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Ambagtsheer F, Haase‐Kromwijk B, Dor FJMF, Moorlock G, Citterio F, Berney T, Massey EK. Global Kidney Exchange: opportunity or exploitation? An ELPAT/ESOT appraisal. Transpl Int 2020; 33:989-998. [PMID: 32349176 PMCID: PMC7540591 DOI: 10.1111/tri.13630] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/11/2020] [Accepted: 04/24/2020] [Indexed: 12/20/2022]
Abstract
This paper addresses ethical, legal, and psychosocial aspects of Global Kidney Exchange (GKE). Concerns have been raised that GKE violates the nonpayment principle, exploits donors in low- and middle-income countries, and detracts from the aim of self-sufficiency. We review the arguments for and against GKE. We argue that while some concerns about GKE are justified based on the available evidence, others are speculative and do not apply exclusively to GKE but to living donation more generally. We posit that concerns can be mitigated by implementing safeguards, by developing minimum quality criteria and by establishing an international committee that independently monitors and evaluates GKE's procedures and outcomes. Several questions remain however that warrant further clarification. What are the experiences and views of recipients and donors participating in GKE? Who manages the escrow funds that have been put in place for donor and recipients? What procedures and safeguards have been put in place to prevent corruption of these funds? What are the inclusion criteria for participating GKE centers? GKE provides opportunity to promote access to donation and transplantation but can only be conducted with the appropriate safeguards. Patients' and donors' voices are missing in this debate.
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Affiliation(s)
- Frederike Ambagtsheer
- Department of Internal Medicine, Nephrology & TransplantationErasmus MCRotterdamThe Netherlands
| | | | - Frank J. M. F. Dor
- Imperial College Renal and Transplant CentreHammersmith HospitalLondonUK
- Department of Surgery and CancerImperial CollegeLondonUK
| | - Greg Moorlock
- Warwick Medical SchoolUniversity of WarwickCoventryUK
| | - Franco Citterio
- Renal Transplantation UnitFondazione Policlinico Universitario, A. GemelliRomeItaly
| | - Thierry Berney
- Division of TransplantationUniversity of Geneva HospitalsGenevaSwitzerland
| | - Emma K. Massey
- Department of Internal Medicine, Nephrology & TransplantationErasmus MCRotterdamThe Netherlands
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Socioeconomic Status in Non-directed and Voucher-based Living Kidney Donation. Eur Urol Focus 2018; 4:185-189. [PMID: 30122635 DOI: 10.1016/j.euf.2018.07.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 07/01/2018] [Accepted: 07/13/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND Little has been reported about the socioeconomic status (SES) and demographics of non-directed (altruistic) and voucher-based donation. OBJECTIVE To analyze common characteristics amongst altruistic donors in order to promote non-directed and voucher-based donation. DESIGN, SETTING, AND PARTICIPANTS Information regarding altruistic donations from 2008 to 2015 and voucher-based donors was obtained from the National Kidney Registry. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS An SES index, created and validated by the Agency for Healthcare Research and Quality (AHRQ), was created by geocoding the donor's zip code and linking it to seven publicly available SES variables found in the 2010 United States Census data. RESULTS AND LIMITATIONS In total, 267 non-directed and 3 voucher-based donations were identified. Non-directed donors were predominantly female (58%), with an average age of 45.6 yr (range, 21-72). The mean SES index score was 55.6 (SD=3.2), which corresponds to the 77th percentile of 1.5 million MediCare beneficiaries as reported by the AHRQ in 2008. Voucher-based donors were Caucasian males of high SES. The study was limited by the number of voucher-based donations. CONCLUSIONS Non-directed and voucher-based donors are in the upper end of the economic spectrum. The voucher-based program has built within it the inherent capacity to remove disincentives to donation, which currently limit altruistic donation. PATIENT SUMMARY We wanted to determine what types of people donated their kidneys altruistically, so that we could understand how to motivate more people to donate their kidneys. The voucher-based program was recently started and is a promising tool to motivate many people to donate kidneys by removing major disincentives to donation.
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Hanson CS, Ralph AF, Manera KE, Gill JS, Kanellis J, Wong G, Craig JC, Chapman JR, Tong A. The Lived Experience of "Being Evaluated" for Organ Donation: Focus Groups with Living Kidney Donors. Clin J Am Soc Nephrol 2017; 12:1852-1861. [PMID: 28993303 PMCID: PMC5672970 DOI: 10.2215/cjn.03550417] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Accepted: 07/17/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND OBJECTIVES Comprehensive evaluations are required to safeguard voluntarism and minimize harm to living kidney donors. This process is lengthy, invasive, and emotionally challenging, with up to one fifth of potential donors opting out. We aimed to describe donors' experiences of the evaluation process. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted 14 focus groups involving 123 kidney donors who completed donation from three transplant centers (Australia and Canada). Transcripts were analyzed thematically. RESULTS We identified six themes reflecting donors' experiences of evaluation. The themes that related to perseverance included emotional investment (prioritizing the recipient's health, desperation for a normal life, protecting eligibility, shame of disappointing others, and overcoming opposition), undeterred by low risks (medical confidence and protection, worthwhile gamble, inherent invincibility, and normalizing risks), and mental preparation (avoiding regret, resolving decisional ambivalence, and managing expectations of recovery). The challenges included underlying fears for health (processing alarming information, unsettling uncertainty, and preoperative panic), system shortfalls (self-advocacy in driving the process, stressful urgency, inconsistent framing of safety, unnerving bodily scrutiny, questioning risk information, and draining finances); and lifestyle interference (living in limbo, onerous lifestyle disruption, and valuing flexibility). CONCLUSIONS Previous donors described an emotional investment in donating and determination to protect their eligibility, despite having concerns for their health, financial and lifestyle disruption, and opposition from their family or community. Our findings suggest the need to prepare donors for surgery and recovery, minimize anxiety and lifestyle burdens, ensure that donors feel comfortable expressing their fears and concerns, reduce unnecessary delays, and make explicit the responsibilities of donors in their assessment process.
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Affiliation(s)
- Camilla S. Hanson
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
| | - Angelique F. Ralph
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
| | - Karine E. Manera
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
| | - John S. Gill
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - John Kanellis
- Department of Nephrology, Monash Health and Centre for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, Victoria, Australia; and
| | - Germaine Wong
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- Centre for Transplant and Renal Research, The Westmead Institute for Medical Research, Westmead, New South Wales, Australia
| | - Jonathan C. Craig
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
| | - Jeremy R. Chapman
- Centre for Transplant and Renal Research, The Westmead Institute for Medical Research, Westmead, New South Wales, Australia
| | - Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
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Klarenbach S, Gill JS, Knoll G, Caulfield T, Boudville N, Prasad GVR, Karpinski M, Storsley L, Treleaven D, Arnold J, Cuerden M, Jacobs P, Garg AX. Economic consequences incurred by living kidney donors: a Canadian multi-center prospective study. Am J Transplant 2014; 14:916-22. [PMID: 24597854 PMCID: PMC4285205 DOI: 10.1111/ajt.12662] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 12/24/2013] [Accepted: 12/26/2013] [Indexed: 01/25/2023]
Abstract
Some living kidney donors incur economic consequences as a result of donation; however, these costs are poorly quantified. We developed a framework to comprehensively assess economic consequences from the donor perspective including out-of-pocket cost, lost wages and home productivity loss. We prospectively enrolled 100 living kidney donors from seven Canadian centers between 2004 and 2008 and collected and valued economic consequences ($CAD 2008) at 3 months and 1 year after donation. Almost all (96%) donors experienced economic consequences, with 94% reporting travel costs and 47% reporting lost pay. The average and median costs of lost pay were $2144 (SD 4167) and $0 (25th-75th percentile 0, 2794), respectively. For other expenses (travel, accommodation, medication and medical), mean and median costs were $1780 (SD 2504) and $821 (25th-75th percentile 242, 2271), respectively. From the donor perspective, mean cost was $3268 (SD 4704); one-third of donors incurred cost >$3000, and 15% >$8000. The majority of donors (83%) reported inability to perform usual household activities for an average duration of 33 days; 8% reported out-of-pocket costs for assistance with these activities. The economic impact of living kidney donation for some individuals is large. We advocate for programs to reimburse living donors for their legitimate costs.
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Affiliation(s)
- S Klarenbach
- Department of Medicine, Institute of Health EconomicsEdmonton, AB, Canada,
*Corresponding author: Scott Klarenbach,
| | - J S Gill
- Department of Medicine, University of British ColumbiaVancouver, BC, Canada
| | - G Knoll
- Department of Medicine, University of OttawaOttawa, ON, Canada
| | - T Caulfield
- Faculty of Law, School of Population and Public Health, University of AlbertaEdmonton, AB, Canada
| | - N Boudville
- School of Medicine, University of Western AustraliaCrawley, WA, Canada
| | - G V R Prasad
- Department of Medicine, University of TorontoToronto, ON, Canada
| | - M Karpinski
- Department of Medicine, University of ManitobaWinnipeg, MB, Canada
| | - L Storsley
- Department of Medicine, University of ManitobaWinnipeg, MB, Canada
| | - D Treleaven
- Department of Medicine, McMaster UniversityHamilton, ON, Canada
| | - J Arnold
- University of Western OntarioLondon, ON, Canada
| | - M Cuerden
- University of Western OntarioLondon, ON, Canada
| | - P Jacobs
- Department of Medicine, Institute of Health EconomicsEdmonton, AB, Canada
| | - A X Garg
- Department of Medicine and Department of Epidemiology and Biostatistics, University of Western OntarioLondon, ON, Canada,Department of Clinical Epidemiology and Biostatistics, McMaster UniversityHamilton, ON, Canada
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