The Motivations and Experiences of Living Kidney Donors: A Thematic Synthesis

Changes in Decisional Conflict and Decisional Regret Among Living Kidney Donors From Pre-Donation to 1-Year Post-Donation

Previous research indicates that most living kidney donors (LKDs) are content with their decision to donate and seldom experience regret. Nevertheless, a small percentage of donors report adverse experiences, such as psychological distress and reduced vitality. Therefore, it is essential to explore the experiences of LKDs, particularly within the context of their decision-making process both before and following kidney donation. This study aimed to examine the decisional conflict and decisional regret experienced by LKDs from the evaluation stage to 12 months post-donation and to identify the associated factors. A longitudinal study design was implemented, and the initial data collection took place when potential LKDs visited the hospital for evaluation (n = 50). Subsequent data collection was conducted at 3 (n = 49), 6, and 12 (n = 46) months post-donation. Variables, including basic demographics, decisional conflict, decisional regret, perceived control, psychological distress, and healthcare orientation, were collected. Generalized estimating equations were used to obtain inferential statistics. Results showed that perceived control characterized by personal control orientation, lower psychological distress, and better healthcare orientation were associated with reduced decisional conflict among LKDs. Meanwhile, lower decisional regret was associated with better self-perceived health status, perceived control inclined toward interpersonal control, and less psychological distress among LKDs. Nurses should assess the decisional conflict and mental health of potential LKDs, and provide clear information to support their decision regarding kidney donation. They should also offer self-care information and stress-coping strategies related to living donor nephrectomy to aid in reducing decisional conflict and regret.

Improving healthcare services for living kidney donors: an experience-based approach in the Netherlands

Living kidney donors voluntarily donate one of their kidneys to someone suffering from end-stage kidney disease. Transplantation is a life-saving opportunity for these patients and generally provides an increase in quality of life. A major goal of research and practice related to living kidney donation concerns the safety of the donor. In comparison, only limited research has been carried out on donor experiences of the donor journey in the full cycle of care. To gain further insight into this, we have performed an experience-based co-design (EBCD) study in a major transplant center in the Netherlands. EBCD is a research approach where professionals and patients share experiences with the purpose of improving the healthcare journey. We identified 11 areas for potential improvement: from intake, throughout surgery and hospitalization, to homecare and aftercare. Donors indicated the importance of person-specific information during the admission process, accurate communication with health professionals and attention to recovery after surgery. Nevertheless, no one regretted their donation, and the overall experience was positive. An important finding for professionals is that donors feel like 'normal' patients and want to be taken care of even though they are healthy. Just like other patients, they can be anxious before surgery and some may have concerns about recovery. Although this is a single-center study, the results should be relevant for all transplant centers that are interested in improving donor experiences. We concluded that the EBCD approach, when embedded in a local context, is a valuable tool for bringing patients' experiences to healthcare improvement.

Living Kidney Donation: A Narrative Review of Mid- and Long-term Psychosocial Outcomes

Living kidney donors make a significant contribution to alleviating the organ shortage. The aim of this article is to provide an overview of mid- and long-term (≥12 mo) living donor psychosocial outcomes and highlight areas that have been understudied and should be immediately addressed in both research and clinical practice. We conducted a narrative review by searching 3 databases. A total of 206 articles were included. Living donors can be divided into those who donate to an emotionally or genetically related person, the so-called directed donors, or to an emotionally or genetically unrelated recipient, the so-called nondirected donors. The most commonly investigated (bio)psychosocial outcome after living donation was health-related quality of life. Other generic (bio)psychological outcomes include specific aspects of mental health such as depression, and fatigue and pain. Social outcomes include financial and employment burdens and problems with insurance. Donation-specific psychosocial outcomes include regret, satisfaction, feelings of abandonment and unmet needs, and benefits of living kidney donation. The experience of living donation is complex and multifaceted, reflected in the co-occurrence of both benefits and burden after donation. Noticeably, no interventions have been developed to improve mid- or long-term psychosocial outcomes among living donors. We highlight areas for methodological improvement and identified 3 areas requiring immediate attention from the transplant community in both research and clinical care: (1) recognizing and providing care for the minority of donors who have poorer long-term psychosocial outcomes after donation, (2) minimizing donation-related financial burden, and (3) studying interventions to minimize long-term psychosocial problems.

Fatigue in living kidney donors compared to a German general population sample: an exploratory study

Background

Clinical studies have not conclusively clarified whether fatigue scores in living kidney donors after donation are fundamentally different from general population samples. Moreover, the association between sociodemographic and donor specific factors and fatigue in donors is not well understood.

Patients and methods

Fatigue scores of 358 living kidney donors on average 7.67 years post-donation were compared with 1896 subjects from the German general population in five strata of age and sex. Fatigue was measured with the Multidimensional Fatigue Inventory (MFI-20). Relationships between the five MFI-20 subscales and the sociodemographic variables sex, age, education, and in the donor sample also years since donation were calculated. Additionally, the association between donor specific variables and fatigue levels were analyzed.

Results

Overall, donors had lower fatigue scores than the population sample. Particularly the age group 65-74 and above reported significantly lower fatigue scores. A significant exception was found in women aged 45-54 years, where donors showed significant higher general fatigue scores than the corresponding subgroup of the general population sample. Multiple regression analyses in the general population sample revealed associations between female sex and higher age with higher values in most MFI-20 subscales, whereas subjects with higher education showed mostly lower fatigue scores. In the donor group, these associations were of little importance. Also, years since donation, partnership, and recipient group were not strongly related to fatigue. However, higher fatigue in donors was associated with more donation regret, a more negative relationship with the recipient, a more negatively perceived recipient health, less perceived family support, and more financial burden.

Conclusion

Fatigue is less prevalent particularly in older donors and predictors of fatigue presented in the general population sample seem to have little importance in the donors. However, middle-aged female donors might be more prone to develop fatigue. This group may require more intense exploration before and after donation to detect and treat the underlying factors timely.

Evaluation of acute postoperative pain management after living donor nephrectomy during the transition from open access to laparoscopic and minimally invasive robotic surgical approach

Background

Living donor nephrectomies (LDN) at our institution transitioned from open access to laparoscopic and, more recently, to a minimally invasive robotic surgical approach between 2019 and 2022. Concurrently, postoperative analgesia transitioned from regional anesthesia to intravenous patient-controlled analgesia (PCA) and eventually to simple analgesics with additional rescue analgesic agents, as needed, in accordance with individual physicians' preferences. This retrospective study was designed to evaluate the impact of these changes on surgical practice on the analgesic requirements and effectiveness of postoperative pain management.

Methods

Electronic records of all LDN cases operated between January 2019 and March 2022 were accessed, and a comparative analysis of patient demographics, surgical approach, duration of surgery, postoperative pain scores, and the analgesics administered within the first 48 h was performed.

Results

LDN (n = 527) was performed via laparoscopic (n = 432, 82%), robotic (n = 87, 17%), and open (n = 8, 2%) approaches. All patients were administered regular paracetamol 1 g 6 hourly. IV PCA was used in 85% of cases, predominantly in the laparoscopic (99%) and open (75%) groups (LG and OG, respectively); in contrast, the robotic group (RG) was mostly treated without PCA (81.7%). A variety of analgesic techniques were employed for the remaining patients, including epidural (25% of OG) and rectus sheath/transversus abdominis plane (TAP) block (2% of LG). Additional rescue analgesics were administered to 98% of the patients; 92% of LG needed 1-3 analgesic agents, whereas all of the OG and 37% of RG needed 1-2 rescue analgesics. No correlation was found between patient demographics and surgery duration on pain scores or analgesic requirements.

Conclusions

Robotic surgery was associated with the lowest postoperative pain scores and analgesic demand; laparoscopic resection was the most painful of all.

Understanding the Healthcare Needs of Living Kidney Donors Using the Picker Principles of Patient-centered Care: A Scoping Review

Living kidney donors (LKDs) undertake a complex and multifaceted journey when pursuing donation and have several unmet healthcare needs. A comprehensive understanding of these needs across their entire donation trajectory can help develop a patient-centered care model. We conducted a scoping review to synthesize empirical evidence, published since 2000, on LKDs' experiences with healthcare from when they decided to pursue donation to postdonation care, and what they reported as their care needs. We categorized them according to the 8 Picker principles of patient-centered care. Of the 4514 articles screened, 47 were included. Ample literature highlighted the need for (1) holistic, adaptable, and linguistically appropriate approaches to education and information; (2) systematic, consistent, and proactive coordination and integration of care; and (3) self-management and preparation to optimize perioperative physical comfort. Some literature highlighted the need for (4) better continuity and transition of care postdonation. Two key unmet needs were the lack of (5) a holistic psychosocial evaluation predonation and predischarge to provide emotional support and alleviation of fear and anxiety; and (6) access to specialty and psychosocial services postdonation especially when adverse events occurred. Limited literature explored the principles of (7) respect for patients' values, preferences, and expressed needs; and (8) involvement of family and friends as caregivers. We summarize several unmet healthcare needs of LKDs throughout their donation journey and highlight knowledge gaps. Addressing them can improve their well-being and experiences, and potentially address inequities in living kidney donation and increase living donor kidney transplantation.

The lived experience of living liver donors: A meta-synthesis of qualitative studies

BACKGROUND

Living liver donors are frequently used for liver transplantation, but they experience many physical changes and psychological challenges. A better understanding of the experiences of liver donors can provide them with comprehensive and individualized patient-centred support and health care. Thus, this study sought to identify and synthesize existing qualitative studies to develop an in-depth understanding of the lived experiences of living liver donors.

METHOD

A meta-synthesis was conducted and reported in accordance with the Enhancing Transparency in Reporting the Synthesis of Qualitative Research statement. Seven databases were systematically searched from inception to March, 2024, using a combination of Medical Subject Headings with keywords. The results were integrated using the three-step thematic synthesis method suggested by Thomas and Harden.

RESULTS

Nine studies met the inclusion criteria and were included in this meta-synthesis. Four themes emerged from the meta-synthesis: (1) facing a life-changing situation, (2) experiencing changes in interpersonal relationships, (3) coping with changes, and (4) achieving personal growth.

CONCLUSIONS

Living liver donors experienced physical, psychological, and social changes after surgery, striving to manage these challenges, highlighting the importance of coping strategies and ultimately achieving personal growth. Future nursing research should focus on psychological interventions, supportive measures, and the positive aspects of living liver donors to help them achieve the optimal quality of life.

TRIAL REGISTRATION

PROSPERO CRD42022328947.

Motivational Factors Affecting Body and Organ Donation in China Identified Based on Grounded Theory

BACKGROUND

In recent decades, China has experienced a shortage of donated bodies and organs for dissection during medical education and clinical transplantation. This study investigated and analyzed motivational factors affecting body and organ donation in China.

METHODOLOGY

Thirty-three body and organ donation volunteers were interviewed in-depth, and their donation motivations were investigated. The data were decomposed, detected, compared, conceptualized, and categorized using open, correlation, and selective coding based on grounded theory.

RESULTS

The results were used to construct a model that elucidates the foundation of body and organ donation based on "humanistic medical care" and "death in existentialism" as driving forces for body and organ donors.

CONCLUSIONS

This study provides new theoretical perspectives that contribute to interpreting behavior related to body and organ donation and offers a theoretical basis for related policymaking and promotional work.

Altruistic kidney donation following the death of a loved one-a coincidence or a post-traumatic growth?

The aim of this study was to examine the case of altruistic kidney donation (AKD) following loss, in light of PTG theory. Loss may facilitate trauma alongside post-traumatic growth (PTG). Although much is known about the motivation for AKD in general, less is known about the motives of bereaved individuals who chose to altruistically donate their kidney post-loss. Employing a narrative approach, 10 bereaved individuals who altruistically donated a kidney were interviewed about their perceptions of the connection between the loss and their decision to donate a kidney post-loss. Content analysis revealed three types of bereaved AKD's perceived connection between the loss and the donation: explicitly direct, indirect, and implicit. Donation post-loss was characterized by aspects of PTG in three domains: self, other and worldviews. The findings are discussed in light of PTG theory and highlight the possible role of AKD in processes of coping and growth following grief.

A qualitative study exploring barriers and facilitators in deceased organ donation process among transplant coordinators in India

Although India's organ donation rate is less than 1 per million population, significant disparities exist between the regions and centres within the country, leading to varying consent rates among different organ donation centres. Therefore, this study aimed to understand the experience of transplant coordinators and their barriers and facilitators in the deceased organ donation process across various organ donation centres in India. A phenomenological study using interviews was conducted among fourteen transplant coordinators purposefully recruited from public and private organ donation centres in India, with experience between six years and more than a decade. Audio recordings were transcribed and analysed using framework analysis. Five themes were identified namely: (1) supportive management policies, (2) infrastructure for the deceased organ donation process, (3) delays in the processing time, (4) active involvement in the identification process, and (5) explaining the concept of brain death. The study identifies that implementation priorities include strengthening teamwork, streamlining processes, optimising infrastructure for sensitive discussions, efficient donor identification, and empathetic handling of donor families' grief stages. Collaborating with law enforcement, applying successful medico-legal strategies, improving family communication, and clarifying brain death concepts ethically and legally can boost consent rates, fostering informed decisions and possibly achieving self-sufficiency in deceased organ donation.

Systemic Factors Contributing to Gender Differences in Living Kidney Donation: A Systematic Review and Meta-Synthesis Using the Social-Ecological Model Lens

INTRODUCTION

The field of living kidney donation is profoundly gendered contributing to a predominance of women, mothers, and wives as living kidney donors (LKDs). Individual factors have traditionally been emphasized, and there is a limited appreciation of relational, community, and sociocultural influences in decision-making. We aimed to comprehensively capture existing evidence to examine the relative importance of these factors.

METHODS

This was a systematic review of existing literature that has explored the motivation of different genders to become LKDs. Of the 3,188 records screened, 16 studies from 13 counties were included. Data were synthesized thematically using the Social-Ecological Model lens.

RESULTS

At the individual level, themes related to intrinsic motivation; thoughtful deliberation; and attitudes, fears, and beliefs; however, evidence demonstrating differences between men and women was minimal. Greater variation between genders emerged along the relational (coercion from family/network, relationship with the intended recipient, self-sacrifice within the family unit, and stability/acceptance within family); community (economic value and geographic proximity to recipient); and sociocultural (gendered societal roles, social norms and beliefs, social privilege, and legislation and policy) dimensions. The relative importance of each factor varied by context; cultural components were inferred in each study, and economic considerations seemed to transcend the gender divide.

CONCLUSIONS

A complex interplay of factors at relational, community, and sociocultural levels influences gender roles, relations, and norms and manifests as gender disparities in living kidney donation. Our findings suggest that to address gender disparities in living donation, dismantling of deep-rooted systemic contributors to gender inequities is needed.

Experiences of Unanticipated Outcomes Among Ethnically Diverse Living Kidney Donors: A Qualitative Pilot Study

INTRODUCTION

Although living kidney donation is generally considered a safe procedure, it is ethically critical that prospective donors are fully informed before consent. However, prospective donors lack a deep understanding of the donation experience, making the postdonation aftermath feel unanticipated. We sought to gain in-depth qualitative descriptions of the short- and long-term risks and benefits associated with kidney donation among an ethnically diverse group of donors to offer a balanced view of the positive and negative experiences that may occur postdonation.

METHODS

We conducted individual narrative in-depth interviews (September 2020-March 2021) using the DIPEx (database of individual patient experiences) method with former living kidney donors primarily via Zoom.

RESULTS

Fourteen donors (10 women; 8 White, 5 Hispanic, and 1 Native American) completed interviews. Interactions with healthcare providers leading up to donation were largely positive; however, lack of clarity regarding postdonation laboratory values among primary care providers led three participants to be erroneously told they developed kidney disease. Most experienced unanticipated outcomes, including postsurgical complications (e.g., hernia), long-term fatigue (i.e., ≥12 weeks), emotional distress (e.g., depression), hypertension, and gout. Difficulty obtaining life insurance following donation was an unexpected challenge. Despite these issues, participants were unanimously enthusiastic about living kidney donation and reported no regrets.

CONCLUSIONS

Enthusiasm for living kidney donation remained high among all participants despite most experiencing negative outcomes. These findings suggest that greater transparency regarding postdonation experiences may not preclude the decision to move forward with living kidney donation. These narratives will be utilized for an online module of lived experiences of donation.

The promise of xenotransplantation: a challenge

According to many scholars, kidney xenotransplantation promises to mitigate the organ supply shortage. This claim has a certain obviousness to it: by flooding the market with a new source of kidneys, xenotransplantation promises to be a panacea. Our goal is to challenge this claim. We argue that xenotransplantation may increase rather than decrease demand for kidneys, may reduce kidney allotransplants, and may be inaccessible or otherwise unused. By offering the challenge, we hope to show deeper reflection is needed on how xenotransplantation will affect the dearth of available organs.

Depression, anxiety, and quality of life among kidney donors before and after the kidney donation: A prospective study from a tertiary care center in India

Background

Kidney donation is a significant procedure that can profoundly impact the emotional, psychological, and social well-being of renal donors. However, there is a lack of sufficient evidence regarding the specific effects of donation on the mental health and quality of life (QOL) of living kidney donors.

Aim

To evaluate and compare the levels of depression, anxiety, and QOL among living kidney donors before and after the donation procedure.

Materials and Methods

We conducted a prospective longitudinal cohort study involving 50 consecutive living renal donors, assessing them before and 3 months after kidney donation. Depression and anxiety were evaluated using the Hamilton Anxiety Rating Scale (HAM-A) and Hamilton Depression Rating Scale (HAM-D), respectively. Furthermore, the QOL of kidney donors was compared using the World Health Organization Quality of Life Brief Version (WHOQOL-BREF).

Result

The average age of kidney donors was 40.86 ± 8.59 years. Pre-transplant HAM-D and HAM-A scores showed significant negative correlations with post-transplant QoL domains (**P < 0.001). Regression analysis highlighted pre-transplant HAM-D as a significant predictor of post-transplant depression (P = 0.013).

Conclusion

Statistically significant differences in pre- and post-donation HAM-D and HAM-A scores were found, but clinical significance is crucial for interpreting real-world implications. Renal transplantation did not worsen mental health or QOL for donors post transplant, highlighting the importance of addressing pre-transplant depression and anxiety. Further research is needed to assess clinical significance and integrate mental health considerations into transplant care.

Post-Donation Evaluation: Emotional Needs for Social Connection and Social Support among Living Kidney Donors-A Systematic Review

INTRODUCTION

Evaluation of post-nephrectomy social health in living kidney donors is essential. This systematic review examines their emotional need for social relatedness post-donation.

METHODS

Following the PRISMA guidelines, we systematically searched Scopus, CINAHL, and PsycINFO.

RESULTS

Among the screened records, 32 quantitative and 16 qualitative papers met the inclusion criteria. Quantitative research predominantly utilized questionnaires featuring generic items on social functioning. However, a minority delved into emotional and social dimensions, aligning with qualitative studies emphasizing the importance of social connection and perceived social support post-donation. Specifically, post-donation changes in connecting with others encompass a sense of belongingness, heightened autonomy, shifts in concern for the recipient's health, and continued care by shielding the recipient from personal health issues. Social acknowledgment and social support from both close and extended networks are reported as relevant for recovery after nephrectomy.

DISCUSSION

These findings underscore the necessity for targeted measures of emotional needs and social functioning to effectively assess post-donation adjustment. They also inform the identification of key health themes for kidney donor Patient-Reported Outcome Measures (PROMs) and Patient-Reported Experience Measures (PREMs) questions.

Solid Organ Transplant Litigation at One of Europe's Largest University Hospitals

Due to its intrinsic complexity and the principle of collective solidarity that governs it, solid organ transplantation (SOT) seems to have been spared from the increase in litigation related to medical activity. Litigation relating to solid organ transplantation that took place in the 29 units of the Assistance Publique-Hôpitaux de Paris and was the subject of a judicial decision between 2015 and 2022 was studied. A total of 52 cases of SOT were recorded, all in adults, representing 1.1% of all cases and increasing from 0.71% to 1.5% over 7 years. The organs transplanted were 25 kidneys (48%), 19 livers (37%), 5 hearts (9%) and 3 lungs (6%). For kidney transplants, 11 complaints (44%) were related to living donor procedures and 6 to donors. The main causes of complaints were early post-operative complications in 31 cases (60%) and late complications in 13 cases (25%). The verdicts were in favour of the institution in 41 cases (79%). Solid organ transplants are increasingly the subject of litigation. Although the medical institution was not held liable in almost 80% of cases, this study makes a strong case for patients, living donors and their relatives to be better informed about SOT.

Knowledge, Attitudes, and Practices Regarding Organ Donation Among Medical Students in India: A Mixed Methods Study

BACKGROUND

Deceased organ donation rates are extremely low in India. As future physicians, medical students can advocate organ donation in society. However, their knowledge, attitudes, and practices regarding organ donation remain understudied in India. Therefore, the present study aimed to assess the knowledge, attitudes, and practices related to deceased organ donation among undergraduate medical students in India using a mixed methods approach.

MATERIALS AND METHODS

This is a mixed-method study with a cross-sectional survey conducted among 400 randomly selected medical students at a medical college in India using a pretested questionnaire. Additionally, 20 in-depth interviews were conducted to gain qualitative insights.

RESULTS

Knowledge was high regarding organ donation (90%) but lower for brain death (27.5%). Most had positive attitudes, but only 11% were registered donors, and 10% had discussed organ donation with family. Multivariate regression revealed that having third- and fourth-year-old students, urban upbringing, good knowledge, and positive attitudes were associated with increased willingness to donate. Qualitative findings revealed gaps in brain death understanding, religious myths, lack of conviction, and family disapproval as barriers.

CONCLUSION

Despite good awareness, gaps in the comprehension of brain death persist among students. However, the registration and family discussion rates are very low. Targeted strategies such as integrating ethical issues into medical curricula, public awareness campaigns busting myths, simplifying donor registration, and promoting family conversations are strongly recommended. This can empower students to become physician advocates driving organ donation uptake in India.

Are Differences in Living Kidney Donation Rates a Sex or a Gender Disparity?

Sex-disaggregated data reveal significant disparities in living kidney donation, with more female than male living kidney donors in most countries and proportions over 60% in some countries. We summarize the present state of knowledge with respect to the potential drivers of this disparity and argue that it is primarily driven by gender-related factors. First, we present the differences between sex and gender and then proceed to summarize the potential medical reasons that have been proposed to explain why males are less likely to be living kidney donors than females, such as the higher prevalence of kidney failure in males. We then present counterarguments as to why biological sex differences are not enough to explain lower living kidney donation among males, such as a higher prevalence of chronic kidney disease among females, which could affect donation rates. We argue that gender differences likely provide a better explanation as to why there are more women than men living kidney donors and explore the role of economic and social factors, as well as gender roles and expectations, in affecting living kidney donation among both men and women. We conclude with the need for a gender analysis to explain this complex psychosocial phenomenon in living kidney donation.

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.

Psychological Impact of Living Kidney Donation: A Systematic Review by the EAU-YAU Kidney Transplant Working Group

We performed a systematic literature review of the psychological impact on donors of living kidney donation. We conducted a literature review in PubMed/Medline according to PRISMA guidelines which included both qualitative (based on interviews) and quantitative studies (based on standardized questionnaire). There were 15 quantitative studies and 8 qualitative studies with 2,732 donors. Given that the methodologies of qualitative and quantitative studies are fundamentally different, we narratively synthetized results of studies according to four axes: quality of life, anxiety/depression, consequences of donation on the donor/recipient relationship, overall satisfaction and regret. The quantitative studies reported that donor quality of life remained unchanged or improved. Donor regret rates were very low and donor-recipient relationships also remained unchanged or improved. Qualitative studies reported more complex donation experiences: one can regret donation and still decide to recommend it as in a social desirability bias. In both study types, donor-recipient relationships were closer but qualitative studies reported that post-donation rebonding was required. The qualitative studies therefore highlighted the psychological complexity of donation for donors, showing that living donation impacts the donor's life whether it is successful or not. A better understanding of the impact of donation on donors could provide better care for donors.

Kidney Donor Perspectives on Acute Postoperative Pain Management

This study employed a qualitative descriptive approach to examine living kidney donor's experience of postoperative pain. Thirteen living kidney donors aged 46.5 (±14.4) years participated in this study. Semi-structured interviews were conducted and transcribed. Transcripts were inductively coded and reviewed for trends, patterns, and insights into donor's experience of postoperative pain. Donors experienced postoperative pain from a variety of sources that hindered recovery and created anxiety and fear in some. Donors managed pain with opioid and non-opioid medications, social support, and ambulation. Donor's past experiences with and expectations about pain, relationships with intended recipients, social support, as well as motivations for and meaning of donation informed their experience of postoperative pain. Prompt pharmacologic intervention for pain, as well as further coaching and education about pain management should be emphasized for nurses caring for living kidney donors. Further study of how donor's motivation might mediate their pain experience is needed.

'It is a life changing experience': The experiences of living kidney donors who live in rural Australia

INTRODUCTION

A growing body of research has examined the physical, psychological, social and financial impacts of living kidney donation. However, little is known about the unique experiences or additional burdens faced by living donors from regional or remote locations.

OBJECTIVE

To explore the experiences of living kidney donors who live outside metropolitan centres and to determine how support services could be orientated to better meet their unique needs.

DESIGN/SETTING/PARTICIPANTS

Seventeen living kidney donors participated in semistructured telephone interviews. Qualitative data were analysed using thematic analysis.

FINDINGS

Eight themes were identified: (1) donor's emotional well-being is influenced by the recipient's outcome, (2) varied levels of access to medical support and other important services in rural areas, (3) travel takes a toll on time, finances and well-being, (4) varied level of financial impact, (5) medical, emotional and social challenges, (6) both lay and health professional support is valued, (7) varied levels of knowledge and experiences accessing information and (8) a worthwhile experience overall.

CONCLUSION

Despite many challenges, and travel adding to the complexity, rural living kidney donors generally consider it to be a worthwhile experience. The provision of additional emotional, practical and educational support would be welcomed by this group.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Attitudes, knowledge, and perceptions among women toward uterus transplantation and donation in the United Kingdom

Objective

To assess the motivations and perceptions of the general public in the United Kingdom toward donating their uterus for Uterus Transplantation after death (UTx).

Design

A cross sectional study.

Setting

A 32-item electronic questionnaire.

Population

One hundred fifty nine females over the age of 16 living in the United Kingdom, consented and took part in the study.

Main outcome measures

The motivations and perceptions toward UTx among the general public including the willingness to donate and barriers preventing donation.

Results

One hundred fifty nine women completed the questionnaire. The majority had never heard of UTx (n = 107, 71%) and most were not aware the uterus could be donated after death (n = 130, 92%). 43% of the cohort were willing to donate their uterus after death (n = 57). 8% stated they wished to donate their organs but not their uterus (n = 10). 30% of women (n = 42) believed the child born following UTx would have genetic links to the donor. Over half of the respondents (n = 65, 51%) strongly agreed or agreed they would feel joy in the knowledge that donation would lead to bringing a new life into the world. A quarter of respondents strongly agreed or agreed (n = 45, 25%) that the use of their uterus by another woman would feel like an extension of life.

Conclusion

The findings indicate a favorable opinion toward UTx and a positive attitude toward donation of the uterus after death among the general public in the United Kingdom. The findings also highlight the need for education around UTx now this therapeutic option is available.

Perceptions of Psychosocial and Ethical Issues and the Psychological Characteristics of Donors in the Clinical Setting of Living Kidney Donors: A Qualitative Study

BACKGROUND

There are several psychosocial and ethical issues surrounding the decision to be a living kidney donor. The present study aimed to determine the perceptions of psychosocial and ethical issues that living kidney donors may have, and analyze their psychological characteristics.

METHODS

Face-to-face semi-structured interviews were conducted with 15 donors. Thematic analysis was then performed to categorize the thematic elements of the transcripts. All procedures were approved by the relevant review board.

RESULTS

Four main categories were identified: Awareness of family dynamics, barriers to a proper understanding, contrasting psychological effects of recipient presence in clinical practice, insufficient information explained in informed consent.

CONCLUSION

Donors felt that they took on the "role as a care giver" for the recipient and were less aware of themselves as patients. This is a new concept that has not been shown in previous studies. Donors exist within the recipient and family, and the range of their autonomy may go beyond the traditional concept of autonomy and be rooted in relational autonomy. This study suggested that medical treatment in the presence of the recipient promotes the relational autonomy of the donor.

Red Flags in the Living Kidney Donor Process

BACKGROUND

Ideally, no live kidney donor should regret their decision or feel they were not fully prepared for the process. Unfortunately, this is not a reality for all donors. The aim of our study is to identify areas for improvement, focusing on factors (red flags) that predict less favorable outcomes from a donor perspective.

MATERIALS AND METHODS

A total of 171 living kidney donors responded to a questionnaire with 24 multiple-choice questions and space for comments. Less favorable outcomes were defined as lower satisfaction, extended physical recovery period, long-term fatigue, and longer sick leave.

RESULTS

Ten red flags were identified. Of these factors, more fatigue (range, P = .000-0.040) or pain (range, P = .005-0.008) than expected while still in hospital, the actual experience being harder or different than expected (range, P = .001-0.010), and the donor wishing to have had but not having been offered a previous donor as mentor (range, P = .008-.040) correlated significantly with at least 3 of the 4 less favorable outcomes. Another significant red flag was keeping existential issues to oneself (P = .006).

CONCLUSION

We identified several factors indicating that a donor could be at an increased risk for a less favorable outcome after donation. Four of these factors have, to our knowledge, not been described earlier: more early fatigue than expected, more postoperative pain than anticipated, not having been offered a mentor at an early stage, and keeping existential issues to oneself. Attention to these red flags already during the donation process could help health care professionals to act early to avoid unfavorable outcomes.

Living uterus donors' perceptions of decision-making and informed consent: a qualitative study of the Dallas Uterus Transplant Study participants

Uterus transplantation is a growing field, but little is known about living uterus donors' perceptions of informed consent or their decision-making processes. This study used semistructured interviews to collect information regarding uterus donors' experiences with uterus donation, perceptions of the informed consent process, and information on how they decided to pursue uterus donation. Interviews were coded for thematic analysis. Three major themes emerged in this study. First, the decision-making process was based on individuals' motivations, rationale, and considerations of alternative contributions to help other women with infertility. Second, participants described how they felt about the process of informed consent, their decision-making processes, and how their experiences compared with their expectations. Third, participants discussed how uterus donation was a valuable experience. This study found that living uterus donors are motivated to give another woman the opportunity to experience pregnancy and childbirth. They were satisfied with the informed consent process, their experiences were in line with their expectations, and the value of uterus donation was associated with the act of donation itself. Our findings suggest that living donor uterus programs should develop robust informed consent processes that provide detailed information about uterus donation and encourage shared decision-making with potential uterus donors.

Moral foundations, values, and judgments in extraordinary altruists

Donating a kidney to a stranger is a rare act of extraordinary altruism that appears to reflect a moral commitment to helping others. Yet little is known about patterns of moral cognition associated with extraordinary altruism. In this preregistered study, we compared the moral foundations, values, and patterns of utilitarian moral judgments in altruistic kidney donors (n = 61) and demographically matched controls (n = 58). Altruists expressed more concern only about the moral foundation of harm, but no other moral foundations. Consistent with this, altruists endorsed utilitarian concerns related to impartial beneficence, but not instrumental harm. Contrary to our predictions, we did not find group differences between altruists and controls in basic values. Extraordinary altruism generally reflected opposite patterns of moral cognition as those seen in individuals with psychopathy, a personality construct characterized by callousness and insensitivity to harm and suffering. Results link real-world, costly, impartial altruism primarily to moral cognitions related to alleviating harm and suffering in others rather than to basic values, fairness concerns, or strict utilitarian decision-making.

Liver Paired Exchange: Programmatic Hopes and Fears

The dearth of deceased liver donors has created a supply demand gap, necessitating creation of living donor liver transplantation. However, living donor liver transplantation has relied on directed donation, whereby many potential directed donors are rejected based on ABO blood group incompatibility, hepatic size incompatibility, or the need for biliary or arterial reconstruction during transplant surgery. Much like kidney paired exchange, liver paired exchange (LPE) circumvents these incompatibility issues by relying on anonymous, nondirected, or bridge donors that are better anatomical or histological matches for recipients. Although Asia has taken the lead in LPE, the process has only recently been adopted in North America, with the first successful surgery done in the United States in 2019. Our review article sheds light on the process of LPE and the success of LPE in the United States thus far and, additionally, highlights the several logistical and ethical challenges that must be considered as transplant centers adopt and scale up LPE across the United States to address the increased demand for liver allografts.

Psychosocial and Ethical Behaviors and Attitudes of Health Care Professionals in the Clinical Setting of Living Kidney Donors: A Qualitative Study

BACKGROUND

There are several psychosocial and ethical issues surrounding the decision making of living kidney transplant donors. This study aimed to determine what health care professionals (HPs) consider in their clinical practice and their attitudes toward donors' decision-making processes.

METHODS

Face-to-face semistructured interviews were conducted with 15 HPs. A thematic analysis was performed to categorize the thematic elements of the transcripts. All procedures were approved by the relevant review board and conducted in accordance with the Declaration of Helsinki.

RESULTS

Six main categories-maintaining family relationships, improving donor understanding, supporting voluntary decision making, setting the environment for the examination, having different attitudes toward the donor's intentions, and resisting confirmation of intent-were identified. The HPs provided diverse considerations to respect the donors' autonomy.

CONCLUSION

In clinical practice, there is a lack of practical methods to confirm living donors' levels of understanding and spontaneity, suggesting that these methods need to be established. Factors related to family functioning may reflect the unique culture of Japan, and this may be indicative of the need to consider treatment based on cultural values.

Psycho-social health and quality of life among kidney donors following transplantation

INTRODUCTION

Living kidney donation is a complex psychological experience for donors. The present study examined the psychosocial impact of kidney donation on donors.

METHODS

The retrospective study included 506 donors who donated a kidney between 2010 and 2018 at a transplant centre in India. These donors responded via a donor insight questionnaire about their hospital anxiety, and their possible level of depression. The information included socio-demographic form with multiple information. The health survey was used periodically evaluate the psychosocial impact among donors following donation, including the transplant outcomes.

RESULTS

The majority of donors were females (79.4%). There was a significant improvement in the quality of life among donors (SF-36) following the donation of a kidney, especially among those donors who maintained good graft functions themselves as well as those who were informed about good kidney function in transplanted recipients. These donors showed a lesser degree of depressive and anxiety scores (HAD score 3.5 and BDI II 4.8) than donors who had problems themselves and/or whose donated kidneys did not function well. Most living donors (89.1%) felt that the act of donation had a positive impact on their lives and those donors would encourage others to donate a kidney. Overall, the graft outcomes impacted the donor's state of mind.

CONCLUSION

The study showed a very positive impact of the acknowledgment of the donor by the recipient, especially those donors whose kidney transplants were well functioning. The state of depression, anxiety, and psycho-social outcomes correlated with the graft outcomes. Donors showed positive insight towards donation, with inner conscience still conclusively willing to donate and encourage others.

The use of nondirected donor organs in living donor liver transplantation: Perspectives and guidance

Interest in anonymous nondirected living organ donation is increasing in the United States and a small number of transplantation centers are accumulating an experience regarding nondirected donation in living donor liver transplantation. Herein, we review current transplant policy, discuss emerging data, draw parallels from nondirected kidney donation, and examine relevant considerations in nondirected living liver donation. We aim to provide a consensus guidance to ensure safe evaluation and selection of nondirected living liver donors and a schema for just allocation of nondirected grafts.

What blood and organ donation can tell us about cooperation?

High-cost cooperation directed towards strangers is difficult to explain from an evolutionary perspective. Here, it is argued that by studying the behaviours, motivations, and preferences of real-world high-cost cooperators - blood and organ donors - insights can be uncovered into the mechanisms supporting cooperation. In this respect, this article details two novel mechanisms to enhance cooperation in the face of free-riding, (1) 'reactive reluctant altruism' whereby people help because they do not trust others to help and (2) the 'Good Shepherd' effect whereby cooperation is enhanced when people observed others cooperate although the social norm is to free-ride. Finally, it is argued that repeated acts of high-cost cooperation are sustained by a self-selection process based on the reinforcing effect of warm-glow.

Positive and negative aspects of mental health after unspecified living kidney donation: A cohort study

Objectives

Unspecified donors give a kidney to a stranger with end‐stage kidney failure. There has been little research on the long‐term impact of unspecified donation on mental health outcomes. The aim of this study was to assess the positive and negative aspects of mental health among unspecified donors.

Design

We invited all unspecified donors who donated a kidney between 2000 and 2016 at our centre to participate in an interview and to complete validated questionnaires.

Methods

We measured positive mental health using the Dutch Mental Health Continuum‐Short Form (MHC‐SF), psychological complaints using the Symptoms Checklist‐90 (SCL‐90) and psychiatric diagnoses using the Mini‐International Neuropsychiatric Interview (M.I.N.I.) Screen for all donors and the M.I.N.I. Plus on indication.

Results

Of the 134 eligible donors, 114 participated (54% female; median age 66 years), a median of 6 years post‐donation. Scores on emotional and social well‐being subscales of the MHC‐SF were significantly higher than in the general population. Psychological symptoms were comparable to the general population. Thirty‐two per cent of donors had a current or lifetime psychiatric diagnosis. Psychological symptoms did not significantly change between the pre‐donation screening and the post‐donation study.

Conclusions

We concluded that, with the appropriate screening, unspecified donation is a safe procedure from a psychological perspective.

Gender and race/ethnicity differences in living kidney donor demographics: Preference or disparity?

In the United States, women are over-represented and Blacks are under-represented as living kidney donors. A traditional bioethics approach would state that as long as living donors believe that the benefits of participation outweigh the risks and harms (beneficence) and they give a voluntary and informed consent, then the demographics reflect a mere difference in preferences. Such an analysis, however, ignores the social, economic and cultural determinants as well as various forms of structural discrimination (e.g., racism, sexism) that may imply that the distribution is less voluntary than may appear initially. The distribution also raises justice concerns regarding the fair recruitment and selection of living donors. We examine the differences in living kidney donor demographics using a vulnerabilities analysis and argue that these gender and racial differences may not reflect mere preferences, but rather, serious justice concerns that need to be addressed at both the individual and systems level.

Exploration Into Donor-Recipient Relationship After Living-Donor Liver Transplantation Using Gift-Exchange Theory

AIM

This qualitative study aimed to explore the donor-recipient relationships following living-donor liver transplantation.

METHOD

A 1-time cross-sectional qualitative interview was conducted with liver transplant recipients (n = 17) and living liver donors (n = 11) post-transplant. The interviews were transcribed verbatim and analyzed manually by using thematic content analysis.

RESULTS

The mean age of the recipients and the donors was 54.41 ± 8.0 (range 39-71) and 36.6 ± 7.69 (range 28-57) years, respectively. Following the interviews, 2 overarching themes emerged: (1) Became care providers, and (2) differentiation in relationships after transplantation. A total of 3 sub-themes were explained under "differentiation in relationships after transplantation;" feeling guilty, becoming closer and more intense owing to a feeling of indebtedness, and putting some distance owing to a feeling of indebtedness.

CONCLUSION

The study focused on the reciprocation stage according to gift-exchange theory. During reciprocation, although recipients expressed positive feelings such as gratitude, closer relationships, and special bonds; they also reported negative feelings like guilt and indebtedness resulting in a purposeful distancing from their donors. Most donors understood what the recipients felt, but they wanted their relationship to return to normal. Married female donors had worse experiences, such as divorce or a weakened marital relationship after donation.

Comparison of the Quality of Life and Emotional Responses in Kidney Transplant Recipients from Living and Deceased Donors in Nephrology Clinics

Background: Quality of life (QoL) is one of the essential measures in assessing a patient's status after kidney transplant, and emotional response is an important factor in evaluating the patient’s compatibility with the transplant. Also, emotional response affects a patient’s QoL. Objectives: This study aimed to compare the QoL and emotional responses of kidney recipients from deceased and living donors. Methods: This descriptive comparative study randomly selected 118 kidney transplant patients (67 recipients from living donors and 51 recipients from deceased) referred to the Nephrology Clinic of Tehran University of Medical Sciences for a post-surgery follow-up. The QoL questionnaire for patients with renal transplants introduced by Laupacis et al. and the emotional response questionnaire (ERQ) by Ziegelmann et al. were used in this study. For data analysis, Mann-Whitney, independent t-test, and Pearson’s correlation tests were used. All the analyses were performed using SPSS software version 20. Results: The kidney recipients from living donors had significantly higher QoL score (especially emotionally) compared with kidney recipients from deceased donors (P=0.04). The score of emotional response was higher in recipients from a living donor, which is related to feeling guilty, transplant disclosure. Furthermore, recipients from a living donor felt guiltier and were unwilling to disclose their transplant compared with recipients from deceased donors. Conclusions: Feeling of guilt and being anxious about transplant disclosure were higher in recipients from living donors. A significant difference was observed in the QoL and emotional response between the two groups of kidney recipients. Therefore, it is important to involve the transplant team, specifically nurses, in the identification of emotional response and planning accordingly to improve the patients’ QoL, especially in recipients from a living donor.

Depression, anxiety, and associated psychological outcomes in living organ transplant donors: A systematic review

With increasing demands for living organ donations, understanding the prevalence of depression and anxiety, which are the commonest psychiatric disorders in donors following organ transplantation, will serve to improve psychiatric care to safeguard donors' mental wellbeing. This descriptive systematic review examines all observational studies in English investigating prevalence of depression and anxiety in adult transplant donors using bibliographic databases. Sixty-two papers were included (kidney, n = 25; liver, n = 25; bone marrow, n = 7; uterus, n = 2; lung, n = 1; kidney and lung concurrently, n = 2). Post-transplantation depression and anxiety prevalence rates (Depression: 0-46.9%, Anxiety: 0-66.7%) did not differ significantly from pre-transplantation and were largely comparable to the general population. Other psychiatric disorders observed included bipolar disorder, conversion disorder, adjustment disorder and sleep disorder. Other psychological outcomes observed included lower quality of life, lower satisfaction of life and regret after donation. Pre-donation risk factors such as poor physical/psychological health status, and post-donation risk factors such as complicated post-surgical recovery and poor physical/psychological health in recipients were identified, predisposing donors to poor psychological outcomes. Individuals with risk factors should be monitored and provided with social support, psychoeducation, psychotherapy and long-term follow up. Future studies should adopt consistent methodological approaches to improve comparability between various studies. More research investigating poor psychological outcomes in other organ donors besides kidney and liver donors, donors who have past psychiatric history, unrelated and parent donors is warranted.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

The Tangible Benefits of Living Donation: Results of a Qualitative Study of Living Kidney Donors

The framework currently used for living kidney donor selection is based on estimation of acceptable donor risk, under the premise that benefits are only experienced by the recipient. However, some interdependent donors might experience tangible benefits from donation that cannot be considered in the current framework (ie, benefits experienced directly by the donor that improve their daily life, well-being, or livelihood).

Association Between the Economic Environment and the Living Organ Donation Rate: Evidence and Implications

BACKGROUND

We studied the contribution of the economic environment to an individual's decision to donate an organ by examining the relationship between the unemployment rate and the living donation rate.

STUDY DESIGN

We obtained living organ donation data from the Organ Procurement and Transplant Network (OPTN) containing 134,138 organ donation events from 1990 through 2016. We obtained monthly unemployment rates from the Bureau of Labor Statistics (BLS) from 1990 through 2016, and obtained quarterly real gross domestic product (real GDP) by state from the Bureau of Economic Analysis (BEA) from 2005 through 2016. We conducted graphical and statistical analysis with regression modeling using state and time fixed effects.

RESULTS

Descriptive graphical plots suggest that unlike the unemployment rate, the donation rate is non-cyclical over time, implying little association between the two factors. This is conferred by a linear regression model using state and calendar month fixed effects, where we found no significant association between the unemployment and donation rates (95% CI [-0.004, 0.008], interpreted as the change in number of donations per 100,000 people associated with 1% change in the unemployment rate). We also did not find any significant association between the real GDP and the donation rates. Subgroup analysis by sex, race, and age also revealed no significant associations.

CONCLUSIONS

The unemployment rate and the real GDP do not appear to be associated with the living organ donation rate, suggesting that the economic environment may not play a major role in the decision to donate an organ.

The experience of donating and receiving a kidney: A systematic review of qualitative studies

BACKGROUND

The experiences described by people who have undergone kidney transplant are complex. Understanding how donors and recipients experience kidney transplantation can help us to design strategies that provide a more person-centred health care.

OBJECTIVES

To review articles that report the experiences of donors and recipients in the living-donor kidney transplantation process.

METHOD

A systematic review of qualitative studies was carried out. PubMed, Scopus, Web of Science, CINAHL and PsycINFO databases were used to search for articles published in English, French and Spanish between 2005 and 2018.

RESULTS

Twenty-nine articles were included in this review. For recipients, receiving a kidney is a positive experience (positive feelings and significant experience) that also involves certain difficulties and stressors (making a difficult decision, fears and worries). The experience of the donors is positive as they are motivated to improve the life of the recipient. They are committed to donating and use coping strategies as well as experiencing personal growth. On the contrary, being a donor involves certain difficulties and stressors (personal investment, mental, physical and economic impact and overcoming opposition) and a perception of deficiency in the health system (lack of information and attentiveness).

CONCLUSION

Donating and receiving a kidney is a positive experience that involves certain difficulties and a variety of stressors for both the donors and recipients. Moreover, the donors note deficiencies in the health system.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparing Emotional Adjustment of Living-donor and Deceased-donor Kidney Transplant Patients

Supplemental Digital Content is available in the text.

Kidney transplantation is regarded as the best treatment option for patients with end-stage renal disease. However, living-donor recipients (LDRs) and deceased-donor recipients (DDRs) still face challenges in transplant-specific emotional adjustment post-transplantation. Research distinguishing emotional adjustment between transplant groups has been limited to Western settings, with little attention given to Asian populations. As such, documenting and comparing the emotional adjustment of LDRs and DDRs in an ethnically diverse Asian setting in Singapore and identifying factors associated with emotional adjustment are of interest.

Predicting donor, recipient and graft survival in living donor kidney transplantation to inform pretransplant counselling: the donor and recipient linked iPREDICTLIVING tool - a retrospective study

Although separate prediction models for donors and recipients were previously published, we identified a need to predict outcomes of donor/recipient simultaneously, as they are clearly not independent of each other. We used characteristics from transplantations performed at the Oslo University Hospital from 1854 live donors and from 837 recipients of a live donor kidney transplant to derive Cox models for predicting donor mortality up to 20 years, and recipient death, and graft loss up to 10 years. The models were developed using the multivariable fractional polynomials algorithm optimizing Akaike’s information criterion, and optimism‐corrected performance was assessed. Age, year of donation, smoking status, cholesterol and creatinine were selected to predict donor mortality (C‐statistic of 0.81). Linear predictors for donor mortality served as summary of donor prognosis in recipient models. Age, sex, year of transplantation, dialysis vintage, primary renal disease, cerebrovascular disease, peripheral vascular disease and HLA mismatch were selected to predict recipient mortality (C‐statistic of 0.77). Age, dialysis vintage, linear predictor of donor mortality, HLA mismatch, peripheral vascular disease and heart disease were selected to predict graft loss (C‐statistic of 0.66). Our prediction models inform decision‐making at the time of transplant counselling and are implemented as online calculators.

Kidney Donation Withdrawal and Related Factors Among the Potential Donors of Living Kidney Transplant

BACKGROUND

This study aimed to discuss the reasons for kidney donation withdrawal and related factors among the potential donors of living kidney transplant.

METHODS

This study was conducted in outpatient departments with purposive sampling. Potential donors received relevant examinations and completed questionnaires when they would donate their kidneys for living related kidney transplant. Researchers tracked the final decision of potential donors. The structured questionnaire included basic data, psychosocial adjustment to illness scale, and decisional conflict scale.

RESULTS

A total of 53 potential donors participated in this study, 46 of whom completed the kidney donation surgery (86.6%). The factors related to the final decision of kidney donation or kidney donation withdrawal included self-ranking health condition, value clarity, feeling supported in decision making, and overall decisional conflict.

CONCLUSION

Organ transplant teams should conduct a complete physical and psychological assessment of potential donors, provide information and support, and assist potential donors to clarify their true values and willingness to undergo kidney donation. Thus, each potential donor can decide to donate in true accordance with their willingness.

The experiences and impact of being deemed ineligible for living kidney donation: Semi-structured interview study

AIM

We aimed to describe the impact and experience of being deemed ineligible as a living kidney donor.

METHODS

Semi-structured interviews were conducted with 27 ineligible donor candidates. Transcripts were analysed thematically.

RESULTS

Seven themes were identified: deriving health and relationship benefits in the process (strengthening emotional connection, identifying problematic health conditions); devastating loss and disappointment (harbouring guilt over personal failings, shattering confidence and hope, undermining relationships with extended family and friends, disrupting home dynamics); constrained within a rigid system (denied autonomy, resorting to other avenues); acknowledging as matter of fact (accepting the clinical decision, reassured by preventing a poor outcome); reluctant to relinquish the donor identity (unable to fulfil family duty, having the donor role stolen, holding onto other opportunities to donate); uncertainty in unpredictability, inconsistency and ambiguities (frustrated by inefficiencies, questioning clinician motivation, suspended donor status, unfairness in changeable eligibility criteria, unresolved concerns and questions of own health); and abandoned in despair (lacking practical support to meet eligibility criteria, ill prepared for rejection, dismissed and discarded by the system).

CONCLUSION

Being deemed unsuitable for donation took an emotional toll on ineligible donor candidates who felt immense guilt for 'failing' the potential recipient. Ineligible donor candidates were frustrated and angry with the perceived lack of support from clinicians and rigidity of the evaluation process. Informing potential donors of available services, including psychological support, communicating the decision sensitively and with sufficient time, and full disclosure of their health status, may contribute to improved adjustment following the ineligibility decision.

Clinicians' attitudes and approaches to evaluating the potential living kidney donor-recipient relationship: An interview study

AIM

Careful assessment of the potential donor-recipient relationship is recommended by guidelines to prevent undue coercion, and to ensure realistic expectations and genuine motivations. However, relationships are complex, nuanced and value-laden, and can be challenging to evaluate in living kidney donation. We aimed to describe the attitudes and approaches of transplant clinicians towards assessing the relationship between potential living kidney donors and their recipients.

METHODS

Semi-structured interviews were conducted with 54 transplant clinicians (nephrologists, surgeons, coordinators, social workers, psychiatrists and psychologists) from 32 transplant centres across nine countries including Australia, United States, Canada and New Zealand. Transcripts were analyzed thematically.

RESULTS

Four themes were identified: protecting against vulnerability and premature decisions (ensuring genuine motivation, uncovering precarious dynamics and pre-empting conflict, shared accountability, relying on specialty psychosocial expertise, trusting intimate bonds, tempering emotional impulsivity); safeguarding against coercion (discerning power imbalance, justified inquiry, awareness of impression management); minimizing potential threat to relationships (preserving the bond, giving equitable attention to donors and recipients, ensuring realistic expectations); and ambiguities in making judgments (adjudicating appropriateness and authenticity of relationships, questioning professional intervening, uncertainties in subjective and emotional assessments).

CONCLUSIONS

Clinicians felt ethically compelled to minimize the risk of undue coercion and to protect donors and recipients when evaluating the donor-recipient relationship. However, disentangling voluntariness and altruism from potential undisclosed pressures to enact societal and family duty, making decisions within this complex, multi-stakeholder context, and avoiding the imposition of undue paternalism and donor autonomy, were challenging. Multidisciplinary expertise and practical strategies for managing uncertainties are required.