Many a Slip Twixt the Intake Form and the Living Donation.

Living donor kidney transplant (LDKT) results in superior allograft and patient survival to deceased donor transplant.1 Despite this, only 30% of kidney transplants in the United States are from living donors, and the rate of LDKT has remained stagnant for a long time.2,3 From 2017 to 2019, the United States observed the first significant growth in the number of LDKTs performed.4 This momentum was abruptly lost when the COVID-19 pandemic hit in 2020.2 Aside from these events, trends in LDKT in the United States have remained puzzling. Increasing LDKT continues to be a challenge for transplant centers across the country. The study of Cholin et al aimed to describe the characteristics of potential and actual living kidney donors in their transplant center to identify barriers to successful LDKT and potential areas of intervention to increase the number of LDKTs.5 They divided their living donor process into 5 phases: intake form, immunologic compatibility testing, clinic evaluation, selection committee review, and donation. They found that two-thirds of potential donors dropped out after completion of the intake form. Of these, the main reason was that almost a quarter did not respond to a follow-up phone call. Around 20% were excluded for medical reasons and another 20% for having a body mass index >35 kg/m2. Among the few who progressed to the next phase, close to 40% were deemed incompatible on immunologic testing. Of their 2500 potential donors, only 7% proceeded to donation. High dropout rates during the donor process have been demonstrated in other countries.6,7 In a single-center study in Korea, a country where the majority of transplants are from living donors, only 50% of potential donors proceeded to donation. The barriers to LDKT are multifaceted. Some factors are inherent to the donor and are nonmodifiable. In their logistic regression model, Cholin et al5 found that White race and first-degree relation to the transplant candidate were associated with an increased odds ratio of donation, as demonstrated in other studies. Some factors, despite being inherent to the donor, can become modifiable by changing external circumstances (Table 1). For example, certain medical conditions such as hypertension and obesity were previously thought to be contraindications to donation but are now considered relative contraindications and modifiable. This change is a result of improvements in knowledge on the long-term outcomes after kidney donation. Tissue and blood-type incompatibilities are now largely addressed by kidney paired donation (KPD) programs. Simulations have shown that optimizing KPD can significantly increase the number of LDKTs.8 Including compatible pairs in the KPD can increase the numbers even more.9 Other modifiable barriers to LDKT relate to the transplant candidate. Interventions like identifying a Living Donor Champion, the social media app Donor (https://www.thedonorapp.com/en/), and the Big Ask Big Give program of the National Kidney Foundation (https://www.kidney.org/transplantation/livingdonors) have been used to help recipients find a donor.10-12 One can argue that many of these donor–candidate barriers should be addressed at a national level because these are shared across centers all over the country. Centralized initiatives like the National Living Donor Assistance Center, which provides financial assistance to donors (https://www.livingdonorassistance.org/), and the American Society of Transplantation Living Donor Toolkit, which helps providers and donors navigate the donor evaluation process, can streamline efforts. Public-private partnerships using the expertise of organizations like the National Kidney Registry and the mandate of the United Network for Organ Sharing may allow for an optimized national KPD program.13 Legislation to ensure donor assistance and safety, especially postdonation, will alleviate a lot of fear and hesitation at multiple levels, from the donor, the provider, up to the transplant center.14TABLE 1.: Modifiable barriers to living kidney donationGiven the dismal number of potential donors who proceed with donation, centers trying to expand their LDKT program should evaluate which interventions they should funnel resources to. Instead of replicating existing national initiatives, centers should act as a bridge between donors and these programs and just provide supplementary services if needed. Although transplant center distance was not a barrier for Cholin et al, it may be an issue for other centers, and promoting the use of telemedicine may be a solution.15 Streamlining the intake process and adding personnel for follow-up calls are simple solutions that can reduce early dropout. Cholin et al also demonstrated that transplant candidates themselves and their network (family or friends) are the highest source of donor referrals over methods like social media. Centers should therefore explore how the pretransplant candidate team can be utilized more to promote living donation during the candidate evaluation process. As already alluded to, centers should optimize internal and national KPD because this likely will have a big impact on the number of LDKT. The study by Cholin et al has several strengths, including providing a more granular insight into the pitfalls of the donor evaluation process, a large sample size, and the use of creative methods such as geocoding to explore how sociodemographic factors relate to living donation. One limitation of a single-center study is its lack of generalizability, but this only highlights how valuable it is for centers to examine their own donor processes to determine the most cost-effective interventions. More studies like Cholin et al are needed to better understand the barriers to LDKT to hopefully benefit the thousands of candidates waiting for a kidney transplant in the country. For the present, however, there is many a slip twixt the intake form and the living donation.