Learning objectives:
To gain insight into the importance of living donation
To provide renal nurses a basic knowledge in living donor kidney transplantation.
Introduction
Since the first successful kidney transplant in 1954, transplantation has been accepted as the superior renal replacement therapy compared to dialysis.1 In particular, living donor kidney transplantation (LDKT) represents one of the most innovative advances in medical treatment option worldwide for many people with end stage renal disease (ESRD).2 LDKT not only improves quality of life but also reduces overall healthcare costs.3
LDKT is practised in most of the EU countries. However, living donation is variable with considerable low rates in many countries, even in those with well set-up transplantation programmes.4 In 2019 the overall number of organ transplant activities in the European Union (EU) was 67.2 per million population and there was a wide difference among countries.4
depicts the LDKT rates in relation to the total kidney transplant activities in the EU countries in 2019.5
LDKT rates in relation to total kidney transplants in the 28 European countries (2019). Source: Global Observatory on Donation and Transplantation. http://www.transplant-observatory.org/export-database/ (Chart own creation based on data obtained from (more...)
The reasons for the variations in transplant activities are, for example4,6:
Differences in legal frameworks and public policies of each country on donation and transplantation activities.
Population characteristics (e.g. health status, socioeconomic status, ethnic minority)
Epidemiologic factors (e.g. prevalence of hypertension, diabetes mellitus and obesity)
Efficacy of prevention therapy
Efficacy of pre-transplant therapy
To address the current differences in transplantation rates within the EU countries, Vanholder et al.4 outlined the roadmap with recommendations to be used as a guide to encourage organ donation and boost transplantation activity. For example, optimizing LDKT is an important consideration due to the demonstrated benefits.
Benefits of LDKT
LDKT has been shown to offer better outcomes2,7 and to be more cost-effective than deceased donor kidney transplantation (DDKT).8 A living donor kidney has about 10 years longer half-life than that of a deceased donor kidney. This helps to reduce the number of patients needing re-transplantation, resulting in more kidneys available for first time recipients8 and for the older age group patients on waiting list.9 LDKT is therefore recommended to be the first and preferred option.10,11
Below are some examples of documented benefits:
1. Recipient perspective:
2. Donor perspective:
The donors feel positive about the opportunity to offer help to someone in need of a transplant. They can also experience benefits in personal growth, interpersonal relationships, self-esteem, social engagement and spiritual/religious life. In an interview study many donors reported less stress and positive benefits which extended to the entire family following donation (able to enjoy things together without restrictions, e.g. meals and planning vacation).
In donors whose recipients were dependent on them stated they feel the relief of caregiver burden following donation as recipients improve their health condition and recover autonomy in self-care. These donors also reported to have more free time, be able to travel together with the recipient (spouse/partner) and be better off financially due to the recipient’s ability to work again.
In the case of a young couple, there is the chance of having a biological child.The above examples are some of the tangible benefits which are often disregarded in living donor evaluation.
13On the whole, donors experience similar or improved psychosocial outcomes in terms of quality of life, post-donation compared with pre-donation, and compared with non-donors.
14
Risks related to living kidney donation
Living kidney donation (LKD) is not risk-free and there is legitimate concern about surgical risks and the donor’s long-term health as it involves the removal of a kidney from a healthy person. However, when the donor is carefully evaluated and selected by adhering to clear guidelines, the risk of developing any significant life-changing health condition is low, as described below.
Short-term:
‘In safe hands, surgical risk is low’ with the practice of laparoscopic nephrectomy. Studies reported 0.03% of perioperative mortality
15, 3-6% of donors faced major perioperative complications and 22% suffered minor peri-operative complications.
14The laparoscopic technique results in quicker medical and social recovery, including faster return to work – shorter hospital stay is safer particularly during the COVID-19 pandemic.
16In a survey, all donors acknowledged that the benefits of donation outweighed the peri- and post-operative risks.
14
Long-term:
Studies have shown that donors’ survival rates are similar to that of the healthy population
15 and the general population.
17The risk of ESRD at 15 years after donation has been reported to be low, although it may be higher, for example, in the younger donors and black males. Kidney failure in donors has been shown to be lower than in the general population but higher than in healthy non-donors.
14The Developing Education Science and Care for Renal Transplantation in European States working group concluded that risks of hypertension and albuminuria are the same as in non-donors.
18Data reported a small number of donors experienced stress/ anxiety/depression or poor relationships, but the majority enjoyed good quality of life with little regret about donation.
14
LDKT awareness and promotion
The scrutiny of current evidence on long-term risks of living donation concluded that the absolute risks are low for the donors.18,19 Long-term risks are determined by the donor’s characteristics, the transplant team must endeavour to perform rigorous donor assessment for proper donor selections. They must also inform potential donors about the importance of a healthy lifestyle after donation.18
Healthcare professionals (HCPs) involved in transplant activities must be aware that careful and regular follow-up of short and long-term risks after LKD is essential to uphold informed consent and public trust in living donation.2,11 Before agreeing to donate, the potential donor must be duly informed about the type and risk of surgery. This information must include possible short and long-term complications (medical and psychological), and to be provided again by another doctor who is not directly involved in the donor/recipient process. The information provided must also be culturally coherent and easy for the potential donor to understand.
The donor must also be informed about possible kidney rejection, medical and surgical complications in the recipient.2,11 Appropriate informed consent is the core of the process.2 To safeguard the potential donor, a multi-disciplinary team approach is recommended in the clinical assessment and evaluation of all donors, including an independent assessor.2,11,20
Another point to be aware of, the donation process may result in living donors having out-of-pocket expenses and lost earnings, or difficulty obtaining health insurance coverage.14 For further details see Chapter 4.
Given the low risk for donors and the significant benefits for recipients, experts consider that LKD is safe to be encouraged and promoted.4,10,11,18,19
Educational programmes to promote LDKT
Structured educational programmes and early discussion are recommended to enhance referral for living donor kidney transplantation.21–23 The following are six main aspects which HCPs identified as barriers to discussing LDKT with patients22:
Lack of communication between dialysis and transplant teams.
Absence of referral guidelines.
Role perception and lack of multidisciplinary involvement (HCPs did not consider themselves to be responsible to discuss LDKT with patients. They perceived this to be the role of the transplant staff).
Negative attitudes of some HCPs towards LDKT.
Patient’s age, culture, language difference, psychosocial needs and belief system can be barriers to discussion of LDKT.
HCP’s lack of knowledge and training regarding training LDKT.
HCPs, particularly nurses, involved in transplantation activities can play a pivotal role in a patient’s decision to seek living donation. These professionals should be aware that low socioeconomic level, unemployment, race/ethnicity (non-white), literacy and health literacy are independent factors associated with patients having less chances of pre-emptive LDKT.24
Conclusion
LDKT is the treatment of choice for suitable recipients with ESRD because it is associated with superior patient and graft survival outcomes. It is also more cost-effective than DDKT. LKD increases the donor pool and transplant opportunities for the whole ESRD population, particularly pre-emptive transplantation. The literature shows that LKD is safe when practised under strict donor evaluation and selection criteria. Therefore, it is recommended that every transplant centre includes LDKT as part of the transplant activity with education programme for HCPs, as well as for patients and their families.
References
- 1.
Tonelli MWiebe NKnoll GBello ABrowne SJadhav Det al. Systematic review: kidney transplantation compared with dialysis in clinically relevant outcomes.
Am J Transplant
. 2011;11(10):2093–109. Available from: [
PubMed: 21883901] [
CrossRef]
- 2.
Guide to the quality and safety of organs for transplantation EDQM 7th Edition 2018, European Committee (Partial Agreement) on Organ Transplantation (CD-P-TO).
- 3.
Haller MGutjahr GKramar RHarnoncourt FOberbauer R Cost-effectiveness analysis of renal replacement therapy in Austria.
Nephrol Dial Transplant
. 2011;26(9):2988–95. Available from: [
PubMed: 21310740] [
CrossRef]
- 4.
- 5.
- 6.
- 7.
de Groot IBVeen JIvan der Boog PJvan Dijk SStiggelbout AMMarang-van de Mheen PJPARTNER-study group. Difference in quality of life, fatigue and societal participation between living and deceased donor kidney transplant recipients.
Clin Transplant
. 2013;27(4):E415–23. Available from: [
PubMed: 23808752] [
CrossRef]
- 8.
Tarantino A Why should we implement living donation in renal transplantation?
Clin Nephrol
. 2000;53(4) suppl:55–63. [
PubMed: 10809438]
- 9.
- 10.
- 11.
- 12.
Bos EMLeuvenink HGvan Goor HPloeg RJ Kidney grafts from brain dead donors: Inferior quality or opportunity for improvement?
Kidney Int
. 2007;72(7):797–805. Available from: [
PubMed: 17653138] [
CrossRef]
- 13.
Van Pilsum Rasmussen SERobin MSaha AEno ALifshitz RWaldram MMet al. The Tangible Benefits of Living Donation: Results of a Qualitative Study of Living Kidney Donors.
Transplant Direct
. 2020;6:e626. Available from: [
PMC free article: PMC7665258] [
PubMed: 33204824] [
CrossRef]
- 14.
- 15.
Segev DLMuzaale ADCaffo BS Perioperative mortality and long-term survival following live kidney donation.
JAMA
. 2010;303:959–966. [
PubMed: 20215610]
- 16.
Vernadakis SMarinaki SDarema MSoukouli IMichelakis JEBeletsioti Cet al. The Evolution of Living Donor Nephrectomy Program at A Hellenic Transplant Center. Laparoscopic vs. Open Donor Nephrectomy: Single-Center Experience.
J Clin Med
. 2021;10(6):1195. Available from: [
PMC free article: PMC8001196] [
PubMed: 33809339] [
CrossRef]
- 17.
Kim YYu MYYoo KDJeong CWKim HHMin SIet al. Long-term Mortality Risks Among Living Kidney Donors in Korea.
Am J Kidney Dis
. 2020;75(6):919–925. Available from: [
PubMed: 31866225] [
CrossRef]
- 18.
Maggiore UBudde KHeemann UHilbrands LOberbauer ROniscu GCet al. for the ERA-EDTA DESCARTES working group. Long-term risks of kidney living donation: review and position paper by the ERA-EDTA DESCARTES working group.
Nephrology Dialysis Transplantation
. 2017;32(2):216–223. Available from: [
PubMed: 28186535] [
CrossRef]
- 19.
- 20.
Bellini MICantisani VLauro AD’Andrea V Living Kidney Donation: Practical Considerations on Setting Up a Program.
Transplantology
. 2021;2:75–86. Available from: [
CrossRef]
- 21.
Waterman ADMorgievich MCohen DJButt ZChakkera HALindower Cet al. Living Donor Kidney Transplantation: Improving Education Outside of Transplant Centers about Live Donor Transplantation-Recommendations from a Consensus Conference.
Clin J Am Soc Nephrol
. 2015;10(9):1659–69. Available from: [
PMC free article: PMC4559502] [
PubMed: 26116651] [
CrossRef]
- 22.
Sandal SCharlebois KFiore JF JrWright DKFortin MFeldman LSet al. Health Professional-Identified Barriers to Living Donor Kidney Transplantation: A Qualitative Study.
Can J Kidney Health Dis
. 2019;6:2054358119828389. Available from: [
PMC free article: PMC6376531] [
PubMed: 30792874] [
CrossRef]
- 23.
Hunt HFRodrigue JRDew MASchaffer RLHenderson MLRandee Bloom Ret al. Strategies for Increasing Knowledge, Communication, and Access to Living Donor Transplantation: an Evidence Review to Inform Patient Education.
Curr Transplant Rep
. 2018;5(1):27–44. Available from: [
PMC free article: PMC6413325] [
PubMed: 30873335] [
CrossRef]
- 24.
Wu DARobb MLWatson CJEForsythe JLRTomson CRVCairns Jet al. Barriers to living donor kidney transplantation in the United Kingdom: a national observational study.
Nephrol Dial Transplant
. 2017;32(5):890–900. Available from: [
PMC free article: PMC5427518] [
PubMed: 28379431] [
CrossRef]
Further Reading
- •.
van Dellen DBurnapp LCitterio FMamode NMoorlock Gvan Assche Ket al. Pre-emptive live donor kidney transplantation-moving barriers to opportunities: An ethical, legal and psychological aspects of organ transplantation view.
World J Transplant
. 2021;11(4):88–98. Available from: [
PMC free article: PMC8058646] [
PubMed: 33954087] [
CrossRef]
- •.
- •.
Waterman ADRobbins MLPeipert JD Educating Prospective Kidney Transplant Recipients and Living Donors about Living Donation: Practical and Theoretical Recommendations for Increasing Living Donation Rates.
Curr Transplant Rep
. 2016;3(1):1–9. Available from: [
PMC free article: PMC4918088] [
PubMed: 27347475] [
CrossRef]
