Experiences of living kidney donors: A synthesis of unsolicited patient narratives

INTRODUCTION

Despite the lauded benefits of living kidney donation, there is growing evidence of the challenges that living kidney donors (LKD) encounter in their donation trajectory and gaps in healthcare service provision. However, most of the evidence is derived from research conducted by clinicians or academic investigators. Significantly less attention has been devoted to analyzing unsolicited accounts of LKDs' experiences.

METHODS

We conducted a review and synthesis of published unsolicited first-person narratives of LKDs and aimed to synthesize their experiences and identify care needs. Four electronic databases were searched and 27 LKD narratives were included in our final analysis. Thematic synthesis was used to generate themes inductively.

RESULTS

Although the majority of LKDs reported the act of donation to be a fulfilling experience, almost 48% reported encountering challenges in the care that they received. Also, 29% of LKDs reported experiencing an adverse clinical event. Five distinct themes emerged surrounding the donation experience and healthcare needs: 1) Educational needs due to perceived lack of transparency and compensating for knowledge gaps; 2) Respect for donor autonomy due to coercive influences from family or healthcare providers, lack of respect for donor preferences and loopholes in the consent process; 3) Unmet care needs related to poor communication with healthcare providers, coordination issues and inconsistent and inadequate long-term care; 4) Unanticipated outcomes due to economic costs and the emotional burden of donation; and 5) Contributing beyond the donation event by advocating for a balanced view of donation and generating support mechanisms.

CONCLUSION

In this synthesis of LKDs narratives, important care gaps and the need to advocate for a balanced perspective on living kidney donation were highlighted. Our review underscores the value of patients' own stories as critical evidence that can inform improvement in healthcare service delivery.

Lean body mass in living kidney donors impacts postoperative renal function

PURPOSE

A living donor kidney transplant is the optimal treatment for chronic renal impairment. Our objective is to assess if lean skeletal muscle mass and donor factors such as body mass index, hypertension, and age impact on renal function following donor nephrectomy.

METHODS

Potential donors undergo CT angiography as part of their work-up in our institution. Using dedicated software (Horos®), standardized skeletal muscle area measured at the L3 vertebrae was calculated. When corrected for height, skeletal muscle index can be derived. Skeletal muscle mass index below predefined levels was classified as sarcopenic. The correlation of CT-derived skeletal muscle index and postoperative renal function at 12 months was assessed. Co-variables including donor gender, age, body mass index (BMI), and presence of pre-op hypertension were also assessed for their impact on postoperative renal function.

RESULTS

275 patients who underwent living donor nephrectomy over 10 years were included. Baseline pre-donation glomerular filtration rate (GFR) and renal function at one year post-op were similar between genders. 29% (n = 82) of patients met the criteria for CT-derived sarcopenia. Sarcopenic patients were more likely to have a higher GFR at one year post-op (69.3 vs 63.9 mL/min/1.73 m2, p < 0.001). The main factors impacting better renal function at one year were the presence of sarcopenia and younger age at donation.

CONCLUSION

When selecting donors, this study highlights that patients with low skeletal mass are unlikely to underperform in terms of recovery of their renal function postoperatively at one year when compared to patients with normal muscle mass and should not be a barrier to kidney donation.

[Robot-assisted kidney transplantation-what is new?]

BACKGROUND

The first robot-assisted kidney transplantation (RAKT) was conducted in 2010, and the first time in Germany in 2016. As more than 5 years have passed, current evidence, technological developments and the latest (German) experience are presented.

OBJECTIVES

The current evidence and experience of RAKT was investigated from an international and German perspective.

MATERIALS AND METHODS

In a systemic search, relevant publications were analyzed and compared with the experiences at a German urological transplant department.

RESULTS

From an international perspective, RAKT can now be considered a standard procedure at experienced departments, as more than 680 RAKT have been documented in Europe. The functional results are excellent with low complication rates and good mid- to long-term functional outcomes. Although RAKT was initially only performed with living organ donations, it has also been successfully conducted with cadaveric grafts. The surgical technique can be applied in challenging and complex situations, such as for arteriosclerotic recipient vessels or for kidney transplantations in children. Although RAKT is still not widely performed in Germany, the university hospital in Marburg, the third urological department in Germany, has successfully initiated a robotic transplant program.

CONCLUSIONS

Compared to open kidney transplantation, robot-assisted kidney transplantation enables at least noninferior results. It further appears to translate the well-documented advantages of minimally invasive surgery to kidney transplantation. However, its spread throughout Germany is only slowly increasing, possibly because only a handful of urological departments still perform kidney transplantations.

Relationships, race/ethnicity, gender, age, and living kidney donation evaluation willingness

Racial/ethnic and gender disparities in living donor kidney transplantation are large and persistent but incompletely explained. One previously unexplored potential contributor to these disparities is differential willingness to donate to recipients in specific relationships such as children, parents, and friends. We collected and analyzed data from an online sample featuring an experimental vignette in which respondents were asked to rate their willingness to donate to a randomly chosen member of their family or social network. Results show very large differences in respondents' willingness to donate to recipients with different relationships to them, favoring children, spouses/partners, siblings, and parents, and disfavoring friends, aunts/uncles, and coworkers. Evidence suggesting an interactive effect between relationship, respondent race/ethnicity, respondent or recipient gender, was limited to a few cases. At the p < 0.05 level, the parent-recipient gender interaction was statistically significant, favoring mothers over fathers, as was other/multiracial respondents' greater willingness to donate to friends compared to Whites. Additionally, other interactions were significant at the p < 0.10 level, such as Hispanics' and women's higher willingness to donate to parents compared to Whites and men respectively, women's lower willingness to donate to friends compared to men, and Blacks' greater willingness to donate to coworkers than Whites. We also examined differences by age and found that older respondents were less willing to donate to recipients other than their parents. Together these results suggest that differential willingness to donate by relationship group may be a moderately important factor in understanding racial/ethnic and gender disparities in living donor kidney transplantation.

Navigating Living Kidney Donation and Transplantation Among South Asian Canadians: The ACTION Project

RATIONALE & OBJECTIVE

South Asian (SA) Canadians with kidney failure have a 50%-77% lower likelihood of kidney transplant and are less likely to identify potential living donors (LDs). This study aimed to identify health system-, patient-, and community-level barriers and facilitators for accessing LD kidney transplantation in the SA community to inform the development of health system- and community-level interventions to address barriers.

STUDY DESIGN

Qualitative study.

SETTING & PARTICIPANTS

20 SA recipients of an LD or deceased-donor kidney transplant, 10 SA LDs, and 41 general SA community members.

ANALYTICAL APPROACH

In-depth multilingual interviews were conducted with recipients and LDs. Gender-, language-, and age-stratified focus groups were conducted with general SA community members. Summative content analysis was used to analyze the data.

RESULTS

Hesitancy in approaching potential donors, fear about the health of potential LDs, information gaps, language barriers, and challenges evaluating out-of-country donors were highlighted as significant barriers by recipients, and financial concerns and information gaps were identified by donors. Cultural barriers in the SA community were highlighted by donors, recipients, and community members as critical factors when considering donation and transplant; women and elderly SA Canadians highlighted nuanced challenges. Participants reported generally a favorable perception of their health care teams, citing SA representation in the teams as important to providing culturally and linguistically sensitive care.

LIMITATIONS

Limited geographic, race, and cultural representation and reliance on virtual data collection.

CONCLUSIONS

This study highlights several culturally relevant barriers to donation and transplant that are potentially modifiable through patient-, health system-, and community-focused engagement and education.

Computed Tomography Renal Volumetry Better Predicts Postoperative Donor Renal Function in Live Kidney Donor Transplantation than Renal Scintigraphy: A Comparative Study

INTRODUCTION AND OBJECTIVES

Both computed tomography (CT) and renal scintigraphy (RS) have been used to assess vascular anatomy, renal status, and split renal function (SRF). In this study, we used a recently developed software that facilitates renal volumetric evaluations to compare RS and automated CT volumetry for assessing residual renal function and, thus, estimating postoperative renal function after donor nephrectomy.

METHODS

Fifty-one cases of donor nephrectomy were analyzed. Residual renal function was estimated based on RS and CT volumetry. The correlation between the postoperative estimated glomerular filtration rate (eGFR) and expected SRF, measured using RS and three types of CT volumetry data (ellipsoid, thin-slice, and 5-mm slice data), was determined.

RESULTS

The correlation coefficient between actual eGFR and expected SRF was significantly associated at each time point and modality (p < 0.0001). At any time point, the difference in correlation coefficient between RS and 5-mm volumetry was significant (p value: 0.003-0.018), whereas the differences in correlation coefficients between RS and the triaxial volume calculation, and the triaxial volume calculation and 5-mm volumetry, were generally statistically insignificant.

CONCLUSIONS

Expected SRF was estimated more accurately by CT volumetric calculations (especially 5-mm slice-based volumetry) than RS.

Respecting living kidney donor autonomy: an argument for liberalising living kidney donor acceptance criteria

Doctors routinely refuse donation offers from prospective living kidney donors with certain comorbidities such as diabetes or obesity out of concern for donor wellbeing. This refusal occurs despite the ongoing shortage of kidney transplants and the superior performance of living donor kidney transplants compared to those from deceased donors. In this paper, we argue that this paternalistic refusal by doctors is unjustified and that, within limits, there should be greater acceptance of such donations. We begin by describing possible weak and strong paternalistic justifications of current conservative donor acceptance guidelines and practices. We then justify our position by outlining the frequently under-recognised benefits and the routinely overestimated harms of such donation, before discussing the need to respect the autonomy of willing donors with certain comorbidities. Finally, we respond to a number of possible objections to our proposal for more liberal kidney donor acceptance criteria. We use the situation in Australia as our case study, but our argument is applicable to comparable situations around the world.

Immunosuppression of HLA identical living-donor kidney transplant recipients: A systematic review

BACKGROUND

Kidney transplant (KT) recipients of HLA identical siblings (HLAid) have lower immunological risk, but there are no specific recommendations for immunosuppression. Our aim was to analyze evidence about results from HLAid living-donor recipients under different immunosuppression in the current era of immunological risk assessment.

METHODS

Systematic review of studies describing associations between outcomes of HLAid living-donor KT recipients according to their immunological risk and applied immunosuppression.

RESULTS

From 1351 studies, 16 (5636 KT recipients) were included in the analysis. All studies were retrospective, ten comparing immunosuppression strategies, and six immunological risk strata. Of those ten, six studies were published in 1990 or earlier and only three included tacrolimus. The evidence is poor, and the inclusion of calcineurin inhibitors does not demonstrate better results. Furthermore, only few studies describe different immunosuppression regimens according to the patient immunological risk and, in general, they do not include the assessment with new solid phase assays.

CONCLUSIONS

There are no studies analyzing the association of outcomes of HLAid KT recipients with current immunological risk tools. In the absence of evidence, no decision or proposal of immunosuppression adapted to modern immunological risk assessment can be made currently by the Descartes Working Group.

The relationship of peritubular capillary density with glomerular volume and kidney function in living kidney donors

BACKGROUND

Peritubular capillary rarefaction plays an important role in the progression of chronic kidney disease. Little is known about the relation between peritubular capillary density, glomerular volume and filtration rate in the healthy kidney.

METHODS

In this single-center study, we included 69 living kidney donors who donated between 2005 and 2008 and had representative renal biopsies available. In all donors, glomerular filtration rate was measured using 125I-Iothalamate before donation and at five years after donation. Before donation, the increase in glomerular filtration rate after dopamine stimulation was measured. Glomerular volume and peritubular capillary density were determined in biopsies taken at the time of transplantation. Pearson's correlation coefficient and linear regression were used to assess relations between parameters.

RESULTS

Mean donor age was 52 ± 11 years and mean measured glomerular filtration rate was 119 ± 22 mL/min before donation and 82 ± 15 mL/min at five years after donation. While peritubular capillary density (measured by either number of peritubular capillaries/50,000 μm2 or number of peritubular capillaries/tubule) was not associated with measured glomerular filtration rate before or after donation, number of peritubular capillaries/tubule was associated with the increase in measured glomerular filtration rate after dopamine stimulation (St.β = 0.33, p = 0.004), and correlated positively with glomerular volume (R = 0.24, p = 0.047). Glomerular volume was associated with unstimulated measured glomerular filtration rate before donation (St.β = 0.31, p = 0.01) and at five years (St.β = 0.30, p = 0.01) after donation, independent of age.

CONCLUSIONS

In summary, peritubular capillary density was not related to unstimulated kidney function before or after kidney donation, in contrast to glomerular volume. However, number of peritubular capillaries/tubule correlated with the increase in glomerular filtration rate after dopamine stimulation in healthy kidneys, and with glomerular volume. These findings suggest that peritubular capillary density and glomerular volume differentially affect kidney function in healthy living kidney donors.

Living kidney donors with HIV: experience and outcomes from a case series by the HOPE in Action Consortium

Background

Living kidney donation is possible for people living with HIV (PLWH) in the United States within research studies under the HIV Organ Policy Equity (HOPE) Act. There are concerns that donor nephrectomy may have an increased risk of end-stage renal disease (ESRD) in PLWH due to HIV-associated kidney disease and antiretroviral therapy (ART) nephrotoxicity. Here we report the first 3 cases of living kidney donors with HIV under the HOPE Act in the United States.

Methods

Within the HOPE in Action Multicenter Consortium, we conducted a prospective study of living kidney donors with HIV. Pre-donation, we estimated the 9-year cumulative incidence of ESRD, performed genetic testing of apolipoprotein L1 (APOL1), excluding individuals with high-risk variants, and performed pre-donation kidney biopsies (HOPE Act requirement). The primary endpoint was ≥grade 3 nephrectomy-related adverse events (AEs) in year one. Post-donation, we monitored glomerular filtration rate (measured by iohexol/Tc-99m DTPA [mGFR] or estimated with serum creatinine [eGFR]), HIV RNA, CD4 count, and ART.

Findings

There were three donors with two-four years of follow-up: a 35 year-old female, a 52 year-old male, and a 47 year-old male. Pre-donation 9-year estimated cumulative incidence of ESRD was 3.01, 8.01, and 7.76 per 10,000 persons, respectively. In two donors with APOL1 testing, no high-risk variants were detected. Biopsies from all three donors showed no kidney disease. Post-donation, two donors developed nephrectomy-related ≥grade 3 AEs: a medically-managed ileus and a laparoscopically-repaired incisional hernia. GFR declined from 103 to 84 mL/min/1.73 m2 at four years (mGFR) in donor 1, from 77 to 52 mL/min/1.73 m2 at three years (eGFR) in donor 2, and from 65 to 39 mL/min/1.73 m2 at two years (eGFR) in donor 3. HIV RNA remained <20 copies/mL and CD4 count remained stable in all donors.

Interpretation

The first three living kidney donors with HIV under the HOPE Act in the United States have had promising outcomes at two-four years, providing proof-of-concept to support living donation from PLWH to recipients with HIV.

Funding

National Institute of Allergy and Infectious Diseases, National Institutes of Health.

Changing landscape in living kidney donation in Greece

Patients with end-stage renal disease in Greece are facing long waiting times to receive a kidney transplant from a deceased donor. Living kidney donation offers a valuable alternative that provides optimal outcomes and significantly expands the donor pool but still remains relatively underutilised. Developments around the world in the field of kidney transplantation mandate a change in current practice to include additional options for living donation through paired exchange, antibody-incompatible transplantation and other strategies, following careful consideration of the cultural and ethical factors involved in these complex clinical decisions. An increase in living donation rates may be achieved in several ways, including targeted campaigning to overcome potential barriers. Educating clinicians on transplantation will prove as equally important as informing patients and prospective donors but requires training and resources. Adoption of established practices and implementation of new strategies must be tailored to the needs of the Greek donor and recipient population. Local beliefs about donation, perception of associated risk and other social characteristics must be considered in the design of future strategies. Facilitating living donation in a safe environment with appropriate donor and recipient education will form the solid foundation of a new era of kidney transplantation in Greece.

Predictive factors of glomerular filtration rate loss associated with living kidney donation: a single-center retrospective study

PURPOSE

Living kidney donors (LKD) partially compensate the initial loss of glomerular filtration rate (GFR), a phenomenon known as renal functional reserve (RFR). RFR is reduced in the elderly, a population with increased prevalence of chronic kidney disease. We hypothesized that the selected, healthy population of LKD, would specifically inform about the physiological determinants of the RFR and studied it using measured GFR (mGFR).

METHODS

We retrospectively analyzed pre-donation and post-donation mGFR in 76 LKD from Tenon Hospital (Paris, France) between 2002 and 2018. In addition to GFR measurements, we collected pre-donation morphologic parameters, demographic data, and kidney volumes.

RESULTS

Mean pre-donation mGFR was 90.11 ± 12.64 mL/min/1.73 m² and decreased to 61.26 ± 9.57 mL/min/1.73 m² 1 year after donation. Pre-donation mGFR correlated with age (p = 0.0003), total kidney volume (p = 0.0004) and pre-donation serum creatinine (p = 0.0453). Pre-donation mGFR strongly predicted 1-year post-donation mGFR. Mean RFR (increase in GFR of the remnant kidney between pre-donation and post-donation) was 36.67 ± 16.67% 1 year after donation. In the multivariate linear model, RFR was negatively correlated to total kidney volume (p = 0.02) but not with age or pre-donation serum creatinine.

CONCLUSIONS

We found that pre-donation mGFR decreases with age and identified low total kidney volume as a predictor of RFR in healthy individuals. This suggests an adaptative and reversible decrease in kidney function rather than age-related damage. Older subjects may have reduced metabolic requirements with subsequent reduction in glomerular filtration and kidney volume and preserved RFR. Therefore, low GFR in older subjects should not preclude kidney donation.

Does the Side Matter? A Retrospective Cohort Study Comparing Left and Right Pure Laparoscopic Donor Nephrectomies

OBJECTIVES

Right laparoscopic donor nephrectomy (RLDN) is no longer regarded inferior to left LDN (LLDN). However, this knowledge is based on many studies suffering from inherent learning curves, center-specific imbalances, and different laparoscopic techniques.

METHODS

Pure LDNs at a high-volume referral center from 2011 to 2016 were retrospectively analyzed. Patient, graft characteristics, outcomes of LDNs, and corresponding open kidney transplantations were compared between LLDN and RLDN including a follow-up.

RESULTS

160 (78.4%) LLDNs and 44 (21.6%) RLDNs only differed regarding graft characteristics, as more right grafts had multiple veins (34.1 vs. 6.9%, p < 0.001) and worse scintigraphic function (44 vs. 51%, p < 0.001). RLDNs were shorter (201 vs. 220 min, p = 0.032) with longer warm ischemia time (165 vs. 140 s, p < 0.001), but left grafts were transplanted faster (160 vs. 171 min, p = 0.048). Recipients of right kidneys had more postoperative complications (grade 3: 25.6 vs. 11.3%, p = 0.020). At a follow-up of 45 (range 6-79) months, neither the kidney function, nor death-censored graft (5-year: LLDN 89 vs. 92%, p = 0.969) and patient survival (5-year: LLDN 95 vs. 98%, p = 0.747) differed.

CONCLUSIONS

Pure LLDN and RLDN can have different outcomes at high-volume centers, especially higher complications for recipients of right grafts. However, long-term function and graft survival are the same irrespective of the chosen side.

Implementation of the Kidney Team at Home Intervention: Evaluating Generalizability, Implementation Process, and Effects

Research has shown that a home-based educational intervention for patients with chronic kidney disease results in better knowledge and communication, and more living donor kidney transplantations (LDKT). Implementation research in the field of renal care is almost non-existent. The aims of this study were (1) to demonstrate generalizability, (2) evaluate the implementation process, and (3) to assess the relationship of intervention effects on LDKT-activity. Eight hospitals participated in the project. Patients eligible for all kidney replacement therapies (KRT) were invited to participate. Effect outcomes were KRT-knowledge and KRT-communication, and treatment choice. Feasibility, fidelity and intervention costs were assessed as part of the process evaluation. 332 patients completed the intervention. There was a significant increase in KRT-knowledge and KRT-communication among participants. 129 out of 332 patients (39%) had LDKT-activity, which was in line with the results of the clinical trials. Protocol adherence, knowledge and age were correlated with LDKT-activity. This unique implementation study shows that the results in practice are comparable to the previous trials, and show that the intervention can be implemented, while maintaining quality. Results from the project resulted in the uptake of the intervention in standard care. We urge other countries to investigate the uptake of the intervention.

[The first 50 robot-assisted donor nephrectomies : Lessons learned]

Hintergrund

Die minimal-invasive Donornephrektomie (DN) ist inzwischen operativer Standard, bezüglich der Rolle von roboterassistierten Verfahren gibt es bisher keinen Konsens.

Fragestellung

Die ersten 50 transperitonealen roboterassistierten Donornephrektomien (RDN) einer urologischen Universitätsklinik in Deutschland wurden retrospektiv ausgewertet.

Material und Methoden

Patientencharakteristika, intra- und postoperative Parameter wurden erfasst und die Nierenfunktion in einem 5‑jährigen Follow-up ausgewertet. Signifikante Prädiktoren für die Nierenfunktion bei Entlassung und ein Jahr postoperativ wurden in einem multivariablen Regressionsmodell bestimmt.

Ergebnisse

Die RDN hat exzellente Ergebnisse mit niedriger Komplikationsrate, kurzer warmer (WIZ) und kalter Ischämiezeit (KIZ) sowie geringem Blutverlust und kurzer Patientenverweildauer. Die Seite der Nierenentnahme hat hierauf keine Auswirkungen. Nach RDN sind etwa 50 % der Spender formal niereninsuffizient, was aber zumeist ohne Relevanz ist, weil sich die Nierenfunktion der Spender im Follow-up nicht weiter verschlechtert. Die postoperative Nierenfunktion lässt sich bei der RDN mithilfe der präoperativen eGFR (errechnete glomeruläre Filtrationsrate) und dem Spenderalter sehr gut vorhersagen.

Schlussfolgerungen

Die robotische DN stellt eine sehr gute Alternative zu anderen minimal-invasiven Operationsverfahren dar, die von Beginn an exzellente operative Ergebnisse ermöglicht.

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.

KDOQI US Commentary on the 2017 KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors

Living kidney donation is widely practiced throughout the world. During the past 2 decades, various groups have provided guidance about the evaluation and care of living donors. However, during this time, our knowledge in the field has advanced substantially and many agreed on the need for a comprehensive, unifying document. KDIGO (Kidney Disease: Improving Global Outcomes) addressed this issue at an international level with the publication of its clinical practice guideline on the evaluation and care of living kidney donors. The KDIGO work group extensively reviewed the available literature and wrote a series of guideline recommendations using various degrees of evidence when available. As has become recent practice, NKF-KDOQI (National Kidney Foundation-Kidney Disease Outcomes Quality Initiative) convened a work group to provide a commentary on the KDIGO guideline, with a focus on how these recommendations apply in the context of the United States. In the United States, the United Network for Organ Sharing (UNOS) guides and regulates the practice of living kidney donation. While the KDIGO guideline for the care of living kidney donors and UNOS policy are similar in most aspects of the care of living kidney donors, several important areas are not consistent or do not align with common practice by US transplantation programs in areas in which UNOS has not set specific policy. For the time being, and recognizing the value of the KDIGO guidelines, US transplantation programs should continue to follow UNOS policy.

Estimation of split renal function using different volumetric methods: inter- and intraindividual comparison between MRI and CT

PURPOSE

This study aims to determine whether contrast-enhanced (CE)-magnetic resonance imaging (MRI) is comparable to CE-computed tomography (CT) for estimation of split renal function (SRF). For this purpose, two different kidney volumetry methods, the renal cortex volumetry (RCV) and modified ellipsoid volume (MELV), are compared for both acquisition types (CT vs. MRI) with regard to accuracy and reliability, subsequently referred to as RCV_CT/RCV_MRI and MELV_CT/MELV_MRI.

METHODS

This retrospective study included 29 patients (18 men and 11 women; mean age 62.8 ± 12.4 years) who underwent CE-MRI and CE-CT of the abdomen within a period of 3 months. Two independent readers (R1/R2) performed RCV and MELV in all datasets with corresponding semiautomated software tools. RCV was performed with datasets in the arterial phase and MELV in the venous phase. Statistics were calculated using one-way ANOVA, two-tailed Student's t test, Pearson´s correlation, and Bland-Altman plots with p ≤ 0.05 being considered statistically significant.

RESULTS

In all datasets, SRF was almost identical for both volumetry methods with a mean difference of < 1%. Bland-Altman analysis comparing RCV in CT and MRI showed very good agreement for R1/R2. Interreader agreement was strong for RCV_CT and good for RCV_MRI (r = 0.89; r = 0.69). MELV_CT/MRI interreader agreement was only moderate (r = 0.54; r = 0.50) with a high range of values. Intrareader agreement was excellent for all measurements, except MELV_MRI which showed a high mean bias and range of values (RCV_CT: r = 0.93, RCV_MRI: r = 0.98, MELV_CT: r = 0.89, MELV_MRI: r = 0.54).

CONCLUSION

Renal volumetric estimates of SRF are almost as accurate and reliable with CE-MRI as with CE-CT using RCV method. In distinction, the calculation of SRF using MELV was inferior to RCV with respect to accuracy and reliability. Thus, RCV method is recommended to estimate SRF, primarily using CT datasets. However, RCV with MRI datasets for kidney volumetry allows for comparable accuracy and reliability while sparing patients and healthy donors of unnecessary radiation exposure.

Glomerular filtration rate: new age- and gender- specific reference ranges and thresholds for living kidney donation

BACKGROUND

There is a need for a large, contemporary, multi-centre series of measured glomerular filtration rates (mGFR) from healthy individuals to determine age- and gender-specific reference ranges for GFR. We aimed to address this and to use the ranges to provide age- and gender-specific advisory GFR thresholds considered acceptable for living kidney donation.

METHODS

Individual-level data including pre-donation mGFR from 2974 prospective living kidney donors from 18 UK renal centres performed between 2003 and 2015 were amalgamated. Age- and gender-specific GFR reference ranges were determined by segmented multiple linear regression and presented as means ± two standard deviations.

RESULTS

Males had a higher GFR than females (92.0 vs 88.1 mL/min/1.73m2, P < 0.0001). Mean mGFR was 100 mL/min/1.73m2 until 35 years of age, following which there was a linear decline that was faster in females compared to males (7.7 vs 6.6 mL/min/1.73m2/decade, P = 0.013); 10.5% of individuals aged > 60 years had a GFR < 60 mL/min/1.73m2. The GFR ranges were used along with other published evidence to provide advisory age- and gender-specific GFR thresholds for living kidney donation.

CONCLUSIONS

These data suggest that GFR declines after 35 years of age, and the decline is faster in females. A significant proportion of the healthy population over 60 years of age have a GFR < 60 mL/min/1.73m2 which may have implications for the definition of chronic kidney disease. Age and gender differences in normal GFR can be used to determine advisory GFR thresholds for living kidney donation.

Influence of CT-based depth correction of renal scintigraphy in evaluation of living kidney donors on side selection and postoperative renal function: is it necessary to know the relative renal function?

PURPOSE

To analyse the influence of CT-based depth correction in the assessment of split renal function in potential living kidney donors.

METHODS

In 116 consecutive living kidney donors preoperative split renal function was assessed using the CT-based depth correction. Influence on donor side selection and postoperative renal function of the living kidney donors were analyzed. Linear regression analysis was performed to identify predictors of postoperative renal function.

RESULTS

A left versus right kidney depth variation of more than 1 cm was found in 40/114 donors (35%). 11 patients (10%) had a difference of more than 5% in relative renal function after depth correction. Kidney depth variation and changes in relative renal function after depth correction would have had influence on side selection in 30 of 114 living kidney donors. CT depth correction did not improve the predictability of postoperative renal function of the living kidney donor. In general, it was not possible to predict the postoperative renal function from preoperative total and relative renal function. In multivariate linear regression analysis, age and BMI were identified as most important predictors for postoperative renal function of the living kidney donors.

CONCLUSIONS

Our results clearly indicate that concerning the postoperative renal function of living kidney donors, the relative renal function of the donated kidney seems to be less important than other factors. A multimodal assessment with consideration of all available results including kidney size, location of the kidney and split renal function remains necessary.

Duration of Living Kidney Transplant Donor Evaluations: Findings From 2 Multicenter Cohort Studies

BACKGROUND

A prolonged living kidney donor evaluation may result in worse outcomes for transplant recipients. Better knowledge of the duration of this process may help inform future donors and identify opportunities for improvement.

STUDY DESIGN

1 prospective and 1 retrospective cohort study.

SETTING & PARTICIPANTS

At 16 Canadian and Australian transplantation centers (prospective cohort) and 5 Ontario transplantation centers (retrospective cohort), we assessed the duration of living kidney donor evaluation and explored donor, recipient, and transplantation factors associated with longer evaluation times. Data were obtained from 2 sources: donor medical records using chart abstraction and health care administrative databases.

PREDICTORS

Donor and recipient demographics, direct versus paired donation, center-level variables.

OUTCOMES

Duration of living donor evaluation.

RESULTS

The median total duration of transplantation evaluation (time from when the candidate started the evaluation until donation) was 10.3 (IQR, 6.5-16.7) months. The median duration from evaluation start until approval to donate was 7.9 (IQR, 4.6-14.1) months, and from approval until donation was 0.7 (IQR, 0.3-2.4) months, respectively. The median time between the first and last consultation among donors who completed a nephrology, surgery, and psychosocial assessment in the prospective cohort was 3.0 (IQR, 1.0-6.3) months, and between computed tomography angiography and donation was 4.8 (IQR, 2.6-9.2) months. After adjustment, the total duration of transplantation evaluation was longer if the donor participated in paired donation (6.6 [95% CI, 1.6-9.7] months) and if the recipient was referred later relative to the donor's evaluation start date (0.9 [95% CI, 0.8-1.0] months [per month of delayed referral]). Results depended on whether the recipient was receiving dialysis.

LIMITATIONS

Living donor candidates who did not donate were not included and proxy measures were used for some dates in the donor evaluation process.

CONCLUSIONS

The duration of kidney transplant donor evaluation is variable and can be lengthy. Better understanding of the reasons for a prolonged evaluation may inform quality improvement initiatives to reduce unnecessary delays.

Coercion, dissatisfaction, and social stigma: an ethnographic study of compensated living kidney donation in Iran

This article updates the qualitative research on Iran reported in the 2012 article by Tong et al. "The experiences of commercial kidney donors: thematic synthesis of qualitative research" (Tong et al. in Transpl Int 25:1138-1149, 2012). The basic approach used in the Tong et al. article is applied to a more recent and more comprehensive study of Iranian living organ donors, providing a clearer picture of what compensated organ donation is like in Iran since the national government began regulating compensated donation. Iran is the only country in the world where kidney selling is legal, regulated, and subsidized by the national government. This article focuses on three themes: (1) coercion and other pressures to donate, (2) donor satisfaction with their donation experience, and (3) whether donors fear social stigma. We found no evidence of coercion, but 68% of the paid living organ donors interviewed felt pressure to donate due to extreme poverty or other family pressures. Even though 27% of the living kidney donors interviewed said they were satisfied with their donation experience, 74% had complaints about the donation process or its results, including some of the donors who said they were satisfied. In addition, 84% of donors indicated they feared experiencing social stigma because of their kidney donation.

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.

Assessment of Glomerular Filtration Rate and End-Stage Kidney Disease Risk in Living Kidney Donor Candidates: A Paradigm for Evaluation, Selection, and Counseling

Living donor kidney transplantation is the preferred treatment option for ESRD. However, recent data suggest a small increase in the long-term risk of kidney failure in living kidney donors when compared to healthy nondonors. These data have led to a need for reconsideration of how donor candidates are evaluated and selected for donation. A Kidney Disease: Improving Global Outcomes (KDIGO) work group completed a comprehensive clinical practice guideline for evaluation of living kidney donor candidates in 2017, based on systematic evidence review, de novo evidence generation, and expert opinion. Central to the evaluation framework is assessment of glomerular filtration rate (GFR), which is used to screen for kidney disease and aid the prediction of long-term kidney failure risk after donation. Accurate estimation of the level of GFR and risk of kidney failure, and communication of estimated risks, can support evidence-based donor selection and shared decision-making. In this review, we discuss approaches to optimal GFR estimation in the donor evaluation process, long-term risk projection, and risk communication to donor candidates, integrating recommendations from the new KDIGO guideline, other recent literature, and experience from our own research and practice. We conclude by highlighting topics for further research in this important area of transplant medicine.

Donation, Not Disease! A Multiple-Hit Hypothesis on Development of Post-Donation Kidney Disease

Purpose of Review

The risks following living kidney donation has been the subject of rigorous investigation in the past several decades. How to utilize the burgeoning new knowledge base to better the risk assessment, education, and health maintenance of donors is unclear. We review the physiologic and epidemiologic evidences on the post-donation state and submit a multiple-hit hypothesis to reconcile the finite elevation in risk of kidney disease after donation with the benign course of most kidney donors.

Recent Findings

The risk of end-stage kidney disease is higher in kidney donors compared to similarly healthy non-kidney donors. Nonetheless, post-donation kidney disease is uncommon and arises mostly in the setting of other “hits”—either a “first hit” present at birth or a “second hit” acquired later in life.

Summary

The transplant community’s focus should be directed toward (1) personalized risk assessment to inform consent before donation and (2) preventing and treating development of “second hits” following kidney donation.

High BMI and male sex as risk factor for increased short-term renal impairment in living kidney donors - Retrospective analysis of 289 consecutive cases

BACKGROUND

Kidney transplantation represents the treatment of choice for end-stage renal disease (ESRD). However, nephrectomy bears certain short- as well as long-term risks for the healthy, voluntary donor. As obesity is increasing and is a known risk factor for surgical complications, we wanted to assess the impact of BMI on perioperative complication rates and renal function.

MATERIALS AND METHODS

We retrospectively assessed patients undergoing living donor kidney nephrectomy at our institution. We identified 289 donors that underwent unilateral nephrectomy between January 2006 and December 2015. Donors were categorized according to their BMI (BMI <25 kg/m², BMI ≥25/<30 kg/m², BMI ≥30 kg/m²). Where indicated, analysis of variance (ANOVA) was used to compare groups, a stepwise linear regression model was used to assess impact of BMI on the change of eGFR.

RESULTS

126 donors (43.6%) had a BMI <25 while 120 (41.5%) had a BMI ≥25/<30 and 43 (14.9%) were obese with a BMI ≥30. BMI had no statistically significant influence on the percentage of laparoscopic approach (86.5% vs. 83.3% vs. 88.4%, p = 0.6564), on conversion rates (0% vs. 2.0% vs. 2.6%, p = 0.2879) or postoperative complication rates defined as Clavien Dindo ≥ II (8.7% vs. 13.3% vs. 14.0%, respectively; p = 0.4474). Notably, there were no Grade III or higher complications in any group. There was no difference in pre-operative kidney function, postoperative surgical site infection or systemic infection. BMI and male sex had a statistically significant influence on short-term decline of eGFR.

CONCLUSION

Obese donors do not suffer from an increased risk of intraoperative or perioperative complication rates. However, male sex and high BMI are associated with a more pronounced short-term decline in renal function. The impact of BMI on long-term consequences for kidney donors needs to be defined in larger prospective cohorts.

Impact of screening for metabolic syndrome on the evaluation of obese living kidney donors

BACKGROUND

We report our experience with metabolic syndrome screening for obese living kidney donor candidates to mitigate the long-term risk of CKD.

METHODS

We retrospectively reviewed 814 obese (BMI≥30) and 993 nonobese living kidney donor evaluations over 12 years. Using logistic regression, we explored interactions between social/clinical variables and candidate acceptance before and after policy implementation.

RESULTS

Obese donor candidate acceptance decreased after metabolic syndrome screening began (56.3%, 46.3%, p < 0.01), while nonobese candidate acceptance remained similar (59.6%, 59.2%, p = 0.59). Adjusting for age, gender, race, BMI, and number of prior evaluations, acceptance of obese candidates decreased significantly more than nonobese (p = 0.025). In candidates without metabolic syndrome, there was no significant change in how age, sex, race, or BMI affected a donor candidate's probability of acceptance.

CONCLUSION

Metabolic syndrome screening is a simple stratification tool for centers with liberal absolute BMI cut-offs to exclude potentially higher-risk obese candidates.

Donor and Recipient Views on Their Relationship in Living Kidney Donation: Thematic Synthesis of Qualitative Studies

BACKGROUND

Many donors and recipients report an improved relationship after transplantation; however, tension, neglect, guilt, and proprietorial concern over the recipient can impede donor and recipient well-being and outcomes. We aimed to describe donor and recipient expectations and experiences of their relationship in the context of living kidney donation.

STUDY DESIGN

Thematic synthesis of qualitative studies.

SETTING & POPULATION

Living kidney donors and recipients.

SEARCH STRATEGY & SOURCES

Electronic databases were searched to October 2015.

ANALYTICAL APPROACH

Thematic synthesis.

RESULTS

From 40 studies involving 1,440 participants (889 donors and 551 recipients) from 13 countries, we identified 6 themes. "Burden of obligation" described the recipient's perpetual sense of duty to demonstrate gratitude to the donor. "Earning acceptance" was the expectation that donation would restore relationships. "Developing a unique connection" reflected the inexplicable bond that donor-recipient dyads developed postdonation. "Desiring attention" was expressed by donors who wanted recognition for the act of donation and were envious and resentful of the attention the recipient received. "Retaining kidney ownership" reflected the donor's inclination to ensure that the recipient protected "their" kidney. "Enhancing social participation" encompassed relieving both the caregiver from the constraints of dialysis and the recipient from increased involvement and contribution in family life.

LIMITATIONS

Non-English articles were excluded.

CONCLUSIONS

Living kidney donation can strengthen donor-recipient relationships but may trigger or exacerbate unresolved angst, tension, jealousy, and resentment. Facilitating access to pre- and posttransplantation psychological support that addresses potential relationship changes may help donors and recipients better adjust to changes in the relationship dynamics, which in turn may contribute to improved psychosocial and transplantation outcomes following living kidney donation.

Investigating kidney donation as a risk factor for hypertension and microalbuminuria: findings from the Swiss prospective follow-up of living kidney donors

OBJECTIVES

To assess the role of nephrectomy as a risk factor for the development of hypertension and microalbuminuria.

DESIGN

Prospective, long-term follow-up study.

SETTING

Swiss Organ Living-Donor Health Registry.

PARTICIPANTS

All living kidney donors in Switzerland between 1993 and 2009.

INTERVENTIONS

Data on health status and renal function before 1 year and biennially after donation were collected.

PRIMARY AND SECONDARY OUTCOME MEASURES

Comparison of 1-year and 5-year occurrences of hypertension among normotensive donors with 1-year and 5-year estimates from the Framingham hypertension risk score. Multivariate random intercept models were used to investigate changes of albumin excretion after donation, correcting for repeated measurements and cofactors such as age, male gender and body mass index.

RESULTS

A total of 1214 donors contributed 3918 data entries with a completed biennial follow-up rate of 74% during a 10-year period. Mean (SD) follow-up of donors was 31.6 months (34.4). Median age at donation was 50.5 years (IQR 42.2-58.8); 806 donors (66.4%) were women. Donation increased the risk of hypertension after 1 year by 3.64 (95% CI 3.52 to 3.76; p<0.001). Those participants remaining normotensive 1 year after donation return to a risk similar to that of the healthy Framingham population. Microalbuminuria before donation was dependent on donor age but not on the presence of hypertension. After nephrectomy, hypertension became the main driver for changes in albumin excretion (OR 1.19; 95% CI 0.13 to 2.25; p=0.03) and donor age had no effect.

CONCLUSIONS

Nephrectomy propagates hypertension and increases susceptibility for the development of hypertension-induced microalbuminuria.

Better the donor you know? A qualitative study of renal patients' views on 'altruistic' live-donor kidney transplantation

BACKGROUND

In the UK there is a short-fall between individuals requiring a renal transplant and kidneys available for transplantation. Non-directed 'altruistic' living kidney donation has emerged as a strategy for bridging this gap between supply and demand, with the number increasing each year.

OBJECTIVE

This study aimed to explore the views of potential recipients towards non-directed 'altruistic' live-donor kidney transplantation.

METHODS

Semi-structured interviews with 32 UK deceased-donor kidney transplant recipients were performed. Interviews explored willingness to consider directed and non-directed live-donor kidney transplants (LDKTs). Interviews were recorded, transcribed verbatim and transcripts were analysed using the constant comparison method described in Grounded Theory.

RESULTS

For those not willing to accept a non-directed 'altruistic' LDKT, the following themes were identified: i) Prioritising other recipients above self; ii) Fear of acquiring an unknown donor's characteristics, and iii) Concern for the donor - unnecessary risk. For those willing to accept a non-directed 'altruistic' LDKT the following themes were identified: iv) Prioritising known above unknown persons, v) Belief that they are as deserving as other potential recipients, and vi) Advantages of a LDKT.

CONCLUSIONS

Drawing on 'gift exchange theory', this study contributes to our understanding of the experience of the intended recipient of a gift. The anonymity of the donor-recipient appears to be seen as a benefit of non-directed 'altruistic' live-donor transplants, freeing recipients from the obligations of the gift. However, those who feel unworthy of the 'gifted transplant' are concerned about the donor and by the lack of opportunity for direct reciprocity. Highlighting the 'reciprocal benefits' reported by donors may allow individuals whose preference is a live-donor transplant to accept one if offered. These insights provide the transplant community with targets for intervention, through which the concerns of potential recipients might be addressed.

From donation to everyday life: Living kidney donors' experiences three months after donation

BACKGROUND

As the number of patients with end stage kidney disease continues to rise internationally, living kidney donation remains a favourable treatment option. Long waiting times on dialysis can be avoided and short and long-term outcomes are better, when compared with deceased donor transplantation. Living kidney donation is a safe procedure for healthy individuals who have completed a rigorous screening programme. Significant experiences can occur during the recovery period.

OBJECTIVE

To investigate donors' experiences of donation and their recovery period, in the first three months after donation.

MATERIALS AND METHODS

The study took a phenomenological-hermeneutic approach. Open interviews were conducted three months after donation. Data were interpreted and discussed in accordance with Ricoeur's text interpretation theory on three levels: naïve reading, structural analysis and critical interpretation and discussion.

FINDINGS

The donation process was experienced as an 'expedition', including preparations, the operation, recovery and everyday life. Positive feelings were challenging to describe; however health troubles and vulnerability were evident. A closer relationship and a need to follow the recipient's progress implied that patient and donor felt they were a part of each other. Support from relatives was important but could also be a burden.

CONCLUSION

The kidney donation process is experienced as being like on an expedition, involving positive feelings, vulnerability, a closer patient-donor relationship and challenges around family relationships. It is essential that nurses are aware of the complexity of the situation and focus on the impact of the process, to support and facilitate donors' needs.

Living kidney donation: considerations and decision-making

BACKGROUND

When possible, renal transplantation is the treatment of choice for patients with end-stage kidney disease. Technological developments in immunology have made it possible to perform kidney transplants between donors and recipients despite antibodies against the donor organ. This allows for a wider range of relationships between recipient and donor. We investigated experiences of, and reflections on, kidney donation among genetic and non-genetic living donors before first consultation at the transplant centre.

OBJECTIVE

The aim was to investigate early experiences in the process of becoming a living kidney donor (LKD).

MATERIALS AND METHODS

The study was conducted within a phenomenological-hermeneutic theoretical framework. Data were generated through semi-structured interviews with 18 potential donors. Data were interpreted and discussed in accordance with the Ricoeur's text interpretation theory on the three levels of naïve reading, structural analysis and critical interpretation and discussion.

RESULTS

Two themes emerged: the decision-making process and dilemmas in decision-making. The study identifies that the decision about donation was made in relation to one's own life, family situation and in relation to the recipient-considerations that demonstrate that a range of dilemmas can occur during the decision-making process. The desire to help was prominent and was of significance in decision-making.

CONCLUSION

The study provides insight and knowledge for the health care professionals to meet and involve donors' narratives in reflections about and modifications to clinical nursing practice. It is essential that health care professionals have an understanding and appreciation of the experiences and concerns among LKDs, and this can help in planning and providing individual nursing care and support to donors.

The Outcomes of Living Kidney Donation from Medically Complex Donors: Implications for the Donor and the Recipient

Living kidney donation is an important option for patients with end-stage renal disease (ESRD), and has improved life expectancy and quality for patients otherwise requiring maintenance dialysis or deceased-donor transplantation. Given the favorable outcomes of live donation and the shortage of organs to transplant, individuals with potentially unfavorable demographic and clinical characteristics are increasingly being permitted to donate kidneys. While this trend has successfully expanded the live donor pool, it has raised concerns as to which acceptance criteria are safe. This review aims to summarize the existing literature on the outcomes of transplantation from medically complex, living kidney donors, including both donor and recipient outcomes when available.