The experiences and impact of being deemed ineligible for living kidney donation: Semi-structured interview study

Understanding the Healthcare Needs of Living Kidney Donors Using the Picker Principles of Patient-centered Care: A Scoping Review

Living kidney donors (LKDs) undertake a complex and multifaceted journey when pursuing donation and have several unmet healthcare needs. A comprehensive understanding of these needs across their entire donation trajectory can help develop a patient-centered care model. We conducted a scoping review to synthesize empirical evidence, published since 2000, on LKDs' experiences with healthcare from when they decided to pursue donation to postdonation care, and what they reported as their care needs. We categorized them according to the 8 Picker principles of patient-centered care. Of the 4514 articles screened, 47 were included. Ample literature highlighted the need for (1) holistic, adaptable, and linguistically appropriate approaches to education and information; (2) systematic, consistent, and proactive coordination and integration of care; and (3) self-management and preparation to optimize perioperative physical comfort. Some literature highlighted the need for (4) better continuity and transition of care postdonation. Two key unmet needs were the lack of (5) a holistic psychosocial evaluation predonation and predischarge to provide emotional support and alleviation of fear and anxiety; and (6) access to specialty and psychosocial services postdonation especially when adverse events occurred. Limited literature explored the principles of (7) respect for patients' values, preferences, and expressed needs; and (8) involvement of family and friends as caregivers. We summarize several unmet healthcare needs of LKDs throughout their donation journey and highlight knowledge gaps. Addressing them can improve their well-being and experiences, and potentially address inequities in living kidney donation and increase living donor kidney transplantation.

Experiences of living kidney donors: A synthesis of unsolicited patient narratives

INTRODUCTION

Despite the lauded benefits of living kidney donation, there is growing evidence of the challenges that living kidney donors (LKD) encounter in their donation trajectory and gaps in healthcare service provision. However, most of the evidence is derived from research conducted by clinicians or academic investigators. Significantly less attention has been devoted to analyzing unsolicited accounts of LKDs' experiences.

METHODS

We conducted a review and synthesis of published unsolicited first-person narratives of LKDs and aimed to synthesize their experiences and identify care needs. Four electronic databases were searched and 27 LKD narratives were included in our final analysis. Thematic synthesis was used to generate themes inductively.

RESULTS

Although the majority of LKDs reported the act of donation to be a fulfilling experience, almost 48% reported encountering challenges in the care that they received. Also, 29% of LKDs reported experiencing an adverse clinical event. Five distinct themes emerged surrounding the donation experience and healthcare needs: 1) Educational needs due to perceived lack of transparency and compensating for knowledge gaps; 2) Respect for donor autonomy due to coercive influences from family or healthcare providers, lack of respect for donor preferences and loopholes in the consent process; 3) Unmet care needs related to poor communication with healthcare providers, coordination issues and inconsistent and inadequate long-term care; 4) Unanticipated outcomes due to economic costs and the emotional burden of donation; and 5) Contributing beyond the donation event by advocating for a balanced view of donation and generating support mechanisms.

CONCLUSION

In this synthesis of LKDs narratives, important care gaps and the need to advocate for a balanced perspective on living kidney donation were highlighted. Our review underscores the value of patients' own stories as critical evidence that can inform improvement in healthcare service delivery.

Values, Perspectives, and Experiences of Indigenous Māori Regarding Kidney Transplantation: A Qualitative Interview Study in Aotearoa/New Zealand

RATIONALE AND OBJECTIVE

In Aotearoa/New Zealand, Indigenous Māori experience inequitable delivery of kidney transplantation, despite disproportionately higher rates of kidney failure. This study describes Māori patients' and families' values, perspectives and experiences related to kidney transplantation.

STUDY DESIGN

Qualitative interview study: Setting and participants: We conducted 40 in-depth interviews of 40 Māori: eight who had received a transplant, twenty with chronic kidney disease which included ten on the deceased donor transplant list, nine who were interested in transplantation and not currently waitlisted or who were ineligible for waitlisting, and one who was not interested in transplantation. We interviewed four live kidney donors and eight family members including six who had experiences with donor assessment.

ANALYTICAL APPROACH

Data were analyzed inductively to generate themes and a conceptual framework.

RESULTS

We identified five major themes: actively seeking a kidney transplant; evolving attitudes toward traditional values and practices; being confronted by interpersonal and systemic racism; poor information and communication; and challenged by social determinants of health.

LIMITATIONS

Participants were recruited nationally through patient advocacy organisations and one regional kidney service. Potential participants unrelated to these groups or region could not be included.

CONCLUSIONS

Māori participants were highly motivated to seek kidney transplantation and were inspired by positive experiences through donating and receiving a kidney. However, they faced barriers including social determinants, racism, and lack of information that impacted both direct experiences of transplantation and access to transplantation services.

Exploring the impact of ineligibility on individuals expressing interest in a trial aimed at improving daily functioning regarding perceptions of self, research and likelihood of future participation

Background

Eligibility guidelines in research trials are necessary to minimise confounds and reduce bias in the interpretation of potential treatment effects. There is limited extant research investigating how being deemed ineligible for such trials might impact patients’ perceptions of themselves and of research. Better understanding of the impact of patient ineligibility could enhance design and implementation of future research studies.

Methods

Eight semi-structured telephone interviews were conducted to explore the impact of ineligibility on self-perceptions; perceptions regarding the nature of research; and the likelihood of expressing interest in future research. Data were collected and analysed thematically through inductive, interpretive phenomenological analysis (IPA).

Results

Five themes emerged regarding the experience of being deemed ineligible: (1) Being deemed ineligible is emotion and reaction evoking; (2) ‘Doing your bit’: Helping others and increasing the value of research; (3) Communication of ineligibility; (4) Appreciation for those who express interest; and (5) Subsequent perceptions and attitudes towards research.

Conclusions

The results suggest that being deemed ineligible can elicit negative emotional outcomes but is not likely to change perceptions of or attitudes towards research, possibly due to a desire to help similar others. Ineligibility can impact future participation in some cases, thus reducing the recruitment pool for subsequent research studies. Recommendations are provided to help minimise this risk. Advising of ineligibility in a personal way is recommended: with enhanced clarity regarding the reasoning behind the decision; providing opportunities to ask questions; and ensuring that appreciation for the patient’s time and interest are communicated.

The Tangible Benefits of Living Donation: Results of a Qualitative Study of Living Kidney Donors

The framework currently used for living kidney donor selection is based on estimation of acceptable donor risk, under the premise that benefits are only experienced by the recipient. However, some interdependent donors might experience tangible benefits from donation that cannot be considered in the current framework (ie, benefits experienced directly by the donor that improve their daily life, well-being, or livelihood).

Ethical challenges in nephrology: a call for action

The American Society of Nephrology, the European Renal Association-European Dialysis and Transplant Association and the International Society of Nephrology Joint Working Group on Ethical Issues in Nephrology have identified ten broad areas of ethical concern as priority challenges that require collaborative action. Here, we describe these challenges - equity in access to kidney failure care, avoiding futile dialysis, reducing dialysis costs, shared decision-making in kidney failure care, living donor risk evaluation and decision-making, priority setting in kidney disease prevention and care, the ethical implications of genetic kidney diseases, responsible advocacy for kidney health and management of conflicts of interest - with the aim of highlighting the need for ethical analysis of specific issues, as well as for the development of tools and training to support clinicians who treat patients with kidney disease in practising ethically and contributing to ethical policy-making.

A RAND-Modified Delphi on Key Indicators to Measure the Efficiency of Living Kidney Donor Candidate Evaluations

BACKGROUND AND OBJECTIVES

Many patients, providers, and potential living donors perceive the living kidney donor evaluation process to be lengthy and difficult to navigate.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We sought consensus on key terms and process and outcome indicators that can be used to measure how efficiently a transplant center evaluates persons interested in becoming a living kidney donor. Using a RAND-modified Delphi method, 77 participants (kidney transplant recipients or recipient candidates, living kidney donors or donor candidates, health care providers, and health care administrators) completed an online survey to define the terms and indicators. The definitions were then further refined during an in-person meeting with ten stakeholders.

RESULTS

We identified 16 process indicators (e.g., average time to evaluate a donor candidate), eight outcome indicators (e.g., annual number of preemptive living kidney donor transplants), and two measures that can be considered both process and outcome indicators (e.g., average number of times a candidate visited the transplant center for the evaluation). Transplant centers wishing to implement this set of indicators will require 22 unique data elements, all of which are either readily available or easily collected prospectively.

CONCLUSIONS

We identified a set of indicators through a consensus-based approach that may be used to monitor and improve the performance of a transplant center in how efficiently it evaluates persons interested in becoming a living kidney donor.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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