Living Anonymous Renal Donors Do Not Regret: Intermediate and Long-Term Follow-Up with a Focus on Motives and Psychosocial Outcomes

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.

Semidirected living donors in Israel: Sociodemographic profile, religiosity, and social tolerance

Living kidney donations in Israel come from 2 sources: family members and individuals who volunteer to donate their kidney to patients with whom they do not have personal acquaintance. We refer to the first group as directed living donors (DLDs) and the second as semidirected living donors (SDLDs). The incidence of SDLD in Israel is ∼60%, the highest in the world. We introduce results of a survey among 749 living donors (349 SDLDs and 400 DLDs). Our data illustrate the sociodemographic profile of the 2 groups and their answers to a series of questions regarding spirituality and social tolerance. We find SDLDs to be sectorial: they are mainly married middle-class religious men who reside in small communities. However, we found no significant difference between SDLDs and DLDs in their social tolerance. Both groups ranked high and expressed tolerance toward different social groups. Semidirected living donation enables donors to express general preferences as to the sociodemographic features of their respected recipients. This stirs a heated debate on the ethics of semidirected living donation. Our study discloses a comprehensive picture of the profile and attitudes of SDLDs in Israel, which adds valuable data to the ongoing debate on the legitimacy of semidirected living donation.

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.

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.

Recommendations for living donor kidney transplantation

This Guide for Living Donor Kidney Transplantation (LDKT) has been prepared with the sponsorship of the Spanish Society of Nephrology (SEN), the Spanish Transplant Society (SET), and the Spanish National Transplant Organization (ONT). It updates evidence to offer the best chronic renal failure treatment when a potential living donor is available. The core aim of this Guide is to supply clinicians who evaluate living donors and transplant recipients with the best decision-making tools, to optimise their outcomes. Moreover, the role of living donors in the current KT context should recover the level of importance it had until recently. To this end the new forms of incompatible HLA and/or ABO donation, as well as the paired donation which is possible in several hospitals with experience in LDKT, offer additional ways to treat renal patients with an incompatible donor. Good results in terms of patient and graft survival have expanded the range of circumstances under which living renal donors are accepted. Older donors are now accepted, as are others with factors that affect the decision, such as a borderline clinical history or alterations, which when evaluated may lead to an additional number of transplantations. This Guide does not forget that LDKT may lead to risk for the donor. Pre-donation evaluation has to centre on the problems which may arise over the short or long-term, and these have to be described to the potential donor so that they are able take them into account. Experience over recent years has led to progress in risk analysis, to protect donors' health. This aspect always has to be taken into account by LDKT programmes when evaluating potential donors. Finally, this Guide has been designed to aid decision-making, with recommendations and suggestions when uncertainties arise in pre-donation studies. Its overarching aim is to ensure that informed consent is based on high quality studies and information supplied to donors and recipients, offering the strongest possible guarantees.

Burden of organ donation after euthanasia in patients with psychiatric disorder

Organ donation after euthanasia (ODE) is rarely performed but the number has gradually increased over the years. It has been suggested that the preparatory investigations for organ donation parallel to the medical-legal procedures for euthanasia may be too much of a burden for the patients and their relatives. Furthermore, dying in an intensive care unit might contribute to this burden. Based on two patients who were granted euthanasia based on a psychiatric disorder, we show that the actual burden may be minimal for some patients and their relatives and may even be helpful in their process of euthanasia. Therefore, we propose that providing patients with information about donation of organs after euthanasia may be important to incorporate early in the medical-legal process of euthanasia instead of waiting for the patient to bring up organ donation, as currently advised in the Dutch guideline for ODE.

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).

Depression, anxiety, and associated psychological outcomes in living organ transplant donors: A systematic review

With increasing demands for living organ donations, understanding the prevalence of depression and anxiety, which are the commonest psychiatric disorders in donors following organ transplantation, will serve to improve psychiatric care to safeguard donors' mental wellbeing. This descriptive systematic review examines all observational studies in English investigating prevalence of depression and anxiety in adult transplant donors using bibliographic databases. Sixty-two papers were included (kidney, n = 25; liver, n = 25; bone marrow, n = 7; uterus, n = 2; lung, n = 1; kidney and lung concurrently, n = 2). Post-transplantation depression and anxiety prevalence rates (Depression: 0-46.9%, Anxiety: 0-66.7%) did not differ significantly from pre-transplantation and were largely comparable to the general population. Other psychiatric disorders observed included bipolar disorder, conversion disorder, adjustment disorder and sleep disorder. Other psychological outcomes observed included lower quality of life, lower satisfaction of life and regret after donation. Pre-donation risk factors such as poor physical/psychological health status, and post-donation risk factors such as complicated post-surgical recovery and poor physical/psychological health in recipients were identified, predisposing donors to poor psychological outcomes. Individuals with risk factors should be monitored and provided with social support, psychoeducation, psychotherapy and long-term follow up. Future studies should adopt consistent methodological approaches to improve comparability between various studies. More research investigating poor psychological outcomes in other organ donors besides kidney and liver donors, donors who have past psychiatric history, unrelated and parent donors is warranted.

Exploring the motives of Israeli Jews who were living kidney donors to strangers

Non-directed living donors are individuals who donate a kidney to a recipient with whom they have neither a genetic nor emotional relationship. Israel legalized this type of donation in 2008. After this law was implemented, living donations significantly expanded. The aim of this article was to determine the motivations, characteristics, and perioperative experiences of non-directed living donors in Israel. Three online questionnaires (own questionnaire, Rosenberg Self-Esteem Scale (RSES), Rushton Self-Report Altruism Scale) were distributed to 180 Jewish kidney donors with the help of Matnat Chaim organization. One hundred and fifteen responses were received (69.3% response rate). The motivation for most donors (60%) was a strong willingness to help and a desire to do good. The majority of donors (78.3%) reported their health status as unchanged after donation; however, 16.5% experienced clinical problems (eg, wound infection, more pain than expected), and 5.2% experienced psychological complications. About 18% reported their health to improve after donation. Most (80%) inspired someone else to also become a kidney donor. This study breaks the myth that Jews do not support organ donation. In fact, their high level of altruism and their positive experience with donation has propelled the practice of non-directed donation in Israel.

Living Donors: Altruism and Feeling Forgotten

OBJECTIVES

Living donors endure several challenges throughout the organ donation process. Physically related effects are further compounded by social and emotional challenges. To date, no previous studies have addressed the motives and impact of organ donations from living donors in Jordan.

MATERIALS AND METHODS

We conducted a qualitative exploratory study to understand the experiences of a random sample of genetically and legally related living donors in Jordan. Participants were identified through the Directorate of the Jordanian Center for Organ Transplantation database. Our sample included Jordanians and non-Jordanians who donated a kidney or liver. Most data were collected by phone interviews with living donors; some donors were personally interviewed. Donors were asked about their experiences during the periods before and after the process of donation, including their feelings, emotions, and motives. Interviews were analyzed using the thematic analysis approach.

RESULTS

In total, 360 participants (337 kidney and 23 liver donors; 290 Jordanians and 70 non-Jordanians) completed the interview. The time from donation to interview ranged from 14 days to 7 years. The period before donation was characterized by fear and confusion. After donation, most donors described a positive emotional state that was marked by selfsatisfaction, pride, and increased support of organ donation. However, many stated that they felt forgotten. Most donors were motivated by social solidarity, and others invoked the role of their religious beliefs as the main motive. Other motives included improving the recipient's life and fear that patients would be abandoned.

CONCLUSIONS

The emotional distress of living donors during the predonation period emphasizes the need for social and psychological support in addition to medical evaluations. Donors who had positive experiences with donation can play a role in advocating for donation. Finally, in Jordan, social solidarity and religious beliefs are the most important factors that motivate donation.