Depression diagnoses after living kidney donation: linking U.S. Registry data and administrative claims.

BACKGROUND: Limited data exist on correlates of psychological outcomes after kidney donation. METHODS: We used a database integrating Organ Procurement and Transplantation Network registrations for 4650 living kidney donors from 1987 to 2007 with administrative data of a U.S. private health insurer (2000-2007 claims) to identify depression diagnoses among prior living donors. The burden and demographic correlates of depression after enrollment in the insurance plan were estimated by Cox regression. Graft failure and death of the donor's recipient were examined as time-varying exposures. RESULTS: After start of insurance benefits, the cumulative frequency of depression diagnosis was 4.2% at 1 year and 11.5% at 5 years, and depression among donors was less common than among age- and gender-matched general insurance beneficiaries (rate ratio, 0.70; 95% confidence intervals [CI], 0.60-0.81). Demographic and clinical correlates of increased likelihood of depression diagnoses among the prior donors included female gender, white race, and some perioperative complications. After adjustment for donor demographic factors, recipient death (adjusted hazard ratio (aHR), 2.23; 95% CI, 1.11-4.48) and death-censored graft failure (aHR, 3.30; 95% CI, 1.49-7.34) were associated with two to three times the relative risk of subsequent depression diagnosis among nonspousal unrelated donors. There were trends toward increased depression diagnoses after recipient death and graft failure among spousal donors but no evidence of associations of these recipient events with the likelihood of depression diagnosis among related donors. CONCLUSIONS: Recipient death and graft loss predict increased depression risk among unrelated living donors in this privately insured sample. Informed consent and postdonation care should consider the potential impact of recipient outcomes on the psychological health of the donor.

How to increase living donation.

Living donation is the key to increasing access to successful solid organ transplantation worldwide. However, the means to expanding the number of living donors on a global scale are not known. Although there have been many suggestions for the best approach, cultural issues may limit the effectiveness of some strategies. Only a few ideas have been studied, and one in particular- outright payment to donors - may raise ethical issues that are difficult to surmount and might negatively alter altruistic behavior. With respect to the present environment, this article will describe some of the approaches that are being discussed to increase the number of living donors, with a particular focus on kidney transplantation.

A qualitative assessment of personal and social responsibility for kidney disease: the Increasing Kidney Disease Awareness Network Transplant Project.

INTRODUCTION: Limited qualitative research has explored opinions of kidney disease health care providers regarding racial and ethnic disparities in access to and receipt of kidney transplantation. METHODS: Key informant interviews were conducted among transplant nephrologists, nephrologists, transplant social workers, and transplant coordinators to determine barriers to transplantation among African Americans compared to whites with end-stage renal disease (ESRD). ANALYSIS: Thirty-eight interviews were audio recorded and transcribed to hardcopy for content analysis. Grounded theory was used to determine dominant themes within the interviews. Reliability and validity were ensured by several coinvestigators independently sorting verbatim responses used for generating themes and subsequent explanations. RESULTS: Several major categories arose from analysis of the transcripts. Under the category of personal and social responsibility for kidney transplantation, interviews revealed 4 major themes: negative personal behaviors, acquisition of and lack of self-treatment of comorbid conditions, lack of individual responsibility, and the need for more social responsibility. Many providers perceived patients as being largely responsible for the development of ESRD, while some providers expressed the idea that more social responsibility was needed to improve poor health status and disparities in kidney transplantation rates. CONCLUSION: Kidney disease health providers seemed torn between notions of patients' accountability and social responsibility for racial disparities in chronic kidney disease and ESRD. Further research is needed to clarify which aspects contribute most to disparities in access to transplantation.

The state of U.S. living kidney donors.

BACKGROUND AND OBJECTIVES: Increasing living kidney donation mandates ongoing assessment of living donors for future health risks and revision of national health policy. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Living kidney donors as reported to the Organ Procurement and Transplant Network database from January 1988 through December 2008 were reviewed for minor medical abnormalities, presence of donor health care coverage, and occurrence of surgical complications and death. RESULTS: At donation in 2008, 19.5% were obese, 2.0% had a history of hypertension, and 3.5% had proteinuria. The median estimated GFR of living donors was 92.2 ml/min. Additionally, 12.2% of donors were reported not to have health insurance at the time of donation. By racial background, 14.9% of black and 17.0% of Hispanic donors did not have insurance at donation. Perioperative complications included blood transfusion (0.4%), reoperation (0.5%), and vascular complications (0.2%). Death occurred within 30 days of donation in 0.03% donating between October 1999 and December 2008. During those same years, overall donor death was 2.8%. CONCLUSIONS: Almost one quarter of living donors have medical conditions that may be associated with future health risk. Close follow-up and a registry of these donors are necessary. Only then will we be able to inform prospective living donors most accurately of the real risk of donation on their health and survival. Additionally, these data speak to the need for a national discussion on the provision of health insurance for living donors.

Controversies in combined liver-kidney transplantation: indications and outcomes.

Controversy surrounds simultaneous transplantation of a kidney and a liver because the practice is increasing, and organs for transplant are limited. Not only do recipients of both organs use 2 rather than 1 organ, but the kidney in dual transplantation jumps to the front of a very long kidney wait-list. Furthermore, there is suspicion that some patients who undergo combined liver and kidney transplantation may have reversible renal failure. Likewise, inappropriate liver transplantation in those with end-stage renal disease is possible given the heavy weighting of kidney dysfunction in the calculation of the model for end-stage liver disease score. Thus, a better way to determine the recoverability of renal dysfunction in liver transplant candidates and the degree of liver disease in end-stage renal disease is needed. Standardized strategies for candidate evaluation, selection, and process review are also necessary to improve organ allocation in those with both liver and kidney disease. However, basic and clinical investigation will be needed before an optimal algorithm is possible.

A state-level application of the chronic illness breakthrough series: results from two collaboratives on diabetes in Washington State.

BACKGROUND: Breakthrough Series Collaboratives addressing chronic conditions have been conducted at the national level and in single health care delivery systems but not at the state level. Two state-level collaboratives were conducted: Diabetes Collaborative I (October 1999-November 2000) included 17 clinic teams from across the state, and Diabetes Collaborative II (February 2001-March 2002) included 30 teams and 6 health plans. METHODS: Both collaboratives took place in Washington State, where a diverse group of primary care practices participated, and health insurance plans partnered with the clinic teams. Teams individually tested and implement changes in their systems of care to address all components of the Chronic Care Model. RESULTS: All 47 teams completed the collaboratives, and all but one maintained a registry throughout the 13 months. Most teams demonstrated some amount of improvement on process and outcome measures that addressed blood sugar testing and control, blood pressure control, lipid testing and control, foot exams, dilated eye exams, and self-management goals. CONCLUSION: The benefits of holding collaboratives more locally include increased technical support and increased participation, translating into wider implementation of prevention-focused, patient-centered care.

Self-management aspects of the improving chronic illness care breakthrough series: implementation with diabetes and heart failure teams.

Self-management is an essential but frequently neglected component of chronic illness management that is challenging to implement. Available effectiveness data regarding self-management interventions tend to be from stand-alone programs rather than from efforts to integrate self-management into routine medical care. This article describes efforts to integrate self-management support into broader health care systems change to improve the quality of patient care in the Chronic Illness Care Breakthrough Series. We describe the general approach to system change (the Chronic Care Model) and the more specific self-management training model used. The process used in training organizations in self-management is discussed, and data are presented on teams from 21 health care systems participating in a 13-month-long Breakthrough Series to address diabetes and heart failure care. Available system-level data suggest that teams from a variety of health care organizations made improvements in support provided for self-management. Improvements were found for both diabetes and heart failure teams, suggesting that this improvement process may be broadly applicable. Lessons learned, keys to success, and directions for future research and practice are discussed.