The shortage of cadaveric organs for transplantation1 and the better results obtained with live donor kidney transplantation (LDKT) make this transplant modality the best and first option that should be offered to those who need short-term renal replacement therapy.2,3 The LDKT aims to significantly improve the survival prognosis and rehabilitation of the living kidney receptor, with minimal damage to the living kidney donor. In an adequately selected live kidney donor the risk of requiring dialysis or transplantation in the future is so small that there is consensus on the ethical justification of donation, under the assumption that the donor is well informed and is free to makes such decision.4–9

Health professionals are key in the final decision of the potential living kidney donor.1 The information provided to patients about the donation process in life is fundamental. It is one of the factors that allow an autonomous and objective decision so, if the kidney transplant is not contraindicated, the donor will consider that the option of the LDKT is of minimum risk and maximum benefit for the receptor.3

In addition to accurate and real knowledge about the process of organ donation and transplantation, the manner in which a person is informed often generates feelings about the donation, and has been positively associated with the attitude toward donation and the decision making process to donate in life.10 The number of living donors and transplants increases when the information is given in an appropriate environment with an optimal presentation and quality of information to patients and family members.11 This is important given the relationship between information provided by health professionals, knowledge, attitude and willingness to donate organs in life.10

Regarding the information of the LDKT process, there are studies taking place in areas and populations different from ours that do not analyze certain characteristics such as the informants, the format of communication used and how donors and recipients perceive the information received. In United States it has been identified aspects of the information and education that may increase the number of living donors for black people, in other minorities, older adults and in patients with low incomes. It was assumed that LDKT was more likely to occur in whites, younger adults and in high family income.12–14

Consequently, we conducted an investigation aiming to learn about the characteristics of the information received by donors and living kidney receptors, before and during the process of evaluation of potential donors and receptors, as well as evaluating their socio-health profile, the sociodemographic characteristics, economic-employment status, health and caregiving activities of donors and receptors.

Achieving these objectives may help to improve renal donation in life. To increase donations, “it is necessary to inform more and better” to both, health professionals and patients.3 It is also important to know the social and health status of living kidney donors and receptors, since some features may predict the levels of well-being and the manifestation of psychological symptoms in the living donor after donation.15 Also acquire a real vision of the donors and recipients, their social and family environment, the style and habits of life, health status, the characteristics that distinguish them from other groups, and even identify the behavior of the population where donors and recipients come from in relation to the LDKT.16

To achieve these objectives, we have performed an observational, descriptive, cross-sectional study including individuals who donated or received a live kidney, between April 8, 2014 and June 8, 2015, in the following University Hospitals: Puerta del Mar (HUPM), of Cádiz, Virgen del Rocío (HUVR), of Seville, and in the University Hospital Complex of Granada (CHUG). All these hospitals belong to the Public Health System of Andalusia.

The target population was all individuals who donated a kidney and the recipients of a kidney from living donor. Recipients under 18 years of age were excluded from the study.

In both living donors and recipients the following information was obtained: sociodemographic data, donor-recipient relationship, living address, employment status, sources of income, whether they had the responsibility of taking care of family members and for how long the had such a duty. To assess their health profile the following parameters were evaluated: weight, height, body mass index (BMI), self perception of health, hospital admissions, visits to emergency rooms, and consumption of tobacco and alcohol. The calculation of daily alcohol consumption was made using the standard drink unit.17

Regarding the characteristics of the information received by living kidney donors and recipients, we identified the informant and how the information was received. In addition, in donors taking care of family members we obtained information about the extrawork as caregivers. In kidney recipients we collected information on the etiology of chronic kidney disease (CKD), the type of renal replacement therapy before transplantation, time on dialysis and on the waiting list, and the degree of autonomy for daily activities.

Researchers collected the information through interviews, before the donation and actual graft implant, to those individuals who accepted to participate in the study.

The protocol was approved by the Research Ethics Committee of the HUVR, under the CEI 2013/PI153 file.

The analysis of the data was made with the statistical program IBM SPSS 21.0 for Windows. The qualitative variables are expressed as frequencies and percentages and the numerical variables with normal distribution are presented as means, standard deviations and maximum and minimum values.

During the study period in the 3 hospitals there were 47 kidney living donors, of which 5 (10.6%) did not answer the survey because they did not have the time to do it before the donation and 2 (4.3%) did not agree to participate in the study. Forty seven patients received a live kidney, of which 4 (8.5%) did not participate in the study because they did not have the time to do it before transplantation and 3 (6.4%) because were not adults (Table 1).

In this paper we analyze the characteristics of the information received by living kidney donors and recipients, before and during the process of donation and transplantation; we also analyze its demographic, social and health profile, in the three hospitals involved.

In our investigation, the average age of the kidney donors (49.73 years) and recipients (44 years) were somewhat lower than in the rest of Spain, with donors (51.4 years) and recipients (46.6 years).20 However, our donors were younger than in other European studies, such as that of Timmerman et al.21 (56 years), although our recipients were somewhat older than those studied by Gozdowska et al. (40 years).22

We have detected a gap in the gender of living kidney donation, since almost twice as many women (65%) donated a living kidney (Table 2). These figures are very similar to the rest of Spain (64% of women donors).20 However, they differed from studies conducted in Israel or United States, where women donors barely reach 60%,23,24 or from the Netherlands, in which there is no such gender gap.15,21 Given these results, and that there are studies that identify a more favorable attitude to donate organs in women than men,1,25 some informative and educational strategies should be explored in our area aiming at promote live renal donation by men.

Half of the our donors had completed bachelor and university studies, which differs from the report by Boas et al.23 or from northern Europe,21 where more than 60% of donors have this level of education. This issue should be investigated since a lower educational level has been identified as a barrier for living kidney donors, who may discard the idea of donating organs in life, due to a limited access to information.26,27

Our research also showed that almost all donations of kidneys in life were between relatives (92.5%), within close family members, and 7.5% were from unrelated donors of cross-transplants program (Table 2). These percentages are similar to the rest of Spain with a 89.1% of donations between relatives,20 however they are different from other areas; Taler et al.24 reported a 66% of donations to relatives and in the study by Erim et al. there were up to 97.2% of donations to relatives.28 The percentage of donors and recipients living in the same house was higher in our patients (57.5%) than in other areas (41.7%).15,21 Our study coincides with the general tendency of being the family the main source for people that choose the option of a LDKT, it is reasonable that an individual who needs a kidney seeks help from the members of their family.

Less than half of our donors were employed (Table 3), and in the study by Boas et al.23 78.9% of donors had a work. Our results, that shows fewer employed donors, may be explained by specific socioeconomic factors of our area and also because our donors are mostly women that have less presence in the labor market. In contrast to our data, other studies show more male donors,23 which may explain a greater number of donors being employed. It is striking, that more than half of our recipients (52.5%) did not work at the time of the transplant, because they were retired or incapacitated by disability (Table 3) despite being relatively young (mean of 44 years). These results contrast with even much higher figures of non-active people (89.2%) obtained by Lorenzo-Sellares et al.29 in a population similar to ours, composed of people with advanced chronic kidney disease and in hemodialysis. The consequences of CKD and renal replacement therapy on heath may justify this situation.30

Regarding the BMI, donors and recipients evaluated were “grade-1 overweight” and “normal weight”31 (Tables 5 and 6). This means that most of them were distant from “type-1 obesity”,31 which marks the beginning of a higher risk of nephropathy since “type-1 obesity” is associated, at the long term, with risk factors such as hypertension, diabetes, etc. This justifies maintaining donors and recipients within a normal weight range during the follow-up. Only 4 recipients met the criteria of “tipo I obesity”, and therefore they would be recommended to reduce their weight before transplantion18,19 (Table 6).

Despite the sequelae of CKD and renal replacement therapy, recipients of our study had a “good” perception of their health before transplantation (6.35 out of 10 points) and two thirds of those recipients perceived their health during the last year as “good” or “very good” (Table 6).

Regarding toxic habits, there were more smokers in our donors (35%) than in the general adult Spanish population (24.08%),32 which is clearly higher than the proportion of smokers in recipients before transplantation (15%). Although 37.5% of the donors and 22.5% of the recipients consumed alcohol (Tables 5 and 6), this prevalence is much lower than that observed in the general population, where alcohol consumption is approximately 89% in men and 74% in women. This may be due mainly to the fact that the recipients, due to their CKD, limit alcohol consumption spontaneously or after recomendation.33 Likewise, no donor or recipient had a harmful alcohol consumption (>40.9mg/day) (Tables 5 and 6), so according to the best practice guidelines it was not necessary to advise any donor to abandon or reduce the consumption of alcohol to be able to donate a kidney in life.18,19

It is noteworthy that the majority of recipients (57.5%) received an early live kidney transplant (Table 7), so they received the optimal therapeutic option for terminal renal failure34 indicating that the study centers consider the possibility of early live transplantation from beginning of CKD. However, the recipients who were on dialysis at the time of transplantation had been for an average of 14.19 months on dialysis, which should be taking into consideration since graft survival is significantly better in recipients that were on dialysis for less than 6 months.34 It is also observed in our study that the proportion of recipients independent for daily activities (90%) (Table 6) is greater than in populations similar to ours, where 81.5% of patients with advanced chronic kidney disease and 69.8 of dialysis patients are capable of self-care.29

Since the nephrologist is responsible for monitoring the patient with CKD, it seems reasonable that the nephrologist inform about the living kidney donation and the process that has to be followed (Tables 8 and 9). However, the joint and complementary action of nephrologists and nurses to inform and promote the possibility of LDKT, may contribute to improve the development and the process of these LDKT.

The vast majority of recipients (87.5%) considered that the information received during the donation and live kidney transplant process was sufficient, but almost half of them would have desired more information (45%) (Table 9). This demand for additional information may imply that there is a lack of knowledge in these patients and insufficient public awareness of the process of renal donation in life.27

Consequently, to improve the LDKT process, the current evaluation procedures and pre-donation information should be reconsidered and adapted to the educational and level of knowledge of candidates and families. The decision to donate should be made only after being well informed with realistic expectations about the results of transplantation in the recipient and, the potential consequences in the donor including possible impact on personal relationships.35 The manner in which health professionals inform and educate potential kidney donors and recipients has long-term implications on the psychosocial and health outcomes of living donors.2 Likewise, in order to improve the LDKT process, novel informative and educational strategies should be implemented,35 focusing especially on potential male donors of our environment, on the possibility of unrelated donation and actively integrating other health professionals in the task of educating and increasing the awareness about kidney donation in life.

As a strength of our research, it is worth mentioning that this is the first time that the information received by living kidney donors and recipients of and its social and health profile has been evaluated in our environment. During the 15 months duration of the study, all the donors and kidney recipients available were evaluated which accounted for 85.1% of the total population (Table 1), with only two refusals to participate in the study (5%). By contrast, our study has the limitations of a descriptive study with a limited number of subjects since living donation depends on the social and cultural characteristics of the area where is being developed. Despite these limitations, we think that our study can be used to improve the information about the process of living kidney donation and transplantation and to establish new lines of research, which should contemplate those candidates that were evaluated, but at the end, the fail to donate.

In short, it can be concluded that since the information provided has a direct impact on the results of the LDKT programs and that a significant number of recipients demand for more information, the evaluation and information processes should be updated to increase donors and living kidney recipients. Renal donations in life in our area are mostly to relatives, and despite the limitations to extrapolate our study, it is observed that the sociodemographic profiles obtained in the donors and recipients studied tend to approximate those of the whole country and to differ from studies obtained in other geographical areas.

Regarding employment and economic profile, a high percentage of kidney donors and recipients do not have a remunerated job, although this inactivity would be compensated with some retirement or disability benefit and would not have an impact on their economy, since almost all of them have some source of income in their family.

Renal donors and recipients care for elderly people in their families in percentages much higher than in the Spanish population and the great majority of these donors and recipients do not have work overload.

In relation to the health profile, the tendency to be over weighted is the only negative aspect identified in the kidney donors and recipients. It should be highlighted that more than half recipients receive an anticipated LDKT and that they are independent for daily activities.

The authors declare to have no conflicts of interest.