Public awareness and attitudes to living organ donation: systematic review and integrative synthesis. Transplantation. 2013;96:429-437. [PMID: 23677051 DOI: 10.1097/tp.0b013e31829282ac]

Attitudes towards living organ donation: a cross-sectional survey study

Objective

Only 18% of kidneys and livers transplanted in the United States come from living donors, and increasing rates of living organ donation could help decrease the critical organ deficit. Non-directed living donation is even less common, with only 1.4% of kidney and liver transplants coming from anonymous donors (1). This study aimed to determine which factors are considered more motivating and more discouraging to living organ donation, how characteristics of potential recipients affect willingness to consider living liver donation, and whether there are any associations related to a person's willingness to consider non-directed living organ donation.

Method

A cross-sectional survey was distributed in-person on a large medical campus, and participation was incentivized with the opportunity to spin a prize wheel. In addition to participant characteristics, the survey queried awareness of directed and non-directed living donation, whether or not the participant would consider directed donation and non-directed donation, motivating and discouraging factors to living donation, vignettes to assess willingness to donate to recipients with different characteristics, and an altruism personality inventory. An optional interpersonal reactivity index was included as well.

Results

Three hundred twenty-six participants scanned a QR code to take the survey. Most participants (299 of 318, 94%) were aware of living donation. Participants who said yes to considering non-directed living donation (67 of 305, 22%) had significantly higher altruism scores than those who said no (123 of 305, 40%). Willingness to consider living liver donation varied based on recipient characteristics, with participants reporting they would be more willing to donate to a recipient with an immune disorder over alcohol-related liver disease, an infant over an adult, a relative over a nonrelative, and a sibling with alcohol-related liver disease over a nonrelative with alcohol-related liver disease.

Conclusion

The most motivating factors for considering living donation were having a child recipient, helping someone in need, high transplant center success rate, and helping a family member or friend. The most discouraging factors were uncompensated expenses, difficulty of surgery recovery, risk of surgery, and length of recovery. Participants were less willing to donate to adults, strangers, and recipients with alcohol-related liver disease.

Medical Suitability and Willingness for Living Kidney Donation Among Older Adults

RATIONALE & OBJECTIVE

The benefits of kidney transplantation compared with treatment with dialysis, including in older adults, are primarily limited by the number of donated kidneys. We studied the potential to expand the use of older living kidney donors.

STUDY DESIGN

Secondary analysis of the Berlin Initiative Study, a population-based cohort.

SETTING & PARTICIPANTS

2,069 adults aged≥70 years in Germany.

EXPOSURE

Age and sex.

OUTCOME

Suitability for living donation assessed by the absence of kidney-related exclusions for donation including albuminuria and low estimated glomerular filtration rate (eGFR) as well as absence of other medical exclusions. Willingness for living and deceased kidney donation assessed by participant survey.

ANALYTICAL APPROACH

Descriptive analysis.

RESULTS

Among the 2,069 participants (median age 80 years, 53% women, median eGFR 63mL/min/1.73m2), 93% had≥1 medical contraindication for living donation at study entry unrelated to eGFR or albuminuria. Using 2 published eGFR and albuminuria thresholds for donor acceptance, 38% to 54% of participants had kidney-related exclusions for donation. Among the 5% to 6% of participants with neither medical nor kidney-related exclusions for living donation at baseline, 11% to 12% remained suitable for donation during 8 years of follow-up. Willingness for living or deceased donation was high (73% and 60%, respectively).

LIMITATIONS

GFR was not measured, and medical exclusions unrelated to eGFR and albuminuria were assessed using a cohort database complemented by claims data.

CONCLUSIONS

One in 20 older adults were potentially suitable for living kidney donation, and willingness for living donation was high. Further studies are warranted to define the feasibility of expanding living kidney donation among older adults.

PLAIN-LANGUAGE SUMMARY

Although potentially beneficial, kidney transplantation remains infrequent among older adults aged≥70 years with kidney failure. Study evaluated the potential to increase living kidney donation among older adults, including their medical suitability as well as willingness to donate. Among 2,069 community-dwelling older adults (median age 80 years), 5% to 6% had no exclusion to donation. Among these individuals, 11% to 12% remained suitable for donation during 8 years of follow-up. Most exclusions were not related to eGFR and albuminuria. Willingness to living donation was high (73%). These findings highlight the potential benefits from expanding the pool of transplantable kidneys through the use of living donation in older adults.

Barriers and facilitators of deceased organ donation among Muslims living globally: An integrative systematic review

AIM

To identify the barriers and facilitators of deceased organ donation among the Muslim community living globally.

METHOD

A systematic search was undertaken in databases such as CINAHL, Medline with full text, Global Health and PsycINFO via EBSCO; Scopus via Elsevier; Web of Science via Clarivate; and PubMed via US National Library of Medicine National Institute of Health were used to retrieve the studies on the 31st of December 2023. Apart from these databases two other journals, the Saudi Journal of Kidney Diseases and Transplantation, and the Journal of Experimental and Clinical Transplantation were also used to search for relevant studies. Quantitative and qualitative studies that addressed the aim of the present review published from the 30th of April 2008 were included.

RESULTS

Of the 10,474 studies, 95 studies were included in the review. The following five themes were generated based on narrative synthesis: 1) knowledge of organ donation, 2) willingness to donate, 3) community influence, 4) bodily influence, and 5) religious influence. While individuals view organ donation as a noble act, societal influences significantly impact their decision to register. Concerns include religious permissibility, potential misuse for commercial purposes, and the dignity and respect given to the deceased donor's body.

CONCLUSIONS

This review finds deceased organ donation decisions in this population are collective, influenced by religious views, and hindered by uncertainty. Interventional studies on strategies to address uncertainty could help us identify best practices for this population to improve deceased organ donation. Rather than an individual approach among this population, a whole-system approach, tailored-made evidence-guided community engagement could improve donation rates.

Organ Donation Organization Architecture: Recommendations From an International Consensus Forum

This report contains recommendations from 1 of 7 domains of the International Donation and Transplantation Legislative and Policy Forum (the Forum). The purpose is to provide expert guidance on the structure and function of Organ and Tissue Donation and Transplantation (OTDT) systems. The intended audience is OTDT stakeholders working to establish or improve existing systems.

Methods

The Forum was initiated by Transplant Québec and co-hosted by the Canadian Donation and Transplantation Program partnered with multiple national and international donation and transplantation organizations. This domain group included administrative, clinical, and academic experts in OTDT systems and 3 patient, family, and donor partners. We identified topic areas and recommendations through consensus, using the nominal group technique. Selected topics were informed by narrative literature reviews and vetted by the Forum's scientific committee. We presented these recommendations publicly, with delegate feedback being incorporated into the final report.

Results

This report has 33 recommendations grouped into 10 topic areas. Topic areas include the need for public and professional education, processes to assure timely referral of patients who are potential donors, and processes to ensure that standards are properly enforced.

Conclusions

The recommendations encompass the multiple roles organ donation organizations play in the donation and transplantation process. We recognize the diversity of local conditions but believe that they could be adapted and applied by organ donation organizations across the world to accomplish their fundamental objectives of assuring that everyone who desires to become an organ donor is given that opportunity in a safe, equitable, and transparent manner.

Barriers and facilitators of deceased organ donation among Muslims living globally: protocol for an integrative systematic review using narrative synthesis

INTRODUCTION

Muslims have been shown to have less favourable attitudes towards organ donation and are less likely to consent to donate their organs. While several studies have been undertaken globally to identify the barriers and facilitators of organ donation, no systematic review has synthesised this evidence to date. Therefore, this systematic review aims to identify the barriers and facilitators of organ donation among Muslims living globally.

METHODS AND ANALYSIS

This systematic review will include cross-sectional surveys and qualitative studies published between 30 April 2008 and 30 June 2023. Evidence will be restricted only to studies reported in English. An extensive search strategy will be used in PubMed, CINAHL, Medline, Scopus, PsycINFO, Global Health and Web of Science, as well as specific relevant journals that may not be indexed in these databases. A quality appraisal will be undertaken using Joanna Briggs Institute quality appraisal tool. An integrative narrative synthesis will be used to synthesise the evidence.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Institute for Health Research Ethics Committee (IHREC) (IHREC987), University of Bedfordshire. The findings of this review will be disseminated widely through peer-reviewed journal articles and leading international conferences.

PROSPERO REGISTRATION NUMBER

CRD42022345100.

Knowledge and Attitude of People With or Without a Medical Education Regarding Organ Donation and Transplant: A Sample From the City of Baghdad

OBJECTIVES

Organ donation is the driving force for transplant. Awareness about donation and transplant is invaluable for improved transplant services in any country. Our objective was to assess the knowledge and attitude toward organ donation and transplant among medically educated adult Iraqis versus adult Iraqis who were not medically educated, in Baghdad, Iraq.

MATERIALS AND METHODS

For this study, we recruited 400 Iraqi residents of Baghdad city from December 1, 2018, to March 1, 2019. We used an interviewer-adm-inistered questionnaire to survey 200 health care professionals and 200 adults who lacked medical education, and then we analyzed the responses from the 2 groups.

RESULTS

The study included 165 males and 235 females (mean age 33.73 ± 10.38 years). Most participants (60%) were aware of organ donation, and a health care provider was the main source of their knowledge. Only 11.25% were aware of Iraqi legislation that permits donation after brain death. Nearly 50% of the participants volunteered to be living donors, and 229/400 (57.25%%) volunteered to donate after death. About 50% accepted the idea of organ donation as an act to save life, whomever the donor. The most important barrier was the fear of future risks to health after living donation and body disfigurement after death. There was a statistically significant difference in the knowledge and attitude scores between the 2 groups. From the study sample, 46.5% accepted the concept of incenting living donors or families of deceased donors.

CONCLUSIONS

Iraqi people are moderately informed about organ donation and transplant. Medically educated people demonstrated an attitude of greater acceptance. Religion and social beliefs were not barriers to organ donation in the study sample. Regulated governmental application of incentive programs may be a useful strategy at present.

A Content Analysis of Living Organ Donation Materials from Certified Transplant Centers

Despite the fact that living organ donation has the great potential to reduce the shortage of transplantable organs, it is still surrounded by many misconceptions, ethical concerns, and myths. Research conducted to understand factors contributing to public misconceptions related to living organ donation is rare. This research takes a content analytic approach to uncover how living organ donation is portrayed in materials developed and delivered by transplant centers across 11 regions. A total of 332 unique materials were analyzed. The results revealed that living kidney donation dominated the corpus of data whereas other living organ donations were largely overlooked. Benefits and risks associated with living organ donation were relatively evenly presented; however, social support necessary to donors and recipients and available resources to obtain social support were not sufficiently addressed. Embedded in these materials were 46 personal narrative stories. Analysis of these stories showed a focus on undirected living organ donation and revealed a wide range of emotional experiences. Significant regional differences were found in several themes, such as benefits and risks, and social support. Inconsistent information regarding living organ donation was present. Practical implications are discussed.

Effects of Humor in Health Communication: Experimental Evidence for Video Sequences Aiming to Increase the Willingness to Donate Organs

Humor has been proven to provide support when dealing with fear-related aspects of life. Therefore, it might be a useful communication strategy for addressing the need for donated organs. We conducted an experimental study among University students in Germany (n = 236) aged about 25 years (M = 24.60, SD = 5.86) investigating the effects of four video sequences related to organ donation on the willingness to donate organs. Based on random allocation, each study participant received one video sequence. The video sequences were presented by either a prominent or non-prominent speaker and included either humorous or neutrally framed information related to organ donation. An online survey was conducted before and after the intervention. A follow-up to investigate long-term effects was conducted 4-6 weeks later. Overall, the four interventions led to high proportions of self-reported willingness to think about organ donation and talk about it with relatives and friends subsequent to the respective intervention. Appraisals beneficial to organ donation improved significantly only in the non-humorous interventions. It seems to be of little relevance whether the humorous message was communicated by a prominent or non-prominent person. However, future investigations should focus on sample populations with lower education, because they are less likely to possess an organ donor card and more likely to have lower levels of positive attitudes toward organ donation and may, therefore, show different results regarding the effectiveness of humorous interventions.

The Impact of Mortality Salience on Organ Donation Attitude, Beliefs, and Behavior

The current study examines the relationship between mortality salience and attitude, beliefs, and behavior toward organ donor registration. Participants (N = 484) completed a laboratory study in a 2 (mortality salience vs. control) x 2 (processing: distal vs. proximal) between-subjects factorial design. Dependent variables included death thought accessibility, attitude, information seeking, and organ donation beliefs (bodily integrity, ick, jinx, and medical mistrust). Differences between conditions were examined with independent samples t-tests and χ2 analyses. Participants in the mortality salience condition reported greater death thought accessibility than those in the control; however, no difference in attitude nor information seeking (non-donors only) was found between the two conditions. No difference in attitude nor information seeking (non-donors only) was observed between participants engaging in distal versus proximal defensive processing. Participants in the mortality salience condition reported higher medical mistrust and bodily integrity than those in the control condition; no difference between ick or jinx was found between the two conditions. Theoretical and practical implications are discussed.

Knowledge and Attitudes Regarding Organ Transplantation Among Cyprus Residents

BACKGROUND

Organ transplantation was one of the greatest achievements of medical science during the 20th century. Knowledge, education, and culture all play prominent roles in transplantation because of the complexity of the process from donation to transplantation.

PURPOSE

The aim of this research was to determine and analyze the knowledge and attitudes about organ donation and transplantation among the general population in Limassol, Cyprus.

METHODS

A quantitative research approach was followed, and a questionnaire consisting of closed-ended questions was completed by adults from the general population in Limassol.

RESULTS

One thousand two hundred adults out of the 1,346 adults who were contacted responded to the survey (response rate: 89%) and were included as participants. Of the participants, 93.4% (p < .05) considered organ donation to be lifesaving, 57% expressed interest (and 39.8% expressed disinterest) in becoming organ donors, 80.6% (p < .05) expressed awareness of there being a waiting list for people in need of organ transplantation, 50.4% agreed that brain death must be confirmed before organ removal for transplantation, and 47% recalled having been informed about organ donation through the media, with 31.5% stating that they had never been informed about organ donation.

CONCLUSIONS

The participants demonstrated limited awareness regarding the organ donation system in Cyprus. Furthermore, a significant percentage stated that they lacked a source for obtaining related information. The Cypriot society should be informed and encouraged to participate in organ donation to increase the rate of organ transplantation.

Knowledge and Willingness for Organ Donation in the Middle Eastern Region: A Meta-analysis

Medical advancements over the past decades brought organ transplantation as a definitive therapy for different end-stage organ failure. However, non-availability of organs required for transplantation is a major challenge worldwide. We aimed to determine the knowledge and willingness to donate organs in various populations and settings in the Middle Eastern region. Literature searches were conducted on PubMed, MEDLINE, Cochrane, and Google scholar electronic databases. Different combinations of search terms such as "organ donation"; "knowledge", "awareness"; "beliefs", "willingness"; and "attitude" along with the country names were used. Additional searches using reference lists of studies and review articles were conducted. Data were extracted using standardized excel form and pilot tested. Three authors independently abstracted the data using a data collection form. Results from different studies were pooled for the analysis when appropriate. The search yielded 1806 articles; 1000 duplicates and review articles were excluded, and a further 792 articles not relevant were excluded. Finally, 14 original studies met the inclusion criteria. Total pooled sample size for assessing knowledge was 6697 and for willingness was 8714. Pooled overall knowledge regarding organ donation was 69% with a 95% CI [64.5, 73.5]. Pooled overall willingness to donate organ was 49.8% with a 95% CI [41.3, 58.4]. Knowledge about organ donation and willingness to donate organs varies in different population and settings in the Middle East. These in fact are linked to multiple social factors ultimately leads to 'consent' for donating organs by a potential donor. Family's influence; religious, traditional and spiritual beliefs; and status of ethnic, minority, and immigrant populace are the important determinants of the decision for organ donation. Understandings on social determinants in organ donation remain crucial and should be addressed while developing policies and organizational developments.

Factors Influencing Decision Making About Living Donation Among Medical Students

AIM

This study aimed to assess the factors influencing decision making about living donation among medical students.

METHOD

Three standardized survey questionnaires (the Altruism Questionnaire A-N, the Individual Questionnaire for studying approaches to transplantology, the Interpersonal Reactivity Index) were used among 316 students of nursing and paramedics.

RESULTS

Nearly all the respondents (98%) approve cell transplantation, tissue transplantation, and organ transplantation if obtained from living donors. Of the respondents, 66% would consent to donate bone marrow, and 26% would give their consent only in specific situations. Most respondents reported to be encouraged to donate organs by the ability to help other people (56%), while their refusal would be because of the fear of undergoing medical procedures (13%). Older age and a higher score in the personal distress subscale are correlated with a lack of consent to donate bone marrow for transplantation. In the case of living organ donation, the increase in the scores in the fantasy scale caused a higher chance for consent to living donation, whereas older age was the predictor of lack of consent. Higher scores in the perspective taking subscale were found to be significantly correlated with fear of surgical treatment as the reason for refusing to give one's consent to living donation. The belief that willingness to become a donor shows a person who has a sense of prosocial behavior was influenced by the fantasy and the empathic concern subscales.

CONCLUSIONS

The study group approves cell transplantation, tissue transplantation, and organ transplantation from living donors. These attitudes are determined by empathic behavior.

Is There Decreasing Public Interest in Renal Transplantation? A Google TrendsTM Analysis

BACKGROUND AND OBJECTIVES

Renal transplantation is the preferred form of renal replacement therapy for the majority of patients with end stage renal disease (ESRD). The Internet is a key tool for people seeking healthcare-related information. This current work explored the interest in kidney transplantation based on Internet search queries using Google Trends^TM.

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

We performed a Google Trends^TM search with the search term "kidney transplantation" between 2004 (year of inception) and 2018. We retrieved and analyzed data on the worldwide trend as well as data from the United Network for Organ Sharing (UNOS), the Organización Nacional de Trasplantes (ONT), the Eurotransplant area, and the National Health Service (NHS) Transplant Register. Google Trends^TM indices were investigated and compared to the numbers of performed kidney transplants, which were extracted from the respective official websites of UNOS, ONT, Eurotransplant, and the NHS.

RESULTS

During an investigational period of 15 years, there was a significant decrease of the worldwide Google Trends^TM index from 76.3 to 25.4, corresponding to an absolute reduction of -50.9% and a relative reduction by -66.7%. The trend was even more pronounced for the UNOS area (-75.2%), while in the same time period the number of transplanted kidneys in the UNOS area increased by 21.9%. Events of public interest had an impact on the search queries in the year of occurrence, as shown by an increase in the Google Trends^TM index by 39.2% in the year 2005 in Austria when a person of public interest received his second live donor kidney transplant.

CONCLUSIONS

This study indicates a decreased public interest in kidney transplantation. There is a clear need to raise public awareness, since transplantation represents the best form of renal replacement therapy for patients with ESRD. Information should be provided on social media, with a special focus on readability and equitable access, as well as on web pages.

Public Solicitation and The Canadian Media: Two Cases of Living Liver Donation, Two Different Stories

Supplemental Digital Content is available in the text.

Background

. Two stories of public solicitation for living liver donors received substantial Canadian media attention in 2015: The Wagner family, with twin toddlers, each needing transplants, and Eugene Melnyk, wealthy owner of a professional hockey team. This study compared the print media coverage of these 2 stories to understand how public solicitation was portrayed and whether coverage differed depending on the individual making the plea.

Methods.

We conducted a content analysis on 155 relevant Canadian newspaper articles published between January 1, 2015 and December 31, 2016. Articles were analyzed for their description of public solicitation, benefits and issues associated with public solicitation, and overall tone with respect to public solicitation.

Results.

The foregrounding of public solicitation and associated ethical issues featured heavily in articles focused on Melnyk but were largely absent when discussing the Wagner family. The fairness of Melnyk's solicitation was the most prominent ethical issue raised. Laws and policies surrounding public solicitation also featured in the Melnyk story but not in articles focused on the Wagners. Public solicitation was portrayed more negatively in the Melnyk articles, but overall, was portrayed positively in relation to both Melnyk and the Wagner family.

Conclusions.

Public solicitation was generally portrayed as a positive phenomenon in Canadian print media, yet there were stark differences in how these cases were presented. The Wagner story was largely portrayed as a human-interest piece about a family in dire circumstances, whereas Melnyk's wealth, status, and influence raised questions of the fairness of his transplant.

Physician Attitudes Toward Living Kidney Donation

Background:

Compared to dialysis, living kidney donation has a greater chance of restoring health and is associated with better outcomes than deceased kidney donation. Although physicians advocate for this treatment, it is uncertain how they would act as potential living kidney donors or recipients.

Methods:

We surveyed 104 physicians, pediatric, and internal medicine nephrologists, to ascertain their attitudes toward living donation.

Results:

Among surveyed nephrologists, there was nearly universal support for living kidney donation as a viable medical option, and nearly all of them would support a healthy and medically cleared patient who wishes to participate. Although support was still strong, nephrologists were significantly less likely to support their friends and relatives participating in living kidney donation, and their support declined further for friends and relatives donating to nonrelatives.

Conclusion:

Our findings suggest the need to more deeply examine physician-perceived risks involved in serving as a living kidney donor. Based on differences in surveyed nephrologist attitudes regarding donation to and from loved ones versus nonrelatives, we suggest that physicians should give careful consideration to how they describe the risks of living donation to potential donors.

Factors Associated With the Willingness of Clinical Health Care Professionals for Living Organ Donation

Understanding the attitudes and willingness in regard to living organ donation of health care professionals is important for clinical practice and needs to be addressed. Thus, the objective of this study was to examine willingness and its influencing factors in regard to living organ donation in clinical health care professionals.

METHODS

This study used a cross-sectional design. A total of 375 health care professionals from a regional teaching hospital in northern Taiwan were included in this study.

RESULTS

Nearly 65% of the participants indicated a willingness to donate their living organ. Of these participants, 97.1% were willing to donate to family members, 80.8% were willing to donate to friends, and 78.9% were willing to donate to strangers. The predictors of willingness to engage in living organ donation were the desire to help others (odds ratio [OR] = 2.96; P < .01), positive attitude toward living organ donation (OR = 1.12; P < .01), financial support from the government (OR = 4.99; P < .01), and fewer physical concerns (OR = 0.97; P = .04). The willingness to donate a living organ was not associated with age, sex, religious belief, education level, participation in voluntary work, years of clinical work, type of profession, or knowledge about living organ donation.

CONCLUSION

In general, health care professionals had a positive attitude toward and willingness to engage in living organ donation. It is hoped that the results of this study will serve as a referent framework for policymaking in regard to living organ donation and transplantation.

Using an informatics education strategy to resolve the dilemma of teaching transplantation in medical institutions: Multidisciplinary medical team perspectives

In Taiwan, the current survival rate 1 year after transplantation exceeds 80%. However, the number of organ/tissue donors per year in Taiwan is extremely low, resulting in increased mortality. This is also true in Europe and in the United States. Recently, data from the Taiwan Organ Registry and Sharing Center showed that, although fundraising for organs/tissues slightly increased, the number of donors did not exhibit a corresponding growth trend. Identifying appropriate donors and the provision of good quality transplantation care by medical team members are current challenges. Hence, the application of information technology to in-service education for organ transplantation professionals has been suggested.This was a qualitative study that employed qualitative content analysis with purposive and snowball sampling. The study participants (n = 8, mean age 39.88 ± 3.06 years) included medical staff involved in tissue/organ transplantation from 4 leading medical centers and 3 regional teaching hospitals, and those who participated in the informatics education system.The interviewees from multidisciplinary medical teams showed the status of and dilemma in organ fundraising/donation/transplantation, noting 6 core themes. Regarding relevant education and training, 4 core themes were identified.Current educational courses for organ fundraising/donation/transplantation are inadequate and seem to provide insufficient information to multidisciplinary medical teams. Hence, it is necessary to develop a theoretical construct to create a complete curriculum framework and to establish complete fit-in professional and ethical organ transplantation learning programs based on informatics technology to increase the interdisciplinary exchange of experience.

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

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

Assessing Living Donor Priorities Through Nominal Group Technique

The need for kidneys for transplantation continues to far surpass the number of donors. Although studies have shown that most people are aware of and support the idea of living donation, it remains unclear what motivates individuals who are aware, knowledgeable, and in support of donation to actually donate, or conversely, what deters them from donating. Utilizing nominal group technique, 30 individuals participated in 4 groups in which they brainstormed factors that would impact willingness to be a living donor and voted on which factors they deemed most important. Responses were analyzed and categorized into themes. Factors that influence the donation decision, from most to least important as rated by participants, were altruism, relationship to recipient, knowledge, personal risk/impact, convenience/access, cost, support, personal benefit, and religion. Participants reported a significant lack of information about donation as well as lack of knowledge about where and how to obtain information that would motivate them to donate or help make the decision to donate. Findings suggest that public campaign efforts seeking to increase rates of living donation should appeal to altruism and increase knowledge about the impact (or lack thereof) of donation on lifestyle factors and future health, and transplant programs should aim to maximize convenience and minimize donor burden. Future research should examine whether tailoring public campaigns to address factors perceived as most salient by potential donors reduces the significant gap in supply of and demand for kidneys.

Physician perceptions about living organ donation in patients with Amyotrophic Lateral Sclerosis

OBJECTIVES

Patients with Amyotrophic Lateral Sclerosis (ALS) have expressed desire to become living organ donors but are unable to do so with current organ donation policies. Our objective is to assess ALS patient's interest in organ donation, and perceived concerns of this practice by ALS neurologists.

PATIENTS AND METHODS

An electronic survey was administered to ALS neurologists across the United States regarding living organ donation in ALS patients prior to respiratory failure.

RESULTS

52 complete responses were received from 121 invites. 67% (35/52) of neurologists expressed no concerns about living organ donation in ALS patients, and 33% had concerns. The concerns related to respiratory failure, anesthesia exposure and renal dysfunction. With their concerns addressed, 71% of neurologists reported that they would endorse living organ donation. 49% of neurologists reported being asked by a patient for information regarding living organ donation. ALS neurologists felt that 22.8% of ALS patients (median 19%) would be interested in learning more about organ donation, while only 6% of neurologists broach this subject with their patients.

CONCLUSION

Our results indicate that 1 in every 4 ALS patients may be interested in exploring options for living organ donation, and this topic is not routinely addressed by ALS clinics. These results indicate an unexplored area of patient interest. To honor a patient's wishes to donate, the transplant community will have to accommodate living organ donation from terminally ill patients, and address neurologist concerns. Such a practice could benefit two groups of patients.

A Study on the Attitude Toward Kidney Transplantation and Factors Among Hemodialysis Patients in China

BACKGROUND

Kidney transplantation (KT) is the most effective treatment for patients with end-stage renal disease. However, objective data regarding the willingness of patients with end-stage renal disease to undergo transplantation are lacking in China. The purpose of this study was to examine the attitudes and impact factors regarding KT among patients with end-stage renal disease undergoing hemodialysis.

METHODS

This study used a cross-sectional approach. Between June and July 2015, a total of 326 hemodialysis outpatients completed a self-designed questionnaire to assess their attitudes toward KT and satisfaction with dialysis.

RESULTS

Patients' mean age was 49.47 years, and the mean duration of hemodialysis was 52 months. Among these patients, 34.9% would like to undergo transplantation, and 4.23% of patients have a potential related living donor. Among the patients wishing to undergo transplantation, 43.93% had started a procedure to be grafted. The minority of patients (45.93%) stated that KT offers a better quality of life; 78.5% believe that it is more expensive than hemodialysis. Overall, 13.36% of patients are willing to become organ donors after death. The main motivating factor for KT was because of study or work difficulties (56.1%). The effects of the following 7 independent variables on attitude were assessed: age, education level, monthly income, sex, duration of hemodialysis, dialysis satisfaction, and reimbursement level.

CONCLUSIONS

To improve hemodialysis patients' accessibility to KT, better information must be provided to patients, their families, and other support providers. Transplantation is the best treatment for patients undergoing hemodialysis, which should be given more attention and political support economically and publicly by the government and some closely related agencies.

Decision aids to increase living donor kidney transplantation

PURPOSE OF REVIEW

For the more than 636,000 adults with end-stage renal disease (ESRD) in the U.S., kidney transplantation is the preferred treatment compared to dialysis. Living donor kidney transplantation (LDKT) comprised 31% of kidney transplantations in 2015, an 8% decrease since 2004. We aimed to summarize the current literature on decision aids that could be used to improve LDKT rates.

RECENT FINDINGS

Decision aids are evidence-based tools designed to help patients and their families make difficult treatment decisions. LDKT decision aids can help ESRD patients, patients' family and friends, and healthcare providers engage in treatment decisions and thereby overcome multifactorial LDKT barriers.

SUMMARY

We identified 12 LDKT decision aids designed to provide information about LDKT, and/or to help ESRD patients identify potential living donors, and/or to help healthcare providers make decisions about treatment for ESRD or living donation. Of these, 4 were shown to be effective in increasing LDKT, donor inquiries, LDKT knowledge, and willingness to discuss LDKT. Although each LDKT decision aid has limitations, adherence to decision aid development guidelines may improve decision aid utilization and access to LDKT.

Concern for Lost Income Following Donation Deters Some Patients From Talking to Potential Living Donors

CONTEXT

Some living kidney donors report lost income during recovery from surgery. Little is known about whether concern for living donor's lost income affects the decision to undergo donation evaluation and the willingness of transplant candidates to discuss living kidney donation (LKD) with others.

OBJECTIVE

To examine whether transplant patients were told by potential donors about lost income concerns and whether patients chose not to discuss LKD with others due to lost income concerns.

DESIGN, SETTING, AND PATIENTS

Kidney transplant patients (185 wait-listed candidates, 171 deceased donor recipients, and 100 live donor recipients) at 2 centers completed a questionnaire to assess whether concern about donor's lost income was a consideration in discussion about LKD with others.

RESULTS

One-third (32%) were told by a family member/friend that they were willing to donate but were concerned about potential lost income. The majority of those who expressed financial concern (64%) did not initiate donation evaluation. Many patients (42%) chose not to discuss living donation with a family member/friend due to concern about the impact of lost income on the donor. In the multivariable model, lower annual household income was the only statistically significant predictor of both having a potential donor expressing lost income concern and choosing not to talk to someone because of lost income concern.

CONCLUSION

Findings from the current study underscore how concern about income loss for living donors may affect decision-making by both transplant candidates and potential donors.

Medical Students' Knowledge, Familiarity, and Attitudes towards Hematopoietic Stem Cell Donation: Stem Cell Donation Behaviors

Hematopoietic stem cell transplantation (HSCT) is a potentially curative treatment for patients with blood disorders and genetic diseases. Approximately 70% of the HSCTs currently performed in the United States use stems cells from an unrelated donor who donated voluntarily. Medical students (MS) are a young, diverse, influential population whose willingness to engage in altruistic acts, such as donating stem cells, may be correlated with knowledge on the topic. A literature gap exists in MS perspectives towards HSCT and the bone marrow registry (BMR) and prior studies suggest that misconceptions about donation deter MS from participation on the BMR, which may decrease opportunities to educate other potential donors. We performed a cross-sectional survey among the 4-year cohort of MS at Mayo Medical School in Rochester, Minnesota. The questionnaire evaluated multiple areas including whether MS were current members of the BMR and/or prior blood donors, MS current knowledge on donor eligibility (DE) and the donation process (DP), MS familiarity with HSCT and the DP, and MS attitudes towards joining the BMR and towards donating stem cells. The responses were analyzed and assessed alongside a self-reported, standardized scale measuring students' altruistic behaviors. There were 99 out of 247 potential respondents (40%), with 45% (n = 44) of MS in preclinical years 1 or 2, 37% (n = 37) in clinical years 3 or 4, and 18% (n = 18) in research or alternative portions of their training, of which 43% (n = 41) in total were current BMR members. BMR status correlated positively with prior blood donation (P = .015) and female sex (P = .014). Respondents had a 57.7% and 63.7% average correct response rate regarding knowledge of DE and DP, respectively, with knowledge of DE not surprisingly higher in BMR members (P < .0001). The majority of MS surveyed, 68% (n = 65), had learned about HSCT during medical school. BMR status correlated with the following attitudes towards donating stem cells: lower concern with all evaluated aspects of HSCT-time, cost, pain, and side effects (for all subsections, P < .05) but not with the altruism score (P = .32). The mean altruism score for respondents was 59.9 ± 11.3 (of a possible 100 points) with no significant difference in age, race, sex, level of training, or participation in the BMR. Altruism scores did not directly correlate with lower concern with aspects of time, cost, and pain of HSCT but did with long-term side effects (P = .021). This latter correlation was regardless of BMR status. Among MS, positive predictors for participation in the BMR included prior blood donation and female sex. BMR status did not ensure knowledge of all aspects of donating stem cells, but it correlated with less concern regarding the DP and was unrelated to altruism score. Improving knowledge gaps regarding the BMR and HSCT for the next generation of physicians and health care providers through expanded medical education curriculum may be beneficial to for the recruitment and retention of donor populations to the BMR.

Psychosocial assessment of living kidney donors: What implications have temperament and character for decision-making?

OBJECTIVE

We compared the personality of kidney donor candidates to non-donor controls and analyzed the personality profile of candidates psychosocially at risk.

METHODS

49 consecutive living kidney donor candidates underwent an extensive psychosocial evaluation. Psychosocial risk factors concerning knowledge of donation risks (1), donor-recipient-relationship (2), and/or mental health (3) were rated on a 3-point rating scale (0=high risk, 2=no risk). Furthermore, candidates as well as 49 age-and gender-matched non-donor controls filled in questionnaires concerning psychological distress (Symptom Checklist 90-R) and personality (Temperament and Character Inventory).

RESULTS

There were no significant differences between candidates and controls concerning psychological distress or personality. Psychosocial assessment identified 13 candidates (26.5%) with increased psychosocial risk. This group displayed compared to candidates without psychosocial risk no difference concerning age, gender, formal education, donor-recipient relationship and psychological distress. However, this group scored significantly higher on reward dependence compared to suitable donors and controls (p<0.05). Reward dependence was associated with a lack of adequate knowledge on donation (r=-0.35, p<0.05).

CONCLUSION

Reward dependence has important implications for decision-making, because it is associated with an increased tendency to deny potential risks of donation. Careful identification and assessment of reward dependent donor candidates is needed to ensure a free-willed decision.

Organ Donation Among Tiers of Health Workers: Expanding Resources to Optimize Organ Availability in a Developing Country

The global increase in end organ failure but disproportional shortage of organ donation calls for attention. Expanding the organ pool by assessing and improving health workers' attitude at all levels of care may be a worthwhile initiative.

METHODS

A questionnaire-based cross sectional study involving tertiary, secondary, and primary health institutions in Southwestern Nigeria was conducted.

RESULTS

Age range was 18 to 62 (36.7 ± 9.2) years. Only 13.5%, 11.7%, and 11.2% from primary, secondary, and tertiary health centers, respectively, would definitely donate despite high level of awareness (>90%) at each level of care. Participants from primary health care are of low income (P < 0.05), and this cohort is less likely to be aware of organ donation (P < 0.05). At each level of care, permission by religion to donate organs influenced positive attitudes (willingness to donate, readiness to counsel families of potential donors, and signing of organ donation cards) toward organ donation. Good knowledge of organ donation only significantly influenced readiness to counsel donors (P < 0.05) and not willingness to donate (P > 0.05). At each level of health care, young health care workers (P < 0.05) and women (P > 0.05) would be willing to donate, whereas men show positive attitude in signing of organ donor cards (P < 0.05) and counseling of families of potential donors (P > 0.05).

CONCLUSIONS

Knowledge and willingness to donate organs among health care levels were not different. Considering the potential advantage of community placement of other tiers of health care (primary and secondary) in Nigeria, integrating them would be strategically beneficial to organ donation.

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.

Focus group study of public opinion about paying living kidney donors in Australia

BACKGROUND AND OBJECTIVES

The unmet demand for kidney transplantation has generated intense controversy about introducing incentives for living kidney donors to increase donation rates. Such debates may affect public perception and acceptance of living kidney donation. This study aims to describe the range and depth of public opinion on financial reimbursement, compensation, and incentives for living kidney donors.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Twelve focus groups were conducted with 113 participants recruited from the general public in three Australian states in February 2013. Thematic analysis was used to analyze the transcripts.

RESULTS

Five themes were identified: creating ethical impasses (commodification of the body, quandary of kidney valuation, pushing moral boundaries), corrupting motivations (exposing the vulnerable, inevitable abuse, supplanting altruism), determining justifiable risk (compromising kidney quality, undue harm, accepting a confined risk, trusting protective mechanisms, right to autonomy), driving access (urgency of organ shortage, minimizing disadvantage, guaranteeing cost-efficiency, providing impetus, counteracting black markets), and honoring donor deservingness (fairness and reason, reassurance and rewards, merited recompense). Reimbursement and justifiable recompense are considered by the Australian public as a legitimate way of supporting donors and reducing disadvantage. Financial payment beyond reimbursement is regarded as morally reprehensible, with the potential for exploitative commercialism. Some contend that regulated compensation could be a defensible strategy to increased donation rates provided that mechanisms are in place to protect donors.

CONCLUSIONS

The perceived threat to community values of human dignity, goodwill, and fairness suggests that there could be strong public resistance to any form of financial inducements for living kidney donors. Policy priorities addressing the removal of disincentives may be more acceptable to the public.

Factors Affecting the Decision to Grant Consent for Organ Donation: A Survey of Adults in England

BACKGROUND

Solid organ transplantation reduces both morbidity and mortality. Donation rates have increased by more than 60% in the last 6 years in the United Kingdom, largely through improved identification and management of potential donors. However, the next of kin (NoK) decline to consent in 43% of cases-the second highest rate in Europe. We aimed to define factors that influence decisions to consent for organ donation.

METHODS

This is an online survey of 1549 adult residents of England with results weighted to national demographics.

RESULTS

Eighty percent would consider donating some or all of their organs. Religion, age, and ethnicity influenced this support. Concerns over body integrity, religion, and effects on the quality of care received reduce support. Only 48% recognized that NoK consent would be sought before any donation. Previous discussion and Organ Donor Register (ODR) enrollment both correlate with NoK consent: 87% would consent after discussion and ODR enrollment, 79% would consent after discussion alone, 55% would consent with ODR registration alone, and 29% would consent without either. Reported misconceptions inhibiting consent included a perceived inability to deregister from the ODR and that individuals were too old to donate. Those who did not wish to donate their own organs were more likely to overrule others' expressed wishes to donate.

CONCLUSIONS

To ensure that organ donation occurs wherever appropriate, attention should focus primarily on determining an individual's wishes before death, ensuring that any misconceptions are corrected before a decision is made, promotion of ODR enrollment, and challenging those NoK who wish to overrule others' wishes.

Between Scylla and Charybdis: charting an ethical course for research into financial incentives for living kidney donation

New approaches to address the kidney scarcity in the United States are urgently needed. The greatest potential source of kidneys is from living donors. Proposals to offer financial incentives to increase living kidney donation rates remain highly controversial. Despite repeated calls for a pilot study to assess the impact of financial compensation on living kidney donation rates, many fear that financial incentives will exploit vulnerable individuals and cast the field of transplantation in a negative public light, ultimately reducing donation rates. This paper provides an ethical justification for conducting a pilot study of a federally regulated approach to providing financial incentives to living kidney donors, with the goal of assessing donors' perceptions.

Living Donor Kidney Transplantation: Overcoming Disparities in Live Kidney Donation in the US--Recommendations from a Consensus Conference

Despite its superior outcomes relative to chronic dialysis and deceased donor kidney transplantation, live donor kidney transplantation (LDKT) is less likely to occur in minorities, older adults, and poor patients than in those who are white, younger, and have higher household income. In addition, there is considerable geographic variability in LDKT rates. Concomitantly, in recent years, the rate of living kidney donation (LKD) has stopped increasing and is declining, after decades of consistent growth. Particularly noteworthy is the decline in LKD among black, younger, male, and lower-income adults. The Live Donor Community of Practice within the American Society of Transplantation, with financial support from 10 other organizations, held a Consensus Conference on Best Practices in Live Kidney Donation in June 2014. The purpose of this meeting was to identify LKD best practices and knowledge gaps that might influence LDKT, with a focus on patient and donor education, evaluation efficiencies, disparities, and systemic barriers to LKD. In this article, we discuss trends in LDKT/LKD and emerging novel strategies for attenuating disparities, and we offer specific recommendations for future clinical practice, education, research, and policy from the Consensus Conference Workgroup focused on disparities.

What's new in clinical solid organ transplantation by 2013

Innovative and exciting advances in the clinical science in solid organ transplantation continuously realize as the results of studies, clinical trials, international conferences, consensus conferences, new technologies and discoveries. This review will address to the full spectrum of news in transplantation, that verified by 2013. The key areas covered are the transplantation activity, with particular regards to the donors, the news for solid organs such as kidney, pancreas, liver, heart and lung, the news in immunosuppressive therapies, the news in the field of tolerance and some of the main complications following transplantation as infections and cancers. The period of time covered by the study starts from the international meetings held in 2012, whose results were published in 2013, up to the 2013 meetings, conferences and consensus published in the first months of 2014. In particular for every organ, the trends in numbers and survival have been reviewed as well as the most relevant problems such as organ preservation, ischemia reperfusion injuries, and rejections with particular regards to the antibody mediated rejection that involves all solid organs. The new drugs and strategies applied in organ transplantation have been divided into new way of using old drugs or strategies and drugs new not yet on the market, but on phase Ito III of clinical studies and trials.

Organ and tissue donation in clinical settings: a systematic review of the impact of interventions aimed at health professionals

In countries where presumed consent for organ donation does not apply, health professionals (HP) are key players for identifying donors and obtaining their consent. This systematic review was designed to verify the efficacy of interventions aimed at HPs to promote organ and tissue donation in clinical settings. CINAHL (1982 to 2012), COCHRANE LIBRARY, EMBASE (1974 to 2012), MEDLINE (1966 to 2012), PsycINFO (1960 to 2012), and ProQuest Dissertations and Theses were searched for papers published in French or English until September 2012. Studies were considered if they met the following criteria: aimed at improving HPs’ practices regarding the donation process or at increasing donation rates; HPs working in clinical settings; and interventions with a control group or pre-post assessments. Intervention behavioral change techniques were analyzed using a validated taxonomy. A risk ratio was computed for each study having a control group. A total of 15 studies were identified, of which only 5 had a control group. Interventions were either educational, organizational or a combination of both, and had a weak theoretical basis. The most common behavior change technique was providing instruction. Two sets of interventions showed a significant risk ratio. However, most studies did not report the information needed to compute their efficacy. Therefore, interventions aimed at improving the donation process or at increasing donation rates should be based on sound theoretical frameworks. They would benefit from more rigorous evaluation methods to ensure good knowledge translation and appropriate organizational decisions to improve professional practices.

Women and kidney transplantation

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