“It was just an unconditional gift.” Self reflections of non-directed living kidney donors

Living Kidney Donation: A Narrative Review of Mid- and Long-term Psychosocial Outcomes

Living kidney donors make a significant contribution to alleviating the organ shortage. The aim of this article is to provide an overview of mid- and long-term (≥12 mo) living donor psychosocial outcomes and highlight areas that have been understudied and should be immediately addressed in both research and clinical practice. We conducted a narrative review by searching 3 databases. A total of 206 articles were included. Living donors can be divided into those who donate to an emotionally or genetically related person, the so-called directed donors, or to an emotionally or genetically unrelated recipient, the so-called nondirected donors. The most commonly investigated (bio)psychosocial outcome after living donation was health-related quality of life. Other generic (bio)psychological outcomes include specific aspects of mental health such as depression, and fatigue and pain. Social outcomes include financial and employment burdens and problems with insurance. Donation-specific psychosocial outcomes include regret, satisfaction, feelings of abandonment and unmet needs, and benefits of living kidney donation. The experience of living donation is complex and multifaceted, reflected in the co-occurrence of both benefits and burden after donation. Noticeably, no interventions have been developed to improve mid- or long-term psychosocial outcomes among living donors. We highlight areas for methodological improvement and identified 3 areas requiring immediate attention from the transplant community in both research and clinical care: (1) recognizing and providing care for the minority of donors who have poorer long-term psychosocial outcomes after donation, (2) minimizing donation-related financial burden, and (3) studying interventions to minimize long-term psychosocial problems.

Understanding the Healthcare Needs of Living Kidney Donors Using the Picker Principles of Patient-centered Care: A Scoping Review

Living kidney donors (LKDs) undertake a complex and multifaceted journey when pursuing donation and have several unmet healthcare needs. A comprehensive understanding of these needs across their entire donation trajectory can help develop a patient-centered care model. We conducted a scoping review to synthesize empirical evidence, published since 2000, on LKDs' experiences with healthcare from when they decided to pursue donation to postdonation care, and what they reported as their care needs. We categorized them according to the 8 Picker principles of patient-centered care. Of the 4514 articles screened, 47 were included. Ample literature highlighted the need for (1) holistic, adaptable, and linguistically appropriate approaches to education and information; (2) systematic, consistent, and proactive coordination and integration of care; and (3) self-management and preparation to optimize perioperative physical comfort. Some literature highlighted the need for (4) better continuity and transition of care postdonation. Two key unmet needs were the lack of (5) a holistic psychosocial evaluation predonation and predischarge to provide emotional support and alleviation of fear and anxiety; and (6) access to specialty and psychosocial services postdonation especially when adverse events occurred. Limited literature explored the principles of (7) respect for patients' values, preferences, and expressed needs; and (8) involvement of family and friends as caregivers. We summarize several unmet healthcare needs of LKDs throughout their donation journey and highlight knowledge gaps. Addressing them can improve their well-being and experiences, and potentially address inequities in living kidney donation and increase living donor kidney transplantation.

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.

Examining behavioural intention towards organ donation in Hong Kong

Although many people report favourable attitudes towards organ donation, Hong Kong has one of the lowest rates of organ donation globally. The present study examined behavioural intention towards organ donation. A convenience sample of 225 Hong Kong Chinese adults (118 = female) aged 18-82 years were recruited to an online survey. Behavioural intention, attitudes, subjective norms, self-efficacy, knowledge and altruism were examined. ANOVA was conducted to examine key differences based on behavioural intention, regression then examined predictors of behavioural intention to donate before exploratory analysis examined the mediating role of subjective norms on the relationship between self-efficacy and behavioural intention. Findings revealed over one third (38%) of respondents were actively registered as organ donors. Women were significantly more likely to be registered as organ donors. Subjective norms and self-efficacy were strong predictors of behavioural intention to donate, and subjective norms significantly mediated the relationship between self-efficacy and behavioural intention to donate.

Twenty Years of Unspecified Kidney Donation: Unspecified Donors Looking Back on Their Donation Experiences

The Netherlands was the first European country to implement unspecified kidney donation in 2000. This qualitative study aimed to evaluate the experiences of unspecified kidney donors (UKDs) in our transplant institute to improve the care for this valuable group of donors. We conducted semi-structured interviews with 106 UKDs who donated between 2000-2016 (response rate 84%). Interviews were audio-recorded, transcribed verbatim and independently coded by 2 researchers in NVivo using thematic analysis. The following 14 themes reflecting donor experiences were found: Satisfaction with donation; Support from social network; Interpersonal stress; Complaints about hospital care; Uncertainty about donor approval; Life on hold between approval and actual donation; Donation requires perseverance and commitment; Recovery took longer than expected; Normalization of the donation; Becoming an advocate for living kidney donation; Satisfaction with anonymity; Ongoing curiosity about outcome or recipient; Importance of anonymous communication; Anonymity is not watertight. The data reinforced that unspecified kidney donation is a positive experience for donors and that they were generally satisfied with the procedures. Most important complaints about the procedure concerned the length of the assessment procedure and the lack of acknowledgment for UKDs from both their recipients and health professionals. Suggestions are made to address the needs of UKDs.

A qualitative systematic review of anonymous/unspecified living kidney and liver donors' perspectives

OBJECTIVES & BACKGROUND

Anonymous live organ donors or unspecified donors are individuals willing to be organ donors for any transplant recipient with whom they have no biological or antecedent emotional relationship. Despite excellent recipient outcomes and the potential to help address organ scarcity, controversy surrounds the unconditional act of gifting one's organs to an unrelated recipient. This qualitative systematic review provides insights into the first-hand experiences, motivations, and challenges that unspecified donors face.

METHODS

A systematic search was conducted on Medline, Embase, CINAHL, PsycINFO, and Web of Science database for qualitative literature regarding unspecified living donors' motivations and experiences in liver and kidney transplantation. An inductive thematic analysis was conducted to generate themes and supportive subthemes.

RESULTS

12 studies were included. The four major themes were (i) motivations, (ii) perception of risks, (iii) donor support, and (iv) benefits of donation. Unspecified donors demonstrated a deep sense of social responsibility but tended to underestimate health risks in favour of benefits for recipients. Despite the lack of emotional support from family and friends, the decision to donate was a resolute personal decision for donors. Majority benefitted emotionally and did not express regret.

CONCLUSION

This qualitative review bridges the gap in literature on unspecified living donor psychology and provides a comprehensive understanding of the decision-making matrix and experiences of donors.

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.

Anonymous living liver donor perspectives on the role of family in their donation experience

Anonymous living organ donation is an understudied but rapidly expanding sector in organ transplantation, in which donors choose to donate anonymously to a recipient in need. The family members and close support network of living donors often play a crucial role in the donation process, and their influence likely has a large impact on the decision to donate as well as the donor's physical and psychosocial state. However, there is limited data examining the impact donor families have on the anonymous donor, and in turn, the impact donation has on donors' families. To assess this, we analyzed a semi-structured qualitative interview on living donor experiences with 26 anonymous living liver donors for common themes concerning donor families. Responses surrounding donor families were grouped into three major categories: (1) family reactions to donation, ranging from (a) pride/support, (b) fear/worry, and (c) jealousy/anger; (2) the impact of donation on donor-family relationships, including (a) positive impacts, (b) negative impacts, (c) a positive ripple effect; (3) gaps in institutional support for donor families. This study provides unique information on anonymous living liver donor perceptions related to their families and will help improve existing programs to accommodate donor family needs and cater to donor relationships.

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.

Uterine Transplantation Using Living Donation: A Cross-sectional Study Assessing Perceptions, Acceptability, and Suitability

Supplemental Digital Content is available in the text.

A uterine transplantation is a nonvital, quality-of-life–enhancing solid organ transplant. Given improvements in donor risk profile and the anticipated shortage of suitable deceased donors, nondirected donation could facilitate sustainability as uterine transplantation moves from research into the clinical realm. The aim of this article is to determine perceptions and identify motivations of potential nondirected living uterus donors and assess acceptability and suitability.

The experience of donating and receiving a kidney: A systematic review of qualitative studies

BACKGROUND

The experiences described by people who have undergone kidney transplant are complex. Understanding how donors and recipients experience kidney transplantation can help us to design strategies that provide a more person-centred health care.

OBJECTIVES

To review articles that report the experiences of donors and recipients in the living-donor kidney transplantation process.

METHOD

A systematic review of qualitative studies was carried out. PubMed, Scopus, Web of Science, CINAHL and PsycINFO databases were used to search for articles published in English, French and Spanish between 2005 and 2018.

RESULTS

Twenty-nine articles were included in this review. For recipients, receiving a kidney is a positive experience (positive feelings and significant experience) that also involves certain difficulties and stressors (making a difficult decision, fears and worries). The experience of the donors is positive as they are motivated to improve the life of the recipient. They are committed to donating and use coping strategies as well as experiencing personal growth. On the contrary, being a donor involves certain difficulties and stressors (personal investment, mental, physical and economic impact and overcoming opposition) and a perception of deficiency in the health system (lack of information and attentiveness).

CONCLUSION

Donating and receiving a kidney is a positive experience that involves certain difficulties and a variety of stressors for both the donors and recipients. Moreover, the donors note deficiencies in the health system.

Donating a Kidney to a Stranger: A Review of the Benefits and Controversies of Unspecified Kidney Donation

OF BACKGROUND DATA

Unspecified kidney donation (UKD) describes living donation of a kidney to a stranger. The practice is playing an increasingly important role within the transplant programme in the United Kingdom, where these donors are commonly used to trigger a chain of transplants; thereby amplifying the benefit derived from their donation. The initial reluctance to accept UKD was in part due to uncertainty about donor motivations and whether the practice was morally and ethically acceptable.

OBJECTIVES

This article provides an overview of UKD and answers common questions regarding the ethical considerations, clinical assessment, and how UKD kidneys are used to maximize utility. Existing literature on outcomes after UKD is also discussed, along with current controversies.

CONCLUSIONS

We believe UKD is an ethically acceptable practice which should continue to grow, despite its controversies. In our experience, these donors are primarily motivated by a desire to help others and utilization of their kidney as part of a sharing scheme means that many more people seek to benefit from their very generous donation.

Key experiences of primary social groups in Unspecified Kidney Donation

BACKGROUND

The role of family members in directed kidney donation is well documented in the literature from both a physiological and psychosocial perspective. The experiences of families, or primary social groups (PSGs), where one member considers donating a kidney via unspecified altruistic kidney donation route (UKD) is poorly understood. This is pertinent as lack of family support has been identified as a potential contributor to donation withdrawal.

OBJECTIVES

This study aimed to explore the relevant psychosocial factors underpinning completed and uncompleted donations.

DESIGN

A qualitative study using semi-structured interviews.

PARTICIPANTS

Qualitative interviews were conducted in the United Kingdom with 35 individuals comprising of: 11 donors who donated their kidney altruistically and 8 of their PSG members, and 11 donors who withdrew and 5 of their PSG members.

APPROACH

Interviews were transcribed verbatim and analysed using Framework Analysis.

RESULTS

Two major themes were identified: (1) Supportability, which contained experiences fundamental to proceeding to donate, underpinned by four subthemes Acceptability, Awareness and Information, Family Risk and Ambivalence;(2) Seeking Resolution, contained discussions of experiences following either withdrawal from or completion of the donation, and comprised two sub-themes, Unfinished Business and Resolve.

CONCLUSIONS

There are key differences in the experiences between those who completed their donation and those who withdrew. It is clear from this study that UKD operates within a PSG's social framework. Clinical implications suggest interventions at the level of addressing ambivalence within the PSG and the need for promotion of better psychosocial outcomes both following completion or withdrawal from donation.

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.

The non-directed living kidney donor: Why donate to strangers?

BACKGROUND

Kidney transplantation improves survival and quality of life for patients with end-stage kidney disease (ESKD). However, there is a shortage of donated organs, resulting in long wait times and the potential for death before a donor is found. Non-directed (also called altruistic) living kidney donation is a growing type of donation; however, few studies have examined the values and motivation of individuals evaluated to be a non-directed donor.

OBJECTIVES

This qualitative study explores the motivations and values of individuals evaluated for non-directed donation.

DESIGN

Focus groups were conducted with individuals who had been evaluated for non-directed living kidney donation. Grounded theory method guided the data analysis.

PARTICIPANTS

Participants (N = 11) were individuals who completed the evaluation for a non-directed living kidney donation.

FINDINGS

Qualitative analyses revealed eight major themes participants considered in making their decision to donate to a non-related person: (i) motivation to donate; (ii) minimise perceived risk; (iii) ideal selected recipient; (iv) change in lifestyle; (v) source of donation knowledge; (vi) history of altruistic acts; (vii) donation chain and (viii) others' response.

CONCLUSIONS

Results suggest that non-directed living kidney donors think deeply about their decision and have a resolve to help others that is aligned with their values. As organ availability remains at a critical shortage, unwillingness to consider non-directed living donors (NDD) due to beliefs of ill motivations appears unsupported. Future directions call for the need of standard practice of care in kidney donation evaluations across transplant centers.

The Meaning of Being a Living Kidney, Liver, or Stem Cell Donor-A Meta-Ethnography

BACKGROUND

Studies on living donors from the donors' perspective show that the donation process involves both positive and negative feelings involving vulnerability. Qualitative studies of living kidney, liver, and allogeneic hematopoietic stem cell donors have not previously been merged in the same analysis. Therefore, our aim was to synthesize current knowledge of these donors' experiences to deepen understanding of the meaning of being a living donor for the purpose of saving or extending someone's life.

METHODS

The meta-ethnography steps presented by Noblit and Hare in 1988 were used.

RESULTS

Forty-one qualitative studies from 1968 to 2016 that fulfilled the inclusion criteria were analyzed. The studies comprised experiences of over 670 donors. The time since donation varied from 2 days to 29 years. A majority of the studies, 25 of 41, were on living kidney donors. The synthesis revealed that the essential meaning of being a donor is doing what one feels one has to do, involving 6 themes; A sense of responsibility, loneliness and abandonment, suffering, pride and gratitude, a sense of togetherness, and a life changing event.

CONCLUSIONS

The main issue is that one donates irrespective of what one donates. The relationship to the recipient determines the motives for donation. The deeper insight into the donors' experiences provides implications for their psychological care.

Should narrative coherence be considered in the assessment of motivation in the non-directed kidney donation?

Donating a kidney to a stranger is known as a Good Samaritan, altruistic, or non-directed donation. Living donation is the only instance in medicine where the "do-no-harm" dictum is intentionally violated. Healthcare professionals 'doing the harm' are ethically responsible to ensure the lowest risk for both the physical and psychological health of the potential donor. To this end, experts in the transplant community published Guidelines for the Psychosocial Evaluation of Living Unrelated Kidney Donors in the United States [1]. These Guidelines focus on the identification of risk and protective factors, and basic principles underlying informed consent and outlined a recommended process for donor evaluation. The components of the evaluation include a comprehensive history and current status, capacity to consent, psychological status, relationship to recipient, motivation, donor knowledge and understanding, social support, and financial suitability. The case of a donor, Ms. Angelo, is presented because her responses during evaluation raised questions about how best to understand her motivation. My proposal is that altruism and motivation are best understood by considering the narrative coherence in the donor's story.

An ethical appraisal of living-anonymous kidney donation using Adam Smith's Theory of Moral Sentiments

Ethical debates continue to shape organ transplant policies, particularly for kidneys. Facing organ shortages, governments have created incentives targeting prospective living-anonymous donors - socially and biologically unrelated to the recipient. However, these policies may transform altruistic exchanges of tissues into trades of commodities. We use Adam Smith's concept of sympathy to outline a new approach to transplantation ethics. This is accomplished using a case study analysis of six countries with established living-anonymous kidney donation practices - Iran, Israel, the Netherlands, Saudi Arabia, the United Kingdom, and the United States. An ethical test was also developed from ethnographies of donors and Smith's Theory of Moral Sentiments. The case study analysis considered the role of religious and historic norms, media campaigns, adherence to the 2008 Declaration of Istanbul guidelines for each case, and how each factor related to Smith's sympathy, categorizing the countries into four tiers of altruism. Iran occupied the least altruistic tier, followed by the Netherlands, the UK and the US, and Saudi Arabia and Israel. The ethical test identified a similar ranking. Our findings suggest that a highly-selected cohort of states with established living-anonymous kidney donation programs may already utilize a Smithian approach for recruiting donors, and that socially-valued government incentives can preserve altruism. The ethical test could become a useful instrument to assess the altruism of emerging incentive policies.

The Lived Experience of "Being Evaluated" for Organ Donation: Focus Groups with Living Kidney Donors

BACKGROUND AND OBJECTIVES

Comprehensive evaluations are required to safeguard voluntarism and minimize harm to living kidney donors. This process is lengthy, invasive, and emotionally challenging, with up to one fifth of potential donors opting out. We aimed to describe donors' experiences of the evaluation process.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted 14 focus groups involving 123 kidney donors who completed donation from three transplant centers (Australia and Canada). Transcripts were analyzed thematically.

RESULTS

We identified six themes reflecting donors' experiences of evaluation. The themes that related to perseverance included emotional investment (prioritizing the recipient's health, desperation for a normal life, protecting eligibility, shame of disappointing others, and overcoming opposition), undeterred by low risks (medical confidence and protection, worthwhile gamble, inherent invincibility, and normalizing risks), and mental preparation (avoiding regret, resolving decisional ambivalence, and managing expectations of recovery). The challenges included underlying fears for health (processing alarming information, unsettling uncertainty, and preoperative panic), system shortfalls (self-advocacy in driving the process, stressful urgency, inconsistent framing of safety, unnerving bodily scrutiny, questioning risk information, and draining finances); and lifestyle interference (living in limbo, onerous lifestyle disruption, and valuing flexibility).

CONCLUSIONS

Previous donors described an emotional investment in donating and determination to protect their eligibility, despite having concerns for their health, financial and lifestyle disruption, and opposition from their family or community. Our findings suggest the need to prepare donors for surgery and recovery, minimize anxiety and lifestyle burdens, ensure that donors feel comfortable expressing their fears and concerns, reduce unnecessary delays, and make explicit the responsibilities of donors in their assessment process.

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.

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.

The Core of Sibling Stem Cell Donation - A Grounded Theory Study

Background:

There is a lack of theoretical framework supporting stem cell transplant nurses in their assessment, judgment and caring interventions of sibling stem cell donors.

Objective:

The purpose of this study was to explore sibling stem cell donors’ main concerns and how they deal with them before and after donation.

Method:

Ten healthy sibling donors, 5 men and 5 women, with a median age of 54 years were included in this study when they were due to donate stem cells to a brother or sister. Data were collected prospectively on three occasions (before the donation and three and twelve months after it) through in-depth interviews, which were recorded and transcribed verbatim for analysis by the Grounded Theory method according to Charmaz.

Results:

This study describes the efforts of the ten donors to fulfil their duty as a sibling by doing what they considered necessary in order to help. Their efforts were summarised in a process wherein the grounded theory generated three main categories; Prepare, Promote and Preserve. A clear path of transition leading to fulfilment is evident, starting before the donation and continuing for one year afterwards.

Conclusions:

Being a sibling stem cell donor means doing what you have to do to fulfil your duty and if possible, saving the life of a seriously ill brother or sister. The relationship between the siblings is strengthened by the donation process. Sibling stem cell donation appears to be about fulfilment and the theoretical framework may support clinicians in their evaluation and support of donors.

[Adaptation Experience of Living Kidney Donors after Donation]

PURPOSE

This study was done to explore adaptation experience of living kidney donors after donation. Specific aims were to identify challenges donors face in the process of adaptation following surgery and how they interact with recipients and other people.

METHODS

Grounded theory methodology was utilized. Participants were 13 living kidney donors at six months or more after donation. Data were collected by in-depth interviews with individual participants. Data were analyzed using constants comparative method with theoretical saturation.

RESULTS

A core category emerged as 'keeping the fences of my family in spite of vulnerability'. The adaptation process after donation was manifested in four phases: exploration, balance, maintenance, and acclimatization. Phenomenon was perception of vulnerability. Strategies to manage the vulnerability were assessing changes of body awareness, tailoring regimen to one's own body condition, coping with health problems, keeping restoration of health, and ruminating on the meaning of one's kidney donation. Consequences were reestablishing family well-being, realizing the values of one's kidney donation, and living with uncertainty.

CONCLUSION

Findings of the study indicate that there is a need for health professionals to understand the vulnerability of living kidney donors and help their family system maintain a healthy and productive life. The results of this study can be used to develop phase-specific, patient-centered, and tailored interventions for living kidney donors.

The Cost of Organ Donation: Potential Living Kidney Donors' Perspectives

Living kidney transplantation is a treatment option for some people with end-stage kidney disease. The procedure has low complication rates and positive outcomes; despite this evidence, the number of living kidney donations has decreased in recent years, and the causes are not well understood. This qualitative study sought to explore the experiences of potential living kidney donors before the transplantation. A total of 19 semistructured interviews were conducted with potential living kidney donors in Perth, Western Australia. Results reported here relate to participants' experience of the employment and financial implications of living kidney donation. Participants incurred direct and indirect costs during the time leading up to the transplantation, and many had concerns about the potential financial impact during the recovery period. Employment status, occupation type, and financial commitments affected participants' experiences, and financial concerns were exacerbated for those who were donating to their partners. Results suggest that potential living kidney donors would benefit from tailored financial planning advice to help them prepare for the time of the surgery and the recovery period.

Exploring the success of Good Samaritan organ donation in New Zealand

The rate of living kidney donation from 2006 to 2012 was roughly the same in Australia and New Zealand, but the rate of Good Samaritan donation was significantly higher in New Zealand (1.49 donors/million) than in Australia (0.23 donors/million). Three possible reasons for New Zealand's high rate of Good Samaritan donation are explored: (1) since 2005, New Zealand has offered a tax-free financial safety net for living donors; (2) unlike Australia, New Zealand is not carved into jurisdictional segments with multiple policies on Good Samaritan donation, lending to a streamlined approach; (3) New Zealand embraces e-technology to communicate the concept of Good Samaritan donation to the public. Additionally, New Zealand's recent initiatives to increase the rate of living donation are described.

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.

Altruism, gift giving and reciprocity in organ donation: a review of cultural perspectives and challenges of the concepts

Living and deceased organ donation are couched in altruism and gift discourse and this article reviews explores cultural views towards these concepts. Altruism and egoism theories and gift and reciprocity theories are outlined from a social exchange theory perspective to highlight the key differences between altruism and the gift and the wider implications of reciprocation. The notion of altruism as a selfless act without expectation or want for repayment juxtaposed with the Maussian gift where there are the obligations to give, receive and reciprocate. Lay perspectives of altruism and the gift in organ donation are outlined and illustrate that there are differences in motivations to donate in different programmes of living donation and for families who decide to donate their relative's organs. These motivations reflect cultural views of altruism and the gift and perceptions of the body and death.

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.

Understanding donation experiences of unspecified (altruistic) kidney donors

OBJECTIVES

Kidney donation from a living donor to an unknown recipient has been legal in the UK since 2006. Yet there is little research into the experiences of unspecified kidney donors (UKDs) in interaction with the health care systems.

DESIGN

This article explores the experiences of 14 UKDs recruited through four regional transplant co-ordinating centres in England. At interview, they were invited to share their donation stories and discuss the antecedents, social, and psychological processes involved. Interviews were audio-taped and transcribed.

METHODS

Transcripts were analysed using a grounded theory approach employing a constant comparison methodology. Themes emerging from the data were named to form categories organized around the central focus of the research, forming an analytical story of UKDs' experiences.

RESULTS

Two major categories emerged: 'connected to others' and 'uneasy negotiations with others'. 'Connected to others' encompasses the motivations and psychological and social consequences of UKD. 'Uneasy negotiations with others' refer to the concerns and conflicts that arose during the donation process.

CONCLUSIONS

This study highlights the importance of social relationships on the process and outcomes of UKD. These UKDs report both intra- and interpersonal benefits from donation. The donation process, however, also created interpersonal stress, and conflicting messages about the acceptability of their donation were experienced in UKDs' personal lives and in their interactions with health care services. Findings are discussed with reference to the wider literature on UKD and altruism and in relation to implications for clinical practice.

STATEMENT OF CONTRIBUTION

What is already known on this subject? Unspecified living kidney donation is an under-researched area with only three research papers published worldwide that report on the motivations and experiences of donors. These studies indicate that donors endorse pro-social values and receive positive interpersonal and intrapersonal benefits from donation. What does this study add? UKDs' experiences are made explicit and provide a framework for future research. Social connections (capital) are an important precursor to and outcome from donation. Assumptions of pathological motivations were encountered by donors in their personal life and within the NHS.

The silence of Good Samaritan kidney donation in Australia: a survey of hospital websites

It is common for living donor candidates to use the Internet as a tool to enhance their decision-making process. Specifically, the websites of transplant hospitals can potentially be a vital source of information for those contemplating living donation. In an effort to explore the low incidence of Good Samaritan kidney donation (donations to strangers) in Australia, two raters conducted a nine-attribute website content analysis for all hospitals which participate in these transplants (n = 15). Overall, the concept of living donation is relatively silent on Australian hospital websites. Only four hospitals mention their living donor program, and only one mentions their Good Samaritan program. No site linked directly to Australia's AKX Paired Kidney Exchange Program - the only program which facilitates pair and chain transplants in Australia. Further, information about deceased donation is nearly absent as well. An individual with the altruistic desire to donate will generally find scant or absent information about donation at the website of their local transplant hospital, although this information could easily be present as an educational tool which supports the consent process. Using a hospital website to educate the public about a clinical service should not be viewed as ethically problematic (solicitation), but rather an ethical essential.