Follow-up Of Living Kidney Donors Research Articles

Health Inequity in Likelihood and Time to Renal Recovery after Living Kidney Donation: Implications for Kidney Health in Black Americans.

Live donor kidney transplantation has been popularized to help mitigate the organ shortage crisis. At the time of living donor nephrectomy, living donors lose 50% of their kidney function or glomerular filtration rate (GFR). Studies have shown that in healthy living donors, the remaining kidney is able to adapt and recover 10% to 25% of postdonation lost GFR. GFR recovery is critical to long-term kidney health, particularly for Black Americans who disproportionately suffer from kidney disease with an incidence 2.5 times White Americans. To date, no study has examined whether health inequities in renal recovery postdonation exist. We retrospectively analyzed 100,121 living kidney donors reported to the Scientific Registry of Transplant Recipients between 1999 and 2021. We estimated GFR (eGFR) using the Chronic Kidney Disease Epidemiology Collaboration 2021 equation and predicted the likelihood (logistic regression) and time (Cox regression) to recovery of 60% and 75% predonation eGFR. Models adjusted for age, sex, race, BMI, and predonation eGFR. Black patients were 47% (adjusted odds ratio 0.53, 95% CI 0.50 to 0.56, p < 0.001) and 43% (adjusted odds ratio 0.57, 95% CI 0.54 to 0.60, p < 0.001) less likely to recover 60% and 75% of predonation eGFR, respectively, compared with their White counterparts. The hazard ratio for time to renal recovery of 60% and 75% of predonation eGFR was 22% (adjusted hazard ratio 0.78, 95% CI 0.76 to 0.80, p < 0.001) and 38% (adjusted hazard ratio 0.62, 95% CI 0.60 to 0.65, p < 0.001) lower, respectively, than White patients. Black living kidney donors were less likely to recover predonation eGFR, and time to renal recovery was significantly longer than their White counterparts. These data highlight the need for enhanced living kidney donor follow-up, particularly for Black living kidney donors who are at greatest future risk of end-stage kidney disease.

Organ-Specific Monitoring of Solitary Kidney after Living Donation by Using Markers of Glomerular Filtration Rate and Urinary Proteins

Background: Effective follow-up after living kidney donation is important for maintaining the renal function of the donor. We investigated whether the estimated glomerular filtration rate (eGFR) and urinary protein and enzyme levels can provide important information regarding the state of the remaining kidney after donor nephrectomy. Methods: Seventy-five living donations were included (prospective/retrospective) in the study. The following parameters were measured up to 1 year after donor nephrectomy: serum creatinine and cystatin C as markers of the GFR; the high-molecular-weight urinary proteins as markers of glomerular injury; and the low-molecular-weight urinary proteins and urinary enzymes as markers of tubular function. Results: One year after kidney donation, the creatinine and cystatin C values were 1.38-fold increased than their initial values, while the eGFR was 32% lower. At that time, 38% of donors had a moderate or high risk of CKD progression. The biochemical urinary glomerular and tubular kidney markers examined showed different behaviors. After a transient increase, the glomerular proteins normalized. Conversely, the detection of low-molecular-weight urinary proteins and enzymes reflected mild tubular damage at the end of the study period. Conclusions: Our findings suggest that for the evaluation of mild tubular damage, low-molecular-weight marker proteins should be included in the urine diagnostic of a personalized living kidney donor follow-up.

Financial incentives versus standard of care to improve patient compliance with live kidney donor follow-up: protocol for a multi-center, parallel-group randomized controlled trial

BackgroundLive kidney donors (LKDs) account for nearly a third of kidney transplants in the United States. While donor nephrectomy poses minimal post-surgical risk, LKDs face an elevated adjusted risk of developing chronic diseases such as hypertension, diabetes, and end-stage renal disease. Routine screening presents an opportunity for the early detection and management of chronic conditions. Transplant hospital reporting requirements mandate the submission of laboratory and clinical data at 6-months, 1-year, and 2-years after kidney donation, but less than 50% of hospitals are able to comply. Strategies to increase patient engagement in follow-up efforts while minimizing administrative burden are needed. We seek to evaluate the effectiveness of using small financial incentives to promote patient compliance with LKD follow-up.Methods/designWe are conducting a two-arm randomized controlled trial (RCT) of patients who undergo live donor nephrectomy at The Johns Hopkins Hospital Comprehensive Transplant Center (MDJH) and the University of Maryland Medical Center Transplant Center (MDUM). Eligible donors will be recruited in-person at their first post-surgical clinic visit or over the phone. We will use block randomization to assign LKDs to the intervention ($25 gift card at each follow-up visit) or control arm (current standard of care). Follow-up compliance will be tracked over time. The primary outcome will be complete (all components addressed) and timely (60 days before or after expected visit date), submission of LKD follow-up data at required 6-month, 1-year, and 2-year time points. The secondary outcome will be transplant hospital-level compliance with federal reporting requirements at each visit. Rates will be compared between the two arms following the intention-to-treat principle.DiscussionSmall financial incentivization might increase patient compliance in the context of LKD follow-up, without placing undue administrative burden on transplant providers. The findings of this RCT will inform potential center- and national-level initiatives to provide all LKDs with small financial incentives to promote engagement with post-donation monitoring efforts.Trial registrationClinicalTrials.gov number: NCT03090646Date of registration: March 2, 2017Sponsors: Johns Hopkins University, University of Maryland Medical CenterFunding: The Living Legacy Foundation of Maryland

Perspectives on implementing mobile health technology for living kidney donor follow-up: In-depth interviews with transplant providers.

United States transplant centers are required to report follow-up data for living kidney donors for 2years post-donation. However, living kidney donor (LKD) follow-up is often incomplete. Mobile health (mHealth) technologies could ease data collection burden but have not yet been explored in this context. We conducted semi-structured in-depth interviews with a convenience sample of 21 transplant providers and thought leaders about challenges in LKD follow-up, and the potential role of mHealth in overcoming these challenges. Participants reported challenges conveying the importance of follow-up to LKDs, limited data from international/out-of-town LKDs, and inadequate staffing. They believed the 2-year requirement was insufficient, but expressed difficulty engaging LKDs for even this short time and inadequate resources for longer-term follow-up. Participants believed an mHealth system for post-donation follow-up could benefit LKDs (by simplifying communication/tasks and improving donor engagement) and transplant centers (by streamlining communication and decreasing workforce burden). Concerns included cost, learning curves, security/privacy, patient language/socioeconomic barriers, and older donor comfort with mHealth technology. Transplant providers felt that mHealth technology could improve LKD follow-up and help centers meet reporting thresholds. However, designing a secure, easy to use, and cost-effective system remains challenging.

Assessing the Attitudes and Perceptions Regarding the Use of Mobile Health Technologies for Living Kidney Donor Follow-Up: Survey Study.

BackgroundIn 2013, the Organ Procurement and Transplantation Network began requiring transplant centers in the United States to collect and report postdonation living kidney donor follow-up data at 6 months, 1 year, and 2 years. Despite this requirement, <50% of transplant centers have been able to collect and report the required data. Previous work identified a number of barriers to living kidney donor follow-up, including logistical and administrative barriers for transplant centers and cost and functional barriers for donors. Novel smartphone-based mobile health (mHealth) technologies might reduce the burden of living kidney donor follow-up for centers and donors. However, the attitudes and perceptions toward the incorporation of mHealth into postdonation care among living kidney donors are unknown. Understanding donor attitudes and perceptions will be vital to the creation of a patient-oriented mHealth system to improve living donor follow-up in the United States.ObjectiveThe goal of this study was to assess living kidney donor attitudes and perceptions associated with the use of mHealth for follow-up.MethodsWe developed and administered a cross-sectional 14-question survey to 100 living kidney donors at our transplant center. All participants were part of an ongoing longitudinal study of long-term outcomes in living kidney donors. The survey included questions on smartphone use, current health maintenance behaviors, accessibility to health information, and attitudes toward using mHealth for living kidney donor follow-up.ResultsOf the 100 participants surveyed, 94 owned a smartphone (35 Android, 58 iPhone, 1 Blackberry), 37 had accessed their electronic medical record on their smartphone, and 38 had tracked their exercise and physical activity on their smartphone. While 77% (72/93) of participants who owned a smartphone and had asked a medical question in the last year placed the most trust with their doctors, nurses, or other health care professionals regarding answering a health-related question, 52% (48/93) most often accessed health information elsewhere. Overall, 79% (74/94) of smartphone-owning participants perceived accessing living kidney donor information and resources on their smartphone as useful. Additionally, 80% (75/94) perceived completing some living kidney donor follow-up via mHealth as useful. There were no significant differences in median age (60 vs 59 years; P=.65), median years since donation (10 vs 12 years; P=.45), gender (36/75, 36%, vs 37/75, 37%, male; P=.57), or race (70/75, 93%, vs 18/19, 95%, white; P=.34) between those who perceived mHealth as useful for living kidney donor follow-up and those who did not, respectively.ConclusionsOverall, smartphone ownership was high (94/100, 94.0%), and 79% (74/94) of surveyed smartphone-owning donors felt that it would be useful to complete their required follow-up with an mHealth tool, with no significant differences by age, sex, or race. These results suggest that patients would benefit from an mHealth tool to perform living donor follow-up.

Validation of Ultrasonographic Kidney Volume Measurements: A Reliable Imaging Modality.

To investigate the kidney selection procedure before donation to maximize donor safety, we investigated whether ultrasonographic measurements of kidney volume are comparable with computed tomography measurements. Predonation volume and increases in kidney size may be important indicators of renal function after donation and subsequent loss of function. Consecutive donors with predonation computed tomography scans were approached preoperatively for additional ultrasonographic examinations. Measurements were independently performed by 2 ultrasonographers and considered accurate when the mean differences between both examiners for length, width, and thickness of the kidneys were < 5 mm. Ultrasonographic volumes were calculated with the ellipsoid equation (length × width × thickness × π/6) and an adjusted equation (length × width × thickness × 0.674), and computed tomography volumes were calculated with the voxel count method, which is considered the criterion standard. For this study (Dutch Trial Register NTR3795), 100 kidneys were measured. The mean differences between examiner 1 and 2 for similar ultrasonography measurements were < 5 mm. The ellipsoid equation underestimated the volume for examiner 1 by 16.9% and for examiner 2 by 14.8%, whereas the adjusted equation overestimated the volume by 6.8% and 9.5% respectively. The correlation between computed tomography and ultrasonographic volume with the adjusted equation was strong for both examiner 1 (r = 0.76; P < .001) and examiner 2 (r = 0.80; P < .001). Ultrasonographic measurements of kidney volume are comparable with computed tomography measurements. Therefore, ultrasonography is a reliable modality for living kidney donor follow-up monitoring of kidney size adaption after donation.

The National Landscape of Living Kidney Donor Follow-Up in the United States.

In 2013, the Organ Procurement and Transplantation Network (OPTN)/ United Network for Organ Sharing (UNOS) mandated that transplant centers collect data on living kidney donors (LKDs) at 6 months, 1 year, and 2 years postdonation, with policy-defined thresholds for the proportion of complete living donor follow-up (LDF) data submitted in a timely manner (60days before or after the expected visit date). While mandated, it was unclear how centers across the country would perform in meeting thresholds, given potential donor and center-level challenges of LDF. To better understand the impact of this policy, we studied Scientific Registry of Transplant Recipients data for 31,615LKDs between January 2010 and June 2015, comparing proportions of complete and timelyLDF form submissionsbefore and after policy implementation. We also used multilevel logistic regression to assess donor- and center-level characteristics associated with complete and timely LDF submissions. Complete and timely 2-year LDF increased from 33% prepolicy (January 2010 through January 2013) to 54% postpolicy (February 2013 through June 2015) (p<0.001). In an adjusted model, the odds of 2-year LDF increased by 22% per year prepolicy (p<0.001) and 23% per year postpolicy (p<0.001). Despite these annual increases in LDF, only 43% (87/202) of centers met the OPTN/UNOS-required 6-month, 1-year, and 2-year LDF thresholds for LKDs who donated in 2013. These findings motivate further evaluation of LDF barriers and the optimal approaches to capturing outcomes after living donation.

Four years' experience of live kidney donor follow-up: a single-centre study

Lifelong annual follow-up, including a review of renal function, as well as general health status, is recommended after donor nephrectomy. Different models of follow-up exist, both locally in general practice and at the transplant or referral centre. In this article, Maha Mohamed et al describe their experience of living donor follow-up, in conjunction with primary care.

Current State of Living Kidney Donor Follow-Up in the United States and the New OPTN Reporting Requirements.

Current State of Living Kidney Donor Follow-Up in the United States and the New OPTN Reporting Requirements.

Six Week Visit With Multidisciplinary Team Improves Long Term Adherence to Live Kidney Donor Follow-Up.

Purpose: The OPTN requires transplant programs to be 80 % compliant with live kidney donor ( KD) clinical follow-up (FU) and 70 % compliant with complete clinical and laboratory data ( CFU) up to 2 years post donation starting December 2014. Designated staff to comply with mandated FU is needed. Despite this some KDs still do not comply; the purpose of the study is to identify factors associated with successful CFU. Methods: In April 2010, we developed a Center for Live Donation with designated clinical staff and a multidisciplinary post donation approach to KD care including a 6 week visit with the Nurse Practitioner (NP) focusing on role of long term health maintenance. Retrospective chart review was performed on KD who donated from June 2010 to July 2012. Data on demographics, psychosocial characteristics, donor outcomes, and center interventions was collected to determine predictors of successful follow up specifically CFU compliance. This was defined as achieving all clinical and laboratory data at 6 months (m), 1 year (yr) and 2 yr after KD. Results: 114 KD were included in the analysis. FU at 6 m, 1 yr, and 2 yr is 97%, 92% and 86% respectively, however CFU in the entire period is 67% with 77%, 81% and 48% at 6 m, 1yr and 2 yrs. Using logistic regression, it was found that KDs who missed the 6 week visit with the NP were significantly less likely to achieve CFU at 6m ( p=.005; OR:10.74 [95% CL: 2.03, 56.7]) and 1yr. (p= .0098; OR: 4.45 [95%CL: 1.4,13.8]). Participation of a dietitian in post KD care improved CDF at 2 yrs. (p= .0089 OR: 5.62 [95% CL1.54, 20.5]). Donor age, sex, ethnicity, education, marital status, employment status, length of evaluation, distance from the program, language spoken, complications, and increase donor risk profile, did not predict compliance with follow-up. Additionally, the number of calls to the KD to arrange FU did not result in improved success. Conclusions: Results support multidisciplinary team interventions to improve KD follow-up. Limits of a small sample may have missed additional factors affecting CFU. KD follow-up is a challenge especially at current regulatory benchmarks; however a Center designated to the care of KD with a multidisciplinary approach and early intervention after surgical issues are resolved can improve CFU and potentially improve long term adherence to surveillance.

Living Kidney Donor Follow-Up: State-of-the-Art and Future Directions, Conference Summary and Recommendations

In light of continued uncertainty regarding postkidney donation medical, psychosocial and socioeconomic outcomes for traditional living donors and especially for donors meeting more relaxed acceptance criteria, a meeting was held in September 2010 to (1) review limitations of existing data on outcomes of living kidney donors; (2) assess and define the need for long-term follow-up of living kidney donors; (3) identify the potential system requirements, infrastructure and costs of long-term follow-up for living kidney donor outcomes in the United States and (4) explore practical options for future development and funding of United States living kidney donor data collection, metrics and endpoints. Conference participants included prior kidney donors, physicians, surgeons, medical ethicists, social scientists, donor coordinators, social workers, independent donor advocates and representatives of payer organizations and the federal government. The findings and recommendations generated at this meeting are presented.

Practices and Barriers in Long-Term Living Kidney Donor Follow-Up: A Survey of U.S. Transplant Centers

Many have called for more comprehensive follow-up of living kidney donors, both for the donor's benefit and to establish a high-quality database of donor outcomes. United Network for Organ Sharing currently requires transplant centers to report donor follow-up information at several time points after donation, but little is known about how frequently this information is obtained, or which barriers exist to compliance with United Network for Organ Sharing requirements. To assess practices and barriers in providing follow-up care to living donors, we sent a questionnaire to all program directors at U.S. transplant centers. Few transplant centers are currently seeing donors for long-term follow-up. Many centers recommend that donor follow-up care be provided by primary care physicians, but follow-up information is rarely received from primary care physicians. The main barriers to collecting more complete information are donor inconvenience, costs, and lack of reimbursement to the transplant center for providing follow-up care. Significant changes are required to improve long-term donor follow-up by U.S. transplant centers.

Living Kidney Donor Follow-Up in a Dedicated Clinic

Long-term effects of uninephrectomy for kidney donation are of particular interest in the currently increasing practice of living-donor transplantation. We have retrospectively analyzed the general health status and renal and cardiovascular consequences of living-related kidney donation. Data of living-related kidney donors who were regularly followed up in a dedicated clinic at the Sindh Institute of Urology and Transplantation between July 2000 and January 2004 was retrieved. They had donated their kidneys from 1986 onward. Data on weight, blood pressure, creatinine clearance, level of proteinuria, and new onset diabetes mellitus were analyzed. Seven hundred and thirty-six donors with a mean age of 36+/-10.9 years (M:F 1.1:1) were evaluated. With a mean postnephrectomy duration of 3+/-3.2 years (range 6 months-18 years), the creatinine clearance fell to 87% of prenephrectomy values, and 49 (6.7%) had a creatinine clearance of less than 60 mL/ min. Hypertension developed in 76 (10.3%) donors, and 179 (24.3%) had proteinuria exceeding 150 mg/24 hr. Overweight (27.8%) and obese subjects (11.5%) had a higher prevalence of hypertension and new onset diabetes mellitus. One donor developed end-stage renal failure. Donor nephrectomy has minimal adverse effects on overall health status. Regular donor follow-up identifies at-risk populations and potentially modifiable factors.

Establishing a transplant coordinator-led living kidney donor follow-up clinic

The long-term risks of renal failure and hypertension are statistically low for living kidney donors as a group, but can have serious consequences for the individual. To describe the experience with a transplant coordinator-led living donor follow-up clinic. Living kidney donors are reviewed on an annual basis by a designated coordinator (registered nurse). A 24-hour urine collection estimates renal function. Blood pressure and blood chemistry are measured and urinalysis performed. Current health status and wound discomfort are assessed. Any medical problems identified are referred to a specialist hospital department or to the donor's family practitioner. Fifty-nine appointments were booked and 12 (20%) donors did not attend. Renal function was within acceptable limits for all attending donors. Three donors had raised blood glucose levels and 8 donors were hypertensive; all were referred to family practitioners. Forty-seven donors (35 new, 12 return) completed a questionnaire on the follow-up provided. Thirty-eight (81%) were satisfied with the follow-up, and 47 (100%) agreed this clinic provided adequate follow-up. Thirty-three (70%) donors stated they preferred that the transplant coordinator performed the follow-up, 3 (6%) preferred the family practitioner, and 11 (23%) had no preference. There are many possible solutions to the provision of lifelong care of living kidney donors. The model of a transplant coordinator-led clinic appears to have a high degree of patient acceptance, perhaps because of the continuity of care provided by a known member of the transplant team. Further work is required to identify reasons for nonattendance.