Concern for Lost Income Following Donation Deters Some Patients From Talking to Potential Living 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.

Pushing the Boundaries of Living Donation Through Kidney Paired Donation

Living-donor kidney transplant (LDKT) is the treatment of choice for patients with advanced kidney disease. Kidney paired donation (KPD), originally proposed to overcome immunological barriers, has now evolved to address biological and chronological incompatibilities and reduce financial disincentives. This strategy has allowed the maximization of the number of LDKTs. In 2021, of the 5,971 LDKTs performed, 1,115 (18.6%) were facilitated by KPD. Although KPD programs vary in size and structure, privately owned KPD programs dominate the landscape. Participation in KPD is far from universal: it is not offered in 40% of transplant centers. Across the United States, there are large areas devoid of transplant centers that offer KPD. As a result, some donor and recipient candidates are missing opportunities for a successful LDKT. Some private KPD programs provide financial and legal protections to living donors. Therefore, access to such donor protections is variable and not available to all donors. In this perspective, we review the evolution of KPD programs, explore ways to enhance participation, discuss the need for transparency about living donation options to donor and recipient candidates, and ultimately call for national action for regulatory oversight and to make living kidney donation financially neutral regardless of participation in KPD.

Neighborhood Socioeconomic Deprivation is Associated with Worse Outcomes in Pediatric Kidney Transplant Recipients

Key Points

This is the largest US cohort study investigating neighborhood socioeconomic deprivation and outcomes among pediatric kidney transplant recipients. High neighborhood deprivation was associated with worse graft survival and lower access to preemptive and living donor transplantation. Findings demonstrate inequities in pediatric kidney transplantation associated with neighborhood-level factors that warrant intervention.

Background

Social determinants of health shape a child's transplant course. We describe the association between neighborhood socioeconomic deprivation, transplant characteristics, and graft survival in US pediatric kidney transplant recipients.

Methods

US recipients younger than 18 years at the time of listing transplanted between January 1, 2010, and May 31, 2022 (N =9178) were included from the Scientific Registry of Transplant Recipients. Recipients were stratified into three groups according to Material Community Deprivation Index score, with greater score representing higher neighborhood socioeconomic deprivation. Outcomes were modeled using multivariable logistic regression and Cox proportional hazards models.

Results

Twenty-four percent (n =110) of recipients from neighborhoods of high socioeconomic deprivation identified as being of Black race, versus 12% (n =383) of recipients from neighborhoods of low socioeconomic deprivation. Neighborhoods of high socioeconomic deprivation had a much greater proportion of recipients identifying as being of Hispanic ethnicity (67%, n =311), versus neighborhoods of low socioeconomic deprivation (17%, n =562). The hazard of graft loss was 55% higher (adjusted hazards ratio [aHR], 1.55; 95% confidence interval [CI], 1.24 to 1.94) for recipients from neighborhoods of high versus low socioeconomic deprivation when adjusted for base covariates, race and ethnicity, and insurance status, with 59% lower odds (adjusted odds ratio [aOR], 0.41; 95% CI, 0.30 to 0.56) of living donor transplantation and, although not statistically significant, 8% lower odds (aOR, 0.92; 95% CI, 0.72 to 1.19) of preemptive transplantation. The hazard of graft loss was 41% higher (aHR, 1.41; 95% CI, 1.25 to 1.60) for recipients from neighborhoods of intermediate versus low socioeconomic deprivation when adjusted for base covariates, race and ethnicity, and insurance status, with 27% lower odds (aOR, 0.73; 95% CI, 0.66 to 0.81) of living donor transplantation and 11% lower odds (aOR, 0.89; 95% CI, 0.80 to 0.99) of preemptive transplantation.

Conclusions

Children from neighborhoods of high socioeconomic deprivation have worse graft survival and lower utilization of preemptive and living donor transplantation. These findings demonstrate inequities in pediatric kidney transplantation that warrant further intervention.

Can non-directed living liver donation help improve access to grafts and correct socioeconomic disparities in pediatric liver transplantation?

BACKGROUND

Each year, children die awaiting LT as the demand for grafts exceeds the available supply. Candidates with public health insurance are significantly less likely to undergo both deceased donor LT and D-LLD LT. ND-LLD is another option to gain access to a graft. The aim of this study was to evaluate if recipient insurance type is associated with likelihood of D-LLD versus ND-LLD LT.

METHODS

The SRTR/OPTN database was reviewed for pediatric LDLT performed between January 1, 2014 (Medicaid expansion era) and December 31, 2019 at centers that performed ≥1 ND-LLD LDLT during the study period. A multivariable logistic regression was performed to assess relationship between type of living donor (directed vs. non-directed) and recipient insurance.

RESULTS

Of 299 pediatric LDLT, 46 (15%) were from ND-LLD performed at 18 transplant centers. Fifty-nine percent of ND-LLD recipients had public insurance in comparison to 40% of D-LLD recipients (p = .02). Public insurance was associated with greater odds of ND-LLD in comparison to D-LLD upon multivariable logistic regression (OR 2.37, 95% CI 1.23-4.58, p = .01).

CONCLUSIONS

ND-LLD allows additional children to receive LTs and may help address some of the socioeconomic disparity in pediatric LDLT, but currently account for only a minority of LDLT and are only performed at a few institutions. Initiatives to improve access to both D-LLD and ND-LLD transplants are needed.

Wages, Travel, and Lodging Reimbursement by the National Kidney Registry: An Important Step Toward Financial Neutrality for Living Kidney Donors in the United States

BACKGROUND

Since 2007, the National Living Donor Assistance Center has provided the most financial support to US living donors meeting specific income criteria by reimbursing travel, meal, and lodging expenses. In 2019, the National Kidney Registry started providing lost wages, travel, and lodging reimbursement via their Donor Shield program. Donor Shield is automatically provided to donors who participate in kidney paired donation through the National Kidney Registry or who donate at a Donor Shield Direct center, without any income restrictions.

METHODS

The support donors across the United States received from the Donor Shield program between January 2019 and February 2020 was studied.

RESULTS

During the study period, 326 (25.9%) of the 1260 donors covered by Donor Shield, from 46 programs received reimbursements amounting to a total of $647 384.45, with $472 389.97 (73.0%) covering lost wages. Median reimbursement per donor was $1813.80 (range, $44.0-$165.63). Eighty-one percent of 108 reimbursed donors who were surveyed reported that the lack of these reimbursements would have posed a financial hardship, and 4% said they would have been unable to donate without this support.

CONCLUSIONS

Expansion of lost wages reimbursement programs to all donors in the United States would be an important step toward achieving financial neutrality for this unique population and could also help meet the growing demand for transplantable organs by increasing living donation rates.

Gender and race/ethnicity differences in living kidney donor demographics: Preference or disparity?

In the United States, women are over-represented and Blacks are under-represented as living kidney donors. A traditional bioethics approach would state that as long as living donors believe that the benefits of participation outweigh the risks and harms (beneficence) and they give a voluntary and informed consent, then the demographics reflect a mere difference in preferences. Such an analysis, however, ignores the social, economic and cultural determinants as well as various forms of structural discrimination (e.g., racism, sexism) that may imply that the distribution is less voluntary than may appear initially. The distribution also raises justice concerns regarding the fair recruitment and selection of living donors. We examine the differences in living kidney donor demographics using a vulnerabilities analysis and argue that these gender and racial differences may not reflect mere preferences, but rather, serious justice concerns that need to be addressed at both the individual and systems level.

How Can We Help Alleviate the Financial Concerns of Non-Directed (Altruistic) Living Kidney Donors?

INTRODUCTION

The recent increase in non-directed donors (NDDs) in the United States (U.S.) may help reduce the overwhelming number of patients on the waitlist. However, non-directed donation may be limiting its full potential. Out-of-pocket donation costs upward of $8,000 may be a barrier to potential donors with altruistic tendencies, but inadequate financial support. This study aimed to describe the financial concerns of 31 U.S. NDDs.

METHODS

We conducted qualitative interviews and administered quantitative demographic surveys between April 2013 and April 2015. Interview transcripts were analyzed using grounded theory techniques to describe and expand on themes relevant to the NDD experience.

FINDINGS

We identified 4 sub-themes related to the theme of financial concerns: (1) direct costs related to transportation, lodging, and parking, (2) indirect costs of lost wages encountered from taking time off work to recover from surgery, (3) sources of financial support, and (4) suggestions for alleviating donor financial burden. Two thirds of participants (20) expressed concerns about direct and indirect donation costs. 11 NDDs reported the negative impact of direct costs,15 NDDs had concerns about indirect costs; only 7 donors received supplemental financial support from state mandates and transplant programs.

DISCUSSION

Understanding the financial concerns of NDDs may guide improvements in the NDD donation experience that could support individuals who are interested in donating but lack the financial stability to donate. Removing financial disincentives may help increase nondirected donation rates, increase the living donor pool, and the number of kidneys available for transplantation.

Living Kidney Donor Evaluation

Long-term safety of living kidney donation (LKD), especially for young donors, has become a real matter of concern in the transplant community and may contribute to creating resistance to LKD. In this context, the criteria that govern living donor donations must live up to very demanding standards as well as adjust to this novel reality. In the first part, we review the existing guidelines published after 2010 and critically examine their recommendations to see how they do not necessarily lead to consistent and universal practices in the choice of specific thresholds for a parameter used to accept or reject a living donor candidate. In the second part, we present the emergence of a new paradigm for LKD developed in the 2017 Kidney Disease: Improving Global Outcomes guidelines with the introduction of an integrative risk-based approach. Finally, we focus on predonation renal function evaluation, a criteria that remain central in the selection process, and discuss several issues surrounding the donor candidate's glomerular filtration rate assessment.

The true risk of living kidney donation

PURPOSE OF REVIEW

The safety of living donor nephrectomy is essential to the continued success, growth, and sustainability of the clinical practice of living donor kidney transplantation. This review summarizes recent advances in our understanding of the perioperative and long-term risks faced by living kidney donors.

RECENT FINDINGS

Although adverse perioperative complications are extremely rare, donors particularly men, Black, or obese, frequently experience minor complications that result in delayed return to normal duties at home and work. Similarly, although long-term complications such as end-stage renal disease (ESRD) are rare, recent studies suggest a relative increase in risk of ESRD that is attributable to donation. Several risk calculators have been developed to help donors and their care providers quantify the baseline and postdonation risk of ESRD based on demographic and health characteristics. Thresholds of risk may help define what is an acceptable level of risk to the donor and the transplant center.

SUMMARY

Individualized risk calculators now allow care providers and potential donors to objectively and transparently participate in shared decision-making about the safety of living kidney donation.

Nonreimbursed Costs Incurred by Living Kidney Donors: A Case Study From Ontario, Canada

BACKGROUND

Living donors may incur out-of-pocket costs during the donation process. While many jurisdictions have programs to reimburse living kidney donors for expenses, few programs have been evaluated.

METHODS

The Program for Reimbursing Expenses of Living Organ Donors was launched in the province of Ontario, Canada in 2008 and reimburses travel, parking, accommodation, meals, and loss of income; each category has a limit and the maximum total reimbursement is $5500 CAD. We conducted a case study to compare donors' incurred costs (out-of-pocket and lost income) with amounts reimbursed by Program for Reimbursing Expenses of Living Organ Donors. Donors with complete or partial cost data from a large prospective cohort study were linked to Ontario's reimbursement program to determine the gap between incurred and reimbursed costs (n = 159).

RESULTS

The mean gap between costs incurred and costs reimbursed to the donors was $1313 CAD for out-of-pocket costs and $1802 CAD for lost income, representing a mean reimbursement gap of $3115 CAD. Nondirected donors had the highest mean loss for out-of-pocket costs ($2691 CAD) and kidney paired donors had the highest mean loss for lost income ($4084 CAD). There were no significant differences in the mean gap across exploratory subgroups.

CONCLUSIONS

Reimbursement programs minimize some of the financial loss for living kidney donors. Opportunities remain to remove the financial burden of living kidney donors.

Financial burden associated with time to return to work after living kidney donation

Many living kidney donors undertake a significant financial burden in order to donate. We studied the association between time to return to work and reported financial burden. Kidney donors who donated from 2/2005 through 12/2015 (n = 1012) were surveyed 6 months after donation and asked about occupation, time to return to work, and financial burden (on a 10-point Likert scale). Of 856 donors working for pay, 629 (73%) responded. After adjusting for donor characteristics, increased length of time to return to work was a significant predictor of financial burden (P < .001). It is notable that those in manual/skilled trade occupations, compared with all other occupations, experienced greater financial burden for each week away from work (P = .003). Older age at donation and nondirected (vs directed) donation were associated with significantly decreased financial burden. These observations provide additional information to better inform donor candidates, and further emphasize the need to develop policies so that living kidney donation can be financially neutral.

Financial Costs Incurred by Living Kidney Donors: A Prospective Cohort Study

BACKGROUND

Approximately 40% of the kidneys for transplant worldwide come from living donors. Despite advantages of living donor transplants, rates have stagnated in recent years. One possible barrier may be costs related to the transplant process that potential willing donors may incur for travel, parking, accommodation, and lost productivity.

METHODS

To better understand and quantify the financial costs incurred by living kidney donors, we conducted a prospective cohort study, recruiting 912 living kidney donors from 12 transplant centers across Canada between 2009 and 2014; 821 of them completed all or a portion of the costing survey. We report microcosted total, out-of-pocket, and lost productivity costs (in 2016 Canadian dollars) for living kidney donors from donor evaluation start to 3 months after donation. We examined costs according to (1) the donor's relationship with their recipient, including spousal (donation to a partner), emotionally related nonspousal (friend, step-parent, in law), or genetically related; and (2) donation type (directed, paired kidney, or nondirected).

RESULTS

Living kidney donors incurred a median (75th percentile) of $1254 ($2589) in out-of-pocket costs and $0 ($1908) in lost productivity costs. On average, total costs were $2226 higher in spousal compared with emotionally related nonspousal donors (P=0.02) and $1664 higher in directed donors compared with nondirected donors (P<0.001). Total costs (out-of-pocket and lost productivity) exceeded $5500 for 205 (25%) donors.

CONCLUSIONS

Our results can be used to inform strategies to minimize the financial burden of living donation, which may help improve the donation experience and increase the number of living donor kidney transplants.