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idney Exchange Programs: Attitudes of Transplant Team Membersoward Living Donation and Kidney Exchanges

.S. Woodle, A. Bohnengel, R. Boardman, K. Downing, for the Ohio Solid Organ Transplant Consortiumidney Committee

ABSTRACT

Introduction. Several living donor kidney exchange programs (LDKEPs) have beenestablished throughout the world; however, none have yet achieved the perceivedsubstantial potential for increasing the number of living donor kidney transplants. Over thepast 2 years, the Ohio Solid Organ Transplant Consortium (OSOTC) has developed andimplemented an LDKEP with a complementary, robust web-based computerized matchingprogram for living donor/recipient pairs. Prior to implementation of the OSOTC LDKEP,attitudes of transplant professionals from each of eight participating kidney transplantprograms were surveyed to determined attitudes toward living donation and LDKEP andto identify potential barriers to LDKEP. The state of decision making toward LDKEP wasalso examined.Methods. Transplant professionals were surveyed using an instrument designed to assessattitudes toward living donation and LDKEPs. Most questions were answered on a Likertscale (1 � strongly agree, 5 � strongly disagree).Results. Respondents agreed that living donor transplantation should be encouraged(mean 1.17 � 0.6) and that the laparoscopic donor procedure was preferred (1.36 � 0.82).Respondents had largely read about KEPs (2.02 � 1.02) but had “thought aboutparticipating in KEPs” (2.57 � 1.26), or actively sought information (2.87 � 1.3) to lesserdegrees. Despite this, significant indecisiveness existed regarding participation in LDKEPs(2.73 � 1.39).Conclusions. Transplant professionals are highly aware of LDKEPs. However, theyremain indecisive about LDKEP participation. These results indicate that barriers exist inthe transplant community toward LDKEP, and these must be defined to increase LDKEP

acceptance and participation.

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LTHOUGH SEVERAL kidney exchange programshave been established throughout the world, their

ubstantial potential for increasing living kidney donationas not been realized. A number of barriers exist that mayontribute to this failure, including ethical barriers,1–3 butittle has been done clinically to identify, characterize, and

easure the effects of these barriers. The purpose of thistudy was to evaluate attitudes of transplant team personneloward living kidney donation and toward living donoridney exchange programs (LDKEPs). By identifying per-eived barriers, it is hoped that specific interventions can beesigned as a means to address and remove these barriers

or LDKEPs. C

041-1345/05/$–see front matteroi:10.1016/j.transproceed.2004.12.091

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ETHODS

ver the past 2 years, a statewide living donor/living donor kidneyxchange program has been established in the state of Ohio, thehio Solid Organ. Transplant Consortium (OSOTC) LDKEP. TheSOTC currently consist of eight kidney transplant programs that

erform over 500 kidney transplants yearly: University of Cincinnati,he Christ Hospital of Cincinnati, Medical College of Ohio,

From the Division of Transplantation, University of Cincinnati,incinnati, Ohio, USA.Address reprint requests to Dr E. Steve Woodle, University ofincinnati, Division of Transplantation, 8425 Preakness Lane,

incinnati OH 45249.

© 2005 by Elsevier Inc. All rights reserved.360 Park Avenue South, New York, NY 10010-1710

Transplantation Proceedings, 37, 600–601 (2005)

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KIDNEY EXCHANGE PROGRAMS 601

niversity Hospitals of Cleveland, the Cleveland Clinic, Akronity Hospital, Miami Valley Hospital (Dayton), and Ohio Stateniversity.The OSOTC LDKEP was developed with a complementary

eb-based computerized matching program that allows enrollmentf all potential living donor/recipient pairs and calculates and ranksll possible exchanges on a monthly basis. Matching of livingonor/recipient pairs is based on several criteria including: HLAatching, donor-donor age matching, donor-recipient age match-

ng, CMV and EBV states, hepatitis B and C status, waiting time,ediatric recipient status, unacceptable ABO and HLA specifici-ies, PRA level, and geographical distance between centers.

Prior to initiation of the OSOTC LDKEP, a survey was con-ucted of transplant program personnel from each of eight partic-

pating programs. Questionnaires were designed to determinettitudes and define perceived and real barriers to LDKEPs. Inddition, questionnaires were designed to assess decision-makingtatus regarding where each individual stood with respect toeciding to actively participate and support LDKEPs. Question-aires were designed for answers primarily in the form of a Likertcore (1 � strongly agree, 5 � strongly disagree).

ESULTS

total of 48 participants completed questionnaires includ-ng: coordinators (n � 17), administrators (n � 12), physi-ians (n � 6), social workers (n � 4), financial counselors (n �), information technologists (n � 3), and transplant assis-ants (n � 3). The following data on responses are ex-ressed as mean Likert scores. Respondents agreed that

iving donor transplantation should be encouraged (1.17 �.6) and that the laparoscopic donor procedure was pre-erred over the open donor procedure (1.36 � 0.82). Withespect to decision-making status regarding LDKEPs, re-pondents indicated a high level of exposure in that theyad read about KEPs (2.02 � 1.02). Respondents hadthought about participating in KEPs” (2.57 � 1.26) orctively sought information (2.87 � 1.3) to somewhat lesseregrees. However, a significant degree of indecisiveness wasxpressed about their decision to participate in LDKEPs2.73 � 1.39). A high level of agreement was expressedegarding the importance of the complementary computer-zed matching program (1.53 � 0.62) and that it enhancedfairness” of matching (1.57 � 0.68). Specific concerns anderceived barriers to LDKEPs included: (1) need foronors to travel to respective recipient centers, (2) financialoncerns, (3) privacy and confidentiality maintenance, (4)edical equity assurance of quality of kidneys, and (5)

otential for medical-legal complications. k

ISCUSSION

cceptance of LDKEPs and enthusiastic identification andeferral of candidates by transplant team personnel is anmportant element in establishment of LDKEPs and foreaching their potential. However, there are a number ofspects of LDKEPs that may be objectionable to transplantrogram personnel, and therefore, sampling and determi-ation of their attitudes is important in determining theircceptance of such programs.

With increasing application and discussion of LDKEPs,any transplant program personnel have at least heard and

ossibly thought about kidney exchange programs. This isn important first step in their decision-making processegarding LDKEPs. The present study indicates that theres a relatively high awareness of LDKEPs among transplantrogram personnel in the OSOTC LDKEP; however, aignificant degree of indecisiveness remains regarding theserograms. It appears that a high degree of acceptance existsegarding laparoscopic living donor nephrectomy and thathe complementary computerized matching program as-ures a sense of fairness in the OSOTC LDKEP.

This study is an important first step in determiningttitudes toward LDKEP among transplant personnel. Ad-itional, in-depth studies to identify the barriers to LDKEP

n general and the OSTOC LDKEP will need to beonducted in the future. Once barriers are identified,nterventions will need to be developed and implemented toddress these issues.

In conclusion, this first survey of attitudes toward KEPsndicates: (1) a high level of support for living donorransplantation, (2) a high degree of awareness of LDKEPs,nd (3) significant indecisiveness about LDKEPs. Indeci-iveness among kidney transplant program personnel mayherefore represent a significant barrier to LDKEP imple-entation.

EFERENCES

1. Zenios SA, Woodle ES, Ross LF: Primum non nocere:voiding harm to vulnerable wait list candidates in an indirectidney exchange. Transplantation 72:648, 20012. Ross LF, Woodle ES: Ethical issues in increasing living

idney donations by expanding kidney paired exchange programs.ransplantation 69:1539, 2000

3. Ross LF, Rubin DT, Siegler M, et al: Ethics of a paired-

idney-exchange program. N Engl J Med 336:1752, 1997