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

Postoperative factors associated with psychological well-being of living kidney donors: results of a retrospective and qualitative study

Introduction

Kidney transplantation from a living donor is the treatment of choice for end- stage kidney disease. Psychological implications of living kidney donation are of great importance, both during preliminary psychiatric assessment and post-donation follow-up. The identification of risk factors worsening the psychological well-being of living kidney donors (LKDs), before and after donation, remains challenging in terms of research.

Methods

At the University Hospitals of Geneva (HUG), our clinical observations and practice compelled us to establish post-donation follow-ups for LKDs at 6 months and 1 year. Pre-and post-donation sociodemographic, physical, psychological, and psychiatric data was collected from the medical records of 115 LKDs who underwent a complete physical and psychological evaluation during the period 2011-2018. We tested for any potential association between the variables under study.

Results

A qualitative and retrospective analysis of this data highlighted the impact of postoperative factors, such as pain, fatigue, recipient-donor relationship, and fulfillment of donors' expectations, on the post-donation psychological well-being of LKDs.

Discussion

With regard to these findings, regular post-donation follow-ups, optimal care of postoperative pain and fatigue, as well as a solid therapeutic alliance with LKDs remain key points for clinicians involved in the dynamic process of living kidney donation.

Prevalence and factors associated with depression and anxiety in living liver donors: A systematic review and meta-analysis

OBJECTIVE

This study aimed to systematically review the prevalence and factors associated with depression and anxiety in living liver donors after liver transplantation.

METHODS

Five English language electronic databases and four Chinese language electronic databases were searched from inception to February 2023. Two investigators independently extracted the data and assessed the study quality. The pooled prevalence was calculated using STATA software (version 14.0). We performed a narrative review to summarize the factors associated with depression and anxiety in living liver donors after liver transplantation. The protocol of this study was registered with the International Prospective Register of Systematic Reviews (PROSPERO) database, registration number: CRD42021290071.

RESULTS

This study included 39 articles involving 18,577 participants. The pooled prevalence was 6.3% [95% confidence interval (CI) (4.1-8.9%)] for depression in living liver donors, and 10.0% [95% CI (4.0-18.1%)] for anxiety. Prevalence of clinically significant depressive or anxiety symptoms was higher (15.7% and 17.4%) compared with disorders (2.7% and 2.2%). The prevalence of depression and anxiety was highest within 3 months post-donation. Specifically, female donors, serious postoperative complications, and recipients' poor health/death have been reported as factors having a negative influence on depression and anxiety.

CONCLUSIONS

Collected evidence showed that the overall prevalence of depression or anxiety of living liver donors was high. Therefore, early detection and timely treatment of psychological disorders are crucial to promote positive psychiatric health outcomes and ensure the quality of life of living liver donors.

Live Donor Assessment Tool (LDAT): Reliability and Validity of the German Version in Living Kidney Donor Candidates

BACKGROUND

The Live Donor Assessment Tool (LDAT) is a semi-structured psychosocial assessment tool for evaluating potential organ donors. It enables standardization of the psychosocial evaluation across institutions and allows the quantification of the evaluation result.

OBJECTIVE

To evaluate the validity and reliability of the German version of the LDAT in living kidney donors.

METHODS

We assessed the internal consistency and convergent validity (using known groups) of the German version of the LDAT in donor candidates who were evaluated at Hannover Medical School from May 2017 to December 2021.

RESULTS

One hundred fifty-two donor candidates were evaluated. The mean age was 50.9 (standard deviation, 12.0), 99 were female (65.1%) and 53 (34.9%) were male candidates. LDAT scores ranged from 39 to 78 (possible maximum score = 82). The mean and median LDAT scores in the entire sample were 69 (standard deviation, 6.4) and 71 (95% confidence interval, 68; 70), respectively. The LDAT items demonstrated good internal consistency (α = 0.737). LDAT scores were significantly lower in high and moderate risk donors compared to a low/no risk group as determined by clinical evaluation. We found a significant positive association of the LDAT total score with age and a negative correlation with levels of depression and anxiety. The best cutoff score in our sample was 66.5 with an area under the curve of 93%.

CONCLUSIONS

The German version of the LDAT was found to be a reliable and valid tool, which seems suitable to support psychosocial donor evaluation.

Worries and Psychological Well-Being in Potential Hematopoietic Stem Cell Donors Before Donation-A Swedish National Study

BACKGROUND

The physical risks involved in donating hematopoietic stem cells have been thoroughly studied, but little is known about the psychological risks potential donors might face before donation. The aim of this study was to describe potential the pre-donation worries and psychological well-being of hematopoietic stem cell donors and investigate possible associations between donor characteristics and psychological well-being.

METHODS

In a cross-sectional, national cohort study, we describe pre-donation worries and psychological well-being and investigate possible associations between donor characteristics and psychological well-being. A questionnaire was sent to prospective adult hematopoietic stem cells donors.

RESULTS

The study included 210 participants, 47% of whom were related and 53% unrelated to the recipient. Of the participants, 39% reported great worry about the recipient and 12% great worry about themselves as potential donors. Symptoms of anxiety were expressed by 21%, whereas symptoms of depression were uncommon and perceived general mental health was slightly lower than in the Swedish population. Great worry about oneself, lower age, and female sex were related to increased anxiety and lower mental health.

CONCLUSION

This study highlighted that some potential donors report high levels of pre-donation worry and that greater worry about oneself, lower age, and female sex are associated with lower psychological well-being. Although further studies are needed to investigate this psychological risk over time, it is clear that some potential donors are particularly vulnerable.

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.

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.

Mental Health and Well-Being of Solid Organ Transplant Donors. The Forgotten Sacrifices

In light of a global organ shortage, living donor transplantation has become increasingly relevant as an alternative to deceased donor transplantation. While current research has revolved around the medical aspects of transplantation, there remains a paucity of literature regarding the quality of life (QOL) of living donors. Hence, this review aims to provide a comprehensive outline of the current landscape of living liver and kidney transplantation, with a focus on the mental health and wellbeing of donors. As highlighted in previous studies, organ donation has a significant impact on both physical and mental aspects of donor wellbeing, with marked deteriorations occurring in the short term. Furthermore, other qualitative aspects such as financial burden contribute greatly to donor distress, reflecting a need for improved donor care. To address these pertinent issues, recommendations for a successful transplant program are detailed in this review, which encompasses psychological and social aspects of donor care throughout the donation process. Further research can be done on the impact of recipient deaths on donor QOL and appropriate interventions. Overall, given the selfless sacrifices of living donors, the care of their mental wellbeing is essential. Therefore, greater emphasis should be placed on the provision of adequate psychosocial support for them.

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.

Live Donor Assessment Tool (LDAT): A Turkish validity and reliability study

BACKGROUND/AIMS

Psychosocial and psychiatric evaluations are crucial components of the assessment of a live donor candidate. The Live Donor Assessment Tool (LDAT) was developed for this purpose. This study aims to evaluate the validity and reliability of the Turkish version of LDAT.

MATERIALS AND METHODS

132 live kidney or liver donor were referred to assess their psychosocial/psychiatric appropriateness for donation and were randomized for clinical evaluation as usual or with LDAT. The internal consistency of LDAT was measured by Chronbach's alpha coefficient. Inter-rater reliability was measured by using Spearman's correlation coefficient. The potential validity of LDAT was assessed by comparing LDAT scores to clinical decisions. The Mann-Whitney U test was used to compare LDAT scores across two clinically classified groups (acceptable/declined). Logistic regression was performed using LDAT scores to predict the clinical decision.

RESULTS

The Turkish version of LDAT items demonstrate good internal consistency (α=0.773). Inter-rater reliability of LDAT demonstrated strong correlation (ICC=0.72). LDAT scores differentiated the accepted/declined groups, and strongly predicted the clinical decision. With a cut-off score of 60.5, LDAT was found to have high sensitivity and specificity.

CONCLUSION

The Turkish version of LDAT was found to be a valid and reliable tool. LDAT could be an appropriate tool to assess live donor candidates.

Education Priorities and What Matters to Those Considering Living Kidney Donation

INTRODUCTION

Although informed consent content elements are prescribed in detailed regulatory guidance, many live kidney donors describe feeling underprepared and under informed. The goal of this pilot study was to explore the educational components needed to support an informed decision-making process for living kidney donors.

METHODS/APPROACH

A qualitative description design was conducted with thematic analysis of 5 focus groups with 2 cohorts: living kidney donor candidates (n = 11) and living kidney donors (n = 8).

FINDINGS

The educational components needed to engage in an informed decision-making process were: 1) contingent upon, and motivated by, personal circumstances; 2) supported through explanation of risks and benefits; 3) enhanced by understanding the overall donation experience; and 4) personalized by talking to another donor.

DISCUSSION

Tailoring education to meet the needs for fully informed decision-making is essential. Current education requirements, as defined by regulatory bodies, remain challenging to transplant teams attempting to ensure fully informed consent of living kidney donor candidates. Information on the emotional, financial, and overall life impact is needed, along with acknowledgement of relational ties driving donor motivations and the hoped-for recipient outcomes. Discussion of care practices, and access to peer mentoring may further strengthen the informed decision-making process.

Psychosocial risk factors for impaired health-related quality of life in living kidney donors: results from the ELIPSY prospective study

Living kidney donors' follow-up is usually focused on the assessment of the surgical and medical outcomes. Whilst the psychosocial follow-up is advocated in literature. It is still not entirely clear which exact psychosocial factors are related to a poor psychosocial outcome of donors. The aim of our study is to prospectively assess the donors' psychosocial risks factors to impaired health-related quality of life at 1-year post-donation and link their psychosocial profile before donation with their respective outcomes. The influence of the recipient's medical outcomes on their donor's psychosocial outcome was also examined. Sixty donors completed a battery of standardized psychometric instruments (quality of life, mental health, coping strategies, personality, socio-economic status), and ad hoc items regarding the donation process (e.g., motivations for donation, decision-making, risk assessment, and donor-recipient relationship). Donors' 1-year psychosocial follow-up was favorable and comparable with the general population. So far, cluster-analysis identified a subgroup of donors (28%) with a post-donation reduction of their health-related quality of life. This subgroup expressed comparatively to the rest, the need for more pre-donation information regarding surgery risks, and elevated fear of losing the recipient and commitment to stop their suffering.

Psychosocial Assessment of Donors in Pediatric Living Donor Liver Transplantation: A Systematic Review

BACKGROUND

Pediatric living donor liver transplantation (LDLT) is the only way to save children with end-stage liver disease. The donor for liver transplantation (LT) may have a complicated psychosocial condition.

PURPOSE

This review aims to identify the domains of the donor psychosocial questions that should be addressed and summarize the aspects and tools future psychosocial assessments should include.

METHODS

We searched the PubMed, Medline, Cochrane Library, Embase, Web of Science, and Google Scholar databases for the terms pediatric, liver transplantation, donor, and psychosocial. We used the Joanna Briggs Institute Critical Appraisal Tool to appraise reporting quality. Two researchers independently selected the papers and performed data extraction and quality appraisal.

RESULTS

The articles included in this review contain 26 quantitative studies and 2 qualitative studies. The study quality was moderate to high. Donors have ambivalence, anxiety, the need for family and social support, the need for adequate information, distress, and low self-esteem during the preoperative period. In the postoperative period they have poor psychological condition, panic disorder, conversion disorder and substance use/abuse disorder, abnormal family functioning, better psychosocial outcome, or among others. The assessment methods consisted of the questionnaire survey and semi-structured interview. Among the 28 studies, 17 different psychosocial domains were mentioned. The most frequently referred to was family and social support.

CONCLUSION

The contents of the psychosocial assessment must include anxiety or depression, family and social support, ambivalence, information, and positive psychosocial characteristics. Assessment methods should use the questionnaire survey and semi-structured interview. According to this review, future research can develop a specific psychosocial assessment tool for pediatric LT donors.

Global Kidney Exchange: opportunity or exploitation? An ELPAT/ESOT appraisal

This paper addresses ethical, legal, and psychosocial aspects of Global Kidney Exchange (GKE). Concerns have been raised that GKE violates the nonpayment principle, exploits donors in low- and middle-income countries, and detracts from the aim of self-sufficiency. We review the arguments for and against GKE. We argue that while some concerns about GKE are justified based on the available evidence, others are speculative and do not apply exclusively to GKE but to living donation more generally. We posit that concerns can be mitigated by implementing safeguards, by developing minimum quality criteria and by establishing an international committee that independently monitors and evaluates GKE's procedures and outcomes. Several questions remain however that warrant further clarification. What are the experiences and views of recipients and donors participating in GKE? Who manages the escrow funds that have been put in place for donor and recipients? What procedures and safeguards have been put in place to prevent corruption of these funds? What are the inclusion criteria for participating GKE centers? GKE provides opportunity to promote access to donation and transplantation but can only be conducted with the appropriate safeguards. Patients' and donors' voices are missing in this debate.

A Mixed-Methods Approach to Understanding Variation in Social Support Requirements and Implications for Access to Transplantation in the United States

Social support is a key component of transplantation evaluation in the United States. Social support definitions and evaluation procedures require examination to achieve clear, consistent implementation. We surveyed psychosocial clinicians from the Society for Transplant Social Workers and American Society of Transplant Surgeons about their definitions and evaluation procedures for using social support to determine transplant eligibility. Bivariate statistical analysis was used for quantitative data and content analysis for qualitative data. Among 276 psychosocial clinicians (50.2% response rate), 92% had ruled out patients from transplantation due to inadequate support. Social support definitions varied significantly: 10% of respondents indicated their center lacked a definition. Key domains of social support included informational, emotional, instrumental, motivational, paid support, and the patient's importance to others. Almost half of clinicians (47%) rarely or never requested second opinions when excluding patients due to social support. Confidence and perceived clarity and consistency in center guidelines were significantly associated with informing patients when support contributed to negative wait-listing decisions (P = .001). Clinicians who excluded fewer patients because of social support offered significantly more supportive health care (P = .02). Clearer definitions and more supportive care may reduce the number of patients excluded from transplant candidacy due to inadequate social support.

Development of a Clinical Decision Support System for Living Kidney Donor Assessment Based on National Guidelines

BACKGROUND

Live donor nephrectomy is an operation that places the donor at risk of complications without the possibility of medical benefit. Rigorous donor selection and assessment is therefore essential to ensure minimization of risk and for this reason robust national guidelines exist. Previous studies have demonstrated poor adherence to donor guidelines.

METHODS

We developed a clinical decision support system (CDSS), based on national living donor guidelines, to facilitate the identification of contraindications, additional investigations, special considerations, and the decision as to nephrectomy side in potential living donors. The CDSS was then tested with patient data from 45 potential kidney donors.

RESULTS

The CDSS comprises 17 core tasks completed by either patient or nurse, and 17 optional tasks that are triggered by certain patient demographics or conditions. Decision rules were able to identify contraindications, additional investigations, special considerations, and predicted operation side in our patient cohort. Seventeen of 45 patients went on to donate a kidney, of whom 7 had major contraindications defined in the national guidelines, many of which were not identified by the clinical team. Only 43% of additional investigations recommended by national guidelines were completed, with the most frequently missed investigations being oral glucose tolerance testing and routine cancer screening.

CONCLUSIONS

We have demonstrated the feasibility of turning a complex set of national guidelines into an easy-to-use machine-readable CDSS. Comparison with real-world decisions suggests that use of this CDSS may improve compliance with guidelines and informed consent tailored to individual patient risks.

Multicenter investigation of the reliability and validity of the live donor assessment tool as an enhancement to the psychosocial evaluation of living donors

The live donor assessment tool (LDAT) is the first psychosocial assessment tool developed to standardize live donor psychosocial evaluations. A multicenter study was conducted to explore reliability and validity of the LDAT and determine its ability to enhance the psychosocial evaluation beyond its center of origin. Four transplant programs participated, each with their own team of evaluators and unique demographics. Liver and kidney living donors (LDs) undergoing both standard psychosocial evaluation and LDAT from June 2015 to September 2016 were studied. LDAT interrater reliability, associations between LDAT scores and psychosocial evaluation outcome, and psychosocial outcomes postdonation were tested. 386 LD evaluations were compared and had a mean LDAT score of 67.34 ± 7.57. In 140 LDs with two LDATs by different observers, the interrater scores correlated (r = 0.63). LDAT scores at each center and overall stratified to the conventional grouping of psychosocial risk level. LDAT scores of 131 subjects who proceeded with donation were expectedly lower in LDs requiring postdonation counseling (t = -2.78, P = .01). The LDAT had good reliability between raters and predicted outcome of the psychosocial evaluation across centers. It can be used to standardize language among clinicians to communicate psychosocial risk of LD candidates and assist teams when anticipating postdonation psychosocial needs.

Supplementing living kidney transplantees' medical records with donor- and recipient-narratives

Norway provides total social welfare coverage for organ transplantations, including free immunosuppressive medication and prepaid life-long follow up for both recipients and donors. Despite these benefits the proportion of living kidney donors (LKD) has in recent years declined from around 40% (2011) of all kidney transplantations to 24% (2016). This study suggests harnessing patient- and donor-narratives as a tool for addressing the current fall in donation rates. The hospital records of 18 recipient/donor dyads were compared with patient and donor accounts elicited in semi-structured interviews. Narratives afford a pertinent supplement to the primarily biomedical and technical information stored in medical records. Even in condensed form, the messages embedded in narratives contribute to a 'thicker' understanding of the complexity of living kidney donation (LKD)-decisions. Narratives represent a source of education for referring-nephrologists wishing to deepen their evaluation skills and avoid making decisions based on insufficient insight into patients' and potential donors' values and life-situation. Recipients' and donors' unedited accounts of their motivations, worries, doubts and expectations afford a revealing and edifying supplement to the primarily biomedical and technical information stored in medical records. In narratives, the predicaments and dilemmas surrounding LKD become visible and debatable and can serve as support for future donors, recipients and the nephrologists responsible for evaluation-conclusions. Generating narratives raises a number of practical, epistemic and normative challenges.

"What if this is my chance to save my life?" A semistructured interview study on the motives and experiences of end-stage renal disease patients who engaged in public solicitation of a living kidney donor

The increase in patients using public solicitation (PS) to find a living kidney donor has generated a debate about the ethical complexities of PS. To investigate why patients engaged in PS and what they experienced during PS, we conducted semistructured interviews with 20 Dutch patients with end-stage renal disease who had publicly solicited a living donor. Transcripts were thematically analyzed. We identified ten themes on patients' considerations preceding PS: cautiousness in discussing living donation within social network; reluctance to accept a kidney from loved ones; rejection/withdrawal of related donor candidates; moral objections to paid donation; the ease of social media; encouraged by others; ends justifying the means; despair and urge to take action; public disclosure of vulnerability; fear of being (perceived to be) selfish. We identified nine themes on patients' experiences: positive emotions and support generated by action; genuine and ulterior motives for donation; patients acting as educators and screeners; time- and energy-consuming process; emotionally taxing process; positive interactions with donor candidates; feeling of dependency and obligation; limited cooperation from health professionals; demands a proactive attitude and media strategy. These results can inform and complement (existing) policies on PS and provide content for education of patients who are considering PS.