The Long-Term Follow-up and Support for Living Organ Donors: A Center-Based Initiative Founded on Developing a Community of Living Donors

Living donor liver transplantation: A multi-disciplinary collaboration towards growth, consensus, and a change in culture

INTRODUCTION

Living donor liver transplantation (LDLT) reduces liver transplant waitlist mortality and provides excellent long-term outcomes for persons with end stage liver disease. Yet, utilization of LDLT has been limited in the United States (US).

METHODS

In October 2021, the American Society of Transplantation held a consensus conference to identify important barriers to broader expansion of LDLT in the US, including data gaps, and make recommendations for impactful and feasible mitigation strategies to overcome these barriers. Domains addressed encompassed the entirety of the LDLT process. Representation from international centers and living donor kidney transplantation were included for their perspective/experience in addition to members across disciplines within the US liver transplantation community. A modified Delphi approach was employed as the consensus methodology.

RESULTS

The predominant theme permeating discussion and polling results centered on culture; the beliefs and behaviors of a group of people perpetuated over time.

CONCLUSIONS

Creating a culture of support for LDLT in the US is key for expansion and includes engagement and education of stakeholders across the spectrum of the process of LDLT. A shift from awareness of LDLT to acknowledgement of benefit of LDLT is the primary goal. Propagation of the maxim "LDLT is the best option" is pivotal.

Managing the Costs of Routine Follow-up Care After Living Kidney Donation: a Review and Survey of Contemporary Experience, Practices, and Challenges

Purpose of Review

While living organ donor follow-up is mandated for 2 years in the USA, formal guidance on recovering associated costs of follow-up care is lacking. In this review, we discuss current billing practices of transplant programs for living kidney donor follow-up, and propose future directions for managing follow-up costs and supporting cost neutrality in donor care.

Recent Findings

Living donors may incur costs and financial risks in the donation process, including travel, lost time from work, and dependent care. In addition, adherence to the Organ Procurement and Transplantation Network (OPTN) mandate for US transplant programs to submit 6-, 12-, and 24-month postdonation follow-up data to the national registry may incur out-of-pocket medical costs for donors. Notably, the Centers for Medicare and Medicaid Services (CMS) has explicitly disallowed transplant programs to bill routine, mandated follow-up costs to the organ acquisition cost center or to the recipient’s Medicare insurance. We conducted a survey of transplant staff in the USA (distributed October 22, 2020–March 15, 2021), which identified that the mechanisms for recovering or covering the costs of mandated routine postdonation follow-up at responding programs commonly include billing recipients’ private insurance (40%), while 41% bill recipients’ Medicare insurance. Many programs reported utilizing institutional allowancing (up to 50%), and some programs billed the organ acquisition cost center (25%). A small percentage (11%) reported billing donors or donors’ insurance.

Summary

To maintain a high level of adherence to living donor follow-up without financially burdening donors, up-to-date resources are needed on handling routine donor follow-up costs in ways that are policy-compliant and effective for donors and programs. Development of a government-supported national living donor follow-up registry like the Living Donor Collective may provide solutions for aspects of postdonation follow-up, but requires transplant program commitment to register donors and donor candidates as well as donor engagement with follow-up outreach contacts after donation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40472-022-00379-w.

A Content Analysis of Living Organ Donation Materials from Certified Transplant Centers

Despite the fact that living organ donation has the great potential to reduce the shortage of transplantable organs, it is still surrounded by many misconceptions, ethical concerns, and myths. Research conducted to understand factors contributing to public misconceptions related to living organ donation is rare. This research takes a content analytic approach to uncover how living organ donation is portrayed in materials developed and delivered by transplant centers across 11 regions. A total of 332 unique materials were analyzed. The results revealed that living kidney donation dominated the corpus of data whereas other living organ donations were largely overlooked. Benefits and risks associated with living organ donation were relatively evenly presented; however, social support necessary to donors and recipients and available resources to obtain social support were not sufficiently addressed. Embedded in these materials were 46 personal narrative stories. Analysis of these stories showed a focus on undirected living organ donation and revealed a wide range of emotional experiences. Significant regional differences were found in several themes, such as benefits and risks, and social support. Inconsistent information regarding living organ donation was present. Practical implications are discussed.

Quantifying Risk Tolerance Among Potential Living Kidney Donors With the Donor-Specific Risk Questionnaire

RATIONALE & OBJECTIVE

Enhanced informed consent tools improve patient engagement. A novel visual aid measured potential donors' risk tolerance to postdonation kidney failure and assessed if the closeness of the relationship to the intended recipient altered willingness to accept risk.

STUDY DESIGN

Cross-sectional analysis of donor evaluations at the time of enrollment into a longitudinal mixed-methods study between November 2014 and February 2016.

SETTING & PARTICIPANTS

Three US kidney transplant centers. English-speaking adults presenting for in-person living kidney donor evaluation.

EXPOSURE

Closeness of the relationship between the potential living donor and intended recipient.

OUTCOME

Willingness to accept postdonation kidney failure.

ANALYTICAL APPROACH

The Donor-Specific Risk Questionnaire, a dot matrix visual diagram, was used to measure willingness to accept kidney failure risk. Multivariable logistic regression assessed associations between risk acceptance and data from social science instruments, which measured donors' perceived closeness with the recipient. Qualitative data were analyzed thematically per grounded theory.

RESULTS

307 participants (response rate: 86%) completed testing. 96% indicated a willingness to accept a risk of kidney failure of 0.9% or greater. Those who were older (OR, 0.98 [95% CI, 0.96-0.99]), women (OR, 0.54 [95% CI, 0.31-0.93]), and Black (OR, 0.25 [95% CI, 0.08-0.76]) were less likely to be in the medium versus low willingness to accept risk group. Closeness of the relationship to the recipient was independently associated with greater risk acceptance (for every 1-point greater closeness score, odds ratios for being in the medium and high willingness to accept risk groups were 1.21 [95% CI, 1.03-1.41] and 2.42 [95% CI, 1.53-3.82] compared with being in the low willingness to accept risk group). With the exception of parental relationships, biological linkages were not associated with accepting higher kidney failure risk.

LIMITATIONS

First demonstration of visual aid that used one risk estimate of kidney failure provided to all participants. Risk estimates were not customized to different demographic groups.

CONCLUSIONS

Relationship closeness was independently associated with a greater willingness to accept postdonation kidney failure. Visual aids can provide transplant teams with individualized donor perspectives on risk thresholds and can potentially facilitate greater patient-centered care for living donors.

Care of international living kidney donor candidates in the United States: A survey of contemporary experience, practice, and challenges

The evaluation and care of non-US citizen, non-US residents who wish to come to the United States to serve as international living kidney donors (ILKDs) can pose unique challenges. We surveyed US transplant programs to better understand practices related to ILKD care. We distributed the survey by email and professional society list-servs (Fall 2018, assessing 2017 experience). Eighty-five programs responded (36.8% program response rate), of which 80 considered ILKD candidates. Only 18 programs had written protocols for ILKD evaluation. Programs had a median of 3 (range: 0,75) ILKD candidates who initiated contact during the year, from origin countries spanning 6 continents. Fewer (median: 1, range: 0,25) were approved for donation. Program-reported reasons for not completing ILKD evaluations included visa barriers (58.6%), inability to complete evaluation (34.3%), concerns regarding follow-up (31.4%) or other healthcare access (28.6%), and financial impacts (21.4%). Programs that did not evaluate ILKDs reported similar concerns. Staff time required to evaluate ILKDs was estimated as 1.5-to-3-times (47.9%) or >3-times (32.9%) that needed for domestic candidates. Among programs accepting ILKDs, on average 55% reported successful completion of 1-year follow-up. ILKD evaluation is a resource-intensive process with variable outcomes. Planning and commitment are necessary to care for this unique candidate group.

Billing for living kidney donor care: Balancing cost recovery, regulatory compliance, and minimized donor burden

PURPOSE

To provide standardized guidance for transplant programs to maximize financial reimbursement related to living donor care, and to minimize financial consequences of evaluation, surgical and follow-up care to living donor candidates and donors.

RECENT FINDINGS

In 2014, the American Society for Transplantation (AST) Live Donor Community of Practice (LDCOP) "Consensus Conference on Best Practices in Live Kidney Donation" identified inconsistencies in billing practices as a barrier to living donor financial neutrality, and issued a strong recommendation that the transplant community actively pursue strategies and policies to make living donation a financially neutral act, within the framework of federal law. The LDCOP convened a multidisciplinary group of experts to review and synthesize current Medicare regulations and commercial payer practices related to billing for living donor care, and the implications for transplant programs and patients. We developed guidance for transplant program staff related to strategies to consistently and appropriately obtain reimbursement via the Medicare Cost Report by utilizing organ acquisition; coordinate available coverage for donor pretesting, evaluation, hospitalization, follow-up care, and complications; coordinate charges in kidney paired donation; and maximize coverage through private insurance contracting. We also offer recommendations to protect donor confidentiality in the context of billing, and to educate and prepare donor candidates and donors about any remaining gaps in coverage related to donation.

SUMMARY

Best practices in billing for living donation-related care should focus on balancing cost recovery, regulatory compliance, and minimized donor burden. Herein we offer 9 recommendations for best practice. We also offer a platform of 7 recommendations for research & advocacy efforts to better understand the climate of living donor medical costs, and to optimize billing practices that support provision of living donor transplant services to all patients who can benefit and to achieve financial neutrality for living donors.

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

Background

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

Objective

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

Design

Retrospective cohort study using linked health care databases.

Setting

Alberta, Canada (2002-2014).

Patients

Living kidney donors.

Measurements

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

Results

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

Limitations

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

Conclusions

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

The National Landscape of Living Kidney Donor Follow-Up in the United States

In 2013, the Organ Procurement and Transplantation Network (OPTN)/ United Network for Organ Sharing (UNOS) mandated that transplant centers collect data on living kidney donors (LKDs) at 6 months, 1 year, and 2 years postdonation, with policy-defined thresholds for the proportion of complete living donor follow-up (LDF) data submitted in a timely manner (60 days before or after the expected visit date). While mandated, it was unclear how centers across the country would perform in meeting thresholds, given potential donor and center-level challenges of LDF. To better understand the impact of this policy, we studied Scientific Registry of Transplant Recipients data for 31,615 LKDs between January 2010 and June 2015, comparing proportions of complete and timely LDF form submissions before and after policy implementation. We also used multilevel logistic regression to assess donor- and center-level characteristics associated with complete and timely LDF submissions. Complete and timely 2-year LDF increased from 33% prepolicy (January 2010 through January 2013) to 54% postpolicy (February 2013 through June 2015) (p < 0.001). In an adjusted model, the odds of 2-year LDF increased by 22% per year prepolicy (p < 0.001) and 23% per year postpolicy (p < 0.001). Despite these annual increases in LDF, only 43% (87/202) of centers met the OPTN/UNOS-required 6-month, 1-year, and 2-year LDF thresholds for LKDs who donated in 2013. These findings motivate further evaluation of LDF barriers and the optimal approaches to capturing outcomes after living donation.

KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors

The 2017 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors is intended to assist medical professionals who evaluate living kidney donor candidates and provide care before, during and after donation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach and guideline recommendations are based on systematic reviews of relevant studies that included critical appraisal of the quality of the evidence and the strength of recommendations. However, many recommendations, for which there was no evidence or no systematic search for evidence was undertaken by the Evidence Review Team, were issued as ungraded expert opinion recommendations. The guideline work group concluded that a comprehensive approach to risk assessment should replace decisions based on assessments of single risk factors in isolation. Original data analyses were undertaken to produce a "proof-in-concept" risk-prediction model for kidney failure to support a framework for quantitative risk assessment in the donor candidate evaluation and defensible shared decision making. This framework is grounded in the simultaneous consideration of each candidate's profile of demographic and health characteristics. The processes and framework for the donor candidate evaluation are presented, along with recommendations for optimal care before, during, and after donation. Limitations of the evidence are discussed, especially regarding the lack of definitive prospective studies and clinical outcome trials. Suggestions for future research, including the need for continued refinement of long-term risk prediction and novel approaches to estimating donation-attributable risks, are also provided.In citing this document, the following format should be used: Kidney Disease: Improving Global Outcomes (KDIGO) Living Kidney Donor Work Group. KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Transplantation. 2017;101(Suppl 8S):S1-S109.