Experience Of Kidney Transplantation Research Articles

The Experience of ABO Incompatible Kidney Transplantation in Japanese Single Center

In Japan, because of lack of deceased kidney donors, living donor kidney transplantation is mainly performed and some quantity of ABO incompatible transplantation is included. ABO incompatible kidney transplantation demonstrate an upward trend and account for about 40% of living donor kidney transplantation in our center today. (Figure 1) 78 cases of ABO incompatible kidney transplantation have been performed in our center so far, and recent results are good. So we report our experience of ABO incompatible kidney transplantation.[Figure 1]Though initial ABO incompatible kidney transplantation in our center was performed on October 9th, 1990, we stopped this program February, 1996 by reason of poor results. 5 years and 8 months later, we restarted ABO incompatible kidney transplantation program with new immunosuppressive regimen using mycophenolate mofetil (MMF). New immunosuppressive regimen lead to a better results, but at that time, we resected recipient's spleen for suppressing the immune reaction by B cells. 4 years later, we started to use rituximab instead of splenectomy. Our recent immunosuppressive regimen contains calcineurin inhibitor (tacrolims or cyclosporin), antimetabolite (MMF or mizoribine (Mz)), prednisolone, rituximab, and basiliximab. Additionally, several time of plasma exchange (PE) or double filtration plasmapheresis (DFPP) is performed preoperatively for removal of blood group antibody and anticoagulant therapy with nafamostat mesilate and administration of fresh frozen plasma (FFP) of blood group AB will be performed after transplantation. Though results in the early period was not good, recent results are very good and comparable to ABO compatible cases. (Figure 2) But long-term graft survivals are inapparent, so more cases and research are needed.[Figure 2]

Maximizing Utilization of Organs from Marginal Donors - A Single-Centre Experience of Dual Kidney Transplantation

Maximizing Utilization of Organs from Marginal Donors - A Single-Centre Experience of Dual Kidney Transplantation

Retroperitoneoscopic Living Donor Nephectomy and Laparoscopic Kidney Transplantation: Experience of First 72 Cases

Introduction: Laparoscopic surgery is having advantages of less pain, early ambulation, better cosmesis and better convalescence in compare to open surgery. Kidney transplantation is conventionally performed by open approach. We herewith present our experience of laparoscopic kidney transplantation following live donor nephrectomy and compare the data with open conventional kidney transplantation. Methods: Between February 2010 and January 2012 total 217 renal transplantations were performed from living donor by single surgical unit. All living donor nephrectomy were performed by retroperitoneoscopic approach. Recipient surgery was performed either laparoscopically (group 1, n= 72) or by conventional open approach (group 2, n=145). Laparoscopic recipient surgery was performed under general anesthesia with endotracheal intubation. Four or five ports were placed and external iliac vessels were mobilized. A 5 cm Pfannenstiel incision was placed and kidney was dropped into abdomen. Renal vessels were anastomosed in end to side fashion by free hand suturing technique using 5/0 polypropylene suture. Ureteroneocystostomy was performed by modified Lich-Gregoir method using 4/0 polyglactin suture. No stent was used in any case. Kidney was retroperitonealized in all but 6 cases. CNI based immunosuppressants were given in all patients. All recipients were followed by color doppler ultrasound at day 1,7 and thenafter as and when required in follow up. Results: Data analysis was performed by SPSS software version 12. Recipients in group 1 were having significant longer operative time and rewarming time than in group 2 (p< 0.03). No significant difference was found in blood loss and delayed graft function. Mean wound length was 5.5 cm± 0.8 cm in group 1 while 17.8 cm ± 4.6 cm in group 2. Serum Creatinine value on day 7 and 30 was significantly more in group 1 (p=0.01) but no difference was found at one year. In group 1, four cases require conversion to open surgery due to vascular complications. One case of urinary leak required open exploration on 9th post operative day for ureteral reimplantation in group 1. No vascular or urinary complications were seen in group 2. Perigraft collection was seen in 9 cases in group 2 while none in group 1. Visual Analogue Score for pain was significantly less in group 1 (p< 0.05). Kaplan Meier curve shows one year graft survival 87.7% and 96.5% p=0.02, and patient survival was 98% and 96.8% in group 1 and 2 respectively. Conclusion: Laparoscopic kidney transplantation following living donor nephrectomy is feasible. It has steep initial learning curve. Retroperitonealization of renal allograft is necessary to avoid torsion and related graft loss. Pain is significantly less in compare to open kidney transplantation surgery.

Kidney donation after circulatory death in a country with a high number of brain dead donors: 10-year experience in Belgium

Worldwide shortage of standard brain dead donors (DBD) has revived the use of kidneys donated after circulatory death (DCD). We reviewed the Belgian DCD kidney transplant (KT) experience since its reintroduction in 2000. Risk factors for delayed graft function (DGF) were identified using multivariate analysis. Five-year patient/graft survival was assessed using Kaplan-Meier curves. The evolution of the kidney donor type and the impact of DCDs on the total KT activity in Belgium were compared with the Netherlands. Between 2000 and 2009, 287 DCD KT were performed. Primary nonfunction occurred in 1% and DGF in 31%. Five-year patient and death-censored graft survival were 93% and 95%, respectively. In multivariate analysis, cold storage (versus machine perfusion), cold ischemic time, and histidine-tryptophan-ketoglutarate solution were independent risk factors for the development of DGF. Despite an increased number of DCD donations and transplantations, the total number of deceased KT did not increase significantly. This could suggest a shift from DBDs to DCDs. To increase KT activity, Belgium should further expand controlled DCD programs while simultaneously improve the identification of all potential DBDs and avoid their referral for donation as DCDs before brain death occurs. Furthermore, living donation remains underused.

Donation after cardiac death: A 29-year experience

To report the long-term outcomes of 1218 organs transplanted from donation after cardiac death (DCD) donors from January 1980 through December 2008. One-thousand two-hundred-eighteen organs were transplanted into 1137 recipients from 577 DCD donors. This includes 1038 kidneys (RTX), 87 livers (LTX), 72 pancreas (PTX), and 21 DCD lungs. The outcomes were compared with 3470 RTX, 1157 LTX, 903 PTX, and 409 lung transplants from donors after brain death (DBD). Both patient and graft survival is comparable between DBD and DCD transplant recipients for kidney, pancreas, and lung after 1, 3, and 10 years. Our findings reveal a significant difference for patient and graft survival of DCD livers at each of these time points. In contrast to the overall kidney transplant experience, the most recent 16-year period (n = 396 DCD and 1,937 DBD) revealed no difference in patient and graft survival, rejection rates, or surgical complications but delayed graft function was higher (44.7% vs 22.0%; P < .001). In DCD LTX, biliary complications (51% vs 33.4%; P < .01) and retransplantation for ischemic cholangiopathy (13.9% vs 0.2%; P < .01) were increased. PTX recipients had no difference in surgical complications, rejection, and hemoglobin A1c levels. Surgical complications were equivalent between DCD and DBD lung recipients. This series represents the largest single center experience with more than 1000 DCD transplants and given the critical demand for organs, demonstrates successful kidney, pancreas, liver, and lung allografts from DCD donors.

11-Year Single-Center Experience in Living-Donor Kidney Transplantation in Poland

Living-donor kidney transplantation (LDKT) is a viable option that is characterized by better short- and long-term results than cadaver-donor kidney transplantation (CKT). In Poland number of LDKT is low (2%–3%). We collected data on all 29 LDKTs performed in our center between 1999 and 2010; 82.7% were obtained from living related donors. The mean recipient age was 34.4 ± 12.8 years (range, 15–58) and mean donor age was 48.5 ± 7 years. Most donors were women ( n = 17; 62%). In 3 cases the LDKT was a second transplantation. The mean numbers of HLA class I and II mismatches were 2.18 ± 0.98 and 0.93 ± 0.6 respectively. The mean total ischemia time was 3.22 ± 1.74 hours. Induction therapy included antithymocyte globulin daclizumab 4; (13.7%) (n = 7; 24.1%); 27.6% of recipients were placed on cyclosporine based immunosuppression and the remaining 72.4% on tacrolimus with 69% also receiving mycophenolate mofetil. All recipients were prescribed steroids. Delayed graft function was observed in 3 cases and an acute rejection episode in 4 subjects. One-year patient and graft survivals were both 100% (98% and 83% for CKT). Five-year patient and graft survival were 100% and 89.6%, respectively, compared with 83% and 69% in CKT. The mean serum creatinine levels at 1, 6, 12, and 60 months were 1.59 ± 0.4, 1.51 ± 0.3, 1.51 ± 0.4 and 1.49 ± 0.3 mg/dL respectively. Our results, albeit concerning a small group of patients, confirmed excellent outcomes of LDKT, which should be actively promoted in our country.

Illinois Statewide Dual Kidney Transplantation Experience—Are We Appropriately Selecting Kidneys?

Dual kidney transplantation is a technique that some transplant centers have adopted to increase organ use. We investigated whether kidneys that were recovered and discarded were similar to those kidneys used for dual kidney transplantation. We reviewed all kidneys recovered, biopsied and placed on machine perfusion in the state of Illinois from January 2002 to October 2009. We selected those kidneys used in dual kidney transplant, and compared their characteristics to those of kidneys that were recovered and biopsied but ultimately discarded. The immediate and 1-year outcomes of the dual kidney transplant recipients were analyzed. During the study period 60 dual transplants were performed while 94 kidney pairs were discarded. Overall donors from the used group had a lower mean creatinine clearance, older mean patient age, lower percentage of glomerulosclerosis, higher final flow rate and lower resistance. However, the comparison between those kidneys used successfully with 1-year graft survival and those discarded demonstrated only 3 less favorable parameters among the discarded group, namely a higher percentage of glomerulosclerosis (18.5% vs 13.9%, p=0.024), a higher degree of interstitial fibrosis and a higher final resistance (0.39 vs 0.31, p<0.001). The considerable overlap in demographics, histology and perfusion parameters between used and discarded kidneys suggests that many kidneys that were recovered and discarded could have been used in dual kidney transplantation with acceptable outcomes. This highlights the need for further study of how kidneys are selected and used.

Case of ABO-Incompatible Living Donor Kidney Transplantation without Blood Products in a Jehovah's Witness

ABO-incompatible kidney transplantations have been performed successfully in Korea without splenectomy using plasmapheresis, anti-CD20 monoclonal antibody infusions and other immunosuppressants. However, there is no report of a case of ABO-incompatible kidney transplantation in a Jehovah’s Witness. Hence, we report our experience of successful ABO-incompatible kidney transplantation without blood products in a Jehovah’s Witness. The recipient was treated with six sessions of plasmapheresis and he received intravenous rituximab before transplantation. Immunosuppressive regimen consisted of tacrolimus, mycophenolate mofetil and steroid. The replacement fluid for plasmapheresis was 5% albumin solution instead of fresh frozen plasma. We measured the clotting factors before and after plasmapheresis and used cryoprecipitate to prevent bleeding.

Successful kidney transplantation in highly sensitized patients

Highly sensitized patients experience an increased number of rejection episodes and have poorer graft survival rates; hence, sensitization is a significant barrier to both access to and the success of organ transplantation. This study reports our experience in kidney transplantation in highly sensitized patients. Fourteen patients with sensitization or high levels of panelreactive antibodies (PRA) were studied. All patients were desensitized with pre-transplant intravenous immunoglobulin (IVIG)/plasmapheresis (PP) with or without rituximab and thymoglobulin induction therapy, combined with a Prograf/MMF/Pred immunosuppressive regimen. Of 14 patients, 10 showed good graft functions without acute rejection (AR) episodes. Acute cellular rejection in two patients was reversed by methylprednisolone. Two patients underwent antibody-mediated rejection; one was treated with PP/IVIG successfully, whereas the other lost graft functions due to the de novo production of donor-specific antibodies (DSA). Graft functions were stable, and there were no AR episodes in other patients. Conclusively, desensitization using PP/IVIG with or without rituximab increases the likelihood of successful live-donor kidney transplantation in sensitized recipients.

Ten-year experience of kidney transplantation at the Hospital of Kaunas University of Medicine: demography, complications, graft and patient survival

During 10 years, 163 cadaveric kidney transplantations were performed at the Hospital of Kaunas University of Medicine. The aim of this study was to analyze the first 10-year experience in kidney transplantation and to evaluate the most frequent early and late complications after transplantation, graft and patient survival, and impact of delayed graft function on graft survival. A total of 159 patients were included into the study. Graft and patient survival was calculated at 1, 3, and 5 years after transplantation using the Kaplan-Meier method; graft function was also analyzed. Fifty-three patients (33.3%) in the early period and 72 (55.4%) in the late period had at least one episode of urinary tract infection. Less than half (47.2%) of patients had complications related to immunosuppressive treatment, mostly cytomegalovirus infection, in the late period. The risk of CMV reactivation was 3.98 times higher among recipients who received prophylaxis only with intravenous ganciclovir as compared to patients who received valganciclovir after a brief course of ganciclovir (OR, 3.98; 95% CI, 1.48-8.19; P=0.003). Delayed graft function was observed in 53 cases (33.3%); 37 (23.3%) grafts were lost. Graft and patient survival at 1, 3, and 5 years after transplantation was 85%, 82%, and 71% and 97%, 94%, and 94%, respectively. Graft survival at 1, 3, and 5 years was worse among patients with delayed graft function as compared to patients with good graft function (69%, 69%, 50% vs. 93%, 86%, 84%, respectively; P<0.05). Urinary tract infection was the most frequent complication after kidney transplantation. Reactivation of cytomegalovirus infection was present only in a quarter of our patients. The administration of valganciclovir was associated with a significantly lower incidence of CMV infection/disease. Graft and patient survival was sufficiently good. Delayed graft function was an independent risk factor for worse graft survival.

Deceased-donor kidney transplantation: improvement in long-term survival

Despite marked improvement in short-term renal allograft survival rates (GSR) in recent years, improvement in long-term GSR remained elusive. We analysed the kidney transplant experience at our centre accrued over four decades to evaluate how short-term and long-term GSR had changed and to identify risk factors affecting graft survival. The study included 1476 adult recipients of a deceased-donor kidney transplant who were transplanted between 1963 and 2006 and who had received one of five distinct immunosuppressive protocols. Five-year actual GSR steadily improved over the years as immunosuppressive therapy evolved (22-86%, P < 0.001) in spite of an increasing trend in the transplantation of higher-risk donor-recipient pairings. For those whose grafts functioned for the first year, subsequent 4-year GSR (5-year conditional GSR) also improved significantly (63-92%, P < 0.001). Acute rejection and delayed graft function (DGF) were the most significant risk factors for actual graft survival, while acute rejection was the only significant risk factor for conditional GSR. Use of kidneys from expanded-criteria donors (ECD) was not a risk factor, compared to the use of standard-criteria donor kidneys for either 5-year actual or conditional GSR. There was an impressive decline in the incidence of acute rejection events (77.4-5.8%, P < 0.001). While the DGF rate had decreased, it still remained high (68.7-38.5%, P < 0.001). We found a significant improvement in both short-term and long-term GSR of deceased-donor kidney transplants over the last four decades. These improvements are most likely related to the decreased incidence of acute rejection episodes. Minimizing acute rejection events and preventing DGF could result in further improvement in the GSR. Our experience in the judicious use of ECD kidneys suggests that this source of kidneys could be expanded further.

Two decades of pediatric kidney transplantation in a multi-ethnic cohort

This study evaluated a 20-yr experience in kidney transplantation in children from a predominantly Hispanic community. A retrospective analysis was carried out in children who received kidney transplants from 1985 to 2005. Of 124 kidney transplants, 81 (65%) were from LD. Racial distribution was Hispanic (48%), followed by AA (24%) and Caucasian (26%). First yr allograft survival was similar in LD and DD and significantly better in LD until seven yr post transplant. eGFR <60 mL/min/1.73 m(2) at one yr post transplant was associated with a median allograft survival of 3.3 yr, compared to 16 yr in those with eGFR > or = 60 mL/min/1.73 m(2) (p < 0.0001). Graft loss in the first five yr was from non-adherence, recurrence of disease, and infections. Those of AA race were more likely to receive a DD and have low socioeconomic status and the poorest median allograft survival compared to Hispanics and Caucasians (6 vs. > or =15 yr; p < 0.001). In conclusion, this predominantly Hispanic cohort emphasizes the disadvantaged profile of AAs compared to other racial groups. Strategies to improve supportive services and living donations in minority populations need to be developed. Long-term renal allograft survival is achievable if GFR is maintained >60 mL/min/1.73 m(2).

Kidney donation from children after cardiac death*

Pediatric kidney donation after cardiac death is an underutilized donor source because of ethical concerns and limited knowledge of the outcome after transplantation. The purpose of this study was to report the Dutch experience of kidney transplantation using pediatric donation after cardiac death. Observational cohort study of a series of consecutive kidney transplantations from pediatric donation after cardiac death from January 1995 to July 2006. Kidneys were procured in seven Dutch procurement areas. Recipients of kidneys from donors after cardiac death aged 2 to 17 yrs. Prospectively collected data from the Dutch Organ Transplant Registry were analyzed. Donor, graft, and recipient characteristics of all pediatric donations after cardiac death kidney transplantations were documented. Recipients were followed-up for glomerular filtration rate, graft, and patient survival. Eighty-eight patients were transplanted with 90 pediatric donation-after-cardiac-death kidneys, which was 31% of the total number of transplanted pediatric donor kidneys. In 77% of recipients, organs were procured from controlled donors, after withdrawal of supportive treatment. Of all donors, 9% were younger than age 6 yrs. Two patients received their graft preemptively. In the others, the incidence of immediate function, delayed graft function, and primary nonfunction were 49%, 44%, and 7%, respectively. Warm ischemia time > or =25 mins was associated with primary nonfunction. Overall graft and patient survival 5 yrs after transplantation were 80% and 88%, respectively. Graft survival after immediate function and delayed graft function was not different. Kidneys from pediatric donation after cardiac death are suitable for transplantation and may substantially expand the donor pool with good transplant outcome.

An Experience of ABO-incompatible Kidney Transplantation Using Plasmapheresis and Anti-CD20 Monoclonal Antibody

Due to an extreme shortage of cadaveric kidneys, many centers in Japan successfully performed ABO-incompatible kidney transplantations using plasmapheresis, splenectomy and immunosuppression. Recently, a protocol including anti-CD20 monoclonal antibody (rituximab) and antigen-selective immunoadsorption has been used for ABO-incompatible transplantation in Europe. In Korea, ABO-incompatible kidney transplantation has been rarely performed. We report an experience of successful ABO-incompatible kidney transplantation using plasmapheresis and rituximab. The patient was a 32-yr-old female suffering from chronic renal failure, and her blood type was O, Rh+. The donor was her husband, and his blood type was B, Rh+. A combination therapy including 5 times of plasmapheresis starting from 10 days before transplantation with 2-day interval, intravenous gammaglobulin, rituximab at 2 weeks before transplantation and potent immunosuppression successfully decreased the titers of anti-A and anti-B antibodies to 1:2 and 1:1, respectively. The kidney transplantation was successful without any sign of hyperacute or acute rejection.

Sexuality, an important component of the quality of life of the kidney transplant recipient

People who receive a kidney transplant experience overall better quality of life (QOL) than those on dialysis. However, one area of QOL that does not seem to improve after transplant is sexuality. The purposes of this review were to evaluate the literature specific to sexuality after kidney and kidney/pancreas transplant, identify gaps in the literature, and suggest directions for future research. Sources for this review included studies published in nursing and medical journals as well as studies from the related fields of social work and psychology. This literature review revealed several factors that may affect posttransplant sexuality and sexual functioning including chronic illnesses, pretransplant dialysis, and medication side effects. In addition, numerous studies have shown that problems with sexual functioning are prevalent in the transplant population affecting up to 50% of kidney transplant recipients. These problems have a strong negative association with QOL and life satisfaction. Future research should focus on identifying the specific sexual concerns of kidney transplant recipients and on the development and testing of interventions to help alleviate these concerns.

Successful kidney transplantation from donation after cardiac death using a load-distributing-band chest compression device during long warm ischemic time

Donation after cardiac death (DCD) is increasing in importance as a potential source of vital organs for clinical transplantation. In Japan, the method of kidney procurement from DCD is one of the critical factors in successful deceased renal transplantation. The efforts to shorten the warm ischemic time (WIT), which is defined as the time from cardiac arrest to initiation of cooling in situ, or maintaining adequate renal blood flow during WIT by consistent chest compression are essential. We experienced one case of successful kidney transplantation using a non-invasive load-distributing-band chest compression device using AutoPulse (ZOLL Circulation, Sunnyvale, California), which is designed for use as an adjunct to cardiopulmonary resuscitation (CPR) to maintain adequate aortic pressure. This is the first report of our experiences of successful kidney transplantation from DCD using a load-distributing-band chest compression device for maintaining renal blood flow during long WIT. We can speculate that this mechanical CPR device can become a bridge to deceased organ transplantation.

Writing the Othered Self: Autoethnography and the Problem of Objectification in Writing About Illness and Disability

The individual's experience of kidney failure, transplantation, and recovery is not as well documented as might be expected. Often it is written about by outsiders (medical practitioners, care providers, academics), whereas the insider's (patient's) expertise is occluded. This conforms to the experience of many people living with illness and disability. The rendering of people as other (not like the norm) comes at a cost to their humanity. People who are ill or disabled can themselves succumb to a way of writing that simplifies their experience and objectifies themselves. I consider what it means to tell the story of oneself against a background of illness autoethnography, my own story of growing up medicalized and living with end-stage renal disease. I identify three types of illness autoethnography, one of which creates a tension between researcher as agent and researcher as object of research, and compels the reader to constantly realign himself or herself.

Living related donor kidney transplantation: analysis of 117 cases

To summarize the clinical experience in living related donor kidney transplantation. 117 patients with different nephropathies underwent transplantation of kidneys donated by their collateral relative in three generations. All donor kidneys were removed by open nephrectomy. Immunosuppressive protocols which consisting of cyclosporine A/tacrolimus, mycophenolate mofetil/azathioprine/rapamycin, and steroid were used in all patients as immunosuppressors. Follow-up was conducted for 1-44 months. Delayed graft function recovery occurred in 2 patients. Acute rejection episodes occurred in 18 patients, and the condition was reversed by high intravenous dose of methyl-prednisolone or polyclonal anti-T-cell antibodies. Follow-up showed that all the patients survived with normal kidney function, and the donors kept good kidney function with normal life quality. Hypertension was found in 2 donors and diabetes mellitus was found in 1 donor. Careful evaluation of both psychological and physical status of the donors and optimal physical status of recipients before operation are critical for successful kidney transplantation. Injury of graft kidney should be reduced and recipients should be treated with sufficient immunosuppressive regimen in early stage after transplantation.

Laparoscopic Gastric Banding Surgery Performed in Obese Dialysis Patients Prior to Kidney Transplantation

Obese patients with end-stage renal disease who receive a kidney transplant experience greater rates of posttransplantation diabetes, delayed graft function, and local wound complications. Many centers exclude obese patients from transplantation programs. Diet, exercise, and medication in general are not reliable weight loss options for patients with end-stage renal disease; hence, bariatric surgery should be considered. We report 3 patients who underwent laparoscopically adjustable gastric banding, which enabled sufficient weight loss to gain eligibility for kidney transplantation. All these patients subsequently underwent successful uncomplicated kidney transplantations.

Gift exchange and organ donation: Donor and recipient experiences of live related kidney transplantation

Background Live transplantation presents many stressors for donors and recipients, yet a holistic understanding of the process, from both perspectives, is limited. Gift exchange is a theory governed by the principles of giving, receiving and reciprocating and has many similarities with the process of organ transplantation. It may therefore provide a framework for understanding donor and recipient experiences of live kidney transplantation. However, the relevance of this theory to live kidney transplantation has not previously been properly explored. Objectives To gain a theoretical understanding of the live transplantation experience from the perspectives of donors and recipients. Design A phenomenological, longitudinal study. Participants All donors and their recipients undergoing live kidney transplantation in a regional renal transplant centre in South-West England (between July 2003 and February 2004) were invited to participate in this study. Of this cohort, 11 families ( n = 55%) volunteered to participate. Methods Data were collected through a series of 3 recorded, semi-structured interviews with donors and recipients. Interviews were conducted pre transplant and at 3 and 10 months post transplant. Data were analysed using a process of thematic content analysis. Findings were also considered within a theoretical framework of gift exchange. Results All donors initially made an instantaneous, voluntary decision to donate and found the decision relatively easy to make. In contrast, recipients found accepting the donors’ offer arduous, because of concern for their wellbeing. They were only able to accept the transplant after discussing the matter with their donor and establishing that it was something that they wanted to do. Recipients’ lives were transformed by a successful transplant and they were subsequently very grateful to the donors for donating. Donors derived immense personal satisfaction from this outcome and it helped to confirm to them that what they had done had been worthwhile. The transplant did not have a detrimental effect on donor–recipient relationships. Conclusions The concept of gift exchange provides a logical explanation of donor and recipients experiences in this study, particularly in relation to factors that influence giving, receiving and reciprocating. This understanding should help health professionals assist donors, recipients and their families throughout this process.