Friday, December 16, 2011

OPTN Public Comment - Medical Evaluation of Living Kidney Donor

The following is my public comment to OPTN on their proposed policy for the Medical Evaluation of the Living Kidney Donor (#10). Deadline is December 23, so you still have time if you want to submit your own (please feel free to borrow heavily from mine if you'd like)




This missive is to express my concerns about the Proposal to Establish Requirements for the Medical Evaluation of the Living Kidney Donor, as posted on the OPTN website in late 2011.

While I believe the Joint Societies Consensus Document takes many strides forward in protecting prospective living donors, it still neglects the importance of the psychosocial evaluation. The psychological & emotional repercussions of living donation have been adequately documented, yet the aspects of the psychosocial evaluation are continually decided by those lacking expertise. Surgeons are not mental health professionals, and the psychological health and well-being of living donors deserves better than the input of three non-voting representatives whose livelihood depend on the transplant industry.

CMS Final Rule 2007 requires the psychosocial evaluation of prospective living donors but leaves the specifics vague. OPTN’s subsequent guidance document has not improved the situation. In 2003, Toronto General Hospital described their facility’s electronic LD evaluation tool in Progress in Transplantation(1). A year later, Schweitzer described the Heidelberg Method of pre and post-donation psychosocial evaluation, a follow-up of his earlier analysis(2). Yet as of today, no consistent or reliable tool or process has been developed(3) in the US.

In March 2008, Schroder’s analysis of existing literature produced a list of living donor motivations known to correlate with detrimental psychosocial consequences(4). Instead of implementing said data, OPTN’s guidance document uses the phrase “attempt to identify factors”, wording that would never be acceptable if used in regards to a prospective LKD’s GFR or creatnine levels.

Mental health professionals are not prescient nor psychic. Their training includes the adoption of specific behavioral skills, as well as the understanding and application of theories and quantifiable data. Obtuse suggestions such as “explore reasons” and “review issues” provide no guidance in interpretation or conclusion.

Much evidence exists between the psychosocial preparation of prospective living donors & post-donation psychosocial complications(5). The transplant process has focused almost exclusively on medical compatibility and suitability, when it should also concern itself with the personal dynamics between the donor and recipient(6). After all, a 2010 study from the University of Minnesota revealed 40% of their LKDs felt at least some pressure to donate, with the amount correlated to their degree of relatedness to their recipient(7). Since transplant centers offer no aftercare or support services for living donors, even though living donors overwhelmingly believe they should(8), a comprehensive psychosocial evaluation is imperative.

The emphasis in transplant must shift from procuring living donor organs to providing full and comprehensive care for the living donor(9). No matter how small the group at risk of psychosocial harm might be, its existence requires that our standard of psychosocial risk assessment be as rigorous as the physical assessment. OPTN policy should reflect this reality.

Sincerely,
Cristy Wright, M.Ed.


References:

1. O’Dell, MI et al. Electronic Psychosocial Evaluation Tool: use in living organ donor transplantation program. Prog Transplant. 2003 Jun;13(2):97-104

2. Schweitzer, J et al. Donor-Recipient Interaction: the Heidelberg Model of evaluation and consultation. Nephrol Dial Transplant (2004) 19 [Supple 4]: iv75-iv78.

3. Smith G, Trauer T, Kerr PG, Shadban S. Prospective psychosocial monitoring of living kidney donors using the short form-36 health survey: results at 12 months. Transplantation. 2004;78(9):1384-1389.

Walter M, Dammann G, Kuchehhoff J, et al. Psychosocial situation of living donors: moods, complaints, and self-image before and after liver transplantation. Med Sci Monit. 2005; 11:CR503-509.

4. Schroder, NM et al. Consideration of psychosocial factors in the evaluation of living donors. Progress in Transplantation, Vol 18, No. 1, March 2008

5. Schweitzer, J. et al. Psychological Consultation Before Living Kidney Donation: Finding Out and Handling Problem Cases. Vol. 76, 1464–1470, No. 10. 1464-1470.

6. Kane F, Clement G, & Kane M (2008). Live kidney donations and the ethic of care. The Journal of medical humanities, 29 (3), 173-88

7. Valapour, M. et al. Assessing Elements of Informed Consent Among Living Donors. Clin Transplant 2010 DOI: 10.1111/j.1399-0012.2010.01374.x

8. Schover LR, Streem SB, Boparai N, Duriak K, Novick AC. The psychosocial impact of donating a kidney: Long-term follow-up from a urology based center. J Urol 1997; 157: 1596–1601.

Fisher PA, Kropp DJ, Fleming EA. Impact on living kidney donors: Quality of life, self-image and family dynamics. Nephrol Nurs J 2005; 32: 489–490, 495–501.

9. Kane F, Clement G, & Kane M (2008). Live kidney donations and the ethic of care. The Journal of medical humanities, 2