Transplant Trajectory and Relational Experience Within Living Kidney Dyads

Ethical challenges in organ transplantation for Syrian refugees in Türkiye

BACKGROUND

There is limited information on the ethical issues encountered in living donor organ transplants performed on refugees and asylum seekers. This study investigates the ethical challenges faced by Syrian refugees under temporary protection in Türkiye who engage in living donor organ transplants.

METHODS

From April to July 2022 in Istanbul, the research employed a qualitative design involving semi-structured, in-depth interviews with 27 participants, including organ donors and recipients. The analysis utilized a thematic analytic method.

RESULTS

The findings elucidate two principal themes related to ethical concerns: justice and autonomy. Under the justice theme, several sub-themes emerged, highlighting the multifaceted challenges Syrian refugees face in accessing healthcare services. These include migration and language barriers, significantly impeding their ability to understand medical procedures and rights. Financial difficulties and restricted movement within the country further complicate their access to necessary healthcare. Despite these hurdles, refugees benefit from free access to organ transplantation services and medications, a policy underscoring Türkiye's commitment to healthcare equity for protected populations. The autonomy theme addresses the ethical handling of donor consent and motivation. The results indicate that Syrian refugees undergo a transplantation process free from coercion, with rigorous oversight by organ transplant ethics committees ensuring the prevention of donor abuse. However, despite these protective measures, challenges persist in the informed consent process, primarily due to language barriers that hinder effective communication between healthcare providers and patients. While the efforts of healthcare professionals to assist are recognized as alleviating some difficulties, the broader issues of access to comprehensive health services remain a significant concern. These barriers suggest a need for enhanced linguistic and financial support to improve healthcare accessibility for refugees.

CONCLUSIONS

This study posits that the healthcare framework provided by Türkiye to Syrians under temporary protection can serve as a model for international human rights and social justice. However, it also emphasizes the importance of addressing the persistent obstacles that limit healthcare access for asylum seekers. Recommendations for policy enhancements focus on improving language services, increasing financial support, and expanding the accessibility of comprehensive health services to ensure equitable health outcomes for refugees.

Ethical Issues in Living Donor Kidney Transplantation: An Update from a Psychosocial Perspective

Living donor kidney transplantation (LDKT) currently represents the treatment of choice for patients with end-stage renal failure. LDKT is a serious event with profound psychological, interpersonal, familial, and social implications. Over the last few years, there has been an exponential growth in living donation programs involving genetically and emotionally related donors, as well as people who donate to an unrelated and unknown subject. The implementation of paired exchange programs, Samaritan donation, and preemptive transplantation raise further ethical issues, which are inextricably linked to the unique psychosocial context of both the donor and the recipient. The present narrative review aims to provide an update on the main ethical challenges related to LDKT. We conducted a comprehensive literature search in PubMed/Medline. The results of the most relevant studies were narratively synthesized from a psychosocial perspective around the four principles of biomedical ethics: autonomy, beneficence, non-maleficence, and justice. Finally, we discussed the potential future directions to provide an effective, patient-centered, and ethical psychosocial assessment and follow-up of living donors and recipients that underwent LDKT.

Post-Donation Evaluation: Emotional Needs for Social Connection and Social Support among Living Kidney Donors-A Systematic Review

INTRODUCTION

Evaluation of post-nephrectomy social health in living kidney donors is essential. This systematic review examines their emotional need for social relatedness post-donation.

METHODS

Following the PRISMA guidelines, we systematically searched Scopus, CINAHL, and PsycINFO.

RESULTS

Among the screened records, 32 quantitative and 16 qualitative papers met the inclusion criteria. Quantitative research predominantly utilized questionnaires featuring generic items on social functioning. However, a minority delved into emotional and social dimensions, aligning with qualitative studies emphasizing the importance of social connection and perceived social support post-donation. Specifically, post-donation changes in connecting with others encompass a sense of belongingness, heightened autonomy, shifts in concern for the recipient's health, and continued care by shielding the recipient from personal health issues. Social acknowledgment and social support from both close and extended networks are reported as relevant for recovery after nephrectomy.

DISCUSSION

These findings underscore the necessity for targeted measures of emotional needs and social functioning to effectively assess post-donation adjustment. They also inform the identification of key health themes for kidney donor Patient-Reported Outcome Measures (PROMs) and Patient-Reported Experience Measures (PREMs) questions.

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.

Living normally without being oneself: A qualitative study on the experience of living with advanced chronic kidney disease

The aim of the study was to describe and analyze the experience of people with advanced chronic kidney disease. Chronic kidney disease is a growing public health problem that is on the increase worldwideThe experience of living with this illness is paradoxical, as it can include feelings of dependent autonomy, distant connection, abnormal normalcy, and uncertain hope. Every chronic disease involves a biographical alteration from the onset. For those who suffer it, it implies a breaking down and reconstruction of their everyday life. Despite the prevalence of the disease and the increase in the number of qualitative research studies in recent decades, there has not been much research on the experience of people with Chronic kidney disease. This is a qualitative study that began in 2018 and concluded in 2021.Twenty-one people with advanced chronic kidney disease were interviewed. They participated voluntarily with informed consent Participants were selected by purposive sampling. Data analysis was guided by grounded theory procedures using the Nvivo 12 software. This study reveals that people with advanced chronic kidney disease do not feel the same as they used to because their control over their lives is limited; because they feel their health is in a continuous state of deterioration; and because of the changes in themselves and in their relationships with others. With chronic kidney disease, their identity is continually called into question. The normal lives of these people-their biographical constructions-are precarious and are continuously being remodelled by the effects of treatment and the inexorable course of this disease. This study contributes to an understanding of the experience of people with advanced chronic kidney disease. It can contribute to helping health care professionals effectively support these patients in their efforts to lead a normal life and in making decisions about their treatment.

Factors Associated with the Willingness to Become a Living Kidney Donor: A National Cross-Sectional Study

Introduction: Living donor kidney transplantation is the preferred method of treating kidney failure. The donor agrees to undergo an elective procedure for the benefit of the recipient. Aim: To assess the attitude toward living kidney donation and to investigate the factors that contribute to kidney donation willingness. Methods: A cross-sectional study was carried out between December 2020 and February 2021. The study covered a representative group of 953 Poles aged 18−77, living in all Polish voivodships. The relationship between sociodemographic factors, personal values (Personal Values List), the total score of life satisfaction (Satisfaction with Life Scale) and the willingness to donate a kidney to another human was assessed using a logistic regression model. Results: The most frequently chosen personal values were: good health; physical and mental fitness; love and friendship; knowledge and wisdom. The most frequently chosen symbols of happiness were: good health, successful family life, being needed by others. The median satisfaction with life for the entire group was 20 [16; 24]. Voluntary donation of a kidney to another human being i.e., family, friends, strangers were more often declared by women (OR = 1.21; Cl95%: 1.03−1.42), for whom the most important symbol of happiness was a life full of adventures, travels (OR = 1.39; Cl95%: 1.06−1.82) and the most important personal value was goodness and tenderness (OR = 1.21; Cl95%: 1.05−1.40). Total scores of The Satisfaction with Life Scale correlated positively with the willingness to voluntarily donate a kidney (OR = 1.03; Cl95%: 1.003−1.06), while age correlated negatively (OR = 0.99; Cl95%: 0.98−0.99). Conclusions: Respondents who declare their willingness to be a living kidney donor are mainly female, for which the most important symbol of happiness is a life full of adventures and travel, and the most important values are personal goodness and tenderness. The desire to donate a kidney to another person decreases with age and grows with life satisfaction. Trial registration: ClinicalTrials.gov (ID: NCT04789122).

The Psychosocial Adjustment of Kidney Recipients in Canada's Kidney Paired Donation Program

Introduction: Kidney paired donation programs have been implemented globally. The involvement of at least 2 donors in these programs might exacerbate recipients' debt of gratitude and guilt, worries about the donor's health, and worries about graft failure documented by previous studies. However, there is an absence of research on the psychosocial implications of kidney paired donation. This study aimed to provide an in-depth examination of recipients' experience of kidney paired donation, with a focus on psychosocial adjustment. Methods/Approach: Individual interviews were conducted with 8 recipients who received a transplant through Canada's Kidney Paired Donation program. Data was analyzed using Interpretative Phenomenological Analysis. Findings: Four themes emerged: (a) an emotionally charged relationship with the known donor, (b) optimal distance regulation in the relationship with the anonymous donor, (c) kidney paired donation as a series of ups and downs, and (d) multilayered gratitude. Discussion: Findings are considered in relation to extant literature. Issues relevant to the transplant community's clinical and research efforts to provide kidney recipients responsive care are discussed.

May I have your uterus? The contribution of considering complexities preceding live uterus transplantation

Uterus transplantation combined with in vitro fertilisation (IVF) (henceforth called UTx-IVF) as a treatment for infertility caused by an absence or malfunction of the uterus is advancing. About 50 transplantations have been conducted worldwide and at least 14 children have been born-9 of them by women taking part in a Swedish research project on UTx-IVF. The Swedish research protocol initially stated that the potential recipient must 'have her own donor' who is preferably related to the recipient. But what does it mean to ask someone for a uterus? What challenges does this question instigate? And what norms may it enact? In this article, I explore how 10 women-who have considered, and sometimes pursued, UTx-IVF-describe their experiences of searching for a donor. I aim to show how an analysis of such accounts can help us unpack some of the specific relational and gendered dimensions of UTx-IVF and by doing so enrich discussions of risks, benefits, care and support in UTx-IVF. Drawing on research in social sciences and medical humanities that has demonstrated how assisted reproductive technologies and organ donation can provoke social and familial conundrums, with respect to such topics as embodiment and identity, I present three patterns that describe different dimensions of the interviewees' quest for a uterus donor. I discuss the negotiations that took place, how expectations unfolded and how entanglements were managed as the interviewees considered asking someone for a donation. Such an examination, I suggest, contributes to make care and support more attuned to the experiences and entanglements that UTx-IVF entails for those pursuing it. This will become increasingly important if (or when) UTx-IVF becomes part of general healthcare. To conclude, I problematise responsibilities and relational challenges in medical innovation, and in this way provide insights into how the ethical debate over UTx-IVF can broaden its scope.

An intersectional gender analysis in kidney transplantation: women who donate a kidney

BACKGROUND

Living-donor transplantation is the best treatment option in patients with chronic kidney failure. Global data show that women are less likely to be kidney recipients than men but are more likely to become living kidney donors. We explored the experience of women who donate a kidney to relatives with biological and socio-cultural ties and to understand the similarities and differences in their experience.

METHODS

A qualitative hermeneutic phenomenological study with an intersectional analysis of gender. Ten women donors accepted in the transplant evaluation period participated, all of whom donated a kidney to a pre-dialysis relative. Two categories were included: women with biological kinship ties (mothers, sisters) and women who have a socio-cultural relationship (wives) with kidney recipient. The data were collected through semi-structured in-depth interviews and analysed using thematic analysis.

RESULTS

Women donate their kidneys in a convinced manner, without worrying about their health, with an optimistic and positive attitude, and without believing that they are acting heroically. Women with biological kinship ties see it as a 'naturalization thing'. In contrast, wives donate conditioned by gender roles, but also as a form of empowerment and as a personal benefit: they donate in order to avoid taking on carer role for their husband and as a way of protecting their children.

CONCLUSION

The study's findings expand the conception of kidney donation as solely altruistic and may help professionals to pay attention to the complexity and intersectionality of features present in women who are living kidney donors.

Organ Transplant Recipients' Experiences of Physical Activity: Health, Self-Care, and Transliminality

Physical activity (PA) is an important lifestyle component of long-term health management for organ transplant recipients, yet little is known about recipients' experiences of PA. The purpose of this study was to shed light on this experience and to investigate the possible implications of PA in the context of what is a complex patient journey. Phenomenological analysis was used to examine interviews with 13 organ transplant recipients who had taken part in sporting opportunities posttransplantation. Findings illuminate how participants' experiences of PA were commonly shaped by the transliminal nature of being an organ transplant recipient as well as a sense of duty to enact health, self-care, and donor-directed gratitude. This analysis underlines the potential role of PA in supporting organ transplant recipients' attempts to live well following transplantation and makes novel connections between PA and our existing knowledge about challenges related to identity, survivorship, obligation, and patient empowerment.

The Tangible Benefits of Living Donation: Results of a Qualitative Study of Living Kidney Donors

The framework currently used for living kidney donor selection is based on estimation of acceptable donor risk, under the premise that benefits are only experienced by the recipient. However, some interdependent donors might experience tangible benefits from donation that cannot be considered in the current framework (ie, benefits experienced directly by the donor that improve their daily life, well-being, or livelihood).

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.

Psychological characteristics and associations between living kidney transplantation recipients and biologically related or unrelated donors

BACKGROUND

Although recipients and donors in living kidney transplantation experience psychological distress-including depression and anxiety-during the pre-operative period, very few studies have evaluated the related psychological reactions. This study aimed to determine the characteristics and correlations of the mood states and personality of recipients and donors (genetically related and unrelated) of living kidney transplantations.

METHODS

A total of 66 pairs of living donors and recipients were enrolled from April 2008 to June 2019 in this study, of whom 53 eligible pairs of living donors and recipients were included in the retrospective analysis of their psychological assessments in the pre-transplantation states. While participants' personality patterns were assessed using the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), mood states were evaluated via both the State-Trait Anxiety Inventory (STAI) and The Center for Epidemiologic Studies Depression Scale (CES-D). Statistical analysis was performed using paired t-tests and Spearman's correlation analyses.

RESULTS

The recipient group showed significantly higher scores for Hypochondriasis (t = - 4.49, p = .0001), Depression (t = - 3.36, p = .0015), and Hysteria (t = - 3.30, p = .0018) of MMPI-2 and CES-D (t = - 3.93, p = .0003) than the donor group. The biologically unrelated recipient group reported higher scores of Hypochondriasis (t = - 3.37, p = .003) and Depression (t = - 2.86, p = 0.0098) than the unrelated donor group. Higher scores for Hypochondriasis (t = - 3.00, p = 0.0054) and CES-D (t = - 3.53, p = .0014) were found in the related recipient group. A positive association was found for Hypomania (r = .40, p = .003) of MMPI-2, STAI-S (r = .36, p = .009), and CES-D (r = .36, p = .008) between the recipient and donor groups.

CONCLUSIONS

Recipients suffered from a higher level of depression and somatic concerns than donors before living kidney transplantation. Psychological problems like depression and anxiety can occur in both living kidney transplantation donors and recipients. This study suggests that clinicians must pay attention to mood states not only in recipients but also in donors because of emotional contagion.

Becoming unique: A qualitative study of identity development of adolescent kidney recipients

Teenagers who receive a renal organ transplant have to take up the double challenge of identity development, the primary task of adolescence, and of overcoming the complexities of their illness. Previous qualitative studies found that adolescents felt that the organ transplant and its treatments mainly defined who they are. The relationship to the donor can be a source of concern for some of them, especially for those who received from a parent and feel an obligation to be obedient and grateful. While donor parents are known to interpret their gesture as giving life for a second time, no research to date has described how this particular gesture may influence adolescent development. The present article aims to examine and describe identity development of teenage kidney recipients in a context of parental or deceased donation. We used a qualitative design involving individual interviews with 10 adolescents. Five of them received from a donor parent, five from a deceased donor. Data were analyzed using IPA. Results suggest that identity development is influenced by similar concerns for all adolescents regardless of donor source: body image, social relationships, and anxiety about the future. One aspect that stood out from the discourse of those who received from a parent was feelings of guilt towards the donor when engaging in behaviors that could comprise graft survival, which was a challenge for identity development. Receiving the transplant freed teens from the struggle of just managing their illness and was a catalyst for exploration and engagement, which are crucial for identity development.

Resolution of diagnosis and parental attitudes among parents of adolescent kidney recipients

The diagnosis of a chronic illness is described as an upsetting event that implies an emotional crisis for parents. Some are able to come to terms with their child's chronic condition and feel a sense of resolution, but for others, strong negative emotions persist through time. The present study examines diagnostic resolution among parents of teenagers with a transplant. The design was qualitative and involved individual interviews with nine parents. Five were donor to their child. Data were analyzed according to the principles of IPA. Early reactions to the diagnosis suggest that parents with an unresolved status experienced trauma. Many factors seem to contribute to diagnostic resolution such as good communication between spouses, positive relationship with the medical staff, and being the parent donor. For all parents, concerns over adherence are central to their relationship with their youth. Results call attention to the support needs of all parents and particularly those with an unresolved status.

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.

Couples' employment after spousal kidney donation

We used data from the United Network for Organ Sharing registry of living kidney donors and recipients to identify correlates of paid employment among couples following spousal living donation. Among such couples, post-transplant employment of both spouses (41%) was as common as employment of the donor only (41%). However, when the recipient was female, donor-only employment after transplant was more than twice as likely as compared to employment of both spouses (relative risk ratio = 2.57; p < .001). We conclude that traditional gender roles regarding paid workforce participation may be associated with the likelihood of employment after spousal kidney donation.

Marital Status and Return to Work After Living Kidney Donation

PURPOSE

Living kidney donation is safe and effective, but patients in need of a transplant continue to outnumber donors. Disincentives to living donation include lost income, risk of job loss, perioperative complications, and unreimbursed medical expenses.

METHODS

This study uses US registry and follow-up data on living kidney donors from 2013 to 2015 to identify social predictors of return to work across gender following living kidney donation.

RESULTS

Using logistic regression, we find that predictors of return to work following living kidney donation differ for women and men. Among women, age, education, smoking status, and procedure type are associated with return to work. Among men, education, procedure type, and hospital readmission within 6 weeks postdonation are associated with return to work. Notably, single and divorced men are less likely to return to work compared to married men (odds ratio [OR] for single men 0.51, 95% confidence interval [CI], 0.37-0.69, P < .001; OR for divorced men 0.51, 95% CI, 0.34-0.75, P = .006). Marital status is not associated with return to work for women. Single and divorced men's greater odds of not returning to work are robust to controls for relevant pre- and postdonation characteristics.

CONCLUSIONS

Single and divorced men's lack of social support may present an obstacle to work resumption following living kidney donation.

Considering Tangible Benefit for Interdependent Donors: Extending a Risk-Benefit Framework in Donor Selection

From its infancy, live donor transplantation has operated within a framework of acceptable risk to donors. Such a framework presumes that risks of living donation are experienced by the donor while all benefits are realized by the recipient, creating an inequitable distribution that demands minimization of donor risk. We suggest that this risk-tolerance framework ignores tangible benefits to the donor. A previously proposed framework more fully considers potential benefits to the donor and argues that risks and benefits must be balanced. We expand on this approach, and posit that donors sharing a household with and/or caring for a potential transplant patient may realize tangible benefits that are absent in a more distantly related donation (e.g. cousin, nondirected). We term these donors, whose well-being is closely tied to their recipient, "interdependent donors." A flexible risk-benefit model that combines risk assessment with benefits to interdependent donors will contribute to donor evaluation and selection that more accurately reflects what is at stake for donors. In so doing, a risk-benefit framework may allow some donors to accept greater risk in donation decisions.

How Not to Let Secrets Out When Conducting Qualitative Research With Dyads

Confidentiality is one of the cornerstones of research involving human participants. Researchers are the frontline gatekeepers of their participants' right to confidentiality, and situations can arise that challenge this responsibility. This is the case when individuals who have shared a common experience (i.e., dyads) are interviewed separately, but interview results are disseminated within the context of dyads. Based on our experience of conducting research with dyads and given how little literature is available to serve as guide, we set out to write this article to share the knowledge we acquired and the solutions we found. We will describe both the ethical challenges and the methodological decisions involved in conducting qualitative research with dyads. The article also describes different modalities of dyadic analysis, their benefits and drawbacks. This endeavor seems especially relevant as research with dyads is emerging in several domains involving couples, families, caregivers and health.

Emotional management and quality of life in mother living versus multi-organ donor renal transplant recipients

The aim of this study was to evaluate psychological differences and quality of life between kidney recipients from living (mother) and multi-organ donor. Overall, 40 patients who had undergone both living (mother) and multi-organ kidney transplantation 3-6 months before were asked to complete four self-report instruments: Toronto Alexithymia Scale, Short Form Health Survey, Regulatory Emotional Self-efficacy, and Attachment Style Questionnaire. A greater difficulty in emotional, social, and mental health functioning was found in recipients receiving kidney from mother living donor. Moreover, in these patients, higher levels of avoidant attachment dimensions were associated with a worse quality of life.