Global trends in the rates of living kidney donation

Knowledge and willingness to donate kidney for transplantation among general population in Saudi Arabia

INTRODUCTION

Kidney transplantation is the preferred treatment for end-stage renal disease (ESRD), offering a superior quality of life and extended survival compared to other renal replacement therapies. As the number of ESRD patients grows, so does the demand for organ transplants. The prevalence of ESRD is anticipated to escalate further due to the rising rates of diabetes mellitus (DM), hypertension (HTN), and obesity. Organ donation, particularly from living donors, remains the main source of transplants in the region, despite the notable underutilization of potential deceased donors' organs. The objective of this research is to assess the level of knowledge, attitudes, and willingness to donate kidneys among the general population, a pivotal step in addressing the organ shortage crisis.

METHODS

This cross-sectional study was conducted in the Aseer region of Saudi Arabia using a previously validated questionnaire. The questionnaire collected demographic data and insights into general attitudes, knowledge, and beliefs about organ donation. Logistic regression was used to identify predictors of knowledge and willingness to donate.

RESULTS

The study involved 705 participants, predominantly young adults with a high level of education. Awareness of kidney donation was high, and knowledge about donation was broad, especially regarding religious permissibility and awareness of the donor registry. However, only 25% expressed willingness to donate their kidneys, and a 4% were already registered as donors. Furthermore, higher educational level was not associated with higher odds of knowledge or willingness to donate.

CONCLUSION

Despite the considerable awareness, actual donor registration rates were low, highlighting the necessity for targeted educational interventions and a deeper understanding of the cultural and socioeconomic barriers that exist.

Care of Adults with Advanced Chronic Kidney Disease

Chronic kidney disease (CKD) impacts over 10% of the global population. Adults with CKD face significant morbidity and mortality. As kidney disease progresses, the risk of adverse outcomes increases. Here, we present an overview of strategies to care for adults with advanced CKD (stage 4-5 CKD, not receiving kidney replacement therapy). We aim to guide clinicians through several aspects of CKD care, ranging from recommended laboratory assessments to interdisciplinary support for patients as they plan for kidney replacement therapy (dialysis, transplantation, or conservative management). We incorporate considerations of health equity and person-centered care, empowering clinicians to deliver high-quality care to people with CKD.

Worsening of Diabetes Control Measures and Decreased Kidney Function in Pre-Diabetic Kidney Donors Compared to Non-Diabetic Donors Whose BMI Before Kidney Donation was Above 30

BACKGROUND

The incidence of end-stage renal disease has increased dramatically over the past two decades. Kidney transplantation is the best treatment option for individuals with end-stage renal disease, and living donor kidney transplantation has significant advantages over deceased donor kidney transplantation. Although there are criteria for assessing living kidney donors, different medical centers handle certain medical problems differently. The aim of this study is to investigate how kidney donation affects renal biochemical indicators, blood pressure measurements, and glucose control in healthy young female adults without diabetes compared to a pre-diabetic group.

METHODS

A prospective cohort study recruited 142 female kidney donors, who were divided into two cohorts based on their diabetic history (pre-diabetic and non-diabetic). The participants were monitored for seven years after kidney donation. Key clinical and biochemical markers were measured before and after donation.

RESULTS

The pre-diabetic group had higher mean values for blood pressure readings, body mass indices, Oral Glucose Tolerance Test, HbA1c (DCCT) (%), serum creatinine levels, proteinuria, and lower e-GFR compared to those in the non-diabetic group. All these findings were statistically significant.

CONCLUSIONS

Pre-diabetic donors are at an increased risk for many adverse clinical and biochemical outcomes, including hypertension, glucose tolerance, and worsening kidney function tests and should be advised that their condition may worsen over time and can result in end-organ complications. If the donors decide to proceed, they should be closely and frequently monitored during both the short- and long-term periods.

Implementation of a One-Day Living Kidney Donor Assessment Clinic to Improve the Efficiency of the Living Kidney Donor Evaluation: Program Report

Purpose of program

A key barrier to becoming a living kidney donor is an inefficient evaluation process, requiring more than 30 tests (eg, laboratory and diagnostic tests), questionnaires, and specialist consultations. Donor candidates make several trips to hospitals and clinics, and often spend months waiting for appointments and test results. The median evaluation time for a donor candidate in Ontario, Canada, is nearly 1 year. Longer wait times are associated with poorer outcomes for the kidney transplant recipient and higher health care costs. A shorter, more efficient donor evaluation process may help more patients with kidney failure receive a transplant, including a pre-emptive kidney transplant (ie, avoiding the need for dialysis). In this report, we describe the development of a quality improvement intervention to improve the efficiency, effectiveness, and patient-centeredness of the donor candidate evaluation process. We developed a One-Day Living Kidney Donor Assessment Clinic, a condensed clinic where interested donor candidates complete all testing and consultations within 1 day.

Sources of information

The One-Day Living Kidney Donor Assessment Clinic was developed after performing a comprehensive review of the literature, receiving feedback from patients who have successfully donated, and meetings with transplant program leadership from St. Joseph's Healthcare Hamilton. A multistakeholder team was formed that included health care staff from nephrology, transplant surgery, radiology, cardiology, social work, nuclear medicine, and patients with the prior lived experience of kidney donation. In the planning stages, the team met regularly to determine the objectives of the clinic, criteria for participation, clinic schedule, patient flow, and clinic metrics.

Methods

Donor candidates entered the One-Day Clinic if they completed initial laboratory testing and agreed to an expedited process. If additional testing was required, it was completed on a different day. Donor candidates were reviewed by the nephrologist, transplant surgeon, and donor coordinator approximately 2 weeks after the clinic for final approval. The team continues to meet regularly to review donor feedback, discuss challenges, and brainstorm solutions.

Key findings

The One-Day Clinic was implemented in March 2019, and has now been running for 4 years, making iterative improvements through continuous patient and provider feedback. To date, we have evaluated more than 150 donor candidates in this clinic. Feedback from donors has been uniformly positive (98% of donors stated they were very satisfied with the clinic), with most noting that the clinic was efficient and minimally impacted work and family obligations. Hospital leadership, including the health care professionals from each participating department, continue to show support and collaborate to create a seamless experience for donor candidates attending the One-Day Clinic.

Limitations

Clinic spots are limited, meaning some interested donor candidates may not be able to enter a One-Day Clinic the same month they come forward.

Implications

This patient-centered quality improvement intervention is designed to improve the efficiency and experience of the living kidney donor evaluation, result in better outcomes for kidney transplant recipients, and potentially increase living donation. Our next step is to conduct a formal evaluation of the clinic, measuring qualitative feedback from health care professionals working in the clinic and donor candidates attending the clinic, and measuring key process and outcome measures in donor candidates who completed the one-day assessment compared with those who underwent the usual care assessment. This program evaluation will provide reliable, regionally relevant evidence that will inform transplant centers across the country as they consider incorporating a similar one-day assessment model.

Fracture Risk Among Living Kidney Donors 25 Years After Donation

Importance

Living kidney donors may have an increased risk of fractures due to reductions in kidney mass, lower concentrations of serum 1,25-dihydroxyvitamin D, and secondary increases in serum parathyroid hormone.

Objective

To compare the overall and site-specific risk of fractures among living kidney donors with strictly matched controls from the general population who would have been eligible to donate a kidney but did not do so.

Design, Setting, and Participants

This survey study was conducted between December 1, 2021, and July 31, 2023. A total of 5065 living kidney donors from 3 large transplant centers in Minnesota were invited to complete a survey about their bone health and history of fractures, and 16 156 population-based nondonor controls without a history of comorbidities that would have precluded kidney donation were identified from the Rochester Epidemiology Project and completed the same survey. A total of 2132 living kidney donors and 2014 nondonor controls responded to the survey. Statistical analyses were performed from May to August 2023.

Exposure

Living kidney donation.

Main Outcomes and Measures

The rates of overall and site-specific fractures were compared between living kidney donors and controls using standardized incidence ratios (SIRs).

Results

At the time of survey, the 2132 living kidney donors had a mean (SD) age of 67.1 (8.9) years and included 1245 women (58.4%), and the 2014 controls had a mean (SD) age of 68.6 (7.9) years and included 1140 women (56.6%). The mean (SD) time between donation or index date and survey date was 24.2 (10.4) years for donors and 27.6 (10.7) years for controls. The overall rate of fractures among living kidney donors was significantly lower than among controls (SIR, 0.89; 95% CI, 0.81-0.97). However, there were significantly more vertebral fractures among living kidney donors than among controls (SIR, 1.42; 95% CI, 1.05-1.83).

Conclusions and Relevance

This survey study found a reduced rate of overall fractures but an excess of vertebral fractures among living kidney donors compared with controls after a mean follow-up of 25 years. Treatment of excess vertebral fractures with dietary supplements such as vitamin D3 may reduce the numbers of vertebral fractures and patient morbidity.

Choosing the larger kidney on CT volumetry: a study on the early post-donation kidney function of living donors

BACKGROUND

Selecting the smaller kidney for donation has been advocated if there is a size difference of > 10% between the 2 kidneys but has never been prospectively evaluated. With increase in donor nephrectomies, it is important to evaluate this to minimize loss of renal function to donors.

METHODS

75 consecutive donor nephrectomy patients were included in our longitudinal study. The Split Renal Volume (SRV) of bilateral kidneys were measured using contrasted computer tomography scans and patients segregated into 2 groups depending on donated kidney having more (Group 1) or less than (Group 2) 52.5% of SRV.

RESULTS

Patients in Group 1 (n = 19) and 2 (n = 56) were of similar age (43.8 vs. 48.3), BMI (22.4 vs. 25.2), sex (57.9 vs. 55.4% women), respectively. Although total kidney volumes were similar in both groups, Group 1 had significantly smaller right kidney volumes (120.4 ± 24.9 vs. 142.7 ± 28.4 mls, p = 0.003). EGFR pre-operatively (116.3 ± 20.8 vs. 106.3 ± 23.8 mL/min/1.73 m2) and at 6-months (65.7 ± 13.3 vs. 66.9 ± 15.5 mL/min/1.73 m2) were not different between groups. However, patients in Group 1 had significantly greater absolute (50.6 ± 14.9 vs. 39.5 ± 14.7 mL/min/1.73 m2) and relative decline (43.0 ± 8.6 vs. 36.3 ± 10.6%) in eGFR at 6 months (p = 0.06, 0.009).

CONCLUSION

With a SRV difference of 5% between the 2 sides, removal of the larger kidney for living kidney donation resulted in greater early decline of renal function than kidney donors whose larger or equivalent kidney is preserved.

Children Are Not Small Adults: Similarities and Differences in Renal Transplantation Between Adults and Pediatrics

Kidney transplantation is the treatment of choice for all patients with end-stage kidney disease, including pediatric patients. Graft survival in pediatrics was lagging behind adults, but now is comparable with the adult cohort. Although many of the protocols have been adopted from adults, there are issues unique to pediatrics that one should be aware of to take care of this population. These issues include recipient size consideration, increased incidence of viral infections, problems related to growth, common occurrence of underlying urological issues, and psychosocial issues. This article addresses the similarities and differences in renal transplantation, from preparing a patient for transplant, the transplant process, to post-transplant complications.

Long-term end-stage renal disease risks after living kidney donation: a systematic review and meta-analysis

BACKGROUND

Recent studies have shown that donor nephrectomy can induce renal function impairment. However, few meta-analysis studies about this have proceeded. Therefore, the objective of this systematic review and meta-analysis including all data of recent research studies was to determine whether living donor nephrectomy (LDN) could induce renal function impairment.

METHODS

By November 2020, comprehensive literature searches were performed on PubMed, Embase, and Cochrane databases. Inclusion criteria were: (1) observational studies with data about overall end-stage renal disease (ESRD) or chronic kidney disease (CKD) of living kidney donors, (2) control group consisted of people without donor nephrectomy, and (3) outcomes of studies included long-term end-stage renal disease risks after living kidney donation. Risk of Bias in Non-randomized Studies of interventions (ROBINS-I) assessment tool was used to evaluate our methodological quality.

RESULTS

The qualitative review included 11 studies and the meta-analysis included 5 studies. In the meta-analysis, the integrated overall ESRD risk was 5.57 (95% CI: 2.03-15.30). Regarding the overall risk of bias using ROBINS-I assessment tool, 0 studies was rated as "Low", 7 studies were rated as "moderate", 2 studies were rated as "Serious", and two studies were rated as "Critical".

CONCLUSIONS

Our study showed that LDN increased ESRD risk in LDN patients. However, in our meta-analysis, variables in included studies were not uniform and the number of included studies was small. To have a definite conclusion, meta-analyses of well-planned and detailed studies need to be conducted in the future.

Experience of ethical dilemmas among professionals working in pediatric transplantation: An international survey

BACKGROUND

Professionals working in pediatric transplantation commonly encounter complex ethical dilemmas. Most ethical research in transplantation is related to adult practice. We aimed to gain insight into ethical issues faced by transplant professionals when dealing with pediatric transplant recipients.

METHODS

A two-stage study was designed; the first part was a questionnaire completed by 190 (80%) members of the International Pediatric Transplant Association (IPTA) from over 30 different countries. This was followed by a multidisciplinary focus group that explored the preliminary data of the survey.

RESULTS

A total of 38% (56 of 149) respondents of the questionnaire had experienced an ethical issue between 2016 and 2018. Surgeons were more likely to have encountered an ethical issue as compared with physicians (60% vs. 35.7%, p = .035). Clinicians from Europe were more likely to have experienced an ethical issue in living organ donation compared with those from North America (78.9% vs. 52.5%, p = .005), with common ethical concerns being psychosocial evaluation and follow-up care of donors. The focus group highlighted the importance of a multidisciplinary approach to ethical issues.

CONCLUSION

The results of this study can direct future research into pediatric transplantation ethics with the aim of producing educational resources, policies, and ethical guidelines.

Challenges of End-Stage Renal Disease Patients in Ethiopia

Affecting all aspects of patients' lives, end-stage renal disease (ESRD) presents significant challenges. Individuals with ESRD face biological, psychological, economic, and social issues. ESRD patients in Ethiopia bear multifaceted burdens of multiple medical conditions, including comorbid hypertension, diabetes, cardiac problems, anemia, gastrointestinal issues, and bone and mineral disorders. The aim of this study was to address the gap in research on patients in Ethiopia with ESRD and examine biopsychosocial and economic challenges. A qualitative hermeneutic phenomenology design was employed. In-depth interviews were held with 10 women and 10 men. Major themes include the physical corollary of ESRD (e.g., fatigue), and psychological (e.g., fear of loss of capacity and/or occupation) and socioeconomic challenges (e.g., difficulty obtaining social and economic support). Along with complications of ESRD and side effects of dialysis, patients face trauma and social and economic repercussions. Social workers are well positioned to help manage associated biopsychosocial and economic challenges. The findings indicate the need for policies that promote multidisciplinary teams in working with patients who are diagnosed with ESRD.

The Living Kidney Donor Safety Study: Protocol of a Prospective Cohort Study

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.

A Cadaveric Study on the Anomalous Origin of Renal and Gonadal Vasculature: An Observational Study

Background: Due to the increasing prevalence of kidney transplantation, a greater awareness of variations in the surrounding vasculature is of surgical importance. During embryological development, both the renal and gonadal arteries arise from lateral mesonephric branches of the dorsal aorta. In adults, gonadal arteries are paired vessels that normally arise from the aorta at the level of the second lumbar vertebra. Methods: Routine cadaveric dissection completed by first-year medical students and dental students incidentally revealed anatomical anomalies. Results: We describe two cadaveric findings in male cases which demonstrate unilateral and bilateral variations of testicular arteries originating from an aberrant renal artery in one case and an accessory renal artery in the other. Conclusion: By increasing awareness of anomalous testicular arteries we hope to encourage the standardization of preoperative vasculature exploration to both minimize intra-operative risk to living male kidney donors and increase patients’ understanding of potential risks and complications prior to consenting to the procedure providing more accurate information prior to surgery.

Perception regarding live kidney donation in the general population of South Korea

This study aimed to know how the general population recognizes live kidney donation in Korea. Participants were randomly selected from the general population after proportional allocation by region, sex, and age. Selected participants received a questionnaire that included demographic information, socioeconomic and marital statuses, prior recognition of live donor kidney transplantation, expected changes after donation, and the need for support after donor nephrectomy. Among the 1,000 participants from the web-based survey, 83.8% answered they fully understood living donor kidney transplantation, 81.1% knew about them, and 51.1% were willing to donate. Various complications after nephrectomy and deterioration in health after donation were the most significant reasons for those reluctant to donate. Most agreed that the government should provide social and economic support to living kidney donors, especially after exposure to the description of donor nephrectomy. Financial support, including surgery and regular medical check-up costs, was the most preferred government support. The Korean general population seemed aware of the value and safety of kidney donation, although only half of them were willing to donate due to concerns about possible complications. Most participants agreed on social and economic support for living kidney donors, especially surgery-related costs.

Living kidney donation in a developing country

BACKGROUND

Living kidney donation has been advocated as a means to ameliorate the chronic shortage of organs for transplantation. Significant rates of comorbidity and familial risk for kidney disease may limit this approach in the local context; there is currently limited data describing living donation in Africa.

METHODS

We assessed reasons for non-donation and outcomes following donation in a cohort of 1208 ethnically diverse potential living donors evaluated over a 32-year period at a single transplant centre in South Africa.

RESULTS

Medical contraindications were the commonest reason for donor exclusion. Black donors were more frequently excluded (52.1% vs. 39.3%; p<0.001), particularly for medical contraindications (44% vs. 35%; p<0.001); 298 donors proceeded to donor nephrectomy (24.7%). Although no donor required kidney replacement therapy, an estimated glomerular filtration rate below 60 ml/min/1.73 m2 was recorded in 27% of donors at a median follow-up of 3.7 years, new onset albuminuria >300 mg/day was observed in 4%, and 12.8% developed new-onset hypertension. Black ethnicity was not associated with an increased risk of adverse post-donation outcomes.

CONCLUSION

This study highlights the difficulties of pursuing live donation in a population with significant medical comorbidity, but provides reassurance of the safety of the procedure in carefully selected donors in the developing world.

Protocol for a Process Evaluation of the Quality Improvement Intervention to Enhance Access to Kidney Transplantation and Living Kidney Donation (EnAKT LKD) Cluster-Randomized Clinical Trial

Background:

Many patients who would benefit from a kidney transplant never receive one. The Enhance Access to Kidney Transplantation and Living Kidney Donation (EnAKT LKD) pragmatic, cluster-randomized clinical trial is testing whether a multi-component quality improvement intervention, provided in chronic kidney disease (CKD) programs (vs. usual care), can help patients with CKD with no recorded contraindications to kidney transplant complete more steps toward receiving a transplant (primary outcome of the trial). The EnAKT LKD intervention has 4 components: (1) quality Improvement teams and administrative support, (2) improved transplant education for patients and healthcare providers, (3) access to support and (4) program-level performance monitoring.

Objective:

To conduct a process evaluation of the EnAKT LKD quality improvement intervention to determine if the components were delivered, received, and enacted as designed (fidelity), and if the intervention addressed intended barriers (mechanisms of change).

Design:

A mixed-methods process evaluation informed by new practice implementation and theories of behavior change.

Setting:

Chronic kidney disease programs in Ontario, Canada, began receiving the EnAKT LKD intervention on November 1, 2017 and will continue to receive it until December 31, 2021. The process evaluation (interviews and surveys) will occur alongside the trial, between December 2020 to May 2021.

Participants:

Healthcare providers (eg, dialysis nurses, nephrologists, members of the multi-care kidney clinic team) at Ontario’s 27 CKD programs.

Methods:

We will survey and interview healthcare providers at each CKD program, and complete an intervention implementation checklist. Quantitative data from the surveys and the intervention implementation checklist will assess fidelity to the intervention, while quantitative and qualitative data from surveys and interviews will provide insight into the mechanisms of change.

Limitations:

The long trial period may result in poor participant recall.

Conclusion:

This process evaluation will enhance interpretation of the trial findings, guide improvements in the intervention components, and inform future implementation.

Trial registration:

Clinicaltrials.gov; identifier: NCT03329521.

Robotic versus hand-assisted laparoscopic living donor nephrectomy: comparison of two minimally invasive techniques in kidney transplantation

Robot-assisted donor nephrectomy (RDN) is increasingly used due to its advantages such as its precision and reduced learning curve when compared to laparoscopic techniques. Concerns remain among surgeons regarding possible longer warm ischemia time. This study aimed to compare patients undergoing robotic living donor nephrectomy to the more frequently used hand-assisted laparoscopic nephrectomy (HLDN) technique, focusing on warm ischemia time, total operative time, learning curve, hospital length of stay, donor renal function and post-operative complications. Retrospective study comparing RDN to HLDN in a collaborative transplant network. 176 patients were included, 72 in RDN and 104 in HLDN. Left-sided nephrectomy was favored in RDN (82% vs 52%, p < 0.01). Operative time was longer in RDN (287 vs 160 min; p < 0.01), while warm ischemia time was similar (221 vs 213 secs, p = 0.446). The hospital stay was shorter in RDN (3.9 vs 5.7 days, p < 0.01).Concerning renal function, a slightpersistent increase of 7% of the creatinine ratio was observed in the RDN compared to the HLDN group (1.56 vs 1.44 at 1-month checkup, p < 0.01). The results show that RDN appears safe and efficient in comparison to the gold-standard HLDN technique. Warm ischemia time was similar for both techniques, whereas RDN operative time was longer. Patients undergoing RDN had a shorter hospital stay, this being possibly mitigated by differences in center release criteria. Donor renal function needs to be assessed on a longer-term basis for both techniques.

Introducing robot-assisted laparoscopic donor nephrectomy after experience in retroperitoneal endoscopic approach: a matched propensity score analysis

OBJECTIVES

To assess the safety and efficacy of introducing robotic-assisted laparoscopic donor nephrectomy (RALDN) to the standard retroperitoneal endoscopic donor nephrectomy (REDN).

METHODS

Data were collected prospectively from 124 consecutive living kidney donors (93 for REDN subgroup and 31 for RALDN subgroup) from February 2018 to December 2020. Donor baseline demographics, perioperative outcomes and recipient outcomes were recorded, and these parameters were compared between the two subgroups before and after propensity-score matching.

RESULTS

Mean age was 51.1 ± 9.1 years; 42.7% were males; mean body mass index was 22.7 ± 2.4; and there were 109 (88%) left kidneys. The following data of REDN and RALDN was, respectively, recorded: operative time (213 ± 43 versus 216 ± 39 min, p = 0.721), warm ischemic time (4.7 ± 1.2 versus 4.9 ± 1.4 min, p = 0.399), postoperative complications (5.4% versus 6.5%, p = 1), haemoglobin (g/L) drop (9.4 ± 7.2 versus 9.7 ± 6.6, p = 0.836), blood creatinine at 6 month (1.15 ± 0.23 versus 1.13 ± 0.24 mg/dL, p = 0.734) and at 1 year (1.09 ± 0.22 versus 1.17 ± 0.28 mg/dL, p = 0.591). In post-propensity score matched analyses, there was no significant differences between the two groups including intraoperative and postoperative complications.

CONCLUSIONS

RALDN could be safely introduced into a living donor program experienced in laparoscopic donor nephrectomy. The outcomes of our study comparing these minimally invasive techniques are mostly similar in terms of intraoperative and postoperative outcomes for kidney donors.

Chyle Leak After Robotic Living Donor Nephrectomy: Literature Review And Management

Chyle leak after living donor nephrectomy is a rare complication and is associated with a significant postoperative burden. To the best of our knowledge, only 1 case of chyle leak after robotic living donor nephrectomy has been reported in the literature. In this study, we present our experience with 2 cases of chyle leak: 1 after and 1 during robotic donor nephrectomy. We discuss previously published studies and man - agement options of chyle leak in kidney donors.

[Living donor nephrectomy: The French guidelines from CTAFU]

OBJECTIVE

To propose surgical recommendations for living donor nephrectomy.

METHOD

Following a systematic approach, a review of the literature (Medline) was conducted by the CTAFU regarding functional and anatomical assessment of kidney donors, including which side the kidney should be harvested from. Distinct surgical techniques and approaches were evaluated. References were considered with a predefined process to propose recommendations with the corresponding levels of evidence.

RESULTS

The recommendations clarify the legal and regulatory framework for kidney donation in France. A rigorous assessment of the donor is one of the essential prerequisites for donor safety. The impact of nephrectomy on kidney function needs to be anticipated. In case of modal vascularization of both kidneys without a relative difference in function or urologic abnormality, removal of the left kidney is the preferred choice to favor a longer vein. Mini-invasive approaches for nephrectomy provide faster donor recovery, less donor pain and shorter hospital stay than open surgery.

CONCLUSION

These French recommendations must contribute to improving surgical management of candidates for kidney donation.

An Environmental Scan and Evaluation of Quality Indicators Across Canadian Kidney Transplant Centers

Background:

Kidney transplantation is the optimal treatment for an individual requiring kidney replacement therapy, resulting in improved survival and quality of life while costing the health care system less than maintenance dialysis. Achieving and maintaining a kidney transplant requires extensive coordination of several different health care services. To improve the quality of kidney transplant care, quality metrics or indicators that encompass all aspects of the individual’s journey to transplant should be measured in a standardized fashion.

Objective:

To identify, categorize, and evaluate strengths and weaknesses of kidney transplant quality indicators currently being used across Canada.

Design:

An environmental scan of quality indicators being used by kidney organizations and programs.

Setting:

A 16-member volunteer pan-Canadian panel with expertise in nephrology, transplant, and quality improvement.

Sample:

Transplant programs, as well as provincial transplant and kidney agencies across Canada.

Methods:

Indicators were first categorized based on the period of transplant care and then using the Institute of Medicine and Donabedian frameworks. A 4-member subcommittee rated each indicator using a modified version of the Delphi consensus technique based on the American College of Physician/Agency for Healthcare Research and Quality criteria. Consensus ratings were subsequently shared with the entire 16-member panel for additional comments.

Results:

We identified 46 measures related to transplant care across 7 Canadian provinces (9 referral and evaluation, 9 waitlist activity and outcomes, 6 hospitalization for transplant surgery, 12 posttransplant care, 6 organ utilization, 4 living donor). We rated 24 indicators (52%) as necessary to distinguish high-quality from low-quality care, most of which measured effective (n = 10) or efficient (n = 6) care. Only 7 (15%) of 46 indicators evaluated person-centered or equitable care. Fourteen common indicators were measured by 5 of 7 provinces, 10 of which were deemed “necessary,” measuring safe (n = 2), effective (n = 5), efficient (n = 2), and equitable (n = 1) care.

Limitations:

The panel lacked patient and allied health representation.

Conclusions:

There are a large number of kidney transplant quality indicators currently being used in Canada, some of which are common across provinces and focus primarily on measuring effective care. Person-centered and equitable care indicators were lacking, and only half of these indicators were deemed “necessary” for quality improvement. Our results should complement ongoing work to achieve national consensus on the standardization of quality indicators in kidney transplantation.

Long-term mortality of living kidney donors: a systematic review and meta-analysis

BACKGROUND

To date, several studies have reported inconsistent findings regarding the mortality risk faced by living kidney donors and controls. Our study assessed the methodological quality of previous studies and performed an updated meta-analysis of the mortality risk.

METHODS

Comprehensive literature searches were conducted involving the PubMed, Embase, and Cochrane databases through September 2020. The search terms used included 'living donor' and 'kidney transplantation' and 'kidney donor' and 'mortality' or 'death' or 'survival'. We evaluated the risk of bias in such studies using ROBINS-I tool. Mortality risk was analyzed using OR and HR.

RESULTS

The qualitative review involved 18 studies and the meta-analysis included nine studies. We identified 3 studies with an overall risk of bias rated as "Low", 2 studies rated as "Moderate", 8 studies rated as "Serious", and 5 studies rated as "Critical". The pooled overall mortality risk in the meta-analysis was 0.984 (95% CI: 0.743, 1.302). In the subgroup analysis of HR and OR, the summary effect estimates did not reach statistical significance. The meta-regression analysis revealed that the donor group of more than 60,000 (1.836, 95% CI: 0.371, 6.410) carried a significantly high mortality risk compared with the donor group of less than 60,000 (0.810, 95% CI: 0.604, 1.086) (P = 0.007). The number of total patients was associated with slightly elevated mortality risks (0.796 for < 10,000, 0.809 for 10,000-60,000, and 1.852 for > 60,000; P < .054).

CONCLUSIONS

Current evidence based on this systematic review suggests that the methodology of previous studies was inconsistent and also carried a high risk in several aspects. Updated meta-analysis showed that the mortality risk was not significantly different. Future studies with well-designed methodology are necessary.

A Quality Improvement Intervention to Enhance Access to Kidney Transplantation and Living Kidney Donation (EnAKT LKD) in Patients With Chronic Kidney Disease: Clinical Research Protocol of a Cluster-Randomized Clinical Trial

Background:

Many patients with kidney failure will live longer and healthier lives if they receive a kidney transplant rather than dialysis. However, multiple barriers prevent patients from accessing this treatment option.

Objective:

To determine if a quality improvement intervention provided in chronic kidney disease (CKD) programs (vs. usual care) enables more patients with no recorded contraindications to kidney transplant to complete more steps toward receiving a kidney transplant.

Design:

This protocol describes a pragmatic 2-arm, parallel-group, open-label, registry-based, cluster-randomized clinical trial—the Enhance Access to Kidney Transplantation and Living Kidney Donation (EnAKT LKD) trial.

Setting:

All 26 CKD programs in Ontario, Canada, with a trial start date of November 1, 2017. The original end date of March 31, 2021 (3.4 years) has been extended to December 31, 2021 (4.1 years) due to the COVID-19 pandemic.

Participants:

During the trial, the 26 CKD programs are expected to care for more than 10 000 adult patients with CKD (including patients approaching the need for dialysis and patients receiving dialysis) with no recorded contraindications to a kidney transplant.

Intervention:

Programs were randomly allocated to provide a quality improvement intervention or usual care. The intervention has 4 main components: (1) local quality improvement teams and administrative support; (2) tailored education and resources for staff, patients, and living kidney donor candidates; (3) support from kidney transplant recipients and living kidney donors; and (4) program-level performance reports and oversight by program leaders.

Primary Outcome:

The primary outcome is the number of key steps completed toward receiving a kidney transplant analyzed at the cluster level (CKD program). The following 4 unique steps per patient will be counted: (1) patient referred to a transplant center for evaluation, (2) at least one living kidney donor candidate contacts a transplant center for an intended recipient and completes a health history questionnaire to begin their evaluation, (3) patient added to the deceased donor transplant wait list, and (4) patient receives a kidney transplant from a living or deceased donor.

Planned Primary Analysis:

Study data will be obtained from Ontario’s linked administrative healthcare databases. An intent-to-treat analysis will be conducted comparing the primary outcome between randomized groups using a 2-stage approach. First stage: residuals are obtained from fitting a regression model to individual-level variables ignoring intervention and clustering effects. Second stage: residuals from the first stage are aggregated at the cluster level as the outcome.

Limitations:

It may not be possible to isolate independent effects of each intervention component, the usual care group could adopt intervention components leading to contamination bias, and the relatively small number of clusters could mean the 2 arms are not balanced on all baseline prognostic factors.

Conclusions:

The EnAKT LKD trial will provide high-quality evidence on whether a multi-component quality improvement intervention helps patients complete more steps toward receiving a kidney transplant.

Trial registration:

Clinicaltrials.gov; identifier: NCT03329521.

Effects of living kidney donation on arterial stiffness: a systematic review protocol

INTRODUCTION

Kidney donors have been reported to have accelerated progression of aortic stiffness and decreased glomerular filtration compared with healthy non-donors. This is a concern because increased aortic stiffness is an independent predictor of overall cardiovascular disease and all-cause mortality in the general population. To confirm if arterial stiffness increases after donation, we will systematically review all studies that evaluated indices of arterial stiffness in healthy individuals who underwent unilateral nephrectomy for kidney donation compared with age-matched healthy non-nephrectomised controls.

METHODS/ANALYSIS

We will comprehensively search for studies published between 1 January 1960 and 15 March 2021 in MEDLINE, EMBASE, Cochrane Central, OVID and EBM reviews. All prospective (cohort, case-control, case series and before-and-after studies) and retrospective non-randomised studies reporting indices of arterial stiffness in nephrectomised and non-nephrectomised healthy participants will be included. Primary outcome will be the difference in the functional metrics of arterial stiffness between donors and non-donors. Secondary outcomes will be the differences in systolic/diastolic blood pressures, serum creatinine, glomerular filtration, carotid artery intima-media thickness and vascular calcification. Study screening, selection and data extraction will be performed by two independent reviewers. Risk of bias will be independently assessed with the ROBINS-I tool and confidence in evidence by the Grading of Recommendations Assessment, Development and Evaluation recommendations. Qualitative and quantitative data syntheses as well as clinical and statistical heterogeneity (Forest plots, I2 and Cochran's Q statistics) will be evaluated. If clinical and statistical heterogeneity are acceptable, inverse variance-weighted effects will be analysed by random effect models.

ETHICS AND DISSEMINATION

No ethical approval is necessary. Our results will be disseminated through peer-review publication and presentations to guide stakeholders on the evaluation and follow-up care of kidney donors.

PROSPERO REGISTRATION NUMBER

CRD42020185551.

Knowledge and Attitudes about Organ Donation among Patient Companion at a Tertiary Hopsital in Ethiopia

BACKGROUND

Worldwide, the supply of organs continues to be much less than the demand. Many studies identify poor knowledge and negative attitude about organ donation for this. The purpose of this study was to assess knowledge and attitude towards organ donation and associated factors among people who accompany patient during hospital visit at tertiary hospital in Ethiopia.

METHODS

A hospital-based cross-sectional study was conducted from March 1st to May 31, 2019, at a tertiary hospital and the only transplant center in Ethiopia. The patient companions were interviewed with structured questionnaires. Descriptive statistics were presented and factors associated with good knowledge and favorable attitude were assessed using Binary logistic regression.

RESULTS

A total of 414 patient companion participated in the study. The mean age of the respondents was 35±13years, and 252(60.9%) were males. Forty-four (10.6%) of the study participants had good knowledge about organ donation. Male gender was significantly associated with improved knowledge (AOR=2.127 95% CI: 1.036, 4.368). A favorable attitude towards donation was found in 219(52.9%) of the study participants. Participants who had completed secondary education were more likely to have unfavorable attitude towards organ donation (AOR =0.498, 95% CI: 0.290, 0.857).

CONCLUSION

Knowledge about organ donation was found to be poor, and attitudes towards organ donation were found to be unfavorable among patient companions at a major medical center in Ethiopia. Strategies focused on education of the general public and broad dissemination of information on the benefits of organ donation will be critical for improving the organ donor pool.

Living in limbo while one's identity is changing: Patients' existential experiences 6 months after a kidney transplantation with a living donor

AIM

To investigate patients' existential experiences in everyday life after a kidney transplantation with a living donor.

DESIGN

A qualitative study anchored in a hermeneutic-phenomenological approach inspired by Ricoeur's theory of narrative and interpretation.

METHOD

Eleven patient interviews were conducted approximately 6 months after a kidney transplantation with a living donor. The interviews were conducted between August 2017-May 2019. Analysis and interpretation are based on Ricoeur's theory of interpretation.

RESULTS

Four themes were identified: Experiencing bodily vulnerability while getting back to life; Feeling guilt while experiencing gratitude; Living in limbo while one's identity is changing; and Facing the future with hope while having reservations.

CONCLUSION

This study reveals that patients experience multifaceted existential challenges in their everyday lives during the transition of the kidney transplantation process. Post-surgery complications for donors lead to feelings of guilt in patients; plus, they must adapt to a new existence, including a new identity. The patients feel they are in limbo, as they experience their existence as uncertain and their identity as unknown.

IMPACT

The study highlights a need for developing a rehabilitation programme to address the individual and various existential challenges faced by patients who need to undergo a kidney transplantation.

Outcomes and surgical complications following living-donor renal transplantation using kidneys retrieved with trans-peritoneal or retro-peritoneal hand-assisted laparoscopic nephrectomy

The best minimally invasive procedure for living-donor kidney retrieval remains debated. Our objective was to assess trans-peritoneal (TP) and retro-peritoneal (RP) hand-assisted laparoscopic donor nephrectomy (HALDN). In this single-center retrospective study, we analyzed results from 317 living-donor renal transplants (RT) performed between 2008 and 2016. Donor and recipient outcomes were compared between TP-HALDN (n = 235) and RP-HALDN (n = 82). Conversion to open nephrectomy (0.4% vs 0%; P = 1.000), intra-operative complications (1.7% vs 1.2%; P = 1.000), and 1-year overall post-operative complications (11.9% vs 17.1%; P = .258) rates were similar in TP-HALDN and RP-HALDN. Overall surgical site infections were higher in RP-HALDN (6.1% vs 1.7%; P = .053), whereas incisional hernias were only recorded following TP-HALDN (3.4% vs 0%; P = .118). The duration of the procedure was 11-minute shorter for TP-HALDN than RP-HALDN (P < .001) but extraction time was equivalent (2, IQR 1.5-2.5 minutes; P = 1.000). RT following TP-HALDN and RP-HALDN showed comparable one-year death-censored allograft survival (97% vs 98.8%; P = .685), primary non-function (0.4% vs 0%; P = .290), delayed graft function (1.3% vs 4.9%; P = .077), and urological complications (2.6% vs 4.9%; P = .290) rates. In our series, donor and recipient outcomes were not substantially affected by the approach used for donor nephrectomy. TP-HALDN and RP-HALDN were both safe and effective.

Psychological characteristics and associations between living kidney transplantation recipients and biologically related or unrelated donors

BACKGROUND

Although recipients and donors in living kidney transplantation experience psychological distress-including depression and anxiety-during the pre-operative period, very few studies have evaluated the related psychological reactions. This study aimed to determine the characteristics and correlations of the mood states and personality of recipients and donors (genetically related and unrelated) of living kidney transplantations.

METHODS

A total of 66 pairs of living donors and recipients were enrolled from April 2008 to June 2019 in this study, of whom 53 eligible pairs of living donors and recipients were included in the retrospective analysis of their psychological assessments in the pre-transplantation states. While participants' personality patterns were assessed using the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), mood states were evaluated via both the State-Trait Anxiety Inventory (STAI) and The Center for Epidemiologic Studies Depression Scale (CES-D). Statistical analysis was performed using paired t-tests and Spearman's correlation analyses.

RESULTS

The recipient group showed significantly higher scores for Hypochondriasis (t = - 4.49, p = .0001), Depression (t = - 3.36, p = .0015), and Hysteria (t = - 3.30, p = .0018) of MMPI-2 and CES-D (t = - 3.93, p = .0003) than the donor group. The biologically unrelated recipient group reported higher scores of Hypochondriasis (t = - 3.37, p = .003) and Depression (t = - 2.86, p = 0.0098) than the unrelated donor group. Higher scores for Hypochondriasis (t = - 3.00, p = 0.0054) and CES-D (t = - 3.53, p = .0014) were found in the related recipient group. A positive association was found for Hypomania (r = .40, p = .003) of MMPI-2, STAI-S (r = .36, p = .009), and CES-D (r = .36, p = .008) between the recipient and donor groups.

CONCLUSIONS

Recipients suffered from a higher level of depression and somatic concerns than donors before living kidney transplantation. Psychological problems like depression and anxiety can occur in both living kidney transplantation donors and recipients. This study suggests that clinicians must pay attention to mood states not only in recipients but also in donors because of emotional contagion.

The impact of country reimbursement programmes on living kidney donations

INTRODUCTION

Living-donor kidney transplantation is the gold standard treatment for patients with end-stage kidney disease. However, potential donors ubiquitously face financial as well as logistical barriers. To remove these disincentives from living kidney donations, the governments of 23 countries have implemented reimbursement programmes that shift the burdens of non-medical costs from donors to the governments or private entities. However, scientific evidence for the effectiveness of these programmes is scarce. The present study investigates whether these reimbursement programmes designed to ease the financial and logistical barriers succeeded in increasing the number of living kidney donations at the country level. The study examined within-country variations in the timing of such reimbursement programmes.

METHOD

The study applied the difference-in-difference (two-way panel fixed-effect) technique on the Poisson distribution to estimate the effects of these reimbursement programmes on a 17 year long (2000-2016) dataset covering 109 countries where living donor kidney transplants were performed.

RESULTS

The results indicated that reimbursement programmes have a statistically significant positive effect. Overall, the model predicted that reimbursement programmes increased country-level donation numbers by a factor of 1.12-1.16.

CONCLUSION

Reimbursement programmes may be an effective approach to alleviate the kidney shortage worldwide. Further analysis is warranted on the type of reimbursement programmes and the ethical dimension of each type of such programmes.

Application of the 2017 KDIGO Guideline for the Evaluation and Care of Living Kidney Donors to Clinical Practice

The Kidney Disease: Improving Global Outcomes (KDIGO) 2017 "Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors" was developed to assist medical professionals who evaluate living kidney donor candidates and provide care before, during, and after donation. This guideline Work Group concluded that a comprehensive approach to donor candidate risk assessment should replace eligibility decisions on the basis of assessments of single risk factors in isolation. To address all issues important to living donors in a pragmatic and comprehensive guideline, many of the guideline recommendations were on the basis of expert consensus opinion even when no direct evidence was available. To advance available evidence, original data analyses were also undertaken to produce a "proof-of-concept" risk projection model for kidney failure. This was done to illustrate how the community can advance a new quantitative framework of risk that considers each candidate's profile of demographic and health characteristics. A public review by stakeholders and subject matter experts as well as industry and professional organizations informed the final formulation of the guideline. This review highlights the guideline framework, key concepts, and recommendations, and uses five patient scenarios and 12 guideline statements to illustrate how the guideline can be applied to support living donor evaluation and care in clinical practice.

Living Donors: Altruism and Feeling Forgotten

OBJECTIVES

Living donors endure several challenges throughout the organ donation process. Physically related effects are further compounded by social and emotional challenges. To date, no previous studies have addressed the motives and impact of organ donations from living donors in Jordan.

MATERIALS AND METHODS

We conducted a qualitative exploratory study to understand the experiences of a random sample of genetically and legally related living donors in Jordan. Participants were identified through the Directorate of the Jordanian Center for Organ Transplantation database. Our sample included Jordanians and non-Jordanians who donated a kidney or liver. Most data were collected by phone interviews with living donors; some donors were personally interviewed. Donors were asked about their experiences during the periods before and after the process of donation, including their feelings, emotions, and motives. Interviews were analyzed using the thematic analysis approach.

RESULTS

In total, 360 participants (337 kidney and 23 liver donors; 290 Jordanians and 70 non-Jordanians) completed the interview. The time from donation to interview ranged from 14 days to 7 years. The period before donation was characterized by fear and confusion. After donation, most donors described a positive emotional state that was marked by selfsatisfaction, pride, and increased support of organ donation. However, many stated that they felt forgotten. Most donors were motivated by social solidarity, and others invoked the role of their religious beliefs as the main motive. Other motives included improving the recipient's life and fear that patients would be abandoned.

CONCLUSIONS

The emotional distress of living donors during the predonation period emphasizes the need for social and psychological support in addition to medical evaluations. Donors who had positive experiences with donation can play a role in advocating for donation. Finally, in Jordan, social solidarity and religious beliefs are the most important factors that motivate donation.

KDOQI US Commentary on the 2017 KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors

Living kidney donation is widely practiced throughout the world. During the past 2 decades, various groups have provided guidance about the evaluation and care of living donors. However, during this time, our knowledge in the field has advanced substantially and many agreed on the need for a comprehensive, unifying document. KDIGO (Kidney Disease: Improving Global Outcomes) addressed this issue at an international level with the publication of its clinical practice guideline on the evaluation and care of living kidney donors. The KDIGO work group extensively reviewed the available literature and wrote a series of guideline recommendations using various degrees of evidence when available. As has become recent practice, NKF-KDOQI (National Kidney Foundation-Kidney Disease Outcomes Quality Initiative) convened a work group to provide a commentary on the KDIGO guideline, with a focus on how these recommendations apply in the context of the United States. In the United States, the United Network for Organ Sharing (UNOS) guides and regulates the practice of living kidney donation. While the KDIGO guideline for the care of living kidney donors and UNOS policy are similar in most aspects of the care of living kidney donors, several important areas are not consistent or do not align with common practice by US transplantation programs in areas in which UNOS has not set specific policy. For the time being, and recognizing the value of the KDIGO guidelines, US transplantation programs should continue to follow UNOS policy.

Living donor hand-assisted laparoscopic nephrectomy in a healthy individual with situs inversus totalis: no need to turn down the donor

A 70-year-old healthy male individual offered to undergo a living donor hand-assisted laparoscopic nephrectomy to enable kidney transplantation for a close relative. As required for all living transplant donor candidates, extensive screening was performed to exclude potential contraindications for donation. Tests revealed a situs inversus totalis, meaning a complete transposition of the thoracic and abdominal organs in the sagittal plane. As other contraindications for living kidney donation were absent, the feasibility of this procedure was determined multidisciplinary. A successful donation procedure was performed without surgical complications for the donor and good short-term transplant outcomes. In line with current developments that have resulted in more liberal criteria for potential living kidney donors, major anatomical deviations should not automatically be a contraindication. With multidisciplinary efforts and thorough surgical preparation at a high-volume transplant centre, this procedure is feasible and safe.

Impact of the donor-recipient gender matching on the graft survival from live donors

Background

Several factors such as recipient age, BMI, serum cratinine, and positive history of dialysis are important in predicting graft survival among kidney transplant recipients. One factor affecting the transplant outcomes is donors and recipients gender, which is usually ignored.

Methods

A total of 1113 kidney transplant recipients were studied in this retrospective cohort study. Several factors were taken into account for graft survival and outcomes such as donors and recipients gender and age in addition to common recipient factors like cratinine, eGFR, BMI, and positive history of dialysis.

Results

The most successful transplant based on donor-recipient gender was observed in male donor to male recipient, and then male donor to female recipient. In female transplant recipients, level of serum cratinine and eGFR, positive dialysis history before transplant, and low donor hemoglobin level can be considered as good prognostic factors recommended for kidney transplant survival.

Conclusions

Our results suggested gender matching for kidney transplant. Only in some exceptional conditions, male donor to female recipient kidney transplant may be successful and female donors to male recipients are not suggested, especially in aged patients with the history of dialysis.

Yearly Trends of Chronic Kidney Disease III Progressions in Living Kidney Donors

PURPOSE

We aim to see the rate of progression to chronic kidney disease stage III after living donor nephrectomy in a single institution annually.

METHODS

Between May 2006 and July 2017, a total of 753 living kidney donors who were followed up more than 6 months were enrolled in the study. We divided normal function vs chronic kidney disease III at 6 months postoperatively. We compared the incidence rate of chronic kidney disease stage III annually. For analysis, the entire period was divided into Era 1 (2006-2008), Era 2 (2009-2011), Era 3 (2012-2014), and Era 4 (2015-2017).

RESULTS

During the period, the incidence of chronic kidney disease stage III was 258 living donors (34.3%). The prevalence of chronic kidney disease stage III was 39.3%, 36.6%, 35.5%, and 29.3% in Era 1, Era 2, Era 3, and Era 4, respectively. The rate of chronic kidney disease stage III incidence serially decreased as the era passed (P = .046). There was no difference in age, smoking status, drinking status, body mass index, preoperative cholesterol, and uric acid among the eras. However, preoperative estimated glomerular filtration rate was 90.86 (SD, 4.12), 94.47 (SD, 16.62), 103.82 (SD, 0.68), and 105.66 (SD, 19.57) mL/min/1.73 m² in Era 1, Era 2, Era 3, and Era 4, respectively (P = .001).

CONCLUSIONS

The incidence of chronic kidney disease stage III in living kidney donors for the last 3 years (Era 4) has decreased compared with the past (Era 1 and 2). The reason for this might be the effect of the change in the living donor guideline. Also, pre- and postoperative management method had an effect on renal function at 6 months.

Structured introduction of retroperitoneoscopic donor nephrectomy provides a high level of safety and reduces the physical burden for the donor compared to an anterior mini incision: A cohort study

INTRODUCTION

A major goal in living donor kidney transplantation is to reduce the physical burden for the donor. Key-hole surgery for donor nephrectomy is a safe procedure, but concerns regarding donor safety during the learning phase might be the reason for surgeons' reluctance to change to a minimal invasive approach.

MATERIAL AND METHODS

We analyzed the first 100 retroperitoneoscopic donor nephrectomies (RPDN) performed at our institution and compared the results to the last 50 mini incision donor nephrectomies (MIDN) regarding donor and recipient outcome, and analyzed the learning curves of RPDN.

RESULTS

The learning phase of RPDN was very short with significantly shorter operative times compared to MIDN (118 vs. 175 min, p < 0.001) and significantly fewer surgical complications (p = 0.03). RPDN patients rated the physical burden (p = 0.01) as lower, and they felt less bothered by the surgical scar (p = 0.03).

CONCLUSION

Introducing RPDN is safe, even during the learning phase of the surgeons. Changing surgical technique from MIDN to RPDN reduces the surgical burden of the procedure. Our study might encourage more transplant centres to adopt a minimally invasive approach.

Assessment of Postdonation Outcomes in US Living Kidney Donors Using Publicly Available Data Sets

Importance

There are limited resources providing postdonation conditions that can occur in living donors (LDs) of solid-organ transplant. Consequently, it is difficult to visualize and understand possible postdonation outcomes in LDs.

Objective

To assemble an open access resource that is representative of the demographic characteristics in the US national registry, maintained by the Organ Procurement and Transplantation Network and administered by the United Network for Organ Sharing, but contains more follow-up information to help to examine postdonation outcomes in LDs.

Design, Setting, and Participants

Cohort study in which the data for the resource and analyses stemmed from the transplant data set derived from 27 clinical studies from the ImmPort database, which is an open access repository for clinical studies. The studies included data collected from 1963 to 2016. Data from the United Network for Organ Sharing Organ Procurement and Transplantation Network national registry collected from October 1987 to March 2016 were used to determine representativeness. Data analysis took place from June 2016 to May 2018. Data from 20 ImmPort clinical studies (including clinical trials and observational studies) were curated, and a cohort of 11 263 LDs was studied, excluding deceased donors, LDs with 95% or more missing data, and studies without a complete data dictionary. The harmonization process involved the extraction of common features from each clinical study based on categories that included demographic characteristics as well as predonation and postdonation data.

Main Outcomes and Measures

Thirty-six postdonation events were identified, represented, and analyzed via a trajectory network analysis.

Results

The curated data contained 10 869 living kidney donors (median [interquartile range] age, 39 [31-48] years; 6175 [56.8%] women; and 9133 [86.6%] of European descent). A total of 9558 living kidney donors with postdonation data were analyzed. Overall, 1406 LDs (14.7%) had postdonation events. The 4 most common events were hypertension (806 [8.4%]), diabetes (190 [2.0%]), proteinuria (171 [1.8%]), and postoperative ileus (147 [1.5%]). Relatively few events (n = 269) occurred before the 2-year postdonation mark. Of the 1746 events that took place 2 years or more after donation, 1575 (90.2%) were nonsurgical; nonsurgical conditions tended to occur in the wide range of 2 to 40 years after donation (odds ratio, 38.3; 95% CI, 4.12-1956.9).

Conclusions and Relevance

Most events that occurred more than 2 years after donation were nonsurgical and could occur up to 40 years after donation. Findings support the construction of a national registry for long-term monitoring of LDs and confirm the value of secondary reanalysis of clinical studies.

Gender disparity in health-related quality of life and fatigue after living renal donation

Background

The clinical outcome and health-related quality of life (HRQoL) of living kidney donors is mostly not detrimental, but some donors experience impairment after donation. Gender-specific effects of living kidney donors was evaluated.

Methods

Clinical outcome was assessed in living kidney donors and HRQoL was obtained by self-reporting validated test systems as the Multidimensional Fatigue Inventory (MFI-20), the Short Form 36 (SF-36), and the Patient Health Questionnaire (PHQ-9).

Results

Two hundred and eleven (211) living renal donors were evaluated (female 62.2%). Response rate was 80.8%. In both genders, a decrease of renal function of 26% was observed after donation. De novo antihypertensives were introduced in 28.3% of women and 36.5% of men. HRQoL was comparable in female and male donors, except for mental HRQoL, which was lower in 51- to 60-year-old female donors, compared to age-matched male donors and to the female general population. Female donors aged 40–59 years demonstrated more fatigue than the age-matched general population. A low mental HRQoL (MCS; SF-36) was associated with higher values for fatigue (General Fatigue Score; MFI-20) in both genders. Multiple regression analysis detected the General Fatigue score of the MFI-20 questionnaire and depression identified by the PHQ-9 score as independent variables predicting MCS of the SF-36 in both genders. Lower age at time of donation contributed to a lower MCS in female donors.

Conclusions

Overall, HRQoL in living kidney donors exceeds that of the general population. Inferior mental health status and fatigue seem to be a problem, especially in middle-aged female donors, but not in all female donors. Psychological evaluation pre donation and psychological support post donation are required.

Electronic supplementary material

The online version of this article (10.1186/s12882-018-1187-8) contains supplementary material, which is available to authorized users.

Comparison of accepted and unaccepted living kidney donors: one-center experience

BACKGROUND

Kidney transplantation from living donors (LD) has stagnated in many countries. This study aimed to check whether correction of LD selection practice could increase the number of kidney transplantations.

METHODS

From January 2003 to December 2012, 241 potential adult LD were evaluated in our hospital. Outcome (mortality and end-stage renal disease-ESRD) of accepted LD (182) was compared with unaccepted (59) donors.

RESULTS

Mortality of LD was comparable with that for the standardized Serbian population (SMR = 1.104; 95% CI (0.730-1.606). Among evaluated potential LD, almost every fourth had been unaccepted, but reasons were modifiable in 42.4% of them. In pre-donation period unaccepted donors were significantly older, measured glomerular filtration rate was lower, with higher 15-year and lifelong projected ESRD risks than accepted donors. Despite this, ten years outcome of both groups LD was similar: none of LD developed ESRD, 9.8% of accepted and 11.8% of unaccepted LD died (p = .803).

CONCLUSIONS

During an average of 101 months of follow-up mortality of accepted LD did not differ significantly as compared to the age standardized Serbian population and none of them developed ESRD. In examination of potential LD, the use of accurate and precise methods for kidney function estimation and the evaluation of risk for ESRD and mortality as well as treatment of modifiable contraindications for kidney donation are necessary.

Living donor risk model for predicting kidney allograft and patient survival in an emerging economy

AIM

Living donor kidney is the main source of donor organs in low to middle income countries. We aimed to develop a living donor risk model that predicts graft and patient survival in an emerging economy.

METHODS

We used data from the Sindh Institute of Urology and Transplantation (SIUT) database (n = 2283 recipients and n = 2283 living kidney donors, transplanted between 1993 and 2009) and conducted Cox proportional hazard analyses to develop a composite score that predicts graft and patient survivals.

RESULTS

Donor factors age, creatinine clearance, nephron dose (estimated by donor/recipient body weight ratio) and human leukocyte antigen (HLA) match were included in the living donor risk model. The adjusted hazard ratios (HRs) for graft failures among those who received a kidney with living donor scores (reference to donor score of zero) of 1, 2, 3 and 4 were 1.14 (95%CI: 0.94-1.39), 1.24 (95%CI:1.03-1.49), 1.25 (95%CI:1.03-1.51) and 1.36 (95%CI:1.08-1.72) (P-value for trend =0.05). Similar findings were observed for patient survival.

CONCLUSIONS

Similar to findings in high income countries, our study suggests that donor characteristics such as age, nephron dose, creatinine clearance and HLA match are important factors that determine the long-term patient and graft survival in low income countries. However, other crucial but undefined factors may play a role in determining the overall risk of graft failure and mortality in living kidney donor transplant recipients.

Follow-up Care of Living Kidney Donors in Alberta, Canada

Background

Previous guidelines recommend that living kidney donors receive lifelong annual follow-up care to assess renal health.

Objective

To determine whether these best practice recommendations are currently being followed.

Design

Retrospective cohort study using linked health care databases.

Setting

Alberta, Canada (2002-2014).

Patients

Living kidney donors.

Measurements

We determined the proportion of donors who had annual outpatient physician visits and laboratory measurements for serum creatinine and albuminuria.

Results

There were 534 living kidney donors with a median follow-up of 7 years (maximum 13 years). The median age at the time of donation was 41 years and 62% were women. Overall, 25% of donors had all 3 markers of care (physician visit, serum creatinine, albuminuria measurement) in each year of follow-up. Adherence to physician visits was higher than serum creatinine or albuminuria measurements (67% vs 31% vs 28% of donors, respectively). Donors with guideline-concordant care were more likely to be older, reside closer to the transplant center, and receive their nephrectomy in more recent years.

Limitations

Our results may not be generalizable to other countries that do not have a similar universal health care system.

Conclusions

These findings suggest significant evidence-practice gaps, in that the majority of donors saw a physician, but the minority had measurements of kidney function or albuminuria. Future interventions should target improving follow-up care for all donors.

Multivariate Analysis of Health-related Quality of Life in Donors After Live Kidney Donation

BACKGROUND

Live-kidney donation has a low mortality rate. Evidence suggests that live-kidney donors experience a quality of life (QoL) comparable to or even superior to that of the general population. There is limited information on factors associated with a decrease in QoL in particular for baseline factors, which would improve information to the donor, donor selection, and convalescence.

METHODS

QoL data on 501 live donors included in three prospective studies between 2001 and 2010 were used. The 36-item short form health survey (SF-36) was used to measure QoL up to 1 year after the procedure. Longitudinal effects on both the mental (MCS) and physical component scales (PCS) were analyzed with multilevel linear regression analyses. Baseline variables were age, gender, body mass index (BMI), pain, operation type, and comorbidity. Other covariates were loss of the graft, glomerular filtration rate, and recipient complications.

RESULTS

After 1 year we observed a small decrease in PCS (effect size = -0.24), whereas the MCS increased (effect size = 0.32). Both PCS and MCS were still well above the norm of the general Dutch population. Factors associated with a change in PCS were BMI (Cohen's d = -0.17 for 5 BMI points) and age (d = -0.13 for each 10 years older).

CONCLUSIONS

Overall, QoL after live-donor nephrectomy is excellent. A lowered PCS is related to age and body weight. Expectations towards a decreased postoperative QoL at 1 year are unjustified. However, one should keep in mind that older and obese donors may develop a reduced physical QoL after live-kidney donation.

Emergence of an Israel faith-based community organization facilitating live donor kidney transplantation

BACKGROUND

The 2014 Consensus Conference on Best Practices in Living Kidney Donations recognized live donor kidney transplantation as the best treatment for late-stage kidney disease, yielding superior graft and patient survival, improved quality of life, fewer requirements for dialysis and increased cost-effectiveness compared to deceased donor kidney transplantation. Yet in spite of the excellent results of living kidney donation, the annual number of living kidney donors is declining in many countries, including the United States. In Israel, a non-profit organization, Matnat Chaim ("Gift of Life" in Hebrew), a faith-based initiative, has emerged as a major force for arranging living donor kidney transplantation mainly by facilitating altruistic living unrelated donor transplantation.

METHODS

A retrospective review of the records of live kidney donations facilitated by the Matnat Chaim organization and referred to Israel transplant centers, since the organization's inception in 2009, was performed and compared to published data from the Israel Ministry of Health.

RESULTS

Matnat Chaim has facilitated 494 live kidney donations since its founding in February 2009 until the end of 2017. Of the 124 live kidney transplants performed in 2016, 111 (90%) were shown to be altruistic and unrelated. This large number of donations was associated with a doubling of the total number of kidney transplantations, performed in Israel (data published by the Israel Ministry of Health).

CONCLUSIONS

The success of an Israel community organization in the promotion of kidney transplantation may serve as a model for other religious and non-religious communities worldwide.

Psychological Aspects of Living Kidney Donation in Poland: Experience of One Center

BACKGROUND

Living kidney transplantation is the optimal treatment of end-stage renal disease. The benefits for recipients are obvious. The psychological consequences for living kidney donors in Poland are not known.

OBJECTIVE

The objective of the study was to evaluate the psychological aspects of living kidney donation in Poland.

PATIENTS AND METHODS

A total of 66 living donor open nephrectomies were performed in our institution between 1995 and 2005. The psychological aspects were assessed in 40 donors after nephrectomy. The study applied the Satisfaction With Life Scale (SWLS), the Situation Assessment Questionnaire, the Health Behaviors Survey, and our own questionnaire. The mean observation period was 65.6 months.

RESULTS

There was a trend toward better life satisfaction in living kidney donors compared to Polish adults. Donor life satisfaction was significantly lower when the recipient was dead than when the recipient was alive. Most donors perceived the kidney donation as a challenge in cognitive judgment. The mean score of the Health Behaviors Survey was not significantly different than in the general population in Poland. The mean pain score after donation was 3.2 in a 5-item scale (1 = severe pain, 5 = mild pain). The mean time of return to work was 3.5 months. No donors regretted their decisions about kidney donation.

CONCLUSION

Living kidney donation in Poland has a positive impact on donors' quality of life. Among living kidney donors, the sense of danger concerning the risk of donation depends on the degree of the relationship with the recipient.

A liver for a kidney: Ethics of trans-organ paired exchange

Living donation provides important access to organ transplantation, which is the optimal therapy for patients with end-stage liver or kidney failure. Paired exchanges have facilitated thousands of kidney transplants and enable transplantation when the donor and recipient are incompatible. However, frequently willing and otherwise healthy donors have contraindications to the donation of the organ that their recipient needs. Trans-organ paired exchanges would enable a donor associated with a kidney recipient to donate a lobe of liver and a donor associated with a liver recipient to donate a kidney. This article explores some of the ethical concerns that trans-organ exchange might encounter including unbalanced donor risks, the validity of informed consent, and effects on deceased organ donation.