Nondirected Donors Research Articles

Personal Viewpoint: Navigating Challenges in Recipient Selection for End-Chain Kidneys

As a result of the increasing number of transplants being facilitated by kidney paired donation, and newer initiatives such as voucher donation, end-chain kidneys now constitute a considerable proportion of kidney paired donation transplants in the United States. Data on end-chain kidneys are limited. They may be lower in quality compared to non-end chain living donor kidneys. However, they can provide unique opportunities for recipient candidates without living donors. There are no data or algorithms available to guide recipient selection for end-chain kidneys accepted by a transplant center. Considering the ethical principles of utility, justice, and respect for persons that underlie organ allocation, we discuss three potential approaches for recipient selection: 1) adherence to the Kidney Allocation System, 2) utility maximization and 3) priority to high-risk candidates, along with examples from our own center’s experience. Similar considerations are also relevant to selection of recipients for non-directed donor organs, and to out-of-sequence allocation for deceased organ donors. Since end-chain kidneys represent an increasingproportion of kidney paired donation-facilitated living kidney donor transplantation in the United States, and will likely get more medically and surgically complex over time, ongoing research on their utilization and outcomes is needed.

How Do Financial Obstacles Affect Decision-Making Among Potential Living Organ Donors?

Introduction: Living donation increases the organ supply, but associated non-medical expenses can disincentivize donation. Programs aimed at increasing living donation need to better understand how financial obstacles, including lost wages, impact the decision to pursue donation. Methods/Approach: Forty-eight interviews were conducted and analyzed using a grounded theory approach. Findings: Three key themes were identified that influenced decision-making: emotional attachment, temporal flexibility, and job security. These themes emerged when dividing interview participants into 3 groups: close relationship donors, broader network donors, and non-directed donors, representing donation to a family member or friend, a specific person they do not know well or at all, or a non-specified individual, respectively. Most close relationship donors wanted to donate regardless of personal financial cost, based on emotional attachment to the recipient. Wage reimbursement did not typically affect their decision-making but could reduce stress. Since non-directed donors did not donate to a specific individual, they could wait to achieve financial stability before donating, if needed. While wage reimbursement might create more proximate stability, non-directed donors had the flexibility to postpone donations until they could independently achieve financial stability. Lacking emotional attachment and temporal flexibility, broader network donors were particularly active decision-makers and most influenced by wage reimbursement. Across all groups, donors with job security were more resolute about donating. Conclusion: The findings underscore the importance of lost wage reimbursement to facilitate donation and reduce stress, and policies to protect donor job security.

Future of U.S. living donor liver transplant: Donor and recipient criteria, transplant indications, transplant oncology, liver paired exchange, and non-directed donor graft allocation.

In the United States, living donor liver transplant (LDLT), from both directed and nondirected living donors, has expanded over the past several years. LDLT is viewed as an important opportunity to expand the overall donor pool for liver transplantation (LT), shorten waiting times for a life-prolonging LT surgery, and reduce LT waitlist mortality. The LT community's focus on LDLT expansion in the United States is fostering discussions around future opportunities, which include the safe expansion of donor and recipient candidate eligibility criteria, broadening indications for LDLT including applications in transplant oncology, developing national initiatives around liver paired exchange, and maintaining vigilance to living donor and recipient candidate risk/benefit equipoise. Potential opportunities for expanding living liver donor and recipient candidate criteria include using donors with more than minimal hepatic steatosis, evaluating older donors, performing LDLT in older recipients to facilitate timely transplantation, and providing candidates who would benefit from an LT, but may otherwise have limited access (ie, lower MELD scores), an avenue to receive a life-prolonging organ. Expansion opportunities for LDLT are particularly robust in the transplant oncology realm, including leveraging LDLT for patients with advanced HCC beyond Milan, intrahepatic cholangiocarcinoma, and nonresectable colorectal cancer liver metastases. With ongoing investment in the deliberate growth of LDLT surgical expertise, experience, and technical advances in the United States, the LT community's future vision to increase transplant access to more patients with end-stage liver disease and selected oncology patients may be successfully realized.

Living Kidney Donation: A Narrative Review of Mid- and Long-term Psychosocial Outcomes.

Living kidney donors make a significant contribution to alleviating the organ shortage. The aim of this article is to provide an overview of mid- and long-term (≥12 mo) living donor psychosocial outcomes and highlight areas that have been understudied and should be immediately addressed in both research and clinical practice. We conducted a narrative review by searching 3 databases. A total of 206 articles were included. Living donors can be divided into those who donate to an emotionally or genetically related person, the so-called directed donors, or to an emotionally or genetically unrelated recipient, the so-called nondirected donors. The most commonly investigated (bio)psychosocial outcome after living donation was health-related quality of life. Other generic (bio)psychological outcomes include specific aspects of mental health such as depression, and fatigue and pain. Social outcomes include financial and employment burdens and problems with insurance. Donation-specific psychosocial outcomes include regret, satisfaction, feelings of abandonment and unmet needs, and benefits of living kidney donation. The experience of living donation is complex and multifaceted, reflected in the co-occurrence of both benefits and burden after donation. Noticeably, no interventions have been developed to improve mid- or long-term psychosocial outcomes among living donors. We highlight areas for methodological improvement and identified 3 areas requiring immediate attention from the transplant community in both research and clinical care: (1) recognizing and providing care for the minority of donors who have poorer long-term psychosocial outcomes after donation, (2) minimizing donation-related financial burden, and (3) studying interventions to minimize long-term psychosocial problems.

Liver paired exchange: A US single-center experience-Pairs, chains, and use of compatible pairs.

In the United States, the discrepancy between organ availability and need has persisted despite changes in allocation, innovations in preservation, and policy initiatives. Living donor liver transplant remains an underutilized means of improving access to timely liver transplantation and decreasing waitlist mortality. Liver paired exchange (LPE) represents an opportunity to overcome living donor liver transplant pair incompatibility due to size, anatomy, or blood type. LPE was adopted as a strategy to augment access to liver transplantation at our institution. Specific educational materials, consent forms, and selection processes were developed to facilitate LPE. From 2019 through October 2023, our center performed 11 LPEs, resulting in 23 living donor liver transplant pairs. The series included several types of LPE: those combining complementary incompatible pairs, the inclusion of compatible pairs to overcome incompatibility, and the use of altruistic nondirected donors to initiate chains. These exchanges facilitated transplantation for 23 recipients, including 1 pediatric patient. LPE improved access to liver transplantation at our institution. The ethical application of LPE includes tailored patient education, assessment and disclosure of exchange balance, mitigation of risk, and maximization of benefit for donors and recipients.

Is it ethically permissible for GPs to promote non-directed altruistic kidney donation to healthy adults?

Doctors hold coexisting ethical duties to avoid causing deliberate harm to their patients (non-maleficence), to act in patients’ best interests (beneficence), to respect patients’ right to self-determination (autonomy) and to...

Improving value delivery in living donor kidney transplant through process improvement.

Living donor kidney evaluation has substantial time variations with significant intercenter variation. One-day donor evaluation has shown to be clinically efficient and improve transplant rates. However, patients' perception of 1-day evaluation is unknown. We hypothesized that 1 day LKD evaluation will improve patient satisfaction and improve living donation rates. All interested LD candidates from April 2018 to May 2020 were enrolled in the study. Non-directed donors, donors greater than 60 years old, and recipients with more than three donors underwent multi-day evaluation (control group) while the rest underwent 1-day evaluation (intervention group). An anonymous survey was filled by both groups to assess their perceptions on different areas including time, communication, experience, information provided, and their preferences on living donor evaluation. Donor candidates in the 1-day evaluation group selected that the time from the questionnaire to clinic evaluation took "under 1 month" or "less than 3 months" (62.5%vs. 15.8%, p=.002), with "excellent" for both scheduling process (65%vs. 31.6%, p=.03) and communication (82.5%vs. 57.9%, p=.09) when compared to candidates in the multiple-days evaluation group. One-day candidates felt "very satisfied" with the overall experience (95%vs. 68.4%, p=.02) and felt "extremely well" with the information provided regarding the living donor process (87.5%vs. 47.4%, p=.003) when compared to multiple-day evaluation group. Regardless of the group, 53 (89.8%) patients preferred 1-day evaluation. We demonstrate 1-day living donor evaluation is efficient, patient preferred, and adds value through improved communication, and better overall patient satisfaction.

Assessing Health-Related Quality of Life in Non-Directed Versus Directed Kidney Donors: Implications for the Promotion of Non-Directed Donation.

Living kidney donation has increased significantly, but little is known about the post-donation health-related quality of life (HRQoL) of non-directed donors (NDs) vs. directed donors (DDs). We thus examined the outcomes of 112 living kidney donors (82 NDs, 30 DDs). For the primary outcomes-namely, the mean physical component summary (PCS) and mental component summary (MCS) scores of the 12-item Short Form Survey (SF-12) questionnaire-scores were significantly higher for the NDs vs. the DDs (PCS: +2.69, MCS: +4.43). For secondary outcomes, NDs had shorter hospital stays (3.4 vs. 4.4days), returned to physical activity earlier (45 vs. 60days), exercised more before and after donation, and continued physical activity post-donation. Regression analyses revealed that donor type and white blood cell count were predictive of the PCS-12 score, and donor type was predictive of the MCS-12 score. Non-directed donation was predictive of a shorter hospital stay (by 0.78days, p < 0.001) and the odds of having PCS-12 and MCS-12 scores above 50 were almost 10 and 16 times higher for NDs, respectively (p < 0.05). These findings indicate the safety and potential benefits of promoting non-directed donation. However, careful selection processes must be maintained to prevent harm and exploitation.

A perspective and review on nondirected liver donation.

A perspective and review on nondirected liver donation.

Non-directed (altruistic) kidney donation: Altruism or insurance policy?

Since non-directed (altruistic) kidney donors do not stand to benefit from the lengthening and strengthening of a relationship that they intrinsically value, their donations are considered to constitute the most altruistic variety of living kidney donation. This paper uses publicly-available data to assess the expected value that accrues to the donor of altruistic kidney donation. Compared to healthy non-donors, living kidney donors experience only marginally increased absolute risks of poor physical health outcomes, and no difference in important psychosocial health outcomes. Crucially, the chance of requiring a kidney donation is only marginally increased by becoming a living kidney donor. In the United Kingdom, previous living kidney donors that subsequently become in need of any organ donation (not only kidneys) themselves are considered priority patients for these donations. They consequently experience shorter waiting times for these organs and reduced exposure to the inherently harmful effects of dialysis therapy (if a kidney donation is required) compared to non-donors in need of organ donation. As such, while key data points required to compute an accurate and complete expected value calculation are unavailable, it is likely that the additional risk incurred by becoming a living kidney donor is outweighed by the benefit of being considered a priority patient for the donation of any type of organ in the event that this is needed. Accordingly, the expected value of becoming a living kidney donor is likely to be positive, meaning the act of doing so may be considered akin to the taking out of an insurance policy. In the context of non-directed (altruistic) kidney donation, this may diminish the extent to which such a donation is considered altruistic.

Psychosocial Outcomes in Nondirected Uterus Donors 1 Y After Donation.

As uterus transplantation transitions to a clinical procedure for women with absolute uterine-factor infertility, transplant centers performing uterus transplantation need information about the experience of living donors. This study examined the psychosocial impact on 17 nondirected uterus donors in the Dallas UtErus Transplant Study 1 y following donation. A prospective longitudinal study was conducted to measure psychosocial outcomes of depression, anxiety, posttraumatic stress, quality of life, and resilience [measured using the Hospital Anxiety and Depression Scale or Patient Health Questionnaire 9-Item, Generalized Anxiety Disorder 7-Item, Posttraumatic Stress Disorder Checklist for the DSM-5, health-related quality of life Short Form-36, and Connor-Davidson Resilience Scale 10-Item, respectively) assessed at baseline, at 6-mo and 1-y follow-up. Differences among baseline, 6-mo, and 1-y postdonation were analyzed. The median age was 38.0 y, 16 were married, 15 were of non-Hispanic/Latino ethnicity. Most donors did not report psychosocial distress; however, 1 donor reported decline on the role limitations because of Emotional Problems Scale and also showed an increase in depression symptoms at the 6 mo, but at 1 y was below the clinical cutoff for depression. A second donor showed modest decline in emotional well-being. Improvements were seen in other donors on the Physical Functioning Scale and posttraumatic stress symptoms. Although most nondirected donors appeared to remain stable, both positive and negative changes were observed over the first year. Larger studies are needed to determine psychosocial risks and benefit and what additional resources might be needed to ensure optimal psychosocial outcomes.

Organ Trafficking in Africa: Pragmatist Ethical Reconsiderations

Abstract This article focuses on examining the situation of organ trafficking in Africa from the aspect of pragmatist ethics. In the mainstream thought, the broader ethical dilemma of organ trafficking is viewed within the moral contestation of altruism as a rule for organ procurement and the resulting worldwide organ shortage. The incapability of altruistic transplant orthodoxy to serve as an applicable foundation for a public policy is considered as a reason for organ trafficking. In fact, to battle organ trafficking, utilitarian-inclined studies suggest organ selling, compensated donations, and non-directed paid donations as practical alternatives. However, when investigating the context of organ trafficking in Africa, the issue goes beyond the mere moral dilemma of altruism and organ shortage. In the region, organ trafficking is rooted within more systemic, structural, socio-economic, and political problems, grounded in the abuse of transplantation, and connected to transplant tourism and migration, which needs a pragmatic multimodal solutions than the earlier mainstream pathways. In pragmatist ethics, the moral assessment and solutions to the underlying problems depend on the context wherein the moral problem arises. Pragmatist ethics does not stick to absolute moral theories; instead, it focuses on the relevant assessment of the felt moral problem in a given context and aims at seeking solutions afresh. Thus, in the subsequent sections, this article looks at the context of organ trafficking in Africa and reassesses it by incorporating it into the ethical debates of transplantation and organ procurements and trading. The final part of this article reflects on solutions with the reconsideration of the context of transplantation and organ trafficking in the region.

Simultaneous 3-way Paired Exchange Liver Transplantation Without Nondirected Donation: Novel Strategy to Expand the Donor Pool.

Simultaneous 3-way Paired Exchange Liver Transplantation Without Nondirected Donation: Novel Strategy to Expand the Donor Pool.

The current landscape of pediatric living donor liver transplantation in the United States: Benefits, challenges, and future directions.

The current landscape of pediatric living donor liver transplantation in the United States: Benefits, challenges, and future directions.

Financial, policy, and ethical barriers to the expansion of living donor liver transplant: Meeting report from a living donor liver transplant consensus conference.

In October 2021, the American Society of Transplantation (AST) hosted a virtual consensus conference aimed at identifying and addressing barriers to the broader, safe expansion of living donor liver transplantation (LDLT) throughout the United States (US). A multidisciplinary group of LDLT experts convened to address issues related to financial implications on the donor, transplant center crisis management, regulatory and oversight policies, and ethical considerations by assessing the relative significance of issues in preventing LDLT growth, with proposed strategies to overcome barriers. Living liver donors endure multiple obstacles including financial instability, loss of job security, and potential morbidity. These concerns, along with other center, state, and federal specific policies can be perceived as significant barriers to expanding LDLT. Donor safety is of paramount importance to the transplant community; however, regulatory and oversight policies aimed at ensuring donor safety can be viewed as ambiguous and complicated leading to time-consuming evaluations that may deter donor motivation and program expansion. Transplant programs need to establish appropriate crisis management plans to mitigate potential negative donor outcomes and ensure program viability and stability. Finally, ethical aspects, including informed consent for high-risk recipients and use of non-directed donors, can be perceived as additional barriers to expanding LDLT.

Living donor liver transplant: A strategy to increase transplant access

Living donor liver transplant: A strategy to increase transplant access

400.2: Family Voucher Programs: An Ethical Way to Increase Nondirected Kidney Donation

Kidney transplant “vouchers” were created in 2014 as a means to overcome the “chronological incompatibility” that arises when a potential donor wants or needs to donate before the relative or friend who is to receive the kidney is ready to have a transplant. In exchange for the donor giving a kidney now, the prospective recipient is provided with what the National Kidney Registry (NKR) calls a “Standard Voucher” (SV), which can be redeemed when the recipient is ready for a transplant. In this paper, we describe the benefits of extending this innovation to altruistic donation and examine preliminary data on the effects. The kidneys supplied by altruistic donors are critical to the success of transplant chains because they typically serve as a non-directed donation that sets in motion a chain of many biologically incompatible donor-recipient pairs. Well-designed chains make possible a large number of transplants which would otherwise not have occurred or would have taken much longer to arrange, especially for highly sensitized or O blood-type recipients. The innovation—termed “Family Vouchers” (FVs) by the NKR— overcomes the “sentimental incompatibility” that leads some potential altruistic donors to back away from donating when they realize that giving a kidney to a stranger now will preclude them from providing a kidney should a loved one need a transplant in the future. FVs differ from SVs because donors are permitted to list up to five intended recipients, though only one may redeem the FV, and the intended recipients do not then have terminal kidney disease and may not develop it in the future. Like SVs, FV-based donors initiate kidney chains, which end with a recipient who lacks a donor. Likewise, the transplant network that issues the voucher will provide a suitable kidney at the end of a future chain when the designated recipient redeems the voucher.The expectation that FVs will attract new donors as well as provide assurance to people who develop doubts about their plan to make an altruistic donation is supported by current data. For example, voucher-based donation, which accounted for a tiny fraction of nondirected donation in the U.S. when it began in 2014 had surpassed altruistic donation by 2019, and its rapid growth helped nondirected donation to triple by 2021 (Figure 1). The Covid-19 pandemic interrupted this steady rise, but the decrease in nondirected donation was much smaller than for living kidney donation generally (Table 1). While altruistic donation went down, the rise in FV-based donations meant that in 2021 the percentage of living donors who were nondirected was the highest ever. Family Voucher programs, which are aligned with a central goal of transplant professionals—shortening the wait for transplants—need to broaden their outreach in minority communities and to carefully self-monitor their ability always to fulfill their moral commitment to provide all voucher-holders with a kidney from a suitable living donor.

247.1: Conditional Altruistic Living-Donor Kidney Donation in Israel and Its Impact on Living-Donor Kidney Transplant Growth

Introduction: With a limited number of deceased organ donors in Israel, transplant tourism was often used as an alternative source for kidneys until the enactment of the Israel Transplant law in 2008 which severely limited that activity. In an effort to find a legitimate path for the supply of kidneys for transplant, the law approved altruistic donation and established a regulated central governmental mechanism to ensure an altruistic motivation for donation. A year later, in 2009, the Matnat Chaim organization started its initiative to promote altruistic donation within the Jewish sector according the highest imperative of saving another’s life according to religious beliefs and social behaviour. Here, we report the results of that activity over the last 8 years. Methods: We used Israel Transplant Centre database and the Matnat Chaim organization’s database reporting the transplant activity for the period of 2013-2021. We looked at the growth of deceased and living-donor kidney transplantation and the proportion of altruistic kidney donations out of the total number of living-donor transplants over that period. We also reviewed the donors’ pre-donation questionnaires to learn about their preferences regarding their paired recipients in terms of age, social sector and religious observance. Results: Over the period studied, the number of kidney transplant candidates on the waiting list increased from 755 to 917 patients while the number of kidney transplants from deceased donors increased from 127 to 149 (excluding combined kidney-liver or kidney-pancreas transplants). The total number of live-donor transplantation increased from 261 to 476. The primary growth in the number of kidney transplants came from altruistic donations, with an increase from 32 to 215 donors a year (X6.7), and their proportion within the overall live donor total increased from 24 to 66% (figure 1). It should be noted that in many cases, Matnat Chaim was responsible for facilitating donation within the family after an initial interview of patients who approached the organization. Although in the majority of cases altruistic donors donated their kidney to a recipient within their community or religious group, on other occasions donors agreed to change the original directed allocation and donate their kidney within a paired exchange program (48 donors) or directly to a highly sensitized patient on the waiting list. However, for many of the altruistic donors, conditional donation was a prerequisite and had they not been allowed to donate within their community, they would not have donated a kidney at all. Conclusions: Conditional altruistic donation within a community is a legitimate path with a major potential to increase organ donation. Unlike non-conditional donation where kidneys are allocated to the waiting list, our system of conditional altruistic donation may raise some ethical issues; however, we consider it a valid option on a scale between a family donation and altruistic non-directed donation. The abstract is in memory of my friend Rabbi Yeshayahu Heber, the founder and chairman of Matnat Chaim. Rabbi Heber was a transplant recipient who died far before his time during the first wave of the COVID-19 pandemic, in April 2020. Over 1200 kidney recipients are alive today due to his vision and determination.

Living Kidney Donation Criteria of Baskent University.

Kidney transplant is the best treatment for patients with end-stage renal disease. Preparation of living related kidney donors and recipients is the major step to achieve their best long-term outcomes. Here, we present the Baskent University criteria for living kidney donors and recipients. The Baskent team has performed >2000 kidney transplants from 1985 to 2022 under leadership of Prof. Mehmet Haberal, a transplantation pioneer in Turkey, who facilitated Turkish legislation on procurement, storage, engraftment, and transplant of organs and tissues in June 1979, which has been adopted in other countries with few changes. Although the main frame is similar, we have constant principles in kidney donation. Baskent University is now known as an exceptional transplant center in Turkey, the Middle East, Europe, and the world and has established its own donor criteria for both kidney and liver transplant. Volunteerism remains a core principle of living kidney donation, regardless of other criteria. At Baskent University, donor protection from social, psychological, and health problems is paramount. Loss-profit and risk of transplant are assessed for every case. Donors must be followed up and remedies sought for failed criteria. Dr. Haberal's principles are the basis of Baskent University donation criteria, and unrelated kidney transplant donors are accepted only in cases of cross-donation. Major distinctions of Baskent University's living related donor criteria are (1) absence of unrelated or nondirected donation, (2) lowest acceptable donor glomerular filtration rate of 100 mL/min, (3) rejection of hypertensive donor candidates (regardless of medication), and (4) obesity must be corrected before transplant if body mass index (measured as body weight in kilograms divided by height in meters squared) is >30. The Baskent University donor selection criteria provide excellent long-term outcomes of kidney donors that have been proved by our recent studies.

Sequential liver and kidney living donors: Making the ultimate gift twice.

There are nearly 150 living donors in the United States who donated more than one solid organ. Using our divisional database, we found 20 individuals who donated a liver and a kidney at different times. We performed a retrospective chart review of these donors, studying their motivating factors, complications and outcomes. The donors included 11 (55%) males and nine females. Thirteen (65%) donated the kidney before the liver. Fourteen (70%) were nondirected donors at the first donation, and four of the six directed donors in the first donation became nondirected in the second donation. Seventeen (85%) were nondirected at the second donation. Common reasons for donating the second time were a good experience with the first donation and knowing that one can donate again. Outcomes and the incidence of early complications were not significantly different after the 2nd versus the 1st donation. All donors recovered and currently are doing well. Our results show a significant number of dual organ donors are nondirected and motivated by their strong desire to help. A positive experience with the 1st donation often was the driving factor for the 2nd. A history of previous organ donation did not negatively impact the 2nd donation.