Motives and decision making of potential living liver donors: comparisons between gender, relationships and ambivalence

A Single-Center Retrospective Study to Identify Causes of Sex Differences in the Living Kidney Donor Evaluation Process

Key Points

Background

Multiple studies have shown that female volunteers are living donors (LDs) for kidney transplantation at higher rates than male volunteers. However, the underlying reasons for this observation are not well understood. We examined the LD evaluation process to determine the point at which sex imbalance arises. On the basis of a previous study, we hypothesized that both sexes are equally likely to become approved as LDs, but female volunteers are more likely to follow through with donation.

Methods

This is a single-institution retrospective chart review of self-referrals for LD evaluation between January 2009 and December 2022. Self-referrals were identified using the Organ Transplant Tracking Record database and cross-referenced with billing data. Exclusion at each stage of evaluation was recorded and compared between sexes using log binomial regression; unadjusted and adjusted (for donor age, race, ethnicity, relationship to recipient, and recipient sex) risk ratios with 95% confidence interval were determined.

Results

One thousand eight hundred sixty-one self-referrals were reviewed, including 1214 female (65.2%) and 647 male (34.8%) volunteers, resulting in 146 approvals and 125 donations (76/125, 60.8% female, 49/125, 39.2% male). Adjusted risk ratios indicated no significant differences between sexes in completing medical and/or psychosocial workup, having medical and/or psychosocial contraindications, being approved for donation, and proceeding with donation. The top medical contraindications for both sexes were obesity, hypertension, and nephrolithiasis.

Conclusions

Female overrepresentation among LDs is likely due to the 1.9 times higher rate of self-referral for evaluation. After this point, both sexes were equally likely to complete workup, be approved, and follow through with donation. Increased efforts to engage male volunteers at the initial self-referral stage has the potential to expand access to LD kidney transplantation.

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Medical-ethical guidelines: Living donation of solid organs

No abstract available.

Quality of life, depression and anxiety in potential living liver donors for pediatric recipients: A retrospective single center experience

BACKGROUND

Living donor liver transplantation is a safe alternative for patients on a liver transplant list. Donor evaluation goes beyond physical variables to include social, emotional, and ethical aspects. The role of pre-donation sociopsychological evaluation of the donor candidate is as important to the success of the procedure as is the medical assessment. Success implies recovery from the operation and prompt engagement in pre-transplant professional and social activities, without leading to psychological or physical distress. Psychological profiling of potential living liver donors (PLLD) and evaluation of quality of life (QOL) can influence outcomes.

AIM

To evaluate the socio-demographics and psychological aspects (QOL, depression, and anxiety) of PLLD for pediatric liver transplantation in a cohort of 250 patients.

METHODS

This was a retrospective cohort study of 250 PLLD who underwent psychological pre-donation evaluation between 2015 and 2019. All the recipients were children. The Beck anxiety inventory, Beck depression inventory, and 36-item short-form health survey (SF-36) scores were used to evaluate anxiety (Beck anxiety inventory), depression (Beck depression inventory), and QOL, respectively.

RESULTS

A total of 250 PLLD were evaluated. Most of them were women (54.4%), and the mean age was 29.2 ± 7.2 years. A total of 120 (48.8%) PLLD were employed at the time of evaluation for donation; however, most had low income (57% earned < 2 times the minimum wage). A total of 110 patients (44%) did not finish the donation process, and 247 PLLD answered a questionnaire to evaluate depression, anxiety, and QOL (SF-36). Prevalence of depression was of 5.2% and anxiety 3.6%. Although most of the PLLD were optimistic regarding the donation process and never had doubts about becoming a donor, some traces of ambivalence were observed: 46% of the respondents said they would feel relieved if a deceased donor became available.

CONCLUSION

PLLD had a low prevalence of anxiety and depression. The foundation for effective and satisfactory results can be found in the pre-transplantation process, during which evaluations must follow rigorous criteria to mitigate potential harm in the future. Pre-donation psychological evaluation plays a predictive role in post-donation emotional responses and mental health issues. The impact of such findings on the donation process and outcomes needs to be further investigated.

Understanding family dynamics in adult-to-adult living donor liver transplantation decision-making in Taiwan: Motivation, communication, and ambivalence

This study investigated how multiple family members co-construct the ethical significance of living donor liver transplantation (LDLT) and how the family structure and dynamics of donor-recipient-caregiver relationships shape the communication and decision-making process within the sociocultural context of Taiwan. We conducted in-depth interviews with 36 participants from 13 families at the Chang Gung Memorial Hospital from February to December 2019. Interviews were audio recorded, transcribed, and translated from Mandarin to English and analyzed utilizing grounded theory and thematic analysis. Our findings revealed that LDLT in Taiwan is not merely a personal choice of either donor or recipient but essentially a collaborative process of family-centered medical decision-making, intertwined with socioeconomic conditions, cultural and social norms, gender roles, and the division of labor in the household. The notion of reciprocity and indebtedness for family members is a central theme underlying the entire process of motivation, deliberation, and decision-making, thereby reinforcing the naturalness of LDLT. However, our study highlighted that donors from families with traditional gender hierarchy and power imbalance may experience psychological and social vulnerabilities. Conclusively, we suggest that healthcare professionals should be sensitive to the contextual and relational factors involved in family dynamics and provide appropriate support to the ambivalent donors.

Eligible blood donors' decisions about donating stool for fecal microbiota transplantation: Does ambivalence play a role?

Blood collection agencies (BCAs) are expanding core business by inviting blood donors to donate stool for fecal microbiota transplantation (FMT). However, whether blood donors also want to donate stool is unclear since, despite its benefits, stool donation is viewed by many as unpleasant. This study examined the prevalence, contributors to, and role of these mixed feelings (ambivalence) in stool donation intentions.

STUDY DESIGN AND METHODS

This cross-sectional study surveyed Australian residents aged 18 years or more who believed themselves eligible to donate blood and met broad criteria for prescreening as a stool donor (eg, healthy, not taking medication). Survey questions assessed attitude, norms, self-efficacy, motives, disgust, ambivalence, and intentions to donate stool.

RESULTS

A total of 382 eligible blood donors aged not more than 50 years (mean, 28.71 years; 48% female, 62% "healthy" body mass index) participated. Six percent indicated no ambivalence about donating stool. In regression, significant determinants of ambivalence were less awareness of FMT, lower self-efficacy, motivated by ensuring that stool is available for loved ones, and more disgust about stool donation. Higher ambivalence contributed to decreased donation intention. Self-efficacy and disgust differentiated participants with moderate ambivalence, a group likely responsive to intervention, from those with low or high ambivalence.

CONCLUSION

Ambivalence about donating stool was common among eligible blood donors. BCAs should raise awareness about stool donation and FMT before requesting donation. BCAs may increase cost savings and donor retention by giving clear guidance about donation requirements and implementing processes that build confidence. Early screening of potential donors for ambivalence and disgust will enable BCAs to provide decision support.

Psychosocial Assessment of Donors in Pediatric Living Donor Liver Transplantation: A Systematic Review

BACKGROUND

Pediatric living donor liver transplantation (LDLT) is the only way to save children with end-stage liver disease. The donor for liver transplantation (LT) may have a complicated psychosocial condition.

PURPOSE

This review aims to identify the domains of the donor psychosocial questions that should be addressed and summarize the aspects and tools future psychosocial assessments should include.

METHODS

We searched the PubMed, Medline, Cochrane Library, Embase, Web of Science, and Google Scholar databases for the terms pediatric, liver transplantation, donor, and psychosocial. We used the Joanna Briggs Institute Critical Appraisal Tool to appraise reporting quality. Two researchers independently selected the papers and performed data extraction and quality appraisal.

RESULTS

The articles included in this review contain 26 quantitative studies and 2 qualitative studies. The study quality was moderate to high. Donors have ambivalence, anxiety, the need for family and social support, the need for adequate information, distress, and low self-esteem during the preoperative period. In the postoperative period they have poor psychological condition, panic disorder, conversion disorder and substance use/abuse disorder, abnormal family functioning, better psychosocial outcome, or among others. The assessment methods consisted of the questionnaire survey and semi-structured interview. Among the 28 studies, 17 different psychosocial domains were mentioned. The most frequently referred to was family and social support.

CONCLUSION

The contents of the psychosocial assessment must include anxiety or depression, family and social support, ambivalence, information, and positive psychosocial characteristics. Assessment methods should use the questionnaire survey and semi-structured interview. According to this review, future research can develop a specific psychosocial assessment tool for pediatric LT donors.

Living Donors: Altruism and Feeling Forgotten

OBJECTIVES

Living donors endure several challenges throughout the organ donation process. Physically related effects are further compounded by social and emotional challenges. To date, no previous studies have addressed the motives and impact of organ donations from living donors in Jordan.

MATERIALS AND METHODS

We conducted a qualitative exploratory study to understand the experiences of a random sample of genetically and legally related living donors in Jordan. Participants were identified through the Directorate of the Jordanian Center for Organ Transplantation database. Our sample included Jordanians and non-Jordanians who donated a kidney or liver. Most data were collected by phone interviews with living donors; some donors were personally interviewed. Donors were asked about their experiences during the periods before and after the process of donation, including their feelings, emotions, and motives. Interviews were analyzed using the thematic analysis approach.

RESULTS

In total, 360 participants (337 kidney and 23 liver donors; 290 Jordanians and 70 non-Jordanians) completed the interview. The time from donation to interview ranged from 14 days to 7 years. The period before donation was characterized by fear and confusion. After donation, most donors described a positive emotional state that was marked by selfsatisfaction, pride, and increased support of organ donation. However, many stated that they felt forgotten. Most donors were motivated by social solidarity, and others invoked the role of their religious beliefs as the main motive. Other motives included improving the recipient's life and fear that patients would be abandoned.

CONCLUSIONS

The emotional distress of living donors during the predonation period emphasizes the need for social and psychological support in addition to medical evaluations. Donors who had positive experiences with donation can play a role in advocating for donation. Finally, in Jordan, social solidarity and religious beliefs are the most important factors that motivate donation.

Psychosocial Issues Related to Donor's Decision-Making in Living Donor Liver Transplantation

Background

The aim of this study was to investigate the detailed motives, concerns, and psychological defensiveness of living liver donor candidates in a Korean population.

Material/Methods

We analyzed data of 102 donor candidates obtained from routine psychosocial evaluation for living donor liver transplantation (LDLT) using descriptive methods. Donor candidates completed 2 questionnaires regarding their motivations and concerns, as well as a validity scale, the K scale from the Minnesota Multiphasic Personality Inventory-2.

Results

Donor candidates were more likely to cite family-related issues (77.5% to 94.1%) including well-being of the whole family and family affection as the reasons for their liver donation rather than personal motives (38.2% to 57.8%). Donors were also more likely to concern about the recipient’s survival and recovery (52.9% to 58.8%) rather than their own difficulties such as surgical complications and occupational disadvantages (19.6% to 38.2%). Twenty-six donors (25.5%) took a psychologically defensive attitude (T-score of K scale ≥65) during the pre-donation evaluation. Psychologically defensive donors expressed a significantly lower level of concern about liver donation compared to non-defensive donors (P<0.01).

Conclusions

We need to pay more attention to the family-related issues and psychological defensiveness of living liver donor candidates when evaluating psychosocial status before LDLT.

Health-related quality of life of living liver donors 1 year after donation

Background

Improving the health-related quality of life (HRQOL) of living liver donors post-donation is an important aspect of care quality. Analyzing the HRQOL of living liver donors prospectively could help improve our understanding of the recovery of HRQOL and help improve the quality of donor care. In this study, we examined the HRQOL of living liver donors at pre-donation and at 1-year post-donation and analyzed the effect of pre- and post-donation factors on the donors' physical and mental HRQOL.

Methods

This was a prospective study. During the enrollment period (August 2013 to December 2015), 68 living liver donors completed the study questionnaires 5 times: at pre-donation and at 1, 3, 6, and 12 months post-donation. The Medical Outcomes Study Questionnaire Short Form-36, which yields both physical (PCS) and mental (MCS) component summary scores, was used to measure the HRQOL. The pre- and post-donation factors included donation ambivalence, recipients' physical condition, post-donation complications, and recipients' survival status.

Results

Participants' mean PCS scores were 43.59 and 56.50 at 1 and 12 months after donation, respectively, whereas their mean MCS scores were 46.89 and 46.28, respectively. The mean PCS score was worse at 1 month after donation but improved significantly over time (P<0.05); conversely, the MCS was quite stable over time (P>0.05). A good PCS score was associated with no surgical complications of donation (coefficient =2.87, P=0.02), whereas a poor MCS score was associated with an education of less than a bachelor's degree (coefficient =-3.60, P=0.004), a higher Model for End-Stage Liver Disease (MELD) score in the recipient (coefficient =-0.13, P=0.03), and recipient death (coefficient =-3.48, P=0.03). Pre-donation ambivalence and sense of coherence were not significant predictors of the PCS or MCS scores.

Conclusions

The impact of living liver donation on HRQOL was strongest in the early stages of the post-surgery period for the physical domain. Health-care professionals should carefully manage and monitor the progress of surgical outcomes, particularly in high-risk groups such as donors with a low education level or donors whose recipients have severe illness or end up dying after the surgery. Doing so may allow for suitable intervention opportunities to improve the HRQOL of living liver donors.

Psychological profiles of excluded living liver donor candidates: An observational study

Living donor liver transplantation has advantages over deceased organ liver transplantation. However, the living liver donor candidates must be carefully assessed before surgery. Candidates may be excluded for various reasons. The purpose of this study was to evaluate the psychological profiles of excluded living liver donor candidates according to the reason for exclusion.A descriptive and cross-sectional study was conducted. Donor candidates were invited to participate if they were at least 20 years of age, related biologically or by marriage to the recipient (within 5 degrees), and had undergone living donor evaluation. Among the 338 participants recruited from August 2013 to December 2015, 116 were excluded for the following reasons: a medical condition (n = 35), failure to be chosen (n = 63), or withdrawal from the selection process (n = 18). The psychological profiles of these 3 exclusion groups were evaluated.There were no significant group differences in age, sex, education level, religion, marital status, and consanguinity (P > .05). The withdrawal group had fewer recipients with an hepatitis B virus infection than did the other groups (χ = 9.28, P = .01). Additionally, compared with the unchosen group, the withdrawal group had lower intimacy with the recipient (F = 5.32, P = .006) and higher ambivalence (F = 5.53, P = .005). In terms of family relationship parameters, the withdrawal group had lower family cohesion than the medical condition and unchosen groups (F = 4.44, P = .01), lower family expressiveness than the medical condition group (F = 3.76, P = .03), and higher family conflict than the medical condition and unchosen groups (F = 7.05, P = .001). The withdrawal group also had lower emotional social support than the medical condition group (F = 3.55, P = .03). There were no significant group difference in motivation, expectations, donation-related concerns, informational social support, value social support, instrumental social support, and health-related quality of life.The living donor candidates who withdrew from the selection process had obvious ambivalence, poorer family relationships, and insufficient emotional social support. The transplantation team should respect the autonomy of the candidate's decision and mitigate the impact of the donation decision on living liver donor candidates.

Prevalence and Predictors of Patient-Reported Long-term Mental and Physical Health After Donation in the Adult-to-Adult Living-Donor Liver Transplantation Cohort Study

BACKGROUND

Prospective and longitudinal studies have examined liver donors' medical outcomes beyond the first 1 to 2 years postdonation. There is no analogous longitudinal evidence on long-term psychosocial outcomes, including patient-reported clinically significant mental health problems and perceptions of physical well-being. We examined prevalence, descriptive characteristics, and predictors of diagnosable mental health conditions and self-reported physical health problems, including fatigue and pain, in the long-term years after liver donation.

METHODS

Donors from 9 centers who initially completed telephone interviews at 3 to 10 years postdonation (mean, 5.8 years; SD, 1.9) were reinterviewed annually for 2 years using validated measures. Outcomes were examined descriptively. Repeated-measures regression analyses evaluated potential predictors and correlates of outcomes.

RESULTS

Of 517 donors initially interviewed (66% of those eligible), 424 (82%) were reassessed at least once. Prevalence rates of major depression and clinically significant pain were similar to general population norms; average fatigue levels were better than norms. All prevalence rates showed little temporal change. Anxiety and alcohol use disorder rates exceeded normative rates at 1 or more assessments. Longer postdonation hospitalization, female sex, higher body mass index, concerns about donation-related health effects, and burdensome donation-related financial costs were associated with increased risk for most outcomes (P's < 0.05). Men were at higher risk for alcohol use disorder (P < 0.001).

CONCLUSIONS

Anxiety and alcohol use disorders were more common than would be expected; they may warrant increased research attention and clinical surveillance. Surveillance for long-term problems in the areas assessed may be optimized by targeting donors at higher risk based on identified predictors and correlates.

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.

Psychosocial Outcomes 3 to 10 Years After Donation in the Adult to Adult Living Donor Liver Transplantation Cohort Study

BACKGROUND

Studies of liver donors' psychosocial outcomes focus on the short term and rely largely on quality-of-life measures not specific to donation. We sought to examine long-term donation effects on 3 psychosocial domains: perceived physical, emotional, and socioeconomic outcomes.

METHODS

Individuals donating 3 to 10 years previously at 9 centers were eligible for telephone surveys. Survey responses were examined descriptively. Cluster analysis was used to identify distinct donor groups based on response profiles across psychosocial domains. Potential predictors of response profiles were evaluated with regression analysis.

RESULTS

Five hundred seventeen donors (66%) participated (M = 5.8 years postdonation, SD = 1.9). Fifteen percent to 48% of donors endorsed current donation-related physical health problems and concerns, and 7%-60% reported socioeconomic concerns (eg, insurance difficulties, financial expenditures). However, on average, donors experienced high psychological growth, and 90% felt positively about donation. Cluster analysis revealed 5 donor groups. One group showed high psychological benefit, with little endorsement of physical or socioeconomic concerns (15% of donors). Four groups showed less favorable profiles, with varying combinations of difficulties. The largest such group showed high endorsement of physical concerns and financial expenditures, and only modest psychological benefit (31% of donors). Men and nonHispanic whites were most likely to have unfavorable response profiles (Ps < 0.01). Compared with donors aged 19 to 30 years, older donors were less likely to have unfavorable profiles; these differences were significant for donors in the >40 to 50 year age group (Ps < 0.008).

CONCLUSIONS

Even many years postdonation, donors report adverse physical and socioeconomic effects, but positive emotional effects as well. Identification of response profiles and predictors may improve targeting of postdonation surveillance and care.

Predictors of decision ambivalence and the differences between actual living liver donors and potential living liver donors

Background

The decision to become a living liver donor is a stressful event. Ambivalence in decision making may result in psychological distress. Thus, the purpose of this study was to provide a description of the ambivalence of potential living liver donors, to examine the predictors of ambivalence, and to compare the ambivalence of potential living liver donors with that of actual living liver donors.

Methods

This descriptive and correlational study was conducted in a medical center from August 2013 to December 2015. Self-reported questionnaires were used to collect data. A total of 263 potential living liver donors who were assessed for donation to their parents were included in this study.

Results

The mean age of the total sample was 30.7 years (SD = 6.39, range = 20–47), and males comprised 53.6% of the sample. The majority of the potential donors had a college education (70.8%) and were single (63.5%). Of the total sample, the mean score for ambivalence was 4.27 (SD = 1.87, range = 0–7). Multivariate analysis revealed that the Mental Component Summary (MCS) of quality of life (β = -0.24, p < 0.01), family support (β = -0.17, p = 0.007), and intimacy (β = -0.13, p = 0.04) were significant protective predictors of ambivalence. Actual living liver donors had significantly lower ambivalence (3.82 versus 4.60), higher intimacy with recipients (3.55 versus 3.34), higher MCS (45.26 versus 42.80), and higher family support (34.39 versus 29.79) than did the remaining potential living liver donors.

Conclusion

Ambivalence is common in potential living liver donors. The MCS of quality of life, family support, and intimacy were protective predictors in terms of ambivalence. Future research should explore other factors and design interventions targeted toward reducing ambivalence, promoting family support, and enhancing the mental dimensions of quality of life in potential living liver donors.

Mental health status after living donor hepatectomy

Donor safety and preservation of donor health after living liver donation are of paramount importance. In addition, the preoperative mental state of a donor is an important factor in determining the psychological impact of donor hepatectomy. Thus, we aimed to explore the mental health status of living liver donors after hepatectomy. We enrolled 60 donors who were scheduled to undergo living donor hepatectomy during the period January 2014 to March 2015 at a single medical center. Mental health status was measured before and 3 months after surgery using 3 self-report questionnaires, namely the Center for Epidemiologic Studies Depression Scale (CES-D) to assess depressive symptoms, the World Health Organization Quality of Life (WHOQOL-BREF) questionnaire to measure quality of life, and the Chinese Health Questionnaire (CHQ) to screen for minor psychiatric disorders. A comparison of the pre- and postdonation CES-D scores revealed a significant reduction in depressive symptoms after surgery (P = .031). There were significant improvements in the physical health domain (P = .031), the psychological health domain (P = .005), the social relationships domain (P = .005), and the environmental health domain (P = .010) of the WHOQOL-BREF. There were no significant changes in CHQ scores after donor hepatectomy (P = .136). All donors reported that they would donate again if required. Approximately one-third (33.3%) of donors experienced more pain than they had anticipated in the immediate postoperative period, and 20.0% of donors had complications after donor hepatectomy. Donor mental health status tended to improve as donors regained physical function during the 1st 3 months of recovery. Long-term monitoring of living donors' mental health is needed to minimize the adverse psychological outcomes of living liver donation.

Social and Financial Outcomes of Living Liver Donation: A Prospective Investigation Within the Adult-to-Adult Living Donor Liver Transplantation Cohort Study 2 (A2ALL-2)

Because results from single-center (mostly kidney) donor studies demonstrate interpersonal relationship and financial strains for some donors, we conducted a liver donor study involving nine centers within the Adult-to-Adult Living Donor Liver Transplantation Cohort Study 2 (A2ALL-2) consortium. Among other initiatives, A2ALL-2 examined the nature of these outcomes following donation. Using validated measures, donors were prospectively surveyed before donation and at 3, 6, 12, and 24 mo after donation. Repeated-measures regression models were used to examine social relationship and financial outcomes over time and to identify relevant predictors. Of 297 eligible donors, 271 (91%) consented and were interviewed at least once. Relationship changes were positive overall across postdonation time points, with nearly one-third reporting improved donor family and spousal or partner relationships and >50% reporting improved recipient relationships. The majority of donors, however, reported cumulative out-of-pocket medical and nonmedical expenses, which were judged burdensome by 44% of donors. Lower income predicted burdensome donation costs. Those who anticipated financial concerns and who held nonprofessional positions before donation were more likely to experience adverse financial outcomes. These data support the need for initiatives to reduce financial burden.

Long-Term Medical and Psychosocial Outcomes in Living Liver Donors

Due to the enduring organ shortage, living donor liver transplantation has been a valuable treatment strategy for advanced liver disease patients for over 20 years. A variety of reviews have summarized the extensive data now available on medical and psychosocial risks to living donors in the aftermath of donation. However, evidence on donor medical and psychosocial outcomes beyond the first year postdonation has not been synthesized in any previous review. The evidence base on such "long-term" outcomes has been growing in recent years. A review of this evidence would therefore be timely and could serve as an important resource to assist transplant centers in their efforts to fully educate prospective donors and gain informed consent, as well as develop appropriate postdonation clinical care and surveillance plans. We reviewed recent literature on long-term donor outcomes, considering (a) medical outcomes, including mortality risk, rates of complications, abnormalities detected in laboratory testing, and the progress of liver regeneration; and (b) donor-reported psychosocial outcomes reflecting physical, emotional, and interpersonal/socioeconomic well-being, as well as overall health-related quality of life. We summarize limitations and gaps in available evidence, and we provide recommendations for future research and clinical care activities focused on long-term outcomes in liver donors.

Emotional and Financial Experiences of Kidney Donors over the Past 50 Years: The RELIVE Study

BACKGROUND AND OBJECTIVES

Most kidney donors view their experience positively, but some may experience psychosocial and financial burdens. We hypothesized that certain donor characteristics, poor outcome of the recipient, negative perceptions of care, and lack of support may be associated with poor psychosocial outcomes for donors.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The Renal and Lung Living Donors Evaluation Study (RELIVE) examined long-term medical and psychosocial outcomes for kidney donors (at three U.S. transplant centers) who donated between 1963 and 2005. Standardized questionnaires evaluated donor perspectives, recovery time, social support, motivation, financial impact, insurability after donation, and current psychological status. Questionnaires were mailed to 6909 donors.

RESULTS

Questionnaires were returned by 2455 donors, who had donated 17 ± 10 years earlier (range, 5-48 years), a response rate of 36%. Most (95%) rated their overall donation experience as good to excellent. Rating the overall donor experience more negatively was associated with donor complications, psychological difficulties, recipient graft failure, and longer time since donation. Nine percent (n=231) reported one or more of the following poor psychosocial outcomes: fair or poor overall donor experience, financial burden, regret or discomfort with decision to donate, or psychological difficulties since donation. Recipient graft failure was the only predictor for reporting one or more of these poor psychosocial outcomes (odds ratio, 1.77; 95% confidence interval, 1.33 to 2.34). Donors with lower educational attainment experienced greater financial burden. One of five employed donors took unpaid leave; 2% reported health and life insurability concerns.

CONCLUSIONS

Although the majority of donors viewed their overall donation experience positively, almost 1 in 10 donors reported at least one negative consequence related to donation. Recipient graft failure was associated with poor psychosocial outcome, defined as one or more of these negative consequences. Some donors were financially disadvantaged, and some experienced insurance difficulties. Interventions to avoid negative psychosocial and financial consequences are warranted.

Informed consent for live liver donors: A qualitative, prospective study

BACKGROUND & AIMS

Adult-to-adult live donor liver transplantation (LDLT) poses serious health risks and no direct health benefits to donors. Ensuring live donors' autonomy through informed consent is critical. We assessed live liver donors' (LD) comprehension, information needs, risk perceptions, and demographics.

METHODS

Semi-structured interviews were prospectively conducted with LDs after completing donor evaluation and informed consent at our transplant center. Likert scales measured informed consent domains. Open-ended responses underwent thematic analysis.

RESULTS

Thirty LDs participated (100% participation rate). Although 90% of LDs reported being informed about donation 'a great deal', only 66% reported understanding information about donation 'a great deal.' Many (40%) reported difficulty understanding medical terminology. Information LDs most desired to feel comfortable with their decision included: incidence and type of donor complications (67%), description of donation procedure (57%), and the process of donor preparation (43%). Most (83%) LDs rated risks to themselves as 'not at all' to 'somewhat' risky, and minimized these risks.

CONCLUSIONS

Although LDs perceived that they were adequately informed, their actual comprehension about donation was inadequate. Findings suggest the value of informed consent for preparation for the procedure and potential periprocedural risks rather than for decision-making. More comprehensible information disclosure may optimize informed consent.

Satisfaction With Life Among Living Kidney Donors: A RELIVE Study of Long-Term Donor Outcomes

BACKGROUND

Little is known about living kidney donors' satisfaction with life (SWL) after donation. We compared donors' SWL to previously reported general population samples and investigated predictors of donors' SWL.

METHODS

Three transplant centers mailed questionnaires to assess SWL, physical health, optimism, retrospective evaluation of the donation experience, and demographic characteristics to living kidney donors' homes between 2010 and 2012. Two thousand four hundred fifty-five donors who were between 5 and 48 years from the time of their donor surgery completed the questionnaire.

RESULTS

Eighty-four percent of donors were satisfied with their lives (scores ≥ 20 on the Satisfaction With Life Scale). Donors were at least as satisfied with their lives as previously reported general population samples. After adjusting for physical health, optimism, and demographics, donors' SWL was significantly associated with donors' recalled experience of donation. Social support and positive effects of the donation on relationships predicted greater SWL. Financial difficulties associated with donation and longer recovery times predicted lower SWL. Recipient outcomes were not significantly related to donor SWL.

DISCUSSION

Limitations include the lack of predonation SWL data, potential bias in postdonation SWL because of the situational context of the questionnaire, and a sample that is not representative of all U.S. living kidney donors. Nonetheless, strategies focused on improving the donation experience, particularly related to recovery time, financial issues, and social support, may result in greater SWL after donation.

Patterns and predictors of sexual function after liver donation: The Adult-to-Adult Living Donor Liver Transplantation Cohort study

Although sexual functioning is an important facet of a living donor's quality of life, it has not received an extensive evaluation in this population. Using data from the Adult-to-Adult Living Donor Liver Transplantation Cohort Study, we examined donor sexual functioning across the donation process from the predonation evaluation to 3 months and 1 year after donation. Donors (n = 208) and a comparison group of nondonors (n = 155) completed self-reported surveys with specific questions on sexual desire, satisfaction, orgasm, and (for men) erectile function. Across the 3 time points, donor sexual functioning was lower at the evaluation phase and 3 months after donation versus 1 year after donation. In the early recovery period, abdominal pain was associated with difficulty reaching orgasm [odds ratio (OR), 3.98; 95% confidence interval (CI), 1.30-12.16], concerns over appearance were associated with lower sexual desire (OR, 4.14; 95% CI, 1.02-16.79), and not feeling back to normal was associated with dissatisfaction with sexual life (OR, 3.58; 95% CI, 1.43-8.99). Efforts to educate donors before the surgery and prepare them for the early recovery phase may improve recovery and reduce distress regarding sexual functioning.

Effect of social support and donation-related concerns on ambivalence of living liver donor candidates

Ambivalence in the decision-making process for living liver donors has the potential to result in their experiencing a negative mental status. To promote donor candidates' well-being, it is important to study the factors related to ambivalence. Thus, the aim of this study was to explore the ambivalence of living liver donor candidates and to investigate the effect of social support and donation-related concerns on their ambivalence. A cross-sectional design was used. In total, 100 living liver donor candidates who underwent a preoperative evaluation between April and October 2009 were recruited for the study. Participants completed a self-administered questionnaire that contained items related to ambivalence, donation-related concerns, and social support. The mean score for ambivalence was 3.14 (standard deviation = 1.8), and the median was 3. Only 7% of the study sample reported no ambivalence during the assessment stage. Ambivalence was positively correlated with donation-related concerns (physical concerns, r = 0.39; psychosocial concerns, r = 0.43; financial concerns, r = 0.29) and negatively correlated with social support (r = -0.16 to -0.33). Those with psychosocial concerns had significantly worse ambivalence (β = 0.29, P = 0.03), but social support mitigated ambivalence (β = -0.34, P = 0.01). When intimacy and social support were included in the model, the effect of psychosocial concerns on ambivalence became nonsignificant (β = 0.24, P = 0.08). Ambivalence is common among living liver donor candidates, but instrumental social support can mediate the negative effect of donation-related concerns. Recommendations include providing appropriate social support to minimize donation-related concerns and, thus, to reduce the ambivalence of living liver candidates.

Live liver donors' risk thresholds: risking a life to save a life

BACKGROUND

There is still some controversy regarding the ethical issues involved in live donor liver transplantation (LDLT) and there is uncertainty on the range of perioperative morbidity and mortality risks that donors will consider acceptable.

METHODS

This study analysed donors' inclinations towards LDLT using decision analysis techniques based on the probability trade-off (PTO) method. Adult individuals with an emotional or biological relationship with a patient affected by end-stage liver disease were enrolled. Of 122 potential candidates, 100 were included in this study.

RESULTS

The vast majority of participants (93%) supported LDLT. The most important factor influencing participants' decisions was their wish to improve the recipient's chance of living a longer life. Participants chose to become donors if the recipient was required to wait longer than a mean ± standard deviation (SD) of 6 ± 5 months for a cadaveric graft, if the mean ± SD probability of survival was at least 46 ± 30% at 1 month and at least 36 ± 29% at 1 year, and if the recipient's life could be prolonged for a mean ± SD of at least 11 ± 22 months.

CONCLUSIONS

Potential donors were risk takers and were willing to donate when given the opportunity. They accepted significant risks, especially if they had a close emotional relationship with the recipient.

Managing the Psychosocial and Financial Consequences of Living Donation

There has been dramatic growth in the last decade in the literature on psychosocial and financial impacts of living organ donation. With this growth has come recognition that these impacts must be considered when educating prospective donors about the donation process, and when planning donor follow-up care after donation. Our review highlights recent studies that provide new information on the nature of psychosocial and financial outcomes in living donors, with special attention to studies examining unrelated donors (i.e., those with no biologic or longstanding emotional connection to the transplant patient), given that these individuals represent a growing segment of the living donor population. Limitations and gaps in available evidence are noted. We also discuss recent recommendations for post-donation monitoring of donors' psychosocial and financial outcomes, and we consider advances in evidence regarding interventions and prevention strategies to minimize any adverse psychosocial and financial impacts of living donation.

Preventive intervention for living donor psychosocial outcomes: feasibility and efficacy in a randomized controlled trial

There are no evidence-based interventions to prevent adverse psychosocial consequences after living donation. We conducted a single-site randomized controlled trial to examine the postdonation impact of a preventive intervention utilizing motivational interviewing (MI) to target a major risk factor for poor psychosocial outcomes, residual ambivalence (i.e. lingering hesitation and uncertainty) about donating. Of 184 prospective kidney or liver donors, 131 screened positive for ambivalence; 113 were randomized to (a) the MI intervention, (b) an active comparison condition (health education) or (c) standard care only before donation. Ambivalence was reassessed postintervention (before donation). Primary trial outcomes-psychosocial variables in somatic, psychological and family interpersonal relationship domains-were assessed at 6 weeks and 3 months postdonation. MI subjects showed the greatest decline in ambivalence (p = 0.050). On somatic outcomes, by 3 months postdonation MI subjects reported fewer physical symptoms (p = 0.038), lower rates of fatigue (p = 0.021) and pain (p = 0.016), shorter recovery times (p = 0.041) and fewer unexpected medical problems (p = 0.023). Among psychological and interpersonal outcomes, they had a lower rate of anxiety symptoms (p = 0.046) and fewer unexpected family-related problems (p = 0.045). They did not differ on depression, feelings about donation or family relationship quality. The findings suggest that the intervention merits testing in a larger, multisite trial.

Race and ethnicity in decisions about unrelated hematopoietic stem cell donation

Large international registries of potential unrelated hematopoietic stem cell (HSC) donors, including the National Marrow Donor program (NMDP), continue to face difficulties finding matched donors for racial/ethnic minorities. One reason, in addition to the generally less common HLA types among minority patients, is the much higher registry attrition rate of racial/ethnic minorities compared with whites. Reasons for the higher attrition among minority potential donors remain unexplained. The goal of our cross-sectional telephone interview study was to generate a diverse sample of potential HSC donors who have preliminarily matched a patient and to identify factors associated with race/ethnicity and with the decision to continue toward potential donation or to opt out of the registry. Multiple culturally related, psychosocial, and donation-related factors were associated both with race/ethnic group membership and attrition from the registry. The most consistent factor associated with opting out of the registry across all race/ethnic groups was ambivalence about donation: doubts and worries, feeling unsure about donation, wishing someone else would donate in one's place. Our findings suggest that universal donor recruitment and management approaches based on reducing donation-related ambivalence and tailored messages and strategies for each of the individual race/ethnic groups are important.

Prevention of poor psychosocial outcomes in living organ donors: from description to theory-driven intervention development and initial feasibility testing

CONTEXT

Although some living donors experience psychological, somatic, and interpersonal difficulties after donation, interventions to prevent such outcomes have not been developed or evaluated.

OBJECTIVE

To (1) summarize empirical evidence on psychosocial outcomes after donation, (2) describe a theoretical framework to guide development of an intervention to prevent poor outcomes, and (3) describe development and initial evaluation of feasibility and acceptability of the intervention.

METHODS

Based on a narrative literature review suggesting that individuals ambivalent about donation are at risk for poor psychosocial outcomes after donation, the intervention targeted this risk factor. Intervention structure and content drew on motivational interviewing principles in order to assist prospective donors to resolve ambivalence. Data were collected on donors' characteristics at our institution to determine whether they constituted a representative population in which to evaluate the intervention. Study participants were then recruited to assess the feasibility and acceptability of the intervention. They were required to have scores greater than 0 on the Simmons Ambivalence Scale (indicating at least some ambivalence about donation).

RESULTS

Our population was similar to the national living donor population on most demographic and donation-related characteristics. Eight individuals who had been approved to donate either a kidney or liver segment were enrolled for pilot testing of the intervention. All successfully completed the 2-session telephone-based intervention before scheduled donation surgery. Participants' ratings of acceptability and satisfaction were high. Open-ended comments indicated that the intervention addressed participants' thoughts and concerns about the decision to donate.

CONCLUSIONS

The intervention is feasible, acceptable, and appears relevant to donor concerns. A clinical trial to evaluate the efficacy of the intervention is warranted.