Effect of bisphosphonates on bone mineral density in liver transplant patients: a meta‐analysis and systematic review of randomized controlled trials

Bone mineral density (BMD) loss after liver transplantation (LT) results in considerable morbidity with the increased risk of fractures. Data on the efficacy of bisphosphonate use in post LT patients is scarce. This meta‐analysis aims to summarize the results from published randomized controlled trials (RCTs) on the topic of interest. Electronic databases were searched to identify relevant publications. A total of 157 articles were identified and reviewed. Individual authors were contacted from relevant RCTs to obtain individual patient data where necessary to uniformly quantify BMD values post LT pre‐ and post LT. A total of six RCTs were used for final data extraction. (i) Lumbar Spine: In 364 patients (six studies, 182 in intervention and control groups each), bisphosphonate therapy improved BMD by 0.03 g/cm² (95% C.I. 0.01–0.05 g/cm²; P = 0.02) at 12 months post LT. (ii) Femoral neck: In 268 patients (four studies, 130 bisphosphonate, 138 control), bisphosphonate use did not result in a statistically significant change in BMD at the end of 1 year. None of the studies noted serious adverse effects related to bisphosphonate administration. Data on incident fractures could not be pooled because of heterogeneity. Bisphosphonate therapy during the first year in LT recipients appears to reduce accelerated bone loss and improve bone mineral density at the lumbar spine.     

Outcomes of bisphosphonate therapy in kidney transplant recipients: a systematic review and meta‐analysis

Mineral and bone disorders that precede kidney transplantation are exacerbated in the post‐transplant setting by tertiary hyperparathyroidism and immunosuppressive regimens. Bone mineral density (BMD) decreases following transplantation, leading to increased fracture risk. The effect of bisphosphonates on fracture is unknown. The aim of this study was to update estimates of change in BMD and fracture rates in bisphosphonate‐treated kidney transplant recipients through meta‐analysis. Studies comparing bisphosphonate therapy to standard of care were included if follow‐up duration was more than 6 months. We performed random‐effects meta‐analysis to determine the effect of bisphosphonates on lumbar spine and femoral neck BMD and fracture rates. Bisphosphonates improved femoral neck and lumbar spine BMD compared with controls (0.055 g/cm², 95% CI 0.012–0.099 and 0.053 g/cm², 95% CI 0.032–0.074, respectively) without adversely affecting serum creatinine or calcium. This corresponded to an unweighted improvement in BMD of 6.0% and 7.4%, respectively. There was no difference in fracture incidence in the two groups. Bisphosphonate therapy in kidney transplant recipients is associated with a statistically significant improvement in BMD at the lumbar spine and femoral neck. There was no difference in fracture incidence. Bisphosphonates did not adversely affect allograft dysfunction or serum calcium levels.     

The prognosis of kidney transplant recipients with aorto-iliac calcification: a systematic review and meta-analysis

The prognosis of kidney transplant recipients (KTR) with vascular calcification (VC) in the aorto-iliac arteries is unclear. We performed a systematic review and meta-analysis to investigate their survival outcomes. Studies from January 1st, 2000 until March 5th, 2019 were included. Outcomes for meta-analysis were patient survival, (death-censored) graft survival and delayed graft function (DGF). Twenty-one studies were identified, eight provided data for meta-analysis. KTR with VC had a significantly increased mortality risk [1-year: risk ratio (RR) 2.19 (1.39–3.44), 5-year: RR 2.28 (1.86–2.79)]. The risk of 1-year graft loss was three times higher in recipients with VC [RR 3.15 (1.30–7.64)]. The risk of graft loss censored for death [1-year: RR 2.26 (0.58–2.73), 3-year: RR 2.19 (0.49–9.82)] and the risk of DGF (RR 1.24, 95% CI 0.98–1.58) were not statistically different. The quality of the evidence was rated as very low. To conclude, the presence of VC was associated with an increased mortality risk and risk of graft loss. In this small sample size, no statistical significant association between VC and DGF or risk of death-censored graft loss could be demonstrated. For interpretation of the outcomes, the quality and sample size of the evidence should be taken into consideration.     

Clinical outcomes of polyvalent immunoglobulin use in solid organ transplant recipients: A systematic review and meta‐analysis

Polyvalent immunoglobulin is commonly used for desensitization and treatment of antibody‐mediated rejection in kidney transplantation but its impact on other outcomes is not known. This systematic review investigated the impact of immunoglobulin prophylaxis on infection, rejection, graft loss, and death following kidney transplantation. A comprehensive literature search located 18 studies (n = 8 randomized controlled trials). None examined the effect of immunoglobulin prophylaxis in transplant recipients with hypogammaglobulinemia. Quality of included studies was variable with high to very high risk of bias. In the randomized trials, immunoglobulin use did not reduce cytomegalovirus infection (OR 0.68 [0.39, 1.21]; 6 studies, n = 295), rejection (OR 0.96 [0.50, 1.82]; 4 studies, n = 187), or graft loss (OR 1.03 [0.46, 2.30]; 6 studies, n = 265). In non‐randomized studies, immunoglobulin did not reduce cytomegalovirus infection (OR 0.63 [0.20, 1.94]; 6 studies, n = 361) or death (OR 1.32 [0.05, 38.79]; 3 studies, n = 222) but reduce rejection (OR 0.47 [0.24, 0.94]; 4 studies, n = 268) and graft loss (OR 0.15 [0.05, 0.43]; 2 studies, n = 118). Data were scarce and sample size of current evidence was small. Adequately powered randomized trials are needed to determine if immunoglobulin is an effective intervention to reduce infection, rejection, graft loss, or death following kidney transplantation with and without hypogammaglobulinemia.     

Ureterovesical anastomotic techniques for kidney transplantation: a systematic review and meta‐analysis

No consensus exists about which ureterovesical anastomosis technique to use for kidney transplantation. The aim of this systematic review was to compare the existing techniques in relation to the risk of urological complications. All studies that compared ureterovesical anastomotic techniques in kidney transplantation were included. Study endpoints were urinary leakage, ureteral stricture, vesicoureteral reflux and hematuria. Subanalyses of stented and nonstented techniques were performed. Two randomized clinical trials and 24 observational studies were included. Meta‐analyses were performed on the Lich‐Gregoir (LG) versus Politano‐Leadbetter (PL) techniques and LG versus U‐stitch (U) techniques. Compared with the PL technique, the LG technique had a significantly lower prevalence of urinary leakage (risk ratio (RR): 0.47, 95% confidence interval (CI): 0.30 to 0.75) and a significantly lower prevalence of hematuria when compared with both PL and U techniques (RR: 0.28, 95% CI: 0.16 to 0.49 and RR: 0.23, 95% CI: 0.11 to 0.50, respectively), regardless of ureteral stenting. There was no difference in the prevalence of ureteral strictures or vesicoureteral reflux between the various techniques. Of the three most frequently used ureterovesical anastomotic techniques, the LG technique results in fewer urological complications than the PL and U techniques.     

Wound events in kidney transplant patients receiving de novo everolimus: a pooled analysis of three randomized controlled trials

Data were pooled from three prospective, multicenter trials in which 1996 de novo kidney transplant recipients were randomized to everolimus 1.5 or 3.0 mg or mycophenolic acid (MPA), with cyclosporine and steroids. Wound healing complications reported as adverse events were retrospectively reviewed in a blinded manner. The incidence of wound healing adverse events was 17.6% (351 of 1996) by day 90 and was similar for everolimus 1.5 mg (16.6% [110 of 661]) vs. MPA (14.3% [95 of 665]) (p = 0.255), but higher with everolimus 3.0 mg (21.8% [146 of 670]) (p < 0.001 vs. MPA). Similar results were observed for wound healing complications reported as serious adverse events. The 12‐month incidence of lymphocele was 11.2% with everolimus 1.5 mg and 8.9% with MPA (p = 0.171), but lymphocele reported as a serious adverse event were more frequent with everolimus 1.5 mg (6.5% vs. 3.5%; p = 0.012). The hazard ratio (HR) for any wound healing complication vs. MPA was not significantly higher for everolimus <3 ng/mL (HR 1.33; 95% CI 0.94–1.88; p = 0.104), but increased to 1.46 (95% CI 1.12–1.90; p = 0.005) for 3–8 ng/mL and 1.69 (95% CI 1.20–2.38; p = 0.002) for >8 ng/mL. These results suggest that de novo kidney transplant patients receiving an initial everolimus dose of 1.5 mg do not appear to have a pronounced increased risk of wound healing complications vs. patients receiving MPA.     

Predicting and preventing readmissions in kidney transplant recipients

A lack of research exploring post‐transplant process optimization to reduce readmissions and increasing readmission rates at our center from 2009 to 2013 led to this study, aimed at assessing the effect of patient and process factors on 30‐d readmission rates after kidney transplantation. This was a retrospective case–control study in adult kidney transplant recipients. Univariate and multivariate analyses were utilized to assess patient and process determinants of 30‐d readmissions. 384 patients were included; 30‐d readmissions were significantly associated with graft loss and death (p = 0.001). Diabetes (p = 0.049), pharmacist identification of poor understanding or adherence, and prolonged time on hemodialysis prior to transplant were associated with an increased risk of 30‐d readmissions. After controlling for risk factors, readmission rates were only independently predicted by pharmacist identification of patient lack of understanding or adherence regarding post‐transplant medications and dialysis exposure for more than three yr (OR 2.3, 95% CI 1.10–4.71, p = 0.026 and OR 2.1, 95% CI 1.22, 3.70, respectively), both of which were significantly modified by history of diabetes. Thirty‐d readmissions are attributable to both patient and process‐level factors. These data suggest that a lack of post‐transplant medication knowledge in high‐risk patients drives early hospital readmission.     

Co-administration of ketoconazole to tacrolimus-treated kidney transplant recipients: a prospective randomized study.

BACKGROUND: Since the introduction of calcineurin inhibitors, there has been a significant improvement in the results of solid organ transplantation, including graft and patient survival. However, high cost, chronic nephrotoxicity and other side effects stand as major challenges for long-term use of these drugs. The long-term safety and financial benefits of the combination ketoconazole-cyclosporine previously studied. However, data about the effect of the addition of ketoconazole addition to tacrolimus-treated patients are scarce. Therefore, this study was conducted to evaluate the safety and financial impact of that combination. METHODS: The subjects of this work included 70 live-donor stable kidney transplant recipients receiving tacrolimus. Their age ranged from 16 to 45 years. Among them, 54 were males and 16 were females. All of them were 6 months or more post-transplantation. Patients were randomly divided into two equal groups. Group I patients initially received ketoconazole 100 mg/day in addition to their usual treatment, while group II patients were considered a control. Patients were followed-up for 6 months. RESULTS: Concomitant ketoconazole-tacrolimus resulted in marked reduction of tacrolimus dose (by 58.7%) and cost (by 56.9%). It also resulted in significant improvement in graft function and fungal skin infection, in addition to a decrease of gastrointestinal episodes and hospitalization. CONCLUSION: We conclude that ketoconazole-tacrolimus combination in kidney transplant recipients is safe, has outstanding impact on treatment costs and improves patient and graft outcome.     

Clinical outcomes of polyvalent immunoglobulin use in solid organ transplant recipients: A systematic review and meta‐analysis – Part II: Non‐kidney transplant

Immunoglobulin (IG) is commonly used to desensitize and treat antibody‐mediated rejection in solid organ transplant (SOT) recipients. The impact of IG on other outcomes such as infection, all‐cause mortality, graft rejection, and graft loss is not clear. We conducted a similar systematic review and meta‐analysis to our previously reported Part I excluding kidney transplant. A comprehensive literature review found 16 studies involving the following organ types: heart (6), lung (4), liver (4), and multiple organs (2). Meta‐analysis could only be performed on mortality outcome in heart and lung studies due to inadequate data on other outcomes. There was a significant reduction in mortality (OR 0.34 [0.17‐0.69]; 4 studies, n = 455) in heart transplant with hypogammaglobulinemia receiving IVIG vs no IVIG. Mortality in lung transplant recipients with hypogammaglobulinemia receiving IVIG was comparable to those of no hypogammaglobulinemia (OR 1.05 [0.49, 2.26]; 2 studies, n = 887). In summary, IVIG targeted prophylaxis may decrease mortality in heart transplant recipients as compared to those with hypogammaglobulinemia not receiving IVIG, or improve mortality to the equivalent level with those without hypogammaglobulinemia in lung transplant recipients, but there is a lack of data to support physicians in making decisions around using immunoglobulins in all SOT recipients for infection prophylaxis.     

Dexmedetomidine for preventing sevoflurane‐related emergence agitation in children: a meta‐analysis of randomized controlled trials

Emergence agitation (EA) is a common problem after sevoflurane anesthesia in children. Prophylactic dexmedetomidine has been directed at this issue; however, the efficacy remains controversial. We therefore conducted a meta‐analysis of randomized controlled trials (RCTs) to evaluate the effectiveness of dexmedetomidine on the incidence of sevoflurane‐related EA. A comprehensive literature search was performed to identify RCTs that compared dexmedetomidine with placebo about the reduction in the incidence of sevoflurane‐related EA for children. Heterogeneity between studies was anticipated; therefore, random effects models were chosen to calculate the pooled risk ratio (RR) and 95% confidence interval (CI), and I² statistics were used to assess statistical heterogeneity. The funnel plot and Egger test were used to assess potential publication bias. Subgroup analysis was run to explore the possible effects of age, surgical procedure, regional block/local anesthetics, supplemental analgesic, propofol, N₂O, pre‐medication and methodological quality on the incidence of EA using dexemedetomidine. Totally, 15 RCTs were included (518 patients received dexmedetomidine and 413 had placebo). Dexmedetomidine reduced the incidence of sevofurane‐related EA (pooled RR = 0.351; 95% CI: 0.275–0.449; P = 0.965; heterogeneity test, I² = 0.0%), and it also resulted in a lower incidence of severe EA (pooled RR = 0.119; 95% CI: 0.033–0.422; P = 0.962; heterogeneity test, I² = 0.0%). All subgroup analyses for potential sources of heterogeneity showed a lower incidence of sevoflurane‐related EA after dexmedetomidine administration. This meta‐analysis demonstrated that dexemedetomidine was effective in reducing the incidence of sevoflurane‐induced EA in children as compared with placebo.     

COVID‐19 in kidney transplant recipients

There is minimal information on coronavirus disease 2019 (COVID‐19) in immunocompromised individuals. We have studied 10 patients treated at 12 adult care hospitals. Ten kidney transplant recipients tested positive for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) by polymerase chain reaction, and 9 were admitted. The median age was 57 (interquartile range [IQR] 47‐67), 60% were male, 40% Caucasian, and 30% Black/African American. Median time from transplant to COVID‐19 testing was 2822 days (IQR 1272‐4592). The most common symptom was fever, followed by cough, myalgia, chills, and fatigue. The most common chest X‐ray and computed tomography abnormality was multifocal patchy opacities. Three patients had no abnormal findings. Leukopenia was seen in 20% of patients, and allograft function was stable in 50% of patients. Nine patients were on tacrolimus and a mycophenolic antimetabolite, and 70% were on prednisone. Hospitalized patients had their antimetabolite agent stopped. All hospitalized patients received hydroxychloroquine and azithromycin. Three patients died (30%), and 5 (50%) developed acute kidney injury. Kidney transplant recipients infected with COVID‐19 should be monitored closely in the setting of lowered immunosuppression. Most individuals required hospitalization and presenting symptoms were similar to those of nontransplant individuals.     

Fish oil treatment for kidney transplant recipients: a meta-analysis of randomized controlled trials

BACKGROUND: Calcineurin inhibitors have adverse effects that contribute to nephrotoxicity and cardiovascular risk profile, and these may be reduced by administration of fish oil. The aim of this review was to assess the benefits and harms of fish oil supplementation in kidney transplant recipients on a calcineurin inhibitor-based immunosuppressive regimen. METHODS: The Cochrane Controlled Trials Registry, MEDLINE, and EMBASE were searched for randomized controlled trials of fish oil treatment in kidney transplant recipients on a calcineurin inhibitor-based immunosuppressive regimen. Trials comparing fish oil to both placebo and statins were included. Data were extracted for patient and graft survival, acute rejection, calcineurin inhibitor toxicity, cardiovascular events, adverse effects, compliance, renal function, blood pressure, and lipid profile. Dichotomous outcomes were reported as relative risk and continuous outcome measures as weighted mean differences (WMD), with 95% confidence intervals. RESULTS: Sixteen suitable trials were analyzed. Fish oil treatment was associated with a lower diastolic blood pressure (WMD 4.5 mmHg, P=0.004) and higher high-density lipoprotein (HDL) cholesterol (WMD 0.12 mmol/L, P=0.01) but did not affect the other outcomes. Fishy aftertaste and gastrointestinal upset were common but did not result in significant dropout. Fish oil effects on lipids were not significantly different than low-dose statins. CONCLUSION: There is insufficient evidence from currently available randomized controlled trials to recommend fish oil therapy to improve renal function, rejection rates, and patient or graft survival. Improvements in HDL cholesterol and diastolic blood pressure were too modest to recommend routine use.     

Comparison of survival outcomes between Expanded Criteria Donor and Standard Criteria Donor kidney transplant recipients: a systematic review and meta‐analysis

In 2002, the United Network for Organ Sharing proposed increasing the pool of donor kidneys to include Expanded Criteria Donor (ECD). Outside the USA, the ECD definition remains the one used without questioning whether such a graft allocation criterion is valid worldwide. We performed a meta‐analysis to quantify the differences between ECD and Standard Criteria Donor (SCD) transplants. We paid particular attention to select studies in which the methodology was appropriate and we took into consideration the geographical area. Thirty‐two publications were included. Only five studies, all from the USA, reported confounder‐adjusted hazard ratios comparing the survival outcomes between ECD and SCD kidney transplant recipients. These five studies confirmed that ECD recipients seemed to have poorer prognosis. From 29 studies reporting appropriate survival curves, we estimated the 5‐year pooled nonadjusted survivals for ECD and SCD recipients. The relative differences between the two groups were lower in Europe than in North America, particularly for death‐censored graft failure. It is of primary importance to propose appropriate studies for external validation of the ECD criteria in non‐US kidney transplant recipients.     

Taking immunosuppressive medications effectively (TIMELink): a pilot randomized controlled trial in adult kidney transplant recipients

Russell C, Conn V, Ashbaugh C, Madsen R, Wakefield M, Webb A, Coffey D, Peace L. Taking immunosuppressive medications effectively (TIMELink): a pilot randomized controlled trial in adult kidney transplant recipients.
Clin Transplant 2011: 25: 864–870. © 2010 John Wiley & Sons A/S. Abstract: Background: Immunosuppressive medication non‐adherence is one of the most prevalent but preventable causes of poor outcomes in adult renal transplant recipients, yet there is a paucity of studies testing interventions in this area. Methods: Using a randomized controlled trial design, 30 adult renal transplant recipients were screened for medication non‐adherence using electronic monitoring. Fifteen non‐adherent participants were randomized to receive either a continuous self‐improvement intervention or attention control management. The six‐month continuous self‐improvement intervention involved the participant and clinical nurse specialist collaboratively identifying the person’s life routines, important people, and possible solutions to enhance medication taking. The participant then received individual monthly medication taking feedback delivered via a graphic printout of daily medication taking generated from electronic monitoring. Results: The mean medication adherence score for the continuous self‐improvement intervention group (n = 8) was statistically significantly higher than the attention control group’s (n = 5) mean medication adherence score (p = 0.03). The continuous self‐improvement intervention effect size (Cohen’s d) was large at 1.4. Participants’ perceptions of the intervention were highly favorable. Conclusions: The continuous self‐improvement intervention shows promise as an effective and feasible approach to improve medication adherence in adult renal transplant recipients. A fully‐powered study with a diverse sample is needed to confirm these preliminary findings.     

Lifetime risk of end‐stage kidney disease in living donors for paediatric kidney transplant recipients in Australia and New Zealand – a retrospective study

Living kidney donors (LKD) for paediatric kidney transplant recipients (KTR) have a heightened motivation to donate for emotional reasons and the clear health benefits to the KTR. We hypothesized that the cohort of LKD for paediatric KTR (LKD‐P) includes motivated young parents with a higher lifetime end‐stage kidney disease (ESKD) risk compared to adult KTR (LKD‐A). Data from the Australia and New Zealand Dialysis and Transplant LKD Registry (2004–2015) was analysed to compare baseline characteristics and predonation ESKD risk in LKD‐P (n = 315) versus LKD‐A (n = 3448). LKD‐P were younger (median age 42 vs. 50 years; P < 0.001) and had a marginally higher lifetime ESKD risk (median 0.44% vs. 0.40%; P < 0.01), with a similar proportion of LKD exceeding 1% risk threshold (5.4% vs. 5.6%; P = NS). Compared to grandparents as LKD‐P, parents (median age 41 vs. 59 years; P < 0.001) had a higher lifetime ESKD (0.44% vs. 0.25%; P < 0.001). Although unique benefits to paediatric KTR justify the minor increase in lifetime ESKD risk in young parents, carefully selected grandparents are an alternative LKD‐P option, allowing parents to donate for subsequent transplants.     

A randomized,controlled trial of everolimus‐based dual immunosuppression versus standard of care in de novo kidney transplant recipients

Kidney transplant recipients receiving calcineurin inhibitor‐based immunosuppression incur increased long‐term risks of cancer and kidney fibrosis. Switch to mammalian target of rapamycin (mTOR) inhibitors may reduce these risks. Steroid or Cyclosporin Removal After Transplant using Everolimus (SOCRATES), a 36‐month, prospective, multinational, open‐label, randomized controlled trial for de novo kidney transplant recipients, assessed whether everolimus switch could enable elimination of mycophenolate plus either steroids or CNI without compromising efficacy. Patients received cyclosporin, mycophenolate and steroids for the first 14 days then everolimus with mycophenolate and CNIwithdrawal (CNI‐WD); everolimus with mycophenolate and steroid withdrawal (steroid‐WD); or cyclosporin, mycophenolate and steroids (control). 126 patients were randomized. The steroid WD arm was terminated prematurely because of excess discontinuations. Mean eGFR at month 12 for CNI‐WD versus control was 65.1 ml/min/1.73 m² vs. 67.1 ml/min/1.73 m² by ITT, which met predefined noninferiority criteria (P = 0.026). The CNI‐WD group experienced a higher rate of BPAR(31% vs. control 13%, P = 0.048) and showed a trend towards higher composite treatment failure (BPAR, graft loss, death, loss to follow‐up). The 12 month results from SOCRATES show noninferiority in eGFR, but a significant excess of acute rejection when everolimus was commenced at week 2 to enable a progressive withdrawal of mycophenolate and cyclosporin in kidney transplant recipients.     

Peritransplant eculizumab does not prevent delayed graft function in deceased donor kidney transplant recipients: Results of two randomized controlled pilot trials

Animal models and observational human data indicate that complement, including C5a, pathogenically participates in ischemia reperfusion (IR) injury that manifests as delayed graft function (DGF) following deceased donor kidney transplantation. We report on the safety/efficacy of anti‐C5 monoclonal antibody eculizumab (Ecu) administered in the operating room prior to reperfusion, to prevent DGF in recipients of deceased donor kidney transplants in two related, investigator‐sponsored, randomized controlled trials. Eight recipients from a single center were enrolled in a pilot study that led to a 19‐subject multicenter trial. Together, 27 deceased donor kidney transplant recipients, 16 Ecu‐treated and 11 controls, were treated with rabbit antithymocyte globulin, tacrolimus, mycophenolate mofetil with or without glucocorticoids, and followed for 6 months. Data analysis showed no epidemiological or transplant‐related differences between study arms. Ecu was well tolerated with a similar severe adverse event incidence between groups. The DGF rate did not differ between Ecu‐treated (44%) and control (45%, P = 1.0) subjects. Serum creatinine reduction in the first week after transplantation, and graft function up to 180‐days post‐transplant, were also similar. Ecu administration was safe but did not reduce the rate of DGF in a high‐risk population of deceased donor recipients.     

Psychosocial impact of pediatric living‐donor kidney and liver transplantation on recipients,donors, and the family: a systematic review

Living‐donor kidney and liver transplantation intend to improve pediatric recipients’ psychosocial well‐being, but psychosocial impact in recipients strongly depends upon the impact on the donor and the quality of family relations. We systematically reviewed quantitative and qualitative studies addressing the psychosocial impact of pediatric living‐donor kidney and liver transplantation in recipients, donors, and the family. In accordance with the PRISMA guidelines, we systematically searched the databases Medline, Web of Knowledge, Cinahl, Embase, ERIC, and Google Scholar. We identified 23 studies that satisfied our inclusion criteria. Recipients had improved coping skills and satisfactory peer relationships, but also reported anxiety and depressive symptoms, worried about the future, and had a negative body image. Similarly, donors experienced increased self‐esteem, empowerment, and community awareness, but also complained of postoperative pain and a lack of emotional support. With respect to family impact, transplantation generated a special bond between the donor and the recipient, characterized by gratitude and admiration, but also raised new expectations concerning the recipient's lifestyle. As psychological problems in recipients were sometimes induced by feelings of guilt and indebtedness toward the donor, we recommend more research on how gift exchange dynamics function within donor–recipient relationships, enrolling donors and recipients within the same study.