Nondirected Donors Research Articles

MP36-04 THE “CANNIBALIZATION” OF ALTRUISTIC KIDNEY DONATION BY VOUCHER-BASED KIDNEY TRANSPLANTATION

You have accessJournal of UrologyCME1 May 2022MP36-04 THE “CANNIBALIZATION” OF ALTRUISTIC KIDNEY DONATION BY VOUCHER-BASED KIDNEY TRANSPLANTATION Nima Nassiri, Torey Averick, and Jeffrey Veale Nima NassiriNima Nassiri More articles by this author , Torey AverickTorey Averick More articles by this author , and Jeffrey VealeJeffrey Veale More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002590.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Barriers to living kidney donation are multi-factorial, and may include logistic, financial, familial, cultural, and religious factors. Less discussed but impactful barriers involve: (1) a reluctance to donate because a present-day donation prohibits future one, and (2) chronological incompatibility. Voucher-based kidney donation seeks to address these latter two barriers. Herein, we sought to evaluate how voucher-based donations have impacted standard altruistic kidney donation. METHODS: Subjects were all patients participating in standard altruistic donation and voucher-based donation through the National Kidney Registry from 2014 to present. Demographic and clinical factors were considered. The impact on downstream chains of transplantation were also evaluated. Both voucher-based and standard altruistic donation were considered “non-directed”. RESULTS: Since 2014, the total number of non-directed donations, either from standard altruistic donation or through the voucher program, has risen by over 3-fold (Figure 1). The number standard altruistic donations has declined since 2018, coinciding with an uptick in the number of voucher-based donations from 22 in 2018 to 113 in 2020. Voucher-based donations continued to grow throughout the pandemic. The following trends have been seen: (1) a steady rise in FV-based donation from the inception of the voucher program to present; (2) a steady shift in the percent involvement from standard altruistic donation to voucher-based donation; and (3) an annual decline in number of standard altruistic donors over the past 3 years. CONCLUSIONS: The following trends have been seen: (1) a steady rise in FV-based donation from the inception of the voucher program to present; (2) a steady shift in the percent involvement from standard altruistic donation to voucher-based donation; and (3) an annual decline in number of standard altruistic donors over the past 3 years. Though greater follow up is required, the short term trends suggest that voucher-based donation may be “cannibalizing” donation. Despite this, the overall number of non-directed donations, and the chains of transplants they spark, have expanded, delivering more high-quality kidneys and shortening the waiting time for kidney-paired exchange. Source of Funding: OneLegacy Foundation © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e597 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nima Nassiri More articles by this author Torey Averick More articles by this author Jeffrey Veale More articles by this author Expand All Advertisement PDF DownloadLoading ...

Examination of Racial and Socioeconomic Disparity in Use of Nondirected Kidney Donation in the US.

Nondirected donor (NDD) kidney transplant (NDDKT) continues to improve organ access for waitlisted candidates. Although NDDs are becoming increasingly common, there has been no contemporary evaluation of NDD allograft use, and it is vital to understand sociodemographic, as well as center-level, use across the US. Using national data from the Scientific Registry for Transplant Recipients, this study characterized NDDs, NDDKT recipients, and center-level distribution of NDDKT. Directed donor and NDD characteristics were compared using Fisher's exact and Wilcoxon rank-sum tests for categorical and continuous variables, respectively. Multivariable logistic regression was used to identify characteristics associated with receiving NDDKT, and center distribution of NDDKT was assessed using the Gini coefficient. NDDKT increased from 1.4% (n = 154) of all living donor kidney transplants in 2010 to 6.5% (n = 338) in 2020. Compared with directed living donors, NDDs were older (median [IQR], 44 [33 to 54] vs 43 [33 to 52], p < 0.01), more often male (40.2% vs 36.7%, p < 0.001), and White (91.4% vs 69.5%, p < 0.001). White adult candidates were more likely to receive NDDKT compared with Black (adjusted odds ratio [aOR], 0.300.340.39, p < 0.001), Hispanic/Latino (aOR, 0.360.420.48, p < 0.001), and Other (aOR, 0.410.470.55, p < 0.001) candidates. Black pediatric candidates had lower odds of receiving NDDKT (aOR, 0.090.220.54, p = 0.02). The proportion of centers performing NDDKT has increased from 2010 to 2020 (Gini = 0.77 vs 0.68). Although more centers are performing NDDKT, racial disparities persist among NDDs and NDDKT recipients. Continued effort is needed to recruit living kidney donors and improve access to living donation for minority groups in the US. (J Am Coll Surg 2022;234:000-00. © 2022 by the American College of Surgeons).

The Landscape of Nondirected Living Liver Donation in the United States.

Living donor liver transplants (LDLTs) including those from nondirected donors (NDDs) have increased during the past decade, and center-level variations in LDLTs have not yet been described. We sought to quantify changes in the volume of NDD transplants over time and variation in NDD volume between transplant centers. We further examined characteristics of living liver donors and identified factors potentially associated with receiving an NDD liver transplant. Using Scientific Registry of Transplant Recipients data between March 01, 2002, and December 31, 2020, we compared 173 NDDs with 5704 DLDs and 167 NDD recipients with 1153 waitlist candidates. NDDs increased from 1 (0.4% of LDLTs) in 2002 to 58 (12% of LDLTs) in 2020. Of 150 transplant centers, 35 performed at least 1 NDD transplant. Compared with waitlist candidates, adult NDD recipients were less frequently males (39% versus 62%, P < 0.001), had a lower model for end-stage liver disease (16 versus 18, P = 0.01), and spent fewer days on the waitlist (173 versus 246, P = 0.02). Compared with waitlist candidates, pediatric NDD recipients were younger (50% versus 12% age <2 y, P < 0.001) and more often diagnosed with biliary atresia (66% versus 41%, P < 0.001). Compared with DLDs, NDDs were older (40 versus 35 y, P < 0.001), college educated (83% versus 64%, P < 0.001), White (92% versus 78%, P < 0.001), and more frequently donated left-lateral segment grafts (32.0% versus 14%, P < 0.001). Liver NDD transplants continue to expand but remain concentrated at a few centers. Graft distribution favors female adults and pediatric patients with biliary atresia. Racial inequities in adult or pediatric center-level NDD graft distribution were not observed.

So Shines a Good Deed in a Weary World.

So Shines a Good Deed in a Weary World.

Long-Term Follow-up of Over 600 Living Related Kidney Donors: Single-Center Experience.

Kidney transplant is the treatment of choice in patients with end-stage renal disease because it offers improved survival and better quality of life. Although most epidemiologic studies have suggested that living kidney donors have a minimal lifetime risk of developing end-stage renal disease, long-term complications and physiologic and psychologic sequelae resulting from donation remain unclear. Here, we examined the long-term results of living-related kidney donors who donated kidneys at the Başkent University Ankara Hospital over the past 25 years. We were able to examine 607 kidney transplant donors (mean age of 52.03 ± 11.54 years) who were seen at our center from 1986 to 2021 and who agreed to a general health evaluation. Collected data included donor age, sex, blood type, body mass index, duration after donation, blood pressure measurements, biochemical parameters, abdominal ultrasonograph for size, structure, and renal blood flow of the solitary kidney, comorbid conditions, chronic drug use, and surgical procedures after donation. Mean time after donation was 10.4 ± 3.2 years. Twenty-four donors (3.9%) were diagnosed with diabetes and 21 (3.4%) with thyroid disease, 64 (10.5%) developed hypertension, and 48 (8.8%) developed atherosclerotic cardiovascular disease. Obesity was found to be an increasing problem in our donor population, with 174 (28.6%) developing mild to moderate obesity (body mass index >25 kg/m2). Older age, obesity, smoking, and hyperlipidemia were found to be the major and independent risk factors of both hypertension and atherosclerotic cardiovascular disease in donors. None of our donors developed endstage renal disease. Obesity and hypertension were the most common comorbidities that developed in our kidney donor population. Our principle is to avoid unrelated and nondirected donors because of the possible long-term complications. Unrelated donors may be desperate if a family member needs donation in the future.

Relinquishing Anonymity in Living Donor Kidney Transplantation: Lessons Learned From the UK Policy for Anonymous Donors.

Anonymous living donor kidney transplantation (LDKT) is performed in many countries and policies on anonymity differ. The UK is the only European country with a conditional policy, allowing pairs to break anonymity post-transplant. There is little evidence on how contact after anonymous LDKT is experienced. In this cross-sectional study participants who donated or received a kidney through non-directed altruistic kidney donation or within the UK living kidney sharing scheme completed a questionnaire on their experiences with and attitudes towards anonymity. Non-parametric statistics were used to analyse the data. 207 recipients and 354 donors participated. Anonymity was relinquished among 11% of recipients and 8% of donors. Non-anonymous participants were generally content with non-anonymity. They reported positive experiences with contact/meeting the other party. Participants who remained anonymous were content with anonymity, however, 38% would have liked to meet post-transplant. If the other party would like to meet, this number increased to 64%. Although participants agreed with anonymity before surgery, they believe that, if desired, a meeting should be allowed after surgery. UK donors and recipients were satisfied with conditional anonymity and experiences with breaking anonymity were positive. These results support the expansion of conditional anonymity to other countries that allow anonymous LDKT.

The use of nondirected donor organs in living donor liver transplantation: Perspectives and guidance.

Interest in anonymous nondirected living organ donation is increasing in the United States and a small number of transplantation centers are accumulating an experience regarding nondirected donation in living donor liver transplantation. Herein, we review current transplant policy, discuss emerging data, draw parallels from nondirected kidney donation, and examine relevant considerations in nondirected living liver donation. We aim to provide a consensus guidance to ensure safe evaluation and selection of nondirected living liver donors and a schema for just allocation of nondirected grafts.

The benefit to waitlist patients in a national paired kidney exchange program: Exploring characteristics of chain end living donor transplants

Nondirected kidney donors can initiate living donor chains that end to patients on the waitlist. We compared 749National Kidney Registry (NKR) waitlist chain end transplants to other transplants from the NKR and the Scientific Registry of Transplant Recipients between February 2008 and September 2020. Compared to other NKR recipients, chain end recipients were more often older (53 vs. 52years), black (32% vs. 15%), publicly insured (71% vs. 46%), and spent longer on dialysis (3.0 vs. 1.0years). Similar differences were noted between chain end recipients and non-NKR living donor recipients. Black patients received chain end kidneys at a rate approaching that of deceased donor kidneys (32% vs. 34%). Chain end donors were older (52 vs. 44years) with slightly lower glomerular filtration rates (93 vs. 98ml/min/1.73m2 ) than other NKR donors. Chain end recipients had elevated risk of graft failure and mortality compared to control living donor recipients (both p<.01) but lower graft failure (p=.03) and mortality (p<.001) compared to deceased donor recipients. Sharing nondirected donors among a multicenter network may improve the diversity of waitlist patients who benefit from living donation.

Recourse in Kidney Exchange Programs

We introduce the problem of selecting patient-donor pairs in a kidney exchange program to undergo a crossmatch test, and we model this selection problem as a two-stage stochastic integer programming problem. The optimal solutions of this new formulation yield a larger expected number of realized transplants than previous approaches based on internal recourse or subset recourse. We settle the computational complexity of the selection problem by showing that it remains NP-hard even for maximum cycle length equal to two. Furthermore, we investigate to what extent different algorithmic approaches, including one based on Benders decomposition, are able to solve instances of the model. We empirically investigate the computational efficiency of this approach by solving randomly generated instances and study the corresponding running times as a function of maximum cycle length, and of the presence of nondirected donors. Summary of Contribution: This paper deals with an important and very complex issue linked to the optimization of transplant matchings in kidney exchange programs, namely, the inherent uncertainty in the assessment of compatibility between donors and recipients of transplants. Although this issue has previously received some attention in the optimization literature, most attempts to date have focused on applying recourse to solutions selected within restricted spaces. The present paper explicitly formulates the maximization of the expected number of transplants as a two-stage stochastic integer programming problem. The formulation turns out to be computationally difficulty, both from a theoretical and from a numerical perspective. Different algorithmic approaches are proposed and tested experimentally for its solution. The quality of the kidney exchanges produced by these algorithms compares favorably with that of earlier models.

Can Living Donor Liver Transplantation in the United States Reach Its Potential?

Living donor liver transplantation (LDLT) is a vital tool to address the growing organ shortage in the United States caused by increasing numbers of patients diagnosed with end-stage liver disease. LDLT still only makes up a very small proportion of all liver transplantations performed each year, but there are many innovations taking place in the field that may increase its acceptance among both transplant programs and patients. These innovations include ways to improve access to LDLT, such as through nondirected donation, paired exchange, transplant chains, transplant of ABO-incompatible donors, and transplants in patients with high Model for End-Stage Liver Disease scores. Surgical innovations, such as laparoscopic donor hepatectomy, robotic hepatectomy, and portal flow modulation, are also increasingly being implemented. Policy changes, including decreasing the financial burden associated with LDLT, may make it a more feasible option for a wider range of patients. Lastly, center-level behavior, such as ensuring surgical expertise and providing culturally competent education, will help toward LDLT expansion. Although it is challenging to know which of these innovations will take hold, we are already seeing LDLT numbers improve within the past 2 years.

Psychological and Socioeconomic Outcomes Among Directed and Non-directed Living Kidney Donors

Non-directed living kidney donors (NDDs) are unique from the traditional directed living donors in terms of the circumstances that led NDDs to undergo a donation. The purpose of this study was to synthesize and discuss key similarities, differences, and existing gaps in the literature comparing their kidney donation process experiences and post-donation outcomes among directed and non-directed donors. A total of eight recent studies were reviewed as part of this study. These studies provided insights into the socioeconomic, physical, and mental health outcomes experienced by NDDs and directed donors throughout the various stages of the evaluation and donation process. Among the studies, NDDs were generally not found to demonstrate having substantial differences as compared to the traditional directed donor within the realms of physical and psychosocial health outcomes post-donation. However, NDDs did have fewer financial burdens as compared to directed donors, which may be related to the differences in demographic characteristics and the limited study sample sizes. Recent evidence on outcomes among non-directed living donors as compared with directed donors should inform efforts to enhance the evaluation and post-donation experiences for this special population. While future studies remain warranted, the current literature signals that further improvements can be made by revisiting the current evaluation screening protocols for living kidney donation as well as the donation system’s infrastructure to help yield enhanced outcomes and experiences among both directed and non-directed donors.

Non-simultaneous kidney exchange cycles in resource-restricted countries without non-directed donation - a prospective single-center cohort study.

Recent reports suggest that bridge-donor reneging is rare (1.5%) in non-simultaneous kidney exchange chains. However, in developing countries, the non-directed donors who would be needed to initiate chains are unavailable, and furthermore, limited surgical space and resources restrain the feasibility of simultaneous kidney exchange cycles. Therefore, the aim of this study was to evaluate the bridge-donor reneging rate during non-simultaneous kidney exchange cycles (NSKEC) in a prospective single-center cohort study (n=67). We describe the protocol used to prepare co-registered donor-recipient pairs for non-simultaneous surgeries, in an effort to minimize the reneging rate. In addition, in order to protect any recipients who might be left vulnerable by this arrangement, we proposed the use of standard criteria deceased-donor kidneys to rectify the injustice in the event of any bridge-donor reneging. We report 17 successful NSKEC resulting in 67 living-donor kidney transplants (LDKT) using 23 bridge-donors without donor renege and no intervening pairs became unavailable. We propose that NSKEC could increase LDKT, especially for difficult-to-match sensitized pairs (25 of our 67 pairs) in countries with limited transplantation resources. Our study confirms that NSKEC can be safely performed with careful patient-donor selection and non-anonymous kidney exchanges.

Dissolving Disincentives to Living Kidney Donation

Despite barriers and disincentives to living kidney donation, a record-setting number of living donor transplants (6,867) were performed in 2019. Additionally, there was a 24% increase in living donor kidney transplants from 2014-2019. These increases are welcome, yet the supply has not kept up with the demand, and the kidney transplant waiting list continues to grow. Innovative solutions are necessary to overcome disincentives to living kidney donation and increase the number of donors. The authors propose changing laws and rules to reimburse donors for all expenses related to donating a kidney; informing them of all the options of donation, including directed, non-directed, paired exchange, remote, and advanced donation; informing them of programs that transplant centers provide, including whether or not the center participates in the National Kidney Registry Donor Shield program; educating each donor about their personal risk; and dispelling misinformation they may have about living kidney donation. Implementing these measures will require a national, standard approach because there is variability between the states in relation to work leave and financial incentives for living donation.

How Can We Help Alleviate the Financial Concerns of Non-Directed (Altruistic) Living Kidney Donors?

The recent increase in non-directed donors (NDDs) in the United States (U.S.) may help reduce the overwhelming number of patients on the waitlist. However, non-directed donation may be limiting its full potential. Out-of-pocket donation costs upward of $8,000 may be a barrier to potential donors with altruistic tendencies, but inadequate financial support. This study aimed to describe the financial concerns of 31 U.S. NDDs. We conducted qualitative interviews and administered quantitative demographic surveys between April 2013 and April 2015. Interview transcripts were analyzed using grounded theory techniques to describe and expand on themes relevant to the NDD experience. We identified 4 sub-themes related to the theme of financial concerns: (1) direct costs related to transportation, lodging, and parking, (2) indirect costs of lost wages encountered from taking time off work to recover from surgery, (3) sources of financial support, and (4) suggestions for alleviating donor financial burden. Two thirds of participants (20) expressed concerns about direct and indirect donation costs. 11 NDDs reported the negative impact of direct costs,15 NDDs had concerns about indirect costs; only 7 donors received supplemental financial support from state mandates and transplant programs. Understanding the financial concerns of NDDs may guide improvements in the NDD donation experience that could support individuals who are interested in donating but lack the financial stability to donate. Removing financial disincentives may help increase nondirected donation rates, increase the living donor pool, and the number of kidneys available for transplantation.

Deceased donors as nondirected donors in kidney paired donation.

As proof of concept, we simulate a revised kidney allocation system that includes deceased donor (DD) kidneys as chain-initiating kidneys (DD-CIK) in a kidney paired donation pool (KPDP), and estimate potential increases in number of transplants. We consider chains of length 2 in which the DD-CIK gives to a candidate in the KPDP, and that candidate's incompatible donor donates to theDD waitlist. In simulations, we vary initial pool size, arrival rates of candidate/donor pairs and (living) nondirected donors (NDDs), and delay time from entry to the KPDP until a candidate is eligible to receive a DD-CIK. Using data on candidate/donor pairs and NDDs from the Alliance for Paired Kidney Donation, and the actual DDs from the Scientific Registry of Transplant Recipients (SRTR) data, simulations extend over 2years. With an initial pool of 400, respective candidate and NDD arrival rates of 2 per day and 3 per month, and delay times for access to DD-CIK of 6months or less, including DD-CIKs increases the number of transplants by at least 447 over 2years, and greatly reduces waiting times of KPDP candidates. Potential effects on waitlist candidates are discussed as are policy and ethical issues.

Postmortem non-directed sperm donation: quality matters

In our paper ‘The ethical case for non-directed postmortem sperm donation’ we argued that it would be ethical for men to donate sperm after death for use by strangers. In...

Health-related quality of life after anonymous nondirected living liver donation: A multicenter collaboration.

Literature on living nondirected liver donation is sparse. The purpose of this study was to assess health-related quality of life (HR-QOL) in anonymous nondirected living liver donors (ND-LLDs). ND-LLDs at 3 centers: University of Alberta (n=12), University of Colorado (n=12), and University of Southern California (n=12), were surveyed. Thirty donors (83%) responded to the Donor Quality of Life (USC DQLS) and Short-Form 36 (SF-36). Most respondents (n=15, 50%) donated their left lateral segment, 27% right lobe, and 23% left lobe. The majority were female (67%) and mean age was 38.9±11.2years at donation. Median follow-up was 1.1 (interquartile range 0.4-3.3)years. Approximately 37% had previously donated a kidney. Eleven experienced ≥1 postoperative complication, with only 1 Clavien-Dindo IIIb. Most reported minimal impact on school or work performance, all felt positive or neutral about their overall health since donation, and none expressed postdonation regrets. No donor reported impacts on health insurability, and 3 of 4 respondents attempting to purchase life insurance postdonation were successful. ND-LLD SF-36 outcomes were similar to US population norms. Overall, ND-LLDs demonstrated acceptable HR-QOL after donation and are appropriate candidates for partial liver donation. Based on evaluation of donation impact, consideration should be given to postdonation support strategies.

Exploring the motives of Israeli Jews who were living kidney donors to strangers.

Non-directed living donors are individuals who donate a kidney to a recipient with whom they have neither a genetic nor emotional relationship. Israel legalized this type of donation in 2008. After this law was implemented, living donations significantly expanded. The aim of this article was to determine the motivations, characteristics, and perioperative experiences of non-directed living donors in Israel. Three online questionnaires (own questionnaire, Rosenberg Self-Esteem Scale (RSES), Rushton Self-Report Altruism Scale) were distributed to 180 Jewish kidney donors with the help of Matnat Chaim organization. One hundred and fifteen responses were received (69.3% response rate). The motivation for most donors (60%) was a strong willingness to help and a desire to do good. The majority of donors (78.3%) reported their health status as unchanged after donation; however, 16.5% experienced clinical problems (eg, wound infection, more pain than expected), and 5.2% experienced psychological complications. About 18% reported their health to improve after donation. Most (80%) inspired someone else to also become a kidney donor. This study breaks the myth that Jews do not support organ donation. In fact, their high level of altruism and their positive experience with donation has propelled the practice of non-directed donation in Israel.

Non-directed postmortem sperm donation: some questions

In their recent ‘The ethical case for non-directed postmortem sperm donation’, Hodson and Parker outline and defend the concept of voluntary non-directed postmortem sperm donation, the idea that men should...

A comparison of matching algorithms for kidney exchange programs addressing waiting time

Kidney exchange programs (KEP) allow an incompatible patient–donor pair, whose donor cannot provide a kidney to the respective patient, to have a transplant exchange with another in a similar situation if there is compatibility. Exchanges can be performed via cycles or chains initiated by non-directed donors (NDD), i.e., donors that do not have an associated patient. The objective for optimization in KEP is generally to maximize the number of possible transplants. Following the course of recent approaches that consider a dynamic matching (exchanges are decided every time a pair or a NDD joins the pool), in this paper we explore two matching policies to find feasible exchanges: periodic, where the algorithm runs within some period (e.g each 3 month); and greedy, in which a matching run is done as soon as the pool is updated with a new pair or NDD. For each policy, we propose a matching algorithm that addresses the waiting times of pairs in a pool. We conduct computational experiments with the proposed algorithms and compare the results with those obtained when periodic and greedy matching aim at maximizing the number of transplants.