Cadaveric versus living donor kidney transplantation: a Medicare payment analysis

A Contemporary Analysis of Mental Well-being Among Living Donor Kidney Applicants

Background

Living donation is paramount for expanding the donor pool. The aim of this study was to assess changes over time in self-reported mental health of living donor kidney applicants in efforts to inform patient-centered discussions with potential donors.

Methods

Kidney donor applications from 2017 through 2021 were compiled. Data included age, gender, race, ethnicity, applicant-recipient relationship, medical history, and medications. Trends over time were analyzed and post hoc analyses were performed.

Results

During the study period, 2479 applicants to the living donor kidney program were evaluated; 73% of applicants were female individuals. More than half of applicants were not related to their intended recipient; this fraction increased from 46% in 2017 to 58% in 2021 (P < 0.01). A similar decline in family relations was not present among Black and Latino applicants. Of all applicants, 18% reported depression and 18% reported anxiety; 20% reported taking antidepressants or anxiolytics. Depression and anxiety increased 170% (P < 0.001) and 136% (P < 0.001) from 2018 to 2019, respectively; antidepressant and anxiolytic use rose 138% (P < 0.001) between 2018 and 2020.

Conclusions

The profile of living donor applicants has changed in recent years, with approximately 1 in 5 requiring antidepressants or anxiolytics. Predonation counseling and postdonation monitoring are imperative to decrease adverse psychological outcomes for living donors.

Long-Term Outcomes of Kidney Paired Donation Transplantation: A Single Center Retrospective Cohort Study

BACKGROUND

This study aimed to compare the kidney paired donation (KPD) program recipients with the traditional living donor kidney transplantation (LDKT) recipients regarding patient and graft survival.

METHODS

We retrospectively analyzed 141 recipients of the KPD program and 141 classic LDKT recipients that we matched for age and sex as controls between July 2005 and June 2019. We compared the 2 transplant groups for patient and kidney survival using the Kaplan-Maier test. We also performed Cox Regression analysis to examine factors affecting patient survival, including transplant type.

RESULTS

The average follow-up period was 96.17 ± 44.22 months. Of the 282 patients, 88 died in the follow-up period. There was no statistically significant difference in graft and patient survival between the KPD and LDKT groups. In the Cox regression model, including the transplant type, only the serum creatinine level measured in the first month after discharge was a significant factor in predicting patient survival.

CONCLUSIONS

The findings of this study indicate that the KPD program is an effective and reliable method to increase LDKT. Country-wide multicentric studies should confirm the results of this study. In countries where cadaver transplantation is insufficient, efforts should be made to expand the KPD program.

Older Age is Associated With Lower Utilization of Living Donor Kidney Transplant

Introduction

Older adults (65 years or older) constitute a substantial and increasing proportion of patients with kidney failure, potentially needing kidney replacement therapy. Living donor kidney transplant (LDKT) offers superior outcomes for suitable patients of all ages. However, exploring LDKT and finding a living donor could be challenging for older adults. Here, we assessed the association between age and utilization of LDKT and assessed effect modification of key variables such as ethnicity and language.

Methods

This is a retrospective cohort study of patients with kidney failure referred for kidney transplant (KT) assessment in Toronto between January 2006 and December 2013. The association between age and having a potential living donor identified was assessed using logistic regression and the association between age and the receipt of LDKT was assessed using Cox proportional hazards models.

Results

Of the 1617 participants, 50% were middle-aged (45-64 years old), and 17% were ≥65 years old. In our final multivariable adjusted models, compared to young adults, middle-aged and older adults had lower odds of having a potential living donor identified (odds ratio [OR], 0.47; confidence interval [CI], [0.35-0.63]; OR, 0.30; CI, [0.20-0.43]; P < 0.001, for middle-aged and older adults, respectively), and were less likely to receive LDKT (hazard ratio [HR], 0.79; CI, [0.63-0.99]; P = 0.04; HR, 0.47; CI, [0.30-0.72]; P = 0.001, for middle-aged and older adults, respectively.).

Conclusion

Age is an independent predictor of receiving LDKT. Considering that nearly 90% of patients with kidney failure in Canada are >45 years of age, these results point to important and potentially modifiable age-related barriers to LDKT.

Is Bigger Better? Living Donor Kidney Volume as Measured by the Donor CT Angiogram in Predicting Donor and Recipient eGFR after Living Donor Kidney Transplantation

BACKGROUND

The role of kidney volume measurement in predicting the donor and recipient kidney function is not clear.

METHODS

We measured kidney volume bilaterally in living kidney donors using CT angiography and assessed the association with the donor remaining kidney and recipient kidney (donated kidney) function at 1 year after kidney transplantation. Donor volume was categorized into tertiles based on lowest, middle, and highest volume.

RESULTS

There were 166 living donor and recipient pairs. The mean donor age was 44.8 years (SD ± 10.8), and donor mean BMI was 25.5 (SD ± 2.9). The recipients of living donor kidneys were 64% male and had a mean age of 43.5 years (SD ± 13.3). Six percent of patients experienced an episode of cellular rejection and were maintained on dialysis for a mean of 18 months (13-32) prior to transplant. Kidney volume was divided into tertiles based on lowest, middle, and highest volume. Kidney volume median (range) in tertiles 1, 2, and 3 was 124 (89-135 ml), 155 (136-164 ml), and 184 (165-240 ml) with donor eGFR ml/min (adjusted for body surface area expressed as ml/min/1.73 m2) at the time of donation in each tertile, 109 (93-129), 110 (92-132), and 101 ml/min (84-117). The median (IQR) eGFR in tertiles 1 to 3 in kidney recipients at 1 year after donation was 54 (44-67), 62 (50-75), and 63 ml/min (58-79), respectively. The median (IQR) eGFR in tertiles 1 to 3 in the remaining kidney of donors at 1 year after donation was 59 (53-66), 65 (57-72), and 65 ml/min (56-73), respectively.

CONCLUSION

Bigger kidney volume was associated with better eGFR at 1 year after transplant in the recipient and marginally in the donor remaining kidney.

Survey of Patient's Experience of Altruistic Nondirected Kidney Donation

The scarcity of organs for donation is an ongoing issue. Change in legislative framework allows for altruistic donations in the UK, but, whereas the number of donations from deceased donors has increased, there has been a slow decline in altruistic living donors. The aim of this study was to review perspectives of altruistic nondirected kidney donors (ANDKD) at our center and outcome of all enquiries to inform service improvement and increase the numbers of donors. All enquiries by potential ANDKD at our center from September 2005 to September 2017 were analyzed. Donor assessment was performed as per the UK Guidelines, prior to obtaining Human Tissue Authority approval. The outcome of donation and results of questionnaires sent to 50 ANDKD were analyzed. During the period, 51 of the 180 enquiries (28.3%) resulted in kidney donation. Questionnaire responses were: 66% donors were retired; most heard about altruistic donation through media (60%); 72% thought psychological or psychiatric assessment was necessary; 95% found the information provided prior to donation adequate; 82% rated their overall experience as good/excellent; and 90% would recommend kidney donation to others. Thirteen of 50 donated kidneys were fed into the kidney exchange program. The mean ± standard error of the mean of the duration from human tissue authority approval to donation were 60.4 ± 5.4 and 131.2 ± 11.2 days, respectively (P = 0.00001). A significant proportion of enquiries for altruistic donation would result in donation but the assessment process needs to be quicker. ANDKD is useful way of priming the National Living Donor Kidney Sharing Scheme.

Kidney Exchange Program Reporting Standards: Evidence-Based Consensus From Europe

Background: Kidney Exchange Programs can play an important role to increase access to the life saving and most cost-effective treatment for End Stage Renal Disease. The rise of national KEPs in Europe brings a need for standardized performance reporting to facilitate the development of an international evidence base on program practices.

Methods: We systematically searched and reviewed the literature to extract kidney exchange program performance measures. Reported measures were initially categorized as structure, process, and outcome measures. Expert feedback was used to redefine categories and extend the set of measures to be considered. Using the Delphi method and a panel of 10 experts, the resulting measures were subsequently classified as mandatory (Base set), optional (Extended set), or deleted.

Results: Out of the initial 1,668 articles identified by systematic literature search, 21 European publications on kidney exchange programs were included to collect performance measures, accompanied by three national program reports. The final measurement categories were Context, Population, Enrollment, Matching, Transplantation, and Outcomes. The set of performance measures resulting from the literature review was modified and classified as mandatory or optional. The resulting Base set and Extended set form the kidney exchange program reporting standard.

Conclusions: The evidence-based and consensus-based kidney exchange program reporting standard can harmonize practical and scientific reporting on kidney exchange programs, thus facilitating the advancement of national programs. In addition, the kidney exchange program reporting standard can promote and align cross-national programs.

Investigating Ethnic Disparity in Living-Donor Kidney Transplantation in the UK: Patient-Identified Reasons for Non-Donation among Family Members

There is ethnic inequity in access to living-donor kidney transplants in the UK. This study asked kidney patients from Black, Asian and minority ethnic groups why members of their family were not able to be living kidney donors. Responses were compared with responses from White individuals. This questionnaire-based mixed-methods study included adults transplanted between 1/4/13–31/3/17 at 14 UK hospitals. Participants were asked to indicate why relatives could not donate, selecting all options applicable from: Age; Health; Weight; Location; Financial/Cost; Job; Blood group; No-one to care for them after donation. A box entitled ‘Other—please give details’ was provided for free-text entries. Multivariable logistic regression was used to analyse the association between the likelihood of selecting each reason for non-donation and the participant’s self-reported ethnicity. Qualitative responses were analysed using inductive thematic analysis. In total, 1240 questionnaires were returned (40% response). There was strong evidence that Black, Asian and minority ethnic group individuals were more likely than White people to indicate that family members lived too far away to donate (adjusted odds ratio (aOR) = 3.25, 95% Confidence Interval (CI) 2.30–4.58), were prevented from donating by financial concerns (aOR = 2.95, 95% CI 2.02–4.29), were unable to take time off work (aOR = 1.88, 95% CI 1.18–3.02), were “not the right blood group” (aOR = 1.65, 95% CI 1.35–2.01), or had no-one to care for them post-donation (aOR = 3.73, 95% CI 2.60–5.35). Four qualitative themes were identified from responses from Black, Asian and minority ethnic group participants: ‘Burden of disease within the family’; ‘Differing religious interpretations’; ‘Geographical concerns’; and ‘A culture of silence’. Patients perceive barriers to living kidney donation in the UK Black, Asian and minority ethnic population. If confirmed, these could be targeted by interventions to redress the observed ethnic inequity.

Has the UK living kidney donor population changed over time? A cross-sectional descriptive analysis of the UK living donor registry between 2006 and 2017

BACKGROUND

A living-donor kidney transplant is the best treatment for most people with kidney failure. Population cohort studies have shown that lifetime living kidney donor risk is modified by sex, age, ethnicity, body mass index (BMI), comorbidity and relationship to the recipient.

OBJECTIVES

We investigated whether the UK population of living kidney donors has changed over time, investigating changes in donor demographics.

DESIGN

We undertook a cross-sectional analysis of the UK living kidney donor registry between January 2006 to December 2017. Data were available on living donor sex, age, ethnicity, BMI, hypertension and relationship to recipient.

SETTING

UK living donor registry.

PARTICIPANTS

11 651 consecutive living kidney donors from January 2006 to December 2017.

OUTCOME MEASURES

Living kidney donor demographic characteristics (sex, age, ethnicity, BMI and relationship to the transplant recipient) were compared across years of donation activity. Donor characteristics were also compared across different ethnic groups.

RESULTS

Over the study period, the mean age of donors increased (from 45.8 to 48.7 years, p<0.001), but this change appears to have been limited to the White population of donors. Black donors were younger than White donors, and a greater proportion were siblings of their intended recipient and male. The proportion of non-genetically related non-partner donations increased over the 12-year period of analysis (p value for linear trend=0.002).

CONCLUSIONS

The increasing age of white living kidney donors in the UK has implications for recipient and donor outcomes. Despite an increase in the number of black, Asian and minority ethnic individuals waitlisted for a kidney transplant, there has been no increase in the ethnic diversity of UK living kidney donors. Black donors in the UK may be at a much greater risk of developing kidney failure due to accumulated risks: whether these risks are being communicated needs to be investigated.

Building Kidney Exchange Programmes in Europe-An Overview of Exchange Practice and Activities

BACKGROUND

Considerable differences exist among the living donor Kidney Exchange Programmes (KEPs) that are in use and being built in Europe, contributing to a variation in the number of living donor transplants (Newsletter Transplant; International figures on donation and transplantation 2016). Efforts of European KEPs to exchange (best) practices and share approaches to address challenges have, however, been limited.

METHODS

Experts from 23 European countries, collaborating on the European Network for Collaboration on Kidney Exchange Programmes Cooperation on Science and Technology Action, developed a questionnaire to collect detailed information on the functioning of all existing KEPs in Europe, as well as their opportunities and challenges. Following a comparative analysis, results were synthesized and interpreted by the same experts.

RESULTS

The practices, opportunities and challenges reported by 17 European countries reveal that some of the 10 operating programs are mature, whereas others are in earlier stages of development. Over 1300 transplants were performed through existing KEPs up to the end of 2016, providing approximately 8% of their countries' living kidney donations in 2015. All countries report challenges to either initiating KEPs or increasing volumes. Some challenges are shared, whereas others differ because of differences in context (eg, country size, effectiveness of deceased donor program) and ethical and legal considerations (eg, regarding living donation as such, nonrelated donors, and altruistic donation). Transnational initiatives have started in Central Europe, Scandinavia, and Southern Europe.

CONCLUSIONS

Exchange of best practices and shared advancement of national programs to address existing challenges, aided by transnational exchanges, may substantially improve access to the most (cost) effective treatment for the increasing number of patients suffering from kidney disease.

Beliefs of UK Transplant Recipients about Living Kidney Donation and Transplantation: Findings from a Multicentre Questionnaire-Based Case-Control Study

Differing beliefs about the acceptability of living-donor kidney transplants (LDKTs) have been proposed as explaining age, ethnic and socioeconomic disparities in their uptake. We investigated whether certain patient groups hold beliefs incompatible with LDKTs. This questionnaire-based case–control study was based at 14 hospitals in the United Kingdom. Participants were adults transplanted between 1 April 2013 and 31 March 2017. LDKT recipients were compared to deceased-donor kidney transplant (DDKT) recipients. Beliefs were determined by the direction and strength of agreement with ten statements. Multivariable logistic regression was used to investigate the association between beliefs and LDKT versus DDKT. Sex, age, ethnicity, religion, and education were investigated as predictors of beliefs. A total of 1240 questionnaires were returned (40% response). DDKT and LDKT recipients responded in the same direction for 9/10 statements. A greater strength of agreement with statements concerning the ‘positive psychosocial effects’ of living kidney donation predicted having an LDKT over a DDKT. Older age, Black, Asian and Minority Ethnic (BAME) group ethnicity, and having a religion other than Christianity were associated with greater degree of uncertainty regarding a number of statements, but there was no evidence that individuals in these groups hold strong beliefs against living kidney donation and transplantation. Interventions should address uncertainty, to increase LDKT activity in these groups.

Healthcare Resource Use, Cost, and Sick Leave Following Kidney Transplantation in Sweden: A Population-Based, 5-Year, Retrospective Study of Outcomes: COIN

Background

Improved understanding of the impact of kidney transplantation on healthcare resource use/costs and loss of productivity could aid decision making about funding allocation and resources needed for the treatment of chronic kidney disease in stage 5.

Material/Methods

This was a retrospective study utilizing data from Swedish national health registers of patients undergoing kidney transplantation. Primary outcomes were renal disease-related healthcare resource utilization and costs during the 5 years after transplantation. Secondary outcomes included total costs and loss of productivity. Regression analysis identified factors that influenced resource use, costs, and loss of productivity.

Results

During the first year after transplantation, patients (N=3120) spent a mean of 25.7 days in hospital and made 21.6 outpatient visits; mean renal disease-related total cost was €66,014. During the next 4 years, resource use was approximately 70% (outpatient) to 80% (inpatient) lower, and costs were 75% lower. Before transplantation, 62.8% were on long-term sick leave, compared with 47.4% 2 years later. Higher resource use and costs were associated with age <10 years, female sex, graft from a deceased donor, prior hemodialysis, receipt of a previous transplant, and presence of comorbidities. Higher levels of sick leave were associated with female sex, history of hemodialysis, and type 1 diabetes. Overall 5-year graft survival was 86.7% (95% CI 85.3–88.2%).

Conclusions

After the first year following transplantation, resource use and related costs decreased, remaining stable for the next 4 years. Demographic and clinical factors, including age <10 years, female sex, and type 1 diabetes were associated with higher costs and resource use.

Living Kidney Donation: Strategies to Increase the Donor Pool

End-stage renal disease (ESRD) is a significant health care burden. Although kidney transplantation is the optimal treatment modality, less than 25% of waiting list patients are transplanted because of organ shortage. Living kidney donation can lead to better recipient and graft survival and increase the number of donors. Not all ESRD patients have potential living donors, and not all living donors are a compatible match to recipients. Kidney paired exchanges allow incompatible pairs to identify compatible living donors for living donor kidney transplants for multiple recipients. Innovative modifications of kidney paired donation can increase the number of kidney transplants, with excellent outcomes.

[Strategic plan for reduction of hospital stay in renal transplantation]

Since January 2015 we have carried out a multiple-intervention strategic plan to reduce hospital stay in renal transplant recipients. The main objective of this study is to compare results of renal transplantation before and after putting into effect this plan in terms of graft and patient survival, readmissions and incidence of acute rejection during the first year post transplantation. In this retrospective analysis we included all patients 18 years of age or older who were transplanted at our institution. The strategic plan resulted in a significant reduction of hospital stay of renal recipients from 13.5 days in the pre-plan group (n=97) to 4.6 days in the post-plan group (n=62; p≤0.0001). The incidence of acute rejection during the first year was similar (pre-plan group=14.4% vs. post-plan group=16% [p=0.77]) as it was graft survival (88% vs. 90% [p=0.71]) and patient survival (95% vs. 98% [p=0.37]), respectively. The multiple-intervention strategic plan has significantly reduced the hospital stay of patients after renal transplantation without affecting graft or patient survival, which are comparable to those internationally published, and without jeopardizing patient's safety.

Hand-Assisted laparoscopic donor nephrectomy PERiumbilical versus Pfannenstiel incision and return to normal physical ACTivity (HAPERPACT): study protocol for a randomized controlled trial

Background

Hand-assisted laparoscopic living donor nephrectomy (HALDN) using a periumbilical or Pfannenstiel incision was developed to improve donor outcome after a kidney transplant. The aim of this study was to investigate two methods of hand assistance and kidney removal during HALDN and their effect on the time it takes for the donor to return to normal physical activity.

Methods/design

This study was initiated in November 2017 and is expected to last for 2 years. To be eligible for the study, donors must be more than 20 years of age and must not be receiving permanent pain therapy. Only donors with a single artery and vein in the graft are being enrolled in this trial. Donors with infections or scars in the periumbilical or hypogastric area, bleeding disorders, chronic use of immunosuppressive agents, or active infection will be excluded. Donors will be randomly allocated to either a control arm (periumbilical incision) or an intervention arm (Pfannenstiel incision). The sample size was calculated as 26 organ donors in each group. The primary endpoint is the number of days it takes the donor to return to normal physical activity (up to 4 weeks after the operation). Secondary endpoints are intraoperative outcomes, including estimated blood loss, warm ischemia time, and duration of the operation. Postoperative pain will be assessed using the visual analog scale, rescue analgesic use, and peak expiratory flow rate. Length of hospital stay, physical activity score, time to return to work, donor satisfaction, cosmetic score, postoperative complications, and all-cause mortality in living donors will also be reported. Delayed graft function, primary non-function, serum creatinine levels, and glomerular filtration rate will also be assessed in the recipients after transplantation.

Discussion

This is the first randomized controlled trial to compare the time it takes the living donor to return to normal physical activity after HALDN using two different types of incision. The comprehensive findings of this study will help decide which nephrectomy procedure is best for living donors with regard to patient comfort and satisfaction as well as graft function in the recipient after transplantation.

Trial registration

ClinicalTrials.gov, NCT03317184. Registered on 23 October 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2775-4) contains supplementary material, which is available to authorized users.

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

BACKGROUND

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

STUDY DESIGN

1 prospective and 1 retrospective cohort study.

SETTING & PARTICIPANTS

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

PREDICTORS

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

OUTCOMES

Duration of living donor evaluation.

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Social Media Use Among Living Kidney Donors and Recipients: Survey on Current Practice and Potential

Background

In the United States, there is a national shortage of organs donated for transplant. Among the solid organs, most often kidneys are donated by living donors, but the lack of information and complicated processes limit the number of individuals who serve as living kidney donors. Social media can be a tool for advocacy, educating the public about the need, process, and outcomes of live kidney donors, yet little is known about social media use by kidney transplant patients.

Objective

The purpose of this study was to examine the social media use of potential kidney transplant patients and their willingness to use social media and their networks to advocate and educate about living kidney donation.

Methods

Using a validated survey, we modified the instrument to apply to the patient population of interest attending the Medical University of South Carolina, Charleston, SC, USA. The questions on the survey inquired about current social media use, sites visited, frequency and duration of social media use, and willingness to use social media to share the need for living kidney donors. We asked patients who had received a transplant and those awaiting a transplant to complete the survey during an office visit. Participation was voluntary.

Results

A total of 199 patients completed the survey. Approximately half of all kidney transplant patients surveyed used social media (104/199, 52.3%), and approximately one-third (66/199, 33.2%) had more than 100 friends in their social media network. Facebook was the most popular site, and 51% (102/199) reported that they would be willing to post information about living kidney donation on their social networks. More than a quarter of the sample (75/199, 37.7%) had posted about their health status in the past.

Conclusions

Social media holds great promise for health-related education and awareness. Our study shows the current social media use of kidney transplant patients. In turn, such information can be used to design interventions to ensure appropriate decision making about live kidney donation. Transplant programs can help increase the number of living donors by providing guidance to kidney transplant patients in how to use social media, to be advocates, and to provide information about living kidney donation to their social network.

The Economics of Kidney Transplantation versus Hemodialysis

Using 1998 data for 8 transplantation centers located in New York City, this study found that kidney transplantation was a more cost-effective treatment than hemodialysis for the Medicare program. The initially higher costs of transplantation were fully recouped by Medicare 2 years and 10 months after surgery. For persons who are eligible for Medicare solely due to their end-stage renal disease status, transplantation would generate average monthly savings of $3800 over dialysis for the 2 years following the break-even point. For those eligible for reasons other than end-stage renal disease, for example, the aged, the average savings would be $2400. The savings difference arises because Medicare coverage for immunosuppressants for the former group ends 36 months after transplantation.

Potential Living Kidney Donors' Health Education Use and Comfort with Donation

Context

Much living kidney donation research focuses on actual donors rather than all donors who are evaluated by the transplant center.

Objective

To determine (1) what concerns and benefits potential donors saw possible from donation, (2) how they educated themselves before contacting the transplant center, and (3) who were the most comfortable donors.

Design

A telephone survey of 91 potential donors before transplant evaluation.

Setting

Barnes-Jewish Hospital Transplant Center in St Louis, Mo.

Main Outcome Measures

Willingness and comfort donating, key concerns and perceived benefits to donation, hours of transplant-related education.

Results

On a 7-point scale, potential donors were very willing (mean=6.65, SD=0.95) and comfortable (mean=6.31, SD=1.12) donating. They were most concerned that their recipients would die if they could not donate, the evaluation and surgery would be anxiety provoking or painful, and they did not understand what donation would require. Donors previously spent an average of 6 hours reading health resources and 32 hours discussing donation. Using logistic regression, those donors with 0 to 4 concerns (odds ratio=7.1, 95% confidence interval [CI], 2.2–23.16), more than 5 benefits (odds ratio=3.7, 95% CI, 1.2–11.0), and who were family members (odds ratio=4.7, 95% CI, 1.4–15.8) were more likely to be extremely comfortable donating compared to others.

Conclusions

Before evaluation, most potential donors are willing to donate because they think that it is important to improve the health of a loved one. Their knowledge of donation varies and they need clear information about medical testing and support coping with any negative donation outcomes.

Living Donation Decision Making: Recipients' Concerns and Educational Needs

Context

Despite the advantages of living donor transplantation, evidence suggests that some potential recipients with living donors have psychological concerns that prevent them from pursuing living donation. Addressing these concerns through education may increase the rates of living donation.

Objective

To understand the psychological barriers and educational needs of potential kidney recipients regarding living donation.

Subjects and Design

Qualitative focus group study of kidney transplant recipients, donors, and family members to explore their assessment of the advantages of dialysis and deceased donor transplantation over living donation, their concerns about living donation, and what types of living donation education would be most helpful.

Results

Kidney recipients reported that they might not pursue living donation because they felt guilty and indebted to the donor, did not want to harm or inconvenience the donor, did not want to accept a kidney that a family member might need later, and did not want to disappoint the donor if the kidney failed. Recipients were generally unaware that donors could personally benefit from donating and would rather wait for donor volunteers than ask anyone directly. Both donors and recipients thought that training on how to make the donation request and education about living donors' motivations for donation and transplant experience could help more renal patients pursue living donation.

Ethical Considerations in Organ Donation and Transplantation

Organ transplantation continues to be an excellent therapeutic option for patients with end-stage organ disease. Due to advances made in immunosuppression, surgical techniques, and critical care management, graft and patient survival rates continue to improve. Although advances in technology have dramatically changed in the field of organ transplantation over the last several decades and complicated ethical decision-making, the fundamental ethical principles of beneficence, nonmaleficence, autonomy, and justice have not. Organ transplantation still remains a problem of supply and demand and challenges transplant professionals to meet society's push to find new organ donor sources.

Going Upstream: Coordination to Improve CKD Care

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

Doctor can I buy a new kidney? I've heard it isn't forbidden: what is the role of the nephrologist when dealing with a patient who wants to buy a kidney?

Organ trafficking is officially banned in several countries and by the main Nephrology Societies. However, this practice is widespread and is allowed or tolerated in many countries, hence, in the absence of a universal law, the caregiver may be asked for advice, placing him/her in a difficult balance between legal aspects, moral principles and ethical judgments.In spite of the Istanbul declaration, which is a widely shared position statement against organ trafficking, the controversy on mercenary organ donation is still open and some experts argue against taking a negative stance. In the absence of clear evidence showing the clinical disadvantages of mercenary transplantation compared to chronic dialysis, self-determination of the patient (and, with several caveats, of the donor) may conflict with other ethical principles, first of all non-maleficence. The present paper was drawn up with the participation of the students, as part of the ethics course at our medical school. It discusses the situation in which the physician acts as a counselor for the patient in the way of a sort of "reverse" informed consent, in which the patient asks advice regarding a complex personal decision, and includes a peculiar application of the four principles (beneficence, non-maleficence, justice and autonomy) to the donor and recipient parties.

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

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

Living kidney donor follow-up: state-of-the-art and future directions

Long-term living kidney donor follow-up has not been considered necessary by many living kidney donor programs because a large number of single-center studies show that living kidney donation is associated with minimal mortality and morbidity. However, some transplant professionals and, more importantly, living donors disagree. To evaluate the need for more data on living kidney donor outcomes, a conference was held in September 2010 (Leichtman and colleagues: Am J Transplant 11: 2561-2568, 2011). Participants were health care professionals, living donors, members of the United Network for Organ Sharing, Health and Human Services, the National Institutes of Health, and insurance companies. This article will discuss the status of living donor follow-up in the context of the follow-up conference. It will also provide a slightly different viewpoint of provider responsibility for donor follow-up than that presented by the conference report.

A description of the costs of living and standard criteria deceased donor kidney transplantation

Kidney transplantation improves quality of life and survival and is associated with lower health care costs compared with dialysis. We described and compared the costs of living and standard criteria for deceased donor kidney transplantation. Patients included adult recipients of a first kidney-only transplant between April 1, 1998, and March 31, 2006, as well as their donor information. All costs (outpatient care, diagnostic imaging, inpatient care, physician claims, laboratory tests and transplant medications) for 2 years after transplant for recipients and transplant-related costs prior to transplant (donor workup and management) were included. Complete cost information was available for 357 recipients. The mean total 2-year cost of transplantation, including donor costs, for recipients of living and deceased donors was $118 347 (95% confidence interval [CI], 110 395-126 299) and $121 121 (95% CI 114 287-127 956), respectively (p = 0.7). The mean cost for a living donor was $18 129 (95% CI 16 845-19 414) and for a deceased donor was $36 989 (95% CI 34 421-39 558). Living donor kidney transplantation has similar costs at 2 years compared with deceased donor transplantation. These results can be used by health care decision makers to inform strategies to increase donation.

Kidney and pancreas transplantation in the United States, 1999-2008: the changing face of living donation

The waiting list for kidney transplantation continued to grow between 1999 and 2008, from 41 177 to 76 089 candidates. However, active candidates represented the minority of this increase (36 951-50 624, a 37% change), while inactive candidates increased over 500% (4226-25 465). There were 5966 living donor (LD) and 10 551 deceased donor (DD) kidney transplants performed in 2008. The total number of pancreas transplants peaked at 1484 in 2004 and has declined to 1273. Although the number of LD transplants increased by 26% from 1999 to 2008, the total number peaked in 2004 at 6647 before declining 10% by 2008. The rate of LD transplantation continues to vary significantly as a function of demographic and geographic factors, including waiting time for DD transplant. Posttransplant survival remains excellent, and there appears to be greater use of induction agents and reduced use of corticosteroids in LD recipients. Significant changes occurred in the pediatric population, with a dramatic reduction in the use of LD organs after passage of the Share 35 rule. Many strategies have been adopted to reverse the decline in LD transplant rates for all age groups, including expansion of kidney paired donation, adoption of laparoscopic donor nephrectomy and use of incompatible LD.

Correlates of support for living donation among African American adults

CONTEXT

Living donation is studied with much less intensity among African Americans than among the general population. Examination of barriers to living donation can lead to effective strategies to educate dialysis patients and their families about this alternative.

OBJECTIVE

To explore the correlates of likelihood of becoming a living donor among community-recruited African American adults.

DESIGN/PARTICIPANTS

Cross-sectional data were gathered via self-administered questionnaire from 425 African American adults, age 18 years and older, who were recruited from 9 churches in Atlanta.

MAIN OUTCOME MEASURES

Self-reported likelihood of becoming a living donor to a close family member, an extended family member or friend, or a stranger.

RESULTS

More than three-quarters of participants were willing to act as living donors to a close family member or spouse and two-thirds to friends or extended family. For likelihood of donating to a friend or extended family member, only willingness to engage in deceased donation was significantly associated; to a stranger, both willingness to engage in deceased donation and attitudes toward donation were significantly associated. Knowledge of and personal experiences with donation and/or transplantation were not significantly associated with likelihood of any type of living donation.

CONCLUSIONS

Findings indicate widespread support for living donation to a close family member or spouse. These findings have important implications for dialysis patients who must decide whether to approach friends and/or family about the possibility of serving as a living donor and emphasize the need for interventions to help facilitate this process.

Reimbursing live organ donors for incurred non-medical expenses: a global perspective on policies and programs

Methods to reimburse living organ donors for the non-medical expenses they incur have been implemented in some jurisdictions and are being considered in others. A global understanding of existing legislation and programs would help decision makers implement and optimize policies and programs. We searched for and collected data from countries that practice living organ donation. We examined legislation and programs that facilitate reimbursement, focusing on policy mechanisms, eligibility criteria, program duration and types of expenses reimbursed. Of 40 countries, reimbursement is expressly legal in 16, unclear in 18, unspecified in 6 and expressly prohibited in 1. Donor reimbursement programs exist in 21 countries; 6 have been enacted in the last 5 years. Lost income is reimbursed in 17 countries, while travel, accommodation, meal and childcare costs are reimbursed in 12 to 19 countries. Ten countries have comprehensive programs, where all major cost categories are reimbursed to some extent. Out-of-country donors are reimbursed in 10 jurisdictions. Reimbursement is conditional on donor income in 7 countries, and recipient income in 2 countries. Many nations have programs that help living donors with their financial costs. These programs differ in operation and scope. Donors in other regions of the world are without support.

Is living kidney donation the answer to the economic problem of end-stage renal disease?

The escalating number and cost of treating patients with end-stage renal disease is a considerable economic concern for health care systems and societies globally. Compared with dialysis, kidney transplantation leads to improved patient survival and quality of life, as well as cost savings to the health payer. Despite efforts to increase kidney transplantation, the gap between supply and demand continues to grow. In this article we explore the economic consideration of both living and deceased transplantation. Although living kidney donation has several advantages from an economic perspective, efforts to increase both deceased and living donation are required. Strategies to increase kidney donation are underfunded, and even costly strategies are likely to lead to net health care savings. However, demonstration of efficacy of these strategies is required to ensure efficient use of resources.

Correlates of Support for Living Donation among African American Adults

Context

Living donation is studied with much less intensity among African Americans than among the general population. Examination of barriers to living donation can lead to effective strategies to educate dialysis patients and their families about this alternative.

Objective

To explore the correlates of likelihood of becoming a living donor among community-recruited African American adults.

Design/Participants

Cross-sectional data were gathered via self-administered questionnaire from 425 African American adults, age 18 years and older, who were recruited from 9 churches in Atlanta.

Main Outcome Measures

Self-reported likelihood of becoming a living donor to a close family member, an extended family member or friend, or a stranger.

Results

More than three-quarters of participants were willing to act as living donors to a close family member or spouse and two-thirds to friends or extended family. For likelihood of donating to a friend or extended family member, only willingness to engage in deceased donation was significantly associated; to a stranger, both willingness to engage in deceased donation and attitudes toward donation were significantly associated. Knowledge of and personal experiences with donation and/or transplantation were not significantly associated with likelihood of any type of living donation.

Conclusions

Findings indicate widespread support for living donation to a close family member or spouse. These findings have important implications for dialysis patients who must decide whether to approach friends and/or family about the possibility of serving as a living donor and emphasize the need for interventions to help facilitate this process.

Life insurance for living kidney donors: a Canadian undercover investigation

Some living kidney donors encounter difficulties obtaining life insurance, despite previous surveys of insurance companies reporting otherwise. To better understand the effect of donation on insurability, we contacted offices of life insurance companies in five major cities in Canada to obtain $100 000 of life insurance (20-year term) for 40 fictitious living kidney donors and 40 paired controls. These profiles were matched on age, gender, family history of kidney disease and presence of hypertension. The companies were blinded to data collection. The study protocol was reviewed by the Office of Research Ethics. The main study outcomes were the annual premium quoted and total time spent on the phone with the insurance agent. All donor and control profiles received a quote, with no significant difference in the premium quoted (medians $190 vs. $209, p = 0.89). More time was spent on the phone for donor compared to control profiles, but the absolute difference was small (medians 9.5 vs. 7.0 min, p = 0.046). Age, gender, family history of kidney disease and new-onset hypertension had no further effect on donor insurability in regression analysis. We found no evidence that kidney donors were disadvantaged in the first step of applying for life insurance. The effect donation has on subsequent phases of insurance underwriting remains to be studied.

Disparities in the utilization of live donor renal transplantation

Despite universal payer coverage with Medicare, sociodemographic disparities confound the care of patients with renal failure. We sought to determine whether adults who realize access to kidney transplantation suffer inequities in the utilization of live donor renal transplantation (LDRT). We identified adults undergoing primary renal transplantation in 2004-2006 from the United Network for Organ Sharing (UNOS). We modeled receipt of live versus deceased donor renal transplant on multilevel multivariate models that examined recipient, center and UNOS region-specific covariates. Among 41 090 adult recipients identified, 39% underwent LDRT. On multivariate analysis, older recipients (OR 0.62, 95% CI 0.56-0.68 for 50-59 year-olds vs. 18-39 year-old recipients), those of African American ethnicity (OR 0.54, 95% CI 0.50-0.59 vs. whites) and of lower socioeconomic status (OR 0.72, 95% CI 0.67-0.79 for high school-educated vs. college-educated recipients; OR 0.78, 95% CI 0.71-0.87 for lowest vs. highest income quartile) had lower odds of LDRT. These characteristics accounted for 14.2% of the variation in LDRT, more than recipient clinical variables, transplant center characteristics and UNOS region level variation. We identified significant racial and socioeconomic disparities in the utilization of LDRT. Educational initiatives and dissemination of processes that enable increased utilization of LDRT may address these disparities.

Improving Preemptive Transplant Education to Increase Living Donation Rates: Reaching Patients Earlier in Their Disease Adjustment Process

Patients who receive a preemptive kidney transplant before starting dialysis avoid the medical complications related to dialysis and have the highest graft success and lowest mortality rates. Because only 2.5% of incident patients receive kidney transplants preemptively, improved psychosocial education may assist more patients in accessing preemptive transplant. This article outlines (1) unique psychosocial issues affecting patients with chronic kidney disease stage 4 (glomerular filtration rates >20 mL/min per 1.73 m2) and (2) how an educational program about preemptive living donor transplant should be designed and administered to increase access to this treatment option. Early referral patients may be overwhelmed in coping with and learning about their disease and, therefore, not ready to make a treatment decision, or they may be highly motivated to obtain a transplant to avoid dialysis and return to a normal life. An education program that defines the quality-of-life and health benefits possible with early transplant is outlined. The program is focused on minimizing the disruption of starting 2 treatment techniques and maximizing early transplant health, graft survival, employability, and retention of insurance coverage. Once the benefits of preemptive living donor transplant are outlined, educators can focus on demystifying the living donor evaluation process and assisting interested patients in planning how to find a living donor. To reach all patients, especially racial minorities, education about preemptive transplant should be available in primary-care physicians' and community nephrologists' offices, at dialysis centers, and through other kidney organizations.

Insurability of living organ donors: a systematic review

Being an organ donor may affect one's ability to obtain life, disability and health insurance. We conducted a systematic review to determine if insurability is affected by living organ donation, and if concern about insurability affects donor decision making. We searched MEDLINE, EMBASE, SCI, EconLit and Cochrane databases for articles in any language, and reviewed reference lists from 1966 until June 2006. All studies discussing the insurability of living organ donors or its impact on donor decision making were included. Data were independently abstracted by two authors, and the methodological quality appraised. Twenty-three studies, from 1972 to 2006, provided data on 2067 living organ donors, 385 potential donors and 239 responses from insurance companies. Almost all companies would provide life and health insurance to living organ donors, usually with no higher premiums. However, concern about insurability was still expressed by 2%-14% of living organ donors in follow-up studies, and 3%-11% of donors actually encountered difficulties with their insurance. In one study, donors whose insurance premiums increased were less likely to reaffirm their decision to donate. Based on available evidence, some living organ donors had difficulties with insurance despite companies reporting otherwise. If better understood, this potential barrier to donation could be corrected through fair health and underwriting policies.

Increasing live donor kidney transplantation: a randomized controlled trial of a home-based educational intervention

With the shortage of deceased donor kidneys and the superior clinical outcomes possible with live donor kidney transplantation (LDKT), more patients should seriously consider LDKT. However, little is known about how best to educate patients and their family members about LDKT. We evaluated the effectiveness of a home-based (HB) educational program in increasing LDKT. Patients were randomized to clinic-based (CB) education alone (CB, n = 69) or CB plus HB education (CB+HB, n = 63). Compared to CB, more patients in the CB+HB group had living donor inquiries (63.8% vs. 82.5%, p = 0.019) and evaluations (34.8% vs. 60.3%, p = 0.005) and LDKTs (30.4% vs. 52.4%, p = 0.013). Assignment to the CB+HB group, White race, more LDKT knowledge, higher willingness to discuss LDKT with others, and fewer LDKT concerns were predictors of having LDKT (p-values < 0.05). Both groups demonstrated an increase in LDKT knowledge after the CB education, but CB+HB led to an additional increase in LDKT knowledge (p < 0.0001) and in willingness to discuss LDKT with others (p < 0.0001), and a decrease in LDKT concerns (p < 0.0001). Results indicate that an HB outreach program is more effective in increasing LDKT rates than CB education alone.

Incompatible kidney donor candidates' willingness to participate in donor-exchange and non-directed donation

Although paired donation, list donation and non-directed donation allow more recipients to receive living donor transplants, policy makers do not know how willing incompatible potential donors are to participate. We surveyed 174 potential donors ruled out for ABO-incompatibility or positive cross-match about their participation willingness. They were more willing to participate in paired donation as compared to list donation where the recipient receives the next deceased donor kidney (63.8% vs. 37.9%, p < 0.001) or non-directed donation (63.8% vs. 12.1%, p < 0.001). Their list donation willingness was greater when their intended recipients moved to the top versus the top 20% of the waiting list (37.9% vs. 19.0%, p < 0.001). Multivariate logistic regression modeling revealed that potential donors' empathy, education level, relationship with their intended recipient and the length of time their intended recipient was on dialysis also affected willingness. For paired donation, close family members of their intended recipient (odds ratio (OR) = 3.01, confidence intervals (CI) = 1.29, 7.02), with high levels of empathy (OR = 2.68, CI = 1.16, 6.21) and less than a college education (OR = 2.67, CI = 1.08, 6.61) were more willing to participate compared to other donors. Extrapolating these levels of willingness nationally, a 1-11% increase in living donation rates yearly (84-711 more transplants) may be possible if donor-exchange programs were available nationwide.

The hospital costs of treating necrotizing fasciitis

BACKGROUND

Management of necrotizing fasciitis places significant demands upon hospital and medical resources. A successful management usually requires extensive surgical intervention and an adjunct hyperbaric oxygen treatment. The cost impact on the health care system has not been well characterized. We have, therefore, analysed the cost of treating this disease at an Australian tertiary referral hospital with extensive case experience and well-developed financial costing systems and have compared this with the current casemix-based government funding arrangements applying in Victoria, Australia.

METHODS

Data was extracted from the medical records of 92 sequential patients treated by the Alfred Hospital (Melbourne, Australia) during the four financial years 2000-04. Clinical costing data and government funding data was provided by the hospital's Finance Departments.

RESULTS

The total Alfred Hospital in-patient costs for treating the patients was $5,935,545 with a mean cost per patient of $64,517 (range, $1025 to $514,889). The total casemix-based funding allocation derived from treating these patients was calculated at $3,208,664 with the per patient mean $34,887 (range, $1331 to $387,168). This analysis does not include allowance for non-Alfred Hospital costs such as those incurred by the ambulance service, referring hospitals, for rehabilitation or as a result of the burden of residual disability.

CONCLUSIONS

This study has confirmed that a significant economic burden is involved in treating necrotizing fasciitis. There is a substantial difference between the hospital costs and government funding for treating these patients in the Australian setting.

Living Donor Kidney Transplant: Medicolegal and Insurance Aspects

Kidney transplantation is quite a routine complex procedure, not without risks and consequences to the donor, the recipient, and the health care professionals. Kidney-related medical malpractice suits are growing rapidly, and for clinicians and surgeons, the risk of being sued can be only reduced by practicing high-quality medicine and by appropriately communicating with donors and recipients. Actually relevant guidelines are available including safety and quality assurance standards for procurements, preservation, processing, and distribution for organs to maximize their quality and thereby the rate of success of transplants and to minimize the risk of such a procedure. We also find it essential that practice of living donor kidney transplant is in line with the general rules of the Convention for the Protection of Human Rights and its Additional Protocol. In this article, financial incentives and insurance aspects related with living donors kidney transplants are also illustrated.

Potential living kidney donors' health education use and comfort with donation

CONTEXT

Much living kidney donation research focuses on actual donors rather than all donors who are evaluated by the transplant center.

OBJECTIVE

To determine (1) what concerns and benefits potential donors saw possible from donation, (2) how they educated themselves before contacting the transplant center, and (3) who were the most comfortable donors.

DESIGN

A telephone survey of 91 potential donors before transplant evaluation.

SETTING

Barnes-Jewish Hospital Transplant Center in St Louis, Mo.

MAIN OUTCOME MEASURES

Willingness and comfort donating, key concerns and perceived benefits to donation, hours of transplant-related education.

RESULTS

On a 7-point scale, potential donors were very willing (mean=6.65, SD=0.95) and comfortable (mean=6.31, SD= 1.12) donating. They were most concerned that their recipients would die if they could not donate, the evaluation and surgery would be anxiety provoking or painful, and they did not understand what donation would require. Donors previously spent an average of 6 hours reading health resources and 32 hours discussing donation. Using logistic regression, those donors with 0 to 4 concerns (odds ratio=7.1, 95% confidence interval [CI], 2.2-23.16), more than 5 benefits (odds ratio=3.7, 95% CI, 1.2-11.0), and who were family members (odds ratio=4.7, 95% CI, 1.4-15.8) were more likely to be extremely comfortable donating compared to others.

CONCLUSIONS

Before evaluation, most potential donors are willing to donate because they think that it is important to improve the health of a loved one. Their knowledge of donation varies and they need clear information about medical testing and support coping with any negative donation outcomes.

The Living Organ Donor Network: a model registry for living kidney donors

The South-Eastern Organ Procurement Foundation presents the first report on a programme to track donors through questionnaires completed at the time of donation, 3 months, 6 months, and yearly thereafter. Donors at participating centres were eligible for an insurance policy with a total benefit of 250,000 US dollars, covering accidental death related to donation, surgery, medical expenses of complications, and disability income. The four participating centres have registered 104 donors. Response rate to the questionnaires was 90.91%. The majority of the donors come from the immediate family (81.62%), either by blood or marriage. The majority of donors are employed full time, with income ranges similar to the national census. Donors rely on employer-provided vacation time and sick leave to recuperate, but the average donor required 12 days of unpaid leave before returning to work. Donors also experienced costs of transportation, lodging, and childcare. Anti-depressants were prescribed to 10.58% of donors, and 4.8% of donors reported they are treated for hypertension. Complications were reported by 37.5% of the donors, but only 7.6% of the complications were serious enough to require hospitalization or surgery. Donors reported higher complication rates than reported by the centres and experience financial burdens afterwards.