A Cross-Sectional Social Network Analysis of Decision-Making About Recruiting a Living Donor for Kidney Transplantation

Rationale & Objective: Most living kidney donors are members of the recipient's social network. Our study aims to characterize patient and social network factors associated with recruiting a living kidney donor. Study Design: A cross-sectional study. Setting & Participants: A total of 106 patients receiving hemodialysis (mean age 60 ± 13 years, 45% female, 75% Black) identified 508 network members (106 who offered to donate and 38 who received a donation request). Predictors: Demographic and network factors (eg instrumental support, strength of relationships between the patients and members). Outcomes: Whether the member offered to donate and whether the member's offer was accepted. Patients’ qualitative reasoning regarding decision-making for recruiting a living kidney donor. Analytic Approach: We performed a mixed-methods egocentric network analysis using multilevel logistic regression models as well as qualitative analysis of open-ended survey questions. Results: Members who provided instrumental support were more likely to offer to donate (odds ratio 3.54; 95% CI [1.80-7.00]; P < 0.001) and have their offer declined (odds ratio 0.12; 95% CI [0.02-0.74]; P = 0.02). Members with stronger relationships with the patient (9.4 [1] vs 8.4 [2.5], P = 0.02) were more likely to be evaluated at a transplant center. Concern and guilt for the member was the most common reason that patients declined offers (41%) or did not make a living donor request (28%), while members’ insistence on donating was a common reason for accepting an offer. Limitations: Small sample of only patients receiving hemodialysis. Conclusions: For many patients, the barrier to living kidney donation was not a lack of potential donors within their network but reticence to recruit a donor due to concern and guilt for the donor. Future living donor kidney transplantation interventions should engage patients and their networks to facilitate communication, address patient-specific concerns and emphasize donor retention. Plain-Language Summary: Despite most living donors being members of a patient's social network, how these networks impact donation is poorly understood. We examined how characteristics of patients and their networks relate to donor recruitment along with qualitative insights on patients’ decision-making. We found that although many network members offered to donate, patients declined due to concern and guilt on their behalf. A member's insistence on donating was a common reason for accepting an offer. Members who had stronger relationships with patients were more likely to be evaluated for transplantation. Future interventions should engage patients and their networks to facilitate communication, address patient-specific concerns, and emphasize donor retention. Such interventions may be particularly effective at reducing disparities in living donor kidney transplantation.