Gender disparity in living renal transplant donation

Experience of Chronic Kidney Disease and Perceptions of Transplantation by Sex

Importance

The pathway to kidney transplantation (KT) begins with the patient's acceptance of this surgical procedure after discussion with the nephrologist. The patients' perceptions of the disease and of KT may influence their willingness to undergo transplantation.

Objective

To describe patients' experiences of kidney disease and their perceptions of KT and the nephrologists' perceptions of the patient experience.

Design, Setting, and Participants

This qualitative study collected data through semistructured interviews with patients with chronic kidney disease and nephrologists in the Bretagne, Île-de-France and Normandie regions, France. Researchers involved in the study in each region purposely selected 99 patients with chronic kidney disease who initiated dialysis in 2021, based on their age, sex, dialysis facility ownership, and also 45 nephrologists, based on their sex and years of experience. Data analysis was performed from January to October 2023.

Main Outcomes and Measures

Themes were identified using inductive thematic analysis. Specific characteristics of men and women as well as the nephrologist's views for each theme were described.

Results

This study included 42 men and 57 women (56 [57%] aged 60 years or older) who started dialysis in 2021 and 45 nephrologists (23 women and 22 men). Six major themes were identified: (1) burden of chronic kidney disease on patients and their families, (2) health care professional-patient relationship and other factors that modulate chronic kidney disease acceptance, (3) dialysis perceived as a restrictive treatment, (4) patients' representation of the kidney graft, (5) role of past experiences in KT perception, and (6) dualistic perception of KT. In some cases, women and nephrologists indicated that women's perceptions and experiences were different than men's; for example, the disease's psychological impact and the living donor KT refusal were mainly reported by 8 women.

Conclusions and Relevance

Patients' past experience of chronic kidney disease in general and of KT in particular, as well as their relationship with their family and nephrologist, were substantial determinants of KT perception in this qualitative study. Targeted policies on these different factors might help to improve access to KT, and more research is needed to understand whether there are sex-based disparities.

Gender and kidney transplantation

Kidney transplantation provides the best form of kidney replacement therapy with improvement in quality of life and longevity. However, disparity exists in its availability, utilisation and outcomes, not only due to donor availability or financial constraints but also arising from the influence of biological sex and its sociocultural attribute i.e., Gender. Women make up the majority of kidney donors but are less likely to be counselled regarding transpantation, be waitlisted or receive living/deceased donor kidney. Biological differences also contribute to differences in kidney transplantation among the sexes. Women are more likely to be sensitised owing to pregnancy, especially in multiparous individuals, complicating donor compatibility. A heightened immune system in women, evidenced by more autoimmune illnesses, increases the risk of allograft rejection and loss. Differences in the pharmacokinetics of transplant drugs owing to biological variances could also contribute to variability in outcomes. Transgender medicine is also increasingly becoming a relevant topic of study, providing greater challenges in the form of hormonal manipulations and anatomic changes. It is thus important to determine and study transplantation and its nuances in this backdrop to be able to provide relevant sex and gender-specific interventions and design better practices for optimum kidney transplant utilisation and outcomes.

Enhancing Kidney Transplant Outcomes: The Impact of Living Donor Programs

INTRODUCTION

The protocol for deceased donor kidney transplants has been standardised. The procedure for a living donor has peculiarities derived from the differences in the graft. When a living kidney donor program is implemented, changes occur in both the profile of the kidney transplant candidate and in the postoperative treatments.

AIMS

To discover whether a living donor program influences the functional outcomes of kidney grafts in a longstanding classical deceased donor kidney transplant program and to identify the factors associated with transplant outcomes.

METHODS

Retrospective observational multicentre study.

SAMPLE

Kidney transplant patients in two urology referral centres for renal transplant in Spain between 1994 and 2019. Groups: TV (living transplant): patients given kidney transplants from living donors (n = 150); TCpre11 (deceased transplant previous to 2011): patients given kidney transplants from deceased donors before the living donor program was implemented (n = 650); and TCpost11 (deceased transplant after 2011): patients given kidney transplants from deceased donors after the living donor program was implemented (n = 500).

RESULTS

Mean age was 55.75 years (18-80 years), higher in TCpre11. There were 493 female patients (37.92%) and 1007 male patients (62.08%). Mean body mass index (BMI) was 26.69 kg/m2 (17.50-42.78 kg/m2), higher in TCpre11. Mean ischemia time was 17.97 h (6-29 h), higher in TCpost11. Median duration of urethral catheter: 8 days (6-98 days), higher in TCpost11. Median duration of double-J ureteral stent: 58 days (24-180 days), higher in TCpost11. Pretransplant UTIs: 17.77%, higher in TCpre11 (25.69%) than in TV (12%), higher in TV (12%) than TCpost11 (9.2%), and higher in TCpre11 (25.69%) than TCpost11 (9.2%). Acute renal rejection in 9.33% of TV, 14.77% of TCpre11, and 9.8% of TCpost11. Multivariate analysis: TCpost11 featured higher BMI, more smoking, and chronic renal failure progression time. Lower use of nonantibiotic prophylaxis to prevent recurrent urinary tract infections, increased duration of urethral catheters due to obstructive problems, and favoured deterioration of kidney function was observed in the deceased donor program. The living donor (LD) program had a strong influence on deceased donor transplants in the prelysis phase. Implementation of a LD program was associated with a decrease in the likelihood of acute rejection in TCpost11 and an increase in the tendency towards normal kidney function.

CONCLUSIONS

Implementing living donor transplant programs affects functional outcomes in deceased donor transplants, reducing the probability of acute rejection and increasing the tendency towards normal kidney function. Preventing recurrent urinary tract infections with measures other than antibiotics, smoking cessation, delaying the removal of the double-J stent from the graft, and pre-emptive transplant (transplant prior to dialysis) are associated with improved renal function of the graft.

Relationships, race/ethnicity, gender, age, and living kidney donation evaluation willingness

Racial/ethnic and gender disparities in living donor kidney transplantation are large and persistent but incompletely explained. One previously unexplored potential contributor to these disparities is differential willingness to donate to recipients in specific relationships such as children, parents, and friends. We collected and analyzed data from an online sample featuring an experimental vignette in which respondents were asked to rate their willingness to donate to a randomly chosen member of their family or social network. Results show very large differences in respondents' willingness to donate to recipients with different relationships to them, favoring children, spouses/partners, siblings, and parents, and disfavoring friends, aunts/uncles, and coworkers. Evidence suggesting an interactive effect between relationship, respondent race/ethnicity, respondent or recipient gender, was limited to a few cases. At the p < 0.05 level, the parent-recipient gender interaction was statistically significant, favoring mothers over fathers, as was other/multiracial respondents' greater willingness to donate to friends compared to Whites. Additionally, other interactions were significant at the p < 0.10 level, such as Hispanics' and women's higher willingness to donate to parents compared to Whites and men respectively, women's lower willingness to donate to friends compared to men, and Blacks' greater willingness to donate to coworkers than Whites. We also examined differences by age and found that older respondents were less willing to donate to recipients other than their parents. Together these results suggest that differential willingness to donate by relationship group may be a moderately important factor in understanding racial/ethnic and gender disparities in living donor kidney transplantation.

Intersectional race and gender disparities in kidney transplant access in the United States: a scoping review

BACKGROUND

Gender and racial disparities in kidney transplant access are well established, however how gender and race interact to shape access to kidney transplant is less clear. Therefore, we examined existing literature to assess what is known about the potential interaction of gender and race and the impact on access to kidney transplantation in the US.

METHODS

Following PRISMA guidelines, we conducted a scoping review and included quantitative and qualitative studies published in English between 1990 and May 31, 2023 among adult end-stage kidney disease patients in the US. All studies reported on access to specific transplant steps or perceived barriers to transplant access in gender and race subgroups, and the intersection between the two. We narratively synthesized findings across studies.

RESULTS

Fourteen studies met inclusion criteria and included outcomes of referral (n = 4, 29%), evaluation (n = 2, 14%), waitlisting (n = 4, 29%), transplantation (n = 5, 36%), provider perceptions of patient transplant candidacy (n = 3, 21%), and patient preferences and requests for a living donor (n = 5, 36%). Overall, we found that White men have the greatest access at all steps of the transplant process, from referral to eventual living or deceased donor transplantation. In contrast, women from racial or ethnic minorities tend to have the lowest access to kidney transplant, in particular living donor transplant, though this was not consistent across all studies.

CONCLUSIONS

Examining how racism and sexism interact to shape kidney transplant access should be investigated in future research, in order to ultimately shape policies and interventions to improve equity.

Are Differences in Living Kidney Donation Rates a Sex or a Gender Disparity?

Sex-disaggregated data reveal significant disparities in living kidney donation, with more female than male living kidney donors in most countries and proportions over 60% in some countries. We summarize the present state of knowledge with respect to the potential drivers of this disparity and argue that it is primarily driven by gender-related factors. First, we present the differences between sex and gender and then proceed to summarize the potential medical reasons that have been proposed to explain why males are less likely to be living kidney donors than females, such as the higher prevalence of kidney failure in males. We then present counterarguments as to why biological sex differences are not enough to explain lower living kidney donation among males, such as a higher prevalence of chronic kidney disease among females, which could affect donation rates. We argue that gender differences likely provide a better explanation as to why there are more women than men living kidney donors and explore the role of economic and social factors, as well as gender roles and expectations, in affecting living kidney donation among both men and women. We conclude with the need for a gender analysis to explain this complex psychosocial phenomenon in living kidney donation.

Sex and racial disparities in living donor liver transplantation in the United States

Sex and racial disparities in deceased donor liver transplantation (DDLT) have been described, but this has not been well studied in living donor liver transplantation (LDLT). We aim to examine these disparities in the US LDLT population and identify potential predictors of these differences. From 2002 to 2021, the Organ Procurement and Transplant Network database was queried to characterize the adult LDLT population and evaluate differences between LDLT and DDLT recipients with regard to sex and race. Donor demographics, Model for End-stage Liver Disease (MELD), and socioeconomic data were all included. Of the 4961 LDLT and 99,984 DDLT recipients, males received the majority of LDLT (55% vs. 45%, p < 0.001) and DDLT (67% vs. 33%, p < 0.001) compared to females. There was a significant difference in race between male and female LDLT recipients ( p < 0.001); 84% of male recipients were White and 78% of females. In both groups, females had lower levels of education and were less likely to have private insurance. There were more female living donors (N = 2545, 51%); 50% of female donors donated to males but only 40% of males donated to females. Donor-recipient relationships varied significantly by sex ( p < 0.001); males received more donations from spouses (62% vs. 39%) and siblings (60% vs. 40%). In the LDLT population, significant disparities exist with respect to sex and race that disadvantage women, but these disparities are less pronounced than in the DDLT population. Although further studies are needed, complex clinical and socioeconomic differences as well as donor factors may explain these variations.

Sex and Gender Disparities in Living Kidney Donation: A Scoping Review

Background

Women are more likely than men to be living kidney donors. We summarized the evidence concerning the reasons behind sex and gender disparities in living kidney donation (LKD).

Methods

A scoping review of quantitative and qualitative evidence on reasons for sex and gender disparities in LKD was conducted from inception to March 2023.

Results

Of 1123 studies screened, 45 were eligible for inclusion. Most studies were from North America, Europe, and Central Asia (n = 33, 73%). A predominance of women as living donors (55%-65%) was observed in 15 out of 18 (83%) studies. Reasons for sex and gender disparities in LKD included socioeconomic, biological, and cognitive or emotional factors. A gendered division of roles within the families was observed in most studies, with men being the primary income earner and women being the main caregiver. Fear of loss of income was a barrier to male donation. Human leukocyte antigen sensitization through pregnancy in female recipients precluded male partner donation, whereas female donation was supported by altruism and a positive attitude toward LKD.

Conclusions

Sex imbalance in LKD is prevalent, with a predominance of women as living donors. Such disparities are driven by societal and cultural perceptions of gender roles, pregnancy-induced sensitization, and attitudes toward donation and at least some of these factors are modifiable. Donor compensation to support predonation assessments and income loss, implementation of innovative desensitization treatments, promotion of paired kidney exchange program, and targeted educational initiatives to promote equitable living donation may help to close the gender gap in LKD.

Pregnancy in Living Kidney Donors: An Evidence-Based Review

Purpose of review

To review the current studies and guidelines on the risk of adverse pregnancy outcomes in female kidney donors.

Recent findings

Living kidney donors include a significant amount of young women of child-bearing age. Safety and possible risks of pregnancy after donation are a concern for female kidney donor candidates. Many current studies indicate a higher risk of preeclampsia in women after kidney donation. Considering the increasing number of living kidney donors, the maternal outcomes of living kidney donation is an active area of research.

Summary

Guidelines and consensus statements on the risk of pregnancy in living kidney donors recommend close monitoring of blood pressure, weight gain, and proteinuria during pregnancy. Current studies indicate an increased risk of hypertensive disorders of pregnancy in living kidney donors. Counseling and informing donor candidates about the possible risks is important.

Sociodemographic Drivers of Donor and Recipient Gender Disparities in Living Kidney Donation in Australia

Background

Females account for 60% of all living kidney donors worldwide. We defined the proportion of female to male donors for living donor kidney transplantation stratified by recipient gender, and explored the factors associated with female kidney donation.

Methods

Data from the ANZDATA (Australian and New Zealand Dialysis and Transplantation) and ANZOD (Australian and New Zealand Organ Donor) registries (2002-2019) were used to identify the sociodemographic characteristics and their interactions associated with living donation from female donors. We derived the predicted probabilities from adjusted logistic models using marginal means.

Results

Of 3523 living donor pairs, 2203 (63%) recipients were male, and 2012 (57%) donors were female. Male recipients were more likely to receive kidneys from female donors than male donors. Donor and recipient sex association was modified by donor-recipient relationship (P < 0.01), with sensitivity analysis suggesting that spousal donor-recipient pairs drive this interaction. Older recipients residing in regional or remote areas were more likely to receive kidneys from female donors compared with those from major cities (aged ≥60 years: 0.67 [0.63-0.71] vs. aged <60 years: 0.57 [0.53-0.60]).

Conclusions

Factors associated with female donation include recipient sex, with spousal donors contributing to the interaction between recipient gender and donor-recipient relationship. Recipient age and location of residence have interactive effects on the likelihood of living donor transplantation from female donors.

Real-world data on renal transplantations from a tertiary-care hospital in North India, in context of Indian regulatory act-transplantation of human organs and tissues act (THOTA): A retrospective analysis

INTRODUCTION

Renal transplantation is the treatment of choice for patients suffering from end stage renal disease (ESRD). Indian regulations defined under Transplantation of Human Organs and Tissues Act (THOTA), 2014 restricts organ donations to near-related living donors to curb any malpractices like 'paid donors' in living-donor kidney transplantation (LDKT). The aim of our study was to look at real-world data of donor-recipient pairs and to identify relationship of donors (with their respective patients) and the common (or uncommon) DNA profiling methods used for supporting "claimed relationship" in accordance with the regulations.

MATERIAL AND METHODS

The donors were categorized and grouped into near-related donor, donors other than near-related donors, swap donors and deceased donors. Claimed relationship was confirmed, commonly by HLA typing, using SSOP method. In few cases, which were uncommon (and infrequent), autosomal DNA analysis, mitochondrial DNA analysis and Y-STR DNA analysis were performed to support the claimed relationship. Data collected included age, gender, relationship, DNA profiling test method.

RESULTS

Among the 514 donor-recipient pairs evaluated, numbers of female donors out-numbered male donors. The decreasing order of relationships in near-related donor group were wife>mother>father>sister>son>brother>husband> daughter>grandmother. 11.9% of donors were in the category of donors other than near-related donors. In 97.86% cases, the claimed relationship was supported by HLA typing and in just 2.1% cases autosomal DNA analysis>mitochondrial DNA analysis> Y-STR DNA analysis, in this order, were performed to establish relationship.

CONCLUSION

This study brought out gender disparity with women out-numbering men as donors. Among recipients, access to renal transplant was largely restricted to men. As far as relationship of donors to recipients was concerned, mostly near-related family members, like wife, were donors and claimed relationship was almost always (99%) was corroborated by HLA typing.

Recommendations for living donor kidney transplantation

This Guide for Living Donor Kidney Transplantation (LDKT) has been prepared with the sponsorship of the Spanish Society of Nephrology (SEN), the Spanish Transplant Society (SET), and the Spanish National Transplant Organization (ONT). It updates evidence to offer the best chronic renal failure treatment when a potential living donor is available. The core aim of this Guide is to supply clinicians who evaluate living donors and transplant recipients with the best decision-making tools, to optimise their outcomes. Moreover, the role of living donors in the current KT context should recover the level of importance it had until recently. To this end the new forms of incompatible HLA and/or ABO donation, as well as the paired donation which is possible in several hospitals with experience in LDKT, offer additional ways to treat renal patients with an incompatible donor. Good results in terms of patient and graft survival have expanded the range of circumstances under which living renal donors are accepted. Older donors are now accepted, as are others with factors that affect the decision, such as a borderline clinical history or alterations, which when evaluated may lead to an additional number of transplantations. This Guide does not forget that LDKT may lead to risk for the donor. Pre-donation evaluation has to centre on the problems which may arise over the short or long-term, and these have to be described to the potential donor so that they are able take them into account. Experience over recent years has led to progress in risk analysis, to protect donors' health. This aspect always has to be taken into account by LDKT programmes when evaluating potential donors. Finally, this Guide has been designed to aid decision-making, with recommendations and suggestions when uncertainties arise in pre-donation studies. Its overarching aim is to ensure that informed consent is based on high quality studies and information supplied to donors and recipients, offering the strongest possible guarantees.

An Analysis by the European Committee on Organ Transplantation of the Council of Europe Outlining the International Landscape of Donors and Recipients Sex in Solid Organ Transplantation

Discrepancies in donation and transplantation by sex and gender have previously been reported. However, whether such differences are invariably the inevitable, unintended outcome of a legitimate process has yet to be determined. The European Committee on Organ Transplantation of the Council of Europe (CD-P-TO) is the committee that actively promotes the development of ethical, quality and safety standards in the field of transplantation in Europe. Whilst the ultimate objective is to shed light on the processes underlying potential gender inequities in transplantation, our initial goal was to represent the distribution by sex among organ donors and recipients in the CD-P-TO Member States and observer countries. Our survey confirms previous evidence that, in most countries, men represent the prevalent source of deceased donors (63.3% in 64 countries: 60.7% and 71.9% for donation after brain and circulatory death, respectively). In contrast, women represent the leading source of organs recovered from living kidney and liver donors (61.1% and 51.2% in 55 and 32 countries, respectively). Across countries, most recovered organs are transplanted into men (65% in 57 countries). These observations may be explained, at least in part, by the higher burden of certain diseases in men, childbearing related immune sensitization in women, and donor-recipient size mismatch. Future research should establish whether gender-related socially-constructed roles and socioeconomic status may play a detrimental role reducing the access of women to transplantation.

Kidneys for Sale: Empirical Evidence From Iran

The kidney market in Iran is the only legal market of this sort globally. Yet, it has not been empirically studied based on real data. For the first time, we obtained data on donors and recipients from the Kidney Foundation in Mashhad, April 2011 up to March 2018, and assessed which individualistic characteristics contribute to a kidney’s price. Our findings indicate that each year of education for both donors and recipients increases the kidney price. Moreover, old patients are willing to make a higher payment to young vendors. We have also provided some policy implications to improve the efficiency of kidney allocations.

Sex and Gender Differences in Kidney Transplantation

Sex and gender often are used interchangeably, but are two distinct entities, with sex being the biological attribute and gender including the social, psychological, and cultural aspects of one's identity. Kidney transplantation has been proven to be the best treatment for end-stage kidney disease, improving both quality of life and life-expectancy for most patients. However, gender disparities in access to and outcomes of kidney transplantation remain despite the plethora of evidence showing the advantages of kidney transplantation to our patients. Data have shown that women are less likely to be waitlisted for a kidney transplant and to receive a deceased donor or a living donor kidney. On the other hand, women are more likely than men to become living kidney donors. Although some state the latter is the result of the female gender to nurture and care for loved ones, others believe this observation is because women often are incompatible with their spouse or child because pregnancy is a strong sensitizing event, which stems from the biological rather than the social differences between the sexes. Influence of sex and gender is not limited to access to kidney transplantation, but rather exist in other areas of transplant medicine, such as the difference observed in transplant outcomes between the sexes, variability in immunosuppression metabolism, and even in more contemporary areas such as recent data showing sex-based differences in outcomes of kidney transplant recipients with coronavirus disease-2019, with males having an increased incidence of acute kidney injury and death.

The Moral Superiority of Bioengineered Wombs and Ectogenesis for Absolute Uterine Factor Infertility

This paper argues that uterine transplants are a potentially dangerous distraction from the development of alternative methods of providing reproductive options for women with absolute uterine factor infertility (AUFI). We consider two alternatives in particular: the bioengineering of wombs using stem cells (which would carry fewer risks than uterine transplants) and ectogenesis (which would not require surgical intervention for either the prospective mother with AUFI or a womb donor). Whether biologically or mechanically engineered, these womb replacements could provide a way for women to have children, including genetically related offspring for those who would value this possibility. Most importantly, this alternative would avoid the challenge of sourcing wombs for transplant, a practice that we argue would likely be exploitative and unethical. Continued research into bioengineering and ectogenesis will therefore remain morally important despite the recent development of uterine transplantation, even if the procedure reaches routine clinical application.

Motivators and Barriers to Living Donor Kidney Transplant as Perceived by Past and Potential Donors

Background:

For patients with end-stage kidney disease, living donor kidney transplant is the treatment of choice due to improved patient outcomes, longer graft survival, and reduced expenses compared with other forms of renal replacement therapy. However, organ shortage remains a challenge, and living donation rates have stagnated in recent years, particularly among men.

Objective:

To understand the motivators and barriers for past and potential living kidney transplant donors and inform policy and practice changes that support donors in the future.

Methods:

Past and potential living donors in British Columbia, Canada in the preceding 2 years were surveyed. Motivators and barriers were examined in 5 categories: family pressures and domestic responsibilities, finances, the recovery process, complications, and the transplant evaluation process. Participants ranked statements in each category on a Likert-type scale.

Results:

A total of 138 responses were collected. In both women and men, policies that address family and domestic responsibilities and finances were most strongly identified as motivators to donate. A large proportion of women and men reported that guaranteed job security (47% women and 38% of men), paid time off (51% of women and 42% of men), reimbursement of lost wages (49% of women and 38% of men), and protections to guarantee no impact on future insurability (62% of women and 52% of men) were significant motivators to donate. Timely and efficient medical evaluation was considered to be an important motivator for donation, with 52% of men and 43% of women reporting support for a “fast-track” option for evaluation to allow for a more rapid evaluation process. Median barrier and motivator scores were similar between women and men.

Conclusion:

Policies to decrease financial burden, ensure job security, improve childcare support, and offer a fast-track medical evaluation may motivate potential living kidney donors, irrespective of gender.

Disparities in living donation

PURPOSE OF REVIEW

Living organ donation provides improved access to transplantation, thereby shortening transplant wait times and allowing for more deceased organ transplants. However, disparity in access to living donation has resulted in decreased rates of living donor transplants for some populations of patients.

RECENT FINDINGS

Though there have been marked improvements in deceased donor equity, there are still challenges as it relates to gender, racial/ethnic, and socio-economic disparity. Improvements in living donation rates in Hispanic and Asian populations are tempered by challenges in African American rates of organ donation. Socio-economic disparity may drive gender disparities in organ donation resulting in disproportionate female living donors. Tailored approaches relating to language-specific interventions as well as directed educational efforts have helped mitigate disparity. Additionally, the use of apolipoprotein1 testing and modifications of glomerular filtration rate calculators may improve rates of African American donation. This review will evaluate recent data in living donor disparity as well as highlight successes in mitigating disparity.

SUMMARY

Though there are still challenges in living donor disparity, many efforts at tailoring education and access as well as modifying living donor evaluation and identifying systemic policy changes may result in improvements in living donation rates.

Join the Lone Kidney Club: incentivising live organ donation

Given the dramatic shortage of transplantable organs, demand cannot be met by established and envisioned organ procurement policies targeting postmortem donation. Live organ donation (LOD) is a medically attractive option, and ethically permissible if informed consent is given and donor beneficence balances recipient non-maleficence. Only a few legal and regulatory frameworks incentivise LOD, with the key exception of Israel's Organ Transplant Law, which has produced significant improvements in organ donation rates. Therefore, I propose an organ procurement system that incentivises LOD by allocating additional priority points to the living donor on any transplant waiting list. I outline benefits and challenges for potential recipients, donors and society at large, and suggest measures to ensure medical protection of marginalised patient groups.

The double gender bias in parental kidney donation among Muslim Arab patients

Previous studies showed that it is usually the mother who agrees to donate her kidney to a child with an end-stage renal disease, while the fathers tend much less to donate. The present study sought to explore decision-making regarding which parent would donate a kidney to their child. Interviews were conducted with twenty-five mothers and six fathers who donated a kidney to their child. Analysis of the narratives reveals unwillingness to donate a kidney to a sick daughter and five reasons why mothers are more willing to donate than fathers. Our study shows that parents' patterns of kidney donation to their children powerfully demonstrate gender relations in Arab society and that culturally related matters have a significant impact on human organ transplantation, hence on quality of life and the chances of survival of nephrological pediatric patients. We recommend that the nursing staff enlist the help of Muslim clerics to increase the willingness of fathers to donate a kidney, for sons as well as for daughters. We call for designing education campaigns aimed at raising awareness and encouraging changes in the attitudes of the families of pediatric ESRD patients as well as of physicians.

An intersectional gender analysis in kidney transplantation: women who donate a kidney

BACKGROUND

Living-donor transplantation is the best treatment option in patients with chronic kidney failure. Global data show that women are less likely to be kidney recipients than men but are more likely to become living kidney donors. We explored the experience of women who donate a kidney to relatives with biological and socio-cultural ties and to understand the similarities and differences in their experience.

METHODS

A qualitative hermeneutic phenomenological study with an intersectional analysis of gender. Ten women donors accepted in the transplant evaluation period participated, all of whom donated a kidney to a pre-dialysis relative. Two categories were included: women with biological kinship ties (mothers, sisters) and women who have a socio-cultural relationship (wives) with kidney recipient. The data were collected through semi-structured in-depth interviews and analysed using thematic analysis.

RESULTS

Women donate their kidneys in a convinced manner, without worrying about their health, with an optimistic and positive attitude, and without believing that they are acting heroically. Women with biological kinship ties see it as a 'naturalization thing'. In contrast, wives donate conditioned by gender roles, but also as a form of empowerment and as a personal benefit: they donate in order to avoid taking on carer role for their husband and as a way of protecting their children.

CONCLUSION

The study's findings expand the conception of kidney donation as solely altruistic and may help professionals to pay attention to the complexity and intersectionality of features present in women who are living kidney donors.

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

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.

Equally Interchangeable? How Sex and Gender Affect Transplantation

Organ transplantation as an option to overcome end-stage diseases is common in countries with advanced healthcare systems and is increasingly provided in emerging and developing countries. A review of the literature points to sex- and gender-based inequity in the field with differences reported at each step of the transplant process, including access to a transplantation waiting list, access to transplantation once waitlisted, as well as outcome after transplantation. In this review, we summarize the data regarding sex- and gender-based disparity in adult and pediatric kidney, liver, lung, heart, and hematopoietic stem cell transplantation and argue that there are not only biological but also psychological and socioeconomic issues that contribute to disparity in the outcome, as well as an inequitable access to transplantation for women and girls. Because the demand for organs has always exceeded the supply, the transplant community has long recognized the need to ensure equity and efficiency of the organ allocation system. In the spirit of equity and equality, the authors call for recognition of these inequities and the development of policies that have the potential to ensure that girls and women have equitable access to transplantation.

Gender Bias in Kidney Donation in India: Has It Changed Over the Past 2 Decades?

OBJECTIVE

To study the trend among Indian women living kidney donation over the past 18 years and see if a gender bias still exists as described in literature before.

METHODS

This is a retrospective, single-center, observational cohort study with data collected from the medical records department of all living donor kidney transplants between January 2001 to December 2018, which were categorized into 2 groups of 9 years each for comparison using categorical variables in form of number, percentage, χ² test, and Pearson correlation coefficient.

RESULTS

A total of 557 kidney transplants were analyzed, with women having 78.5% higher incidence of donation (P < .001). Among them, parents (72.20% mothers), spouses (87.20% wives), siblings (47.50% sisters), and children (44.44% daughters) were the major participants. Further analysis revealed wife donation reduced from 92.3% to 85.6% (P = .41) and mother donation reduced from 72.5% to 71.7% (P = .91), whereas sister donation increased from 28.5% to 51.5% (P = .14) and daughter donation increased from 0% to 44.4% during the 18-year period. Also, female to male donation decreased from 63.8% to 51.6% (P = .02) during the same period. Thus, the overall percentage of female donation is decreasing (73.9% to 61.4%, P = .01), and a significant negative correlation with time was observed in this study (correlation coefficient, r = -0.55, P = .017).

CONCLUSIONS

A lot has changed over the past 18 years, with more male kidney donors now coming forward. Larger prospective studies are required to understand the diverse reason for this sex discrepancy.

Impact of gender and gender disparities in patients with kidney disease

PURPOSE OF REVIEW

Despite evidence of gender-specific differences in epidemiology and outcomes in all stages of chronic kidney disease (CKD), most studies ignore the issue of gender. This review addresses this knowledge gap by evaluating data on gender disparity in this population.

RECENT FINDINGS

Population-based studies indicate a higher prevalence of CKD in women; however, there are fewer women on renal replacement therapy than men. Men may progress to end-stage kidney disease more rapidly. Gender differences in rates of CKD progression may be influenced by potential antifibrotic and antiapoptotic effects of estrogen or proinflammatory deleterious effects of testosterone. Women are referred later for kidney replacement therapy and receive fewer arteriovenous fistulas than men receive, irrespective of race. Women are also less likely to receive kidney transplants as compared with men but are more likely to donate a kidney.

SUMMARY

Recommendations for medical management of CKD patients are currently made in a gender-blind manner, despite the fact that women have differing underlying physiology. Addressing gender differences and disparities is an important and overlooked area in the care of patients with kidney disease.

Blood Transfusions in Laparoscopic Living Donor Nephrectomy: Single Center Experience from 500 Cases

INTRODUCTION

Laparoscopic surgery has been acknowledged to reduce the morbidity rate thus improving patient safety. During the LLDN, the most frequent complication is renal vessels injuries, which often requires a blood transfusion. Besides the need for a blood transfusion, major bleeding caused by renal vessels injuries requires open conversion and repair. Thus, this study would like to descript and analyze the need for blood transfusion in laparoscopic living donor nephrectomy surgery in our center.

METHODS

We performed a retrospective cohort study in the Department of Urology at Cipto Mangunkusumo National Hospital. The records of all kidney transplantation donor patients who underwent LLDN procedures carried out at our institution from November 2011 to October 2017 were reviewed. Data including donor age, preoperative hemoglobin level, postoperative hemoglobin level, intraoperative bleeding, number of artery(ies), number of vein(s), donor side, conversion to open surgery, surgery duration, and donor BMI were collected and analyzed. These data were further correlated with the transfusion rate.

RESULTS

There were 500 patients underwent laparoscopic living donor nephrectomy procedure at our institution. All of the patients had LLDN with a transperitoneal approach. The difference in blood transfusion rate proportion between male patients with 0.9% compared to 0.6% in female patients was not significant (p=0.782). There is no significant difference in blood transfusion rate proportion regarding renal side (p=0.494), number of artery (p=0.362), age (p=0.978), BMI (p=0.569), and preoperative hemoglobin (p=0.766). Median estimated blood loss in patients who received intraoperative blood transfusion was significantly much greater than in patients who did not receive a blood transfusion (p<0.001).

CONCLUSION

Based on this study, we suggest that in our institution, preoperative blood products are not necessarily needed. The surgeon's learning curve and technique play a significant role in preventing intraoperative complications and blood loss.

Sex Differences in Kidney Replacement Therapy Initiation and Maintenance

BACKGROUND AND OBJECTIVES

More men than women undergo kidney replacement therapy (KRT) despite a larger number of women being affected by CKD. The aim of this multinational European study was to explore whether there might be historic and geographic trends in sex-specific incidence and prevalence of various KRT modalities.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We assessed sex-specific differences in KRT incidence and prevalence using data from nine countries reporting to the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry for at least 40 years, during the period 1965-2015. Sex distribution data were compared with the European general population (Eurostat). Statistical methodology included basic descriptive statistics, incidence and prevalence calculations per million population (pmp), as well as their male-to-female ratios. Analyses were stratified by age group and diabetic status.

RESULTS

We analyzed data from 230,378 patients receiving KRT (38% women). For all KRT modalities, the incidence and prevalence rates were consistently higher in men than women. For example, the KRT incidence increased from 8 pmp in 1965-1974 to 98 pmp in 2005-2015 in women, whereas it rose from 12 to 173 pmp in men during the same period. Male-to-female ratios, calculated for incident and prevalent KRT patients, increased with age (range 1.2-2.4), showing consistency over decades and for individual countries, despite marked changes in primary kidney disease (diabetes more prevalent than glomerulonephritis in recent decades). The proportion of kidney transplants decreased less with age in incident and prevalent men compared with women on KRT. Stratified analysis of patients who were diabetic versus nondiabetic revealed that the male-to-female ratio was markedly higher for kidney transplantation in patients with diabetes.

CONCLUSIONS

Since the beginning of KRT programs reporting to the ERA-EDTA Registry since the 1960s, fewer women than men have received KRT. The relative difference between men and women initiating and undergoing KRT has remained consistent over the last five decades and in all studied countries.

Characteristics of kidney donors and recipients in Iranian kidney market: Evidence from Mashhad

The Iranian model of kidney transplantation is an example of a regulated living unrelated renal donation. In this paper, we collected and analyzed a unique dataset of 436 paired kidney donors and recipients, including their characteristics and the realized price of a kidney in Mashhad. As opposed to the global picture of kidney donation, we find that women are less likely to donate and more likely to receive a kidney. Moreover, the average price of a kidney amounts less than 2 years of work with the minimum level of wage.

A Retrospective Evaluation of 728 Kidney Donors Who Applied for Organ Donation

OBJECTIVE

The aim of this study was to determine the sociodemographic characteristics of people who applied to be kidney donors at an organ transplantation center.

MATERIAL AND METHODS

A total of 728 participants in the kidney donor program were included in the study between 2015 and 2018 at Istanbul Yeniyüzyıl University Gaziosmanpaşa Hospital. The sociodemographic data of the participants were retrospectively analyzed through computer records, and data were analyzed.

RESULTS

Two hundred thirty-nine men and 489 women were included into the study. Six hundred ten were live donors, and 118 were cadaveric donors. Of the donors included in the study, 24.9% were illiterate, 52.1% were primary school graduates, 17.3% were high school graduates, and 5.7% were university graduates. Of the living donors, 156 (25.5%) were spouses, 91 (14.9%) were mothers, 72 (11.9%) were siblings, 65 (10.5%) were fathers, 64 (10.7%) were children, 46 were (7.5%) were other relatives, and 116 (19.0%) were nonrelatives.

CONCLUSIONS

In recent years, the number of live kidney transplantations has increased. Therefore, it is necessary to protect their well-being by using evidence-based donor evaluation and treatment strategies to prevent and treat negative consequences of donations.

A care ethics approach to the Gender Kidney Donation Gap

Many studies have shown that women are more likely than men to be living kidney donors, and the discrepancy is particularly marked in heterosexual couples: wives are more likely than husbands to donate a kidney to their spouse. This 'Gender Kidney Donation Gap' can be understood in terms of Carol Gilligan's claims about gender differences in ethical decision-making style, making it appropriate to analyse responses to this imbalance using an ethic of care. This article centres the vast majority of living donors, those who donate in the context of a significant pre-existing relationship. A cost-neutral approach is unfair on donors who make society richer and healthier by helping a loved one. However, models of kidney sale fail to offer an acceptable alternative, either (a) compelling donors to sell into a pool where they do not know the recipient or (b) allowing affluent individuals unfair access to kidneys. Drawing on surrogacy law in England and Wales, a model of compensation is proposed that includes a range of non-financial benefits. This option celebrates donation and expresses gratitude to all donors while avoiding the pitfalls of the marketplace, with an emphasis on fair treatment of donors. Nevertheless, if more generous treatment led to a 10% increase in directed donation, then it would be equivalent to doubling 'altruistic' stranger donations. As long as the Gender Kidney Donation Gap persists, the best response is to minimise the discomfort and disruption caused to donors by their profound act of kindness.

Spirituality and religiosity of non-directed (altruistic) living kidney donors

AIMS AND OBJECTIVES

To describe the spirituality and religiosity of 30 non-directed (altruistic) living kidney donors in the USA and explore how they may have affected their motivations to donate and donation process experiences.

BACKGROUND

The rise in non-directed donors and their ability to initiate kidney chains offer a novel approach to help alleviate the overextended kidney transplant wait list in the USA. However, little is known about the non-directed donors' motivations, characteristics and experiences.

DESIGN

We conducted a qualitative-dominant study and used a grounded theory approach to analyse data.

METHODS

Thirty participants completed in-depth interviews between April 2013-April 2015. Three analysts independently read and coded interview transcripts. Grounded theory techniques were used to develop descriptive categories and identify topics related to the non-directed donors donation experience.

RESULTS

Sixteen of the 30 non-directed donorss discussed the topic of spirituality and religiosity when describing their donation experiences, regardless of whether they were actively practising a religion at the time of donation. Specifically, three themes were identified within spirituality and religiosity: motivation to donate, support in the process, and justification of their donation decisions postdonation.

CONCLUSIONS

Findings from this study are the first to describe how spirituality and religiosity influenced the experiences of U.S. non-directed donorss and may help improve non-directed donors educational resources for future spiritual or religious non-directed donors, and the overall non-directed donors donation experience in efforts to increase the living donor pool.

RELEVANCE TO CLINICAL PRACTICE

Spirituality and religiosity are often overlooked yet potentially influential factors in Western medicine, as demonstrated through the experiences of Jehovah's Witnesses and their religious restrictions while undergoing surgery and the beliefs of Christian Scientists against taking medications and receiving medical procedures. Understanding needs of non-directed donors specifically with spirituality and religiosity can better position kidney transplant centres and teams to improve predonation screening of non-directed donor candidates and provide support services during the donation process.

The Change in Living Kidney Donation in Women and Men in the United States (2005-2015): A Population-Based Analysis

The factors underlying the decline in living kidney donation in the United States since 2005 must be understood to inform strategies to ensure access to this option for future patients. Population-based estimates provide a better assessment of donation activity than do trends in the number of living donor transplants. Using data from the Scientific Registry of Transplant Recipients and the United States Census, we determined longitudinal changes in living kidney donation between 2005 and 2015, focusing on the effect of sex and income. We used multilevel Poisson models to adjust for differences in age, race, the incidence of ESRD, and geographic factors (including population density, urbanization, and daily commuting). During the study period, the unadjusted rate of donation was 30.1 and 19.3 per million population in women and men, respectively, and the adjusted incidence of donation was 44% higher in women (incidence rate ratio [IRR], 1.44; 95% confidence interval [95% CI], 1.39 to 1.49). The incidence of donation was stable in women (IRR, 0.95; 95% CI, 0.84 to 1.07) but declined in men (IRR, 0.75; 95% CI, 0.68 to 0.83). Income was associated with longitudinal changes in donation in both sexes, yet donation was stable in the highest two population income quartiles in women but only in the highest income quartile in men. In both sexes, living related donations declined, irrespective of income. In conclusion, living donation declined in men but remained stable in women between 2005 and 2015, and income appeared to have a greater effect on living donation in men.

Sex and gender disparities in the epidemiology and outcomes of chronic kidney disease

Improved understanding of sex and gender-specific differences in the aetiology, mechanisms and epidemiology of chronic kidney disease (CKD) could help nephrologists better address the needs of their patients. Population-based studies indicate that CKD epidemiology differs by sex, affecting more women than men, especially with regard to stage G3 CKD. The effects of longer life expectancy on the natural decline of glomerular filtration rate (GFR) with age, as well as potential overdiagnosis of CKD through the inappropriate use of GFR equations, might be in part responsible for the greater prevalence of CKD in women. Somewhat paradoxically, there seems to be a preponderance of men among patients starting renal replacement therapy (RRT); the protective effects of oestrogens in women and/or the damaging effects of testosterone, together with unhealthier lifestyles, might cause kidney function to decline faster in men than in women. Additionally, elderly women seem to be more inclined to choose conservative care instead of RRT. Dissimilarities between the sexes are also apparent in the outcomes of CKD. In patients with predialysis CKD, mortality is higher in men than women; however, this difference disappears for patients on RRT. Although access to living donor kidneys among men and women seems equal, women have reduced access to deceased donor transplantation. Lastly, health-related quality of life while on RRT is poorer in women than men, and women report a higher burden of symptoms. These findings provide insights into differences in the underlying pathophysiology of disease as well as societal factors that can be addressed to reduce disparities in access to care and outcomes for patients with CKD.

Sex and gender disparities in the epidemiology and outcomes of chronic kidney disease

Improved understanding of sex and gender-specific differences in the aetiology, mechanisms and epidemiology of chronic kidney disease (CKD) could help nephrologists better address the needs of their patients. Population-based studies indicate that CKD epidemiology differs by sex, affecting more women than men, especially with regard to stage G3 CKD. The effects of longer life expectancy on the natural decline of glomerular filtration rate (GFR) with age, as well as potential overdiagnosis of CKD through the inappropriate use of GFR equations, might be in part responsible for the greater prevalence of CKD in women. Somewhat paradoxically, there seems to be a preponderance of men among patients starting renal replacement therapy (RRT); the protective effects of oestrogens in women and/or the damaging effects of testosterone, together with unhealthier lifestyles, might cause kidney function to decline faster in men than in women. Additionally, elderly women seem to be more inclined to choose conservative care instead of RRT. Dissimilarities between the sexes are also apparent in the outcomes of CKD. In patients with predialysis CKD, mortality is higher in men than women; however, this difference disappears for patients on RRT. Although access to living donor kidneys among men and women seems equal, women have reduced access to deceased donor transplantation. Lastly, health-related quality of life while on RRT is poorer in women than men, and women report a higher burden of symptoms. These findings provide insights into differences in the underlying pathophysiology of disease as well as societal factors that can be addressed to reduce disparities in access to care and outcomes for patients with CKD.

Blood Products and the Commodification Debate: The Blurry Concept of Altruism and the 'Implicit Price' of Readily Available Body Parts

There is a widespread consensus that a commodification of body parts is to be prevented. Numerous policy papers by international organizations extend this view to the blood supply and recommend a system of uncompensated volunteers in this area--often, however, without making the arguments for this view explicit. This situation seems to indicate that a relevant source of justified worry or unease about the blood supply system has to do with the issue of commodification. As a result, the current health minister of Ontario is proposing a ban on compensation even for blood plasma--despite the fact that Canada can only generate 30 % of the plasma needed for fractionation into important plasma protein products and has to purchase the rest abroad. In the following, I am going to suggest a number of alternative perspectives on the debate in order to facilitate a less dogmatic and more differentiated debate about the matter. Especially in light of the often over-simplified notions of altruism and commodification, I conclude that the debate has not conclusively established that it would be morally objectionable to provide blood plasma donors with monetary compensation or with other forms of explicit social recognition as an incentive. This is especially true of donations for fractionation into medicinal products by profit-oriented pharmaceutical companies.

Living Kidney Donor Decision Making: State of the Science and Directions for Future Research

Background

The Federal government and transplantation organizations have called for further study of living donation at a time when 3 new living donor protocols are being introduced throughout the United States that promise to significantly increase the donor pool and change the face of living donation. Donation to a once incompatible and sometimes unknown recipient may now occur through the use of plasmapheresis therapy or paired and nondirected living donor protocols.

Objective

To describe the state of the science on living kidney donor decision making, and to provide recommendations for future research to guide donor education and care.

Data Sources

Automated literature search using PubMed and CINAHL scientific literature databases.

Study Data Extraction

Research papers on living donor decision making from 1997 to 2003. Studies available only as abstracts were excluded. Data Synthesis Studies of living kidney donor decision making and outcomes have been limited in scope, with small sample sizes and inconsistent reports of racial and ethnic characteristics of the sample. The retrospective nature of the majority of living donor studies is a significant limitation.

Conclusions

Future prospective studies that are diverse by sex, race, and ethnicity will contribute to our knowledge of factors that influence the decision to be a living kidney donor.

Gender Mainstreaming and Transplant Surgery

BACKGROUND

Gender differences in medicine are gaining in importance. In transplant surgery, not only the patient's gender but also that of the donor play an important role in the outcome of transplantation due to sociocultural and genetic factors.

METHODS

This review article gives an overview of the latest investigations into gender-related influences in the field of visceral transplantation. For this purpose, a systematic review of the literature was performed.

RESULTS

In general, women are less often evaluated for and subjected to transplantation worldwide. Significantly poorer outcome can be observed in women with liver transplantation following hepatitis C cirrhosis. Furthermore, female renal grafts are less favorable in terms of outcome and survival. Gender disparities affect transplant medicine due to subtle gender-specific immunological factors. Sociocultural factors also lead to differences in the clinical treatment of men and women, which may influence overall survival.

CONCLUSION

For a better understanding of gender-specific differences in transplant medicine and a possible improvement in outcome, further research in this field is necessary.

Impact of Donor Source on the Outcome of Live Donor Kidney Transplantation: A Single Center Experience

BACKGROUND

Renal transplantation is the ideal method for management of end-stage renal disease. The use of living donors for renal transplantation was critical for early development in the field and preceded the use of cadaveric donors. Most donors are related genetically to the recipients, like a parent, a child, or a sibling of the recipient, but there are an increasing percentage of cases where donors are genetically unrelated like spouses, friends, or altruistic individuals. Donor shortages constitute the major barrier for kidney transplantation, and much effort has been made to increase the supply of living donors. The impact of donor source on the outcome of renal transplantation is not adequately studied in our country.

OBJECTIVES

The aim of the study was to evaluate the impact of donor source on the outcome of live donor kidney transplantation.

PATIENTS AND METHODS

From March 1976 to December 2013, the number of patients that underwent living renal transplantation sharing at least one HLA haplotype with their donors was 2,485. We divided these patients into two groups: (1) 2,075 kidney transplant recipients (1,554 or 74.9% male and 521 or 25.1% female) for whom the donors were living related, (2) 410 kidney transplant recipients (297 or 72.4% male and 113 or 27.6% female) for whom the donors were living unrelated. All patients received immunosuppressive therapy, consisting of a calcineurin inhibitor, mycophenolate mofetil, or azathioprine and prednisolone. We compared acute rejection and complication rates, as well as long-term graft and patient survival of both groups. Demographic characteristics were compared using the chi-square test. Graft survival and patient survival were calculated using the Kaplan-Meier method.

RESULTS

The percentages of patients with acute vascular rejection were significantly higher in the unrelated group, while percentages of patients with no rejection were significantly higher in the related group, but there were no significant differences regarding patient and graft survivals between both groups.

CONCLUSIONS

Kidney transplant recipients who received their grafts either from live related donors or live unrelated donors had comparable patient and graft survival outcomes.

Maintenance Dialysis throughout the World in Years 1990 and 2010

Rapidly rising global rates of chronic diseases portend a consequent rise in ESRD. Despite this, kidney disease is not included in the list of noncommunicable diseases (NCDs) targeted by the United Nations for 25% reduction by year 2025. In an effort to accurately report the trajectory and pattern of global growth of maintenance dialysis, we present the change in prevalence and incidence from 1990 to 2010. Data were extracted from the Global Burden of Disease 2010 epidemiologic database. The results are on the basis of an analysis of data from worldwide national and regional renal disease registries and detailed systematic literature review for years 1980-2010. Incidence and prevalence estimates of provision of maintenance dialysis from this database were updated using a negative binomial Bayesian meta-regression tool for 187 countries. Results indicate substantial growth in utilization of maintenance dialysis in almost all world regions. Changes in population structure, changes in aging, and the worldwide increase in diabetes mellitus and hypertension explain a significant portion, but not all, of the increase because increased dialysis provision also accounts for a portion of the rise. These findings argue for the importance of inclusion of kidney disease among NCD targets for reducing premature death throughout the world.

From potential donor to actual donation: does socioeconomic position affect living kidney donation? A systematic review of the evidence

Evidence from Europe, Australia and the United States demonstrates that socioeconomically deprived individuals with advanced chronic kidney disease are less likely to receive a living kidney transplant compared with less deprived individuals. This systematic review focuses on how socioeconomic position (SEP) may influence hypothetical and actual living kidney donors and where appropriate, summarizes the quantitative evidence.In the general population, a higher SEP appears to be associated with an increased 'hypothetical' willingness to be a living kidney donor but with marked heterogeneity in the absolute differences (I = 95.9%, P < 0.001). In a commercial setting, lower SEP motivates people to donate. Outside of this setting, there is no evidence of discordance in the SEP of donors and recipients that would suggest undisclosed financial exchange. There is evidence for a complex interaction between SEP and other variables, such as ethnicity, sex, and the national economic climate. Some evidence suggests that measures to remove financial disincentives to donation are associated with an increase in living donation rates. Future research needs to study how SEP impacts the potential donor population from willingness to donate, progression through donor assessment to actual donor nephrectomy.

Histocompatibility testing for organ transplantation purposes in Albania: a single center experience

BACKGROUND

Histocompatibility testing (HT) which includes donor-recipient human leukocyte antigen (HLA) matching, cross-match testing (XMT) and anti-HLA antibody searching are crucial examinations in solid organ transplantation aiming to avoid the hyperacute graft rejection and also to predict the immunological outcome of the graft.

AIMS

The aim of this study was to analyse the tissue typing data collected at the Laboratory of Immunology and Histocompatibility of the University Hospital Center of Tirana, Albania, in order to define those actions that should be taken for improvements in the situation of kidney transplantation in Albania.

STUDY DESIGN

Descriptive study.

METHODS

The donor/recipient cross-match testing was performed through a standard complement-dependent cytotoxicity (CDC) assay using separated donor T and B cells that were tested in parallel with the recipient serum sample. All recipient sera were screened for anti-Class I and anti-Class II HLA antibodies using a bead based Luminex anti-HLA antibody screening test. In the case of detected positivity, an allele-specific anti-HLA antibody determination was conducted with the respective Luminex anti-Class I and Class II HLA antibody determination kits.

RESULTS

A total of 174 recipients and 202 donors were typed for the purpose of living donor kidney transplantation at our laboratory between January 2006 and December 2012. The mean age and female gender proportion of patients were 34.9 years and 34.5%, respectively, and 48.0 years and 65.3% for the donors, respectively. Here, 25.9% of the patients reported a positive complement-dependent cytotoxicity cross-match test and/or a positive anti-HLA antibody testing result. Eighteen patients that were negative for the complement-dependent cytotoxicity cross-match test were positive for anti-HLA antibodies.

CONCLUSION

The predominant causes of end-stage renal disease (ESRD) in our patient population are chronic pyelonephritis and glomerulonephritis. The female gender is significantly more frequent among donors, which emphasises the need for more gender equity as far as the altruistic willingness for organ donation is concerned. The significant number of patients with Luminex anti-HLA antibody positivity combined with complement-dependent cytotoxicity cross-match negative results underlines the necessity of using additional methods like cell-based flow cytometry or bead-based Luminex anti-HLA antibody assays for the detection of anti-donor-specific antibodies. We also suggest that the number of kidney transplantations in Albania needs to be increased significantly by expanding it with paired exchange living donation and also by implementing an efficient deceased donor kidney transplantation program.