Flying Kidneys or Flying Donors: What Do Prior Canadian Living Kidney Donors Think?

To the editor, In many regions of the world with kidney-paired donation (KPD) programs, the practice of procuring and then transporting a kidney rather than having the living kidney donor (LKD) travel to donate is an acceptable practice. Although transporting kidneys results in longer cold ischemia times increasing the risk of delayed graft function, this is not associated with inferior short- and long-term graft outcomes [1-3]. For example, using the National Kidney Registry data from 2008 to 2015, living donor kidney transplants using transported kidneys in the KPD program had a median cold ischemia time of 9.3 h compared to 1.0 h for those that were not shipped and 0.93 h for non-KPD living donor kidney transplants. Longer cold ischemia time was associated with a 6% higher risk of delayed graft function; however, at a median follow-up of 3.2 years, no significant association with all-cause graft failure, death-censored graft failure, or kidney mortality was reported. Thus, this practice is considered acceptable. However, there is a dearth of data reporting the thoughts of prior LKDs, particularly those who had to travel to donate their kidney. The KPD program was implemented in Canada in 2009, and traditionally, most LKDs traveled to the transplant center where the intended recipient was located to donate their kidney [4]. Canada is the second largest country in the world geographically, and this practice was the norm until the COVID-19 pandemic. National practices were then adapted, and “shipping kidneys” became a more widespread practice. As of December 6, 2024, 274 kidneys have been transported across Canada from LKDs to recipients [5]. We have collected the input of previous LKDs regarding this practice, as part of our larger qualitative study of the healthcare experiences of 49 LKDs to identify their unmet healthcare needs [6]. This letter reports their thoughts on the practice of transporting kidney rather than the LKD, as many participants were unaware of this change in the national KPD program. A detailed methodology was published previously, and the study was approved by the Research Ethics Board of the McGill University Health Centre [6]. Briefly, we recruited adult (age >18 years) direct or nondirect LKDs, who spoke English or French and donated across Canada before March 2020 (to minimize the impact of the pandemic). The March 2020 cutoff point was selected to ensure that the COVID-19 pandemic-related healthcare disruptions did not affect the clinical evaluation and care experiences. Informed consent was obtained, and semistructured interviews were conducted between August and October 2022 by a bilingual female researcher over the telephone or via the Zoom platform. Interview data were analyzed using inductive thematic analysis. A descriptive analysis yielded three major, and two minor themes that are presented in Table 1 with illustrative quotes from some participants. LKDs acknowledged that the practice of transporting kidneys over donor travel was beneficial to the LKD, lowered the costs incurred by the donor, and could increase living kidney donation. “Donor comfort” was a major theme acknowledged by both those participants who had to travel to donate and those who did not. Donating in a familiar setting was perceived as being less stressful and described as a “game changer”. However, many participants expressed concerns about whether this can decrease the chances of their kidney working and the risk of unexpected events leading to organ discard. These concerns were also raised by those who had traveled to donate a kidney and were nondirected LKDs. Concern about delayed graft function Worry about the unexpected Donor comfort Lowering cost Facilitate kidney donation Our results have important implications for the transplant community. First, LKDs expressed concerns about the risk of delayed graft function and the risk of prolonged cold ischemia time on transplant outcomes. As part of donor education, we suggest incorporating evidence that reassures donors that the risks are minimal and likely offset by health risks associated with donor travel. Second, as we strive to advance the concept of financial neutrality for LKDs, it is important to highlight that LKDs and companions incur out-of-pocket expenses when traveling to a different center to donate. Transporting kidneys is thus an approach to minimize this financial and emotional burden on LKDs and their companions. Last, even though many participants traveled to donate a kidney and reported being inconvenienced, they expected the most optimal outcome from their donated organ. Thus, the ethical principle of utility must continue to guide practices in the KPD program. Overall, our findings suggest that LKDs find transporting kidneys as a suitable option, provided outcomes are acceptable and robust logistical processes are in place. Katya Loban: designed the work; data collection, analysis, and interpretation; revised the manuscript; and approved the final version. Kathleen Gaudio: helped with data collection, revised the manuscript, and approved the final version. Shaifali Sandal: conceived and designed the work, participant recruitment, data interpretation, drafted the manuscript, and approved the final version. Shaifali Sandal is supported by the Chercheur boursier clinicien–Junior 1 award from the Fonds de recherche du Québec–Santé. The authors would like to sincerely thank the 49 LKDs who participated in this study and the Organ and Tissue Donation and Transplantation Advisory Committees of the Canadian Blood Services for their help with recruitment. Shaifali Sandal has received an education grant from Amgen Canada to increase living donor kidney transplantation and a speaking honorarium from AstraZeneca. She is also a member of the Living Donor Advisory Committee of the Canadian Blood Services (nonpaying role). The other authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.

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