In most cases, the initial contact between transplant center and potential candidates occurs at the pretransplant evaluation (1). In its early years, with multidisciplinary committees determining candidacy based on value to society and rehabilitation potential, psychiatric problems were considered a major contraindication to kidney transplantation. Now, psychiatric illnesses, if appropriately treated, rarely preclude transplantation (2). At most centers, psychiatric consultation remains an important component of the evaluation process (3). Nowadays, the purpose of psychiatric consultation is to identify problems that might potentially compromise transplant outcomes, enabling implementation of appropriate treatment prior to transplantation if not already ongoing.

Initial assessment of a potential transplant candidate must address level of cognitive function (2). Granting informed consent requires an end-stage renal disease (ESRD) patient to comprehend risks and benefits of transplantation relative to dialysis. After transplantation, the recipient must possess cognitive skills adequate to understand and follow complicated immunosuppressant and follow-up regimens. At times, ESRD is associated with significant organic illness (anemia, vitamin deficiencies, etc.) that can impair cognition, and should be aggressively diagnosed and treated. As transplantation becomes more widespread among the elderly, limited longevity benefit and comorbidity become the primary elements impacting therapeutic choices; only rarely will cognitive dysfunction be the major determinant of transplant candidacy. In some ESRD patients, cognitive deficits may improve after transplantation with more definitive resolution of the uremic state. However, at times, even patients with severe, irreversible cognitive deficits may still benefit from transplantation with availability of a committed caregiver (4,5). This opportunity is especially important for pediatric transplant candidates, many of whom by definition are unable on their own to grant informed consent. Thus, assessment of this parameter must always be individualized, with evaluation of social support systems and potential reversibility of cognitive deficits critical to determining candidacy.

As noted above, overt psychiatric illness is not often a contraindication to kidney transplantation (Table 15.1). Rather, most transplant centers would require that psychiatric disturbances be adequately treated and with a reasonably benign prognosis before proceeding (3). As among those with other chronic illnesses, as many as 30% of ESRD patients display symptoms of depression, often amenable to pharmacologic therapy (6). Under adequate care and supervision,
even patients with major psychiatric disturbances (including bipolar disorder and schizophrenia) may be able to understand their illness, grant informed consent, and comply with medical regimens.

In contrast, many centers consider ongoing substance abuse to be an important contraindication to transplantation (3). A significant history of alcohol or drug abuse is reasonably common among ESRD patients, and chemical dependency may again impair one’s ability to choose appropriately among treatment modalities and to comply with posttransplant therapeutic regimens. Although little evidence exists to support long-term benefits of such intervention, a common practice is to require documentation of a 6 to 12 month drug-free period prior to transplantation (3,4). This approach often includes counseling and random drug testing.

Finally, successful transplantation requires ongoing access to immunosuppressive drugs, physicians, and laboratory testing. In the United States, with its complex and often confusing system of health care financing, socioeconomic assessment is an important part of most pretransplant evaluations (7). Usually, this task is performed by a social worker familiar with requirements for posttransplant care who can document, on an individual basis, the resources each candidate brings to the transplant process. These include insurance coverage, ability to travel to and from the transplant center, current employment, and prospects of future employment. For the ESRD patient, transplantation changes the dynamic of access to socioeconomic resources, removing them from the defined benefits and relatively easy access associated with chronic dialytic therapy. Terms of insurance coverage often change, and patients may lose disability benefits after transplantation; at a time when access to medications assumes immense importance, reimbursement for associated expenses may fade away. Many patients need the assistance of trained professionals to navigate these waters successfully; thorough assessment before transplantation simplifies coping with events after transplantation.

Most ESRD patients identified as suitable transplant candidates remain under the care of a practicing nephrologist (not the transplant center) while awaiting transplantation (1,8). As time awaiting transplantation grows lengthier, new psychosocial challenges may arise (9). It is the treating physician’s responsibility to ensure that any new psychologic problems are addressed promptly and that the transplant center is notified of the change. Likewise, ongoing contact between the candidate and transplant center may be beneficial. Up-to-date knowledge of cognitive impairments, mental illness, substance abuse, or significant changes in insurance coverage or social support systems is crucial in determining whether to proceed with transplantation when an organ becomes available.

Kidney transplantation owes its very existence to the volunteerism of the living donor. The courage of early twin donors, coupled with the innovative insight of surgeons and physicians, enabled successful engraftment of a healthy kidney into an ill recipient (10). In the United States, roughly half of all transplants now utilize kidneys from live donors, a threefold increase over the last decade (11). From the beginning, transplant professionals have struggled to reconcile the competing interests operative in living donor transplantation. Murray, Merrill, and colleagues articulated three basic principles concerning utilization of live donors (12). There must be 1) a high chance of a successful outcome for the recipient, 2) low risk to the donor, and 3) the desire of an informed donor to participate in the process. Affirming this tradition, a recent consensus conference concluded that donors must be “competent, willing to donate, free from coercion…psychosocially suitable…and fully informed…” clearly establishing a high standard for current practice (13). Thus, in live donor transplantation, several psychosocial variables are operative and of key importance.

In the United States, the National Organ Transplant Act of 1984 prohibited “valuable consideration” to compensate persons for their organs (14). Thus, by statute, donors must be motivated by other interests. It is, however, permissible for donors to be compensated for out-of-pocket expenses and even lost wages (15).

Formal psychosocial evaluation is customarily a part of all donor evaluations, allowing identification of issues that may preclude donation, or, as a result of timely intervention, may enhance the process (16). This evaluation should first attempt to uncover any underlying psychiatric illness, including major affective disorders, personality disorders, or chemical dependency. Active psychiatric illness and ongoing substance abuse may interfere not only with assessing competence (see below), but may also impede proper care in the operative and postoperative periods. In the potential donor with a significant psychiatric history, it may be advisable to include the opinions of the personal psychiatrist in the evaluation process. While appropriate therapy of these disorders may allow donation to proceed, careful consideration is necessary. For instance, treatment of bipolar disorders may require lithium; potential nephrotoxicity from use of this agent may be of greater concern in an otherwise healthy donor than in a recipient. As is customary with transplant candidates, potential donors with a history of chemical dependency
may be required to demonstrate 6 to 12 months of abstinence before nephrectomy (17).

Given variability in motivation, with a relationship between risk and benefit more complex than in other areas of medicine, assessing competence in a potential donor can be quite complex. In its simplest application, competent implies the ability to understand the risks, benefits, and imponderables operative in the process of live donor nephrectomy, and to grant informed consent to proceed. A representative (or representatives) of the transplant team must fully disclose all data pertinent to the live donor process, including diagnostic and surgical risks, anticipated duration of recovery, potential complications, expenses, and expected outcomes for donor and recipient. Only after the potential donor assimilates these and other pertinent facts can there be an informed decision to grant consent. At our centers, competence of potential donors, as well as freedom from coercion, is assessed independently by psychiatrists, social workers, coordinators, and physicians at several different steps in the evaluation process. It has been recommended that each transplant center employ a “donor advocate,” an otherwise uninvolved professional whose primary allegiance is to the donor, to ensure that the interests of the donor do not become secondary to those of the recipient (13). Although at times incompetent persons (minors, the disabled) may wish to serve as donors, the precedent of parents and/or guardians granting consent on behalf of another is not strong (18).

Finally, there may be some psychosocial risks associated with donor nephrectomy. It is common for the donor, having just undergone a major surgical procedure, to feel excluded from the celebration that accompanies successful transplantation in the recipient. While quality of life remains stable for most, as many as 30% of donors report feelings of depression in the postoperative period (19,20). Depression may be even more common if the allograft is lost. Thus, psychosocial suitability indicates not only absence of definable pathology, but also sufficient stability and support systems to sustain a donor through what can be difficult times after the transplant. Some centers are now developing programs designed to assist donors with psychosocial aspects of recovery after nephrectomy, including counseling, support groups, and social services (21,22). A recent survey of major insurers in the United States indicated that donors should not encounter difficulties in obtaining life insurance after nephrectomy (23).