Exploring donors' and recipients' attitudes about living donor kidney transplantation

Destination Transplant: Protocol for a Parallel-group Randomized Trial of an Educational Intervention to Increase Kidney Transplant Among Black People on the Transplant Waiting List

For most patients with kidney failure, living donor kidney transplant (LDKT) is their best treatment option. Compared with White people, Black people are more likely to have kidney failure but less likely to receive LDKTs. In this study, the investigators will test an educational intervention, Destination Transplant, designed to reduce this disparity, among Black people already listed for kidney transplant.

METHODS

The investigators will conduct a parallel group, 2-arm randomized clinical trial among 500 Black kidney transplant candidates. The main objective of this study is to test an educational and behavioral intervention that is designed to increase receipt of LDKT among transplant candidates (persons active on the deceased donor kidney transplant waiting list) who are Black. Candidates on the kidney transplant waiting list will be randomly assigned to 1 of 2 conditions: (1) a control group that will receive Usual Care, or (2) an Intervention group that will receive Destination Transplant, a 9-month intervention that includes an in-person group-based education session, postcards at monthly intervals, and a follow-up phone call from a transplant educator. At baseline and during 18 months of follow-up, demographic and clinical variables will be collected, as well as variables such as transplant derailers (factors that might be sources of delay, difficulty, or challenge to pursuing transplant), transplant knowledge, and health literacy, small steps taken to pursue LDKT, readiness for LDKT, decisional balance and self-efficacy LDKT, decisional conflict, family support, availability of potential living donors, and general health status.

CONCLUSIONS

This educational intervention aims to increase both readiness to pursue LDKT and actual receipt of LDKTs among Black and African American patients who are already on the kidney transplant waiting list. The aim of the intervention is to reduce racial disparities in access to LDKT.

Addressing Racial Disparities in Live Donor Kidney Transplantation Through Education and Advocacy Training

Background.

The Live Donor Champion (LDC) program trains kidney transplant (KT) candidates and their family/friends (“champions”) as educator-advocates for live donor KT (LDKT). This program was created to empower patients and champions, particularly African American (AA) waitlist candidates that historically had lower access to LDKT. We assessed changes in knowledge about and comfort discussing live donation and donor referral associated with LDC participation, both overall and by participant race.

Methods.

We compared 163 adult KT candidates who were LDC participants from October 2013 to May 2016 with 489 matched controls, both overall and by race. We compared changes in comfort and knowledge post-LDC using rank-sum tests among participants by race. We compared time to first live donor referral for participants versus controls, by race, using Cox regression.

Results.

Post-LDC versus pre-LDC, participants had higher median knowledge (83% versus 63% on 12-question quiz; P < 0.001) and comfort (1.8 versus 1 on 4-point Likert scale; P < 0.001). Among participants, AAs had similar baseline and final knowledge (P = 0.9 and P = 0.1, respectively) and baseline comfort (P > 0.9) as non-AAs but higher final comfort (2 versus 1.4; P = 0.005) than non-AAs. LDC participants were 5.8 times as likely as controls to have a live donor referral (aHR _3.765.78_8.89; P < 0.001); the impact of LDC participation was similar among non-AAs and AAs (p-interaction = 0.6).

Conclusions.

The LDC program increased knowledge, comfort, and live donor referral for non-AA and AA participants, underscoring the effectiveness in the program in promoting LDKT in a population with historically lower access to LDKT.

Comparing Emotional Adjustment of Living-donor and Deceased-donor Kidney Transplant Patients

Supplemental Digital Content is available in the text.

Kidney transplantation is regarded as the best treatment option for patients with end-stage renal disease. However, living-donor recipients (LDRs) and deceased-donor recipients (DDRs) still face challenges in transplant-specific emotional adjustment post-transplantation. Research distinguishing emotional adjustment between transplant groups has been limited to Western settings, with little attention given to Asian populations. As such, documenting and comparing the emotional adjustment of LDRs and DDRs in an ethnically diverse Asian setting in Singapore and identifying factors associated with emotional adjustment are of interest.

Decision support needs of kidney transplant candidates regarding the deceased donor waiting list: A qualitative study and conceptual framework

BACKGROUND

Kidney transplant candidates face complex decisions about transplant options such as living donation or acceptance of lower quality kidneys. We sought to characterize knowledge and decision support needs regarding kidney transplant outcomes and options.

METHODS

We conducted 10 interviews and four focus groups of 28 adult kidney transplant candidates from two centers in Minnesota. Transcripts were analyzed thematically using a grounded theory approach.

RESULTS

We identified four themes: First, candidates have a limited understanding of treatment options and demonstrate confusion or a lack of awareness about waiting list outcomes and prognosis. Second, candidates desired frank discussions about likely outcomes and individualized prognosis. Third, emotional barriers impact how patients make informed decisions. Finally, participants relied on the support of family and friends to help process information, and many favored the medical community engaging their family and friends in their medical decisions. These findings were incorporated into a conceptual model to support kidney transplant candidates in medical decision making.

CONCLUSIONS

Transplant candidates had limited understanding about treatment options and outcomes on the kidney transplant waiting list. Individualized risk information and cognitive approaches that recognize how patients process information and balance competing risks may improve informed decision making.

Moon phases and moon signs do not influence morbidity, mortality and long-term survival, after living donor kidney transplantation

Background

Approximately 11% of the German population are convinced that certain moon phases and moon signs may impact their health and the onset and clinical course of diseases. Before elective surgery, a considerable number of patients look to optimize the timing of the procedure based on the lunar cycle. Especially patients awaiting living donor kidney transplantation (LDKT) commonly look for an adjustment of the date of transplantation according to the moon calendar. This study therefore investigated the perioperative and long-term outcome of LDKT dependent on moon phases and zodiac signs.

Methods

Patient data were prospectively collected in a continuously updated kidney transplant database. Two hundred and seventy-eight consecutive patients who underwent LDKT between 1994 and December 2009 were selected for the study and retrospectively assigned to the four moon phases (new-moon, waxing-moon, full-moon, and waning-moon) and the corresponding zodiac sign (moon sign Libra), based on the date of transplantation. Preexisting comorbidities, perioperative mortality, surgical outcome, and long-term survival data were analyzed.

Results

Of all LDKT procedures, 11.9, 39.9, 11.5, and 36.5% were performed during the new, waxing, full, and waning moon, respectively, and 6.2% during the moon sign Libra, which is believed to interfere with renal surgery. Survival rates at 1, 5, and 10 years after transplantation were 98.9, 92, and 88.7% (patient survival) and 97.4, 91.6, and 80.6% (graft survival) without any differences between all groups of lunar phases and moon signs. Overall perioperative complications and early graft loss occurred in 21.2 and 1.4%, without statistical difference (p > 0.05) between groups.

Conclusion

Moon phases and the moon sign Libra had no impact on early and long-term outcome measures following LDKT in our study. Thus, concerns of patients awaiting LDKT regarding the ideal time of surgery can be allayed, and surgery may be scheduled independently of the lunar phases.

Concerns, Mental Health, and Quality of Life in Living Kidney Donation-Parent Donor Candidates Worry Less about Themselves

Even though the majority of living kidney donor candidates appear in good mental health and show few concerns little is known concerning the influence of the type of donor-recipient relationship on donor candidates' specific concerns with regard to kidney donation. 136 donor candidates at Virgen del Rocío University Hospital of Seville filled in the Scale of Concerns Regarding Living Kidney Donation of whom 105 donor candidates and their corresponding recipients (105 patients with End-Stage Renal Disease) were further evaluated with regard to mental health (Hospital Anxiety and Depression Scale, Beck Depression Inventory-II) and quality of life (SF-36 Health Survey). As hypothesized recipients scored higher on depression and lower on quality of life. Donor candidates intending to donate to their children were significantly less concerned about risks of donation for themselves compared to donor candidates donating to siblings. Our findings highlight the importance of the type of donor-recipient relationship to understand specific concerns of donor candidates and optimize psychosocial assessment and support. From an evolutionary perspective parents lack of concern about their own well-being can be seen as an altruistic behavior to increase children's fitness at the (potential) expense of their own fitness.

Expanding living kidney donor criteria with ex-vivo surgery for renal anomalies

INTRODUCTION

Renal transplantation remains the gold standard treatment for end-stage renal disease, with living donor kidneys providing the best outcomes in terms of allograft survival. As the number of patients on the waitlist continues to grow, solutions to expand the donor pool are ongoing. A paradigm shift in the eligibility of donors with renal anomalies has been looked at as a potential source to expand the living donor pool. We sought to determine how many patients presented with anatomic renal anomalies at our transplant centre and describe the ex-vivo surgical techniques used to render these kidneys suitable for transplantation.

METHODS

A retrospective review was performed of all patients referred for surgical suitability to undergo laparoscopic donor nephrectomy between January 2011 and January 2015. Patient charts were analyzed for demographic information, perioperative variables, urological histories, and postoperative outcomes.

RESULTS

96 referrals were identified, of which 81 patients underwent laparoscopic donor nephrectomy. Of these patients, 11 (13.6%) were identified as having a renal anomaly that could potentially exclude them from the donation process. These anomalies included five patients with unilateral nephrolithiasis, four patients with large renal cysts (>4 cm diameter), one patient with an angiomyolipoma (AML) and one patient with a calyceal diverticulum filled with stones. A description of the ex-vivo surgical techniques used to correct these renal anomalies is provided.

CONCLUSIONS

We have shown here that ex-vivo surgical techniques can safely and effectively help correct some of these renal anomalies to render these kidneys transplantable, helping to expand the living donor pool.

Inter- and Intrapersonal Barriers to Living Donor Kidney Transplant among Black Recipients and Donors

CONTEXT

End-stage renal disease (ESRD) is more common among Blacks, but Blacks are less likely to receive a live donor kidney transplant (LDKT).

OBJECTIVE

The objective of this study is to identify barriers and coping mechanisms that Black LDKT recipients and donors experienced while receiving or donating a kidney.

DESIGN

A qualitative study was conducted using structured interviews. Thematic analysis was used for data interpretation.

PARTICIPANTS

All 20 participants identified as Black, with two participants identifying themselves as multiracial. The mean age for the 14 recipients was 60, and the average age for the 6 living donors was 47.

RESULTS

Themes emerging from the data suggest both recipients and donors faced barriers in the LDKT experience. Recipients faced barriers associated with their denial and avoidance of the severity of their ESRD, their desire to maintain the privacy of their health status, and their refusal to approach potential donors. Donors encountered negative responses from others about the donors' desire to donate and the initial refusal of recipients to accept a LDKT offer. Recipients identified faith as a coping mechanism, while donors identified normalization of donation as their method of coping. Various types of social support helped donors and recipients navigate the transplant process.

CONCLUSION

Black LDKT recipients and donors must overcome barriers prior to receiving or donating a kidney. Most of these barriers arise from communication and interactions with others that are either lacking or undesirable. Future interventions to promote LDKT among Blacks may benefit by specifically targeting these barriers.

'Because you can't live on love': living kidney donors' perspectives on compensation and payment for organ donation

CONTEXT AND OBJECTIVE

Living kidney donation accounts for approximately half of all kidney transplantation in many countries and is central to health policy focused on increasing organ supply. However, little examination of the economic consequences of living kidney donation has been undertaken from the perspective of donors themselves. This article documents living kidney donors' views regarding recompense and payment for organ donation, based on their experience.

PARTICIPANTS

Twenty-five living kidney donors from New Zealand participated in this study.

METHODS

This qualitative study, based on thematic analysis, uses semi-structured in-depth interviews to examine the experiences of living kidney donors. Themes were organized around altruism and the 'gift', perceptions of shared corporeality and identity, and donor support.

RESULTS

Most participants agreed the donation process was costly in terms of time and money. Many incurred personal costs, and some experienced financial hardship. All the participants viewed financial hardship as a barrier to organ donation and favoured recompense for direct and indirect costs. Most did not support payment for organs, and none supported commercialization.

DISCUSSION AND CONCLUSIONS

The findings show that framing organ donation as a 'gift' can stymie discussion about reciprocity, remuneration and exchange, making talk about financial recompense difficult. Financial well-being, nonetheless, has implications for the ability to care for self and others post-operatively. We conclude that the economic consequences for living kidney donors in jurisdictions where recompense for direct and indirect costs is insufficient are unfair. Review of financial assistance for live organ donors is therefore recommended.

Mistrust, misperceptions, and miscommunication: a qualitative study of preferences about kidney transplantation among African Americans

BACKGROUND

Kidney transplantation rates in the United States are lower among African Americans than among whites. Well-documented racial disparities in access to transplantation explain some, but not all, of these differences. Prior survey-based research suggests that African American dialysis patients are less likely than whites to desire transplantation, but little research has focused on an in-depth exploration of preferences about kidney transplantation among African Americans. Thus, the purposes of this study were to explore preferences and to compare patients' expectations about transplantation with actual status on the transplant list.

METHODS

We conducted semistructured interviews with 16 African Americans receiving chronic hemodialysis. We analyzed the interviews using the constant comparative method of qualitative analysis. We also reviewed the dialysis center's transplant list.

RESULTS

Four dominant themes emerged: (1) varied desire for transplant; (2) concerns about donor source; (3) barriers to transplantation; and (4) lack of communication with nephrologists and the transplantation team. A thread of mistrust about equity in the transplantation process flowed through themes 2-4. In 7/16 cases, patients' understanding of their transplant listing status was discordant with their actual status.

CONCLUSIONS

Our study suggests that many African Americans on hemodialysis are interested in kidney transplantation, but that interest is often tempered by concerns about transplantation, including misconceptions about the risks to recipients and donors. Mistrust about equity in the organ allocation process also contributed to ambivalence. The discordance between patients' perceptions of listing status and actual status suggests communication gaps between African American hemodialysis patients and physicians. Clinicians should avoid interpreting ambivalence about transplantation as lack of interest.

The RaDIANT community study protocol: community-based participatory research for reducing disparities in access to kidney transplantation

BACKGROUND

The Southeastern United States has the lowest kidney transplant rates in the nation, and racial disparities in kidney transplant access are concentrated in this region. The Southeastern Kidney Transplant Coalition (SEKTC) of Georgia, North Carolina, and South Carolina is an academic and community partnership that was formed with the mission to improve access to kidney transplantation and reduce disparities among African American (AA) end stage renal disease (ESRD) patients in the Southeastern United States.

METHODS/DESIGN

We describe the community-based participatory research (CBPR) process utilized in planning the Reducing Disparities In Access to kidNey Transplantation (RaDIANT) Community Study, a trial developed by the SEKTC to reduce health disparities in access to kidney transplantation among AA ESRD patients in Georgia, the state with the lowest kidney transplant rates in the nation. The SEKTC Coalition conducted a needs assessment of the ESRD population in the Southeast and used results to develop a multicomponent, dialysis facility-randomized, quality improvement intervention to improve transplant access among dialysis facilities in GA. A total of 134 dialysis facilities are randomized to receive either: (1) standard of care or "usual" transplant education, or (2) the multicomponent intervention consisting of transplant education and engagement activities targeting dialysis facility leadership, staff, and patients within dialysis facilities. The primary outcome is change in facility-level referral for kidney transplantation from baseline to 12 months; the secondary outcome is reduction in racial disparity in transplant referral.

DISCUSSION

The RaDIANT Community Study aims to improve equity in access to kidney transplantation for ESRD patients in the Southeast.

TRIAL REGISTRATION

Clinicaltrials.gov number NCT02092727.

Your Path to Transplant: a randomized controlled trial of a tailored computer education intervention to increase living donor kidney transplant

BACKGROUND

Because of the deceased donor organ shortage, more kidney patients are considering whether to receive kidneys from family and friends, a process called living donor kidney transplantation (LDKT). Although Blacks and Hispanics are 3.4 and 1.5 times more likely, respectively, to develop end stage renal disease (ESRD) than Whites, they are less likely to receive LDKTs. To address this disparity, a new randomized controlled trial (RCT) will assess whether Black, Hispanic, and White transplant patients' knowledge, readiness to pursue LDKT, and receipt of LDKTs can be increased when they participate in the Your Path to Transplant (YPT) computer-tailored intervention.

METHODS/DESIGN

Nine hundred Black, Hispanic, and White ESRD patients presenting for transplant evaluation at University of California, Los Angeles Kidney and Pancreas Transplant Program (UCLA-KPTP) will be randomly assigned to one of two education conditions, YPT or Usual Care Control Education (UC). As they undergo transplant evaluation, patients in the YPT condition will receive individually-tailored telephonic coaching sessions, feedback reports, video and print transplant education resources, and assistance with reducing any known socioeconomic barriers to LDKT. Patients receiving UC will only receive transplant education provided by UCLA-KPTP. Changes in transplant knowledge, readiness, pros and cons, and self-efficacy to pursue LDKT will be assessed prior to presenting at the transplant center (baseline), during transplant evaluation, and 4- and 8-months post-baseline, while completion of transplant evaluation and receipt of LDKTs will be assessed at 18-months post-baseline. The RCT will determine, compared to UC, whether Black, Hispanic, and White patients receiving YPT increase in their readiness to pursue LDKT and transplant knowledge, and become more likely to complete transplant medical evaluation and pursue LDKT. It will also examine how known patient, family, and healthcare system barriers to LDKT act alone and in combination with YPT to affect patients' transplant decision-making and behavior. Statistical analyses will be performed under an intent-to-treat approach.

DISCUSSION

At the conclusion of the study, we will have assessed the effectiveness of an innovative and cost-effective YPT intervention that could be utilized to tailor LDKT discussion and education based on the needs of individual patients of different races in many healthcare settings.

TRIAL REGISTRATION

ClinicalTrials.gov, number NCT02181114.

Health-related and psychosocial concerns about transplantation among patients initiating dialysis

BACKGROUND AND OBJECTIVES

Disparities in kidney transplantation remain; one mechanism for disparities in access to transplantation (ATT) may be patient-perceived concerns about pursuing transplantation. This study sought to characterize prevalence of patient-perceived concerns, explore interrelationships between concerns, determine patient characteristics associated with concerns, and assess the effect of concerns on ATT.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Prevalences of 12 patient-perceived concerns about pursuing transplantation were determined among 348 adults who recently initiated dialysis, recruited from 26 free-standing dialysis centers around Baltimore, Maryland (January 2009-March 2012). Using variable reduction techniques, concerns were clustered into two categories (health-related and psychosocial) and quantified with scale scores. Associations between patient characteristics and concerns were estimated using modified Poisson regression. Associations between concerns and ATT were estimated using Cox models.

RESULTS

The most frequently cited patient-perceived concerns were that participants felt they were doing fine on dialysis (68.4%) and felt uncomfortable asking someone to donate a kidney (29.9%). Older age was independently associated with having high health-related (adjusted relative risk, 1.35 [95% confidence interval, 1.20 to 1.51], for every 5 years older for those ≥ 60 years) or psychosocial (1.15 [1.00 to 1.31], for every 5 years older for those aged ≥ 60 years) concerns, as was being a woman (1.72 [1.21 to 2.43] and 1.55 [1.09 to 2.20]), having less education (1.59 [1.08 to 2.35] and 1.77 [1.17 to 2.68], comparing postsecondary education to grade school or less), and having more comorbidities (1.18 [1.08 to 1.30] and 1.18 [1.07 to 1.29], per one comorbidity increase). Having never seen a nephrologist before dialysis initiation was associated with high psychosocial concerns (1.48 [1.01 to 2.18]). Those with high health-related (0.37 [0.16 to 0.87]) or psychosocial (0.47 [0.23 to 0.95]) concerns were less likely to achieve ATT (median follow-up time 2.2 years; interquartile range, 1.6-3.2).

CONCLUSIONS

Patient-perceived concerns about pursuing kidney transplantation are highly prevalent, particularly among older adults and women. Reducing these concerns may help decrease disparities in ATT.

Communication self-efficacy, perceived conversational difficulty, and renal patients' discussions about transplantation

OBJECTIVE

Many patients with chronic and end-stage renal disease (ESRD) have reported difficulties initiating and managing discussions about kidney transplantation, particularly live donor transplantation (LDT). Limited communication has demonstrable impact on patients' access to transplantation, the duration of dialysis treatments, and the length of time awaiting a transplantable kidney. This formative study sought to identify the specific communicative and conversational elements impeding ESRD patients' discussions about transplantation to inform the design of an educational program facilitating transplant-related discussions.

METHODS

From March to July 2012, semi-structured telephone interviews (n=63) were conducted with ESRD patients waitlisted for kidney transplantation at one mid-Atlantic transplant center.

RESULTS

Although 85.7% (n=54) of patients reported holding discussions about transplantation, qualitative analyses of open-ended responses revealed that the majority (66.7%) had limited conversations. Patients reported difficulties managing a variety of logistical and content-related aspects of LDT discussions. Moderate levels of communication self-efficacy were also found (mean=19.2 out of 28); self-efficacy was highest among respondents having held discussions and was significantly related to perceived magnitude of difficulty handling conversational aspects.

CONCLUSION

Results support comprehensive communication skills training for ESRD patients awaiting kidney transplantation.

PRACTICE IMPLICATIONS

Potential topics to be included in such training are discussed.

Understanding the relationship between trust in health care and attitudes toward living donor transplant among African Americans with end-stage renal disease

Transplantation is the favored therapy for patients with end-stage renal disease (ESRD). Unfortunately, demand for available organs far outpaces the supply. African Americans are disproportionately affected by the ever-widening gap between organ supply and demand. Additionally, structural, biological, and social factors contribute to feelings of unease some African Americans may feel regarding living donor transplant (LDT). The present research examines the relationship between trust in health care and attitudes toward LDT among African American ESRD patients. We hypothesized that lower trust in health care would be significantly associated with negative attitudes toward LDT, and that this relationship would be moderated by patient attitudes toward dialysis. Data were collected from August 2011 to April 2012 as part of a larger study. Measures included trust (of doctors, racial equity of treatment, and hospitals) and attitudes toward both LDT and dialysis. Bivariate analysis revealed that trust in one's doctor, hospital, and in racial equity in health care was significantly correlated with attitudes toward LDT (r = 0.265; r = 0.131; and r = 0.202, respectively). Additionally, attitudes toward dialysis moderated the relationships between Trust in Doctors/Attitudes toward LDT and Trust in Racial equity of treatment/Attitudes toward LDT. Findings suggest a strong relationship between trust in health care and attitudes toward LDT. These findings also shed light on how dialysis experiences are related to the relationship between trust in health care and attitudes toward LDT.

Decision making around living and deceased donor kidney transplantation: a qualitative study exploring the importance of expected relationship changes

Background

Limited data exist on the impact of living kidney donation on the donor-recipient relationship. Purpose of this study was to explore motivations to donate or accept a (living donor) kidney, whether expected relationship changes influence decision making and whether relationship changes are actually experienced.

Methods

We conducted 6 focus groups in 47 of 114 invited individuals (41%), asking retrospectively about motivations and decision making around transplantation. We used qualitative and quantitative methods to analyze the focus group transcripts.

Results

Most deceased donor kidney recipients had a potential living donor available which they refused or did not want. They mostly waited for a deceased donor because of concern for the donor’s health (75%). They more often expected negative relationship changes than living donor kidney recipients (75% vs. 27%, p = 0.01) who also expected positive changes. Living donor kidney recipients mostly accepted the kidney to improve their own quality of life (47%). Donors mostly donated a kidney because transplantation would make the recipient less dependent (25%). After transplantation both positive and negative relationship changes are experienced.

Conclusion

Expected relationship changes and concerns about the donor’s health lead some kidney patients to wait for a deceased donor, despite having a potential living donor available. Further research is needed to assess whether this concerns a selected group.

Living kidney donor decision making and communication

There is high demand for kidney donors in the United States, and it is widely accepted that living donation is optimal for individuals who need a kidney. Much research has focused on the potential recipient, but little has been studied about the communication and decision making of living kidney donors. Interviews assessed the communication and decision-making processes of 43 kidney donor volunteers. Almost all of the participants were not asked, but instead volunteered, to donate. The majority of donors reported having conversations with the recipient and speaking about their decisions with other individuals in their social networks besides the recipient. Some participants said that they stopped talking to others because of negative feedback. Future research should further examine the communication of donors with non-recipient others and potential methods of training recipients and donors to communicate effectively about the donation process.

Correlates of support for living donation among African American adults

CONTEXT

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

OBJECTIVE

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

DESIGN/PARTICIPANTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Haemodialysis patients' readiness to pursue live donor kidney transplantation

BACKGROUND

Despite the benefits of live donor kidney transplantation (LDKT) over deceased donor kidney transplantation, patients hesitate to pursue this option.

METHODS

A total of 324 transplant-eligible haemodialysis patients attending 14 dialysis facilities in Maryland, Northern Virginia and Southern Pennsylvania were asked about their stages of readiness to pursue LDKT, attitudes towards LKDT and demographics. Logistic regressions were used to test the effect of patients' attitudes and demographics on their stages of readiness to pursue LDKT.

RESULTS

Fewer than half of the patients who had heard about LDKT were considering this option. Among patients considering LDKT, 26% had not talked to their loved ones about LDKT and 54% had not asked anyone for a kidney. Concerns about the surgical procedure for the donor were associated with a lower likelihood of considering LDKT (adjusted OR = 0.38; CI 0.18-0.79), talking about LDKT (adjusted OR = 0.38; CI 0.18-0.78) and asking for a kidney (adjusted OR = 0.14; CI 0.06-0.36). Being satisfied with the information the patient received about LDKT was associated with a higher likelihood of talking with someone about LDKT and asking for a kidney (adjusted OR = 2.26; CI 1.33-3.83 and 3.89; CI 1.78-8.51). Women and younger patients were more likely to talk with family/friends about LDKT (respectively, adjusted OR = 1.76; CI 1.26-2.47 and 0.97; CI 0.95-0.99) and to ask for a kidney (respectively, adjusted OR = 4.36; CI 2.57-7.40 and 0.97; CI 0.94-0.99).

CONCLUSION

Tailored educational programmes considering the patient's stage of readiness and related attitudinal and demographic factors might help patients move towards LDKT.

A survey of nephrologists' views on preemptive transplantation

BACKGROUND AND OBJECTIVES

Despite emerging evidence that preemptive transplantation is the best treatment modality for patients reaching end-stage renal disease (ESRD), it is underutilized. Nephrologists' views on preemptive transplantation are explored herein.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A web-based survey elicited barriers to preemptive transplantation as perceived by nephrologists as well as demographic and practice variables associated with a favorable attitude toward preemptive transplantation.

RESULTS

Four hundred seventy-six of 5,901 eligible nephrologists responded (8% participation rate). Seventy-one percent of respondents agreed that preemptive transplantation is the best treatment modality for eligible chronic kidney disease (CKD) patients reaching ESRD, 69% reported that late referrals did not allow enough time for patients to be evaluated for preemptive transplantation, and 50% stated that there was too much delay between a patient's referral and the time the patient was seen at the transplant center. Nephrologists agreed to a lesser extent that they should be held accountable for CKD patients' education (26%) and preemptive transplant referrals (23%). The most important patient factors considered when deciding not to discuss preemptive transplant were poor health status (70%), lack of compliance (69%), other medical problems (51%), being too old (40%), lack of prescription coverage (37%), and lack of health insurance to cover the costs of the procedure (36%).

CONCLUSIONS

Surveyed nephrologists consider preemptive transplantation as the optimal treatment modality for eligible patients. Late referral, patient health and insurance status, and delayed transplant center evaluation are perceived as major barriers to preemptive transplantation.

The association of state and national legislation with living kidney donation rates in the United States: a national study

The effect of state legislation and federal policies supporting living donors on living kidney donation rates in the United States is unknown. We studied living kidney donation rates from 1988 to 2006, and we assessed changes in donation before and after the enactment of state legislation and the launch of federal initiatives supporting donors. During the study, 27 states enacted legislation. Among states enacting legislation, there was no statistically significant difference in the average rate of increase in overall living kidney donations after compared to before state legislation enactment (annual increase in donations per 1 000 000 population [95% confidence interval] 2.39 [1.94-2.84] compared to 1.68 [0.89-2.47] respectively, p > 0.05). Among states not enacting legislation, there was a statistically significantly greater annual increase in overall donation rates from 1997 to 2002 compared to before 1997 when federal initiatives commenced, but there was no growth in annual rates after 2002. State and federal legislation were associated with increases in living-unrelated donation. These findings suggest that although existing public policies were not associated with improvements in the majority of donations from living-related donors, they may have had a selective effect on barriers to living-unrelated kidney donation.

Experience of donation and quality of life in living kidney and liver donors

Italian guidelines on living donation demand that we ascertain the donor's free and informed consent. Assessments to do so have to be conducted by an independent 'third party' who has nothing to do with the medical team treating the recipient. From February 2002 to December 2006, the Veneto Regional Authority's Third Party Commission evaluated 201 living liver and kidney donors. A sample of these were contacted after their surgery to assess their living donation experience and quality of life (QoL); 81 were eligible for the assessment and 69 (85.2%) responded. All donors involved in the study completed an anonymous document that included the SF-36 and a questionnaire on their donation experience. The majority (96%) of the sample expressed a positive global opinion of the experience. We concluded that the donation had positive effects on their QoL and that family support had a fundamental influence on their general well-being, and their psychic balance in particular. Some crucial issues emerged, however, i.e. 11% of donors judged the information received before the operation inadequate, 17% reported a subjective perception of bodily changes after the operation and 14% were concerned about their current health: these findings emphasize the importance of informing potential donors thoroughly before they submit to surgery.

The dynamics of recipient-donor relationships in living kidney transplantation

Psychosocial issues in kidney transplant donors and recipients are a cause for concern. We reviewed studies that investigated psychosocial issues in donors and recipients of living kidney transplants. A variety of instruments were used for this purpose. However, there was a lack of consensus regarding the structure and method of psychosocial assessment in living kidney donors. We found that only a few centers currently carry out a systematic psychosocial follow-up of recipients and their donors. The majority of psychosocial studies were of living kidney donors, indicating a preference of researchers to study psychosocial issues in live kidney donors. We believe living kidney transplant recipients are also an important group, and more studies should be done to better understand the psychosocial issues in this group. The majority of studies were retrospective in nature. We also discuss relationships, interactions, and communication patterns that characterize living kidney donation. We place emphasis on understanding the relational history of donors and recipients to provide supportive intervention and enable the potential donor make an informed decision about surgery. We recommend comprehensive psychosocial screening before and after transplantation and donation. This may decrease psychological problems and increase satisfaction with the transplantation process. Furthermore, the transplant community will need to address the type of instruments, duration of follow-up, and funding sources to carry out our recommendations.

Donor Gender Balance in a Living-Related Kidney Transplantation Program in Oman

It has been observed in several Eastern and Western countries that there is a gender imbalance among kidney donors. In the international experience, approximately 65% of live kidney donors have been women. We retrospectively studied the distribution of female and male donors or recipients among living kidney transplantations performed from 1980 to 2005, namely 198 Omani recipients of living-related kidney transplantations. To examine cultural influences, transplantations performed or expatriates were excluded from the study. For the whole period, 98 out of 198 donors (49.5%) were women. The number of female recipients 75 of 198 (38%) versus males were 123 (62%) recipients. We then subdivided the period into three intervals: 1980 to 1990, 1991 to 2000, and 2001 to 2005. The numbers of female donors for these three periods were 29 of 64 (45%), 42 of 89 (47%), and 27 of 45 (60%), respectively. There was a persistent preponderance of male recipients ranging from 58% to 66% during these periods. We concluded that there was no gender imbalance for kidney donors. Nevertheless, there was a male preponderance in the recipient group.

Improving on-line information for potential living kidney donors

Individuals who consider becoming living kidney donors often search the internet for reliable information before contacting the transplant center. The quality of such information requires due consideration. Using the search engines Google and Yahoo and the WebMD information portal, two reviewers independently abstracted data on the classification, readability, and general quality of websites. The coverage and accuracy of each site's discussion of the risks, benefits, and process of living donation was also assessed against a checklist of recommended information. Eighty-six unique websites on living kidney donation were found. Most were created by transplant programs and transplant organizations. Although the content of most sites was accurate, almost all (98%) were written above the recommended patient reading level (i.e., fifth grade). On average, each site covered 38% of the recommended information on living donation (range 8-76%). Educational topics of potential long-term medical risks, psychological risks, and expected benefits to the donor were often missing. The most visited websites were often not ranked among the best sites to provide information. By better understanding the nature of on-line information, transplant professionals can direct their patients to the best available websites. Local educational efforts, including the effective use of internet resources, will ensure living donation and complete understanding of the risks by potential donors and recipients.

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

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

Living donors' experiences 1 wk after donating a kidney

In Norway living kidney donors account for approximately 40% of all renal transplants. There is a shortage of information about how living kidney donors experience the donation process during the initial recovery from surgery. The aim of this study was to explore physical and psychosocial issues related to the experiences of living kidney donors 1 wk after open donor nephrectomy. A total of 12 living kidney donors participated in the study. Data were collected by individual in-depth interviews and analysed using empirical phenomenological method. Being a living kidney donor is a complex experience. The informants expressed strong feelings of responsibility and obligation concerning the recipients and had a positive attitude towards the donation. On the other hand, the donors experienced it strange to be a fit individual and go through a major operation. Several of the donors reported that it was painful to go through donor surgery and regarded the recovery period as troublesome. Some donors also reported the double role of being both a patient and a relative to be a stressful experience. This study reveals the importance of being aware of the complex situation of living kidney donors. Health professionals need to understand the nature of the donation process and the donors' needs. It is essential to focus on physical, mental and interpersonal factors when counselling potential living kidney donors.