The nondirected live-kidney donor: ethical considerations and practice guidelines: A National Conference Report

Non-Maleficence toward Young Kidney Donors: A Call for Stronger Ethical Standards and Associated Factors in Multidisciplinary Nephrology Teams

BACKGROUND

The rising frequency of live kidney donations is accompanied by growing ethical concerns as to donor autonomy, the comprehensiveness of disclosure, and donors' understanding of long-term consequences.

AIM

To explore donors' satisfaction with the ethical competence of multi-professional nephrology teams regarding disclosure of donation consequences to live kidney donors.

METHODS

A cross-sectional study was performed among Israeli live kidney donors who had donated a kidney in two hospitals that belonged to the Ministry of Health's Transplantation Center one year after the donation, from December 2018 to December 2020. Data collection was conducted online and through face-to-face interviews with the donors in their native language (Hebrew or Arabic).

RESULTS

Overall, 91 live kidney donors aged 18-49 years were enrolled. Of those, 65.9% were males, and 54.9% were academic donors. Among the live kidney donors, 59.3% reported that the motivation behind the donation was a first-degree family member vs. 35.2% altruistic and 5.5% commercial. Only 13.2% reported that the provided disclosure adequately explained the possible consequences of living with a single kidney. Approximately 20% of the participants reported that the disclosure included information regarding their risk of developing ESRD, hypertension, and proteinuria. The donors reported a low mean of the index score that indicates a low follow-up by the physician after the donation (mean = 1.16, SD = 0.37). The mean GFR level was significantly lower in the post-donation period one year following a kidney donation (117.8 mL/min/1.73 m2) compared with the pre-donation period (84.0 mL/min/1.73 m2), p < 0.001.

CONCLUSION

Our findings display that donors' satisfaction with the ethical competence of multi-professional nephrology teams regarding the disclosure of donation consequences to live kidney donors is low. This study indicates that donors are at an increased risk of worsening kidney functions (creatinine and GFR), and BMI. Our findings underscore the imperative to advise donors that their condition may worsen over time and can result in complications; thus, they should be monitored during short and long-term follow-up periods. This study was not registered.

Semidirected living donors in Israel: Sociodemographic profile, religiosity, and social tolerance

Living kidney donations in Israel come from 2 sources: family members and individuals who volunteer to donate their kidney to patients with whom they do not have personal acquaintance. We refer to the first group as directed living donors (DLDs) and the second as semidirected living donors (SDLDs). The incidence of SDLD in Israel is ∼60%, the highest in the world. We introduce results of a survey among 749 living donors (349 SDLDs and 400 DLDs). Our data illustrate the sociodemographic profile of the 2 groups and their answers to a series of questions regarding spirituality and social tolerance. We find SDLDs to be sectorial: they are mainly married middle-class religious men who reside in small communities. However, we found no significant difference between SDLDs and DLDs in their social tolerance. Both groups ranked high and expressed tolerance toward different social groups. Semidirected living donation enables donors to express general preferences as to the sociodemographic features of their respected recipients. This stirs a heated debate on the ethics of semidirected living donation. Our study discloses a comprehensive picture of the profile and attitudes of SDLDs in Israel, which adds valuable data to the ongoing debate on the legitimacy of semidirected living donation.

Exploring Staff Attitudes Towards Unspecified Kidney Donors in the United Kingdom: Results From the BOUnD Study

Unspecified kidney donation (UKD) has made substantial contributions to the UK living donor programme. Nevertheless, some transplant professionals are uncomfortable with these individuals undergoing surgery. This study aimed to qualitatively explore the attitudes of UK healthcare professionals towards UKD. An opportunistic sample was recruited through the Barriers and Outcomes in Unspecified Donation (BOUnD) study covering six UK transplant centres: three high volume and three low volume centres. Interview transcripts were analysed using inductive thematic analysis. The study provided comprehensive coverage of the UK transplant community, involving 59 transplant professionals. We identified five themes: staff's conception of the ethics of UKD; presence of the known recipient in the donor-recipient dyad; need for better management of patient expectations; managing visceral reactions about the "typical" unspecified kidney donor; complex attitudes toward a promising new practice. This is the first in-depth qualitative study of attitudes of transplant professionals towards UKD. The data uncovered findings with strong clinical implications for the UKD programme, including the need for a uniform approach towards younger candidates that is adhered to by all transplant centres, the need to equally extend the rigorous assessment to both specified and unspecified donors, and a new approach to managing donor expectations.

The psychological examination and evaluation of unrelated kidney donors in Israel: a suggested model

Altruistic organ donors represent a special population when compared to related living donors, requiring appropriate protection and attention regarding informed consent and psychological aspects related to the donation. Following the introduction of the Israeli Transplant Law of 2008, a retrospective study of altruistic donor files revealed that important psycho-diagnostic aspects were not emphasized in the existing guidelines. Thus, a new tool was formulated which incorporated those elements, including assessment of emotional maturity, ego strength, degree of interest in others, reality testing, degree of pressure to donate, anxiety, dysphoric and depressive factors and the ability to function under stress. The study examined 598 cases reviewed by the Central Evaluation Board over the period May 2008 - June 2016. Overall, 23.4% candidates were disqualified of whom 41% were declined on grounds related to mental health. Most of the donors were rejected based on 3-5 elements. Of these, a deficient assessment of reality in ambiguous situations, lack of emotional maturity, and lacking or partial ability to function effectively under stress, were most commonly cited as reasons for rejection. This model allowed the detection of important conditions previously not incorporated into existing guidelines and may serve as a model for other transplantation programs worldwide.

Anonymity in Kidney Paired Donation: A Systematic Review of Reasons

The objective of this study was to investigate reasons for or against anonymity that are pertinent to kidney paired donations (KPD). We conducted a systematic review of reasons using PubMed and Google Scholar until May 2022 and through snowballing. Inclusion criteria were publications that: 1) discussed organ donation anonymity; 2) was peer-reviewed; 3) presented at least one reason on anonymity. Exclusion criteria: 1) not published in a scientific journal; 2) grey literature and dissertations. Four researchers independently reviewed and selected papers based on the criteria, extracted text passages and coded them into narrow and broad reason types, selected reasons that were valid for kidney paired donations. 50 articles were included, 62 narrow reasons (n = 24 for; n = 38 against) and 13 broad reasons were coded. Broad reasons were: protection against harm, general benefits, gratitude, curiosity, unrealistic to implement, fundamental rights, respect people's wishes, professional neutrality, timing is important, information disclosure, altruism, reciprocity and donation pool. We did not find reasons that justify legal prohibition of donor-recipient interactions for KPD, if they consented to meet. Professional counselling, follow-up and careful evaluations to prevent potential harm.

The use of nondirected donor organs in living donor liver transplantation: Perspectives and guidance

Interest in anonymous nondirected living organ donation is increasing in the United States and a small number of transplantation centers are accumulating an experience regarding nondirected donation in living donor liver transplantation. Herein, we review current transplant policy, discuss emerging data, draw parallels from nondirected kidney donation, and examine relevant considerations in nondirected living liver donation. We aim to provide a consensus guidance to ensure safe evaluation and selection of nondirected living liver donors and a schema for just allocation of nondirected grafts.

Positive and negative aspects of mental health after unspecified living kidney donation: A cohort study

Objectives

Unspecified donors give a kidney to a stranger with end‐stage kidney failure. There has been little research on the long‐term impact of unspecified donation on mental health outcomes. The aim of this study was to assess the positive and negative aspects of mental health among unspecified donors.

Design

We invited all unspecified donors who donated a kidney between 2000 and 2016 at our centre to participate in an interview and to complete validated questionnaires.

Methods

We measured positive mental health using the Dutch Mental Health Continuum‐Short Form (MHC‐SF), psychological complaints using the Symptoms Checklist‐90 (SCL‐90) and psychiatric diagnoses using the Mini‐International Neuropsychiatric Interview (M.I.N.I.) Screen for all donors and the M.I.N.I. Plus on indication.

Results

Of the 134 eligible donors, 114 participated (54% female; median age 66 years), a median of 6 years post‐donation. Scores on emotional and social well‐being subscales of the MHC‐SF were significantly higher than in the general population. Psychological symptoms were comparable to the general population. Thirty‐two per cent of donors had a current or lifetime psychiatric diagnosis. Psychological symptoms did not significantly change between the pre‐donation screening and the post‐donation study.

Conclusions

We concluded that, with the appropriate screening, unspecified donation is a safe procedure from a psychological perspective.

Have we reached the limits in altruistic kidney donation?

Altruistic donation (unspecified donation) is an important aspect of living donor kidney transplantation. Although donation to a stranger is lawful and supported in many countries, it remains uncommon and not actively promoted. Herein, we ask the question if we have reached the limit in altruistic donation. In doing so, we examine important ethical questions that define the limits of unspecified donation, such as the appropriate balance between autonomous decision-making and paternalistic protection of the donor, the extent of outcome uncertainty and risk-benefit analyses that donors should be allowed to accept. We also consider the scrutiny and acceptance of donor motives, the potential for commercialization, donation to particular categories of recipients (including those encountered through social media) and the ethical boundaries of active promotion of unspecified kidney donation. We conclude that there is scope to increase the number of living donation kidney transplants further by optimizing existing practices to support and promote unspecified donation. A number of strategies including optimization of the assessment process, innovative approaches to reach potential donors together with reimbursement of expenses and a more specific recognition of unspecified donation are likely to lead to a meaningful increase in this type of donation.

The experiences of parents and caregiver(s) whose child received an organ from a living anonymous liver donor

BACKGROUND

Anonymous living donor transplantation is a potential strategy to address the shortage of available organs for transplant. A living anonymous donor (LAD) is a donor with no biological connection and whose identity is unknown to the recipient. This study captured the lived experiences of pediatric liver transplant recipient families whose child received an organ from a LAD.

METHODS

Qualitative data collection and analysis were guided by a theoretical framework of phenomenology. Data analysis highlighted themes through an inductive process of reviewing transcript paragraphs to code for significant statements that represented key concepts and captured depth of experience.

RESULTS

A total of nine interviews were conducted with 10 participants. Data analysis yielded themes of emotional turbulence through their transplant journey. Pre-transplant experiences were characterized by feelings of helplessness and desperation. Receiving a LAD transplant prompted shock, relief, and acceptance of the donation. Post-transplant experiences were characterized by altered life-perspectives and varied levels of connectedness to the donor, marked by gratitude and concern for donor well-being.

CONCLUSION

Anonymous donation in liver transplantation is perceived by recipient families as a remarkable gift and a viable donor option. Our preliminary findings can be used to inform strategy development regarding future delivery of care.

KPDGUI: An interactive application for optimization and management of a virtual kidney paired donation program

BACKGROUND AND OBJECTIVES

The aim in kidney paired donation (KPD) is typically to maximize the number of transplants achieved through the exchange of donors in a pool comprising incompatible donor-candidate pairs and non-directed (or altruistic) donors. With many possible options in a KPD pool at any given time, the most appropriate set of exchanges cannot be determined by simple inspection. In practice, computer algorithms are used to determine the optimal set of exchanges to pursue. Here, we present our software application, KPDGUI (Kidney Paired Donation Graphical User Interface), for management and optimization of KPD programs.

METHODS

While proprietary software platforms for managing KPD programs exist to provide solutions to the standard KPD problem, our application implements newly investigated optimization criteria that account for uncertainty regarding the viability of selected transplants and arrange for fallback options in cases where potential exchanges cannot proceed, with intuitive resources for visualizing alternative optimization solutions.

RESULTS

We illustrate the advantage of accounting for uncertainty and arranging for fallback options in KPD using our application through a case study involving real data from a paired donation program, comparing solutions produced under different optimization criteria and algorithmic priorities.

CONCLUSIONS

KPDGUI is a flexible and powerful tool for offering decision support to clinicians and researchers on possible KPD transplant options to pursue under different user-specified optimization schemes.

Long-term psychosocial outcomes after nondirected donation: A single-center experience

Short-term studies have demonstrated that nondirected donors (NDDs) have psychosocial outcomes that are similar to donors who donate directly, but long-term studies have not been done. NDDs at our center were surveyed regarding motivation; support during donation; stress related to donation; regret; financial resources used for donation; preferences about communication with the recipient; and cost reimbursement. Of 100 NDDs who donated at our center in the last 20 years, 95 remain in contact with us, and 77 responded to our survey (mean ± standard deviation [SD] 6.7 ± 4 years postdonation). The most common motivation for donation was the desire to help another (99%). Many NDDs received support from family, friends, and employers. NDDs voiced stress about the possibility of recipient kidney rejection, physical consequences to themselves, and financial burden. Only one donor expressed regret. Almost half wanted some recipient information at donation; 61% preferred routine recipient status updates; 56% believed meeting the recipient should occur at any mutually agreeable time; and 55% endorsed reimbursement for expenses. Stressors for NDDs are analogous to those of directed donors; NDDs prefer having some information about the recipient and prefer to be given a choice regarding the timing for communication with the recipient. NDDs supported donation being financially neutral.

Valuing Sets of Potential Transplants in a Kidney Paired Donation Network

In kidney paired donation (KPD), incompatible donor-candidate pairs and non-directed (also known as altruistic) donors are pooled together with the aim of maximizing the total utility of transplants realized via donor exchanges. We consider a setting in which disjoint sets of potential transplants are selected at regular intervals, with fallback options available within each proposed set in the case of individual donor, candidate or match failure. We develop methods for calculating the expected utility for such sets under a realistic probability model for the KPD. Exact expected utility calculations for these sets are compared to estimates based on Monte Carlo samples of the underlying network. Models and methods are extended to include transplant candidates who join KPD with more than one incompatible donor. Microsimulations demonstrate the superiority of accounting for failure probability and fallback options, as well as candidates joining with additional donors, in terms of realized transplants and waiting time for candidates.

Swaps and Chains and Vouchers, Oh My!: Evaluating How Saving More Lives Impacts the Equitable Allocation of Live Donor Kidneys

Live kidney donation involves a delicate balance between saving the most lives possible and maintaining a transplant system that is fair to the many thousands of patients on the transplant waiting list. Federal law and regulations require that kidney allocation be equitable, but the pressure to save patients subject to ever-lengthening waiting times for a transplant has been swinging the balance toward optimizing utility at the expense of justice. This article traces the progression of innovations created to make optimum use of a patient's own live donors. It starts with the simplest - direct donation by family members - and ends with voucher donations, a very recent and unique innovation because the donor can donate 20 or more years before the intended recipient is expected to need a kidney. In return for the donation, the intended recipient receives a voucher that can be redeemed for a live kidney when it is needed. Other innovations that are discussed include kidney exchanges and list paired donation, which are used to facilitate donor swaps when donor/recipient pairs have incompatible blood types. The discussion of each new innovation shows how the equity issues build on each other and how, with each new innovation, it becomes progressively harder to find an acceptable balance between utility and justice. The article culminates with an analysis of two recent allocation methods that have the potential to save many additional lives, but also affirmatively harm some patients on the deceased donor waiting list by increasing their waiting time for a life-saving kidney. The article concludes that saving additional lives does not justify harming patients on the waiting list unless that harm can be minimized. It also proposes solutions to minimize the harm so these new innovations can equitably perform their intended function of stimulating additional transplants and extending the lives of many transplant patients.

Donor and Recipient Perspectives on Anonymity in Kidney Donation From Live Donors: A Multicenter Survey Study

BACKGROUND

Maintaining anonymity is a requirement in the Netherlands and Sweden for kidney donation from live donors in the context of nondirected (or unspecified) and paired exchange (or specified indirect) donation. Despite this policy, some donors and recipients express the desire to know one another. Little empirical evidence informs the debate on anonymity. This study explored the experiences, preferences, and attitudes of donors and recipients toward anonymity.

STUDY DESIGN

Retrospective observational multicenter study using both qualitative and quantitative methods.

SETTING & PARTICIPANTS

414 participants from Dutch and Swedish transplantation centers who received or donated a kidney anonymously (nondirected or paired exchange) completed a questionnaire about anonymity. Participation was a median of 31 months after surgery.

FACTORS

Country of residence, donor/recipient status, transplant type, time since surgery.

OUTCOMES

Experiences, preferences, and attitudes toward anonymity.

RESULTS

Most participants were satisfied with their experience of anonymity before and after surgery. A minority would have liked to have met the other party before (donors, 7%; recipients, 15%) or after (donors, 22%; recipients, 31%) surgery. Significantly more recipients than donors wanted to meet the other party. Most study participants were open to meeting the other party if the desire was mutual (donors, 58%; recipients, 60%). Donors agree significantly more with the principle of anonymity before and after surgery than recipients. Donors and recipients thought that if both parties agreed, it should be permissible to meet before or after surgery. There were few associations between country or time since surgery and experiences or attitudes. The pros and cons of anonymity reported by participants were clustered into relational and emotional, ethical, and practical and logistical domains.

LIMITATIONS

The relatively low response rate of recipients may have reduced generalizability. Recall bias was possible given the time lag between transplantation and data collection.

CONCLUSIONS

This exploratory study illustrated that although donors and recipients were usually satisfied with anonymity, the majority viewed a strict policy on anonymity as unnecessary. These results may inform policy and education on anonymity.

The ELPAT living organ donor Psychosocial Assessment Tool (EPAT): from 'what' to 'how' of psychosocial screening - a pilot study

Thorough psychosocial screening of donor candidates is required in order to minimize potential negative consequences and to strive for optimal safety within living donation programmes. We aimed to develop an evidence-based tool to standardize the psychosocial screening process. Key concepts of psychosocial screening were used to structure our tool: motivation and decision-making, personal resources, psychopathology, social resources, ethical and legal factors and information and risk processing. We (i) discussed how each item per concept could be measured, (ii) reviewed and rated available validated tools, (iii) where necessary developed new items, (iv) assessed content validity and (v) pilot-tested the new items. The resulting ELPAT living organ donor Psychosocial Assessment Tool (EPAT) consists of a selection of validated questionnaires (28 items in total), a semi-structured interview (43 questions) and a Red Flag Checklist. We outline optimal procedures and conditions for implementing this tool. The EPAT and user manual are available from the authors. Use of this tool will standardize the psychosocial screening procedure ensuring that no psychosocial issues are overlooked and ensure that comparable selection criteria are used and facilitate generation of comparable psychosocial data on living donor candidates.

Safe and ethical living kidney donation in Qatar: A national health system's approach

The increasing incidence of end-stage kidney disease in Qatar has led to growing demand for donor kidneys. The deceased donor kidney program has yet to achieve its full potential; hence, living kidney donation has been widely adopted as an appropriate alternative. The reliance on living kidney donors however, raises a number of social, ethical, and legal concerns surrounding informed consent, voluntarism, psychosocial evaluation, perioperative care, and long-term follow-up of living kidney donors. Many of these concerns become heightened in a multicultural, multilingual society within a Gulf country such as Qatar. This article provides an insight into the challenges that living kidney donation poses in a multiethnic society with significant socioeconomic divides. It also discusses the remedial measures that the Qatari government, healthcare authorities, and transplant community have adopted to address these issues.

Living Kidney Donor Phenotype and Likelihood of Postdonation Follow-up

BACKGROUND

The Organ Procurement and Transplantation Network requires that United States transplant centers maintain follow-up with living donors for 2 years postdonation, but lack of donor follow-up is pervasive. Donor characteristics, including younger age, minority race, and lower education, have been associated with incomplete follow-up, but it is unknown whether altruistic donors, having no previous connection to their recipient, differ from traditional donors in their likelihood of follow-up.

METHODS

Using the Scientific Registry of Transplant Recipients data, we examined all adult living kidney donors from 2005 to 2015 (n = 63 592) classified as altruistic or traditional, and compared likelihood of 6-month medical follow-up using modified Poisson regression.

RESULTS

Altruistic donors did not differ from traditional donors in likelihood of follow-up (adjusted relative risk [aRR], 1.02; 95% confidence interval [CI], 0.99-1.06). Among previously identified at-risk subgroups, however, altruistic donors were more likely to have follow-up than their traditional counterparts, including those who were younger (aRR, 1.04; 95% CI, 1.00-1.09), had less than college education (aRR, 1.05; 95% CI, 1.00-1.11), and were unmarried (aRR, 1.08; 95% CI, 1.04-1.12). Having medical follow-up at 6 months was significantly associated with having follow-up at 1 year (aRR, 1.84; 95% CI, 1.75-1.93) and 2 years (aRR, 1.63; 95% CI, 1.56-1.70) postdonation.

CONCLUSIONS

These data provide additional granularity on living donor phenotypes associated with short-term (6 month) postdonation follow-up, which is important given its association with future likelihood of follow-up. These findings offer the opportunity to tailor and direct educational efforts to increase living donor follow-up, particularly among groups at higher risk of loss to follow-up.

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.

[Living liver donor: indications and technical aspects]

Living donor liver transplantation (LDLT) nowadays represents an important and safe alternative to conventional deceased donor liver transplantation (DDLT). A major concern related to the LDLT procedure is still represented by donor safety because a serious operation not without risks must be carried out on a healthy individual. In the present review of the indications for LDLT the technical concepts of donor surgery, criteria for donor selection and evaluation and morbidity and mortality results related to the procedure are presented. In general, the indications for LDLT are almost the same as for DDLT. The donor hepatectomy (right, left or left lateral) is presented in five main phases. The reported morbidity rates vary between 10 % and 60 % and are strongly related to the experience of the transplant center. The currently reported postoperative mortality rates for left and right hepatectomy are 0.1 % and 0.5 %, respectively. The results of LDLT are similar if not even better than those for DDLT depending on the specific indications.

Practices for Supporting and Confirming Decision-Making Involved in Kidney and Liver Donation by Related Living Donors in Japan: A Nationwide Survey

This nationwide survey investigated the actual practices for supporting and confirming the decision-making involved in related living-organ donations in Japan, focusing on organ type and program size differences. Answers to a questionnaire survey were collected from 89 of the 126 (71%) kidney and 30 of the 35 (86%) liver transplantation programs in Japan that were involved in living-donor transplantations in 2013. In 70% of the kidney and 90% of the liver transplantation programs, all donors underwent "third-party" interviews to confirm their voluntariness. The most common third parties were psychiatrists (90% and 83%, respectively). Many programs engaged in practices to support decision-making by donor candidates, including guaranteeing the right to withdraw consent to donate (70% and 100%, respectively) and prescribing a set "cooling-off period" (88% and 100%, respectively). Most donors were offered care by mental health specialists (86% and 93%, respectively). Third parties were designated by more of the larger kidney transplant programs compared with the smaller programs. In conclusion, the actual practices supporting and confirming the decision to donate a living organ varied depending on the organ concerned and the number of patients in the program.

BARTERING FOR A COMPATIBLE KIDNEY USING YOUR INCOMPATIBLE, LIVE KIDNEY DONOR: LEGAL AND ETHICAL ISSUES RELATED TO KIDNEY CHAINS

Kidney chains are a recent and novel method of increasing the number of available kidneys for transplantation and have the potential to save thousands of lives. However, because they are novel, kidney chains do not fit neatly within existing legal and ethicalframeworks, raising potential barriers to their full implementation. Kidney chains are an extension of paired kidney donation, which began in the United States in 2000. Paired kidney donations allow kidney patients with willing, but incompatible, donors to swap donors to increase the number of donor/recipient pairs and consequently, the number of transplants. More recently, transplant centers have been using non-simultaneous, extended, altruistic donor ("NEAD") kidney chains--which consist of a sequence of donations by incompatible donors--to further expand the number of donations. This Article fully explains paired kidney donation and kidney chains and focuses on whether NEAD chains are more coercive than traditional kidney donation to a family member or close friend and whether NEAD chains violate the National Organ Transplant Act's prohibition on the transfer of organs for valuable consideration.

Disclosing Health and Health Behavior Information between Living Donors and Their Recipients

BACKGROUND AND OBJECTIVES

Living donor guidelines-both national and international-either do not address or are vague about what information can be shared between prospective living donors and transplant candidates, as well as when to make such disclosures and who should make them. This study explored the attitudes of donors and recipients regarding how much information they believe should be shared.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Two Email invitations were sent by the National Kidney Foundation (national headquarters) to its Email listservs, inviting members to participate in an online survey to assess the attitudes of kidney transplant stakeholders regarding the disclosure of health and health risk behavior information.

RESULTS

From approximately 4200 unique Email addresses, 392 (9.3%) respondents completed part or all of the survey. The analyses were limited to the 236 respondents who self-identified as either donors (potential and actual, n=160) or recipients (candidates and actual, n=76). Overall, 79% (186 of 234) of respondents supported disclosure of general recipient health information that would affect post-transplant outcome to donors, and 88% (207 of 235) supported disclosure of general donor health information to recipients. Recipients and donors were also supportive of sharing donor and recipient information, particularly information relevant to graft and patient survival. There is some reticence, however, about sharing social information. The closer the relationship, the more information they are willing to share. Both donors and recipients wanted the transplant team involved in the information disclosure. Over three quarters of donors (79%) and recipients (78%) did not think the recipient had a right to know why a donor was excluded from donating.

CONCLUSIONS

Both donors and recipients want a significant amount of health information to be disclosed. The opinions of other stakeholders need to be surveyed to determine whether a revision of current policies and practices is warranted.

Motivations, outcomes, and characteristics of unspecified (nondirected altruistic) kidney donors in the United Kingdom

BACKGROUND

Unspecified (nondirected altruistic) kidney donation is becoming increasingly common in the United Kingdom. Questions regarding motivation and characteristics of these donors persist, alongside concerns about regret and long-term psychosocial outcomes. The aims of this study were to compare psychosocial and physical outcomes in unspecified kidney donors (UKDs) versus specified kidney donors (SKDs).

METHODS

We performed a cross-sectional study, in which a detailed assessment of psychosocial outcomes was made using validated questionnaires. Additional questions specific to donation were also asked, including questions regarding motivation, regret, and anonymity.

RESULTS

One hundred ninety responses were received from 296 participants studied (110 UKDs [74.3%] vs. 80 SKDs [54.1%], P<0.001). Unspecified kidney donors were older (54 years vs. 44 years; P<0.001), predominantly white (99.1% vs. 78.5%; P<0.001), and donated more recently (1.3 years vs. 2.6 years; P<0.001). There was no difference in psychiatric history or personality type, or current depression, anxiety, stress, self-esteem, or well-being between the groups (P>0.05). Unspecified kidney donors were more engaged in other altruistic behaviours (P<0.001). There was no difference in physical outcomes, although UKDs recovered quicker (P<0.001). Regret was low (3.7% UKDs vs. 7.5% SKDs; P=0.078).

CONCLUSION

This study has demonstrated that UKDs have comparable physical and psychosocial outcomes to SKDs. These favorable outcomes may be, in part, because of the rigorous evaluation process which currently includes a mental health assessment. We conclude that the program can continue to expand safely across the United Kingdom.

Ethical issues regarding related and nonrelated living organ donors

The ethics of the clinical practice of transplanting human organs for end-stage organ disease is a fascinating topic. Who is the "owner" of the transplantable organs of a deceased, brain-dead patient? Who should have a right to receive these organs? Who set the boundaries between a living donor's autonomy and a "paternalistic" doctor? What constitutes a proper consent? These questions are only some of the ethical issues that have been discussed in the last 60 years. All of these ethical issues are intensified by the fact that supply of human organs does not match demand, and that, as a consequence, living-donor organ transplantation is widely utilized. The aim of this article is not to be exhaustive but to present the general ethical principles of beneficence, nonmaleficence, and justice as applied to organ transplantation. Moreover, the topic of reimbursement for organ donation is also discussed.

Living kidney donor assessment: challenges, uncertainties and controversies among transplant nephrologists and surgeons

The assessment of living kidney donors presents unique ethical challenges and complex psychosocial implications. This study aimed to ascertain the perspectives of transplant nephrologists and surgeons on living kidney donor assessment. Semi-structured, face-to-face interviews were conducted with 110 transplant nephrologists and surgeons from 43 transplant units in 12 countries from Europe, Australasia and North America. The challenge of defining acceptable risk to the donor was central to five themes identified: burden of responsibility (personal accountability, policing morality, democratic decision making, meeting legal obligations, optimizing outcomes and innovation, relinquished control); medical protectiveness (prognostic uncertainty, skepticism of donor risk perception, avoidance of undue coercion, concerns for dubious motivations and coercion, safeguard donor well-being, ethical information disclosure); respecting donor autonomy (facilitate informed-decision making, concede to donor risk acceptance, benefit of the doubt, donor mandate to maintain health, acceptable altruism); driving ideologies (preserving equity, championing living donation, cognizance of anti-paternalism) and contextual pressures (evolving donor demographic, resource limitations). Living kidney donor assessment involves complex interactions between safeguarding the donors' welfare and respecting their autonomy. In our opinion, authoritative and well-described transplant unit, hospital and public policy positions that make explicit the considerations that are often implicit may reduce the uncertainty within which living donors are assessed today.

‘It seemed churlish not to’: How living non-directed kidney donors construct their altruism

Our objective was to explore how prospective altruistic kidney donors construct their decision to donate. Using a qualitative design and biographical-narrative semi-structured interviews, we aimed to produce text for analysis on two levels: the social implications for subjectivity and practice and a tentative psychodynamic explanation of the participants’ psychological investment in the discourses they used. A total of six prospective altruistic kidney donors were interviewed. A psychosocial approach to the analysis was taken. In-depth discourse analysis integrated Foucauldian with psycho-discursive approaches and psychodynamic theory was applied to sections of text in which participants seemed to have particular emotional investment. Analysis generated three major discursive themes: other-oriented, rational and self-oriented discourses. The desire to donate was experienced as compelling by participants. Participants used discourses to position themselves as concerned with the needs of the recipient, to resist questioning and criticism, and to manage difficult feelings around mortality. Participants tended to reject personal motivations for altruistic donation, positioning relatives’ disapproval as selfish and illogical. These results suggest that the term ‘altruistic’ for living non-directed organ donation constrains available discourses, severely limiting what can be said, felt, thought and done by donors, clinicians and the public. A more useful approach would acknowledge potential psychological motives and gains for the donor.

Unspecified kidney donation--a review of principles, practice and potential

Unspecified kidney donation is an emerging resource to bridge the gap between supply and demand of kidneys for transplantation. However, uncertainty remains among both the transplantation community and lay public with regard to the intention, motivation, and legitimacy of such donors. Even within programs that use unspecified kidney donors, there is a lack of consensus regarding how to optimize the potential of the gifted kidney (and indirectly potentiate the altruistic benefit for the donor). Despite emerging guidance on how to work up unspecified donors, centers have adopted individualized unspecified donor pathways with regards to assessment, evaluation, and use. There are a variety of models for unspecified kidney donation, ranging from donation directly to deceased-donor waiting lists to benefit one recipient or chain transplantations occurring simultaneously (domino-paired donation) or nonsimultaneously (extended altruistic donor chains) to benefit many. After a brief exploration on the basis of altruism, this review will discuss the assessment, evaluation, and reported outcomes associated with unspecified kidney donation. It will also critique current utilization models and highlight some unresolved controversies. The aim is to highlight the principles, practice, and potential of unspecified kidney donation to bridge the current disparate international practice.

Acute liver failure and liver transplantation

Acute liver failure (ALF) is defined by the presence of coagulopathy (International Normalized Ratio ≥ 1.5) and hepatic encephalopathy due to severe liver damage in patients without pre-existing liver disease. Although the mortality due to ALF without liver transplantation is over 80%, the survival rates of patients have considerably improved with the advent of liver transplantation, up to 60% to 90% in the last two decades. Recent large studies in Western countries reported 1, 5, and 10-year patient survival rates after liver transplantation for ALF of approximately 80%, 70%, and 65%, respectively. Living donor liver transplantation (LDLT), which has mainly evolved in Asian countries where organ availability from deceased donors is extremely scarce, has also improved the survival rate of ALF patients in these regions. According to recent reports, the overall survival rate of adult ALF patients who underwent LDLT ranges from 60% to 90%. Although there is still controversy regarding the graft type, optimal graft volume, and ethical issues, LDLT has become an established treatment option for ALF in areas where the use of deceased donor organs is severely restricted.

Living organ donation practices in Europe - results from an online survey

In Europe, living organ donation (LOD) is increasingly accepted as a valuable solution to overcome the organ shortage. However, considerable differences exist between European countries regarding frequency, practices and acceptance of donor-recipient relations. As a response, the Coordination Action project 'Living Organ Donation in Europe' (www.eulod.eu), funded by the Seventh Framework Programme of the European Commission, was initiated. Transplant professionals from 331 European kidney and liver transplant centres were invited to complete an online survey on living kidney donation (LKD) and living liver donation (LLD). In total, 113 kidney transplant centres from 40 countries and 39 liver transplant centres from 24 countries responded. 96.5% and 71.8% performed LKD and LLD respectively. The content of the medical screening of donors was similar, but criteria for donor acceptance varied. Few absolute contraindications for donation existed. The reimbursement policies diverged and the majority of the donors did not get reimbursed for their income loss during recovery. Large discrepancies were found between geographical European regions (the Eastern, the Mediterranean and the North-Western). As a result of this survey we suggest several recommendations to improve quality and safety of LOD in Europe.

Informed consent for living donation: a review of key empirical studies, ethical challenges and future research

Given the organ scarcity, live organ donation is increasingly considered a viable alternative for kidney and liver transplantation. Yet living donation challenges the ethical principle of nonmaleficence by subjecting healthy individuals to medical, psychosocial and unknown risks. Therefore, transplant providers, policy-makers and donors are committed to ensuring that prospective donors provide adequate informed consent to undergo the procedure. Informed consent for living donation is ethically required as a means of demonstrating respect for donor's autonomy and protecting their safety. However, all elements of informed consent are fraught with difficulties due to the unique nature of the donation process and outcome. This paper reviews empirical research on informed consent for live kidney donors (LKD) and live liver donors (LLD) for both adult and pediatric recipients. As this review shows, studies that empirically assessed the quality of informed consent elements reveal considerable variability and deficiencies across the informed consent process, suggesting the need for improvement. This review highlights challenges to each element of consent for both LKDs and LLDs, and situates trends within broader policy contexts, ethical debates and avenues for future innovative research.

The prohibition of kidney sales and organ markets should remain

PURPOSE OF REVIEW

There is an ongoing vigorous debate regarding the wisdom of the current prohibition of organ sales in the United States. We argue that this prohibition must remain in place. We discuss the current international realities regarding organ vending in order to show that even a so-called 'regulated' market brings with it danger to the welfare of transplant donors, their recipients, and potential recipients of nonrenal organs. We counter the specific arguments made in favor of organ sales while recommending multiple measures that can serve to remove disincentives to noncommercial organ donation. We encourage the investment in innovative healthy transplant practice for the benefit of all.

RECENT FINDINGS

In 'natural experiments' performed in developing countries the outcome for kidney vendors, in terms of both their medical and psychosocial health, has been shown to be poor. A high incidence of serious infections has been reported in recipients of vended organs.

SUMMARY

Commercialization of living kidney donation does not serve the interests of the donors, endangers the health of recipients, and undermines the healthy development of the international transplant endeavor.

The socioeconomic status of donors and recipients of living unrelated renal transplants in the United States

PURPOSE

We evaluated unrelated living kidney donation in the United States and examined the characteristics of unrelated donor-recipient pairs.

MATERIALS AND METHODS

We accessed United Network for Organ Sharing files to identify adult living donor renal transplant recipients who received a transplant between 1997 and 2007. We evaluated factors associated with unrelated donation and compared a composite index of the socioeconomic characteristics of donor and recipient ZIP Codes between living unrelated and living related renal transplantation pairs. Spousal pairs were categorized as living related.

RESULTS

Of 39,168 adult renal transplant recipients 19% underwent living unrelated renal transplantation. These recipients were more likely white (vs black, Hispanic and other race OR 0.77-0.82, p <0.05) and more highly educated (college vs less than high school OR 0.66, 95% CI 0.54-0.77), and more commonly received care at high volume transplant centers (vs lowest volume centers OR 0.89, 95% CI 0.82-0.95). Living unrelated renal transplantation recipients and donors lived in higher socioeconomic status index ZIP Codes than living related recipients (mean ± SD recipients and donors 0.62 ± 3.74 and 0.44 ± 3.63 vs 0.03 ± 3.85 and 0.10 ± 3.87, respectively, each p <0.001).

CONCLUSIONS

Living unrelated renal transplantation donors and recipients are generally of higher socioeconomic status than their living related renal transplantation counterparts. There is restricted access to unrelated donors among underserved populations.

Screening and follow-up of living kidney donors: a systematic review of clinical practice guidelines

To minimize the health risks faced by living kidney donors, multiple clinical practice guidelines have been developed on the assessment and care of potential donors. This study aims to compare the quality, scope, and consistency of these guidelines. We searched for guidelines on living kidney donation in electronic databases, guideline registries, and relevant Web sites to February 21, 2011. Methodological quality was assessed using the Appraisal of Guidelines for Research and Education (AGREE) instrument. Textual synthesis was used to compare guideline recommendations. Ten guidelines, published from 1996 to 2010, were identified. Although generally comprehensive, scope varied considerably and mostly appeared to lack methodological rigor. Many recommendations were consistent, but important differences were evident, particularly for thresholds for comorbidities which precluded donation; obesity/overweight (body mass index, 30-35 kg/m), diabetes/prediabetes (fasting blood glucose level, 6.1-7.0 mmol/L and oral glucose tolerance test, 7.8-11.1 mmol/L), hypertension (130/85 to 140/90 mm Hg), cardiovascular disease, malignancy, and nephrolithiasis. The importance of informed voluntary consent, genuine motivation, support, and psychological health were recognized but difficult to implement as specific tools for conducting psychosocial assessments were not recommended. Multiple major guidelines for living kidney donation have been published recently, resulting in unnecessary duplicative efforts. Most do not meet standard processes for development, and important recommendations about thresholds for exclusion based on comorbidities are contradictory. There is an urgent need for international collaboration and coordination to ensure, where possible, that guidelines for living donation are consistent, evidence based, and comprehensive to promote best outcomes for a precious resource.

New classification of ELPAT for living organ donation

In the literature, varying terminology for living organ donation can be found. However, there seems to be a need for a new classification to avoid confusion. Therefore, we assessed existing terminology in the light of current living organ donation practices and suggest a more straightforward classification. We propose to concentrate on the degree of specificity with which donors identify intended recipients and to subsequently verify whether the donation to these recipients occurs directly or indirectly. According to this approach, one could distinguish between "specified" and "unspecified" donation. Within specified donation, a distinction can be made between "direct" and "indirect" donation.

Disclosing recipient information to potential living donors: preferences of donors and recipients, before and after surgery

Consensus guidelines, while recommending that potential living donors should be given information that could impact their donation decision, are nonspecific about the types of information that should be disclosed. We surveyed potential (n = 36) and past (n = 45) living donors and transplant candidates (n = 45) and recipients (n = 45) about their preferences for sharing or knowing specific information about the recipient, how this information would impact decision-making, and who should be responsible for disclosing information. Potential donors were less likely than all others to feel that recipient information should be disclosed to potential donors. Donors and recipients felt most strongly about disclosing if the recipient lost a previously transplanted kidney due to medication nonadherence as well as the likelihood of 1- and 5-year graft survival. Most donors would be less likely to pursue donation if the recipient lost a previously transplanted kidney due to medication nonadherence or generally had problems with taking medications as prescribed. Transplant programs should consider how to best balance the potential donor's right to receive information that could reasonably be expected to affect their decision-making process with the recipient's right to privacy and confidentiality.

Altruistic kidney donation to a stranger: psychosocial and functional outcomes at two US transplant centers

BACKGROUND

The number of living kidney donors with no preexisting relationship to the recipient has increased sharply. This study compared the psychosocial and functional outcomes of these altruistic donors to a stranger (ADs) with donors with a longstanding relationship with the recipient (traditional donors [TDs]).

METHODS

ADs (n=39) and TDs (n=52), who were similar on age, sex, and year of donation, were recruited from two transplant programs in the United States. Participants completed validated measures of psychosocial and functional outcomes a median of 5 years after donation (range, 1-12 years).

RESULTS

ADs and TDs did not differ significantly in the total number of donation motives. Both were motivated by a desire to help, the benefits to the recipient outweighing the risks to the donor, a sense of moral duty, and imagining oneself in the position of the recipient. Psychological benefits were endorsed equally by both types of donors, although TDs reported higher Quid Pro Quo scores relative to ADs (P=0.04). ADs and TDs did not differ significantly on any of the Short Form-36, Version 2 scales (P values ranged from 0.19 to 0.85). Few donors (3 ADs and 1 TD) regretted their donation decision.

CONCLUSION

Overall, findings indicate that carefully screened ADs experience psychosocial and functional outcomes comparable with those of TDs and should not be systematically excluded from the opportunity to donate.

Attitudes of medical professionals and transplantation facilities toward living-donor liver transplantation in Japan

The Japan Society for Transplantation (JST) revised their guidelines in 2003 to specify that a living donor must be "a relative by blood within the sixth degree or an in-law within the third degree." Although several criticisms have been raised on this issue, these criteria have persisted without any empirical data showing the opinions and attitudes of people who are affected by the revision. Therefore, we performed a questionnaire survey to determine what Japanese medical professionals involved with living-donor liver transplantation (LDLT) regarded as eligible relationships for donation, as well as the kind of relationship for which they would be willing to donate their liver, and what donor eligibility criteria was currently used by their institutions. Among the 71 representatives of the Japanese Liver Transplantation Society, >90% answered that liver donations to emotionally close parents, siblings, children, or spouses were acceptable. However, the numbers were considerably lower for donation to emotionally close blood relatives, in-laws, friends, and strangers (78.2%, 52.1%, 18.6%, and 5.9%, respectively). This gap was more prominent when participants were questioned about their own willingness to donate. More than two-thirds of facilities that perform LDLTs have independent regulations for donor eligibility that are more conservative than the JST guidelines. No facility accepted friends or strangers as donors. When introducing policies or guidelines, it is important to carefully investigate the views of the people who are affected. The data obtained in this study should serve as a resource for ongoing discussions about the JST revised guidelines.

Ethical considerations for participation of nondirected living donors in kidney exchange programs

Kidneys from nondirected donors (NDDs) have historically been allocated directly to the deceased donor wait list (DDWL). Recently, however, NDDs have participated in kidney exchange (KE) procedures, including KE 'chains', which have received considerable media attention. This increasing application of KE chains with NDD participation has occurred with limited ethical analysis and without ethical guidelines. This article aims to provide a rigorous ethical evaluation of NDDs and chain KEs. NDDs and bridge donors (BDs) (i.e. living donors who link KE procedures within KE chains) raise several ethical concerns including coercion, privacy, confidentiality, exploitation and commercialization. In addition, although NDD participation in KE procedures may increase transplant numbers, it may also reduce NDD kidney allocation to the DDWL, and disadvantage vulnerable populations, particularly O blood group candidates. Open KE chains (also termed 'never-ending' chains) result in a permanent diversion of NDD kidneys from the DDWL. The concept of limited KE chains is discussed as an ethically preferable means for protecting NDDs and BDs from coercion and minimizing 'backing out', whereas 'honor systems' are rejected because they are coercive and override autonomy. Recent occurrences of BDs backing out argue for adoption of ethically based protective measures for NDD participation in KE.

Encouraging psychological outcomes after altruistic donation to a stranger

In a growing number of transplant centers worldwide, altruistic donors are accepted to anonymously donate a kidney to a stranger. An important hesitation to expand these transplantation programs is the fear of evoking psychological distress in the altruistic donor after donation. To what extent this fear is justified has not yet been systematically investigated. In this study, 24 altruistic donors were interviewed on average 2 years after donation. Lifetime mental health history, current psychological complaints, satisfaction with and impact of the donation on well-being, motives for donation, communication with recipient and donation experience were assessed. Altruistic donors report a considerable positive impact of donation on psychological well-being, whereas negative impact was limited. Satisfaction with donation was very high. Although a history of a psychiatric diagnosis was ascertained in almost half of the donors, psychological complaints before and after donation were comparable to national average norm scores. Motives for donation were genuine and the experience of donation generally conformed to their expectations. In conclusion, living kidney donation to a stranger does not appear to exacerbate psychological complaints. Moreover, altruistic donors report considerable satisfaction and personal benefit. The exceptional gift of altruistic donors can contribute toward solving the current organ shortage issue.

Altruistic donor triggered domino-paired kidney donation for unsuccessful couples from the kidney-exchange program

Between January 2000 and July 2009, 132 individuals inquired about altruistic kidney donation to strangers. These donors were willing to donate to genetically and emotionally unrelated patients. Some altruistic donors wished to donate to a specific person, but most wished to donate anonymously. In domino-paired donation, the altruistic donor donates to the recipient of an incompatible couple; the donor of that couple (domino-donor) donates to another couple or to the waiting list. In contrast to kidney-exchange donation where bilateral matching of couples is required, recipient and donor matching are unlinked in domino-paired donation. This facilitates matching for unsuccessful couples from the kidney-exchange program where blood type O prevails in recipients and is under-represented in donors. Fifty-one altruistic donors (39%) donated their kidney and 35 domino-donors were involved. There were 29 domino procedures, 24 with 1 altruistic donor and 1 domino-donor, 5 with more domino-donors. Eighty-six transplantations were performed. Donor and recipient blood type distribution in the couples limited allocation to blood type non-O waiting list patients. The success rate of domino-paired donation is dependent on the composition of the pool of incompatible pairs, but it offers opportunities for difficult to match pairs that were unsuccessful in the kidney-exchange program.

Renal transplantation across HLA and ABO antibody barriers: integrating paired donation into desensitization protocols

The field of desensitization and incompatible transplantation has made great gains over the past decade. There are now several options and effective therapies for many patients who face antibody barriers. Kidney paired donation (KPD) and desensitization have traditionally been considered competing strategies and patients have been offered one or the other without regard for the probability of a successful outcome. It is now possible to predict which donor/recipient phenotypes will benefit from each of these modalities. KPD should be favored among patients with immunologic phenotypes that are likely to match without prolonged waiting times. However, as many as 50% of patients with incompatible donors will fail to find a match in a KPD pool and many of these patients could be desensitized to their donor. Positive crossmatch and ABO incompatible transplantation has been accomplished in selective cases without the need for heavy immunosuppression or B-cell ablative therapy. Patients who are both difficult-to-match due to broad sensitization and hard-to-desensitize because of strong donor reactivity can often be successfully transplanted through a combination of desensitization and KPD. Using these various modalities it is estimated that most patients with incompatible live donors can undergo successful renal transplantation.