The Psychosocial Evaluation of Living Kidney Donation: Time for Standardization in Practice

INTRODUCTION The transplant community has an opportunity to improve clinical follow-up and data collection opportunities, to implement standardized psychometrics instruments in the living kidney donor evaluation process and optimize psychosocial team structures. Clifton et al1 was an American Society of Transplantation Living Donor Community of Practice Mental Health Working Group product. Their survey reached 53% of active US living donor programs with the intent of understanding composition of psychosocial teams evaluating donor candidates, what the evaluation process entailed, and postdonation psychosocial follow-up. Although policy has been established for more than a decade, there is much transplant hospital variation in living donor evaluation screening mechanisms, acceptance practices, and support offered. Although generalizable, data from only about half the active centers are a limitation to understand the totality of the national landscape. The authors suggest that the Organ Procurement and Transplantation Network (OPTN) should require living donor programs respond to inquiries about practice patterns (such as about psychosocial evaluation) that do have minimum standards written into OPTN Policy (Policy 14, Living Donation, established in 2013).2 Current OPTN policy requires member quality to audit living kidney donor programs every 3 ye. Communication of identified common deficiencies impacting donor safety is needed, so other centers can improve the evaluation process in their programs. Furthermore, the OPTN has no policy recommendations about psychosocial follow-up required for living kidney donors despite variations in psychosocial risk profiles of living donors cleared for donation. DATA COLLECTION IS NOT THE SAME AS CLINICAL FOLLOW-UP AND ENGAGEMENT The OPTN requires follow-up data collected at 6-, 12-, and 24-mo postdonation but does not include comprehensive psychosocial indicators. Both functional status and return to work are included in OPTN follow-up forms,3 which are not sufficient to understand the psychosocial and mental health status of the donor after donation. The Kidney Disease Improving Global Outcomes Living Donor Guidelines call for the collection of data on psychosocial wellbeing to understand burden and causes, and to enable solutions to be generated for donors accepted with higher risk. However, data collection is not the same as clinical follow-up care and engagement with living donors. Transplant centers should feel obligated to ensure living donors' medical and psychological needs are addressed throughout the donation continuum. There is variation in center-level acceptance of living donor candidates with mental health and substance use history or disorders (ie, cannabis use disorder, active anxiety, and depression).1 Only half of respondents said active depression was a contraindication to donation, whereas only 27% reported active anxiety disorder as an absolute exclusion criterion. More than 90% of respondents indicated that donor candidates with known mental health or substance use disorders underwent initial evaluation.1 With such variation in acceptance patterns, living kidney donors deserve active clinical postdonation follow-up care management. If transplant centers are going to accept donor candidates with active depression or an anxiety disorder, they should be responsible for providing postdonation psychosocial assistance. Of note, Clifton et al1 reported that 71% of respondents are conducting postdonation psychosocial assessments and using local resources to support donors. Living kidney donation can have unique, varying, and significant impacts on the mental health of donors. Transplant centers are much more equipped to understand, diagnose, and manage conditions that may arise in living kidney donors than community-based mental health professionals with little to no experience in this area. QUALITY OF PSYCHOSOCIAL EVALUATION TEAMS AND IMPLEMENTING VALIDATED TOOLS Clifton et al1 shows broad variation in how psychosocial assessments are conducted, including varying levels of clinical providers and very minimal use of standardized psychometric instruments that were for the assessment of the living donor. In addition to a social worker, programs should have a psychiatric medical professional (psychiatrist, psychologist, or nurse practitioner) on the transplant team to ensure the opportunity to manage medications or psychiatric conditions throughout the donation continuum. Most of these programs were not using psychometric instruments to standardize the psychosocial assessment and instead were relying on the self-reported Patient Health Questionnaire that incorporates Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition depression criteria with other leading major depressive symptoms.1 Very few programs are using validated, transplant-specific assessment tools to supplement to the traditional semistructured psychosocial interview. Such tools provide a structure and standardization to the assessment and can improve the evaluation process. The live donor assessment tool4 is a validated tool designed for donor screening and evaluation. The live donor assessment tool demonstrated utility in predicting living donors who are at risk for negative postdonation outcomes, specifically the need for counseling postdonation. Furthermore, it has clinical utility beyond the standard psychosocial evaluation. It can provide objectivity to the assessment and provide a standardize way to communicate risk among psychosocial providers and other team members as well. More importantly, it helps guide the team in the development of interventions to improve donor candidacy.5 CONCLUSION Identification of best practices and standardization is necessary for psychosocial evaluation and follow-up in the United States. Follow-up for clinical care and for data collection and research are very different. We believe that transplant centers should commit to the comprehensive care of living donors, so they are managed by the psychosocial team through the donation continuation. Ultimately, the transplant community should work toward consensus on what psychosocial data elements would be useful to collect, recognizing these have different implications for, donor selection, evaluation, postdonation care management and research. We acknowledge that this plan does require financial commitment from the hospital to support its transplant program. This approach might be easier to achieve in countries with universal healthcare, and advocacy is needed to require that health insurers commit to living donor follow-up care in the United States.