Emotional and Financial Experiences of Kidney Donors over the Past 50 Years: The RELIVE Study

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.

Use of Federal Reimbursement for Living Donor Costs by Racial and Ethnic Minorities: Implications for Disparities in Access to Living Donor Transplantation

BACKGROUND

Minority race, ethnicity, and financial barriers are associated with lower rates of living donor (LD) kidney transplantation (LDKT). Financial reimbursement for LD costs may impact social determinants of health and, therefore, impact disparities in access to LDKT.

METHODS

Among US LDKTs, we studied associations between racial and ethnic minority status and utilization of the National Living Donor Assistance Center (NLDAC), a means-tested reimbursement program for nonmedical LD costs. We analyzed demographic, clinical, income, and survey data from NLDAC and the Scientific Registry of Transplant Recipients (January 1, 2011, to December 31, 2022) to identify predictors of NLDAC utilization.

RESULTS

Among 70 069 US LDKTs, 6093 NLDAC applicants were identified (9% of US LDKTs). Racial and ethnic minorities were over-represented in NLDAC-supported LDKTs compared with non-NLDAC US LDKTs (Black donors 12% versus 9%; Black recipients 15% versus 12%; Hispanic donors 21% versus 14%; Hispanic recipients 23% versus 15%; all P < 0.001). Among preemptive transplants, use of NLDAC by donors to Hispanic recipients (11%) was nearly twice as high as that of non-Hispanic recipients (6%) (P < 0.001). At time of NLDAC application, 72% stated NLDAC "will make it possible" to donate; higher proportions of minority applicants agreed (Black 80%, White 70%, P < 0.001; Hispanic 79%, non-Hispanic 70%, P < 0.001). Racial and ethnic minority-concordant transplants were significantly more likely to use NLDAC (donor/recipient: Black/Black risk-adjusted odds ratio [OR], 1.85, other/other OR 2.59, Hispanic/Hispanic OR 1.53; all P < 0.05).

CONCLUSIONS

Reduction of LD financial barriers may increase access to LDKT, particularly in racial and ethnic minority communities.

Psychosocial characteristics of potential and actual living kidney donors

The psychosocial assessment is an essential component of the living kidney donor (LKD) evaluation. However, it remains uncertain how specific psychosocial factors impact LKD eligibility. We performed a retrospective chart review of LKD candidates who initiated the evaluation process and who had completed a required, in-person licensed social work (LSW) visit. LSW notes were reviewed for frequency of psychosocial factors that may impact the success of LKD candidate approval by the selection committee. 325 LKD candidates were included in the study: 104 not-approved and 221 approved. Not-approved LKD candidates were more likely to receive a negative family reaction to wanting to donate than approved LKD candidates (8.7% vs 1.4%, p < 0.01). On multivariate analysis, Black race, history of psychiatric illness, highest level of education being high school, and high psychosocial risk score assignment were all associated with a lower odds ratio of being approved. The majority of not-approved LKD candidates were disqualified for medical reasons (N = 76, 73.1%). In conclusion, psychosocial factors impact donation even after LKD candidates make it to an in-person evaluation.

Quality of Life in Kidney Donors: A Single-Center Experience

BACKGROUND

Live kidney donation is used to treat end-stage renal disease, but it poses risks and decision-making challenges for donors. This study examines kidney donors' long-term quality of life (QOL).

METHODS

 We conducted a cross-sectional survey on kidney donors between 1982 and 2018. We used the Short Form-36 (SF-36) (Arabic version) to measure the donors' QOL. Out of 60 donors contacted, 44 agreed to participate and responded. Demographic information, donor-recipient relationships, and specific questions about the donation were collected and analyzed.

RESULTS

The mean age of the donors was 50.1 ± 11.7 years at follow-up, and 26 (59.1%) were males. Most donors were siblings and parents, accounting for 36.4% (n=16) each. The time since the donation was 111.5 ± 97.1 months. All donors decided voluntarily to donate and all of them would do it again if given a chance. However, one donor (2.3%) complained that the donation had caused problems in his marriage, while six donors (13.4%) experienced clinically relevant distress, and two donors (4.5%) experienced financial disadvantages. Donors had high QOL scores, with a mean score of 73.1 and 96.9 (on a scale of 1-100) for the eight subscales. The highest score was for role social functioning, while the lowest was for energy/fatigue. The mean scores for the four fatigue subscales were low, ranging from 61.8 to 86.8. The lowest score was for feeling calm and reassured, while the highest was for feeling frustrated. In social functioning, the highest score was for the effect of mental health on work performance (97.2). We analyzed various demographic factors and their correlation with QOL and found no significant correlation in most domains regarding sociodemographic characteristics.

CONCLUSIONS

Our research indicates that most kidney donors have had a positive experience over the past four decades. Both male and female donors of all ages reported good long-term QOL, further enhanced by recognition and support from their families and friends. These findings provide further support for our current policy on organ 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.

Quality of life, anxiety and depression symptoms in living related kidney donors: a cross‑sectional study

OBJECTIVES

Few studies have examined the quality of life of living kidney donors in mainland China. The data on anxiety and depression of living kidney donors was also scant. This study aimed to investigate quality of life, anxiety, and depression and identify their influencing factors among living kidney donors in mainland China.

METHODS

A cross-sectional study included 122 living kidney donors from a kidney transplantation center in China. The abbreviated World Health Organization Quality of Life questionnaire, Generalized Anxiety Disorder 2-item and Patient Health Questionnaire 2-item were used to assess the quality of life, anxiety and depression symptoms, respectively.

RESULTS

Our study found that the physical related quality of life of our donors was poorer than that of the domestic general population. Among 122 donors, 43.4% and 29.5% of them were found to have anxiety and depression symptoms, respectively. Poor health condition of recipient was identified as not only negative factors affecting all domains of quality of life, but also closely related to anxiety and depression of kidney donors. Donors with proteinuria were more likely to have a poor psychological, social related quality of life, as well as anxiety and depression symptoms.

CONCLUSIONS

Living kidney donation has an impact on the physical and mental health of donors. Both the physical and mental health of living kidney donors should not be ignored. More attention and support should be given to donors with proteinuria and donors whose relative recipient suffering poor health condition.

Reasons for kidney transplant refusal among patients receiving peritoneal dialysis: A qualitative study

BACKGROUND

Even though kidney transplantation has better outcomes compared to dialysis therapies, some patients undergoing peritoneal dialysis (PD) refuse to consider kidney transplantation. Identification of the underlying reason for patient refusal may improve patients' acceptance of kidney transplantation.

AIM

The aim of this study was to describe the reasons given by Iranian PD patients for refusing kidney transplantation.

METHOD

Eighteen patients undergoing PD participated. Data were collected using semi-structured interviews and were analysed using conventional qualitative content analysis.

RESULTS

The analysis leads to the emergence of two categories and six subcategories: negative outcomes of kidney transplantation (financial burden, psychosocial problems and physical complications) and doubtful factors for kidney transplantation (negative attitudes towards kidney transplantation, long waiting time for kidney transplantation and compatibility of PD with daily life). The financial burden and long waiting time for kidney transplantation were the most important factors in the reluctance of kidney transplantation by PD patients.

IMPLICATION FOR PRACTICE

Patients undergoing PD declined kidney transplantation for several reasons, such as financial burden, fear of post-transplantation side effects, long waiting time for kidney transplantation. Reducing the time of kidney transplantation and insurance coverage of transplant costs can change the attitude of PD patients towards transplant.

Anxiety and depression among living kidney donors in tertiary care hospital of low resource country setting Nepal

Introduction

Kidneys accounted for the majority of transplanted organs worldwide in 2018, according to the Global Observatory on Donation and Transplantation. Living kidney donors continue to have negative psychosocial effects after donation. We aimed to assess anxiety and depression among Nepalese living kidney donors.

Methods

This was an observational, cross-sectional study conducted from May 2020 to January 2021. All patients who had undergone donor nephrectomy and had completed 6 months of post-donation period were included in the study. Anxiety and depression was assessed using the Hospital Anxiety and Depression Scale (HADS). Fischer exact and chi-square test was used to determine the association between variables and the level of significance was maintained at 5% with p < 0.05 considered statistically significant.

Results

A total of 147 kidney donors undergoing nephrectomies were included in the study. Among them 69.4% of participants were female and 55.8% of participants were aged 50 years or more. The prevalence of anxiety and depression among kidney donors was 27.9% and 6.2% respectively. Gender, earner, parental relations, occupation, and educational status were related to symptoms of anxiety among the living kidney donors. Similarly, earner was associated with symptoms of depression.

Conclusion

In addition to physical health measures, routine evaluations of kidney donors should include assessments of depression and other emotional disorders. The actual issue is to come up with effective treatments for depressive symptoms and to improve health outcomes following kidney donation.

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The prevalence of anxiety and depression among live kidney donors were 27.9% and 6.2% respectively.

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Gender, parental relations, occupation, and educational status were related with symptoms of anxiety.

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Routine evaluations of kidney donors should include assessments of depression and other emotional disorders.

Sequential liver and kidney living donors: Making the ultimate gift twice

There are nearly 150 living donors in the United States who donated more than one solid organ. Using our divisional database, we found 20 individuals who donated a liver and a kidney at different times. We performed a retrospective chart review of these donors, studying their motivating factors, complications and outcomes. The donors included 11 (55%) males and nine females. Thirteen (65%) donated the kidney before the liver. Fourteen (70%) were nondirected donors at the first donation, and four of the six directed donors in the first donation became nondirected in the second donation. Seventeen (85%) were nondirected at the second donation. Common reasons for donating the second time were a good experience with the first donation and knowing that one can donate again. Outcomes and the incidence of early complications were not significantly different after the 2nd versus the 1st donation. All donors recovered and currently are doing well. Our results show a significant number of dual organ donors are nondirected and motivated by their strong desire to help. A positive experience with the 1st donation often was the driving factor for the 2nd. A history of previous organ donation did not negatively impact the 2nd donation.

Combining transplant professional's psychosocial donor evaluation and donor self-report measures to optimise the prediction of HRQoL after kidney donation: an observational prospective multicentre study

OBJECTIVES

Living donor kidney transplantation is currently the preferred treatment for patients with end-stage renal disease. The psychosocial evaluation of kidney donor candidates relies mostly on the clinical viewpoint of transplant professionals because evidence-based guidelines for psychosocial donor eligibility are currently lacking. However, the accuracy of these clinical risk judgements and the potential added value of a systematic self-reported screening procedure are as yet unknown. The current study examined the effectiveness of the psychosocial evaluation by transplant professionals and the potential value of donor self-report measures in optimising the donor evaluation. Based on the stress-vulnerability model, the predictive value of predonation, intradonation and postdonation factors to impaired longer term health-related quality of life (HRQoL) of kidney donors was studied.

DESIGN

An observational prospective multicentre study.

SETTING

Seven Dutch transplantation centres.

PARTICIPANTS

588 potential donors participated, of whom 361 donated. Complete prospective data of 230 donors were available. Also, 1048 risk estimation questionnaires were completed by healthcare professionals.

METHODS

Transplant professionals (nephrologists, coordinating nurses, social workers and psychologists) filled in risk estimation questionnaires on kidney donor candidates. Furthermore, 230 kidney donors completed questionnaires (eg, on HRQoL) before and 6 and 12 months after donation.

PRIMARY AND SECONDARY OUTCOME MEASURES

HRQoL, demographic and preoperative, intraoperative and postoperative health characteristics, perceived support, donor cognitions, recipient functioning and professionals risk estimation questionnaires.

RESULTS

On top of other predictors, such as the transplant professionals' risk assessments, donor self-report measures significantly predicted impaired longer term HRQoL after donation, particularly by poorer predonation physical (17%-28% explained variance) and psychological functioning (23%).

CONCLUSIONS

The current study endorses the effectiveness of the psychosocial donor evaluation by professionals and the additional value of donor self-report measures in optimising the psychosocial evaluation. Consequently, systematic screening of donors based on the most prominent risk factors provide ground for tailored interventions for donors at risk.

Extreme living donation: A single center simultaneous and sequential living liver-kidney donor experience with long-term outcomes under literature review

Objective: Living liver and kidney donor surgeries are major surgical procedures applied to healthy people with mortality and morbidity risks not providing any direct therapeutic advantage to the donor. In this study, we aimed to share our simultaneous and sequential living liver-kidney donor experience under literature review in this worldwide rare practice.

Material and Methods: Between January 2007 and February 2018, a total of 1109 living donor nephrectomies and 867 living liver donor hepatectomies were performed with no mortality to living-related donors. Eight donors who were simultaneous or sequential living liver-kidney donors in this time period were retrospectively reviewed and presented with their minimum 2- year follow-up.

Results: Of the 8 donors, 3 of them were simultaneous and 5 of them were sequential liver-kidney donation. All of them were close relatives. Mean age was 39 (26-61) years and mean BMI was 25.7 (17.7-40). In 3 donors, right lobe, in 4 donors, left lateral sector, and in 1 donor, left lobe hepatectomy were performed. Median hospital stay was 9 (7-13) days. Two donors experienced early and late postoperative complications (Grade 3b and Grade 1). No mortality and no other long-term complication occurred.

Conclusion: Expansion of the donor pool by utilizing grafts from living donors is a globally-accepted proposition since it provides safety and successful outcomes. Simultaneous or sequential liver and kidney donation from the same donor seems to be a reasonable option for combined liver-kidney transplant recipients in special circumstances with acceptable outcomes.

Economic Impact of Donating a Kidney on Living Donors: A Korean Cohort Study

RATIONALE & OBJECTIVE

Although existing studies have reported adverse health outcomes after kidney donation, its socioeconomic impact on living donors requires further study.

STUDY DESIGN

A retrospective observational cohort study including a matched comparison group.

SETTING & PARTICIPANTS

1,285 living kidney donors from 7 tertiary hospitals between 2003 and 2016, and a matched comparison group consisting of the same number of health screening examinees with similar baseline clinical characteristics and socioeconomic status. All participants were receiving Korean national health insurance.

EXPOSURE

Kidney donation as reflected in the Korean National Health Insurance System (NHIS) database.

OUTCOME

Changes in household economic status estimated by Korean national health insurance fees and changes in employment status reflected in the NHIS database.

ANALYTICAL APPROACH

The outcomes of the donor group and matched control group were compared annually using multivariable logistic regression analyses adjusted for clinical and demographic characteristics.

RESULTS

The median ages of the donors and matched controls were 45 and 46 years, respectively; 44.6% of both groups were male. Compared to the comparison group, living donors were at higher risk of being unemployed or losing employment during the first 2 years after donation (eg, first-year loss of employment: odds ratio (OR), 2.27 [95% CI, 1.55-3.33]); however, this association did not persist. Donors also had a significantly lower odds of improvement in economic status (OR, 0.57 [95% CI, 0.47-0.71]) and a higher odds of deterioration in financial status (OR, 1.54 [95% CI, 1.23-1.93]) in the first year after transplantation and subsequently.

LIMITATIONS

Unmeasured differences between donors and matched controls creating residual selection bias and confounding.

CONCLUSIONS

Living kidney donors may suffer loss of employment and poor economic status after their voluntary donation. The socioeconomic impact on these donors should be considered in conjunction with the potential long-term adverse health outcomes after donation.

Living Kidney Donors' Financial Expenses and Mental Health

BACKGROUND

Living kidney donors incur donation-related expenses, but how these expenses impact postdonation mental health is unknown.

METHODS

In this prospective cohort study, the association between mental health and donor-incurred expenses (both out-of-pocket costs and lost wages) was examined in 821 people who donated a kidney at one of the 12 transplant centers in Canada between 2009 and 2014. Mental health was measured by the RAND Short Form-36 Health Survey along with Beck Anxiety Inventory and Beck Depression Inventory.

RESULTS

A total of 209 donors (25%) reported expenses of >5500 Canadian dollars. Compared with donors who incurred lower expenses, those who incurred higher expenses demonstrated significantly worse mental health-related quality of life 3 months after donation, with a trend towards worse anxiety and depression, after controlling for predonation mental health-related quality of life and other risk factors for psychological distress. Between-group differences for donors with lower and higher expenses on these measures were no longer significant 12 months after donation.

CONCLUSIONS

Living kidney donor transplant programs should ensure that adequate psychosocial support is available to all donors who need it, based on known and unknown risk factors. Efforts to minimize donor-incurred expenses and to better support the mental well-being of donors need to continue. Further research is needed to investigate the effect of donor reimbursement programs, which mitigate donor expenses, on postdonation mental health.

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.

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.

Experiencing one's own body and body image in living kidney donors-A sociological and psychological study

BACKGROUND

The aim of the study was to perform an in-depth exploratory analysis of the experience and image of one's body among living kidney donors.

METHOD

The research was carried out using mixed methodology. The study on experiencing one's own body was carried out using the sociological methodology of the grounded theory (qualitative research). This method was supplemented with psychometric measurement-the Body Esteem Scale (quantitative research). The basic research method was the in-depth interview. Using this method, a group of 25 living kidney donors who had not experienced any serious health or psychological problems after donation was examined. The participants of the study came from three transplant centers in Poland.

RESULTS

The data from the sociological interviews indicate that the donors: 1. do not experience radical changes in the functioning of their body; 2. maintain full control over it and do not feel the absence of a kidney in the body; 3. consciously and reflectively take care of their body after donation. In addition, the sociological research indicates that caring for one's own body also includes the transferred organ. The kidney donors experience a kind of bodily identity extension, including the recipient's body. However, the personal and social identity of the studied kidney donors is not disturbed in any way. The psychometric data correspond to the sociological results and indicate: 1. a lack of extreme emotional assessments about one's body; 2. awareness of one's own body and consistency of its image; 3. reduced emotional assessment of body zones directly related to the surgery; 4. differences in body image between the sexes.

CONCLUSIONS

The research results presented in the text indicate not only the possibility, but also the need for triangulation of research methods in the study of the experience and image of one's own body in living kidney donors. The proposed research approach employing mixed methodology within the fields of sociology and psychology for researching the phenomenon of living kidney donation is not very common.

Economic Consequences of Adult Living Kidney Donation: A Systematic Review

OBJECTIVES

Current guidelines mandate organ donation to be financially neutral such that it neither rewards nor exploits donors. This systematic review was conducted to assess the magnitude and type of costs incurred by adult living kidney donors and to identify those at risk of financial hardship.

METHODS

We searched English-language journal articles and working papers assessing direct and indirect costs incurred by donors on PubMed, MEDLINE, Scopus, the National Institute for Health Research Economic Evaluation Database, Research Papers in Economics, and EconLit in 2005 and thereafter. Estimates of total costs, types of costs, and characteristics of donors who incurred the financial burden were extracted.

RESULTS

Sixteen studies were identified involving 6158 donors. Average donor-borne costs ranged from US$900 to US$19 900 (2019 values) over the period from predonation evaluation to the end of the first postoperative year. Less than half of donors sought financial assistance and 80% had financial loss. Out-of-pocket payments for travel and health services were the most reported items where lost income accounted for the largest proportion (23.2%-83.7%) of total costs. New indirect cost items were identified to be insurance difficulty, exercise impairment, and caregiver income loss. Donors from lower-income households and those who traveled long distances reported the greatest financial hardship.

CONCLUSIONS

Most kidney donors are undercompensated. Our findings highlight gaps in donor compensation for predonation evaluation, long-distance donations, and lifetime insurance protection. Additional studies outside of North America are needed to gain a global prospective on how to provide for financial neutrality for kidney donors.

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.

The Spanish Version of the Fear of Kidney Failure Questionnaire: Validity, Reliability, and Characterization of Living Donors With the Highest Fear of Kidney Failure

Background.

Measures of fear of progression or recurrence of illnesses have been criticized for neglecting cross-cultural validity. Therefore, we assessed the psychometric properties of the Spanish version of the Fear of Kidney Failure Questionnaire (FKFQ), to determine whether postdonation fear of kidney failure (FKF) influenced the donors’ psychosocial status, and define variables that characterized donors with high FKFQ scores.

Methods.

We included 492 participants (211 donors) in a multicenter, 11-year, retrospective, cross-sectional study. Donors were classified with a Latent Class Analysis of the FKFQ-item scores and characterized with a multivariable logistic regression analysis. We calculated the risk ratio based on predicted marginal probabilities.

Results.

The Spanish version of the FKFQ showed acceptable psychometric properties. FKF was uncommon among donors, but we detected a small subgroup (n = 21, 9.9%) with high FKF (mean FKFQ score = 14.5, 3.1 SD). Compared with other donors, these donors reported higher anxiety and depression (38% and 29% of potential anxiety and depressive disorders), worse quality of life, and less satisfaction with the donation. Donors with high FKFQ scores were characterized by higher neuroticism combined with postdonation physical symptoms that interfered with daily activities.

Conclusions.

The FKFQ was cross-culturally valid, and thus, it may be used to assess the FKF in Spanish-speaking donors. New interventions that promote positive affectivity and evidence-based treatments for worry could be adapted for treating FKF.

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.

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).

Quality of life, depression and anxiety in living donor kidney transplantation

Due to its numerous advantages, transplantation from a living kidney donor is the best method of renal replacement therapy. However, the characteristics of the procedure require to consider well-being of not only the recipient, but also the donor - a person who suddenly becomes a patient despite former good health. The living donation is a selfless act, but also a decision that may endanger one's own health. The aim of this article was to review the current knowledge concerning the quality of life, symptoms of anxiety and depression occurring among living kidney donors and recipients. In order to do that, we performed a systematic research in the PubMed, Google Scholar and CINAHL databases for the years 2000-2019 with the use of key words. The inclusion and exclusion criteria were met by only 15 articles. This study shows that the mental state of donors is generally better than that of recipients. Additionally, reduction of anxiety and depression as well as increase in the quality of life occurs in both donors and recipients in the post-transplant period compared to the time before surgery. Further research is needed on this topic in order to improve psychological aspects of care of live kidney donors and recipients.

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.

Psychosocial consequences of living kidney donation: a prospective multicentre study on health-related quality of life, donor-recipient relationships and regret

BACKGROUND

Previous studies have indicated decreased health-related quality of life (HRQoL) shortly after kidney donation, returning to baseline in the longer term. However, a subgroup of donors experiences persistent HRQoL problems. To identify which HRQoL aspects are impacted most by the donation and to identify at-risk donors, more specific insight into psychosocial donation consequences is needed.

METHODS

The current study examined the HRQoL course, donor-perceived consequences of donation for donors, recipients and donor-recipient relationships, and regret up to 12 months post-donation in donors from seven Dutch transplantation centres. Kidney donor candidates (n = 588) completed self-report questionnaires early in the screening procedure, of which 361 (61%) donated their kidney.

RESULTS

Data for 230 donors (64%) with complete assessments before donation and 6 and 12 months post-donation were analysed. Results indicated that donor physical HRQoL was comparable at all time points, except for an increase in fatigue that lasted up to 12 months post-donation. Mental HRQoL decreased at 6 months post-donation, but returned to baseline at 12 months. Donors reported large improvements in recipient's functioning and a smaller influence of the recipient's kidney disease or transplantation on the donor's life over time. A subgroup experienced negative donation consequences with 14% experiencing regret 12 months post-donation. Predictors of regret were more negative health perceptions and worse social functioning 6 months post-donation. The strongest baseline predictors of higher fatigue levels after donation were more pre-donation fatigue, worse general physical functioning and a younger age.

CONCLUSIONS

Future research should examine predictors of HRQoL after donation to improve screening and to provide potential interventions in at-risk donors.

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.

The Effect of Donors' Demographic Characteristics in Renal Function Post-Living Kidney Donation. Analysis of a UK Single Centre Cohort

Introduction: There is a great need to increase the organ donor pool, particularly for living donors. This study analyses the difference in post-living donation kidney function according to pre-donation characteristics of age, genetic relationship with the recipient, sex, ethnicity, and Body Mass Index (BMI). Methods: Retrospective single centre analysis of the trajectory of estimated Glomerular Filtration Rate (eGFR) post-living kidney donation, as a measure of kidney function. Mean eGFR of the different groups was compared at 6 months and during the 60 months follow up. Results: Mean age was 46 ± 13 years, 57% were female, and 60% Caucasian. Mean BMI was 27 ± 5 kg/m², with more than a quarter of the cohort having a BMI > 30 (26%), and the majority of the donors genetically related to their recipients (56%). The higher decline rate in eGFR was at 6 months after donation, with female sex, non-Caucasian ethnicity, and age lower than 60 years being independently associated with higher recovery in kidney function (p < 0.05). In the 60 months follow up, older age, genetic relationship with the recipient, and male sex led to higher percentual difference in eGFR post-donation. Conclusion: In this study, with a high proportion of high BMI living kidney donors, female sex, age lower than 60 years, and non-genetic relationship with recipient were persistently associated with higher increase in post-donation kidney function. Ethnicity and BMI, per se, should not be a barrier to increasing the living donor kidney pool.

Adherence to Medical Appointments Among Living Kidney Donors After Donation Under a Monitored Approach and Long-term Clinical Outcomes: A Brazilian Single-center Cohort Study

BACKGROUND

There is little information about living donor long-term follow-up among Brazilian living donors. The aim of this study was to evaluate the main outcomes among living donors and to measure their adherence to regular medical appointments.

METHODS

This is a Brazilian single-center cohort study that included 397 living donors with 87.1 months of follow-up and measured adherence to clinical appointments. Before 2010, the appointments were scheduled only spontaneously; after that an approach was structured to check the returns of donors, who were monitored actively. We also evaluated long-term outcomes such as survival and chronic kidney disease development and, secondarily, the incidences of hypertension, diabetes mellitus (DM), and dyslipidemia after donation.

RESULTS

The donors' adherence to annual clinical appointments was 75.8% (54.7% of them presenting annual regularity). Before 2010 the adherence was lower than 40%; 10-year cumulative incidences of hypertension, DM, and dyslipidemia were 20.4%, 5.7%, and 23.5%, respectively. The crude mortality was 1% and 10-year donor survival was 98.5%. The incidence of chronic kidney disease 5 years after donation was 19%, with 16.4% of patients staged in 3a and 2.6% in 3b.

CONCLUSION

A structured approach to check donor returns to long-term clinical appointments has doubled the adherence to visits returns (compared to historical data). We identified lower incidence of arterial hypertension and DM among donors as compared with the incidence of arterial hypertension and DM in the Brazilian general population, but the 5-year chronic kidney disease incidence was considered high, taking into consideration data that have been published in the last years.

Long-term psychosocial outcomes after nondirected donation: A single-center experience

Short-term studies have demonstrated that nondirected donors (NDDs) have psychosocial outcomes that are similar to donors who donate directly, but long-term studies have not been done. NDDs at our center were surveyed regarding motivation; support during donation; stress related to donation; regret; financial resources used for donation; preferences about communication with the recipient; and cost reimbursement. Of 100 NDDs who donated at our center in the last 20 years, 95 remain in contact with us, and 77 responded to our survey (mean ± standard deviation [SD] 6.7 ± 4 years postdonation). The most common motivation for donation was the desire to help another (99%). Many NDDs received support from family, friends, and employers. NDDs voiced stress about the possibility of recipient kidney rejection, physical consequences to themselves, and financial burden. Only one donor expressed regret. Almost half wanted some recipient information at donation; 61% preferred routine recipient status updates; 56% believed meeting the recipient should occur at any mutually agreeable time; and 55% endorsed reimbursement for expenses. Stressors for NDDs are analogous to those of directed donors; NDDs prefer having some information about the recipient and prefer to be given a choice regarding the timing for communication with the recipient. NDDs supported donation being financially neutral.

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

BACKGROUND Living anonymous donation (LAD) of kidneys was introduced in Sweden in 2004. This study reports on outcomes of Swedish LAD experiences from 2004 to 2016, focusing on donors' motives, the care they received, psychosocial aspects, and medical status at follow-up. MATERIAL AND METHODS Donor data were collected through a physician interview, medical check-up, review of medical charts, the Hospital Anxiety Depression Scale (HADS), and a routine national questionnaire. Of the 26 LADs during the study period, 1 donor died and 1 declined to participate, leaving a study population of 24. RESULTS Half of the donors were male, which is a higher proportion than for directed living donors. The major motive detected was altruism. Of the 24 LADs, 96% were very satisfied and would donate again if possible, 46% noted increased self-esteem, and a third were happier after the donation. Sixty-two percent received anonymous information about the recipient and 40% would have liked to meet the recipient. HADS scores were normal. Two donors had antidepressant treatment, 1 of whom had received treatment before donation. Half mentioned that the pre-donation assessment took too long. At follow-up, mean eGFR was 62±12 mL/min/1.73 m², of which 16 were in CKD II and 8 were in CKD III. Four donors had developed hypertension, 1 of whom also developed type 2 diabetes. CONCLUSIONS Swedish LADs are very satisfied and medical outcomes are acceptable. We propose that the transplant community and the National Board of Health and Welfare take a more active approach to informing the general public about LAD.

Assessment of Postdonation Outcomes in US Living Kidney Donors Using Publicly Available Data Sets

Importance

There are limited resources providing postdonation conditions that can occur in living donors (LDs) of solid-organ transplant. Consequently, it is difficult to visualize and understand possible postdonation outcomes in LDs.

Objective

To assemble an open access resource that is representative of the demographic characteristics in the US national registry, maintained by the Organ Procurement and Transplantation Network and administered by the United Network for Organ Sharing, but contains more follow-up information to help to examine postdonation outcomes in LDs.

Design, Setting, and Participants

Cohort study in which the data for the resource and analyses stemmed from the transplant data set derived from 27 clinical studies from the ImmPort database, which is an open access repository for clinical studies. The studies included data collected from 1963 to 2016. Data from the United Network for Organ Sharing Organ Procurement and Transplantation Network national registry collected from October 1987 to March 2016 were used to determine representativeness. Data analysis took place from June 2016 to May 2018. Data from 20 ImmPort clinical studies (including clinical trials and observational studies) were curated, and a cohort of 11 263 LDs was studied, excluding deceased donors, LDs with 95% or more missing data, and studies without a complete data dictionary. The harmonization process involved the extraction of common features from each clinical study based on categories that included demographic characteristics as well as predonation and postdonation data.

Main Outcomes and Measures

Thirty-six postdonation events were identified, represented, and analyzed via a trajectory network analysis.

Results

The curated data contained 10 869 living kidney donors (median [interquartile range] age, 39 [31-48] years; 6175 [56.8%] women; and 9133 [86.6%] of European descent). A total of 9558 living kidney donors with postdonation data were analyzed. Overall, 1406 LDs (14.7%) had postdonation events. The 4 most common events were hypertension (806 [8.4%]), diabetes (190 [2.0%]), proteinuria (171 [1.8%]), and postoperative ileus (147 [1.5%]). Relatively few events (n = 269) occurred before the 2-year postdonation mark. Of the 1746 events that took place 2 years or more after donation, 1575 (90.2%) were nonsurgical; nonsurgical conditions tended to occur in the wide range of 2 to 40 years after donation (odds ratio, 38.3; 95% CI, 4.12-1956.9).

Conclusions and Relevance

Most events that occurred more than 2 years after donation were nonsurgical and could occur up to 40 years after donation. Findings support the construction of a national registry for long-term monitoring of LDs and confirm the value of secondary reanalysis of clinical studies.

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.

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.

Helping More Patients Receive a Living Donor Kidney Transplant

The best treatment option for many patients with kidney failure is a kidney transplant from a living donor. Countries that successfully increase their rate of living kidney donation will decrease their reliance on dialysis, the most expensive and high-risk form of kidney replacement therapy. Outlined here are some barriers that prevent some patients from pursuing living kidney donation and current knowledge on some potential solutions to these barriers. Also described are strategies to promote living kidney donation in a defensible system of practice. Safely increasing the rate of living kidney donation will require better programs and policies to improve the experiences of living donors and their recipients, to safeguard the practice for years to come.

Effective Decision-Making and Decisional Regret in Living Kidney Donors of Taiwan

BACKGROUND

While most living kidney donors are satisfied with their decision and do not regret donating, few studies have been conducted on the determinants related to the effectiveness and regret of the decision. This study aims to explore the relationship between basic attributes, quality of life, positive affect, negative affect, effectiveness of decision-making, and regret in living kidney donors.

METHODS

In this cross-sectional study, living kidney donors were recruited from urology and kidney transplant outpatient services. The structured questionnaire used to collect the data included the Positive and Negative Affect Schedule, Medical Outcomes Study 12-Item Short-Form Health Survey, Decision Conflict Scale, and Decision Regret Scale.

RESULTS

The findings indicate that living donors with better health status, 24-hour creatinine clearance, physical health-related quality of life (HRQOL), and positive affect experienced greater feelings of effective decision-making. Moreover, women and donors with better physical HRQOL, positive affect, and decision effectiveness were less regretful about the decision of kidney donation.

CONCLUSION

Health status, physical HRQOL, and positive affect are related to decision validity and regret of living donors. Therefore, clinical care providers should regularly assess the mood and health of living kidney donors. Furthermore, activities promoting their health should be encouraged, especially for men.

Anxiety, depression, and regret of donation in living kidney donors

Background

Previous studies have reported a wide range of prevalence of post-donation anxiety, depression, and regret in living kidney donors (LKDs). It is also unclear what risk factors are associated with these outcomes.

Methods

We screened 825 LKDs for anxiety and depression using 2-item GAD-2 and PHQ-2 scales and asked about regret.

Results

Overall, 5.5% screened positive for anxiety, 4.2% for depression, and 2.1% reported regretting their donation. While there was moderate correlation between positive anxiety and depression screens (r = 0.52), there was no correlation between regret and positive screens (r < 0.1 for both). A positive anxiety screen was more likely in LKDs with a positive depression screen (adjusted relative risk [aRR] 13.72, 95% confidence interval [CI] 6.78–27.74, p < 0.001). Similarly, a positive depression screen was more likely in LKDs with a positive anxiety screen (aRR 19.50, 95% CI 6.94–54.81, p < 0.001), as well as in those whose recipients experienced graft loss (aRR 5.38, 95% CI 1.29–22.32, p = 0.02). Regret was more likely in LKDs with a positive anxiety screen (aRR 5.68, 95% CI 1.20–26.90, p = 0.03). This was a single center cross-sectional study which may limit generalizability and examination of causal effects. Also, due to the low prevalence of adverse psychosocial outcomes, we may lack power to detect some associations between donor characteristics and anxiety, depression, or regret.

Conclusions

Although there is a low prevalence of anxiety, depression, and regret of donation among LKDs, these are interrelated conditions and a positive screen for one condition should prompt evaluation for other conditions.

Uterus Transplantation: The Ethics of Using Deceased Versus Living Donors

Research teams have made considerable progress in treating absolute uterine factor infertility through uterus transplantation, though studies have differed on the choice of either deceased or living donors. While researchers continue to analyze the medical feasibility of both approaches, little attention has been paid to the ethics of using deceased versus living donors as well as the protections that must be in place for each. Both types of uterus donation also pose unique regulatory challenges, including how to allocate donated organs; whether the donor / donor's family has any rights to the uterus and resulting child; how to manage contact between the donor / donor's family, recipient, and resulting child; and how to track outcomes moving forward.

Development and feasibility of a guided and tailored internet-based cognitive-behavioural intervention for kidney donors and kidney donor candidates

OBJECTIVES

Living donor kidney transplantation is currently the preferred treatment for patients with end-stage renal disease. A subgroup of the kidney donor population experiences adjustment problems during or after the donation procedure (eg, anxiety or fatigue). There is a need for evidence-based interventions that decrease donation-related difficulties before or after donation. In the current study, a guided and tailored internet-based cognitive-behavioural therapy (ICBT) intervention for donors and donor candidates was developed and the feasibility and perceived effectiveness were evaluated.

DESIGN

Pilot study including qualitative and quantitative research methods for intervention development and evaluation.

SETTING

Living kidney donor population of two Dutch transplantation centres.

PARTICIPANTS

Donors and healthcare professionals participated in focus group interviews conducted to identify intervention themes and to map attitudes towards internet-based interventions. In a pilot feasibility study, 99 donors and donor candidates participated, of whom 38 completed the screening. Eight donors or donor candidates with a risk profile (ie, impaired mental health-related quality of life (HRQoL)) received and evaluated the intervention.

INTERVENTIONS

A guided and tailored ICBT intervention for donors and donor candidates was developed. Donation-related treatment modules, assignments and psychoeducation were integrated within an existing disease-generic ICBT intervention.

OUTCOME MEASURES

HRQoL, anxiety and depression were assessed before and after the ICBT intervention. Additional questionnaires were included to identify specific problem areas of donor functioning to tailor the ICBT intervention to the donor's needs.

RESULTS

Different intervention themes were derived from the focus group interviews (eg, physical limitations, and donation-specific emotional and social-relational problems). Participants were satisfied about the intervention content (7.7±0.8 on a 0-10 scale) and the therapeutic relationship (4.4±0.6 on a 1-5 scale), and indicated an improvement on domains of their treatment goals (3.2±0.7 on a 1-4 scale).

CONCLUSION

This study showed positive evaluations concerning both feasibility and perceived effectiveness of the tailored ICBT intervention in kidney donors and donor candidates, in line with previous studies using comparable ICBT treatment protocols in other populations. Future research should examine the possibilities of integrating the intervention into psychosocial care for kidney donors.

Unspoken ambivalence in kinship obligation in living donation

BACKGROUND

Traditionally, living kidney donors were first-degree relatives due to both greater biological compatibility and concerns about extrafamilial motivation. Because familial relationships often entail distinctive experiences of moral obligation, health-care providers must be attentive to potential undue influences on intrafamilial donor decision-making processes to ensure that decisions are voluntary.

METHODS

Qualitative interviews were conducted with 20 individuals who donated kidneys to first-degree relatives and subsequently developed end-stage renal disease themselves.

FINDINGS

We analyze the different influences kinship obligations had on participants' decision-making processes. Although participants described their decision to donate as obvious, an appropriate kin response, and free from external pressure, they indirectly expressed some ambivalence-both by their description of the rapidity of the process and in their concern about exposing an intimate to the risks of living donation.

DISCUSSION

Our data uncovered an asymmetry. Although our participants claimed that they would donate again, none received a living donor kidney. Our data also highlight the moral significance of the interdependence of donor and recipient in intrafamilial kidney donation and its impact on the range of voluntary choices as perceived by the donor. Their decision-making must be understood as embedded within a network of intimate social relations.

Positive and Negative Affects in Living Kidney Donors

OBJECTIVE

This study aimed to identify the factors influencing the positive and negative affects and the health-related quality of life (HRQOL) of living kidney donors.

METHODS

With the use of a cross-sectional study design and a structured questionnaire, information on the basic characteristics, positive affect, negative affect, and HRQOL of 41 living kidney donors were compared.

RESULTS

The negative affect in living kidney donors was similar to that of the general population, but the positive affect was slightly lower. The physical HRQOL of living kidney donors was slightly higher than that of the general population, and the mental HRQOL was similar. Female donors showed a greater positive affect than male donors. The donors who were siblings of the recipients showed a more negative affect. Donors without chronic disease and with good perceived physical health showed improved positive affect, negative affect, and mental HRQOL. Furthermore, living kidney donors with better positive and negative affects showed improved physical and mental HRQOLs.

CONCLUSIONS

Clinical health providers should evaluate and determine the positive affect, negative affect, and quality of life of living kidney donors, especially in men, siblings of the recipients, those with chronic disease, and those with poorer perceived physical health. Moreover, psychosocial interventions should be provided to improve these factors.

Return on investment for financial assistance for living kidney donors in the United States

BACKGROUND

The National Living Donor Assistance Center (NLDAC) enables living donor kidney transplants through financial assistance of living donors, but its return on investment (ROI) through savings on dialysis costs remains unknown.

METHODS

We retrospectively reviewed 2012-2015 data from NLDAC, the United States Renal Data System, and the Scientific Registry of Transplant Recipients to construct 1-, 3-, and 5-year ROI models based on NLDAC applications and national dialysis and transplant cost data. ROI was defined as state-specific federal dialysis cost minus (NLDAC program costs plus state-specific transplant cost), adjusted for median waiting time (WT).

RESULTS

A total of 2425 NLDAC applications were approved, and NLDAC costs were USD $6.76 million. Median donor age was 41 years, 66.1% were female, and median income was $33 759; 43.6% were evaluated at centers with WT >72 months. Median dialysis cost/patient-year was $81 485 (IQR $74 489-$89 802). Median kidney transplant cost/patient-year was $30 101 (IQR $26 832-$33 916). Overall, ROI varied from 5.1-fold (1-year) to 28.2-fold (5-year), resulting in $256 million in savings. Higher ROI was significantly associated with high WT, larger dialysis and transplant costs differences, and more NLDAC applicants completing the donation process.

CONCLUSIONS

Financial support for donor out-of-pocket expenses produces dramatic federal savings through incremental living donor kidney transplants.

Factors associated with perceived donation-related financial burden among living kidney donors

The perception of living kidney donation-related financial burden affects willingness to donate and the experience of donation, yet no existing tools identify donors who are at higher risk of perceived financial burden. We sought to identify characteristics that predicted higher risk of perceived financial burden. We surveyed 51 living kidney donors (LKDs) who donated from 01/2015 to 3/2016 about socioeconomic characteristics, predonation cost concerns, and perceived financial burden. We tested associations between both self-reported and ZIP code-level characteristics and perceived burden using Fisher's exact test and bivariate modified Poisson regression. Donors who perceived donation-related financial burden were less likely to have an income above their ZIP code median (14% vs. 72%, P = .006); however, they were more likely than donors who did not perceive burden to rent their home (57% vs. 16%, P = .03), have an income <$60 000 (86% vs. 20%, P = .002), or have had predonation cost concerns (43% vs. 7%, P = .03). Perceived financial burden was 3.6-fold as likely among those with predonation cost concerns and 10.6-fold as likely for those with incomes <$60 000. Collecting socioeconomic characteristics and asking about donation-related cost concerns prior to donation might allow transplant centers to target financial support interventions toward potential donors at higher risk of perceiving donation-related financial burden.

Experiences of living kidney donors during the donation process

BACKGROUND

The shortage of organs from deceased donors has led to more living donation. Furthermore, immunological developments have made it possible to perform kidney transplantation despite preformed antibodies against the donor organ. This has led to a broader recruitment base of living donors.

OBJECTIVE

The objective was to investigate experiences and considerations on becoming, and during the process of being, a living kidney donor.

MATERIALS AND METHODS

Interviews and participant observation were conducted before, during and after the donation. Data were analysed in accordance with Ricoeur's theory of interpretation on three levels: naïve reading, structural analysis and critical interpretation and discussion. Eighteen potential donors over the age of 18 were included.

RESULTS

Potential donors' decision to donate was based on a desire to help the recipient. At all stages of the process, donors experienced joy, dilemmas, vulnerability and hope. Rejected donors experienced frustration and disappointment. The accepted donors experienced both joy and vulnerability. Interaction between the donor and the recipient and the relatives played a significant role. The transition from being a healthy individual to being a surgical patient was an overwhelming experience.

CONCLUSION

The process of donating a kidney and the return to everyday life involved significant experiences of joy, dilemmas, vulnerability and hope that influenced donors' lives on physical, psychological and social levels. Support and clear communication from the health professionals was essential.