Depression diagnoses after living kidney donation: linking U.S. Registry data and administrative claims

Hospitalizations following living donor nephrectomy in the United States

BACKGROUND AND OBJECTIVES

Living donors represented 43% of United States kidney donors in 2012. Although research suggests minimal long-term consequences of donation, few comprehensive longitudinal studies for this population have been performed. The primary aims of this study were to examine the incidence, risk factors, and causes of rehospitalization following donation.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

State Inpatient Databases (SID) compiled by the Agency for Healthcare Research and Quality were used to identify living donors in four different states between 2005 and 2010 (n=4524). Multivariable survival models were used to examine risks for rehospitalization, and patient characteristics were compared with data from the Scientific Registry of Transplant Recipients (SRTR). Outcomes among patients undergoing appendectomy (n=200,274), cholecystectomy (n=255,231), and nephrectomy for nonmetastatic carcinoma (n=1314) were contrasted.

RESULTS

The study population was similar to United States donors (for SRTR and SID, respectively: mean age, 41 and 41 years; African Americans, 12% and 10%; women, 60% and 61%). The 3-year incidence of rehospitalization following donation was 11% for all causes and 9% excluding pregnancy-related hospitalizations. After censoring of models for pregnancy-related rehospitalizations, older age (adjusted hazard ratio [AHR], 1.02 per year; 95% confidence interval [95% CI], 1.01 to 1.03), African American race (AHR, 2.16; 95% CI, 1.54 to 3.03), depression (AHR, 1.88; 95% CI, 1.12 to 3.14), hypothyroidism (AHR, 1.63; 95% CI, 1.06 to 2.49), and longer initial length of stay were related to higher rehospitalization rates among donors. Compared with living donors, adjusted risks for rehospitalizations were greater among patients undergoing appendectomy (AHR, 1.58; 95% CI, 1.42 to 1.75), cholecystectomy (AHR, 2.25; 95% CI, 2.03 to 2.50), and nephrectomy for nonmetastatic carcinoma (AHR, 2.95; 95% CI, 2.58 to 3.37). Risks for rehospitalizations were higher among African Americans than whites in each of the surgical groups.

CONCLUSIONS

The SID is a valuable source for evaluating characteristics and outcomes of living kidney donors that are not available in traditional transplant databases. Rehospitalizations following donor nephrectomy are less than seen with other comparable surgical procedures but are relatively higher among donors who are older, are African American, and have select comorbid conditions. The increased risks for rehospitalizations among African Americans are not unique to living donation.

Shortened length of stay improves financial outcomes in living donor kidney transplantation

Kidney transplantation is the preferred clinical and most cost-effective option for end-stage renal disease. Significant advances have taken place in the care of the transplant patients with improvements in clinical outcomes. The optimization of the costs of transplantation has been a constant goal as well. We present herein the impact in financial outcomes of a shortened length of stay after kidney transplant.

Managing the Psychosocial and Financial Consequences of Living Donation

There has been dramatic growth in the last decade in the literature on psychosocial and financial impacts of living organ donation. With this growth has come recognition that these impacts must be considered when educating prospective donors about the donation process, and when planning donor follow-up care after donation. Our review highlights recent studies that provide new information on the nature of psychosocial and financial outcomes in living donors, with special attention to studies examining unrelated donors (i.e., those with no biologic or longstanding emotional connection to the transplant patient), given that these individuals represent a growing segment of the living donor population. Limitations and gaps in available evidence are noted. We also discuss recent recommendations for post-donation monitoring of donors' psychosocial and financial outcomes, and we consider advances in evidence regarding interventions and prevention strategies to minimize any adverse psychosocial and financial impacts of living donation.

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

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

Women and kidney transplantation

Kidney transplant is the best kidney replacement treatment for end-stage kidney disease. The first step in moving toward kidney transplantation is referral to a transplant center for transplant evaluation. Education of dialysis staff and health-care providers may help increase referrals for evaluation. Patient education has been shown to enhance patient completion of the evaluation process. Patients have difficulty asking others to donate a kidney, but this process can be improved with home and community education. Living donors are more likely to be women than men, especially spousal donors. Deceased donors are more likely to be males younger than 35 years of age. There is a slight decrease in the rate of transplantation of women as compared with men, although not statistically significant. Pretransplant development of anti-human leukocyte antigen antibodies is more common amongst women and can be a barrier to successful transplantation and may prolong the waiting time for transplant. The long-term management of cardiovascular risk factors, osteoporosis, and age-appropriate cancer screening need to be addressed with posttransplant recipients. Women have an overall increased patient and graft survival as compared with men after transplant.