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Avrami C, Liossatou A, Ho TM, editors. Current Strategies for Living Donor Kidney Transplantation [Internet]. Hergiswil (CH): European Dialysis and Transplant Nurses Association/European Renal Care Association (EDTNA/ERCA); 2021.

Cover of Current Strategies for Living Donor Kidney Transplantation

Current Strategies for Living Donor Kidney Transplantation [Internet].

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CHAPTER 6Psychological aspects of care in living donor kidney transplantation

, BSc (Hons), D.Clin.Psychol., PG Dip CT and , BSc (Hons), D.Clin.Psychol.

Author Information

Learning objectives:

  1. To develop understanding of psychological factors in living kidney donation
  2. To gain knowledge of psychological assessment for live donation
  3. To describe intervention pre- and post-donation


Consideration of psychological factors is essential throughout the process of live kidney donation for donor and recipient. Research shows donor psychological outcome is largely positive with donors reporting similar rates of quality of life, depression and anxiety as controls or the general population, limited regret and no change or improvement in self-esteem and relationship with the recipient.14 Donors may also benefit from improvements in quality of life as a couple or family post-transplant.5,6 However, it is also important to note that some donors have been found to experience residual difficulties such as depression, anxiety, stress, health worries, regret and some negative impact on their relationship with the recipient.1,6-8 Whilst physical benefits for the recipient are likely to be greater than for the donor, transplantation is major surgery and involves significant physical and psychological adjustment.9,10

Psychological and emotional support, including long term follow up should be integral to multidisciplinary delivery of care in order to maximize positive psychological outcome for both donors and recipients.3,9 Some services have embedded specialist psychological input whilst others may need to access this externally.


Psychological assessment of donors and recipients is complex and involves consideration of a multitude of factors. Comprehensive assessment helps to support decision-making, identify psychological contraindications to donation and recognize individuals who may require increased psychological support. Discussions with prospective donors and recipients should highlight the potential range of psychological and emotional factors, which can also help to manage expectations.3,11

Donor: Tools such as the Living Donor Assessment Tool (LDAT)12 and the ELPAT living organ donor Psychosocial Assessment Tool (EPAT)13 have been developed to offer evidence-based frameworks for psychological assessment of live donors. The use of such frameworks can increase consistency in donor psychological assessment across transplant centres which has been highlighted as a need.8 These assessment tools cover areas such as: expectations, feelings about donation, commitment, motives, mental/cognitive capacity, coercion, stability in life, conflicts in relationship, legality, psychiatric disorder/substance misuse, knowledge, social support, socio-economic factors and nonverbal observations. It is also important to provide support for prospective donors who are turned down or who choose not to continue.8,14

Recipient: Many factors included in donor assessment tools are also relevant in recipient assessment. Additional recipient factors to consider include adherence issues, the complexities of finding a donor, family/relationship dynamics, feelings of guilt, perceived pressure for successful outcome and managing difficult feelings if this is not the case.6,15,16

Intervention pre-donation

The early stages of considering live donation can raise many emotions for both donors and recipients.3 Initial decisions as to whether to pursue live donation and raising the idea with family and friends can bring challenges for recipients.3 Perceptions of the potential impact on their relationship with the donor can be a significant factor in the recipient's decision-making process.5 Distress or upset may also be felt by those who do not have available or forthcoming donors. Psychological input may be required to support recipients through these processes. Decision-making for donors may also raise anxieties, doubts or concerns. Donor assessment (above) can be an important part of this process and additional support may be required before or during the workup. Ralph et al.6 have highlighted the need to assess the donor-recipient relationship throughout the process and provide appropriate support both pre- and post-donation.

Support may be required with issues such as weight loss or other lifestyle changes to be accepted for surgery. Specific psychological difficulties such as anxiety, procedural distress, adherence difficulties or depression may require specialist psychological intervention before donation can proceed. During assessment and pre-donation, it is also important to develop a post donation support plan, particularly where historic or current psychological issues have been identified.8

Studies have identified that some donors who had withdrawn or were found to be unsuitable for live donation reported negative psychological impact. Services can respond by managing expectations from the start, ensuring such endings are well managed, communicating clearly and sensitively, sending a letter of acknowledgement, providing opportunities to discuss the psychological impact and help in accessing specialist support where required.11,17

Follow-up/long-term factors

Post-transplant donor and recipient follow-up should include assessment of psychological wellbeing and signposting for additional support where required.3,8,18,19 Some issues may be difficult for people to articulate due to feelings of guilt or shame and these discussions need to be approached sensitively. Specific concerns to consider when reviewing donors and recipients include:

Donor:1,3, 6-8

  • Reduced quality of life
  • Higher levels of fatigue
  • Relationship changes
  • Anxiety
  • Depression
  • Stress and worries about health
  • Regret
  • Potential for psychological difficulties where there are negative outcomes for the recipient


  • Adherence
  • Adjusting to new medications
  • Anxiety
  • Depression
  • Sleep problems
  • Cognitive impairment
  • Relationship issues
  • Guilt/feeling indebted
  • Lack of family support

In their systematic review, De Pasquale et al.21 highlight that psychological support for recipients pre- and post-transplant can increase adherence and reduce the possibility of anxiety and depression after transplant.

Non-directed donors and their recipients may choose to write and/or receive a letter, which can generate mixed emotions and may require support from the transplant team.11,22 Zuchowski et al.11 highlight how lack of a letter or similar can reduce satisfaction with donation in unspecified kidney donors and it is important to manage expectations that this may not occur and may feel difficult.


The impact of the COVID-19 pandemic on both donor and recipient psychological and social wellbeing needs to be considered. Recipients and donors may benefit from additional psychological support with issues such as:

  • Social and financial pressure
  • Reduced access to practical and emotional support
  • Reduced opportunity to discuss their decision to donate with family and friends
  • Anxiety about hospitalization/contracting the virus
  • Coping with cancellation/postponement of surgery

Lack of opportunity for face-to-face connection between donor and recipient also needs to be acknowledged. Whilst these factors are not necessarily a contraindication to donation going ahead, time to consider and discuss these issues and establish support structures is essential.

Implications for Practice

  • Psychological factors should be considered throughout assessment and workup of both donor and recipient, beginning in the early stages of decision-making about live donation.1,3,5,6,8,11-13,16,18,19,21
  • Donor assessment tools such as the EPAT should be used across centres for consistency.8,13,18
  • Access to further specialist psychological support should be available at all stages where required. Plans for post-donation support for both donor and recipient should be made in particular where there is a history of psychological difficulties and routine checks on recipient and donor psychological wellbeing should be made in the short- and longer-term post-donation.1,3,8,18,19,21
  • Attention to the donor-recipient relationship is also important as relationship factors have the potential to be linked to negative psychological experiences pre- and post-donation.3,5,6,18 At times of significant events such as complications for the recipient post-transplant, the psychological needs of both donor and recipient should be checked.1,3, 6-8,18
  • Psychological needs of donors and recipients who withdraw from the live donor process need to be supported.8,11,14,17
  • Multidisciplinary members of Live Donor Teams need to be aware of the range of psychological factors in live kidney donation, communicating sensitively about these with donors and recipients which can help manage expectations3,11,18 and referring for specialist psychological support where required.
  • Training may be required to support Live Donor Teams with the above and services will require appropriate access to specialist psychological support for both donors and recipients. These are important aspects for services to consider in workforce planning.


Consideration of psychological aspects of live kidney donation is an important element of service delivery and impacts on donor/recipient experience and outcome. Appropriate awareness of psychological factors is essential to enable teams to integrate the required screening, assessment, and access to specialist psychological provision.


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Bookshelf ID: NBK581474PMID: 35816603


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