Kidney transplantation and HIV: does recipient privacy outweigh the donor's right to information?

Patients' right to know: A scoping review

AIMS AND OBJECTIVES

To analyse research-based evidence about patients' right to know from their own perspective to promote ethically high-quality nursing and to identify future research areas.

BACKGROUND

Patients' right to know is a fundamental right. Although of topical research interest, the current state of scientific evidence on patients' right to know has not been reviewed.

DESIGN

A scoping review according to the methodological framework by Arksey & O'Malley and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews.

METHODS

In June 2022, a literature search was conducted in the Ovid Medline, CINAHL and Cochrane Library databases. The inclusion criteria were peer-reviewed, empirical studies on the right to know with samples comprising adult patients. Data were analysed with inductive content analysis, and methodological quality was assessed with Mixed Methods Appraisal Tool.

RESULTS

Out of 2658 identified reports, 12 were selected for analysis. Based on the results, the research on patients' right to know can be classified into two main content categories: (1) expectations of the right and (2) realisation of the right. In the quality assessment, most of the reports did not meet all the quality criteria, the most common deficits being related to instrumentation and risk of bias.

CONCLUSIONS

Research-based evidence on patients' right to know provided a general insight into expectations and realisation of the right to know and not to know. The results indicate a need for continued efforts for novel approaches with high-quality methodological choices in future studies.

RELEVANCE TO CLINICAL PRACTICE

Nurses make constantly ethical decisions: The findings of this study can be useful for their decision-making and understanding of the patient's perspective on knowledge issues, and therefore, support ethically high-quality patient education.

PATIENT OR PUBLIC CONTRIBUTION

No direct patient or public contribution to the review.

Living kidney donor assessment: challenges, uncertainties and controversies among transplant nephrologists and surgeons

The assessment of living kidney donors presents unique ethical challenges and complex psychosocial implications. This study aimed to ascertain the perspectives of transplant nephrologists and surgeons on living kidney donor assessment. Semi-structured, face-to-face interviews were conducted with 110 transplant nephrologists and surgeons from 43 transplant units in 12 countries from Europe, Australasia and North America. The challenge of defining acceptable risk to the donor was central to five themes identified: burden of responsibility (personal accountability, policing morality, democratic decision making, meeting legal obligations, optimizing outcomes and innovation, relinquished control); medical protectiveness (prognostic uncertainty, skepticism of donor risk perception, avoidance of undue coercion, concerns for dubious motivations and coercion, safeguard donor well-being, ethical information disclosure); respecting donor autonomy (facilitate informed-decision making, concede to donor risk acceptance, benefit of the doubt, donor mandate to maintain health, acceptable altruism); driving ideologies (preserving equity, championing living donation, cognizance of anti-paternalism) and contextual pressures (evolving donor demographic, resource limitations). Living kidney donor assessment involves complex interactions between safeguarding the donors' welfare and respecting their autonomy. In our opinion, authoritative and well-described transplant unit, hospital and public policy positions that make explicit the considerations that are often implicit may reduce the uncertainty within which living donors are assessed today.

Written informed consent for living kidney donors: practices and compliance with CMS and OPTN requirements

We sought to assess how written informed consent practices for candidate living kidney donors have changed over the last 5 years and to assess compliance with Centers for Medicare and Medicaid (CMS) and Organ Procurement and Transplantation Network (OPTN) regulations that took effect in 2007. We requested evaluation consent forms from US centers that performed >5 living kidney transplants during the prior year (n = 184). We received 148 consent forms; each was reviewed for information provided and inclusion of CMS- and OPTN-required elements. We found that nearly all transplant centers now obtain written consent for living kidney donor evaluation. However, most centers' evaluation consent forms do not include all CMS and OPTN requirements. Multiple items balancing donor and recipient interests and confidentiality were omitted. In addition, information about payment for routine follow-up care, complications related to surgery and other health problems following surgery were highly variable and frequently ambiguous. As centers revise their consent forms to address the 2013 OPTN policies, our findings may help them identify areas of potential deficiency. We propose that UNOS develop a uniform donor evaluation consent form to improve the clarity, consistency and efficiency of living donor consent.

Allowing HIV-positive organ donation: ethical, legal and operational considerations

Case reports of kidney transplantation using HIV-positive (HIV+) donors in South Africa and advances in the clinical care of HIV+ transplant recipients have drawn attention to the legal prohibition of transplanting organs from HIV+ donors in the United States. For HIV+ transplant candidates, who face high barriers to transplant access, this prohibition violates beneficence by placing an unjustified limitation on the organ supply. However, transplanting HIV+ organs raises nonmaleficence concerns given limited data on recipient outcomes. Informed consent and careful monitoring of outcome data should mitigate these concerns, even in the rare circumstance when an HIV+ organ is intentionally transplanted into an HIV-negative recipient. For potential donors, the federal ban on transplanting HIV+ organs raises justice concerns. While in practice there are a number of medical criteria that preclude organ donation, only HIV+ status is singled out as a mandated exclusion to donation under the National Organ Transplant Act (NOTA). Operational objections could be addressed by adapting existing approaches used for organ donors with hepatitis. Center-specific outcomes should be adjusted for HIV donor and recipient status. In summary, transplant professionals should advocate for eliminating the ban on HIV+ organ donation and funding studies to determine outcomes after transplantation of these organs.

Willingness to pursue live-donor kidney transplantation among waitlisted patients infected with human immunodeficiency virus (HIV): a preliminary investigation

We show that HIV-infected waitlisted patients (n=33) had significantly lower knowledge (P<0.001), more concerns (P=0.01), and lower willingness to pursue live-donor kidney transplantation (LDKT; P=0.02) than matched noninfected patients. The majority (78%) of patients felt that their HIV status reduced their chance of LDKT. Although limited to a single center and a small sample, our data suggest that HIV-infected patients who are waitlisted for kidney transplantation may need more education about the potential benefits of LDKT and may benefit from patient-centered decision support to facilitate a risk-benefit assessment consistent with their preferences and values.

Transparent vessels?: What organ donors should be allowed to know about their recipients

A live organ donor needs to be informed carefully about the risks and benefits of her donation for both herself and her recipient, but a key ethical question is how much the donor is allowed to know about the recipient. To decide this question, we must first decide whether, out of respect for autonomy, the donor should decide how much she wants to know, or whether the transplant team, as the professionals, should decide what information is relevant to the donor's decision. I argue that the transplant team should control the process. While the donor has the right to know enough about her recipient to assess the risk to herself and the prospects for a successful donation, she is not entitled to any further information, no matter how much she wants it. In particular, I argue that donors are not entitled to information that has not been shown to affect outcomes, but that they should be told if a recipient is HIV or that he has rejected a previous organ due to non-compliance. Donors have a right to make decisions with all the information they need, but recipients need not make their lives completely transparent.

Renal disease in HIV-infected individuals

PURPOSE OF REVIEW

Highly active antiretroviral therapy (HAART) has resulted in a marked decrease in AIDS-related conditions and death. With improved survival, cardiovascular disease, hepatic, renal disease, and non-AIDS-related cancers represent an increasing burden for HIV-infected individuals.

RECENT FINDINGS

HIV-associated nephropathy (HIVAN), acute renal injury, HAART, and comorbid conditions such as hepatitis C, hypertension, and diabetes are among the multiple causes of renal disease. In HIVAN there is incomplete understanding of the interaction of the virus with renal cells and the host genetics leading to susceptibility to this form of renal dysfunction. There is agreement that a baseline estimated glomerular filtration should be obtained and that renal function should be monitored during antiretroviral therapy. There is, however, no agreement as to the most accurate method of estimating GFR. Renal transplantation has emerged as a feasible and successful modality of management of end-stage renal disease (ESRD) in HIV-infected individuals.

SUMMARY

Kidney disease represents an increasing concern in the care of HIV-infected persons, although there are questions remaining regarding the pathophysiology of HIVAN. Transplantation, however, can be carried out safely in infected persons with ESRD.

Disclosing recipient information to potential living donors: preferences of donors and recipients, before and after surgery

Consensus guidelines, while recommending that potential living donors should be given information that could impact their donation decision, are nonspecific about the types of information that should be disclosed. We surveyed potential (n = 36) and past (n = 45) living donors and transplant candidates (n = 45) and recipients (n = 45) about their preferences for sharing or knowing specific information about the recipient, how this information would impact decision-making, and who should be responsible for disclosing information. Potential donors were less likely than all others to feel that recipient information should be disclosed to potential donors. Donors and recipients felt most strongly about disclosing if the recipient lost a previously transplanted kidney due to medication nonadherence as well as the likelihood of 1- and 5-year graft survival. Most donors would be less likely to pursue donation if the recipient lost a previously transplanted kidney due to medication nonadherence or generally had problems with taking medications as prescribed. Transplant programs should consider how to best balance the potential donor's right to receive information that could reasonably be expected to affect their decision-making process with the recipient's right to privacy and confidentiality.