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

Why Do They Persist? Understanding Living Kidney Donors and Persistence

Many participants persist through the living kidney donation process, although it is challenging, multifaceted, and burdensome, particularly during the predonation evaluation (PDE) phase. This study uses a constructivist grounded theory approach to analyze the experiences of living kidney donors (LKDs) undergoing evaluation who shared their perspectives in blog reflections. One hundred five (105) blog posts met the inclusion criteria. They generated three overarching themes: (1) Facilitators to completing the PDE qualification process, (2) Burdens experienced during the PDE qualification process, and (3) Tools to mitigate burdens or enhance facilitators. Internal facilitators, such as the desire to help and other motivating emotions, emerged as key drivers for LKDs to persist through the donation process. Religious belief or faith, an external facilitator, is also crucial in motivating donors. Conversely, internal burdens, such as doubts, fears, financial concerns, and health risks, posed challenges to the donation process. External burdens also included recipient relationship management, delays and setbacks, poor communication, qualification testing, lack of support, and being denied as a donor. This study's findings shed light on the complex interplay between burdens, facilitators, and tools in shaping the experiences of LKDs during the PDE, which enabled their persistence through the process and highlights a potential persistence spectrum. The insights gained from this research can inform interventions to better support living kidney donors throughout their donation journey, enhancing the overall donor experience and potentially increasing the number of living kidney donations.

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.

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.

Renal function outcomes in living kidney donors in a transplant center in Colombia

Introduction

Living kidney donation is currently low in Colombia, and this is associated with the lack of knowledge of the risks and renal function outcomes of potential donors; there are no studies that evaluate these outcomes. The objective of this study is to evaluate the outcomes of renal function, the incidence of metabolic diseases, arterial hypertension, as well as the finding of albuminuria and/or proteinuria in living kidney donors with a 2-year follow-up post donation.

Methods

Observational study in living kidney donor patients, in which renal function outcomes were evaluated between the predonation period and up to 24 months postdonation.

Results

Ninety-one patients were included, with a median predonation glomerular filtration rate of 98 ml/min/1.73 m2, interquartile range (90.5-109), and 24-month postdonation of 66.3 ml/min/1.73 m2 interquartile range (57.9-75). A total of 60.26% of the population was in stage 2 at the end of follow-up and no patient had a glomerular filtration rate less than 30 ml/min/1.73 m2 or required renal support therapy.

Conclusion

A living donor evaluation process based on risk factor stratification and adequate assessment of renal function was found to generate safe renal function outcomes both in the perioperative period and in medium- and long-term follow-up.

Strategies to address perceived barriers to timely kidney transplantation in the Netherlands: A qualitative study from a stakeholders' perspective

Objective

We present strategies to perceived barriers to access to kidney transplantation (KT) in the Netherlands.

Methods

This qualitative study (N = 70) includes nephrologists, social workers, surgeons, nurses, patients, former living kidney donors, policy employees, and insurance representatives. Interviews were conducted both in focus groups and individually and coded with NVivo.

Results

Participants proposed strategies within five domains. 1.Policy: Making KT guideline more visible. 2.Medical: Increase access and transparency to KT medical eligibility criteria (e.g., age, BMI) for patients and healthcare providers. 3.Psychological: Support patients who continue to use dialysis because of social interaction opportunities associated with dialysis settings to find such interaction elsewhere. Link kidney patients with fears for KT to experienced experts or trained professionals. 4.Social: Support patients with language barriers with interpreters and visual explanations. Support patients using social media, e.g. Facebook, to identify potential donors. Better expectation management to reduce reports of inadequate aftercare for living donors. 5.Economical: Solving negative economic incentives for KT by changing incentives.

Conclusion

Stakeholders see strategies for barriers in the entire care pathway.

Innovation

This large qualitative study gives an important overview which strategies stakeholders see improving access to KT. Some strategies offer opportunities to solve barriers in the short-term.

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.

The psychosocial adjustment of kidney recipients across donation contexts

The objective of this study was to investigate kidney recipients' experiences within deceased and living donation contexts and, in the latter, by donor relationship type, to identify differences by context and mechanisms by which the relationship with the donor may impact recipients' psychosocial well-being. Individual interviews were conducted with 12 participants and analyzed using Interpretative Phenomenological Analysis. Three themes emerged: (a) salience of and sensitivity toward sacrifice and loss, (b) honoring the sacrifice by honoring the gift, and (c) relational imbalance mirroring perceived burden of donation. Findings were contextualized in relation to the transplantation literature, and their clinical implications discussed.

Twenty Years of Unspecified Kidney Donation: Unspecified Donors Looking Back on Their Donation Experiences

The Netherlands was the first European country to implement unspecified kidney donation in 2000. This qualitative study aimed to evaluate the experiences of unspecified kidney donors (UKDs) in our transplant institute to improve the care for this valuable group of donors. We conducted semi-structured interviews with 106 UKDs who donated between 2000-2016 (response rate 84%). Interviews were audio-recorded, transcribed verbatim and independently coded by 2 researchers in NVivo using thematic analysis. The following 14 themes reflecting donor experiences were found: Satisfaction with donation; Support from social network; Interpersonal stress; Complaints about hospital care; Uncertainty about donor approval; Life on hold between approval and actual donation; Donation requires perseverance and commitment; Recovery took longer than expected; Normalization of the donation; Becoming an advocate for living kidney donation; Satisfaction with anonymity; Ongoing curiosity about outcome or recipient; Importance of anonymous communication; Anonymity is not watertight. The data reinforced that unspecified kidney donation is a positive experience for donors and that they were generally satisfied with the procedures. Most important complaints about the procedure concerned the length of the assessment procedure and the lack of acknowledgment for UKDs from both their recipients and health professionals. Suggestions are made to address the needs of UKDs.

A scoping review of the experiences and well-being of siblings of children with chronic kidney disease: implications for practice and research

BACKGROUND

Children with chronic kidney disease (CKD) and their families deal with challenging circumstances. While numerous studies have shown that both patients and parents in these families can experience a variety of challenges and concerns, the experience of siblings is less well understood. The focus of this scoping review was on research addressing the experiences and well-being of siblings of children with CKD.

METHODS

Following scoping review methodology, five databases were searched for peer-reviewed research or graduate theses published in English that addressed the experience or well-being of siblings aged 25 years or younger (biological, step or foster) of children with CKD; studies from any year or location were included. Two independent coders identified relevant studies. Findings were summarized and synthesized.

RESULTS

Of the 2990 studies identified, 19 were chosen for full text review and eight fit the inclusion criteria. Five of the selected studies were qualitative, two were quantitative and one used mixed-methods. Four broad themes across studies were identified including family functioning, significant relationships, psychological well-being, and coping strategies. While there was some convergence between qualitative and quantitative findings, these linkages were weak.

CONCLUSIONS

Several unmet needs of siblings were uncovered by this review. Sibling perceptions of differential parental treatment and desire for information about CKD emerged as priorities for practice. Using a strength-based approach in order to better understand sibling experiences and well-being was also recommended for future research. A higher resolution version of the Graphical abstract is available as Supplementary information.

Outcomes of living unrelated donor kidney transplants in children: An Organ Procurement and Transplant Network database analysis

BACKGROUND

There are conflicting data on long-term outcomes of pediatric LURD renal Txs compared to Txs of kidneys from other donor sources.

METHODS

An analysis of the OPTN database was conducted in children (<18 years) who had received their 1st kidney-only Tx between January 1, 2000, and September 30, 2021. The primary outcome measure was time to graft failure or death. Cox event history regression model for time to primary outcome, categorized by donor source and adjusting for confounders was performed.

RESULTS

Of the 12 089 subjects, 327 (2.7%) received kidneys from LURDs, 4349 (36%) from LRDs and 7413 (61%) from DD. One year graft failure rate was 3.56%. On regression analyses, compared to LRD kidney recipients, LURD recipients had comparable graft survival (graft failure AHR 1.15, 95th percentile confidence interval 0.87-1.51; p .31) and DD recipients had lower graft survival (graft failure hazard ratio 1.26, 95th percentile confidence interval 1.10-1.43; p < .001). When using living unrelated kidney recipients as the reference group, DD kidney recipients had comparable graft survival, with a wide confidence interval (hazard ratio for graft failure 1.09; 0.83-1.43, p .53).

CONCLUSIONS

Pediatric LURD kidney recipients have comparable graft survival to LRD kidney recipients; DD kidney recipients had the poorest survival. Our study, the largest to date, should encourage centers to embrace non-commercial living-unrelated transplantation as a viable option for children, preferable to DD kidneys.

Anxiety and depression among living kidney donors in tertiary care hospital of low resource country setting Nepal

Introduction

Kidneys accounted for the majority of transplanted organs worldwide in 2018, according to the Global Observatory on Donation and Transplantation. Living kidney donors continue to have negative psychosocial effects after donation. We aimed to assess anxiety and depression among Nepalese living kidney donors.

Methods

This was an observational, cross-sectional study conducted from May 2020 to January 2021. All patients who had undergone donor nephrectomy and had completed 6 months of post-donation period were included in the study. Anxiety and depression was assessed using the Hospital Anxiety and Depression Scale (HADS). Fischer exact and chi-square test was used to determine the association between variables and the level of significance was maintained at 5% with p < 0.05 considered statistically significant.

Results

A total of 147 kidney donors undergoing nephrectomies were included in the study. Among them 69.4% of participants were female and 55.8% of participants were aged 50 years or more. The prevalence of anxiety and depression among kidney donors was 27.9% and 6.2% respectively. Gender, earner, parental relations, occupation, and educational status were related to symptoms of anxiety among the living kidney donors. Similarly, earner was associated with symptoms of depression.

Conclusion

In addition to physical health measures, routine evaluations of kidney donors should include assessments of depression and other emotional disorders. The actual issue is to come up with effective treatments for depressive symptoms and to improve health outcomes following kidney donation.

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The prevalence of anxiety and depression among live kidney donors were 27.9% and 6.2% respectively.

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Gender, parental relations, occupation, and educational status were related with symptoms of anxiety.

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Routine evaluations of kidney donors should include assessments of depression and other emotional disorders.

Risk Assessment and Management for Potential Living Kidney Donors: The Role of “Third-Party” Commission

Living kidney donation is the most common type of living-donor transplant. Italian guidelines allow the living donations from emotionally related donors only after clear and voluntary consent expressed by both the donor and the recipient involved. Living donation raises ethical and legal issues because donors voluntarily undergo a surgical procedure to remove a healthy kidney in order to help another person. According to the Italian standards, the assessment of living donor-recipient pair has to be conducted by a medical “third party”, completely independent from both the patients involved and the medical team treating the recipient. Starting from the Hospital “Città della Salute e della Scienza” of Turin (Italy) experience, including 116 living kidney donations, the Authors divided the evaluation process performed by the “Third-Party” Commission into four stages, with a particular attention to the potential donor. Living donation procedures should reflect fiduciary duties that healthcare providers have toward their patients, originating from the relationship of trust between physician and patient. In addition to that, the social implications are enormous if one considers the worldwide campaigns to promote public awareness about organ donation and transplantation, and to encourage people to register their organ donation decisions. The systematic process proposed here can be a tool that proactively reduces and controls the risks of coercion, organ trafficking, vitiated consent, insufficient weighting of donative choice, that could arise especially in donors involved in living kidney donation.

"Giving the gift of life twice": Understanding the lived experiences of parent donors and nondonors in pediatric haploidentical hematopoietic cell transplantation

BACKGROUND

The use of parental donors in pediatric haploidentical hematopoietic cell transplantation is increasing, but research on the psychosocial impact of parental donation is currently limited.

OBJECTIVES

As part of a larger study, we conducted a retrospective, qualitative analysis to explore parental perceptions of the donation process and the impact of being a donor (or nondonor) on parents' adjustment and coping with their child's transplant experience.

METHODS

Parents/caregivers of children who underwent transplantation with a parental donor or a matched unrelated donor (N = 136) participated in interviews and completed an open-ended questionnaire.

RESULTS

Six themes were identified in the data: level of understanding and satisfaction; perception of choice; preparation for donation; perceptions of donation and infusion; benefit finding; and psychological impact of transplantation. Most parents were satisfied with the information they received and reported a good understanding of transplantation and donation procedures. Parents were divided on perspectives of choice, but their responses reflect that the necessity of saving their child's life does not allow for choice. They described considerable effort to prepare for transplantation, physically, emotionally, and logistically. Parents acknowledged the psychological impact while identifying positive outcomes that resulted from their child's transplant journey.

CONCLUSIONS

Results highlight the unique experiences of parental donors and nondonors from the anticipation phase to the completion of their child's transplant. Additionally, findings inform supportive care guidance by highlighting the need to assess parental donors' emotional functioning, provide support post donation, and conduct bereavement follow-up.

The Psychosocial Adjustment of Kidney Recipients in Canada's Kidney Paired Donation Program

Introduction: Kidney paired donation programs have been implemented globally. The involvement of at least 2 donors in these programs might exacerbate recipients' debt of gratitude and guilt, worries about the donor's health, and worries about graft failure documented by previous studies. However, there is an absence of research on the psychosocial implications of kidney paired donation. This study aimed to provide an in-depth examination of recipients' experience of kidney paired donation, with a focus on psychosocial adjustment. Methods/Approach: Individual interviews were conducted with 8 recipients who received a transplant through Canada's Kidney Paired Donation program. Data was analyzed using Interpretative Phenomenological Analysis. Findings: Four themes emerged: (a) an emotionally charged relationship with the known donor, (b) optimal distance regulation in the relationship with the anonymous donor, (c) kidney paired donation as a series of ups and downs, and (d) multilayered gratitude. Discussion: Findings are considered in relation to extant literature. Issues relevant to the transplant community's clinical and research efforts to provide kidney recipients responsive care are discussed.

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.

Quality of life, depression and anxiety in living donor kidney transplantation

Due to its numerous advantages, transplantation from a living kidney donor is the best method of renal replacement therapy. However, the characteristics of the procedure require to consider well-being of not only the recipient, but also the donor - a person who suddenly becomes a patient despite former good health. The living donation is a selfless act, but also a decision that may endanger one's own health. The aim of this article was to review the current knowledge concerning the quality of life, symptoms of anxiety and depression occurring among living kidney donors and recipients. In order to do that, we performed a systematic research in the PubMed, Google Scholar and CINAHL databases for the years 2000-2019 with the use of key words. The inclusion and exclusion criteria were met by only 15 articles. This study shows that the mental state of donors is generally better than that of recipients. Additionally, reduction of anxiety and depression as well as increase in the quality of life occurs in both donors and recipients in the post-transplant period compared to the time before surgery. Further research is needed on this topic in order to improve psychological aspects of care of live kidney donors and recipients.

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.

Critical Behavior and Psychopathologic Variables of the Parent-Child Couple in Living Kidney Transplantation

BACKGROUND

Living kidney donation is a complex emotional experience for donor candidates and recipients. The international literature underlines the importance of the type of donor-recipient bond to understand specific problems of donor candidates and optimize psychosocial evaluation and support for these patients.

METHODS

The aim of our study was to analyze the emotional experience of donating in the living couple according to the type of donor-recipient bond (parental/nonparental) and the possible presence of psychopathologic symptoms in the couples pretransplantation and post-transplantation.

RESULTS

Thirty donor-recipient couples (8 nonparental, emotionally linked couples [husband-wife or wife-husband], 22 genetically linked parental couples [16 parent-son or parent-daughter, 6 siblings]), recruited at the Organ Transplant Unit (University Hospital of Catania), were evaluated with a questionnaire (prepared ad hoc by the authors) to investigate the experience of donation in the couple and the aspects of the donor-recipient relationship in pre- and post-transplantation, and with the SCL-90-R to study the couples' possible psychopathologic variables before the donation and in the follow-up 24 months post-transplant.

CONCLUSIONS

The authors have seen in their study how, in particular, the parent-child bond complicates the donation process, especially when the sons are young subjects. The "mental distress" that emerged and the "unpredictability" of behaviors of these subjects makes the adaptation process more complicated with difficulty in accepting the organ received. It is certainly necessary for transplant psychiatrists and psychologists to keep them "hooked" and work with them to increase awareness and therefore clarity of their behaviors.

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.

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.

Living kidney donor and recipient perspectives on their relationship: longitudinal semi-structured interviews

BACKGROUND AND OBJECTIVES

Many donors and recipients report an improved bond posttransplantation; however, unexpected conflicts and tension may also occur. Insights into the lived experiences of the donor-recipient relationship can inform strategies for interventions and support. We aimed to describe donor and recipient expectations and experiences of their relationship before and after living kidney donor transplantation.

DESIGN, SETTING AND PARTICIPANTS

Semistructured interviews were conducted with 16 donor-recipient pairs before the transplant and 11-14 months post-transplant. Transcripts were analysed thematically.

RESULTS

We identified seven themes (with respective subthemes): donation as enacting familial responsibility for care; analytical decision making to mitigate regret (avoiding anticipated regret and maintaining control, removing emotional impulsivity); strengthened interpersonal ties (gaining a deeper appreciation among family members, stronger empathy for each other, improving social participation); instability of relational impacts (anger and aggression threatening dynamics, unanticipated stress and emotional lability, triggering familial tension); renegotiating social roles (unexpected continuation of caregiving responsibilities, inability to relinquish the caregiving role, disappointment with unfulfilled renewal of intimacy, dissatisfaction over discrepant energy levels); guilt over unmet expectations and inevitability of the gift relationship (vague and transient indebtedness, expectation of reciprocity, transferring kidney ownership).

CONCLUSIONS

Donor-recipient relationships may be improved through increased empathy, appreciation, and ability to participate in life together; however, unfulfilled expectations and behavioural and emotional changes in recipients (a side effect related to immunosuppression) remain unresolved consequences of living kidney donor transplantation. Education and counselling to help donors and recipients adjust to potential changes in relationship dynamics may help protect and foster relational stability postdonation.

Chronic pain after hand-assisted laparoscopic donor nephrectomy

BACKGROUND

Data on chronic pain after kidney donation are sparse. The aim of this study was to assess the incidence of chronic pain after hand-assisted laparoscopic nephrectomy.

METHODS

Living kidney donors who donated between 2011 and 2017 at the University Medical Centre Groningen were included. All patients underwent hand-assisted laparoscopic donor nephrectomy. Postdonation pain and movement disabilities were assessed using the Carolinas Comfort Scale (CCS) and a visual analogue scale (VAS). The prevalence, severity of pain and the need for analgesics were reported.

RESULTS

Some 333 living kidney donors with a mean age of 56 years were included. At a median of 19 (i.q.r. 10-33) months after donation, 82 donors (24·6 per cent) had a CCS score above 0, of which 58 (71 per cent) had a CCS score of at least 2 and 57 (70 per cent) reported movement limitations. Some 110 donors (33·0 per cent) had a VAS score of more than 0. Complaints mainly occurred during bending over (12·3 per cent) and exercising (12·4 per cent). Thirty-two donors (9·7 per cent) required analgesics during follow-up between donation and the time of measurement, and six of 82 (7 per cent) reported chronic inguinal pain. In multivariable analysis, donor age (odds ratio (OR) 0·97, 95 per cent c.i. 0·95 to 0·99; P = 0·020) and length of hospital stay (OR 1·21, 1·01 to 1·51; P = 0·041) were independently associated with chronic pain.

CONCLUSION

One-quarter of donors experienced chronic postdonation pain or discomfort, most of which was bothersome. Younger donors and those with a longer postoperative hospital stay had more symptoms.

Risks of Living Kidney Donation: Current State of Knowledge on Outcomes Important to Donors

In the past decade, there have been increasing efforts to better define and quantify the short- and long-term risks of living kidney donation. Recent studies have expanded upon the previous literature by focusing on outcomes that are important to potential and previous donors, applying unique databases and/or registries to follow large cohorts of donors for longer periods of time, and comparing outcomes with healthy nondonor controls to estimate attributable risks of donation. Leading outcomes important to living kidney donors include kidney health, surgical risks, and psychosocial effects of donation. Recent data support that living donors may experience a small increased risk of severe CKD and ESKD compared with healthy nondonors. For most donors, the 15-year risk of kidney failure is <1%, but for certain populations, such as young, black men, this risk may be higher. New risk prediction tools that combine the effects of demographic and health factors, and innovations in genetic risk markers are improving kidney risk stratification. Minor perioperative complications occur in 10%-20% of donor nephrectomy cases, but major complications occur in <3%, and the risk of perioperative death is <0.03%. Generally, living kidney donors have similar or improved psychosocial outcomes, such as quality of life, after donation compared with before donation and compared with nondonors. Although the donation process should be financially neutral, living kidney donors may experience out-of-pocket expenses and lost wages that may or may not be completely covered through regional or national reimbursement programs, and may face difficulties arranging subsequent life and health insurance. Living kidney donors should be fully informed of the perioperative and long-term risks before making their decision to donate. Follow-up care allows for preventative care measures to mitigate risk and ongoing surveillance and reporting of donor outcomes to inform prior and future living kidney donors.

Psychological and Emotional Aspects in Living Donor Kidney Transplantation

BACKGROUND

The decision to resort to living donor transplantation determines a particular condition characterized by a strong mental and emotional anguish, both for the patients and their families. The purpose of the study was to correlate the relational dynamics between donor-recipient, donor/recipient couple with the health team, and the family support perceived by the couple with the quality of life 6 months before transplant and 12 months after transplant and compare the data between the 2 time points after participating in the psychotherapy program of counseling about behavioral change.

PATIENTS AND METHODS

Twenty-seven donor and recipient pairs consented to participate. The quality of life was studied through the Complete Form Health Survey (SF-36). All subjects completed a questionnaire that investigated the 3 types of fundamental relationships (donor-recipient, donor/recipient with the health team, and family support perceived by the couple). All participants were involved in an 18-month psychotherapy program in the pre- and post-transplant phase.

RESULTS

The quality of the donor-recipient relationship significantly positively influences the subjective perception of psychophysical well-being before and after transplant. Post-transplant family support is crucial in ensuring a good perception of psychological and emotional health in donors and recipients. The relationship with the health team is important in ensuring a good perception of psychophysical health only in recipients after transplant.

CONCLUSIONS

This study suggests that patients should be assisted by a multidisciplinary health care team and receive continuous support from relatives during the post-transplant adaptation process. This facilitates the donor and recipient postoperative quality of life.