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McElroy LM, Mohottige D, Cooper A, Sanoff S, Davis LA, Collins BH, Gordon EJ, Wang V, Boulware LE. Improving Health Equity in Living Donor Kidney Transplant: Application of an Implementation Science Framework. Transplant Proc 2024; 56:68-74. [PMID: 38184377 DOI: 10.1016/j.transproceed.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 12/19/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND Interventions to improve racial equity in access to living donor kidney transplants (LDKT) have focused primarily on patients, ignoring the contributions of clinicians, transplant centers, and health system factors. Obtaining access to LDKT is a complex, multi-step process involving patients, their families, clinicians, and health system functions. An implementation science framework can help elucidate multi-level barriers to achieving racial equity in LDKT and guide the implementation of interventions targeted at all levels. METHODS We adopted the Pragmatic Robust Implementation and Sustainability Model (PRISM), an implementation science framework for racial equity in LDKT. The purpose was to provide a guide for assessment, inform intervention design, and support planning for the implementation of interventions. RESULTS We applied 4 main PRISM domains to racial equity in LDKT: Organizational Characteristics, Program Components, External Environment, and Patient Characteristics. We specified elements within each domain that consider perspectives of the health system, transplant center, clinical staff, and patients. CONCLUSION The applied PRISM framework provides a foundation for the examination of multi-level influences across the entirety of LDKT care. Researchers, quality improvement staff, and clinicians can use the applied PRISM framework to guide the assessment of inequities, support collaborative intervention development, monitor intervention implementation, and inform resource allocation to improve equity in access to LDKT.
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Affiliation(s)
- Lisa M McElroy
- Department of Surgery, Duke University, Durham, North Carolina; Department of Population Health Sciences, Duke University, Durham, North Carolina.
| | | | - Alexandra Cooper
- Social Science Research Institute, Duke University, Durham, North Carolina
| | - Scott Sanoff
- Department of Medicine, Duke University, Durham, North Carolina
| | - LaShara A Davis
- Department of Surgery and J.C. Walter Jr. Transplant Center, Houston Methodist Hospital, Houston, Texas
| | | | - Elisa J Gordon
- Department of Surgery, Vanderbilt University, Nashville, Tennessee
| | - Virginia Wang
- Department of Population Health Sciences, Duke University, Durham, North Carolina; Department of Medicine, Duke University, Durham, North Carolina
| | - L Ebony Boulware
- Department of Population Health Sciences, Duke University, Durham, North Carolina; Department of Medicine, Duke University, Durham, North Carolina
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Paoletti F, Giorgio V, Jaser A, Zanoni NR, Ricciardi W, Citterio F, De Belvis AG. Process control: simply a matter of efficiency or of survival and costs? A single-centre quality improvement project in living donor renal transplant. BMC Health Serv Res 2023; 23:192. [PMID: 36823623 PMCID: PMC9947903 DOI: 10.1186/s12913-023-09183-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 02/15/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Rising incidence and prevalence of end-stage renal disease is a worldwide concern for sustainability of healthcare systems and societies. Living donor renal transplant [LDRT] provides highest health achievements and cost containment than any alternative form of renal replacement therapy. Nonetheless, about 25% of potential LDRTs are missed for causes directly related with inadequate timing in donor assessment. Our quality improvement (QI) project implement process control tools and strategy aiming at reducing total evaluation time for donor candidates and minimizing dialysis exposure for intended recipients, which are the two main determinants of clinical outcomes and costs. METHODS The study includes patients who underwent donor nephrectomy between January 1, 2017 and December 31, 2021. Six Sigma DMAIC approach was adopted to assess Base Case performance (Jan2017-Jun2019) and to design and implement our QI project. Study of current state analysis focused on distribution of time intervals within the assessment process, analysis of roles and impacts of involved healthcare providers and identification of targets of improvement. Improved Scenario (Jul2019-Dec2021) was assessed in terms of total lead time reduction, total pre-transplantation dialysis exposure and costs reduction, and increase in pre-emptive transplantations. The study was reported following SQUIRE 2.0 Guidelines for QI projects. RESULTS Study population includes 63 patients, 37 in Base Case and 26 in Improved Scenario. Total lead time reduced from a median of 293 to 166 days and this in turn reduced pre-transplantation dialysis exposure and costs by 45%. Rate of potential pre-emptive donors' loss changes from 44% to 27%. CONCLUSIONS Lean methodology is an effective tool to improve quality and efficiency of healthcare processes, in the interest of patients, healthcare professionals and payers.
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Affiliation(s)
- Filippo Paoletti
- Clinical Pathways and Outcome Evaluation Unit, Fondazione Policlinico Universitario A.Gemelli IRCSS, Rome, Italy.
| | | | - Adel Jaser
- grid.432235.1Lean Program Unit, IREN, Turin, Italy
| | - Natalia Romina Zanoni
- grid.411075.60000 0004 1760 4193Department of Medical and Surgical Sciences, Urology, Nephrology and Renal Transplant Area, Fondazione Policlinico Universitario A.Gemelli IRCSS, Rome, Italy
| | - Walter Ricciardi
- grid.8142.f0000 0001 0941 3192Section of Hygiene, Department of Health Science and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Franco Citterio
- grid.411075.60000 0004 1760 4193Department of Medical and Surgical Sciences, Urology, Nephrology and Renal Transplant Area, Fondazione Policlinico Universitario A.Gemelli IRCSS, Rome, Italy
| | - Antonio Giulio De Belvis
- grid.411075.60000 0004 1760 4193Clinical Pathways and Outcome Evaluation Unit, Fondazione Policlinico Universitario A.Gemelli IRCSS, Rome, Italy
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Arabi Z, Hamad A, Bukhari M, Altheaby A, Kaysi S. Practice Patterns for the Acceptance of Medically Complex Living Kidney Donors with Hematuria, Sickle Cell Trait, Smoking, Illegal Drug Use, or Urological Issues: A Multinational Survey. Avicenna J Med 2021; 11:185-195. [PMID: 34881201 PMCID: PMC8648410 DOI: 10.1055/s-0041-1736542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Background To review the practice patterns for the acceptance of medically complex living kidney donors (MCLKD) among the transplant providers of the international transplant community. Methods We distributed a survey globally, through major international transplantation societies, among nephrologists and transplant surgeons (TS). The survey contained questions regarding potential donors with microscopic hematuria, sickle cell trait, renal cysts, kidney stones, smoking, or illegal drug use. Results There were 239 respondents from 29 countries, including nephrologists (42%) and TS (58%). Although most respondents would investigate microscopic hematuria, one-third of them indicated they would decline these potential donors without investigation. Interestingly, most respondents accepted heavy smokers, intermittent illegal drug users (with advice to quit), and those with incidentally identified kidney stones, remote history of renal colic or simple renal cysts. We found multiple areas of consensus in practice with some interesting differences between nephrologists and TS. Conclusions This survey highlights the practice patterns of the acceptance of MCLKDs among the international community. In the absence of clear guidelines, this survey provides additional information to counsel kidney donors with microscopic hematuria, sickle cell trait, renal cysts, kidney stones, heavy smoking, or illegal drug use.
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Affiliation(s)
- Ziad Arabi
- Department of the Organ Transplant Center, Division of Adult Transplant Nephrology, King Abdulaziz Medical City, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdullah Hamad
- Department of Medicine, Division of Nephrology, Regional Medical Center of Orangeburg and Calhoun Counties, Orangeburg, South Carolina, United Sates
| | - Muhammad Bukhari
- Department of Medicine, Division of Adult Nephrology, Taif University, Taif, Saudi Arabia
| | - Abdulrahman Altheaby
- Department of the Organ Transplant Center, Division of Adult Transplant Nephrology, King Abdulaziz Medical City, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Saleh Kaysi
- Department of Medicine, Division of Nephrology, CHU Clermont-Ferrand, France
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Lentine KL, Pastan S, Mohan S, Reese PP, Leichtman A, Delmonico FL, Danovitch GM, Larsen CP, Harshman L, Wiseman A, Kramer HJ, Vassalotti J, Joseph J, Longino K, Cooper M, Axelrod DA. A Roadmap for Innovation to Advance Transplant Access and Outcomes: A Position Statement From the National Kidney Foundation. Am J Kidney Dis 2021; 78:319-332. [PMID: 34330526 DOI: 10.1053/j.ajkd.2021.05.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 05/01/2021] [Indexed: 02/07/2023]
Abstract
Over the past 65 years, kidney transplantation has evolved into the optimal treatment for patients with kidney failure, dramatically reducing suffering through improved survival and quality of life. However, access to transplant is still limited by organ supply, opportunities for transplant are inequitably distributed, and lifelong transplant survival remains elusive. To address these persistent needs, the National Kidney Foundation convened an expert panel to define an agenda for future research. The key priorities identified by the panel center on the needs to develop and evaluate strategies to expand living donation, improve waitlist management and transplant readiness, maximize use of available deceased donor organs, and extend allograft longevity. Strategies targeting the critical goal of decreasing organ discard that warrant research investment include educating patients and clinicians about potential benefits of accepting nonstandard organs, use of novel organ assessment technologies and real-time decision support, and approaches to preserve and resuscitate allografts before implantation. The development of personalized strategies to reduce the burden of lifelong immunosuppression and support "one transplant for life" was also identified as a vital priority. The panel noted the specific goal of improving transplant access and graft survival for children with kidney failure. This ambitious agenda will focus research investment to promote greater equity and efficiency in access to transplantation, and help sustain long-term benefits of the gift of life for more patients in need.
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Affiliation(s)
- Krista L Lentine
- Saint Louis University Center for Abdominal Transplantation, St Louis, MO.
| | - Stephen Pastan
- Department of Medicine, Emory Transplant Center, Atlanta, GA
| | - Sumit Mohan
- Department of Medicine, Columbia University Medical Center, New York, NY
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA
| | - Alan Leichtman
- Department of Medicine, University of Michigan, Ann Arbor, MI
| | | | | | | | - Lyndsay Harshman
- Department of Pediatrics, University of Iowa Transplant Institute, Iowa City, IA
| | - Alexander Wiseman
- Department of Medicine, Centura Health-Porter Adventist Hospital, Aurora, CO
| | | | - Joseph Vassalotti
- National Kidney Foundation, New York, NY; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | - Matthew Cooper
- Department of Surgery, Medstar Georgetown Transplant Institute, Washington, DC
| | - David A Axelrod
- Department of Surgery, University of Iowa Transplant Institute, Iowa City, IA
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Harper KC, Salameh JP, Akhlaq N, McInnes MDF, Ivankovic V, Beydoun MH, Clark EG, Zeng W, Blew BDM, Burns KD, Sood MM, Bugeja A. The impact of measuring split kidney function on post-donation kidney function: A retrospective cohort study. PLoS One 2021; 16:e0253609. [PMID: 34214103 PMCID: PMC8253423 DOI: 10.1371/journal.pone.0253609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 06/08/2021] [Indexed: 11/30/2022] Open
Abstract
Background Studies have reported agreement between computed tomography (CT) and renography for the determination of split kidney function. However, their correlation with post-donation kidney function remains unclear. We compared CT measurements with renography in assessment of split kidney function (SKF) and their correlations with post-donation kidney function. Methods A single-centre, retrospective cohort study of 248 donors from January 1, 2009-July 31, 2019 were assessed. Pearson correlations were used to assess post-donation kidney function with renography and CT-based measurements. Furthermore, we examined high risk groups with SKF difference greater than 10% on renography and donors with post-donation eGFR less than 60 mL/min/1.73m2. Results 62% of donors were women with a mean (standard deviation) pre-donation eGFR 99 (20) and post-donation eGFR 67 (22) mL/min/1.73m2 at 31 months of follow-up. Post-donation kidney function was poorly correlated with both CT-based measurements and renography, including the subgroup of donors with post-donation eGFR less than 60 mL/min/1.73m2 (r less than 0.4 for all). There was agreement between CT-based measurements and renography for SKF determination (Bland-Altman agreement [bias, 95% limits of agreement] for renography vs: CT volume, 0.76%, -7.60–9.15%; modified ellipsoid,1.01%, -8.38–10.42%; CC dimension, 0.44%, -7.06–7.94); however, CT missed SKF greater than 10% found by renography in 20 out 26 (77%) of donors. Conclusions In a single centre study of 248 living donors, we found no correlation between CT or renography and post-donation eGFR. Further research is needed to determine optimal ways to predict remaining kidney function after donation.
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Affiliation(s)
- Kelly C. Harper
- Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Jean-Paul Salameh
- Ottawa Hospital Research Institute Clinical Epidemiology Program, Ottawa, Ontario, Canada
| | - Natasha Akhlaq
- Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Matthew D. F. McInnes
- Department of Radiology, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute Clinical Epidemiology Program, Ottawa, Ontario, Canada
| | | | - Mahdi H. Beydoun
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Edward G. Clark
- Division of Nephrology, Department of Medicine, Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Wanzhen Zeng
- Division of Nuclear Medicine, Department of Medicine, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Brian D. M. Blew
- Division of Urology, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Kevin D. Burns
- Division of Nephrology, Department of Medicine, Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Manish M. Sood
- Ottawa Hospital Research Institute Clinical Epidemiology Program, Ottawa, Ontario, Canada
- Division of Nephrology, Department of Medicine, Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Ann Bugeja
- Division of Nephrology, Department of Medicine, Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
- * E-mail:
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Glavinovic T, Vinson AJ, Silver SA, Yohanna S. An Environmental Scan and Evaluation of Quality Indicators Across Canadian Kidney Transplant Centers. Can J Kidney Health Dis 2021; 8:20543581211027969. [PMID: 34262781 PMCID: PMC8243101 DOI: 10.1177/20543581211027969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/15/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Kidney transplantation is the optimal treatment for an individual requiring kidney replacement therapy, resulting in improved survival and quality of life while costing the health care system less than maintenance dialysis. Achieving and maintaining a kidney transplant requires extensive coordination of several different health care services. To improve the quality of kidney transplant care, quality metrics or indicators that encompass all aspects of the individual’s journey to transplant should be measured in a standardized fashion. Objective: To identify, categorize, and evaluate strengths and weaknesses of kidney transplant quality indicators currently being used across Canada. Design: An environmental scan of quality indicators being used by kidney organizations and programs. Setting: A 16-member volunteer pan-Canadian panel with expertise in nephrology, transplant, and quality improvement. Sample: Transplant programs, as well as provincial transplant and kidney agencies across Canada. Methods: Indicators were first categorized based on the period of transplant care and then using the Institute of Medicine and Donabedian frameworks. A 4-member subcommittee rated each indicator using a modified version of the Delphi consensus technique based on the American College of Physician/Agency for Healthcare Research and Quality criteria. Consensus ratings were subsequently shared with the entire 16-member panel for additional comments. Results: We identified 46 measures related to transplant care across 7 Canadian provinces (9 referral and evaluation, 9 waitlist activity and outcomes, 6 hospitalization for transplant surgery, 12 posttransplant care, 6 organ utilization, 4 living donor). We rated 24 indicators (52%) as necessary to distinguish high-quality from low-quality care, most of which measured effective (n = 10) or efficient (n = 6) care. Only 7 (15%) of 46 indicators evaluated person-centered or equitable care. Fourteen common indicators were measured by 5 of 7 provinces, 10 of which were deemed “necessary,” measuring safe (n = 2), effective (n = 5), efficient (n = 2), and equitable (n = 1) care. Limitations: The panel lacked patient and allied health representation. Conclusions: There are a large number of kidney transplant quality indicators currently being used in Canada, some of which are common across provinces and focus primarily on measuring effective care. Person-centered and equitable care indicators were lacking, and only half of these indicators were deemed “necessary” for quality improvement. Our results should complement ongoing work to achieve national consensus on the standardization of quality indicators in kidney transplantation.
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Affiliation(s)
- Tamara Glavinovic
- Department of Medicine, Division of Nephrology, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada
| | - Amanda J Vinson
- Department of Medicine, Division of Nephrology, Nova Scotia Health Authority, Dalhousie University, Halifax, NS, Canada
| | - Samuel A Silver
- Department of Medicine, Division of Nephrology, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Seychelle Yohanna
- Department of Medicine, Division of Nephrology, St. Joseph's Healthcare Hamilton, McMaster University, Hamilton, ON, Canada
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7
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Gaillard F, Jacquemont L, Lazareth H, Albano L, Barrou B, Bouvier N, Buchler M, Titeca-Beauport D, Couzi L, Delahousse M, Ducloux D, Etienne I, Frimat L, Garrouste C, Glotz D, Grimbert P, Hazzan M, Hertig A, Hourmant M, Kamar N, Le Meur Y, Le Quintrec M, Legendre C, Moal V, Moulin B, Mousson C, Pouteil-Noble C, Rieu P, Ouali N, Rostaing L, Thierry A, Toure F, Chemouny J, Delanaye P, Courbebaisse M, Mariat C. Living kidney donor evaluation for all candidates with normal estimated GFR for age. Transpl Int 2021; 34:1123-1133. [PMID: 33774875 DOI: 10.1111/tri.13870] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 03/01/2021] [Accepted: 03/21/2021] [Indexed: 12/01/2022]
Abstract
Multiple days assessments are frequent for the evaluation of candidates to living kidney donation, combined with an early GFR estimation (eGFR). Living kidney donation is questionable when eGFR is <90 ml/min/1.73 m2 (KDIGO guidelines) or 80 ml/min/1.73 m2 (most US centres). However, age-related GFR decline results in a lower eGFR for older candidates. That may limit the number of older kidney donors. Yet, continuing the screening with a GFR measure increases the number of eligible donors. We hypothesized that in-depth screening should be proposed to all candidates with a normal eGFR for age. We compared the evolution of eGFR after donation between three groups of predonation eGFR: normal for age (Sage ) higher than 90 or 80 ml/min/1.73 m2 (S90 and S80, respectively); across three age groups (<45, 45-55, >55 years) in a population of 1825 French living kidney donors with a median follow-up of 5.9 years. In donors younger than 45, postdonation eGFR, absolute- and relative-eGFR variation were not different between the three groups. For older donors, postdonation eGFR was higher in S90 than in S80 or Sage but other comparators were identical. Postdonation eGFR slope was comparable between all groups. Our results are in favour of in-depth screening for all candidates to donation with a normal eGFR for age.
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Affiliation(s)
- François Gaillard
- Department of Nephrology, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Centre de recherche sur l'inflammation, INSERM UMR1149, CNRS EL8252, Laboratoire d'Excellence Inflamex, Université de Paris, Paris, France
| | - Lola Jacquemont
- Nephrology and Renal Transplantation Department, CHU Nantes, Nantes, France
| | - Hélène Lazareth
- Nephrology Department, Hopital Européen Georges Pompidou, Paris, France
| | - Laetitia Albano
- Nephrology and Renal Transplantation Department, Pasteur Hospital, Nice, France
| | - Benoit Barrou
- Urology Department, Pitié-Salpêtrière, Paris, France
| | - Nicolas Bouvier
- Nephrology, Dialysis, Transplantation Department, CHU Cote de Nacre, Caen University, Caen, France
| | - Mathias Buchler
- Service de Néphrologie et Immunologie Clinique, CHU Tours, Université de Tours, Tours, France
| | | | - Lionel Couzi
- Nephrology, Transplantation and Dialysis, CHU Bordeaux, CNRS UMR 5164, Bordeaux University, Bordeaux, France
| | - Michel Delahousse
- Nephrology, Dialysis and Renal Transplantation Department, Foch Hospital, Suresnes, France
| | - Didier Ducloux
- Nephrology, Dialysis and Transplantation Department, CHU Besançon, Besançon, France
| | | | - Luc Frimat
- Nephrology, Dialysis and Transplantation Department, CHU, Nancy, France
| | - Cyril Garrouste
- Nephrology, Dialysis and Transplantation Department, CHU, Clermont Ferrand, France
| | - Denis Glotz
- Department of Nephrology and Renal Transplantation, Hopital Saint Louis, Paris, France
| | - Philippe Grimbert
- Nephrology and Transplantation Department, UPEC University, Créteil, France
| | - Marc Hazzan
- Nephrology Department, University Hospital, Lille, France
| | - Alexandre Hertig
- Nephrology and Transplantation, Hopital Pitié Salpétrière, Paris, France
| | - Maryvonne Hourmant
- Nephrology and Renal Transplantation Department, CHU Nantes, Nantes, France
| | - Nassim Kamar
- Department of Nephrology, Dialysis and Organ Transplantation, CHU Rangueil, INSERM U1043, IFR-BMT, University Paul Sabatier, Toulouse, France
| | - Yann Le Meur
- Department of Nephrology and Renal Transplantation, CHU Brest, Brest, France
| | - Moglie Le Quintrec
- Nephrology, Transplantation and Dialysis Department, CHU Lapeyronie, and IRMB, INSERM U1183, Montpellier, France
| | - Christophe Legendre
- Nephrology and Renal Transplantation Department, Hopital Necker, Paris, France
| | - Valérie Moal
- Nephrology and Renal Transplantation, APHM, Marseille, France
| | - Bruno Moulin
- Nephrology and Transplantation Department, University Hospital, Strasbourg, France
| | | | - Claire Pouteil-Noble
- Renal Transplantation Department, Hospices Civils de Lyon, Claude Bernard University, Lyon, France
| | - Philippe Rieu
- Nephrology and Renal Transplantation Department, University Hospital, Reims, France
| | - Nacera Ouali
- Nephrology and Renal Transplantation, Hopital Tenon, Paris, France
| | - Lionel Rostaing
- Nephrology, Hemodialysis, Apheresis and Transplantation Department, University Hospital, Grenoble, France
| | - Antoine Thierry
- Nephrology Department, University Hospital and Poitiers University, INSERM U1082, Poitiers, France
| | - Fatouma Toure
- Nephrology, Dialysis and Renal Transplantation Department, CHU, Limoges, France
| | - Jonathan Chemouny
- Nephrology, Dialysis and Transplantation Department, University Hospital, Rennes, France
| | - Pierre Delanaye
- Department of Nephrology-Dialysis-Transplantation, University of Liège (ULg CHU), Liège, Belgium.,Department of Nephrology-Dialysis-Apheresis, Hopital Universitaire Caremeau, Nimes, France
| | - Marie Courbebaisse
- Department of Physiology, European Georges Pompidou Hospital, APHP, INSERM U1151, Paris University, Paris, France
| | - Christophe Mariat
- Nephrology, Dialysis and Renal Transplantation Department, Hôpital Nord, CHU de Saint-Etienne, Jean Monnet University, COMUE Université de Lyon, Lyon, France
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8
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Luján P, Chiurchiu C, Capra R, de Arteaga J, de la Fuente J, Douthat W. Post-kidney donation glomerular filtration rate measurement and estimation. Nefrologia 2021; 41:191-199. [PMID: 36165380 DOI: 10.1016/j.nefroe.2020.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 07/10/2020] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Long-term consequences associated with kidney donation are controversial. Pre- and post-donation glomerular filtration rates (GFRs) are determinants of renal and cardiovascular risk weighting. In Latin America, there is limited experience in evaluating kidney function using GFR measurement techniques in kidney donors. The MDRD 4-variable and CKD-EPI equations are considered reasonable options. The objective of this study was to evaluate the performance of the MDRD and CKD-EPI equations in post-nephrectomy GFR dynamics in kidney donors. MATERIALS AND METHODS A prospective cohort study with GFR measurement and estimation in 189 kidney donors who underwent nephrectomy between 2007 and 2016 at the Hospital Privado Universitario de Córdoba [Private University Hospital of Córdoba] in Córdoba, Argentina. GFRs were evaluated before and after nephrectomy by iothalamate clearance determined by HPLC and by the MDRD and CKD-EPI equations for estimating GFR. Two groups were formed for this study: Group 1 (n=107), with an evaluation time subsequent to GFR stabilization (3 months) of up to 5 years, and Group 2 (n=82), with an evaluation time of 5-10 years following donation. Measured GFR (mGFR) was assessed by iothalamate clearance determined by HPLC. RESULTS Renal compensation values were 61.9% (52.0%-71.1%) and 75.6% (64.9%-84.4%) for Group 1 (n=107) and Group 2 (n=82), respectively. MDRD underestimated the GFR in 3.2% (90ml/min/1.73m2) and 38.6% (60ml/min/1.73m2) compared to the mGFR, and CKD-EPI underestimated the GFR in 2.6% (90ml/min/1.73m2) and 13.8% (60ml/min/1.73m2). Diagnostic performance was evaluated with a ROC curve (mGFR<60ml/min/1.73m2) for MDRD (ABC=0.66; CI: 0.59-0.73; sensitivity: 98.7%; specificity: 63.3%) and for CKD-EPI (ABC=0.79 CI: 0.73-0.85; sensitivity: 96.9%; specificity: 76.4%. Estimated GFR (eGFR) showed poor performance for estimating the glomerular filtration rate in the post-nephrectomy follow-up of donors over 50 years of age. CONCLUSIONS Equations for estimating GFRs showed poor performance for long-term follow-up of post-nephrectomy GFRs. Measuring GFRs to determine kidney function is recommended in the screening and follow-up of some donors under the current selection criteria.
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Affiliation(s)
- Pablo Luján
- Laboratorio de Bioquímica Clínica, Hospital Privado Universitario de Córdoba, Córdoba, Argentina.
| | - Carlos Chiurchiu
- Servicio de Nefrología, Hospital Privado Universitario de Córdoba y Carrera de posgrado de Nefrología, Universidad Católica de Córdoba, Córdoba, Argentina
| | - Raúl Capra
- Laboratorio de Bioquímica Clínica, Hospital Privado Universitario de Córdoba, Córdoba, Argentina
| | - Javier de Arteaga
- Servicio de Nefrología, Hospital Privado Universitario de Córdoba y Carrera de posgrado de Nefrología, Universidad Católica de Córdoba, Córdoba, Argentina
| | - Jorge de la Fuente
- Servicio de Nefrología, Hospital Privado Universitario de Córdoba y Carrera de posgrado de Nefrología, Universidad Católica de Córdoba, Córdoba, Argentina
| | - Walter Douthat
- Servicio de Nefrología, Hospital Privado Universitario de Córdoba y Carrera de posgrado de Nefrología, Universidad Católica de Córdoba, Córdoba, Argentina
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Clark EG, Knoll G. More than ever, efficient evaluation of potential living kidney donors is needed. Kidney Int 2020; 98:1395-1397. [PMID: 33276864 DOI: 10.1016/j.kint.2020.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 07/31/2020] [Indexed: 10/22/2022]
Abstract
In this issue, Habbous et al. reported that simultaneously evaluating multiple potential living kidney donors for the same intended recipient, rather than sequentially, is more effective and less expensive. This important study highlighted how quicker living kidney donor evaluations benefit patients and lower costs by reducing time spent on dialysis. Given the backlog precipitated by the coronavirus disease 2019 pandemic, devoting resources to ensure efficient living kidney donor evaluations is a better investment than ever before.
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Affiliation(s)
- Edward G Clark
- Division of Nephrology, Department of Medicine and Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Greg Knoll
- Division of Nephrology, Department of Medicine and Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
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10
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Habbous S, Barnieh L, Klarenbach S, Manns B, Sarma S, Begen MA, Litchfield K, Lentine KL, Singh S, Garg AX. Evaluating multiple living kidney donor candidates simultaneously is more cost-effective than sequentially. Kidney Int 2020; 98:1578-1588. [DOI: 10.1016/j.kint.2020.06.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 05/13/2020] [Accepted: 06/04/2020] [Indexed: 01/11/2023]
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11
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Habbous S, Barnieh L, Litchfield K, McKenzie S, Reich M, Lam NN, Mucsi I, Bugeja A, Yohanna S, Mainra R, Chong K, Fantus D, Prasad GVR, Dipchand C, Gill J, Getchell L, Garg AX. A RAND-Modified Delphi on Key Indicators to Measure the Efficiency of Living Kidney Donor Candidate Evaluations. Clin J Am Soc Nephrol 2020; 15:1464-1473. [PMID: 32972951 PMCID: PMC7536753 DOI: 10.2215/cjn.03780320] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 07/16/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES Many patients, providers, and potential living donors perceive the living kidney donor evaluation process to be lengthy and difficult to navigate. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We sought consensus on key terms and process and outcome indicators that can be used to measure how efficiently a transplant center evaluates persons interested in becoming a living kidney donor. Using a RAND-modified Delphi method, 77 participants (kidney transplant recipients or recipient candidates, living kidney donors or donor candidates, health care providers, and health care administrators) completed an online survey to define the terms and indicators. The definitions were then further refined during an in-person meeting with ten stakeholders. RESULTS We identified 16 process indicators (e.g., average time to evaluate a donor candidate), eight outcome indicators (e.g., annual number of preemptive living kidney donor transplants), and two measures that can be considered both process and outcome indicators (e.g., average number of times a candidate visited the transplant center for the evaluation). Transplant centers wishing to implement this set of indicators will require 22 unique data elements, all of which are either readily available or easily collected prospectively. CONCLUSIONS We identified a set of indicators through a consensus-based approach that may be used to monitor and improve the performance of a transplant center in how efficiently it evaluates persons interested in becoming a living kidney donor.
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Affiliation(s)
- Steven Habbous
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada .,Quality, Measurement, and Evaluation, Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - Lianne Barnieh
- Department of Nephrology, London Health Sciences Centre, London, Ontario, Canada
| | - Kenneth Litchfield
- Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease, Canada
| | - Susan McKenzie
- Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease, Canada
| | - Marian Reich
- Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease, Canada
| | - Ngan N Lam
- Division of Nephrology, University of Calgary, Calgary, Alberta, Canada
| | - Istvan Mucsi
- Kidney Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Ann Bugeja
- Division of Nephrology, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Seychelle Yohanna
- Division of Nephrology, McMaster University, Hamilton, Ontario, Canada
| | - Rahul Mainra
- Saskatchewan Transplant Program, Saskatoon Health Region, Saskatoon, Saskatchewan, Canada
| | - Kate Chong
- Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease, Canada
| | - Daniel Fantus
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - G V Ramesh Prasad
- Kidney Transplant Program, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Christine Dipchand
- Division of Nephrology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jagbir Gill
- Division of Nephrology, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Leah Getchell
- Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease, Canada
| | - Amit X Garg
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada.,Department of Nephrology, London Health Sciences Centre, London, Ontario, Canada
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12
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Akoh JA, Schumacher KJ. Living kidney donor assessment: Kidney length vs differential function. World J Transplant 2020; 10:173-182. [PMID: 32742950 PMCID: PMC7360526 DOI: 10.5500/wjt.v10.i6.173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 05/19/2020] [Accepted: 05/21/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The key question in living kidney donor assessment is how best to determine the contribution of each kidney to overall renal function and guide selection of which kidney to donate, ensuring safety of procedure and good outcome for both recipient and donor. It is thought that a length difference > 2 cm may indicate significant difference in function and therefore need for measurement of differential function. AIM To determine the effect of using kidney length to decide which kidney to donate in a retrospective cohort of potential donors. METHODS All 333 potential living kidney donors between January 2009 and August 2018 who completed assessment were retrospectively evaluated. Donor assessment was performed as per United Kingdom guidelines. Data included age, sex, kidney length (cranio-caudal) obtained by computed tomography/ultrasono-graphy,51-chromium ethylenediamine tetraacetatic acid measured glomerular filtration rate, mercapto acetyl tri glycine split function and vascular anatomy. There were 48 exclusions due to inadequate data or incomplete investigations. Statistical analysis was performed using Excel pivot tables and GraphPad Prism. Correlation between kidney length and differential function was determined with Pearson's correlation coefficient. RESULTS Of 285 potential donors included in the study, there were 144 males (mean age 49.9 ± 14.75) and 141 females (mean age 51.2 ± 11.23). Overall, the Pearson's correlation between differences in length and divided function of kidney pairs was 0.1630, P = 0.0058. Of 73 with significant difference (> 10%) in divided function, 18 (24.7%) had no difference in kidney length; 54 (74%) had a difference of < 2 cm and only one of > 2 cm. Using a length difference of > 1 cm would only predict significant difference in divided function in 8/34 (23.5%) of cases. Using a difference of > 2 cm as cut off for performing split function would lead to false reassurance in 72 patients (6 had > 20% difference in divided function whereas 66 had 10%-20% difference). CONCLUSION Length difference between kidney pairs alone is not sufficient to replace measurement of divided function. This issue requires a randomised controlled trial to resolve it.
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Affiliation(s)
- Jacob A Akoh
- Department of Surgery, Derriford Hospital, University Hospitals Plymouth NHS Trust, Plymouth PL6 8DH, Devon, United Kingdom
- South West Transplant Centre, Derriford Hospital, University Hospitals Plymouth NHS Trust, Plymouth PL6 8DH, Devon, United Kingdom
| | - Katharina J Schumacher
- Department of Surgery, Derriford Hospital, University Hospitals Plymouth NHS Trust, Plymouth PL6 8DH, Devon, United Kingdom
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13
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Efficacy of Educational Interventions in Improving Measures of Living-donor Kidney Transplantation Activity: A Systematic Review and Meta-analysis. Transplantation 2020; 103:2566-2575. [PMID: 30946222 DOI: 10.1097/tp.0000000000002715] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND To address patient-level barriers to living-donor kidney transplantation (LDKT), centers have implemented educational interventions. Recently, some have highlighted several gaps in knowledge and lack of evidence of efficacy of these interventions. No review has synthesized the available data. METHODS We conducted a systematic review and meta-analysis of studies conducted to increase measures of LDKT. Outcomes of interest were LDKT rates, donor evaluation, donor contact/inquiry, total transplantation rates, and change in knowledge scores and pursuit behaviors. A literature search was conducted across 7 databases from inception until 2017. Educational interventions were a decision/teaching aid alone or with personalized sessions. Comparator was another intervention or nonspecific education. Random effects meta-analysis was performed to pool risk ratios (RRs) across studies. RESULTS Of the 1813 references, 15 met the inclusion criteria; 9 were randomized control trials. When compared with nonspecific education, interventions increased LDKT rates (RR = 2.54; 95% confidence interval [CI], 1.49-4.35), donor evaluation (RR = 3.82; 95% CI, 1.91-7.64), and donor inquiry/contact (RR = 2.41; 95% CI, 1.53-3.80), but not total transplants (RR = 1.24; 95% CI, 0.96-1.61). Significant increased mean knowledge scores postintervention was noted, and most showed favorable trends in pursuit behaviors. Quality across the studies was mixed and sometimes difficult to assess. The biggest limitations were small sample size, selection bias, and short follow-ups. CONCLUSIONS Educational interventions improve measures of LDKT activity; however, current literature is heterogeneous and at risk of selection bias. Prospective studies with diverse patient populations, longer follow-ups, and robust outcomes are needed to inform clinical practice.
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Habbous S, Garcia-Ochoa C, Brahm G, Nguan C, Garg AX. Can Split Renal Volume Assessment by Computed Tomography Replace Nuclear Split Renal Function in Living Kidney Donor Evaluations? A Systematic Review and Meta-Analysis. Can J Kidney Health Dis 2019; 6:2054358119875459. [PMID: 31555456 PMCID: PMC6753513 DOI: 10.1177/2054358119875459] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 07/18/2019] [Indexed: 12/13/2022] Open
Abstract
Background: As part of their living kidney donor assessment, all living donor candidates
complete a computed tomography (CT) angiogram, but some also receive a
nuclear renogram for split renal function (SRF%). Objective: We considered whether split renal volume (SRV%) assessed by CT can predict
SRF%. Design: Systematic review and meta-analysis. Setting: Living donor candidates undergoing evaluation as potential living kidney
donors. Patients: Living donor candidates who received both a nuclear renogram for split
function and CT for SRV as part of their living donor work-up. Measurements: Split renal volume from CT scans and SRF from nuclear renography. Methods: We performed a systematic review and meta-analysis of the literature,
abstracting data and digitizing plots where possible. We searched Medline,
EMBASE, and the Cochrane Library. We added data from donor candidates
assessed in London, Ontario from 2013 to 2016. We used fixed and
random-effects models to pool Fisher’s z-transformed
Pearson’s correlation coefficient (r). We conducted
random-effects meta-regression on digitized and aggregate data. Studies were
restricted to living kidney donors or living donor candidates. Results: After pooling 19 studies (n = 1479), we obtained a pooled correlation of
r = 0.74 (95% confidence interval [CI] = 0.61-0.82). By
linear regression using individual-level data, we observed a 0.76% (95% CI =
0.71-0.81) increase in SRF% for every 1% increase in SRV%. Split renal
volume had a specificity of 88% for discriminating SRF at a threshold that
could influence the decision of which kidney is to be removed
(between-kidney difference ≥10%). Predonation SRV and SRF both moderately
predicted kidney function 6 to 12 months after donation: r
= 0.75 for SRV and r = 0.73 for SRF; Δr =
0.05 (–0.02, 0.13). Limitations: Most studies were retrospective and measured SRV and SRF only on selected
living donor candidates. Efficiency gains in removing the SRF from the
evaluation will depend on the transplant program. Conclusion: Split renal volume has the potential to replace SRF for some candidates.
However, it is uncertain whether it can do so reliably and routinely across
different transplant centers. The impact on clinical decision-making needs
to be assessed in well-designed prospective studies. Trial registration: The digitized data are registered with Mendeley Data
(doi10.17632/dyn2bfgxxj.2).
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Affiliation(s)
- Steven Habbous
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Carlos Garcia-Ochoa
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Gary Brahm
- Department of Radiology, London Health Sciences, ON, Canada
| | | | - Amit X Garg
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.,Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
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15
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Bozkurt O, Uyar M, Demir ÜF. Determination of Health Anxiety Level in Living Organ Donation. Transplant Proc 2019; 51:1139-1142. [PMID: 31101187 DOI: 10.1016/j.transproceed.2019.01.097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 01/21/2019] [Indexed: 10/27/2022]
Abstract
The aim of this study was to determine the level of pre-donation health anxiety using the Short Form Health Anxiety Inventory (SHAI) questionnaire for persons who applied to donate their kidney to a relative in need, and to evaluate whether there was a difference between these donors and a control group who did not experience health problems. The study group was comprised of 30 patients who applied for kidney donation to a relative, while the control group was comprised of 30 age- and sex-adjusted healthy subjects whose relatives did not have any health problems. The SHAI, consisting of 18 questions and some sociodemographic characteristics, was administered to both groups. The study group consisted of 60 participants, 28 (46.7%) of whom were male and 32 (53.3%) of whom were female. The mean SHAI score of the case group was 10.3 ± 7.3, while the mean of the control group was 17.6 ± 8.5. The difference between the groups was statistically significant (P = .001). The mean score of those who were donating to their wife or husband was 20.0 ± 11.7, while the mean score of those who donated to other relatives was 9.2 ± 6.1. The difference was significant (P = .014). Our study found that the case group had significantly lower health anxiety than the control group. Furthermore, those who were donating to their spouse were found to have higher anxiety than those who were donating to other relatives.
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Affiliation(s)
- O Bozkurt
- Department of Psychiatry, Yeniyuzyil University Gaziosmanpasa Hospital, İstanbul, Turkey.
| | - M Uyar
- Department of Internal Medicine and Organ Transplantation, Yeniyuzyil University Gaziosmanpasa Hospital, İstanbul, Turkey
| | - Ü F Demir
- Department of Neurology, Yeniyuzyil University Gaziosmanpasa Hospital, İstanbul, Turkey
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