Living-Donor Kidney Transplantation

Abstract

Live-donor kidney transplantation (LDKT) is the best treatment for eligible people with late-stage kidney disease. Despite this, living kidney donation rates have declined in the United States in recent years. A potential source of this decline is the financial impact on potential and actual living kidney donors (LKDs). Recent evidence indicates that the economic climate may be associated with the decline in LDKT and that there are nontrivial financial ramifications for some LKDs. In June 2014, the American Society of Transplantation's Live Donor Community of Practice convened a Consensus Conference on Best Practices in Live Kidney Donation. The conference included transplant professionals, patients, and other key stakeholders (with the financial support of 10 other organizations) and sought to identify best practices, knowledge gaps, and opportunities pertaining to living kidney donation. This workgroup was tasked with exploring systemic and financial barriers to living kidney donation. The workgroup reviewed literature that assessed the financial effect of living kidney donation, analyzed employment and insurance factors, discussed international models for addressing direct and indirect costs faced by LKDs, and summarized current available resources. The workgroup developed the following series of recommendations to reduce financial and systemic barriers and achieve financial neutrality for LKDs: (1) allocate resources for standardized reimbursement of LKDs' lost wages and incidental costs; (2) pass legislation to offer employment and insurability protections to LKDs; (3) create an LKD financial toolkit to provide standardized, vetted education to donors and providers about options to maximize donor coverage and minimize financial effect within the current climate; and (4) promote further research to identify systemic barriers to living donation and LDKT to ensure the creation of mitigation strategies.

Direct and Indirect Costs Following Living Kidney Donation: Findings From the KDOC Study

“…We found that some donors, whether labs are drawn in the transplant clinic or by a provider closer to home, incur costs associated with followup care-a likely unintended consequence of this shift in mandated follow-up data collection. We strongly support the recommendation from the 2014 Consensus Conference on Best Practices in Living Kidney Donation to develop a Living Kidney Donation Financial Toolkit, which would provide a summary of known financial risks, an equation model for estimating donation-related costs, linkages to NLDAC and other sources of financial assistance, and strategies for talking to employers about recovery time and access to benefits (10,29).…”

“…Collectively, LKDs received $118 654 in total financial assistance, against a backdrop of $622 324 in direct and indirect expenses. NLDAC provided the most financial support, both in percentage of donors helped (9%) and funds disbursed ($57 389); however, it is our impression that these financial assistance programs are fragmented, inaccessible to many donors, and limited in what types of expenses are reimbursable (1,10). NLDAC, for instance, considers the financial resources of both donors and their recipients in determining whether eligibility criteria are met, and legislation establishing the program specifically prohibits reimbursement of lost wages (1).…”

Health Insurance Trends in United States Living Kidney Donors (2004 to 2015)

“…Particularly troubling is that lack of insurance is more common in LKDs with known health disparities (e.g., minorities, least educated) and those who have two or more pre-existing health risk factors (e.g., obesity, smoking, hypertension, low eGFR, proteinuria). Data from this study should be considered in discussions regarding the provision of health insurance benefits to previous and future LKDs in the U.S.[8,10,23,42,43]…”

“…[3–6] One characteristic that remains controversial in determining donation eligibility is the presence or absence of health insurance in the potential LKD. [4–10] In a survey of U.S. kidney transplant programs, the lack of health insurance in the donor was an absolute and relative contraindication to donation in 15% and 42% of programs, respectively. [4]…”

Little effect of state policies on organ donation in the USA

“…For many donors, unreimbursed wages lost during recovery are a substantial stressor. 5,6 Most donors also have outofpocket inci dental expenses (such as travel, child care and unreimbursed medical expenses) that are not insignificant. We commend states that have adopted policies to reimburse lost wages and reduce outofpocket costs for donors.…”