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

Awareness, Attitudes, and Willingness: A Cross-Sectional Study of Organ Donation in Saudi Arabia

BACKGROUND

Organ transplantation is inherently dependent on the availability of organ donors. There is a noticeable paucity of literature addressing the rates of organ donation registration and the awareness of Islamic regulations (Fatwa) regarding organ donation within Saudi Arabia. Our study aimed to evaluate the level of organ donation registration, awareness of Islamic regulations, and knowledge of the Saudi Center for Organ Transplantation (SCOT) within the Saudi society.

METHODS

We conducted a cross-sectional survey from 30 March to 9 April 2023. This survey aimed to assess the awareness of Islamic (Fatwa) guidance on organ donation, the role of SCOT, and the rate of organ donation registration facilitated through the Tawakkalna app, the official health passport application in Saudi Arabia.

RESULTS

Out of 2329 respondents, 21% had registered as potential deceased organ donors, despite 87% acknowledging the importance of organ donation. Awareness of the Islamic Fatwa regarding organ donation was reported by 54.7% of respondents, and 37% recognized the Fatwa's acceptance of brain death criteria. The likelihood of registration as organ donors was higher among Saudi citizens under 45 years of age, females, healthcare workers (HCWs), individuals with higher education, relatives of patients awaiting organ donations, those informed about the Islamic Fatwas, and those willing to donate organs to friends. Conversely, being over the age of 25, Saudi nationality, employment as an HCW, awareness of SCOT, and prior organ donation registration were predictive of a heightened awareness of Islamic Fatwas. However, perceiving the importance of organ donation correlated with a lower awareness of the Fatwas. Significant positive correlations were found between awareness of SCOT, awareness of Fatwas, and registration for organ donation.

CONCLUSIONS

While the Saudi population exhibits a high regard for the importance of organ donation, this recognition is not adequately translated into registration rates. The discrepancy may be attributable to limited awareness of SCOT and the relevant Islamic Fatwas. It is imperative to initiate organ donation awareness campaigns that focus on religious authorization to boost organ donation rates and rectify prevalent misconceptions.

Identifying the barriers to kidney transplantation for patients in rural and remote areas: a scoping review

BACKGROUND

Populations in rural and remote areas have higher rates of chronic kidney disease and kidney failure than those in urban or metropolitan areas, and mortality rates for chronic kidney disease are almost twice as high in remote areas compared to major cities. Despite this, patients residing in regional, rural, or remote areas are less likely to be wait-listed for or receive a kidney transplant. The objective of this scoping review is to identify specific barriers to kidney transplantation for adult patients residing in rural and remote areas from the perspectives of health professionals and patients/carers.

METHODS

Studies were identified through database (MEDLINE, CINAHL, Emcare, Scopus) searches and assessed against inclusion criteria to determine eligibility. A descriptive content analysis was undertaken to identify and describe barriers as key themes.

RESULTS

The 24 selected studies included both quantitative (n = 5) and qualitative (n = 19) methodologies. In studies conducted in health professional populations (n = 10) the most prevalent themes identified were perceived social and cultural issues (80%), burden of travel and distance from treatment (60%), and system-level factors as barriers (60%). In patient/carer populations (n = 14), the most prevalent themes were limited understanding of illness and treatment options (71%), dislocation from family and support network (71%), and physical and psychosocial effects of treatment (71%).

CONCLUSIONS

Patients in regional, rural, and remote areas face many additional barriers to kidney transplantation, which are predominantly associated with the need to travel or relocate to access required medical testing and transplantation facilities.

Equity of access to renal transplantation: a European perspective

PURPOSE OF REVIEW

Renal transplantation offers the chance for patients with end-stage renal disease (ESRD) to have a significantly longer, healthier and better quality life compared with remaining on dialysis. Inequities have been demonstrated at multiple points in the transplantation pathway. In this review, the factors contributing to inequity in access to renal transplantation will be explored from a European perspective.

RECENT FINDINGS

Despite improvements in patient assessment and revision of organ-offering schemes, there remain persistent inequities in access to the waiting list, allocation of a deceased donor transplant, receiving a living donor transplant and achieving preemptive transplantation. Older age, lower socioeconomic status and health literacy are key factors that continue to impact equity of access to transplantation.

SUMMARY

A number of modifiable factors have been identified affecting access to transplantation, Increased patient education together with a better access to and promotion of living donation may help address some of these inequities.

Gender and race/ethnicity differences in living kidney donor demographics: Preference or disparity?

In the United States, women are over-represented and Blacks are under-represented as living kidney donors. A traditional bioethics approach would state that as long as living donors believe that the benefits of participation outweigh the risks and harms (beneficence) and they give a voluntary and informed consent, then the demographics reflect a mere difference in preferences. Such an analysis, however, ignores the social, economic and cultural determinants as well as various forms of structural discrimination (e.g., racism, sexism) that may imply that the distribution is less voluntary than may appear initially. The distribution also raises justice concerns regarding the fair recruitment and selection of living donors. We examine the differences in living kidney donor demographics using a vulnerabilities analysis and argue that these gender and racial differences may not reflect mere preferences, but rather, serious justice concerns that need to be addressed at both the individual and systems level.

Outcomes of Living Kidney Donor Candidate Evaluations in the Living Donor Collective Pilot Registry

Supplemental Digital Content is available in the text.

Background.

Gaps in our knowledge of long-term outcomes affect decision making for potential living kidney donors.

Methods.

The Scientific Registry of Transplant Recipients was asked to determine the feasibility of a candidate registry.

Results.

Ten living kidney donor programs evaluated 2107 consecutive kidney donor candidates; 2099 of 2107 (99.6%) completed evaluations, 1578 of 2099 (75.2%) had a decision, and 790 of 1578 (50.1%) were approved to donate as of March 12, 2020. By logistic regression, candidates most likely to be approved were married or had attended college or technical school; those least likely to be approved had ≥1 of the following characteristics: Black race, history of cigarette smoking, and higher blood pressure, higher triglycerides, or higher urine albumin-to-creatinine ratios. Reasons for 617 candidates not being approved included medical issues other than chronic kidney disease risk (25.3%), chronic kidney disease risk (18.5%), candidate withdrawal (15.2%), recipient reason (13.6%), anatomical risk to the recipient (10.3%), noneconomic psychosocial (10.3%), economic (0.5%), and other reasons (6.4%).

Conclusions.

These results suggest that a comprehensive living donor registry is both feasible and necessary to assess long-term outcomes that may inform decision making for future living donor candidates. There may be socioeconomic barriers to donation that require more granular identification so that active measures can address inequities. Some candidates who did not donate may be suitable controls for discerning the appropriateness of acceptance decisions and the long-term outcomes attributable to donation. We anticipate that these issues will be better identified with modifications to the data collection and expansion of the registry to all centers over the next several years.

Pre-transplant Social Adaptability Index and clinical outcomes in renal transplantation: The Swiss Transplant Cohort study

BACKGROUND

The impact of pre-transplant social determinants of health on post-transplant outcomes remains understudied. In the United States, poor clinical outcomes are associated with underprivileged status, as assessed by the Social Adaptability Index (SAI), a composite score of education, employment status, marital status, household income, and substance abuse. Using data from the Swiss Transplant Cohort Study (STCS), we determined the SAI's predictive value regarding two post-transplant outcomes: all-cause mortality and return to dialysis.

METHODS

Between 2012 and 2018, we included adult renal transplant patients (aged ≥ 18 years) with pre-transplant assessment SAI scores, calculated from a STCS Psychosocial Questionnaire. Time to all-cause mortality and return to dialysis were predicted using Cox regression.

RESULTS

Of 1238 included patients (mean age: 53.8 ± 13.2 years; 37.9% female; median follow-up time: 4.4 years [IQR: 2.7]), 93 (7.5%) died and 57 (4.6%) returned to dialysis. The SAI's hazard ratio was 0.94 (95%CI: 0.88-1.01; p = .09) for mortality and 0.93 (95%CI: 0.85-1.02; p = .15) for return to dialysis.

CONCLUSIONS

In contrast to most published studies on social deprivation, analysis of this Swiss sample detected no significant association between SAI score and mortality or return to dialysis.

Work of being an adult patient with chronic kidney disease: a systematic review of qualitative studies

INTRODUCTION

Chronic kidney disease (CKD) requires patients and caregivers to invest in self-care and self-management of their disease. We aimed to describe the work for adult patients that follows from these investments and develop an understanding of burden of treatment (BoT).

METHODS

Systematic review of qualitative primary studies that builds on EXPERTS1 Protocol, PROSPERO registration number: CRD42014014547. We included research published in English, Spanish and Portuguese, from 2000 to present, describing experience of illness and healthcare of people with CKD and caregivers. Searches were conducted in MEDLINE, Embase, CINAHL Plus, PsycINFO, Scopus, Scientific Electronic Library Online and Red de Revistas Científicas de América Latina y el Caribe, España y Portugal. Content was analysed with theoretical framework using middle-range theories.

RESULTS

Searches resulted in 260 studies from 30 countries (5115 patients and 1071 carers). Socioeconomic status was central to the experience of CKD, especially in its advanced stages when renal replacement treatment is necessary. Unfunded healthcare was fragmented and of indeterminate duration, with patients often depending on emergency care. Treatment could lead to unemployment, and in turn, to uninsurance or underinsurance. Patients feared catastrophic events because of diminished financial capacity and made strenuous efforts to prevent them. Transportation to and from haemodialysis centre, with variable availability and cost, was a common problem, aggravated for patients in non-urban areas, or with young children, and low resources. Additional work for those uninsured or underinsured included fund-raising. Transplanted patients needed to manage finances and responsibilities in an uncertain context. Information on the disease, treatment options and immunosuppressants side effects was a widespread problem.

CONCLUSIONS

Being a person with end-stage kidney disease always implied high burden, time-consuming, invasive and exhausting tasks, impacting on all aspects of patients' and caregivers' lives. Further research on BoT could inform healthcare professionals and policy makers about factors that shape patients' trajectories and contribute towards a better illness experience for those living with CKD.

PROSPERO REGISTRATION NUMBER

CRD42014014547.

Barriers to living donor kidney transplantation in the United Kingdom: a national observational study

Background. Living donor kidney transplantation (LDKT) provides more timely access to transplantation and better clinical outcomes than deceased donor kidney transplantation (DDKT). This study investigated disparities in the utilization of LDKT in the UK.

Methods. A total of 2055 adults undergoing kidney transplantation between November 2011 and March 2013 were prospectively recruited from all 23 UK transplant centres as part of the Access to Transplantation and Transplant Outcome Measures (ATTOM) study. Recipient variables independently associated with receipt of LDKT versus DDKT were identified.

Results. Of the 2055 patients, 807 (39.3%) received LDKT and 1248 (60.7%) received DDKT. Multivariable modelling demonstrated a significant reduction in the likelihood of LDKT for older age {odds ratio [OR] 0.11 [95% confidence interval (CI) 0.08–0.17], P < 0.0001 for 65–75 years versus 18–34 years}; Asian ethnicity [OR 0.55 (95% CI 0.39–0.77), P = 0.0006 versus White]; Black ethnicity [OR 0.64 (95% CI 0.42–0.99), P = 0.047 versus White]; divorced, separated or widowed [OR 0.63 (95% CI 0.46–0.88), P = 0.030 versus married]; no qualifications [OR 0.55 (95% CI 0.42–0.74), P < 0.0001 versus higher education qualifications]; no car ownership [OR 0.51 (95% CI 0.37–0.72), P = 0.0001] and no home ownership [OR 0.65 (95% CI 0.85–0.79), P = 0.002]. The odds of LDKT varied significantly between countries in the UK.

Conclusions. Among patients undergoing kidney transplantation in the UK, there are significant age, ethnic, socio-economic and geographic disparities in the utilization of LDKT. Further work is needed to explore the potential for targeted interventions to improve equity in living donor transplantation.

Commercial Kidney Transplantation: Attitude, Knowledge, Perception, and Experience of Recipients

INTRODUCTION

Kidney transplantation is the gold standard for patients with end-stage kidney disease. In view of shortages of available organs, long wait times for possible transplantation, and strict regulation, many patients opt for commercial transplantation. This study elicits the reasons and motivations for patients with end-stage kidney disease to elect for commercial transplant.

METHODS

A questionnaire-based evaluation was conducted during the period from July 2015 until late December 2015. It consisted of 29 multiple choice questions and was distributed to all patients who underwent commercial kidney transplantation.

RESULTS

One hundred and fifty patients were approached to participate and 106 agreed. Of the participants, 60% were male with an average age of 41.5 (SD 14.8) years and ranged from 18 to 83 years. The majority (82%) of our participants were educated ranging from primary to college level. The major reason (71%) for these participants to obtain commercial transplants was stated as the unavailability of a live related donor. Thirteen percent stated that they objected to getting a kidney donated from a family member, and 9% stated that they were worried about taking a kidney from a family member. Finally, 3% of participants stated that they needed prompt transplant and could not wait for a long time for transplant investigations and the workup associated with this program.

DISCUSSION

The study showed that the most common underlying cause for seeking commercial transplantation is the unavailability of a national transplant program, particularly transplantation from deceased sources. All western ethical arguments turn out to become of vital importance in developing countries, because transplantation is the cheapest renal replacement therapy. However, it must be emphasized that commercial transplants should not be an alternative to building a national transplant initiative. The national diseased program must be a priority with full financial and administrative support. All government agencies including religious affairs must work together to support the program and to provide the citizens with a good transplantation service and ameliorate the impact of commercial transplantation.