Concerns of ABO incompatible and crossmatch-positive potential donors and recipients about participating in kidney exchanges

Characteristics of Potential and Actual Living Kidney Donors: A Single-center Experience

BACKGROUND

There are limited data and no national capture of barriers associated with initiating and completing the donation process for potential living kidney donors (LKDs).

METHODS

We performed a retrospective analysis of 3001 intake forms completed by prospective LKDs from 2016 to 2019 at a single transplant center. We analyzed data from all potential donors who completed the intake until they became ineligible or withdrew or donation was complete. We used univariate and multivariate models to evaluate independent factors associated with donation at various stages in the donation process.

RESULTS

The donation process was deconstructed into 5 steps: intake form, immunologic compatibility testing, clinic evaluation, selection committee review, and donation. The highest percentage of potential donors dropped out after completing the intake form, primarily because of not responding to the follow-up phone call (22.6%). Of 455 potential LKDs that completed immunologic compatibility testing, 36% were ABO or crossmatch incompatible. One-hundred eighty-eight (7.5%) of all LKD applicants reached donation, the majority of whom were White (91.0%) and female (63.8%).

CONCLUSIONS

A minority of LKD applicants make it to donation. Our ability to track all potential LKDs from the initial touch point to the transplant center will help us develop interventions to address barriers to a successful donation.

Paired kidney exchange transplantation - pushing the boundaries

The scarcity of living organ donors makes it imperative to develop newer innovations to optimize and maximize the utilization of the available pool. ABO and HLA sensitization are important immunological barriers in renal transplant and can potentially lead to rejection of almost one-third of the willing living donors. Paired kidney exchange (PKE) is a rapidly growing method used to overcome these barriers and has grown in popularity over the last three decades since its introduction in 1986. Evolution of the matching strategies and use of complex algorithms has led to increase in the number of possible matches thereby benefiting multiple recipients. The use of altruistic donors and compatible pairs has also helped in increasing the possible exchanges. This review provides an in-depth analysis of the evolution, the present global scenario, and the future of PKE. It also discusses the recent trends of advanced donation, trans-organ paired exchange and global kidney exchange and the associated ethical concerns.

Kidney Vouchers and Inequity in Transplantation

This article probes the voucher program from an ethical perspective. It focuses mainly on an issue of inequity. A disparity exists in US kidney transplantation. Although African-Americans suffer far higher rates of ESRD than whites, African-Americans are much less likely than whites to get a transplant (Ilori et al., 2015, 1). The article explores the voucher program in light of this disparity. It motivates the view that, at least in the short term, more whites than African-Americans are likely to take advantage of the voucher program. The program is, thus, likely to increase the gap in transplantation rates between the two groups. If this is correct, what impact does it have on the moral acceptability of the program?

Pre-donation cognitions of potential living organ donors: the development of the Donation Cognition Instrument in potential kidney donors

Background

Cognitions surrounding living organ donation, including the motivation to donate, expectations of donation and worries about donation, are relevant themes during living donor evaluation. However, there is no reliable psychometric instrument assessing all these different cognitions. This study developed and validated a questionnaire to assess pre-donation motivations, expectations and worries regarding donation, entitled the Donation Cognition Instrument (DCI).

Methods

Psychometric properties of the DCI were examined using exploratory factor analysis for scale structure and associations with validated questionnaires for construct validity assessment.

Results

From seven Dutch transplantation centres, 719 potential living kidney donors were included. The DCI distinguishes cognitions about donor benefits, recipient benefits, idealistic incentives, gratitude and worries about donation (Cronbach's alpha 0.76-0.81). Scores on pre-donation cognitions differed with regard to gender, age, marital status, religion and donation type. With regard to construct validity, the DCI was moderately correlated with expectations regarding donor's personal well-being and slightly to moderately to health-related quality of life.

Conclusions

The DCI is found to be a reliable instrument assessing cognitions surrounding living organ donation, which might add to pre-donation quality of life measures in facilitating psychosocial donor evaluation by healthcare professionals.

Survey of Living Organ Donors' Experience and Directions for Process Improvement

INTRODUCTION

Understanding living organ donors' experience with donation and challenges faced during the process is necessary to guide the development of effective strategies to maximize donor benefit and increase the number of living donors.

METHODS

An anonymous self-administered survey, specifically designed for this population based on key informant interviews, was mailed to 426 individuals who donated a kidney or liver at our institution. Quantitative and qualitative methods including open and axial coding were used to analyze donor responses.

FINDINGS

Of the 141 survey respondents, 94% would encourage others to become donors; however, nearly half (44%) thought the donation process could be improved and offered numerous suggestions. Five major themes arose: (1) desire for greater convenience in testing and scheduling; (2) involvement of previous donors throughout the process; (3) education and promotion of donation through social media; (4) unanticipated difficulties, specifically pain; and (5) financial concerns.

DISCUSSION

Donor feedback has been translated into performance improvements at our hospital, many of which are applicable to other institutions. Population-specific survey development helps to identify vital patient concerns and provides valuable feedback to enhance the delivery of care.

Pregnancy-Induced Sensitization Promotes Sex Disparity in Living Donor Kidney Transplantation

The presence of sex disparity in living donor kidney transplantation (LDKT) remains controversial. To determine if women fall behind men in LDKT evaluation, we performed an intention to treat study of 2587 candidates listed for kidney transplant at a single transplant center over 7 years. We found that women and men kidney transplant candidates engaged an equivalent type and number of prospective living donors. However, sex-specific differences in sensitization history and histocompatibility reduced the rate of LDKT for women by 30%. Pregnancy-induced incompatibility with spouse donors was limiting given that spouses were among the individuals most likely to complete donation. Notably, participation in a kidney paired exchange program eliminated sex-based differences in LDKT. Collectively, these data suggest that pregnancy is a formidable biologic barrier for women and contributes uniquely to sex disparity in LDKT. Targeted efforts to improve transplant center participation in paired kidney exchanges may increase sex equity in LDKT.

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.