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American Journal of Kidney Diseases

The Evaluation of Living Kidney Donors: How Long Is Too Long?

      Related Article, p. 483
      Living donor kidney transplantation (LDKT) is the preferred treatment for chronic kidney failure, but the annual number of LDKTs performed in the United States has declined since 2004 and remained at less than 6,000 per year from 2011 to 2017. This decline likely arose from multiple causes,
      • Rodrigue J.R.
      • Schold J.D.
      • Mandelbrot D.A.
      The decline in living kidney donation in the United States: random variation or cause for concern?.
      including growing awareness of the small yet real long-term risks of living kidney donation.
      • Muzaale A.D.
      • Massie A.B.
      • Wang M.C.
      • et al.
      Risk of end-stage renal disease following live kidney donation.
      One possible deterrent to increasing LDKTs could be an inefficient donor evaluation process. In one qualitative study, one-third of living kidney donors criticized general delays and lack of coordination within the donor evaluation.
      • Sanner M.A.
      The donation process of living kidney donors.
      In another study, among potential living donors who contacted a transplantation center to start the donor evaluation, 30% were lost to follow-up,
      • Lunsford S.L.
      • Simpson K.S.
      • Chavin K.D.
      • et al.
      Racial disparities in living kidney donation: is there a lack of willing donors or an excess of medically unsuitable candidates?.
      possibly due to a protracted evaluation. In one single-center study, 12 to 30 months after starting the evaluation, 22% of potential donors were still undergoing evaluation.
      • Lapasia J.B.
      • Kong S.Y.
      • Busque S.
      • Scandling J.D.
      • Chertow G.M.
      • Tan J.C.
      Living donor evaluation and exclusion: the Stanford experience.
      A recent observational study reported that a streamlined 1-day assessment of living donors was associated with a nearly 8-fold increase in living donation in that geographic region.
      • Graham J.M.
      • Courtney A.E.
      The adoption of a one-day donor assessment model in a living kidney donor transplant program: a quality improvement project.
      Delays in the donor evaluation may delay LDKT, and delays in LDKT are associated with worse recipient outcomes.
      • Mange K.C.
      • Joffe M.M.
      • Feldman H.I.
      Effect of the use or nonuse of long-term dialysis on the subsequent survival of renal transplants from living donors.
      • Meier-Kriesche H.U.
      • Port F.K.
      • Ojo A.O.
      • et al.
      Effect of waiting time on renal transplant outcome.
      Although delays in the donor evaluation are well known to most transplantation physicians, few studies have quantified the duration of the donor evaluation and its discrete components.
      In this issue, Habbous et al
      • Habbous S.
      • Arnold J.
      • Begen M.A.
      • et al.
      Duration of living kidney transplant donor evaluations: findings from 2 multicenter cohort studies.
      determined donor evaluation times in: (1) a prospective cohort of 849 living kidney donors in Canada and Australia for whom the approval date was available, and (2) a retrospective cohort of 1,140 donors in Ontario, Canada. Across these centers, living donors’ total evaluation times varied but were often lengthy, with a median of 10.3 (interquartile range [IQR], 6.5-16.7) months. In addition to total evaluation time, the authors examined 4 other process measures: (1) total approval time (time from evaluation start until approval to donate, which was a median of 7.9 [IQR, 4.6-14.1] months), (2) time to donation postapproval (time from approval to donation, which was a median of 0.7 [IQR, 0.3-2.4] months), (3) time from computed tomography until donation (time from first computed tomography angiography until donation, which was a median of 4.8 [IQR, 2.6-9.2] and 4.9 [IQR, 2.8-8.8] months in the prospective and retrospective cohorts, respectively), and (4) time between consultations (period between first and last nephrologist, surgeon, other consultants, and psychosocial assessments, which was a median of 3.0 [IQR, 1.0-6.3] and 6.3 [IQR, 2.3-17.2] months in the prospective and retrospective cohorts, respectively). Delay in recipient referral and older age of the donor were associated with a prolonged donor evaluation, and preemptive transplantation was associated with a shorter evaluation.
      In the Habbous et al study, there was significant intercenter variation in the duration of each process measure. This variation suggests that center-level factors affect evaluation time and provides an opportunity for performance and process improvement. These opportunities will differ at different centers. For example, at one Canadian center (center I) with a slightly shorter median total evaluation time (9.9 months), time from approval to donation was a median of 4.5 months. Most centers had less than a 1-month median time from approval to donation. Center I’s longer time to donation postapproval could have several causes. If this longer time stems from lack of operating room or transplantation surgeon availability, efforts to improve the donation process could focus on enhancing surgical capacity or creating reserved operating room times for LDKTs.
      However, Center E had one of the longest total evaluation times (median, 15.9 months) with a long total approval time (15.2 months) and time between consultations (6.9 months), but very short time from approval to donation (0.2 months). At Center E, efforts to improve the donation process could focus on shortening the time elapsed between consults. In the inpatient and other health care settings, “daily huddles” appear to enhance communication, collaboration, and problem solving among team members.
      • Melton L.
      • Lengerich A.
      • Collins M.
      • et al.
      Evaluation of huddles: a multisite study.
      • McBeth C.L.
      • Durbin-Johnson B.
      • Siegel E.O.
      Interprofessional huddle: one children's hospital's approach to improving patient flow.
      In other industries, such as software development, brief daily meetings are also used to coordinate and complete large complex projects.
      • Sutherland J.
      • Sutherland J.J.
      Scrum: The Art of Doing Twice the Work in Half the Time.
      At centers with long total approval times, similar scheduled meetings (not necessarily daily) may provide regular opportunities for the involved physicians, nurses, social workers, and assistants to discuss ongoing donor evaluations and address any delays or barriers. To reduce long times between consultations (with nephrology, surgery, and psychosocial specialists), centers can also reorganize clinician schedules (eg, reserving appointment slots each week for donor evaluations). One potential strategy to reduce total approval time is a streamlined 1- to 2-day donor evaluation. A compressed donor evaluation was the norm at 3 centers in the Habbous et al study and has been associated with increased rates of LDKT.
      • Graham J.M.
      • Courtney A.E.
      The adoption of a one-day donor assessment model in a living kidney donor transplant program: a quality improvement project.
      Medical issues in the recipient may derail LDKT and prolong the evaluation process. At some centers, the recipient and donor evaluations may occur simultaneously (“in parallel”). If team members fail to communicate, they may only belatedly recognize recipient medical issues, after the living donor is approved, leading to prolonged time from approval to donation. In such cases, halting the donor evaluation until the recipient is ready may be prudent. At other centers, the recipient and donor evaluations usually occur successively and linearly (“in series”). The recipient is evaluated first and the donor evaluation can move forward only after completion, or near-completion, of the recipient evaluation.
      In this study, data were unavailable regarding how centers performed the recipient evaluation (in parallel vs in series) relative to the donor evaluation. The authors collected recipient referral dates and curiously, most donors started their evaluation before the recipient referral. At centers that perform recipient and donor evaluations in series, donors’ total evaluation times may be artificially long due to the required wait for recipients to complete their evaluations.
      Transplantation center characteristics that were measured and collected by the authors, such as LDKT volume, deceased donor kidney transplantation volume, nurse coordinator full-time equivalents, and use of “same day” physician consultations, were not associated with total evaluation time. This lack of association suggests that other center-level factors, which may be difficult to capture and measure, may affect evaluation time. For example, physician availability to perform the living donor evaluations may plausibly serve as a rate-limiting step in the donor evaluation. Even more important than the raw number of nurse or staff full-time equivalents is how each center organizes their living donor team and evaluations. Future studies, possibly qualitative ones, could examine different transplantation center organizational structures and their association with the efficiency and duration of the living donor evaluation.
      A subtler center-level factor that may affect donor evaluation time is the number of potential donors who were evaluated but did not donate. Some centers may rule out potential donors relatively early in the donation process. Web-based screening of potential donors now allows transplantation centers to decline persons who clearly do not meet medical criteria for donation at the start of the evaluation process.
      • Moore D.R.
      • Feurer I.D.
      • Zavala E.Y.
      • et al.
      A web-based application for initial screening of living kidney donors: development, implementation and evaluation.
      However, other centers may perform in-person or telephone screening and then tests and evaluations on many donors before ultimately declining these donors. At the latter type of center, many donor evaluations may be “in process,” relative to the available resources and full-time equivalents. At these centers, staff and resources may be consumed by the evaluation of many potential donors who ultimately do not donate. The result would be extended donor evaluation times for the few potential donors who ultimately donate.
      Several characteristics of the living donors in this study appear noteworthy. Sixteen percent of donors in the prospective cohort had open, rather than laparoscopic, nephrectomies. This percentage is surprisingly high given the near elimination of open nephrectomy as the intended donor procedure type.
      • Hart A.
      • Smith J.M.
      • Skeans M.A.
      • et al.
      OPTN/SRTR 2016 Annual Data Report: Kidney.
      The authors do not report how many of these open nephrectomies were planned (vs unplanned due to intraoperative emergencies) or whether open nephrectomies were clustered at a few centers. The much longer recovery time from a planned open nephrectomy may conceivably lead some donors to delay donation to a later more convenient time, thereby prolonging evaluation times. However, the authors found no effect of procedure type (open vs laparoscopic) on evaluation time. In addition, 25% of donors had cardiac evaluations and 45% needed oral glucose tolerance tests. The percentages that required cardiac or glucose tolerance testing appear a bit high and may reflect donors' medical and family histories, as well as centers' policies and practices regarding such donors. At centers that mandated more cardiac or metabolic testing, such testing could have prolonged donor evaluation times.
      Finally, the evaluation durations described in this study should be interpreted with caution and may have limited generalizability beyond Canada and Australia. For example, in the United States, bureaucratic hurdles, patient diversity (including racial disparities), and limited access to care may further increase donor evaluation times. Nevertheless, evaluation times in the United States are unlikely to be dramatically shorter than the durations reported in this study.
      What can we take away from this study? First, the evaluation of most living donors stretches over a duration that is likely too long. This long duration can lead to missed opportunities for LDKT (eg, the intended recipient becomes too ill for transplantation while the donor is being evaluated) or worse outcomes post-LDKT. We suggest that a reasonable and attainable goal would be for transplantation centers to aim for median total evaluation times of 3 to 6 months, with total approval times closer to 3 months than 6 months. Second, because of the importance of an expeditious donor evaluation, transplantation centers should assess their own donor evaluation times. Such times can be easily calculated from the dates when donors contact the transplantation center and are evaluated, approved, and donate. Knowledge of these times will allow centers to identify areas of improvement in their donor evaluations. In the United States, such measurements can be part of quality assurance and performance improvement programs that are required of all transplantation programs. Finally, transplantation centers would benefit from sharing best practices in the donor evaluation. Although the causes of a prolonged donor evaluation are often specific to each transplantation center, there are probably a handful of barriers (eg, lack of surgical capacity) that lead to prolonged evaluation times at many centers. By working together, it’s possible that transplantation centers can safely shorten the evaluation time for donors to better serve donors and their recipients.

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