecified donation) is an important aspect of living donor kidney transplantation. Although donation to a stranger is lawful and supported in many countries, it remains uncommon and not actively promoted. Herein, we ask the question if we have reached the limit in altruistic donation. In doing so, we examine important ethical questions that define the limits of unspecified donation, such as the appropriate balance between autonomous decision-making and paternalistic protection of the donor, the extent of outcome uncertainty and risk-benefit analyses that donors should be allowed to accept. We also consider the scrutiny and acceptance of donor motives, the potential for commercialization, donation to particular categories of recipients (including those encountered through social media) and the ethical boundaries of active promotion of unspecified kidney donation. We conclude that there is scope to increase the number of living donation kidney transplants further by optimizing existing practices to support and promote unspecified donation. A number of strategies including optimization of the assessment process, innovative approaches to reach potential donors together with reimbursement of expenses and a more specific recognition of unspecified donation are likely to lead to a meaningful increase in this type of donation.
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Affiliation(s)
- Rachel Thomas
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK
| | | | - Gabriel C Oniscu
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK.,Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK
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6
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Thiessen C, Gannon J, Li S, Skrip L, Dobosz D, Gan G, Deng Y, Kennedy K, Gray D, Mussell A, Reese PP, Gordon EJ, Kulkarni S. Quantifying Risk Tolerance Among Potential Living Kidney Donors With the Donor-Specific Risk Questionnaire. Am J Kidney Dis 2021; 78:246-258. [PMID: 33508397 DOI: 10.1053/j.ajkd.2020.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 11/11/2020] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Enhanced informed consent tools improve patient engagement. A novel visual aid measured potential donors' risk tolerance to postdonation kidney failure and assessed if the closeness of the relationship to the intended recipient altered willingness to accept risk. STUDY DESIGN Cross-sectional analysis of donor evaluations at the time of enrollment into a longitudinal mixed-methods study between November 2014 and February 2016. SETTING & PARTICIPANTS Three US kidney transplant centers. English-speaking adults presenting for in-person living kidney donor evaluation. EXPOSURE Closeness of the relationship between the potential living donor and intended recipient. OUTCOME Willingness to accept postdonation kidney failure. ANALYTICAL APPROACH The Donor-Specific Risk Questionnaire, a dot matrix visual diagram, was used to measure willingness to accept kidney failure risk. Multivariable logistic regression assessed associations between risk acceptance and data from social science instruments, which measured donors' perceived closeness with the recipient. Qualitative data were analyzed thematically per grounded theory. RESULTS 307 participants (response rate: 86%) completed testing. 96% indicated a willingness to accept a risk of kidney failure of 0.9% or greater. Those who were older (OR, 0.98 [95% CI, 0.96-0.99]), women (OR, 0.54 [95% CI, 0.31-0.93]), and Black (OR, 0.25 [95% CI, 0.08-0.76]) were less likely to be in the medium versus low willingness to accept risk group. Closeness of the relationship to the recipient was independently associated with greater risk acceptance (for every 1-point greater closeness score, odds ratios for being in the medium and high willingness to accept risk groups were 1.21 [95% CI, 1.03-1.41] and 2.42 [95% CI, 1.53-3.82] compared with being in the low willingness to accept risk group). With the exception of parental relationships, biological linkages were not associated with accepting higher kidney failure risk. LIMITATIONS First demonstration of visual aid that used one risk estimate of kidney failure provided to all participants. Risk estimates were not customized to different demographic groups. CONCLUSIONS Relationship closeness was independently associated with a greater willingness to accept postdonation kidney failure. Visual aids can provide transplant teams with individualized donor perspectives on risk thresholds and can potentially facilitate greater patient-centered care for living donors.
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Affiliation(s)
| | | | - Sienna Li
- Department of Surgery, Yale University, New Haven, CT
| | - Laura Skrip
- Department of Surgery, Yale University, New Haven, CT
| | | | - Geilang Gan
- Yale Center for Analytical Sciences, Yale University, New Haven, CT
| | - Yanhong Deng
- Yale Center for Analytical Sciences, Yale University, New Haven, CT
| | - Kristie Kennedy
- Department of Surgery, Center for Bioethics & Medical Humanities, Northwestern University, Evanston, IL
| | - Daniel Gray
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA
| | - Adam Mussell
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA; Department of Biostatistics, Biostatistics and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA
| | - Elisa J Gordon
- Department of Surgery, Center for Bioethics & Medical Humanities, Northwestern University, Evanston, IL
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Lam NN, Dipchand C, Fortin MC, Foster BJ, Ghanekar A, Houde I, Kiberd B, Klarenbach S, Knoll GA, Landsberg D, Luke PP, Mainra R, Singh SK, Storsley L, Gill J. Canadian Society of Transplantation and Canadian Society of Nephrology Commentary on the 2017 KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Can J Kidney Health Dis 2020; 7:2054358120918457. [PMID: 32577294 PMCID: PMC7288834 DOI: 10.1177/2054358120918457] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 02/25/2020] [Indexed: 12/15/2022] Open
Abstract
Purpose of review: To review an international guideline on the evaluation and care of living
kidney donors and provide a commentary on the applicability of the
recommendations to the Canadian donor population. Sources of information: We reviewed the 2017 Kidney Disease: Improving Global Outcomes (KDIGO)
Clinical Practice Guideline on the Evaluation and Care of Living Kidney
Donors and compared this guideline to the Canadian 2014 Kidney Paired
Donation (KPD) Protocol for Participating Donors. Methods: A working group was formed consisting of members from the Canadian Society of
Transplantation and the Canadian Society of Nephrology. Members were
selected to have representation from across Canada and in various
subspecialties related to living kidney donation, including nephrology,
surgery, transplantation, pediatrics, and ethics. Key findings: Many of the KDIGO Guideline recommendations align with the KPD Protocol
recommendations. Canadian researchers have contributed to much of the
evidence on donor evaluation and outcomes used to support the KDIGO
Guideline recommendations. Limitations: Certain outcomes and risk assessment tools have yet to be validated in the
Canadian donor population. Implications: Living kidney donors should be counseled on the risks of postdonation
outcomes given recent evidence, understanding the limitations of the
literature with respect to its generalizability to the Canadian donor
population.
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Affiliation(s)
- Ngan N Lam
- Division of Nephrology, University of Calgary, AB, Canada
| | | | | | - Bethany J Foster
- Division of Pediatric Nephrology, McGill University, Montréal, QC, Canada
| | - Anand Ghanekar
- Department of Surgery, University of Toronto, ON, Canada
| | - Isabelle Houde
- Division of Nephrology, Centre Hospitalier de l'Université de Québec, Québec City, Canada
| | - Bryce Kiberd
- Division of Nephrology, Dalhousie University, Halifax, NS, Canada
| | | | - Greg A Knoll
- Division of Nephrology, University of Ottawa, ON, Canada
| | - David Landsberg
- Division of Nephrology, University of British Columbia, Vancouver, Canada
| | - Patrick P Luke
- Division of Urology, Western University, London, ON, Canada
| | - Rahul Mainra
- Division of Nephrology, University of Saskatchewan, Saskatoon, Canada
| | - Sunita K Singh
- Division of Nephrology, University of Toronto, ON, Canada
| | - Leroy Storsley
- Section of Nephrology, University of Manitoba, Winnipeg, Canada
| | - Jagbir Gill
- Division of Nephrology, University of British Columbia, Vancouver, Canada
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8
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Informative for Decision Making? The Spectrum and Consistency of Outcomes After Living Kidney Donation Reported in Trials and Observational Studies. Transplantation 2019; 103:284-290. [DOI: 10.1097/tp.0000000000002489] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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9
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Nguyen QL, Merville P, Couzi L. Impact of the individualized risks of end-stage renal disease on living kidney donor selection. Nephrol Dial Transplant 2018; 33:2245-2252. [PMID: 29846692 DOI: 10.1093/ndt/gfy145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 04/18/2018] [Indexed: 11/13/2022] Open
Abstract
Background It is recommended to determine the risks of end-stage renal disease (ESRD) in living donor candidates. The aim of this study was to determine how many candidates would have been cleared for donation according to different thresholds of risks. Methods Four pre-donation and post-donation risks of ESRD were calculated retrospectively using online tools (http://www.transplantmodels.com/) and the calculator of the University of Minnesota for 151 living kidney donors and 27 patients disqualified for living donation based on a glomerular filtration rate (GFR) <80 mL/min/1.73 m2. Results A complete overlap of the pre-donation 15-year ESRD risk, pre-donation projected lifetime ESRD risk, post-donation 15-year ESRD risk and the Minnesota post-donation 15-year risk of ESRD or GFR <30 mL/min/1.73 m2 was observed for the living kidney donors and the disqualified candidates. We next defined different thresholds of pre- and post-donation risks of ESRD that could be used for clearing living donation. In candidates over 61 years of age, the use of a pre-donation 15-year ESRD risk of 0.25% and/or a post-donation 15-year ESRD risk of 50 per 10 000 would increase the percentage of donors by 28.6% and 26.3%, respectively. Conversely, only 22.3% of donors aged 18-35 years would have been selected by using a pre-donation projected lifetime ESRD risk <0.5%. Conclusions The use of these ESRD risks would significantly modify donor selection by increasing the percentage of donors ≥61 years of age with GFR <80 mL/min/1.73 m2 and by decreasing the percentage of donors aged 18-35 years with a high GFR.
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Affiliation(s)
- Quang-Linh Nguyen
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Bordeaux University Hospital, Bordeaux, France
| | - Pierre Merville
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Bordeaux University Hospital, Bordeaux, France.,Immuno ConcEpT, CNRS UMR 5164, Bordeaux University, Bordeaux, France
| | - Lionel Couzi
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Bordeaux University Hospital, Bordeaux, France.,Immuno ConcEpT, CNRS UMR 5164, Bordeaux University, Bordeaux, France
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Garavito DM, Reyna VF, DeTello JE. A concussion by any other name: Differences in willingness to risk brain injury by label and level of participation in high-school and college sports. APPLIED COGNITIVE PSYCHOLOGY 2018. [DOI: 10.1002/acp.3481] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Valerie F. Reyna
- Department of Human Development; Cornell University; Ithaca New York USA
| | - Joseph E. DeTello
- Department of Human Development; Cornell University; Ithaca New York USA
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11
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Hanson CS, Chapman JR, Gill JS, Kanellis J, Wong G, Craig JC, Teixeira-Pinto A, Chadban SJ, Garg AX, Ralph AF, Pinter J, Lewis JR, Tong A. Identifying Outcomes that Are Important to Living Kidney Donors: A Nominal Group Technique Study. Clin J Am Soc Nephrol 2018; 13:916-926. [PMID: 29853616 PMCID: PMC5989678 DOI: 10.2215/cjn.13441217] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 03/14/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Living kidney donor candidates accept a range of risks and benefits when they decide to proceed with nephrectomy. Informed consent around this decision assumes they receive reliable data about outcomes they regard as critical to their decision making. We identified the outcomes most important to living kidney donors and described the reasons for their choices. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Previous donors were purposively sampled from three transplant units in Australia (Sydney and Melbourne) and Canada (Vancouver). In focus groups using the nominal group technique, participants identified outcomes of donation, ranked them in order of importance, and discussed the reasons for their preferences. An importance score was calculated for each outcome. Qualitative data were analyzed thematically. RESULTS Across 14 groups, 123 donors aged 27-78 years identified 35 outcomes. Across all participants, the ten highest ranked outcomes were kidney function (importance=0.40, scale 0-1), time to recovery (0.27), surgical complications (0.24), effect on family (0.22), donor-recipient relationship (0.21), life satisfaction (0.18), lifestyle restrictions (0.18), kidney failure (0.14), mortality (0.13), and acute pain/discomfort (0.12). Kidney function and kidney failure were more important to Canadian participants, compared with Australian donors. The themes identified included worthwhile sacrifice, insignificance of risks and harms, confidence and empowerment, unfulfilled expectations, and heightened susceptibility. CONCLUSIONS Living kidney donors prioritized a range of outcomes, with the most important being kidney health and the surgical, lifestyle, functional, and psychosocial effects of donation. Donors also valued improvements to their family life and donor-recipient relationship. There were clear regional differences in the rankings.
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Affiliation(s)
- Camilla S. Hanson
- Sydney School of Public Health and
- Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
| | - Jeremy R. Chapman
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, The University of Sydney, Westmead, New South Wales, Australia
| | - John S. Gill
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - John Kanellis
- Department of Nephrology, Monash Health and Centre for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Germaine Wong
- Sydney School of Public Health and
- Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, The University of Sydney, Westmead, New South Wales, Australia
| | - Jonathan C. Craig
- Sydney School of Public Health and
- Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
| | - Armando Teixeira-Pinto
- Sydney School of Public Health and
- Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
| | - Steve J. Chadban
- Kidney Node, Charles Perkins Centre, The University of Sydney, Sydney, New South Wales, Australia
- Renal Medicine, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Amit X. Garg
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada; and
| | - Angelique F. Ralph
- Sydney School of Public Health and
- Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
| | - Jule Pinter
- Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
- Division of Nephrology, Department of Medicine, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Joshua R. Lewis
- Sydney School of Public Health and
- Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
| | - Allison Tong
- Sydney School of Public Health and
- Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
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Graham JM, Courtney AE. The Adoption of a One-Day Donor Assessment Model in a Living Kidney Donor Transplant Program: A Quality Improvement Project. Am J Kidney Dis 2017; 71:209-215. [PMID: 29150247 DOI: 10.1053/j.ajkd.2017.07.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 07/26/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND Survival of kidney transplants and their recipients is significantly better after living donor than after deceased donor transplantation. However, historically, Northern Ireland has had a low rate of living donor kidney transplantation. The length and complexity of donor evaluation has been one of the main factors contributing to this pattern. STUDY DESIGN Quality improvement project. SETTINGS & PARTICIPANTS All people in Northern Ireland expressing an interest in becoming a living kidney donor between 2010 and 2015. QUALITY IMPROVEMENT INTERVENTION Potential donors deemed to be suitable after a screening questionnaire attended a comprehensive 1-day evaluation including all investigations that had been previously been implemented across multiple clinical visits. OUTCOME Change in rate of living donor transplantation following the quality improvement intervention. MEASUREMENTS Demographic data and reasons for nondonation. RESULTS 431 potential donors underwent a 1-day assessment, with 284 (66%) ultimately donating and 12 (3%) still active in the program. Of the 135 (31%) potential donors who did not donate, 48 were unsuitable due to medical or surgical issues, 2 became pregnant, and 18 withdrew. For 38 (9%) potential donors, intended recipients found an alternative living or deceased donor transplant. For 29 (6%) potential donors, the transplantation did not proceed because of recipient-related issues. The annual rate of living donor kidney transplantation in Northern Ireland increased from a mean of 4.3 per million population (pmp) between 2000 and 2009 to 32.6 pmp between 2011 and 2015. LIMITATIONS Single geographical region with a potentially unrepresentative population and health care organization. Retrospective observational study. Paucity of data from the preintervention period. CONCLUSIONS Following implementation of a 1-day assessment process, we observed a considerable and sustained increase in the rate of living donor kidney transplantation. Making donor evaluation easier holds promise to increase the number of living donor kidney transplants, potentially optimizing outcomes for both recipients and donors.
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Affiliation(s)
- Judi M Graham
- Regional Nephrology Unit, Belfast City Hospital, Belfast, United Kingdom.
| | - Aisling E Courtney
- Regional Nephrology Unit, Belfast City Hospital, Belfast, United Kingdom
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Lentine KL, Kasiske BL, Levey AS, Adams PL, Alberú J, Bakr MA, Gallon L, Garvey CA, Guleria S, Li PKT, Segev DL, Taler SJ, Tanabe K, Wright L, Zeier MG, Cheung M, Garg AX. KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Transplantation 2017; 101:S1-S109. [PMID: 28742762 PMCID: PMC5540357 DOI: 10.1097/tp.0000000000001769] [Citation(s) in RCA: 207] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 03/20/2017] [Indexed: 12/17/2022]
Abstract
The 2017 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors is intended to assist medical professionals who evaluate living kidney donor candidates and provide care before, during and after donation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach and guideline recommendations are based on systematic reviews of relevant studies that included critical appraisal of the quality of the evidence and the strength of recommendations. However, many recommendations, for which there was no evidence or no systematic search for evidence was undertaken by the Evidence Review Team, were issued as ungraded expert opinion recommendations. The guideline work group concluded that a comprehensive approach to risk assessment should replace decisions based on assessments of single risk factors in isolation. Original data analyses were undertaken to produce a "proof-in-concept" risk-prediction model for kidney failure to support a framework for quantitative risk assessment in the donor candidate evaluation and defensible shared decision making. This framework is grounded in the simultaneous consideration of each candidate's profile of demographic and health characteristics. The processes and framework for the donor candidate evaluation are presented, along with recommendations for optimal care before, during, and after donation. Limitations of the evidence are discussed, especially regarding the lack of definitive prospective studies and clinical outcome trials. Suggestions for future research, including the need for continued refinement of long-term risk prediction and novel approaches to estimating donation-attributable risks, are also provided.In citing this document, the following format should be used: Kidney Disease: Improving Global Outcomes (KDIGO) Living Kidney Donor Work Group. KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Transplantation. 2017;101(Suppl 8S):S1-S109.
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Affiliation(s)
| | | | | | | | - Josefina Alberú
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | | | | | | | - Dorry L. Segev
- Johns Hopkins University, School of Medicine, Baltimore, MD
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14
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Galizzi MM, Miraldo M, Stavropoulou C. In Sickness but Not in Wealth. Med Decis Making 2016; 36:503-17. [DOI: 10.1177/0272989x15626406] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Accepted: 12/09/2015] [Indexed: 11/17/2022]
Abstract
We present results from a hypothetical framed field experiment assessing whether risk preferences significantly differ across the health and financial domains when they are elicited through the same multiple price list paired-lottery method. We consider a sample of 300 patients attending outpatient clinics in a university hospital in Athens during the Greek financial crisis. Risk preferences in finance were elicited using paired-lottery questions with hypothetical payments. The questions were adapted to the health domain by framing the lotteries as risky treatments in hypothetical health care scenarios. Using maximum likelihood methods, we estimated the degree of risk aversion, allowing for the estimates to be dependent on domain and individual characteristics. The subjects in our sample, who were exposed to both health and financial distress, tended to be less risk averse in the financial domain than in the health domain.
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Affiliation(s)
- Matteo M. Galizzi
- Department of Social Policy, LSE Health and Social Care, and LSE Behavioural Science, London School of Economics, London, UK (MMG)
- Hospinnomics, École d’Économie de Paris, Paris, France (MMG, MM)
- Management Group, Imperial College Business School, London, UK (MM)
- School of Health Sciences, and City Health Economics Centre, City University London, London, UK (CS)
| | - Marisa Miraldo
- Department of Social Policy, LSE Health and Social Care, and LSE Behavioural Science, London School of Economics, London, UK (MMG)
- Hospinnomics, École d’Économie de Paris, Paris, France (MMG, MM)
- Management Group, Imperial College Business School, London, UK (MM)
- School of Health Sciences, and City Health Economics Centre, City University London, London, UK (CS)
| | - Charitini Stavropoulou
- Department of Social Policy, LSE Health and Social Care, and LSE Behavioural Science, London School of Economics, London, UK (MMG)
- Hospinnomics, École d’Économie de Paris, Paris, France (MMG, MM)
- Management Group, Imperial College Business School, London, UK (MM)
- School of Health Sciences, and City Health Economics Centre, City University London, London, UK (CS)
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15
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Connaughton DM, Harmon G, Cooney A, Williams Y, O'Regan J, O'Neill D, Cunningham P, Counihan A, O'Kelly P, McHale S, Denton M, O'Seaghdha CM, Magee C, Conlon P, Little D, Keogan M, de Freitas DG. The Irish living kidney donor program - why potential donors do not proceed to live kidney donation? Clin Transplant 2015; 30:17-25. [PMID: 26426147 DOI: 10.1111/ctr.12641] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Living donation is not only a method to increase access to kidney transplantation but can also offer superior outcomes. We report the experience of the living donor (LD) program in the Republic of Ireland and explore reasons why potential donors do not proceed to live donation. METHODS Retrospective cohort study of all potential donors from January 2000 to March 2014 who presented wishing to undergo donor work-up and their subsequent outcomes. RESULTS A total of 956 donors for 496 recipients contacted the live kidney donation program of which 883 potential donors proceeded to the initial stage of assessment. The donor dropout rate at this stage was 64.2% (614/956 potential donors did not proceed to further evaluation). Thereafter, 269 (28.1%) donors underwent further assessment by the multidisciplinary team. In total, 93 (9.7%) donors were declined following this assessment with 176 (18.4%) donors ultimately proceeding to live kidney donation. The major reason for declining a donor was a medical contraindication (n = 63, 67.7%). In term of recipients, 54.2% (n = 269/496) had a potential donor proceed for further assessment of which 65.4% (n = 176/269) ultimately proceeding to live donation. CONCLUSION Further evaluation of the declined donor group is warranted to allow for expansion of the LD program.
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Affiliation(s)
- Dervla M Connaughton
- Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Grainne Harmon
- The National Histocompatibility and Immunogenetics Service for Solid Organ Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Anne Cooney
- Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Yvonne Williams
- Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland
| | - John O'Regan
- Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Derek O'Neill
- The National Histocompatibility and Immunogenetics Service for Solid Organ Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Phyllis Cunningham
- Transplant Coordinator Services, Department of Kidney Transplantation and Urology, Beaumont Hospital, Dublin, Ireland
| | - Aileen Counihan
- Transplant Coordinator Services, Department of Kidney Transplantation and Urology, Beaumont Hospital, Dublin, Ireland
| | - Patrick O'Kelly
- Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Siobhan McHale
- Department of Psychiatry, Beaumont Hospital, Dublin, Ireland
| | - Mark Denton
- Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Conall M O'Seaghdha
- Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Colm Magee
- Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Peter Conlon
- Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Dilly Little
- Department of Kidney Transplantation and Urology, Beaumont Hospital, Dublin, Ireland
| | - Mary Keogan
- The National Histocompatibility and Immunogenetics Service for Solid Organ Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Declan G de Freitas
- Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland
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16
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Thiessen C, Gordon EJ, Reese PP, Kulkarni S. Development of a Donor-Centered Approach to Risk Assessment: Rebalancing Nonmaleficence and Autonomy. Am J Transplant 2015; 15:2314-23. [PMID: 25868787 DOI: 10.1111/ajt.13272] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 02/11/2015] [Accepted: 02/17/2015] [Indexed: 01/25/2023]
Abstract
Living kidney donors are often excluded from the shared decision making and patient-centered models that are advocated in medical practice. Thresholds for acceptable risk vary between transplant centers, and between clinicians and donors. Although donor selection committees commonly focus on medical risks, potential donors also consider nonmedical risks and burdens, which may alter their assessment of an acceptable level of medical risk. Thus, transplant centers may encounter ethical tensions between nonmaleficence and respect for donor autonomy. A donor-centered model of risk assessment and risk reconciliation would integrate the donor's values and preferences in a shared decision about their eligibility to donate. This paper argues for shifting to a donor-centered model of risk assessment, and presents a research agenda to facilitate the greater participation of donors in their own evaluation and approval processes.
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Affiliation(s)
- C Thiessen
- Department of Surgery, Section of Organ Transplantation & Immunology, Yale University School of Medicine, New Haven, CT
| | - E J Gordon
- Comprehensive Transplant Center, Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - P P Reese
- Renal-Electrolyte and Hypertension Division, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - S Kulkarni
- Department of Surgery, Section of Organ Transplantation & Immunology, Yale University School of Medicine, New Haven, CT
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Lam NN, McArthur E, Kim SJ, Prasad GR, Lentine KL, Reese PP, Kasiske BL, Lok CE, Feldman LS, Garg AX, Arnold J, Boudville N, Bugeja A, Dipchand C, Doshi M, Gill J, Karpinski M, Klarenbach S, Knoll G, Monroy-Cuadros M, Nguan CY, Sontrop J, Storsley L, Treleaven D, Young A. Gout After Living Kidney Donation: A Matched Cohort Study. Am J Kidney Dis 2015; 65:925-32. [DOI: 10.1053/j.ajkd.2015.01.017] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 01/15/2015] [Indexed: 11/11/2022]
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DOSPERT+M: A survey of medical risk attitudes in the United States. JUDGMENT AND DECISION MAKING 2013. [DOI: 10.1017/s1930297500005313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AbstractBackground:The Domain-Specific Risk Taking scale (DOSPERT) has been recommended as a tool for measuring risk attitudes in medical studies, but does not contain items specific to health care. Butler, et al. (2012) developed a medical risk domain subscale for DOSPERT.Objective:To characterize medical risk attitudes in a nationally-representative U.S. sample using the full DOSPERT scale with the medical risk domain add-on (DOSPERT+M), and examine associations with other risk domains.Methods:Members of a nationally-representative online panel (KnowledgePanel®) were randomized to complete pairs of DOSPERT+M tasks (risk attitude, risk perception, expected benefits). We explored relationships among domains through correlational and factor analysis; we tested the hypothesis that the medical risk domain and DOSPERT’s health/safety domains were not highly correlated.Participants:Three hundred forty-four panelists.Results:The medical risk domain subscale had low inter-item reliability in the risk-taking task and moderate inter-item reliability in the other tasks. Medical risk domain scores were poorly correlated with the DOSPERT health/safety domain. Exploratory factor analysis largely recovered the expected DOSPERT domain structure.Conclusion:Attitudes toward risky medical activities may constitute a distinct domain from those measured by the standard DOSPERT items. Additional work is required to develop a medical risk subscale with higher inter-item reliability.
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Ethical considerations in live donor transplantation: should complications be tolerated? Curr Opin Organ Transplant 2013; 18:235-40. [PMID: 23425790 DOI: 10.1097/mot.0b013e32835f3f2c] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Although living donor transplantation is considered an ethically acceptable undertaking for the purpose of saving another's life, its safety remains under investigation. RECENT FINDINGS Although living donors undertake considerable medical risks for no direct medical benefit, the question remains whether the risks are acceptable and should be tolerated by providers and patients or whether additional interventions and safeguards are needed to reduce and/or prevent complications. By reviewing complication risk statistics and synthesizing empirical research regarding risk-taking thresholds and attitudes, this paper examines the possibilities for determining an acceptable level of complication risk for living donors. This paper also delineates the ethical tensions surrounding protecting donors from unnecessary risk versus respecting donor autonomy to accept risks, and concludes by discussing the importance of donor follow-up and the value of donor registries. SUMMARY In the absence of information on long-term donor outcomes, transplant centers should take special precautions to protect prospective donors given increasing pressures to reduce the organ shortage and concerns that donors often disregard risks to themselves to save the lives of others.
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Kiberd BA. Estimating the long term impact of kidney donation on life expectancy and end stage renal disease. Transplant Res 2013; 2:2. [PMID: 23414596 PMCID: PMC3577426 DOI: 10.1186/2047-1440-2-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Accepted: 01/30/2013] [Indexed: 11/10/2022] Open
Abstract
Background Long term studies of live kidney donation do not show evidence of appreciable risks to the donor. However nephrectomy reduces total glomerular filtration rates (GFR) and is associated with increased rates of proteinuria and possibly hypertension. It is not clear to what extent these changes are associated with reduced life expectancy (LE) or increased risk of end stage renal disease (ESRD) since follow up is incomplete in most reports. Methods In a computer simulation model based on a US population chronic kidney disease model, increased hazard rates for higher blood pressure, proteinuria and low GFR were applied to healthy individuals undergoing donor nephrectomy. Subsequent LE and cumulative risk of ESRD were calculated. Results Kidney donation is projected to reduce LE by 0.83 years and increase the absolute cumulative risk of ESRD by 0.89% for a 40-year-old white male. White females were predicted to have slightly greater loss of life and less added ESRD risk. Conversely, Blacks have greater risks of ESRD after donation. Older donors with hypertension were predicted to lose less life years and lower cumulative ESRD risks than young donors. Despite these increased risks most donors will have better life expectancy and lower ESRD rates than the general population since they are a highly selected cohort. Conclusions This study attempts to quantify increases in death and ESRD from donor nephrectomy assuming the risk factors of hypertension, low GFR and proteinuria have the same significance in this population as in the general population. Further study is required to better estimate the risks of donation and test whether these assumptions are valid.
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Affiliation(s)
- Bryce A Kiberd
- Department of Medicine, Dalhousie University, Halifax, 5082 Dickson Building, Queen Elizabeth II HSC VG site, University Ave, Nova Scotia, B3H 1V8, Canada.
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Muñoz Sastre MT, de Sousa S, Bodi E, Sorum PC, Mullet E. Under what conditions would people be willing to make a living organ donation? PSYCHOL HEALTH MED 2012; 17:323-34. [DOI: 10.1080/13548506.2011.630400] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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22
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A medical risk attitude subscale for DOSPERT. JUDGMENT AND DECISION MAKING 2012. [DOI: 10.1017/s1930297500003028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AbstractBackground: The Domain-Specific Risk Taking scale (DOSPERT) is a widely used instrument that measures perceived risk and benefit and attitude toward risk for activities in several domains, but does not include medical risks.Objective: To develop a medical risk domain subscale for DOSPERT.Methods: Sixteen candidate risk items were developed through expert discussion. We conducted cognitive telephone interviews, an online survey, and a random-digit dialing (RDD) telephone survey to reduce and refine the scale, explore its factor structure, and obtain estimates of reliability.Participants: Eight patients recruited from UIC medical center waiting rooms participated in 45-60 minute cognitive interviews. Thirty Amazon Mechanical Turk workers completed the online survey. One hundred Chicago-area residents completed the RDD telephone survey.Results: On the basis of cognitive interviews, we eliminated five items due to poor variance or participant misunderstanding. The online survey suggested that two additional items were negatively correlated with the scale, and we considered them candidates for removal. Factor analysis of the responses in the RDD telephone survey and non-statistical factors led us to recommend a final set of 6 items to represent the medical risk domain. The final set of items included blood donation, kidney donation, daily medication use for allergies, knee replacement surgery, general anesthesia in dentistry, and clinical trial participation. The interitem reliability (Cronbach’s α) of the final set of 6 items ranged from 0.57-0.59 depending on the response task. Older respondents gave lower overall ratings of expected benefit from the activities.Conclusion: We refined a set of items to measure risk and benefit perceptions for medical activities. Our next step will be to add these items to the complete DOSPERT scale, confirm the scale’s psychometric properties, determine whether medical risks constitute a psychologically distinct domain from other risky activities, and characterize individual differences in medical risk attitudes.
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23
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Rodrigue JR, Ladin K, Pavlakis M, Mandelbrot DA. Disclosing recipient information to potential living donors: preferences of donors and recipients, before and after surgery. Am J Transplant 2011; 11:1270-8. [PMID: 21645257 DOI: 10.1111/j.1600-6143.2011.03580.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Consensus guidelines, while recommending that potential living donors should be given information that could impact their donation decision, are nonspecific about the types of information that should be disclosed. We surveyed potential (n = 36) and past (n = 45) living donors and transplant candidates (n = 45) and recipients (n = 45) about their preferences for sharing or knowing specific information about the recipient, how this information would impact decision-making, and who should be responsible for disclosing information. Potential donors were less likely than all others to feel that recipient information should be disclosed to potential donors. Donors and recipients felt most strongly about disclosing if the recipient lost a previously transplanted kidney due to medication nonadherence as well as the likelihood of 1- and 5-year graft survival. Most donors would be less likely to pursue donation if the recipient lost a previously transplanted kidney due to medication nonadherence or generally had problems with taking medications as prescribed. Transplant programs should consider how to best balance the potential donor's right to receive information that could reasonably be expected to affect their decision-making process with the recipient's right to privacy and confidentiality.
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Affiliation(s)
- J R Rodrigue
- Center for Transplant Outcomes and Quality Improvement, The Transplant Institute, Beth Israel Deaconess Medical Center, Boston, MA, USA.
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Halpern SD, Raz A, Kohn R, Rey M, Asch DA, Reese P. Regulated payments for living kidney donation: an empirical assessment of the ethical concerns. Ann Intern Med 2010; 152:358-65. [PMID: 20231566 PMCID: PMC2865248 DOI: 10.7326/0003-4819-152-6-201003160-00005] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Although regulated payments to encourage living kidney donation could reduce morbidity and mortality among patients waiting for a kidney transplant, doing so raises several ethical concerns. OBJECTIVE To determine the extent to which the 3 main concerns with paying kidney donors might manifest if a regulated market were created. DESIGN Cross-sectional study of participants' willingness to donate a kidney in 12 scenarios. SETTING Regional rail and urban trolley lines in Philadelphia County, Philadelphia, Pennsylvania. PARTICIPANTS Of 550 potential participants, 409 completed the questionnaire (response rate, 74.4%); 342 of these participants were medically eligible to donate. INTERVENTION Across scenarios, researchers experimentally manipulated the amount of money that participants would receive, the participants' risk for subsequently developing kidney failure themselves, and who would receive the donated kidney. MEASUREMENTS The researchers determined whether payment represents an undue inducement by evaluating participants' sensitivity to risk in relation to the payment offered or an unjust inducement by evaluating participants' sensitivity to payment as a function of their annual income. The researchers also evaluated whether introducing payment would hinder altruistic donations by comparing participants' willingness to donate altruistically before versus after the introduction of payments. RESULTS Generalized estimating equation models revealed that participants' willingness to donate increased significantly as their risk for kidney failure decreased, as the payment offered increased, and when the kidney recipient was a family member rather than a patient on a public waiting list (P < 0.001 for each). No statistical interactions were identified between payment and risk (odds ratio, 1.00 [95% CI, 0.96 to 1.03]) or between payment and income (odds ratio, 1.01 [CI, 0.99 to 1.03]). The proximity of these estimates to 1.0 and narrowness of the CIs suggest that payment is neither an undue nor an unjust inducement, respectively. Alerting participants to the possibility of payment did not alter their willingness to donate for altruistic reasons (P = 0.40). LIMITATION Choices revealed in hypothetical scenarios may not reflect real-world behaviors. CONCLUSION Theoretical concerns about paying persons for living kidney donation are not corroborated by empirical evidence. A real-world test of regulated payments for kidney donation is needed to definitively show whether payment provides a viable and ethical method to increase the supply of kidneys available for transplantation. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Scott D Halpern
- University of Pennsylvania School of Medicine and Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania 19104-6021, USA.
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Martin SC, Stone AM, Scott AM, Brashers DE. Medical, personal, and social forms of uncertainty across the transplantation trajectory. QUALITATIVE HEALTH RESEARCH 2010; 20:182-196. [PMID: 19955227 DOI: 10.1177/1049732309356284] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
We designed this study to identify sources of uncertainty across the transplantation trajectory. We interviewed 38 transplant patients, who reported medical, personal, and social forms of uncertainty. Prior to transplantation, they reported uncertainty related to insufficient information about diagnosis, complex decisions about transplantation, unknown/unknowable organ availability, unclear expectations about medical procedures/outcomes, ambiguity in meaning of life, complex role and identity challenges, unclear financial consequences, questioning from others, and unclear relational implications. They reported that uncertainty experienced after transplantation was related to complex medication regimens, unpredictable future health/prognosis, complex role and identity challenges, unclear financial consequences, possible stigmatizing reactions, unclear relational implications, and complex interactions with the deceased donor's family. These findings lay the groundwork for additional research on uncertainty management for transplant patients, and suggest that health care professionals and supportive others cannot apply a one-size-fits-all solution when aiding in uncertainty management.
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Yang J, Singh AK, Magee CC, Pendergrass ML, Ahmed SB. A potential living kidney donor with prediabetes. Kidney Int 2009; 76:673-7. [PMID: 19177151 DOI: 10.1038/ki.2008.664] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Jiao Yang
- Department of Medicine, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
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Hays R, Waterman A. Improving preemptive transplant education to increase living donation rates: reaching patients earlier in their disease adjustment process. Prog Transplant 2008. [DOI: 10.7182/prtr.18.4.w3706w0tk23r9618] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Hays R, Waterman AD. Improving Preemptive Transplant Education to Increase Living Donation Rates: Reaching Patients Earlier in Their Disease Adjustment Process. Prog Transplant 2008; 18:251-6. [DOI: 10.1177/152692480801800407] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Patients who receive a preemptive kidney transplant before starting dialysis avoid the medical complications related to dialysis and have the highest graft success and lowest mortality rates. Because only 2.5% of incident patients receive kidney transplants preemptively, improved psychosocial education may assist more patients in accessing preemptive transplant. This article outlines (1) unique psychosocial issues affecting patients with chronic kidney disease stage 4 (glomerular filtration rates >20 mL/min per 1.73 m2) and (2) how an educational program about preemptive living donor transplant should be designed and administered to increase access to this treatment option. Early referral patients may be overwhelmed in coping with and learning about their disease and, therefore, not ready to make a treatment decision, or they may be highly motivated to obtain a transplant to avoid dialysis and return to a normal life. An education program that defines the quality-of-life and health benefits possible with early transplant is outlined. The program is focused on minimizing the disruption of starting 2 treatment techniques and maximizing early transplant health, graft survival, employability, and retention of insurance coverage. Once the benefits of preemptive living donor transplant are outlined, educators can focus on demystifying the living donor evaluation process and assisting interested patients in planning how to find a living donor. To reach all patients, especially racial minorities, education about preemptive transplant should be available in primary-care physicians' and community nephrologists' offices, at dialysis centers, and through other kidney organizations.
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Affiliation(s)
- Rebecca Hays
- University of Wisconsin Hospital and Clinics, Madison (RH), Washington University School of Medicine, St Louis, Missouri (ADW)
| | - Amy D. Waterman
- University of Wisconsin Hospital and Clinics, Madison (RH), Washington University School of Medicine, St Louis, Missouri (ADW)
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Cardiovascular disease and hypertension risk in living kidney donors: an analysis of health administrative data in Ontario, Canada. Transplantation 2008; 86:399-406. [PMID: 18698242 DOI: 10.1097/tp.0b013e31817ba9e3] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Knowledge of any harm associated with living kidney donation guides informed consent and living donor follow-up. Risk estimates in the literature are variable, and most studies did not use a healthy control group to assess outcomes attributable to donation. METHODS We observed a retrospective cohort using health administrative data for donations which occurred in Ontario, Canada between the years 1993 and 2005. There were a total of 1278 living donors and 6359 healthy adults who acted as a control group. Individuals were followed for a mean of 6.2 years (range, 1-13 years) after donation. The primary outcome was a composite of time to death or first cardiovascular event (myocardial infarction, stroke, angioplasty, and bypass surgery). The secondary outcome was time to a diagnosis of hypertension. RESULTS There was no significant difference in death or cardiovascular events between donors and controls (1.3% vs. 1.7%; hazard ratio 0.7, 95% confidence interval 0.4-1.2). Donors were more frequently diagnosed with hypertension than controls (16.3% vs. 11.9%, hazard ratio 1.4, 95% confidence interval 1.2-1.7) but were also seen more often by their primary care physicians (median [interquartile range] 3.6 [1.9-6.1] vs. 2.6 [1.4-4.3] visits per person year, P<0.001). CONCLUSIONS Based on administrative data, the risk of cardiovascular disease was unchanged in the first decade after kidney donation. The observed increase in diagnosed hypertension may be due to nephrectomy or more blood pressure measurements received by donors in follow-up and requires prospective study.
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The dynamics of kidney donation: viewpoints from the donor, the recipients, and the transplant team. Kidney Int 2008; 73:1108-10. [PMID: 18449178 DOI: 10.1038/ki.2008.118] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Living kidney transplantation has become increasingly widespread to reduce organ shortage. Very few studies have prospectively investigated the donor's long-term risks. Living donation is a complex medical decision in which different actors are involved. This therapeutic option needs educational programs for potential donors, recipients, and transplant professionals to make them aware of the possible risks and benefits. It is important to fully exploit living-donor kidney transplantation.
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