AS

ABM

Ohciiesmbdritd(

0d

3

ttitude Toward Living Liver Donation in Transplant Hospitals inpain, Mexico and Cuba

. Ríos, A. López-Navas, M.A. Ayala-García, M.J. Sebastián, A. Abdo-Cuza, L. Martínez-Alarcón,

. González, E.J. Ramírez, G. Muñoz, A. Camacho, J. Suárez-López, R. Castellanos, J.S. Rodríguez,.A. Martínez, A. Nieto, G. Ramis, P. Ramírez, and P. Parrilla

ABSTRACT

Background. Transplantation hospitals have played a key role in developing deceasedorgan donation and transplantation (ODT). To reduce the number of deaths on thetransplant waiting list, it is essential to encourage living liver donation (LLD). Involvementof personnel in these hospitals is crucial.Purpose. We analyzed the attitudes toward LLD among hospital personnel in Spain,Mexico, and Cuba.Materials and methods. Data were obtained from 5 transplant hospitals in Spain,Mexico, and Cuba. The sample was stratified according to job category and type of service(n � 2273). A validated questionnaire about living donation was used as the instrument.Results. Most respondents (82%) were in favor of related LLD. If the LLD was notrelated, acceptance fell to 21%. A total of 85% of physicians, 79% of nursing personnel,74% of nursing assistants, and 83% of auxiliary staff were in favor (p � .001). A favorableattitude toward LLD was associated (P � .05) with age (37 � 10 y vs 39 � 10 y), a favorableattitude toward deceased donation, a belief that a possible transplant is needed, acceptance ofLLD if necessary, a favorable attitude toward living kidney donation, family discussion aboutODT, a partner’s favorable attitude toward ODT, an intention to participate in prosocialactivities, being a Catholic, and a belief that one’s religion is in favor of ODT.Conclusions. Personnel from Spanish, Mexican, and Cuban transplantation hospitalshave favorable attitudes toward LLD. This suggests that there may be an increase in LLD

in the future, provided that there is the necessary sociopolitical and economic support.

okpC

nLdidcda

d

ptimal organ donation occurs when there is the bestresult for the patient who needs the organ and no

arm to the donor. Therefore, as far as the liver is con-erned, deceased donation is better, given that it does notnvolve the mutilation of a living being and that it canmprove the recipient’s health and quality of life.1–3 How-ver, due to the organ deficit from deceased donors and theustained increase in demand, together with increasedortality on the liver transplant waiting list, an attempt is

eing made by most countries to encourage living liveronation (LLD).4,6 For example, transplantation of theight liver lobe from a living donor to an adult recipient isncreasing in Japan, the USA, and some European coun-ries.4–6 In Spain, despite initial enthusiasm, this type ofonation is currently minimal—0.6 per million population

pmp).7 In Mexico (0.07 pmp in 2008)8 and Cuba, the rates a

041-1345/10/$–see front matteroi:10.1016/j.transproceed.2010.05.074

102

f LLD are also minimal, in spite of the fact that livingidney donation rates are higher than those in Spain (0.6mp) (15.92 pmp in 2008 in Mexico,8 2.5 pmp in 2008 inuba9).

From the Hospital Universitario Virgen de la Arrixaca, Coordi-ación Autonómica de Trasplantes, Murcia, Spain (A.R., A.L.-N.,.M.-A., G.R., P.R., P.P.); Hospital Regional de Alta Especialidadel Bajío y Universidad de Guanajuato, León, Guanajuato, Mex-

co (M.A.A.-G., B.G., E.J.R., G.M., J.S.R., M.A.M., A.N.); Coor-inación de Donación y Trasplantes, UMAE Hospital de Espe-ialidades no. 25 IMSS, Monterrey, Mexico (M.J.S., A.C.); Centroe Investigaciones Médico-Quirúrgicas, Cuba (A.A.-C., R.C.);nd the Hospital Hermanos Ameijeiras, Cuba (J.S.-L.).Address reprint requests to Dr. Antonio Ríos Zambudio, Avd.

e la Libertad 208, Casillas, Murcia 30007, Spain. E-mail:

rzrios@teleline.es

© 2010 by Elsevier Inc. All rights reserved.360 Park Avenue South, New York, NY 10010-1710

Transplantation Proceedings, 42, 3102–3105 (2010)

htitoLl

MS

DMhcCaaw

O

Aawtavaiv

S

Tdaoc

RA

Mffr

B

Ii M

MaL[l.t

TRANSPLANTATION STAFF ATTITUDES TOWARD LIVING LIVER DONATION 3103

One possible barrier to the development of LLD may beospital professionals, who are not always in favor. It washerefore important to discover the attitudes of personneln transplantation hospitals, because they would contributeo whether living donation gains greater importance. Thebjective of this study was to analyze the attitudes towardLD among personnel from transplantation hospitals with

iver programs in Spain, Mexico, and Cuba.

ATERIALS AND METHODStudy Population

ata were obtained as part of the “Proyecto Donante Vivo,urcia” international collaborative program of 5 transplantation

ospitals, each having a liver program. The hospitals were in 3ountries: 1 in Spain (n � 1,168), 2 in Mexico (n � 903), and 2 inuba (n � 202). The random sample in these centers was stratifiedccording to job category: physician, nursing personnel, nursingssistant, and auxiliary personnel. The total number of respondentsas 2,273.

pinion Survey and Study Variables

validated survey previously used in our workplace was used to evaluatettitudes toward living donation.1,3,13,21 The self-administered surveyas completed anonymously. The dependent variables were atti-

ude toward related and unrelated LLD. The independent vari-bles were grouped as: 1) demographic variables; 2) sociopersonalariables; 3) job variables; 4) variables of knowledge about andttitude toward donation and transplantation; 5) variables of socialnteraction and prosocial behavior; 6) religious variables; and 7)ariables of attitude toward the body.

tatistical Analysis

he data were analyzed using the SPSS 15.0 statistical package. Aescriptive statistical analysis included the bivariate Student t testnd chi-squared test as well as logistic regression analysis. P valuesf �.05 were considered to represent statistically significant asso-iations.

ESULTSttitudes Toward Living Liver Donation

ost hospital personnel (82%; n � 1,861) surveyed were inavor of related LLD, although only 21% (n � 478) were inavor if it was unrelated. Only 10% (n � 226) were againstelated LLD, and 8% undecided (n � 186).

ivariate Analysis of the Factors Affecting Attitudes

n the analysis of variables affecting LLD the followingmportant significant associations were observed:

1) Demographic variables: Although attitudes towardLLD were somewhat more favorable among hospitalpersonnel from Cuban (86%; n � 174) than Mexican(83%; n � 751) or Spanish (80%; n � 936) centers,the differences were not significant (P � .05).

2) Sociopersonal variables: Younger workers were morewilling to accept LLD than older respondents (37 y vs

39 y; P � .004). 3

3) Job variables: Physicians had the most favorableattitudes toward LLD (85%; n � 508). Resultsamong the other job categories were: staff 83% (n �618), nursing staff 79% (n � 490), and health careassistants 74% (n � 173; P � .001). The remainingjob variables showed no important associations.

4) Variables of knowledge about and attitudes towarddonation and transplantation: Those in favor of LLDalso seemed to be in favor of deceased organ dona-tion (86% vs 69%; P � .001) and living kidneydonation (92% vs 11%; P � .001). Those who hadconsidered the possibility of needing a transplant inthe future had more favorable attitudes toward LLDthan those who had not (89% vs 70%; P � .001).Regarding a willingness to accept a liver from a livingdonor, those who would be willing to accept one weremore in favor of LLD than those who were unde-cided (96% vs 61%; P � .001).

5) Social interaction and prosocial behavior activities:Those respondents who had discussed the subject ofdonation and transplantation within the family weremore in favor of LLD (84% vs 78%; P � .001). Apartner’s attitude also influenced acceptance of thistype of donation. Those whose partner had a favor-able attitude toward donation and transplantationwere more in favor of LLD than those whose partnerwas against it (89% vs 78%; P � .001). Participation(or a willingness to participate) in prosocial activitieswas positively associated with favorable attitudestoward LLD compared with those who had nevertaken part and had no intention of doing so (84% vs73%; P � .001).

6) Religious variables: Catholics were more in favor ofLLD than followers of other religions (86% vs 73%;P � .034). Moreover, if respondents believed thattheir religion had a positive view of donation andtransplantation, they tended to have a more favor-able acceptance rate of LLD compared with thosewho believed that their religion did not have afavorable view of donation (87% vs 74%; P � .035).

7) Variables of attitude toward the body: Those whowere not worried about mutilation of the body afterdonation had a more favorable attitude toward LLDthan those who were worried about it (87% vs 82%;P � .019).

ultivariate Analysis

ultivariate analysis (Table 1) showed the following vari-bles to be significantly associated with attitudes towardLD: 1) attitudes toward living kidney donation (odds ratio

OR] 47.619; P � .001); 2) willingness to accept part of aiver from a living donor if one were needed (OR 9.615; P �001); 3) family discussion about donation and transplanta-ion (OR 1.522; P � .038); and 4) catholic religion (OR

.067; P � .029).

D

LdssdL

lartceaides

hSpt

acitatFwtsts

t

d(ewAptolpwas

wHwttadlldnds

ffpftt

R

V

A

A

F

R

308

3104 RÍOS, LÓPEZ-NAVAS, AYALA-GARCÍA ET AL

ISCUSSION

iving liver transplantation is an alternative therapy toeceased liver transplantation, although some controversytill exists, mainly because of the risks involved in the donorurgery and the inferior results compared with deceasedonation.1,10,11 Consequently, although most countries haveLD programs, they are insufficient with only a few LLDs.In Spain, this type of donation is currently minimal. Popu-

ation studies in Spain have shown that the general public havefavorable attitude toward living donation, provided it is for a

elation or family member.3,12 In those cases, attitudesoward living donation were higher than those reported forohorts in favor of deceased donation.12,14 Studies amongmployees from hospital centers have shown favorablettitudes,1,16,18–20 although this possibility is not consideredn daily clinical practice as a real alternative option toeceased donation.15 In Mexico, the rate is 0.07 pmp8; it isxclusively destined for pediatric patients, because of thehortage of deceased donor organs for them.

Our data showed that the attitudes toward LLD amongospital personnel from liver transplantation centers inpain, Mexico, and Cuba were favorable, especially amonghysicians. This is important, because physicians are essen-ial to promote and apply this therapy.

Of particular interest was the strong association betweenttitudes toward the different kinds of donation, ie, de-eased and living. An important aspect seems to be accept-ng that extraction of healthy organs is a correct and ethicalherapeutic option. This way of thinking is part of anltruistic concept of life; if a person is able to accept oneype of donation he or she generally accepts the other type.1

eelings of reciprocity, treating others in the same way weould like to be treated, are also included. For example, in

he present study it was seen that the hospital personnelurveyed had more favorable attitudes toward LLD whenhey believed that they themselves may need a transplant atome time.

The donation process involves many factors, including

Table 1. Factors Affecting Attitude Toward Living Live

ariableRegr

Coeffi

ttitude toward living kidney donationNot in favor (n � 271)In favor (n � 2,002) 3.

cceptance of part of a donated living liverI don’t know (n � 692)Yes, I would accept it (n � 1,279) 2.No, I would wait on the waiting list (n � 302) 0.

amily discussion about donation and transplantationNo (n � 613)Yes (n � 1,660) 0.

espondent’s religionOther religion (n � 48)Catholic (n � 1,780) 1.Agnostic (n � 328) 0.

he attitudes of family members. Family discussion about p

onation and transplantation encouraged its acceptanceOR 1.522; P � .038). It was also seen that family consid-ration and comment had a promotional effect and was aay of encouraging acceptance of donation in our study.1,11

wareness is also necessary of the attitudes shown byatients on the transplant waiting list, given that the atti-udes of a Spanish patient16 are not the same as those inther countries, where the deceased organ donation rate is

ow.6,12 Patients in Spain know that in a relatively shorteriod they can obtain a deceased donor organ and that itill probably not be necessary for a family member to donaten organ while alive. In other countries, living donation isometimes the only likely way of achieving a transplantation.

Given that LLD has important risks for the donor andorse results in the recipient, it is ethically unacceptable.owever, it must be encouraged to avoid mortality on theaiting list if no deceased donor is available.13,17 We should

ry to complement deceased donation with living donationo prevent mortality on the waiting list while taking intoccount the need to prevent morbidity and mortality amongonors. In Spain, mortality on the liver transplant waiting

ist is �10%, which would give us an objective to achieve iniver transplantation. In Mexico and Cuba, the reality isifferent and regardless of whether living liver donation isecessary or not, it is necessary to encourage deceasedonation and transplantation as the first and fundamentaltep.

In conclusion, attitudes toward LLD among personnelrom Spanish, Mexican, and Cuban transplant hospitals wereavorable, forming an essential part of the current importantromotion of this type of transplantation activity. Theseacts suggest that there may be an increase in living liverransplantation in the coming years, provided that there ishe necessary social, political, and economic support.

EFERENCES

nation in Transplant Hospitals: Multivariate Analysis

�)Standard

ErrorOdds Ratio

(Confidence Interval) P Value

10.280 47.619 (83.333–27.777) �.001

10.237 9.615 (15.151–6.024) �.0010.220 1.334 (0.867–2.052) .190

10.202 1.522 (2.257–1.024) .038

10.512 3.067 (8.333–1.122) .0290.595 1.360 (4.366–0.423) .605

r Do

essioncient (

869

261288

420

120

1. Ríos A, Ramírez P, Rodríguez MM, et al: Attitude of hospitalersonnel faced with living liver donation in a Spanish center with

a2

tk

iS

dT

t8

Bo

2

ic

dQaiS

tvp

c

lc2

fAs

tt

f

td2

pl2

d

htC

pi

l

TRANSPLANTATION STAFF ATTITUDES TOWARD LIVING LIVER DONATION 3105

living donor liver transplant program. Liver Transplant 13:1049,0072. Ríos A, Martinez L, Sánchez J, et al: Factors that influence

he attitude of East European residents in Spain toward livingidney donation. Transplant Int 22:707, 20093. Conesa C, Ríos A, Ramírez P, et al: Socio-personal factors

nfluencing public attitude towards living donation in south-easternpain. Nephrol Dial Transplant 19:2874, 20044. Settmacher U, Theruvath T, Pascher A, Neuhaus P: Living-

onor liver transplantation—European experiences. Nephrol Dialransplant 19:16, 20045. Tanaka K, Kiuchi T, Kaihara S: Living related liver donor

ransplantation: techniques and caution. Surg Clin North Am4:481, 20046. Ríos A, Cascales P, Martínez L, et al: Emigration from the

ritish Isles to southeastern Spain: a study of attitudes towardrgan donation. Am J Transplant 7:2020, 20077. Memoria de actividades ONT 2009. Rev Esp Traspl 14:1,

0098. CENATRA Estadísticas y registros históricos. Mexico: Reg-

stro Nacional de Trasplantes, 2007. Available at: http://www.enatra.salud.gob.mx/

9. Méndez D, Valdivia J, Abdo A, et al: Trasplante renal cononante vivo: experiencia del Centro de Investigaciones Médicouirúrgicas de Cuba. Propuesta de un protocolo de estudio,

ceptación y evolución en actualización en trasplantes. Ed. Comis-ón de Trasplantes. Hospitales Universitarios Virgen del Rocío,evilla, Spain, 297, 2008.10. Ríos A, Ramírez P, Montoya M, et al: Are personnel in

ransplant hospitals in favor of cadaveric organ donation? Multi-ariate attitudinal study in a hospital with a solid organ transplantrogram. Clin Transplant 20:719, 200611. Ríos A, Ramírez P, Rodríguez MM, et al: Personnel in

adaveric organ transplant-related hospital units faced with living t

iver donation. An attitudinal study in a Spanish hospital with aadaveric and living liver transplant programme. Liver Int 27:687,00712. Ríos A, Martínez-Alarcón L, Sánchez J, et al: The quest for

avourable subgroups to encourage living kidney donation in Spain.n attitudinal study among British and Irish citizen resident in

outheastern Spain. Nephrol Dial Transplant 23:1720, 200813. Delair S, Feeley TH, Kim H, et al: A peer-based intervention

o educate liver transplant candidates about living donor liverransplantation. Liver Transpl 16:42, 2010

14. Conesa C, Ríos A, Ramírez P, et al: Psycho-social profile inavour of organ donation. Transplant Proc 35:1276, 2003

15. Martínez-Alarcón L, Ríos A, Conesa C, et al: Attitudeoward living related donation of patients on the waiting list foreceased donor solid organ transplant. Transplant Proc 37:3614,00516. Ríos A, Ramírez P, Rodríguez M, et al: Attitude of ancillary

ersonnel faced with living kidney donation in a hospital with aiving donor kidney transplant program. Transplantation 83:336,00717. Concejero AM, Chen CL: Ethical perspectives on living

onor organ transplantation in Asia. Liver Transpl 15:1658, 200918. Ríos A, Ramírez P, Martínez L: Are personnel in transplant

ospitals in favor of cadaveric organ donation? Multivariate atti-udinal study in a hospital with a solid organ transplant program.lin Transplant 20:743, 200619. Ríos A, Ramírez P, Galindo PJ, et al: Primary health care

ersonnel faced with cadaveric organ donation: a multicenter studyn south-eastern Spain. Clin Transplant 22:657, 2008

20. Ríos A, Conesa C, Ramírez P, et al: Attitude toward livingiver donation among hospital personnel in services not related to

ransplantation. Transplant Proc 37:3636, 2005