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Introduction: Although informed consent content elements are prescribed in detailed regulatory guidance, many live kidney donors describe feeling underprepared and under informed. The goal of this pilot study was to explore the educational components needed to support an informed decision-making process for living kidney donors., Methods/approach: A qualitative description design was conducted with thematic analysis of 5 focus groups with 2 cohorts: living kidney donor candidates (n = 11) and living kidney donors (n = 8)., Findings: The educational components needed to engage in an informed decision-making process were: 1) contingent upon, and motivated by, personal circumstances; 2) supported through explanation of risks and benefits; 3) enhanced by understanding the overall donation experience; and 4) personalized by talking to another donor., Discussion: Tailoring education to meet the needs for fully informed decision-making is essential. Current education requirements, as defined by regulatory bodies, remain challenging to transplant teams attempting to ensure fully informed consent of living kidney donor candidates. Information on the emotional, financial, and overall life impact is needed, along with acknowledgement of relational ties driving donor motivations and the hoped-for recipient outcomes. Discussion of care practices, and access to peer mentoring may further strengthen the informed decision-making process.

Introduction: The benefit and short-term safety of ketorolac have been established in previous studies however, the risk of bleeding and long-term renal impairment in patients undergoing donor nephrectomy remain unclear. We report our experience at a high-volume transplant center., Method: Between January 1996 and January 2014, 862 consecutive patients underwent laparoscopic donor nephrectomy. Exclusion criteria included nonsteroidal anti-inflammatory drug allergy, asthma, bleeding disorders, long-term opioid use, intraoperative blood loss >700 mL, peptic ulcer disease, bleeding diathesis, and baseline creatinine greater than 1.9 mg/dL. Intravenous ketorolac was administered within 30 minutes following the surgical procedure at a dose of 15 to 30 mg every 6 hours. Patients were categorized into 2 groups according to the administration of ketorolac after surgery. Differences between the groups were analyzed. Primary outcomes were changes in serum creatinine and hemoglobin levels. Poor outcome was defined as postsurgical complications., Results: During this time, 469 (55.3%) received ketorolac. The mean donor age was 39 years, and 360 (42.5%) were male. Left kidneys were procured in 82%. Operative time averaged 210 minutes and warm ischemia time117 seconds. Baseline demographic and operative outcomes were comparable in both groups. No statistically significant differences were found between the ketorolac group and the nonketorolac group in preoperative and postoperative hemoglobin levels and serum creatinine at 1 week, 1 year, and 5 years ( P = .6). Ketorolac use was not associated with increased perioperative morbidity ( P = NS)., Conclusion: The use of intravenous ketorolac in patients undergoing donor nephrectomy was not associated with an increased risk of bleeding or renal impairment.

Objective: To explore the psychosocial characteristics of living liver and kidney donors to identify common traits including personality traits, purpose in life, resilience, and post donation growth., Methods: Questionnaires were mailed to 835 living donors. Included were a survey of demographic characteristics and donation experiences, the NEO Five-Factor Inventory, the Purpose in Life Scale, the Posttraumatic Growth Inventory, and the Connor-Davidson Resilience Scale. Analyses compared the donor groups with the scale norms (where available) and compared differences between donor groups., Results: Eighteen percent of donors (n=151) responded anonymously. The sample was as resilient as the general population and significantly more resilient than the population of primary care patients. Kidney donors were significantly more resilient than liver donors. Live donors demonstrated scores on the NEO Five-Factor Inventory in the "high" range for agreeableness and conscientiousness and "low" for neuroticism. Kidney donors scored significantly lower on the neuroticism scale than liver donors scored. Purpose in Life scores and Post Donation Growth scores were skewed and were overwhelmingly high in this sample. Additional differences in psychosocial variables are also described., Conclusion: Live donors are resilient and show adaptive personality traits. It is difficult to conclude whether these traits were inspired by the act of donation or if they make one more apt to choose donation. Moreover, the study methods introduce the possibility of selection bias: those with certain characteristics may have been more likely to respond. Prospective studies before and after donation are warranted.

Many controversies arise when living donor candidates present themselves for consideration as donors for urgent liver transplants. Nonparent living donors for urgent pediatric transplant recipients are a unique donor candidate population with specific considerations that need to be acknowledged and addressed by the independent donor advocacy team. Such a team educates about donation, identifies potential contraindications, examines the distant relationships between donor and recipient, and considers ethical issues about the ability to make an informed decision in an urgent situation. A center for living donation dealt with such ethical issues when a donor candidate with a distant relationship was evaluated for living donation. Multiple relative contraindications were identified, and the donor candidate was declined. Careful management by the independent donor advocacy team is necessary to ensure the psychosocial safety and to provide needed psychosocial support and intervention for donor candidates with psychological contraindications to donation. Standard follow-up protocols need to be developed for declined donor candidates.

For decades, live organ donors have been cared for within the transplant program by the same team that cared for the recipient without any standardization, practice guidelines, or evidence-based evaluation. In an effort to improve the care of living donors, regulations and guidelines to dictate care and follow-up have been instituted. Practices still vary from center to center, and the quality of care that live donors receive also varies. A "Living Donor Center" focused solely on the care of actual and potential donors before and after donation is one way to provide the infrastructure to comply with regulatory mandates and deliver high-quality care to this specialized population of patients. A Center for Living Donation was developed within a Transplantation Institute to address the short- and long-term needs of live donors and confine all donor care to a team of experts led by a doctorally prepared nurse practitioner as the director. A transplant nurse practitioner is uniquely poised to assume such a role because of such competencies as clinical and professional leadership, ability to act as a change agent, communication skills, and ability to lead a multidisciplinary team.

Living donor transplant has developed as a direct result of the critical shortage of deceased donors. Federal regulations require transplant programs to appoint an independent donor advocate to ensure safe evaluation and care of live donors. Ethical and pragmatic issues surround the donor advocate. These issues include the composition of a team versus an individual advocate, who appoints them, and the role that the advocate(s) play in the process. A team approach to donor advocacy is recommended. Common goals of the independent donor advocacy team should be protocol development, education, medical and psychosocial evaluation, advocacy, support, and documentation throughout the donation process. The team's involvement should not end with consent and donation but should continue through short- and long-term follow-up and management. Ultimately it is the goal of the independent donor advocacy team to assist donors to advocate for themselves. Once deemed medically and psychologically suitable, donors must determine for themselves what they wish to do and must be free to vocalize this to their team. The decision to donate or not affects the donor first. Optimal outcomes begin with prepared, educated, uncoerced, and motivated donors, and it is the team's goal to help donors reach this point.

Adult living donor liver transplantation has developed as a direct result of the critical shortage of deceased donors. Recent regulations passed by New York State require transplant programs to appoint an Independent Donor Advocacy Team to evaluate, educate, and consent to all potential living liver donors. Ethical issues surround the composition of the team, who appoints them, and the role the team plays in the process. Critics of living liver donation have questioned issues surrounding motivation and the ability of donors to provide true informed consent during a time of family crisis. This article will address issues surrounding the controversies and discuss how using the team can effectively evaluate and educate potential living liver donors and improve practice to ensure safety of living donors.

Background: Living donor kidney transplantation is considered a safe and effective means to treat end-stage renal disease, and has now exceeded the number of deceased donor kidney transplantations performed annually. Living donor liver transplantation is more controversial and has received criticism in the medical and lay community. Studies focus on recipient outcomes and medical safety. The impact of the donation on donors is not well understood., Objective: To compare experiences from both kidney and liver living donors, including their motivation, perceived risks, and postoperative experience., Methods: Questionnaires about the donation experience were mailed to 70 patients who underwent laparoscopic donor nephrectomy and 85 patients who underwent hepatectomy at a large academic medical center. Results of kidney and liver donors were compared., Results: No differences were found in mean age, marital status, ethnicity, relationship to the recipient, and employment status of the 2 groups. Women were more prevalent in both groups. The most common motivating factor in both kidney and liver donors was "because it was family," 81% and 82%, respectively. Kidney donors describe the decision to donate as easy compared to the liver donors (P = .049). In neither group did donors feel pressure to donate or have family conflicts regarding their decision to donate. Both groups felt they were well informed of the risks. Neither group described unexpected problems, and neither group regretted their decision to donate and would do it again if asked., Conclusion: Donors in both groups reported favorable outcomes. A greater concern for risk of death, bleeding, altered appearance, and infection existed among liver donors compared to kidney donors. The actual outcomes were better than the perceived risks.

As a result of the cadaveric organ shortage, the number of centers performing living donor liver transplantation has increased. Living donor liver transplantation provides immediate organ availability and avoids the risk of life-threatening complications that occur with long waiting times for cadaveric organs; however, it puts a healthy person at risk for little personal gain. A standardized approach to donor evaluation ensures safety to potential donors. Careful medical (physical examination as well as laboratory and radiological evaluation) and psychological evaluation is imperative to reduce donor complications and ensure good outcomes in recipients. A social worker and psychiatrist assess for mental competency, provide emotional support, and can serve as independent donor advocates. Informed understanding and consent are crucial aspects of the evaluation and include ensuring that the donor understands all potential complications and is free of coercion. Safety of the donor must be the highest priority.