Background: Living Donor Kidney Transplant (LDKT) is the optimal treatment for patients with End-Stage Kidney Disease (ESKD), however many eligible candidates are not able to receive LDKT. To our knowledge, no published studies have assessed the relationship between taking steps to pursue LDKT and the likelihood of securing an offer of living donation (OLD). We explored the relationship between patients taking specific actions to pursue LDKT and having received an OLD.
Methods: We used a cross-sectional, convenience sample of adult patients with ESKD from several hospitals in the Greater Toronto Area. Non-English speaking patients and patients unwilling to consent were excluded. Patients were asked whether they had taken specific steps in pursuing LDKT (exposure variables, see Table 1) and if anyone had offered to be a living donor for them (outcome variable). Univariable and multivariable logistic regression was used to analyze the association between exposure and outcome variables in STATA14.
Results: Data from 367 participants was analyzed. The mean (±SD) age was 58(±13) years, and 60% (221) of participants were male. Seventy one percent (260) of patients reported having greater than 12 years of education and 46% (168) were married or in a common-law relationship. The median time patients had been on dialysis was 2.1 years (IQR: 1.0-5.2 years) and 43% (156) had diabetes. Thirty eight percent (141) were White while 32% (117) were Black. Forty five percent (164) reported having received an OLD.
Patients who reported having asked potential donors directly to be tested for eligibility were more likely to have received an OLD (OR=9.31, CI: 4.21-20.60, P<0.05) compared to those who had not yet asked. The association remained significant after adjusting for age, gender, education, ethnicity, marital status and transplant knowledge score (OR=6.80, CI: 2.89-16.00, P<0.05). Similarly, patients who reported having spoken to family or friends about the possibility of getting LDKT were more likely to have received an OLD (OR=6.54, CI: 3.76-11.36, P<0.05), after adjusting for age, gender, education, ethnicity, marital status and transplant knowledge score. Similar results were seen for patients who had “allowed others to tell people of their willingness to pursue LDKT”, “talked to people about their interest in LDKT” and “shared educational material about LDKT”. 
Discussion: Taking small, specific steps towards pursuing LDKT may lead to successfully securing a living donor offer. Thus, patients who appear to be unable or unwilling to take these steps may be at a significant disadvantage.
Conclusion: Patients who have actively taken steps to pursue living donation are more likely to have received an OLD compared to those who have not taken these steps. Future research will be needed to identify the potentially modifiable barriers to taking these steps and to develop interventions to help patients explore the optimal treatment for ESKD.