Program Streamlining Donor Assessment Process Improves Rate of Living Donor Transplantations

The best outcomes related to patient survival and quality of life for patients with end-stage renal disease (ESRD) are associated with renal transplantation. Greater transplant and patient survival seen in living versus deceased donor transplants; however, efforts to increase rates of living donation need to be balanced with ensuring patient safety via a comprehensive screening process.

Prior to 2010 the rate of living donor transplantation in Northern Ireland was low (4.3 per million population per year) and there were few preemptive kidney transplantations performed. Part of the reason for the low living donor rate was a lengthy donor workup process that could take 2 years, resulting in donor fatigue and subsequent dropout.

In March 2010, a 1-day donor assessment pathway was introduced to improve the process for potential donors. The quality improvement project aimed to limit the number of hospital visits for each donor by streamlining the process and conducting all investigations in 1 day; the model required collaboration among multiple specialties, including radiology, histocompatibility and immunogenetics, nuclear medicine, and cardiac investigations. The local transplantation service also had to be reorganized.

Judi M. Graham, MBBCH, BAO, MRCP, and Aisling E. Courtney, BSc, MPhil, FRCP, of the Regional Nephrology Unit at Belfast City Hospital, Belfast, United Kingdom, reported on the outcomes of potential donors who entered the streamlined process between March 2010 and March 2015. The authors also explored reasons donors did not complete the process, and the impact on the initiative on the rate of living kidney donation in the region. The report was published in the American Journal of Kidney Diseases [2018;71(2):209-215].

All potential donors who self-referred to the program were evaluated. Belfast City Hospital is the only institute for transplantation, living kidney donation, and donor assessment in the region.

The Northern Ireland Kidney Transplant Database that prospectively records all kidney transplantations performed in Northern Ireland and the clinical outcomes of patients receiving a kidney transplant was used to determine annual rates of living donation; demographics of all individuals who completed the initial donor screening questionnaire were prospectively recorded in the Northern Ireland Living Donor Database. Characteristics recorded included donor age, sex, race, relationship to the recipient, date of assessment, outcome, and, for those who did not complete the process, reasons for not proceeding. All patients who donated a kidney in 2011 were invited to complete a questionnaire following their recovery.

Following completion of the questionnaire, potential donors deemed to be suitable attended a 1-day evaluation involving all investigations that had previously been conducted across multiple clinical visits. Following implementation of the quality improvement project, the primary outcome of interest was the change in the rate of living donor transplantation.

Of the 431 potential donors who completed the 1-day screening, 44% (n=190) were men, median age was 48 years, and all were of European ancestry. Relationships between potential donors and recipients included sibling (n=137), parent (n=82), spouse/partner (n=79), offspring (n=51), second-degree relative (n=22), relative by marriage other than spouse (n=9), friend (n=12), and acquaintance/altruistic donation (n=39).

Of the 431 potential donors screened, 66% (n=284) had donated a kidney by December 1, 2016, and 3% (n=12) remained active as potential donors in the program. A total of 135 individuals exited the program. Reasons for nondonation included donor being unsuitable due to medical or surgical contraindications (11%, n=48), donor withdrawal (4%, n=18), and donor pregnancy (1%, n=2).

Recipients of 9% (n=38) of the donors found an alternative living donor or received a deceased donor transplantation; recipients of 5% (n=23) of the donors developed issues that made transplantation no longer feasible; and 1% (n=6) of recipients withdrew for other reasons.

Between 2000 and 2009, the mean annual rate in living donor kidney transplantation in Northern Ireland was 4.3 per million population; between 2011 and 2015, the mean annual rate in living donor kidney transplantation was 32.6 per million population. Living donor transplantation now accounts for the majority of kidney transplantations in the region. In addition, there has been an annual increase in the proportion of living donor transplantations undertaken preemptively (<10% in 2005 to >50% in 2015).

Limitations to the study cited by the authors included the retrospective observational design of the analysis; the program being conducted in a single geographical region, possibly limiting the generalizability of the findings; and the scarcity of data from the period prior to the intervention.

“In conclusion, a 1-day assessment pathway for living kidney donors is a comprehensive process that, when implemented, was followed by an increase in living kidney donation in this United Kingdom region. In addition, there has been an increase in preemptive transplantation rates and a decrease in the prevalent dialysis population. We conclude that a philosophy of making it as easy as possible for people to donate and ensuring that the assessment process is donor focused and as efficient as possible are key to the success of this living donation program. This simple approach should be easily transferrable to other centers and is likely to result in a similarly positive impact,” the researchers said.

Takeaway Points

  1. Living donor kidney transplants results in improved outcomes compared with deceased donor transplantation; rates of living donor transplantations in Northern Ireland were low prior to 2010.
  2. The Belfast City Hospital, Belfast, United Kingdom, implemented a quality improvement model consisting of a 1-day donor assessment for potential donors.
  3. Between 2000 and 2009, the mean rate of living donor kidney transplantations in Northern Ireland was 4.3 per million population. Following implementation of the program (between 2011 and 2015), the mean rate was 32.6 per million population.