Nondirected Donors Research Articles

Can We Improve the Effectiveness of the Spanish Nondirected Donation Program?

BackgroundA nondirected altruistic living kidney donor is a person who wants to donate a kidney to anyone in need. In 2010, the Spanish National Transplant Organization developed a national protocol to make the assessment of every potential nondirected living kidney donor. The aim of this study was to describe the potential donor pool and its characteristics and the overall effect of the program. Material and MethodsA retrospective analysis was performed using data from the Spanish National Registry of Transplant Activity, and the Nondirected Donors National Database, between 2010 and 2017. Data related to sociodemographic characteristics, main motivations toward donation, and causes of dismissal were collected from all potential donors.The assessment of each candidate was carried out in a step-by-step process based on the national protocol. ResultsTwo hundred seventy-two people contacted us, showing interest in the nondirected kidney donation, only 203 people underwent the early triage, and 16 of them successfully completed the assessment proces s, representing 8% of the total. The main motivation toward anonymous donation (n = 161) was: social awareness (22%) and to improve the quality of life of other people (9%). One hundred eighty-two candidates did not proceed, due to medical and psychological contraindications (42%) or donor refusal after specific information about the donation process (33%).The number of utilized nondirected altruistic living donors was 13 out of 203 (6%) of the candidates who began the early triage. Twelve transplant chains and a direct donation were performed, which made 38 kidney transplants possible (2.9 transplants per nondirected donor). ConclusionsWe have to continue working to optimize our program. Our next steps will be to review the evaluation process, to detect areas for improvement, to understand why we lost many possible donors, and to ascertain if any of the reasons could be avoided.

Beyond Survival in Solid Organ Transplantation: A Summary of Expert Presentations from the Sandoz 6th Standalone Transplantation Meeting, 2018.

Beyond Survival in Solid Organ Transplantation: A Summary of Expert Presentations from the Sandoz 6th Standalone Transplantation Meeting, 2018.

KPDGUI: An interactive application for optimization and management of a virtual kidney paired donation program

Background and objectivesThe aim in kidney paired donation (KPD) is typically to maximize the number of transplants achieved through the exchange of donors in a pool comprising incompatible donor-candidate pairs and non-directed (or altruistic) donors. With many possible options in a KPD pool at any given time, the most appropriate set of exchanges cannot be determined by simple inspection. In practice, computer algorithms are used to determine the optimal set of exchanges to pursue. Here, we present our software application, KPDGUI (Kidney Paired Donation Graphical User Interface), for management and optimization of KPD programs. MethodsWhile proprietary software platforms for managing KPD programs exist to provide solutions to the standard KPD problem, our application implements newly investigated optimization criteria that account for uncertainty regarding the viability of selected transplants and arrange for fallback options in cases where potential exchanges cannot proceed, with intuitive resources for visualizing alternative optimization solutions. ResultsWe illustrate the advantage of accounting for uncertainty and arranging for fallback options in KPD using our application through a case study involving real data from a paired donation program, comparing solutions produced under different optimization criteria and algorithmic priorities. ConclusionsKPDGUI is a flexible and powerful tool for offering decision support to clinicians and researchers on possible KPD transplant options to pursue under different user-specified optimization schemes.

Utilization of deceased donor kidneys to initiate living donor chains

Utilization of deceased donor kidneys to initiate living donor chains

Long-term psychosocial outcomes after nondirected donation: A single-center experience.

Short-term studies have demonstrated that nondirected donors (NDDs) have psychosocial outcomes that are similar to donors who donate directly, but long-term studies have not been done. NDDs at our center were surveyed regarding motivation; support during donation; stress related to donation; regret; financial resources used for donation; preferences about communication with the recipient; and cost reimbursement. Of 100 NDDs who donated at our center in the last 20years, 95 remain in contact with us, and 77 responded to our survey (mean ± standard deviation [SD] 6.7±4years postdonation). The most common motivation for donation was the desire to help another (99%). Many NDDs received support from family, friends, and employers. NDDs voiced stress about the possibility of recipient kidney rejection, physical consequences to themselves, and financial burden. Only one donor expressed regret. Almost half wanted some recipient information at donation; 61% preferred routine recipient status updates; 56% believed meeting the recipient should occur at any mutually agreeable time; and 55% endorsed reimbursement for expenses. Stressors for NDDs are analogous to those of directed donors; NDDs prefer having some information about the recipient and prefer to be given a choice regarding the timing for communication with the recipient. NDDs supported donation being financially neutral.

Financial Costs Incurred by Living Kidney Donors: A Prospective Cohort Study.

Approximately 40% of the kidneys for transplant worldwide come from living donors. Despite advantages of living donor transplants, rates have stagnated in recent years. One possible barrier may be costs related to the transplant process that potential willing donors may incur for travel, parking, accommodation, and lost productivity. To better understand and quantify the financial costs incurred by living kidney donors, we conducted a prospective cohort study, recruiting 912 living kidney donors from 12 transplant centers across Canada between 2009 and 2014; 821 of them completed all or a portion of the costing survey. We report microcosted total, out-of-pocket, and lost productivity costs (in 2016 Canadian dollars) for living kidney donors from donor evaluation start to 3 months after donation. We examined costs according to (1) the donor's relationship with their recipient, including spousal (donation to a partner), emotionally related nonspousal (friend, step-parent, in law), or genetically related; and (2) donation type (directed, paired kidney, or nondirected). Living kidney donors incurred a median (75th percentile) of $1254 ($2589) in out-of-pocket costs and $0 ($1908) in lost productivity costs. On average, total costs were $2226 higher in spousal compared with emotionally related nonspousal donors (P=0.02) and $1664 higher in directed donors compared with nondirected donors (P<0.001). Total costs (out-of-pocket and lost productivity) exceeded $5500 for 205 (25%) donors. Our results can be used to inform strategies to minimize the financial burden of living donation, which may help improve the donation experience and increase the number of living donor kidney transplants.

An efficient algorithm to enumerate sets with fallbacks in a kidney paired donation program

Kidney paired donation is a partial solution to overcoming biological incompatibility preventing kidney transplants. A kidney paired donation (KPD) program consists of altruistic or non-directed donors (NDDs) and pairs, each of which comprises a candidate in need of a kidney transplant and her/his willing but incompatible donor. Potential transplants from NDDs or donors in pairs to compatible candidates in other pairs are determined by computer assessment, though various situations involving either the donor, candidate, or proposed transplant may lead to a potential transplant failing to proceed. A KPD program can be viewed as a directed graph with NDDs and pairs as vertices and potential transplants as edges, where failure probabilities are associated with each vertex and edge. Transplants are carried out in the form of directed cycles among pairs and directed paths initiated by NDDs, which we refer to respectively as cycles and chains. Previous research shows that selecting disjoint subgraphs with a view to creating fallback options when failures occur generates more realized transplants than optimal selection of disjoint chains and cycles. In this paper, we define such subgraphs, which are called locally relevant (LR) subgraphs, and present an efficient algorithm to enumerate all LR subgraphs. Its computational efficiency is significantly better than the previous, more restrictive, algorithms.

Temporal changes in the composition of a large multicenter kidney exchange clearinghouse: Do the hard-to-match accumulate?

One criticism of kidney paired donation (KPD) is that easy-to-match candidates leave the registry quickly, thus concentrating the pool with hard-to-match sensitized and blood type O candidates. We studied candidate/donor pairs who registered with the National Kidney Registry (NKR), the largest US KPD clearinghouse, from January 2012-June 2016. There were no changes in age, gender, BMI, race, ABO blood type, or panel-reactive antibody (PRA) of newly registering candidates over time, with consistent registration of hard-to-match candidates (59% type O and 38% PRA ≥97%). However, there was no accumulation of type O candidates over time, presumably due to increasing numbers of nondirected type O donors. Although there was an initial accumulation of candidates with PRA ≥97% (from 33% of the pool in 2012% to 43% in 2014, P=.03), the proportion decreased to 17% by June 2016 (P<.001). Some of this is explained by an increase in the proportion of candidates with PRA ≥97% who underwent a deceased donor kidney transplantation (DDKT) after the implementation of the Kidney Allocation System (KAS), from 8% of 2012 registrants to 17% of 2015 registrants (P=.02). In this large KPD clearinghouse, increasing participation of nondirected donors and the KAS have lessened the accumulation of hard-to-match candidates, but highly sensitized candidates remain hard-to-match.

Chris Burns-Cox: driving force behind altruistic kidney donation

Chris Burns-Cox was a campaigning physician who wanted to alleviate suffering wherever he found it and championed many humane causes throughout his life. He became a driving force in the...

P135 Living donor kidney paired donation transplantation: First report from Kingdom of Saudi Arabia

Aim Kidney paired donation (KPD) is an effective way to transplant patients with willing but incompatible donors. We report our experience with KPD through development of local Registry for incompatible pairs. Methods 62 recipients & their incompatible donors plus 3 non-directed donors were entered into KPD registry. Incompatibility was due to ABO-incompatibility (ABOi) in 25% & HLA-incompatibility (HLAi) in 75%. Patients with HLAi had cPRA between 60–99%. Antibodies with MFI of ⩾ 3000 by SAB assay were listed as unacceptable antigens. We used balanced, unbalanced & non-directed anonymous donors (NDAD). ABOi donors were accepted if patients had low titer ( ⩽ 16) of Isohemagglutinins. Amenable DSA for desensitization are those weak, single or multiple that yielded negative or weakly positive flow cross match ( Results 23 candidates (37%) were transplanted, enabling pre-emptive transplant in 1 patient. The longest chain was seven -ways domino chain initiated by a NDAD & ended in transplant of deceased donor listed patient with multiple access failure. Additional desensitization was used for 9 patients due to DSA and/ or positive FXM. 1 patient received TPE due to anti ABO antibody titer of 16. We had one case of DGF, AMR occurred in 2 patients & 1 patient had ACR. Graft function was good through follow-up time of 6–18 months but one patient died 8 months post-transplant due to refractory sepsis. Conclusions Although our series is early with 62 patients, transplant rate is excellent compared to other old programs(Netherlands, UK, & Canada) where the transplant rate were 37%, 29%, 44% respectively. This might be attributed to involving NDAD, accepting ABOi & combining desensitization for low level DSA in selected patients. Considering that 75% of the patients were highly sensitized yet received living transplants with excellent results, our experience demonstrates promising short-term outcomes. However, longer follow-up is needed to assess the impact of KPD on organ shortage & the outcome of highly sensitized patients transplanted through KPD program.

Landscape of Living Multiorgan Donation in the United States: A Registry-Based Cohort Study.

The donation of multiple allografts from a single living donor is a rare practice, and the patient characteristics and outcomes associated with these procedures are not well described. Using the Scientific Registry of Transplant Recipients, we identified 101 living multiorgan donors and their 133 recipients. The 49 sequential (donations during separate procedures) multiorgan donors provided grafts to 81 recipients: 21 kidney-then-liver, 15 liver-then-kidney, 5 lung-then-kidney, 3 liver-then-intestine, 3 kidney-then-pancreas, 1 lung-then-liver, and 1 pancreas-then-kidney. Of these donors, 38% donated 2 grafts to the same recipient and 15% donated 2 grafts as non-directed donors. Compared to recipients from first-time, single organ living donors, recipients from second-time living donors had similar graft and patient survival. The 52 simultaneous (multiple donations during one procedure) multiorgan donors provided 2 grafts to 1 recipient each: 48 kidney-pancreas and 4 liver-intestine. Donors had median of 13.4 years (interquartile range, 8.3-18.5 years) of follow-up. There was one reported death of a sequential donor (2.5 years after second donation). Few postdonation complications were reported over a median of 116 days (interquartile range, 0-295 days) of follow-up; however, routine living donor follow-up data were sparse. Recipients of kidneys from second-time living donors had similar graft (P = 0.2) and patient survival (P = 0.4) when compared with recipients from first-time living donors. Similarly, recipients of livers from second-time living donors had similar graft survival (P = 0.9) and patient survival (P = 0.7) when compared with recipients from first-time living donors. Careful documentation of outcomes is needed to ensure ethical practices in selection, informed consent, and postdonation care of this unique donor community.

Inclusion of Incompatible Directed Deceased Donor Organs in Kidney Transplant Exchanges

In many instances, kidney transplants cannot be performed because of incompatibility (such as blood type or cross-match) among donors and recipients. One established way to address this finding is by means of donor exchanges, where incompatible pairs are enrolled in a registry. Registries can lead to paired exchanges or to donor chains. In chains, a non-directed (altruistic) donor initiates a sequence of transplants that culminates with a so-called bridge-donor. Studies have estimated that a non-directed donor triggers on average 4.8 to 8 (if blood type O) transplants (1). Although incompatibility is usually viewed as affecting potential recipients of live donors, it is also encountered in instances of directed donation of deceased donors. In these cases, the family or guardian of a deceased donor requests that an organ be assigned to a recipient of their choice (such as a relative or friend) in the deceased donor wait list. It has been reported (2) that “in recent years, at least 100 deceased donor transplants each year have occurred through directed donation.” Although most chains involve only live donors, current proposals (1) consider the initiation of chains with deceased donors. Arguments for such approach include an increased overall number of transplants by maximizing the potential of chains, and the eventual return of a live donor kidney to the deceased donor wait list. Ethical and organizational concerns have been raised with respect to the initiation of chains with deceased donors. Furthermore, selecting blood type O donors to initiate chains could disadvantage blood type O wait list recipients. We believe it would be particularly interesting to develop exchanges (as diagrammed below) initiated with deceased donor kidneys from incompatible directed donations. Rather than denying the donor family and the designated recipient the possibility of a transplant, the organ would be allocated to initiate an exchange. As part of the exchange, the previously incompatible recipient would receive a compatible live donor kidney. Advantages of this exchange include: • Transplantation of the designated deceased donor recipient (who would otherwise not be immediately transplanted) with a live donor kidney• Provides a live donor kidney to the deceased donor wait list • Potentially 5.8 people or more could benefit from this process (at least 4.8 recipients from a chain plus the otherwise incompatible recipient of the directed deceased donor organ) • No net loss of deceased donor kidneys • Likely no O blood type disadvantage

Single Centre Experience of Altruistic Non-Directed Kidney Donation

Introduction The continuing scarcity of organs for transplantation coupled with advances in technology and changes in the legislative framework in the UK have encouraged more opportunity and choice in the options for living donor kidney transplantation. We reviewed the experience of altruistic non-directed kidney donors (ANDKD) at our centre to determine useful ways of optimizing the service while increasing the numbers of donors. Materials and Methods All enquiries by potential ANDKD at our centre from October 2007 to September 2017 were analysed. Donor assessment and preparation for donation were performed as per UK Guidelines and local protocol, including mental health and local independent assessment, prior to obtaining Human Tissue Authority approval. 185 enquiries resulted in 50 donations. Forty nine donors underwent hand-assisted laparoscopic donor nephrectomy while one had open nephrectomy. The ANDKD were sent questionnaires and the responses were analysed. The outcome of donation and reasons why the remaining did not proceed to donation were analysed. Results and Discussion During the period, 50 of the 185 enquiries (27%) resulted in kidney donation. There were 27 female donors and 23 males with an overall age range of 22 – 82 years (mean 58). Only 35 of 50 questionnaires (70%) were returned. Two donors had died of causes unrelated to kidney donation. Of the 35 responses, 23(66%) donors were retired, 5 (14%) self-employed and 7 (20%) were employed at the time of donation. Most donors heard about altruistic donation through media (43%) and internet services (31%). Five patients underwent both psychological and psychiatric assessments whereas 28 had psychological and two had psychiatric assessment alone. Twenty four donors (68.6%) thought psychological or psychiatric assessment was necessary while 11 (31.4%) thought it was not. Thirty three of 35(94%) found the information provided prior to donation adequate and 80% (28/35) rated their experience of the process as good/excellent. A significant proportion felt the process could have been more streamlined and quicker. Attitude towards ANDKD were changed negatively in 3 (8.6%) patients after donation but 88.6% (31/35) donors would recommend kidney donation to others. Thirty six of the donated kidneys were sent to recipients identified by the national Transplant office whereas 14 were fed into the paired/pooled kidney exchange program. Conclusions A significant proportion of enquiries for altruistic donation would result in donation. Psychiatric evaluation should be reserved for cases were clinically indicated. The process needs to be optimized to make the assessment process quicker. All transplant surgeons and nephrologists involved in the altruistic kidney donation program.

Financial burden associated with time to return to work after living kidney donation.

Many living kidney donors undertake a significant financial burden in order to donate. We studied the association between time to return to work and reported financial burden. Kidney donors who donated from 2/2005 through 12/2015 (n=1012) were surveyed 6months after donation and asked about occupation, time to return to work, and financial burden (on a 10-point Likert scale). Of 856 donors working for pay, 629 (73%) responded. After adjusting for donor characteristics, increased length of time to return to work was a significant predictor of financial burden (P<.001). It is notable that those in manual/skilled trade occupations, compared with all other occupations, experienced greater financial burden for each week away from work (P=.003). Older age at donation and nondirected (vs directed) donation were associated with significantly decreased financial burden. These observations provide additional information to better inform donor candidates, and further emphasize the need to develop policies so that living kidney donation can be financially neutral.

Perceptions of experiences of having a sibling stem cell donor

Objective: The aim was to explore stem cell recipients’ perceptions of experiences of having a sibling donor from pretransplantation to one year afterwards in order to support their learning process.Methods: Ten adult recipients, five women and four men, with a mean age of 52 years (19-68 years) receiving stem cells from a sibling donor were included consecutively. We used a phenomenographic approach to analyse the 28 open-ended interviews that took place before transplantation and three months and one year afterwards.Results: Ten categories emerged comprising 110 different perceptions pertaining to: Advantages, Acknowledgement, Risk evaluation, Complexity, Family impact, Non-directed donors, Self-identity, Facing the reality, Knowledge seeking and Caring encounters. Three distinct phases of the learning process were identified from before transplantation to one year afterwards, i.e., risk-benefit analysis, outcome expectations and facing the reality.Conclusions: Before transplantation the recipients had many perceptions about having a sibling donor and focused on a thorough risk versus benefit analysis for both themselves and the donor. Three months after transplantation the recipients sought knowledge in order to have realistic expectations and comprehend their future. One year after transplantation the recipients had few perceptions and focused on facing the reality, irrespective of whether the outcome was good or bad. The generic perceptions of the recipients over time were that serious blood diseases are burdensome and lethal, while treatment should include continuity of care.

Spirituality and religiosity of non-directed (altruistic) living kidney donors.

To describe the spirituality and religiosity of 30 non-directed (altruistic) living kidney donors in the USA and explore how they may have affected their motivations to donate and donation process experiences. The rise in non-directed donors and their ability to initiate kidney chains offer a novel approach to help alleviate the overextended kidney transplant wait list in the USA. However, little is known about the non-directed donors' motivations, characteristics and experiences. We conducted a qualitative-dominant study and used a grounded theory approach to analyse data. Thirty participants completed in-depth interviews between April 2013-April 2015. Three analysts independently read and coded interview transcripts. Grounded theory techniques were used to develop descriptive categories and identify topics related to the non-directed donors donation experience. Sixteen of the 30 non-directed donorss discussed the topic of spirituality and religiosity when describing their donation experiences, regardless of whether they were actively practising a religion at the time of donation. Specifically, three themes were identified within spirituality and religiosity: motivation to donate, support in the process, and justification of their donation decisions postdonation. Findings from this study are the first to describe how spirituality and religiosity influenced the experiences of U.S. non-directed donorss and may help improve non-directed donors educational resources for future spiritual or religious non-directed donors, and the overall non-directed donors donation experience in efforts to increase the living donor pool. Spirituality and religiosity are often overlooked yet potentially influential factors in Western medicine, as demonstrated through the experiences of Jehovah's Witnesses and their religious restrictions while undergoing surgery and the beliefs of Christian Scientists against taking medications and receiving medical procedures. Understanding needs of non-directed donors specifically with spirituality and religiosity can better position kidney transplant centres and teams to improve predonation screening of non-directed donor candidates and provide support services during the donation process.

Valuing Sets of Potential Transplants in a Kidney Paired Donation Network.

In kidney paired donation (KPD), incompatible donor-candidate pairs and non-directed (also known as altruistic) donors are pooled together with the aim of maximizing the total utility of transplants realized via donor exchanges. We consider a setting in which disjoint sets of potential transplants are selected at regular intervals, with fallback options available within each proposed set in the case of individual donor, candidate or match failure. We develop methods for calculating the expected utility for such sets under a realistic probability model for the KPD. Exact expected utility calculations for these sets are compared to estimates based on Monte Carlo samples of the underlying network. Models and methods are extended to include transplant candidates who join KPD with more than one incompatible donor. Microsimulations demonstrate the superiority of accounting for failure probability and fallback options, as well as candidates joining with additional donors, in terms of realized transplants and waiting time for candidates.

Live nondirected uterus donors: Psychological characteristics and motivation for donation.

Emerging research suggests that uterus transplantation is a viable option for women without a uterus who want to become pregnant and carry a child to term. Currently, no knowledge exists regarding nondirected uterus donors. This study (NCT 02656550) explored the baseline psychological characteristics of nondirected uterus donors at a single study site. Of the 62 potential donors who underwent initial screening, 6 nondirected donors were chosen and participated in uterus donation. Participants received a comprehensive evaluation, which included clinical history and psychological assessments. The mean age of the donors was 42years; most (83%) were white/not Hispanic, and all had a college degree. Current depression was reported by 2 participants, past depression was reported in 2 participants, and past anxiety was reported in 3 participants. Based on several different psychological measures, donors had a higher general well-being than the normative sample, and none of the participants' scores indicated psychological distress. All 6 women indicated that giving another woman an opportunity to carry her own child was a motivation for pursuing uterus donation. Further research on potential psychological motives and gains for the donor as well as long-term effects on donors is crucial for ethical practice.

Living uterus donation and transplantation: experience of interest and screening in a single center in the United States

Little is known about attitudes toward uterus donation and transplantation in society and the interest of the women the treatment is aimed to assist. This study examined the interest of recipients and living donors in our uterus transplantation program; it describes the screening protocol we developed and the results of the screening and reports demographic data and characteristics of screened candidates. Initial screening and evaluation included physical examinations by a gynecologist and a transplant surgeon; psychological evaluation; imaging (x-ray, computed tomography, ultrasound); blood tests; immunological testing; viral, bacterial, and fungal testing; drug screen; hormonal testing; Papanicolau smear; urinalysis; and electrocardiogram. For selected recipients, the process also included invitro fertilization. A total of 351 women contacted our department with interest in participating in uterus transplantation; 272 were potential recipients and 79 were potential donors. Among these women, 179 potential recipients and 62 potential donors continued the evaluation after the initial telephone screening. The mean age of the donor candidates was 40 years; all had completed their own family, and 80% were nondirected. Most recipient candidates (92%) had an anatomical lack of the uterus, and of these, 36% had a congenital malformation. The women with a congenital uterine absence were in general younger than the women in the group whose uterus had been removed (mean of 28 and 33 years, respectively). In every step of the initial screening and evaluation process, there were donor and recipient candidates that chose not to continue the process. The reasons for self-withdrawal after expressing interest were not returning phone calls or e-mails (17 donors and 76 recipients); after initial phone screening, no longer interested (1 donor and 9 recipients); in step 1, health history questionnaire not returned after 1 reminder (10 donors and 9 recipients); step 2, not right in their current life situation (2 donors and 2 recipients), and in step 3, chose another way to achieve motherhood (1 recipient). Most donor and recipient candidates (52% and 78%, respectively) could be screened out (because of self-withdrawal or transplant team's decision) during the noninvasive and cost-efficient initial screening. Our initial experience shows a great interest in participating in a trial of uterus transplantation by both potential recipients and donors. It is the first study to show interest in nondirected donation. A sufficient but thoughtful screening process of living donors and recipients is essential and should aim both to assure donor/recipient safety and to provide good quality grafts.

Effect of match-run frequencies on the number of transplants and waiting times in kidney exchange.

Numerous kidney exchange (kidney paired donation [KPD]) registries in the United States have gradually shifted to high-frequency match-runs, raising the question of whether this harms the number of transplants. We conducted simulations using clinical data from 2 KPD registries-the Alliance for Paired Donation, which runs multihospital exchanges, and Methodist San Antonio, which runs single-center exchanges-to study how the frequency of match-runs impacts the number of transplants and the average waiting times. We simulate the options facing each of the 2 registries by repeated resampling from their historical pools of patient-donor pairs and nondirected donors, with arrival and departure rates corresponding to the historical data. We find that longer intervals between match-runs do not increase the total number of transplants, and that prioritizing highly sensitized patients is more effective than waiting longer between match-runs for transplanting highly sensitized patients. While we do not find that frequent match-runs result in fewer transplanted pairs, we do find that increasing arrival rates of new pairs improves both the fraction of transplanted pairs and waiting times.