Living Donor Kidney Transplantation: Improving Education Outside of Transplant Centers about Live Donor Transplantation--Recommendations from a Consensus Conference

Banking on Living Kidney Donors-A New Way to Facilitate Donation without Compromising on Ethical Values

Public surveys conducted in many countries report widespread willingness of individuals to donate a kidney while alive to a family member or close friend, yet thousands suffer and many die each year while waiting for a kidney transplant. Advocates of financial incentive programs or "regulated markets" in kidneys present the problem of the kidney shortage as one of insufficient public motivation to donate, arguing that incentives will increase the number of donors. Others believe the solutions lie-at least in part-in facilitating so-called "altruistic donation;" harnessing the willingness of relatives and friends to donate by addressing the many barriers which serve as disincentives to living donation. Strategies designed to minimize financial barriers to donation and the use of paired kidney exchange programs are increasingly enabling donation, and now, an innovative program designed to address what has been termed "chronologically incompatible donation" is being piloted at the University of California, Los Angeles, and elsewhere in the United States. In this program, a person whose kidney is not currently required for transplantation in a specific recipient may instead donate to the paired exchange program; in return, a commitment is made to the specified recipient that priority access for a living-donor transplant in a paired exchange program will be offered when or if the need arises in the future. We address here potential ethical concerns related to this form of organ "banking" from living donors, and argue that it offers significant benefits without undermining the well-established ethical principles and values currently underpinning living donation programs.

Variation in Dialysis Exposure Prior to Nonpreemptive Living Donor Kidney Transplantation in the United States and Its Association With Allograft Outcomes

BACKGROUND

The impact of dialysis exposure before nonpreemptive living donor kidney transplantation on allograft outcomes is uncertain.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

Adult first-time recipients of kidney-only living donor transplants in the United States who were recorded within the Scientific Registry of Transplant Recipients for 2000 to 2016.

FACTORS

Duration of pretransplantation dialysis exposure.

OUTCOMES

Kidney transplant failure from any cause including death, death-censored transplant failure, and death with allograft function.

RESULTS

Among the 77,607 living donor transplant recipients studied, longer pretransplantation dialysis exposure was independently associated with progressively higher risk for transplant failure from any cause, including death beginning 6 months after transplantation. Compared with patients with 0.1 to 3.0 months of dialysis exposure, the HR for transplant failure from any cause including death increased from 1.16 (95% CI, 1.07-1.31) among patients with 6.1 to 9.0 months of dialysis exposure to 1.60 (95% CI, 1.43-1.79) among patients with more than 60.0 months of dialysis exposure. Pretransplantation dialysis exposure varied markedly among centers; median exposures were 11.0 and 18.9 months for centers in the 10th and 90th percentiles of dialysis exposure, respectively. Centers with the highest proportions of living donor transplantations had the shortest pretransplantation dialysis exposures. In multivariable analysis, patients of black race, with low income, with nonprivate insurance, with less than high school education, and not working for income had longer pretransplantation dialysis exposures. Dialysis exposure in patients with these characteristics also varied 2-fold between transplantation centers.

LIMITATIONS

Why longer dialysis exposure is associated with transplant failure could not be determined.

CONCLUSIONS

Longer pretransplantation dialysis exposure in nonpreemptive living donor kidney transplantation is associated with increased risk for allograft failure. Pretransplantation dialysis exposure is associated with recipients' sociodemographic and transplantation centers' characteristics. Understanding whether limiting pretransplantation dialysis exposure could improve living donor transplant outcomes will require further study.

Health Disparities in Kidney Transplantation for African Americans

BACKGROUND

The persistent challenges of bridging healthcare disparities for African Americans (AAs) in need of kidney transplantation continue to be unresolved at the national level. This healthcare disparity is multifactorial: stemming from limited kidney donors suitable for AAs; inconsistent care coordination and suboptimal risk factor control; social determinants, low socioeconomic status, reduced access to care; and mistrust of clinicians and the healthcare system.

SUMMARY

There are numerous opportunities to significantly lessen the disparities in kidney transplantation for AAs through the following measures: the adoption of new care and patient engagement models that include education, enhanced practice-level cultural sensitivity, and timely referral as well as increased research on the impact of the environment on genetic risk, and implementation of new transplantation-related policies. Key Messages: This systematic review describes pretransplant concerns related to access to kidney transplantation, posttransplant complications, and policy interventions to address the challenging issues associated with kidney transplantation in AAs.

KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors

The 2017 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors is intended to assist medical professionals who evaluate living kidney donor candidates and provide care before, during and after donation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach and guideline recommendations are based on systematic reviews of relevant studies that included critical appraisal of the quality of the evidence and the strength of recommendations. However, many recommendations, for which there was no evidence or no systematic search for evidence was undertaken by the Evidence Review Team, were issued as ungraded expert opinion recommendations. The guideline work group concluded that a comprehensive approach to risk assessment should replace decisions based on assessments of single risk factors in isolation. Original data analyses were undertaken to produce a "proof-in-concept" risk-prediction model for kidney failure to support a framework for quantitative risk assessment in the donor candidate evaluation and defensible shared decision making. This framework is grounded in the simultaneous consideration of each candidate's profile of demographic and health characteristics. The processes and framework for the donor candidate evaluation are presented, along with recommendations for optimal care before, during, and after donation. Limitations of the evidence are discussed, especially regarding the lack of definitive prospective studies and clinical outcome trials. Suggestions for future research, including the need for continued refinement of long-term risk prediction and novel approaches to estimating donation-attributable risks, are also provided.In citing this document, the following format should be used: Kidney Disease: Improving Global Outcomes (KDIGO) Living Kidney Donor Work Group. KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Transplantation. 2017;101(Suppl 8S):S1-S109.

The Effect of Transplant Education on Nurses Attitudes Toward Organ Donation and Advocacy for Transplantation

Nurses are the largest group of health-care professionals, yet they are not uniformly educated regarding transplantation and organ donation. The future of transplantation hinges on education of this group. Before meaningful studies can be conducted, an instrument to measure attitudes and commitment to organ transplantation is needed. The purpose of this study was to examine content and construct validity as well as establish internal reliability of an investigator-developed online instrument to measure nurses' attitudes and commitment to organ transplantation by registered nurses. The online instrument was administered to registered nurses enrolled in transplantation electives at the University of Alabama in Huntsville and Vanderbilt University. Exploratory factor analysis revealed 4 components with eigenvalues over 1.0. The components were as follows: (1) desire to work in transplantation, (2) confidence in transplantation advocacy, (3) organ donation advocacy, and (4) procurement. Internal consistency of the revised instrument was established (α = .94). The Transplant-Registered Nurse (TXP-RN) instrument is a new instrument with excellent reliability and validity that can be used to measure attitudes and knowledge of American nurses about organ donation and transplantation. This important step is necessary before educational interventions can be accurately assessed.

Cardiovascular Risk Assessment in Elderly Living Kidney Donors: Risk Comparison Before and After Donation Using QRISK Equation

OBJECTIVES

This study aimed to assess whether donor age would increase the risk of cardiovascular comorbidities during the first few years after donation. Cardiovascular risk was calculated using the QRISK tool (University of Nottingham and EMIS, Nottingham, UK).

MATERIALS AND METHODS

Data were collected from 221 living renal transplant donors at St. George's University Hospital NHS Foundation Trust between 2008 and 2012 before and after donation (at 6, 12, and 24 mo). QRISK scores were calculated for each patient at these time points before stratifying our patients into 2 cohorts: cohort A (age ≤ 59 y) and cohort B (age ≥ 60 y). QRISK scores were then compared using unpaired t tests.

RESULTS

Before donation, mean QRISK scores were 3.4% in cohort A and 12.4% in cohort B (P < .001). At 6, 12, and 24 months after kidney donation, the risks were 3.3% and 12.2% (P < .001), 3.8% and 13.6% (P < .001), and 5% and 15.4% (P < .001) in cohort A versus cohort B.

CONCLUSIONS

When we analyzed risk before donation, both age groups showed a significant increase in cardiovascular risk at 24 months. This subtle increase in cardiovascular risk in the 2 groups may be attributed to changing patient demographics, such as the increasing age of patients, rather than the donation itself. Elderly kidney donors, therefore, are a key source of donation after satisfactory cardiovascular work-up. However, elderly kidney donors will require long-term postoperative follow-up care and specific counseling aimed at reducing modifiable cardiovascular risk factors.

Predictors and Moderators of Educational Interventions to Increase the Likelihood of Potential Living Donors for Black Patients Awaiting Kidney Transplantation

Our aim was to identify predictors and moderators of the effects of a house calls (HC) educational intervention, relative to a group-based (GB) intervention and to individual counseling (IC), in a randomized controlled trial to increase the likelihood of having living donor (LD) evaluations initiated and live donor kidney transplantation (LDKT). Black adults wait listed for kidney transplantation (N = 152) were randomized into one of the three educational conditions. We examined demographic, clinical, psychosocial, and socio-contextual baseline characteristics as predictors and moderators of having a potential LD initiate evaluation. HC assignment (OR = 2.024.7311.05, P = 0.001), younger age (OR = 0.910.940.98, P = 0.001), more willingness to discuss donation with others (OR = 1.081.371.75, P = 0.01), and larger social network (OR = 1.011.091.18, P = 0.04) were significant multivariable predictors of having ≥1 LD initiate evaluation. Age (P = 0.03) and social network size (P = 0.02) moderated the effect of HC relative to IC and GB, but not GB relative to IC, on LD evaluation initiation. Our findings suggest that HC is most effective for patients <60 years old and those with average or large social network size.

Socioeconomic deprivation and barriers to live-donor kidney transplantation: a qualitative study of deceased-donor kidney transplant recipients

OBJECTIVES

Socioeconomically deprived individuals with renal disease are less likely to receive a live-donor kidney transplant than less-deprived individuals. This qualitative study aimed to identify reasons for the observed socioeconomic disparity in live-donor kidney transplantation.

DESIGN

A qualitative study using face-to-face in-depth semistructured interviews.

SETTING

A UK tertiary renal referral hospital and transplant centre.

PARTICIPANTS

Purposive sampling was used to select deceased-donor transplant recipients from areas of high socioeconomic deprivation (SED) (19 participants), followed by a low SED comparison group (13 participants), aiming for maximum diversity in terms of age, gender, ethnicity, primary renal disease and previous renal replacement therapy.

METHODS

Participants were interviewed following their routine transplant clinic review. Interviews were digitally audio-recorded and transcribed verbatim. Transcripts were coded using NVivo software and analysed using the constant comparison method described in Grounded Theory.

RESULTS

Themes common and distinct to each socioeconomic group emerged. 6 themes appeared to distinguish between individuals from areas of high and low SED. 4 themes were distinct to participants from areas of high SED: (1) Passivity, (2) Disempowerment, (3) Lack of social support and (4) Short-term focus. 2 themes were distinct to the low SED group: (1) Financial concerns and (2) Location of donor.

CONCLUSIONS

Several of the emerging themes from the high SED individuals relate to an individual's lack of confidence and skill in managing their health and healthcare; themes that are in keeping with low levels of patient activation. Inadequate empowerment of socioeconomically deprived individuals by healthcare practitioners was also described. Financial concerns did not emerge as a barrier from interviews with the high SED group. Interventions aiming to redress the observed socioeconomic inequity should be targeted at both patients and clinical teams to increase empowerment and ensure shared decision-making.

Educating Prospective Kidney Transplant Recipients and Living Donors about Living Donation: Practical and Theoretical Recommendations for Increasing Living Donation Rates

A promising strategy for increasing living donor kidney transplant (LDKT) rates is improving education about living donation for both prospective kidney transplant recipients and living donors to help overcome the proven knowledge, psychological, and socioeconomic barriers to LDKT. A recent Consensus Conference on Best Practices in Live Kidney Donation recommended that comprehensive LDKT education be made available to patients at all stages of chronic kidney disease (CKD). However, in considering how to implement this recommendation across different healthcare learning environments, the current lack of available guidance regarding how to design, deliver, and measure the efficacy of LDKT education programs is notable. In the current article, we provide an overview of how one behavior change theory, the Transtheoretical Model of Behavior Change, can guide the delivery of LDKT education for patients at various stages of CKD and readiness for LDKT. We also discuss the importance of creating educational programs for both potential kidney transplant recipients and living donors, and identify key priorities for educational research to reduce racial disparities in LDKT and increase LDKT rates.

Going Upstream: Coordination to Improve CKD Care

Care coordination for patients with chronic kidney disease has been shown to be effective in improving outcomes and reducing costs. However, few patients with CKD benefit from this systematic management of their kidney disease and other medical conditions. As a result, outcomes for patients with kidney disease are not optimal, and their cost of care is increased. For those patients who transition to kidney failure treatment in the United States, the transition does not go as well as it could. The effectiveness of treatments to delay progression of kidney disease in contemporary clinical practice does not match the efficacy of these treatments in clinical trials. Conservative care for kidney disease, which should be an option for patients who are very old and very sick, is not considered often enough or seriously enough. Opportunities for early and even pre-emptive transplantation are missed, as are opportunities for home dialysis. The process of dialysis access creation is rarely optimal. The consequence is care which is not as good as it could be, and much more expensive than it should be. We describe our initial efforts to implement care coordination for chronic kidney disease in routine clinical care and attempt to project some of the benefits to patients and the cost savings.