Patient Perspectives on Weight Management for Living Kidney Donation.

BACKGROUND: Living kidney donors (LKDs) with obesity have increased perioperative risks and risk of end-stage renal disease after donation. Consequently, obesity serves as a barrier to donation, as many transplant centers encourage or require weight loss before donation for obese LKD candidates. Therefore, this study sought to assess patients' perspectives on weight management strategies before donation among obese LKD candidates. We hypothesized that willingness to participate in a weight loss program may be associated with donor-recipient relationship. MATERIALS AND METHODS: Obese (BMI ≥30 kg/m2) LKD candidates evaluated at a single institution from September 2017 to August 2018 were recruited. A survey was administered to assess LKD candidates' baseline exercise and dietary habits and their interest in weight management strategies for the purpose of donation approval. Participants were grouped by relationship to the recipient (close relatives: first-degree relatives or spouses [n = 29], compared with all other relationships [n = 21]). Descriptive statistics were used to summarize the data. RESULTS: 50 of 51 obese LKD candidates who were approached completed the survey. 90% of participants expressed willingness to lose weight if necessary to become eligible for donor nephrectomy. Compared with all other LKD candidates, close relatives were more likely to be interested in combined diet and exercise programs at our institution (P = 0.01). CONCLUSIONS: Among obese LKD candidates, there was an interest in weight loss for the purposes of living kidney donation approval, particularly among close relatives of potential recipients. Future programs designed to promote weight management efforts for obese LKD candidates should be considered.

Long-term donor quality of life after living donor liver transplantation in Japan.

AIMS: This study examined the long-term quality of life (QOL) of living liver donors (LLDs) in Japan using both generic and LLD-specific instruments. METHODS: The sample comprised 374 LLDs from five university hospitals in Japan who underwent surgery more than a year previously. QOL was evaluated using the Short Form-36 health survey (SF-36) and LLD-QOL scale. RESULTS: SF-36 results indicated that the overall long-term QOL of LLDs was significantly better than the Japanese standard. When comparing by donor factors, LLDs whose recipients were children scored higher for "satisfaction" than those whose recipients were adults on the LLD-QOL scale. LLDs with complications had lower QOL for "scars" and "burden" on the LLD-QOL scale but no differences in SF-36 scores. LLDs with longer hospital stay had lower physical QOL on SF-36 and lower QOL for "scars" and "after-effects" on the LLD-QOL scale. LLDs whose recipients have died showed lower mental QOL on SF-36 and lower "satisfaction" and greater "lack of understanding of donor health" on the LLD-QOL scale. CONCLUSIONS: Our multicenter study clarified the long-term QOL of LLDs and suggested that donors' QOL was related to the donors' and recipients' ages, donor's complications and hospital stay length, and recipient's prognosis.

Autologous Breast Reconstruction With the Latissimus Dorsi Muscle With Immediate Fat Grafting: Long-term Results and Patient Satisfaction.

OBJECTIVE: The aim of this study was to describe a variation of the breast reconstruction technique with myocutaneous flap of the fat-grafted latissimus dorsi muscle and its outcomes and evaluation of patient satisfaction. METHOD: This prospective cohort study included 18 patients and 19 reconstructed breasts, with 1 bilateral case. There were 7 cases of late reconstruction and 11 cases of immediate reconstruction. The flap was prepared with fat at the time of surgery, which was injected before its preparation. The evaluation of the results regarding shape, volume, and symmetry was performed through a satisfaction scale completed by patients and 2 physicians from 12 to 18 months after reconstruction. RESULTS: On average, 171.31 mL of fat was injected (100-275 mL); the average time of unilateral surgery was 3 hours 42 minutes (3 hours to 4 hours 30 minutes). After a mean follow-up of 26.38 months (13-38 months), we did not observe complications of this new technique. In the evaluation performed by patients regarding the shape, volume, and symmetry, more than 80% rated the outcome as excellent and good, and the evaluations by the medical team were also satisfactory. In the comparative analysis between immediate and late reconstruction, patients who underwent immediate reconstruction were more satisfied. CONCLUSIONS: This reconstruction technique with autologous fat injection was effective, with satisfactory and long-lasting results, and without the requirement for implants to set breast shape and volume.

Factors associated with perceived donation-related financial burden among living kidney donors.

The perception of living kidney donation-related financial burden affects willingness to donate and the experience of donation, yet no existing tools identify donors who are at higher risk of perceived financial burden. We sought to identify characteristics that predicted higher risk of perceived financial burden. We surveyed 51 living kidney donors (LKDs) who donated from 01/2015 to 3/2016 about socioeconomic characteristics, predonation cost concerns, and perceived financial burden. We tested associations between both self-reported and ZIP code-level characteristics and perceived burden using Fisher's exact test and bivariate modified Poisson regression. Donors who perceived donation-related financial burden were less likely to have an income above their ZIP code median (14% vs. 72%, P = .006); however, they were more likely than donors who did not perceive burden to rent their home (57% vs. 16%, P = .03), have an income <$60 000 (86% vs. 20%, P = .002), or have had predonation cost concerns (43% vs. 7%, P = .03). Perceived financial burden was 3.6-fold as likely among those with predonation cost concerns and 10.6-fold as likely for those with incomes <$60 000. Collecting socioeconomic characteristics and asking about donation-related cost concerns prior to donation might allow transplant centers to target financial support interventions toward potential donors at higher risk of perceiving donation-related financial burden.

Donor and Recipient Perspectives on Anonymity in Kidney Donation From Live Donors: A Multicenter Survey Study.

BACKGROUND: Maintaining anonymity is a requirement in the Netherlands and Sweden for kidney donation from live donors in the context of nondirected (or unspecified) and paired exchange (or specified indirect) donation. Despite this policy, some donors and recipients express the desire to know one another. Little empirical evidence informs the debate on anonymity. This study explored the experiences, preferences, and attitudes of donors and recipients toward anonymity. STUDY DESIGN: Retrospective observational multicenter study using both qualitative and quantitative methods. SETTING & PARTICIPANTS: 414 participants from Dutch and Swedish transplantation centers who received or donated a kidney anonymously (nondirected or paired exchange) completed a questionnaire about anonymity. Participation was a median of 31 months after surgery. FACTORS: Country of residence, donor/recipient status, transplant type, time since surgery. OUTCOMES: Experiences, preferences, and attitudes toward anonymity. RESULTS: Most participants were satisfied with their experience of anonymity before and after surgery. A minority would have liked to have met the other party before (donors, 7%; recipients, 15%) or after (donors, 22%; recipients, 31%) surgery. Significantly more recipients than donors wanted to meet the other party. Most study participants were open to meeting the other party if the desire was mutual (donors, 58%; recipients, 60%). Donors agree significantly more with the principle of anonymity before and after surgery than recipients. Donors and recipients thought that if both parties agreed, it should be permissible to meet before or after surgery. There were few associations between country or time since surgery and experiences or attitudes. The pros and cons of anonymity reported by participants were clustered into relational and emotional, ethical, and practical and logistical domains. LIMITATIONS: The relatively low response rate of recipients may have reduced generalizability. Recall bias was possible given the time lag between transplantation and data collection. CONCLUSIONS: This exploratory study illustrated that although donors and recipients were usually satisfied with anonymity, the majority viewed a strict policy on anonymity as unnecessary. These results may inform policy and education on anonymity.

Organ Donation Following Neurologic and Circulatory Determination of Death.

OBJECTIVES: To describe important considerations during the process of caring for critically ill children who may be potential organ donors and supporting the family during the death of their child. DESIGN: Literature review and expert commentary. MEASUREMENT AND MAIN RESULTS: Medical literature focusing on pediatric donation, best pediatric donation practices, donor management, and factors influencing donation were reviewed. Additional pediatric data were obtained and reviewed from the U.S. Organ Procurement and Transplantation Network. Achieving successful organ donation requires the coordinated efforts of the critical care team, organ donation organization, and transplant team to effectively manage a potential donor and recover suitable organs for transplantation. Collaboration between these teams is essential to ensure that all potential organs are recovered in optimal condition, to reduce death and morbidity in children on transplantation waiting lists as well as fulfilling the family's wishes for their dying child to become a donor. CONCLUSIONS: Organ donation is an important component of end-of-life care and can help the healing process for families and medical staff following the death of a child. The process of pediatric organ donation requires healthcare providers to actively work to preserve the option of donation before the death of the child and ensure donation occurs after consent/authorization has been obtained from the family. Medical management of the pediatric organ donor requires the expertise of a multidisciplinary medical team skilled in the unique needs of caring for children after neurologic determination of death and those who become donors following circulatory death after withdrawal of life-sustaining medical therapies.

Opting out: a single-centre pilot study assessing the reasons for and the psychosocial impact of withdrawing from living kidney donor evaluation.

Understanding why individuals opt out of living donation is crucial to enhancing protections for all living donors and to identify modifiable barriers to donation. We developed an ethical approach to conducting research on individuals who opted out of living kidney donation and applied it in a small-scale qualitative study at one US transplant centre. The seven study participants (64% response rate) had varied reasons for opting out, the most prominent of which was concern about the financial burden from lost wages during the postoperative period. Several reported feeling alone during their decision-making process. Although no participants used an alibi, a centre-provided statement of non-eligibility to donate, all believed that centres should offer alibis to help preserve donor autonomy. Given the complexity of participants' decisions and the emotions they experienced before and after deciding not to donate, we suggest approaches for independent living donor advocates to support this population. This study demonstrates that research on individuals who opt out of donation is feasible and yields valuable insight into methods to improve the evaluation experience for potential living donors.

What information about donation after circulatory death is available on the Internet for potential donor families?

INTRODUCTION: The purpose of this study is to determine what information about donation after circulatory death (DCD) is available on the Internet and to document the common statements for and against DCD. METHODS: The search terms non-heart-beating donor, donation after cardiac death, DCD, deceased donor, organ donation, and organ harvesting were entered into the four most-accessed English-language Internet search engines. The top 10 webpages from each search (240 webpages) yielded 116 unique sites. Three reviewers reviewed each webpage and recorded statements for and against DCD as well as site type, tone, and mention of DCD. RESULTS: While 59 (50.9%) of the overall 116 sites included DCD information, only 10% of sites found with the term "organ donation" mentioned DCD at all. The sites that did include DCD were mostly (78%) of the type "medical journal" or "hospital or university webpage" and 89% of these had a positive or neutral tone. Nine positive and nine negative tropes were defined using the Grounded Theory Method. CONCLUSION: This study reveals the lack of information regarding DCD in organ donation webpages. Thoughtful responses to these statements should be considered in family discussions and in the design of future webpages.

The learning curves in living donor hemiliver graft procurement using small upper midline incision.

The learning curve for performing living donor hemiliver procurement (LDHP) via small upper midline incision (UMI) has not been determined. Living donors (n=101) who underwent LDHP via UMI were included to investigate the learning curve using cumulative sum analysis. The cumulative sum analysis showed that nine cases for right lobe (case #23) and 19 cases for left lobe (case #32 in the whole series) are needed for stable and acceptable surgical outcomes in LDHP via UMI. The established phase (n=69, since case #33) had a significantly shorter operative time, a smaller incision size, and less blood loss than the previous learning phase (n=32, serial case number up to the last 19th left lobe case). Multivariate analysis showed that the learning phase, high body mass index ≥25 kg/m2 , and left lobe graft procurement are the factors associated with surgical events including operative blood loss ≥400 mL, operative time ≥300 minutes, or surgical complications ≥Clavien-Dindo grade II. There is an obvious learning curve in performing LDHP via UMI, and 32 cases including both 19 cases for left lobe and nine cases for right lobe are needed for having stable and acceptable surgical outcomes.

Does financial compensation for living kidney donation change willingness to donate?

The potential use of financial compensation to increase living kidney donation rates remains controversial in potentially introducing undue inducement of vulnerable populations to donate. This cross-sectional study assessed amounts of financial compensation that would generate motivation and an undue inducement to donate to family/friends or strangers. Individuals leaving six Departments of Motor Vehicles were surveyed. Of the 210 participants who provided verbal consent (94% participation rate), respondents' willingness to donate would not change (70%), or would increase (29%) with compensation. Median lowest amounts of financial compensation for which participants would begin to consider donating a kidney were $5000 for family/friends, and $10,000 for strangers; respondents reporting $0 for family/friends (52%) or strangers (26%) were excluded from analysis. Median lowest amounts of financial compensation for which participants could no longer decline (perceive an undue inducement) were $50,000 for family/friends, and $100,000 for strangers; respondents reporting $0 for family/friends (44%) or strangers (23%) were excluded from analysis. The two most preferred forms of compensation included: direct payment of money (61%) and paid leave (21%). The two most preferred uses of compensation included: paying off debt (38%) and paying nonmedical expenses associated with the transplant (29%). Findings suggest tolerance for, but little practical impact of, financial compensation. Certain compensation amounts could motivate the public to donate without being perceived as an undue inducement.

Latin Americans in Spain and their attitude toward living kidney donation.

INTRODUCTION: The Latin American (LA) population in Spain is ever increasing in size and is perfectly integrated into the social structure. The objectives were to analyze the attitude of citizens, born in Latin America and living in Spain, toward living kidney donation (LKD) and to determine the psychosocial variables affecting this attitude. MATERIAL AND METHODS: A sample of LA residents living in Spain was obtained randomly in 2010 and stratified according to the respondent's nationality (n = 1314). Attitude was evaluated using a validated questionnaire ("Proyecto Colaborativo Internacional Donante sobre Donación de Vivo Renal" Ríos). The survey was self-administered and completed anonymously. RESULTS: The questionnaire completion rate was 86% (n = 1.132). A total of 89% (n = 1003) were in favor of related living donation, and 30% if the donation were unrelated. The variables associated with attitude toward LKD were as follows: sex (p = 0.043); marital status (p = 0.013); previous experience of organ donation (p = 0.009); attitude toward deceased organ donation (p < 0.001); a respondent's belief that he or she could be a possible recipient of a future transplant (p < 0.001); knowledge of a partner's opinion (p = 0.021); family discussion about organ donation (p = 0.001); knowledge of the view of one's religion toward donation (p < 0.001); concern about "mutilation" after donation (p = 0.004); and evaluation of the risk from living donation (p = 0.036). CONCLUSIONS: The attitude of LA citizens residing in Spain was favorable both toward related LKD and unrelated living donation.

Easy come, easy go. Retention of blood donors.

Retention of blood donors has benefits over recruitment of new blood donors. Retention is defined as preventing donors from lapsing and eventually becoming inactive. This review paper discusses literature on the importance of efforts to retain donors, specifically new donors, since lapsing is most common before the fifth donation. Studies have found that intention to donate, attitudes towards blood donation and self-efficacy (does one feel capable of donating blood) are predictors of blood donation. Feelings of 'warm glow' predict donation behaviour better than altruism. The existing literature further suggests that first time donors can be retained by paying extra attention to adverse events (vasovagal reactions and fatigue). These events could be reduced by drinking water and muscle tension exercises. Feelings of anxiety (in regular donors) and stress can further prevent donors from returning. Planning donations amongst busy lives can help retention, and suggestions are given on which interventions might be helpful.

To be or not to be an organ donor: differences in attitudes between freshmen and senior medical students.

Despite a plethora of studies on overall attitudes related to organ donation in a health care setting, little is known as to whether or not medical students at various levels of undergraduate training have distinctive attitudes towards donation. The purpose of this study was to analyze attitudes of first- and sixth-year students towards organ donation. A total of 988 students in first (573) and the final, sixth, year (415) were recruited at the Faculty of Medicine, University of Belgrade (Serbia), in the period 2-9 December, 2013. Data were collected using an anonymous questionnaire. There were 3.0% of first-year and 3.9% of sixth-year students who were registered donors (p = 0.019). Sixth-year students felt statistically significantly more positive towards signing an organ donor card [odds ratio (OR) 1.45, 95% confidence interval (CI) 1.13-1.88]. Sixth-year students also considered that organ donation was sufficiently promoted, as well as that organ donation should be practiced unless there is a written notice of objection. In addition, sixth-year students had more confidence in local organ transplant institutions. In a multivariate logistic regression analysis significant predictor of positive attitude for signing organ donor card was being blood donor (OR 1.55, 95% CI 1.03-2.35). Undergraduate training and increase in overall medical knowledge seem to contribute in shaping positive attitudes towards being an organ donor. It would be beneficial that strategies for organ donation promotion target local centers for blood donor recruitment. Nevertheless, further promotion of organ donation is necessary to expand the total donor pool.

Living organ procurement from the mentally incompetent: the need for more appropriate guidelines.

With the case of Belgium as a negative example, this paper will evaluate the legitimacy of using mentally incompetents as organ sources. The first section examines the underlying moral dilemma that results from the necessity of balancing the principle of respect for persons with the obligation to help people in desperate need. We argue for the rejection of a radical utilitarian approach but also question the appropriateness of a categorical prohibition. Section two aims to strike a fair balance between the competing interests at stake and to define the conditions under which organ harvest from mentally incompetents might be morally acceptable. To this end, we morally assess the main requirements that have been put forward to allow organ removal from incompetent donors. We conclude that the current Belgian legislation is far too permissive and that national regulations that do not permit the harvest of non-regenerable organs from mentally incompetents in exceptional circumstances are too restrictive. On the basis of this discussion, we propose a number of guiding principles for decision-making in this area.

Attitudes to deceased organ donation and registration as a donor among minority ethnic groups in North America and the U.K.: a synthesis of quantitative and qualitative research.

OBJECTIVES: A systematic review and synthesis of quantitative and qualitative research were undertaken to examine attitudes to deceased donation and registration as an organ donor among ethnic minorities in the U.K. and North America. DESIGN: A systematic search and assessments of relevance and quality were conducted. Parallel syntheses were then undertaken of 14 quantitative and 12 qualitative papers followed by their integration. The synthesis was organised around five barriers that emerged as key issues: (1) knowledge regarding deceased donation and registration as a donor; (2) discussion of donation/registration with family members; (3) faith and cultural beliefs; (4) bodily concerns including disfigurement and intactness; and (5) trust in doctors and the health care system. RESULTS: In all countries, knowledge of organ donation and registration remained low despite public campaigns, with African-Americans and Black African and Black Caribbean populations in the U.K. often regarding organ donation as a 'white' issue. Each of the four attitudinal barriers was also more prevalent among ethnic minorities compared with the majority population. However, the significance of trust and uncertainties regarding religion/faith differed between groups, reflecting salient aspects of ethnic identity and experiences. Differences were also identified within ethnic groups associated with age and generation, although respect for the views of elders often influenced younger peoples' willingness to donate. CONCLUSION: There is a need for a more nuanced understanding of ethnicity and of variations in attitudes associated with country of origin, age/generation, socio-economic status and area of residence, to inform public campaigns and promote sensitive discussions with bereaved ethnic minority families. The traditional focus on knowledge and attitudes also requires to be complemented by a greater emphasis on organisational and service-related barriers and changes required to enhance ethnic minorities' access to registration as a donor and consent to deceased donation.

"It was just an unconditional gift." Self reflections of non-directed living kidney donors.

Non-directed living kidney donation is an important emerging type of donation, but there are concerns about ulterior motives and irrational decision-making. This study aimed to elicit the motivations and experiences of non-directed living kidney donors. Qualitative interviews were conducted with all 18 people who donated a kidney in the transplant unit of the South Island, New Zealand. Six major themes were identified: offering the chance of life (opportunity for normalcy in the recipient, good samaritanism), determination (resolute personal decision, rooted in stability, urgency, opportuneness), minimizing perceived risks (live with one kidney, trust in the medical system, physical and genetic resilience, taking chances, mental preparation, mild inconvenience), preserving anonymity (protecting donor anonymity, respecting recipient choice, receiving appreciation, knowing recipient outcomes, developing relationships), donor support (psychologic preparation, efficient coordination, reimbursement of expenses), and gaining benefits (improved fitness, empowerment and satisfaction, connectedness). Non-directed living kidney donors want to offer someone a chance of normal life; a decision driven by resoluteness and a sense of urgency. Kidney donation is perceived to offer improved fitness, and a sense of empowerment, satisfaction, and connectedness. Reluctance to consider non-directed donation programs solely on concerns of unrealistic or ill-motivations and potential feelings of donor regret appear unwarranted.

Comparison between psychosocial long-term outcomes of recipients and donors after adult-to-adult living donor liver transplantation.

The purpose of this study was to examine psychosocial states of recipients and donors several years after living donor liver transplantation (LDLT) and to find out the pre-transplant predictors of desirable post-transplant psychosocial states. The recipients and donors of adult-to-adult LDLT at Kyoto University Hospital, Japan, from November 2001 through July 2003 were interviewed and examined by means of questionnaires about anxiety, depression, and quality of life (QOL), and the participants were evaluated by the same test batteries sent by mail three to five yr after LDLT. Twenty-seven pairs of recipients and donors, 13 recipients, and three donors participated in this study. The recipients and the donors had a decline in social QOL. The main predictor of psychosocial states of the recipients was the length of wait for LDLT, and the predictors of the donors were family or support system availability and recipients' depressive states at LDLT. The donors who were spouses of the recipients had better QOL than other donors. It might be better to perform LDLT as soon as possible once LDLT has been judged to be necessary, and the relative who is on close terms with the recipient should be selected as donor.

Tacitly consenting to donate one's organs.

The common objection to opt-out systems of postmortal organ procurement is that they allow removal of a deceased person's organs without their actual consent. However, under certain conditions it is possible for 'silence'--failure to register any objection--conventionally and/or legally to count as genuine consent. Prominent conditions are that the consenter should be fully informed about the meaning of his or her silence and that the costs of registering dissent should be insignificant. This paper explicates this thesis and discusses some possible objections to it: (1) it cannot possibly be guaranteed that each citizen is aware of the meaning of silence; and (2) the system is slightly manipulative because it exploits a common defect in autonomous decision-making.