Ngan N. Lam

Key Points: This qualitative study explored patient, caregiver, and provider perceived barriers to retransplantation after kidney allograft loss. We identified four medical and nonmedical barriers to retransplantation and four additional barriers to pursuing living donor retransplantation. System-, transplant center–, provider-, and patient-level approaches to address these barriers are highlighted. Background: Many kidney transplant recipients experience graft loss, and retransplantation offers a significant survival benefit when compared with waitlisted patients. Yet, trends related to preemptive relisting/retransplantation are suboptimal. Little empirical evidence has explored barriers to kidney retransplantation. We aimed to identify the predominant barriers to retransplantation after graft loss and factors that hinder the pursuit of living kidney donor (LKD) retransplantation. Methods: This was a qualitative study that used an interpretive descriptive design. Participants included patients with a history of graft loss, caregivers who supported them, and transplant nephrologists, recruited using purposive and snowball sampling techniques. Data collection entailed semistructured interviews that were coded, and an inductive thematic analysis was conducted. Results: We synthesized the perspectives of 23 patients, 23 caregivers, and 11 transplant nephrologists representing 11 Canadian transplant programs. Through our analysis, we identified four key barriers to retransplantation: high antibody sensitization resulting in scarcity of compatible donors; prevalence of comorbidities leading to ineligibility or wait list withdrawal; history of nonadherence among the recipients leading to ineligibility or delays in transplant referral and reevaluation; and delayed referrals and poor coordination of retransplant workup. Additional barriers to LKD retransplantation included patient preference for deceased donor transplantation that was unlikely to change after graft loss; perceived smaller pool of eligible LKDs felt to have been exhausted with the first transplant; the psychological burden of unresolved issues related to previous LKD transplant loss; and overall structural barriers to living kidney donation. Conclusions: This analysis highlights both medical and nonmedical barriers to retransplantation and that the pursuit of retransplantation entails persistent as well as additional and compounding challenges. A list of implications that arise from these findings is presented. Given the well-established benefits of kidney transplantation and that graft loss remains a leading cause of dialysis initiation, these findings have important implications for the nephrology community.

Background: An underappreciated complication of laparoscopic nephrectomy in male living kidney donors is testicular pain, swelling, and hydrocele development. A recent cohort study in Ontario, Canada, found that male donors had a higher rate of hydrocelectomy (7.7 vs. 0.1 events/1000 person-years) and scrotal ultrasounds (25.6 vs. 6.9 events/1000 person-years) than nondonors, when followed for a median of 9 years. Objective: To conduct a replication study in Alberta, Canada, examining the long-term risk of hydrocelectomy after laparoscopic living donor nephrectomy, comparing male donors to nondonors from the general population matched on baseline health indicators. Design: Population-based matched cohort study using linked healthcare databases. Setting: Alberta, Canada (April 1, 2002, to March 31, 2021). Patients: We matched 115 male kidney donors who underwent a laparoscopic nephrectomy with 1150 nondonors. The matching characteristics were age at cohort entry, date of cohort entry, rural residence, income, prior vasectomy, and prior inguinal hernia repair. Measure: ments: The primary outcome was a hydrocelectomy, and the secondary outcome was receipt of a scrotal ultrasound. Methods: Males were followed for a median of eight years, with a maximum follow-up of 19 years. Results: The rate of hydrocelectomy was higher in donors than in nondonors (3 of 115 [2.6%] vs. 1 of 1150 [0.1%]; 3.3 vs. 0.1 events/1000 person-years; P < 0.001). The rate of scrotal ultrasounds was also higher among donors than among nondonors (23.4 vs. 7.5 events/1000 person-years; P < 0.001). Limitations: A low event rate impeded a precise estimation of the risk of hydrocelectomy attributable to donation. Conclusions: In this population-based cohort study from Alberta, Canada, rates of hydrocelectomy and receipt of a scrotal ultrasound were significantly higher in males who underwent laparoscopic living donor nephrectomy than in male nondonors matched for age and other factors. Males considering living kidney donation should be informed of the risk of developing a symptomatic ipsilateral scrotal hydrocele in the years following laparoscopic nephrectomy.

Background: Many living kidney donors (LKDs) describe their evaluation process as the most difficult part of donating a kidney. The process is often lengthy, complex and inefficient, frequently requiring several months to complete. A more efficient and donor-centered evaluation may improve LKD experiences, reduce attrition, and encourage more individuals to donate. Methods: We employed a Delphi approach to define and select metrics of a high-quality LKD evaluation. Four multidisciplinary working groups were created in which LKDs (n=8), healthcare professionals (n=11), and administrators (n=3) collaborated to develop evidence and experience informed recommendations. Results: This work culminated in a national consensus conference held virtually in September 2024, which brought together over 100 LKDs, nurses, nephrologists, surgeons, researchers, and representatives from transplant organizations. Of the 42 recommendations evaluated through the e-Delphi process, 35 achieved consensus (≥75% agreement) across four domains. Ninety-two percent were supported by moderate-quality evidence, while 8% had no supporting evidence, reflecting the limited empirical data available for several aspects of donor evaluation processes. The recommendations clustered into four overarching themes included: (1) increasing donor numbers and evaluation efficiency (e.g., eligibility for donation determined within three to six months), (2) enhancing program resources and donor reimbursement (e.g., metrics on donor financial neutrality), (3) ensuring a donor-centered evaluation process (e.g., donor-centered metrics such as donor satisfaction), and (4) promoting consistency and evidence-based practice across programs (e.g., consistent evaluation nationally). Conclusion: Collectively, these recommendations provide a framework to guide quality improvement, benchmarking, and policy development, with implications for strengthening the LKD evaluation process worldwide.

Background: A prior study of living kidney donors demonstrated a substantially higher long-term risk of hydrocelectomy among male living kidney donors who underwent laparoscopic nephrectomy compared with nondonors. Given the potential shared anatomical pathways between hydrocele and indirect inguinal hernia formation, we aimed to evaluate the donation-attributable risk of inguinal hernia repair. Objective: To evaluate long-term rates of inguinal hernia repair in male living kidney donors compared to nondonors. Design and Setting: Population-based, retrospective matched cohort study using linked health administrative databases from Ontario, Canada. Patients: 848 male living kidney donors aged ≥18 years who underwent laparoscopic donor nephrectomy between April 1, 2002, and March 31, 2023, were matched (1:10) to 8480 healthy male nondonors based on age, cohort entry date, rurality, neighbourhood income, and prior vasectomy. Individuals with prior scrotal conditions or previous inguinal hernia repair were excluded. Measurements: The primary outcome was inguinal hernia repair. Methods: Risk was assessed using Cox proportional hazards models with robust variance. Cumulative incidence was estimated at key time points using Aalen–Johansen methods, treating death as a competing event. To contextualize the findings, incidence rates were also examined after other renal (e.g., nondonor nephrectomy, pyeloplasty) and abdominal surgeries. Results: Over a median follow-up of 8.8 years, 4.7% of donors (40 of 848) and 3.4% of nondonors (287 of 8480) underwent inguinal hernia repair. Donors had a modestly higher risk of undergoing inguinal hernia repair than nondonors (4.9 vs. 3.5 events per 1000 person-years; hazard ratio (HR) 1.40; 95% CI, 1.01–1.93; P = 0.043). The cumulative incidence of inguinal hernia repair after laparoscopic donor nephrectomy was comparable to that observed after other renal and abdominal surgeries. Limitations: This study relied on administrative data, which lacked information on hernia type (direct or indirect), laterality, pre-existing asymptomatic hernias, and key confounders such as body mass index and occupation. Donors may differ from nondonors in care-seeking behaviours and lifestyle factors, which could influence the observed risk. Conclusions: In contrast to the markedly higher risk of hydrocele repair, the donation-attributable risk of inguinal hernia repair in the years following laparoscopic donor nephrectomy appears modest, and in some comparisons was not evident. These findings support current counselling and selection practices for prospective donors, for which this outcome does not warrant specific consideration.

The evaluation of living kidney donor candidates is a complicated process to determine eligibility for donation and ensure that candidates are well-informed of postdonation risks, along with any uncertainty in risk estimations. The 2017 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors provided recommendations to assist transplant programs in the evaluation and care of donors before, during, and after donation. In this review, we highlight new research that has changed the landscape of the evaluation and counseling of donor candidates. In 2021, a race-neutral equation for eGFR aimed to promote health equity; however, relying solely on this measure to assess kidney function may lead to more Black candidates being excluded from living kidney donation. The role of genetic testing in the evaluation of donor candidates continues to evolve as evidence accumulates about the higher risk of kidney failure among biologically related donors. Recent recommendations emphasize targeted evaluation for familial monogenic kidney diseases and suggest offering apolipoprotein L1 genotyping to living kidney donors of African ancestry, although the implications of apolipoprotein L1 results for donor eligibility is an area of ongoing research and debate. In 2025, North American guidelines revised the BP threshold for diagnosing and treating hypertension from ≥140/90 to ≥130/80 mm Hg. This will have implications in the assessment of donor candidates, who may be more likely to be declined for donation or put on hold until these new BP targets are reached. Finally, new evidence supports that male donor candidates should be informed of the higher risk of testicular-related complications postdonation compared with nondonors. Policy makers, guidance workgroups, and transplant programs will need to consider how these findings influence local practices related to the evaluation, counseling, and care of donor candidates.

A potential long-term complication of living kidney donation in male donors is scrotal swelling on the same side as the nephrectomy, and some undergo surgery to relieve discomfort from the fluid collection. The long-term risk for this outcome attributable to donation is unknown. To evaluate long-term scrotal surgery rates after laparoscopic nephrectomy in male living kidney donors compared with nondonors. Population-based cohort study (2002 to 2024). (ClinicalTrials.gov: NCT06716723). Linked administrative health care databases in Ontario, Canada. 898 male living kidney donors who had a laparoscopic nephrectomy were matched in a 1:10 ratio with 8980 male nondonors from the general population. The matching characteristics were age, date of cohort entry, rural residence, income, prior vasectomy, and prior inguinal hernia repair. Participants were followed for a median of 9 years, up to 22 years. The primary outcome was hospitalization for surgery to address a unilateral scrotal fluid collection. Donors and matched nondonors had a median age of 45 years. The rate of scrotal surgery was higher in donors than nondonors (70 of 898 donors [7.8%] vs. 19 of 8980 nondonors [0.2%]; 8.3 vs. 0.2 events per 1000 person-years; hazard ratio, 38.8 [95% CI, 22.1 to 67.9]; P < 0.001). The median time from donation to scrotal surgery was 5.2 years (IQR, 3.3 to 8.4 years); more than 90% of the surgeries were hydrocelectomies and were performed under general anesthesia. Over 20 years, the cumulative incidence was 13.8% in donors versus 0.7% in nondonors. The precise causal mechanism remains unknown. Laparoscopic nephrectomy is associated with a higher risk for subsequent scrotal surgery in male living kidney donors. Canadian Institutes of Health Research.

Background: Sex-disaggregated data demonstrate that there are more female than male living kidney donors (LKDs), and this is widely thought to be a manifestation of gender inequities. A better understanding of how gender norms, roles, and relations influence the living kidney donation process is needed. Objective: We aimed to develop an analytical tool that can be used to conduct a systematic gender analysis of the living kidney donation process. Design: A participatory research approach was used. Setting: Canada. Participants: Canadian living kidney donors and health care professionals. Methods: Using a participatory research approach, we co-designed a gender analysis matrix (GAM) applicable to the context of living kidney donation. This tool is the first step into conducting a gender analysis of the living kidney donation process. Participants included 11 healthcare professionals, 6 LKDs, 1 patient partner, and a core methodology team (3 qualitative researchers and a gender analysis expert). Results: Following an iterative process, a final LKD-GAM with 4 columns and 4 rows was created. The gender-specific domains are access to resources, division of labor and everyday practices, social norms and beliefs, and decision-making power and autonomy. Context-specific domains are the decision to donate, physical and mental wellbeing, experiences with health services, and broader social and economic impacts of (non-)donation. Key insights for our future work include diversity in our sample (include LKD candidates, men, and different life stages) and unpacking the notions of consent, constrained consent, and subtle coercion. Limitations: The GAM’s scope is likely limited to the Canadian context. The study was also limited by the recruitment of LKDs from a past list of participants and by the lack of cultural and linguistic diversity in the sample. Conclusion: Using a participatory co-design approach, we have developed a robust tool that will inform a multinational qualitative study to better understand factors contributing to gender disparities in living kidney donation.

Background: Current guidelines recommend that living kidney donors should avoid non-steroidal anti-inflammatory drugs due to their potential nephrotoxic effects. It is unclear if physicians are adhering to this recommendation. Objective: Our aim was to determine the proportion of living kidney donors that filled a non-steroidal anti-inflammatory drug prescription post-donation and the proportion with measurement of kidney function post-prescription. Design: We conducted a population-based, retrospective cohort study. Setting: We identified kidney donors in Alberta, Canada that had accessed the healthcare system in the outpatient, emergency department, or inpatient setting. Patients: Adult living kidney donors in Alberta, Canada who donated between 2002 and 2019. Measurements: We measured the number of non-steroidal anti-inflammatory drug prescriptions, type of prescribing physician, and evidence of post-prescription measurement of creatinine and potassium. Methods: We identified the proportion of donors who filled a non-steroidal anti-inflammatory drug prescription at least 1 year post-donation. We also assessed how many donors underwent laboratory testing for kidney function and potassium within 14 days following the first prescription. Results: Of the 759 living kidney donors included in our study, 273 (36%) had at least one non-steroidal anti-inflammatory drug prescription over a median follow-up of 7.2 years (interquartile range 3.5-11.5). The proportion of donors with at least one prescription in follow-up remained stable over time (~10% per year). Family physicians accounted for 66% of all non-steroidal anti-inflammatory drug prescriptions. Approximately, 10% of donors had measurements of serum creatinine or potassium post-prescription. Limitations: This study was limited by the inability to capture over-the-counter non-steroidal anti-inflammatory drug use, indication for the prescriptions, and indication for bloodwork being completed in the post-prescription period. Conclusions: Over one-third of living kidney donors are prescribed non-steroidal anti-inflammatory drugs despite current guideline recommendations, with only a minority undergoing post-prescription laboratory testing. Further research assessing outcomes following non-steroidal anti-inflammatory drug use is recommended to better inform optimal pain-management strategies for living kidney donors.

Background: There are limited data on the outcomes following medical management alone versus revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) after coronary angiography in kidney transplant recipients. Objective: The objective was to compare survival and graft loss in kidney transplant recipients treated with medical therapy alone versus coronary revascularization following coronary angiography. Design: We conducted a retrospective, population-based cohort study using linked health care databases. Setting: This study was conducted in Alberta, Canada. Patients: We included adult, kidney-only transplant recipients between January 1997 and March 2015 who survived at least 1-year post-transplant with a functioning graft and had a coronary angiography during follow-up. Measurements: The outcomes were all-cause mortality, death-censored graft failure, death with a functioning graft, and all-cause graft failure. Methods: We ascertained baseline characteristics, covariate information, and outcome data from the Alberta Kidney Disease Network (AKDN) and Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) databases. We used Cox proportional hazards models to compare mortality and graft loss between recipients treated with medical management versus revascularization (PCI or CABG) following angiography. Results: We identified 142 kidney transplant recipients who received a coronary angiography: 69 (49%) were treated with medical management, and 73 (51%) were treated with revascularization (PCI n = 52, CABG n = 21). The median age was 60 years (interquartile range [IQR] 50-66), 76% were male, the median baseline estimated glomerular filtration rate (eGFR) was 54 mL/min/1.73 m ² (IQR 41-69), and the median follow-up was 5 years (IQR 2-8). Compared to medical management, recipients treated with revascularization did not have statistically higher risk of all-cause mortality (55% vs 62%; 80 vs 102 events/1000 person-years; adjusted hazard ratio [aHR] 1.32, 95% CI 0.86-2.02; P = .21). There was no significant difference in death-censored graft failure between the two treatment groups (20% vs 22%; 33 vs 40 events/1000 person-years; aHR 1.22, 95% CI 0.58-2.58; P = .60). Limitations: The clinical indications for medical management alone versus revascularization might influence the choice of these interventions. Due to the smaller sample size, we could not present the outcomes by PCI versus CABG. We also did not have complete data on blood pressure, body mass index, or medication usage which might have influenced our outcomes. Conclusions: In kidney transplant recipients undergoing coronary angiography, the rate of mortality was more than double that of graft failure, regardless of post-angiography management of coronary artery disease. The high overall risk for both groups requires further exploration in larger cohorts with longer follow-up.