- Email: [email protected]
The Attitude of Older People Toward Living Donation
The Attitude of Older People Toward Living Donation B. Febreroa,b, I. Rosb, J. Almela-Baezac,*, M.B. Pérez-Sánchezd, J.M. Rodrígueza,b, F. Alconchela, J.J. Ruiz-Manzaneraa, L.A. Martínez-Insfranb, J. Domingoa, L. Martínez-Alarcóna,b, A. Ríosa,b, P. Parrillaa,b, and P. Ramíreza,b a
Transplant Unit, General Surgery, Virgen de la Arrixaca University Hospital, Mucian Institute of Biomedical Investigations, Murcia, Spain; bDepartment of Surgery, Pediatrics, Gynecology and Obstetrics, University of Murcia School of Medicine, Murcia, Spain; c Faculty of Communication and Documentation, University of Murcia, Murcia, Spain; and dDepartment of Statistics, Mathematics and Informatics, University of Miguel Hernández, Elche, Spain
ABSTRACT Background. Living donation is a potential source of organs that could help to reduce the organ transplant deficit. Given that we have a worldwide aging population, it is important to assess the opinion of older people toward this type of donation. Objectives. To analyze the attitude of people aged > 65 years toward living kidney donation (LKD) and living liver donation (LLD) and to investigate the variables affecting their attitudes. Methods. A multicentric study was carried out using a representative sample of people > 65 years stratified by sex and geographic location in southeastern Spain (n ¼ 420). The measurement instrument was a validated questionnaire about LKD and LLD. Statistics were analyzed using SPSS version 21.0 (IBM Corp, Armonk, NY, United States) software. Descriptive analysis was carried out using Student t test, c2 test, and a multivariate analysis. Results. The questionnaire completion rate was 84% (n ¼ 351) with 88% (n ¼ 310) in favor of LKD, and 89% (n ¼ 311) in favor of LLD. Favorable attitude decreased to 3% when the donation under consideration was unrelated. Attitudes toward LKD and LLD were associated with having received information from the television (P ¼ .016 and P ¼ .045) and from friends (P ¼ .017 and P ¼ .03); accepting an autopsy after death (P ¼ .001 and P ¼ .002); and not being worried about scars (P ¼ .015 and P ¼ .044). In the multivariate analysis, the following variables continued to be significant: having received information from the television (odds ratio [OR], 2) and from friends (OR, 10.3); and the acceptance of an autopsy (OR, 2). Conclusions. Older people are in favor of both LKD and LLD, assuming it is a related donation. In addition, the information the elderly population receives regarding organ donation and transplantation affects their attitudes.
L
IVING donation still provides an important source of organs that should be taken into account when dealing with the current deficit in transplant organs, although in 2018, the number of transplants resulting from this type of donation only reached 6% of cases in Spain [1]. A recent study in the United States analyzed the factors that could be causing a decline in living donation, revealing how belonging to some subgroups of the population and socioeconomic level could be factors to take into account, among
ª 2020 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, XX, 1e3 (2020)
others [2]. In this sense, it is important to detect those groups of the population that are less aware of this type of organ donation in order to create targeted educational intervention strategies, which are one of the most important
*Address correspondence to Javier Almela-Baeza, Calle Campus Universitario, 8, 30100 Murcia, Spain. Tel: þ34691507629. E-mail: [email protected] 0041-1345/20 https://doi.org/10.1016/j.transproceed.2019.09.022
1
2
points to consider as measures for improving living donation rates [3,4]. The studies undertaken until now investigating the attitudes of the general public [5] and different subgroups of the population in our region (eg, teenagers [6] and immigrants [7e10]) have shown that there is a generally favorable attitude toward living donation. We are currently witnessing a worldwide aging of the population, and this is leading to a greater proportion of recipients and older donors. In the last year alone, 58% of donors in our region were older than 60 years, and 37% were older than 70 years [1]. In this regard, it is important to find out the opinion of older people toward this type of donation, taking into account that previous studies have shown that older donors might have a better general predisposition toward organ donation and transplantation (ODT) [5,11]. The objective of our study was to analyze the attitude of people > 65 years of age toward living kidney donation (LKD) and living liver donation (LLD) and the psychosocial variables affecting this attitude.
FEBRERO, ROS, ALMELA-BAEZA ET AL Table 1. A Multivariate Analysis of the Variables Affecting Attitude Toward LKD and LLD
LKD Variables
Receiving information about ODT from the television Receiving information about ODT from friends Acceptance of an autopsy Receiving information about ODT from friends Acceptance of an autopsy
Regression Coefficient (b)
SE
OR (95% CI)
P Value*
0.767
0.384 2.154 (1.016-4.567)
.045
2.341
1.084 10.389 (1.240-87.026) .031
0.819
0.364 2.268 (1.111-4.629)
2.392
1.079 10.939 (1.320-90.633) .027
1.515
0.358 2.443 (1.212-4.925)
.025
.013
Abbreviations: CI, confidence interval; LKD, living kidney donation; ODT, organ donation and transplantation; OR, odds ratio. *P < .05 indicates statistical significance.
METHODS An observational sociologic study was conducted. A multicentric study was carried out using a representative sample of people aged > 65 years stratified by sex and geographic location in southeastern Spain (n ¼ 420). The attitude was assessed using a validated questionnaire of attitude toward ODT. The questionnaire was designed by the International Collaborative Organ Donation project about LKD and LLD [12,13]. The questionnaire included items distributed into 3 subscales or factors, and they were validated in the Spanish population, having a total explained variance of 63.995% and a Cronbach a reliability coefficient of 0.778. The questionnaire was completed anonymously and self-administered.
Statistical Analysis The data were stored on a database and analyzed using a statistical package. Descriptive statistical analysis was carried out for the bivariate analysis. Student t test and the c2 test were complemented by an analysis of remainders. Fisher exact test was applied when the contingency tables had cells with an expected frequency of < 5. A multivariate analysis was applied to the variables that were significant in the bivariate analysis (P < .05).
RESULTS
The questionnaire completion rate was 84% (n ¼ 351). Eighty-five percent (n ¼ 300) of those aged > 65 years were in favor of related LKD: 3% (n ¼ 10) would donate a kidney to anyone; 8% (n ¼ 28) would not donate a living kidney; and 4% (n ¼ 13) were unsure. A favorable attitude toward LKD was related to a favorable attitude toward (1) the donation of a family member’s organs after death (92% vs 85%; P ¼ .031); (2) having received information about ODT from the television (94% vs 78%; P ¼ .016) and from friends (96% vs 86%; P ¼ .017); (3) having accepted an autopsy after death (93% vs 82%; P ¼ .001); and (4) not being worried about scars, compared to being worried about or having doubts about them (90% vs 77% vs 67%; P ¼ .015).
With regard to LLD, 86% (n ¼ 302) of the people > 65 years old would be in favor, although only if the donation was to a family member. A further 3% (n ¼ 9) would donate part of their liver while alive to anyone, 7% (n ¼ 24) would not donate it, and 4% (n ¼ 16) had doubts about donation. Having a favorable attitude toward LLD was related to having a favorable attitude toward the donation of a family member’s organs after death (92% vs 85%; P ¼ .045) and to the following factors: (1) having received information about ODT from the television (91% vs 80%; P ¼ .045) and from friends (96% vs 87%; P ¼ .03); (2) having accepted an autopsy after death (93% vs 83%; P ¼ .002); and (3) not being worried about scars (90% vs 81% vs 67%; P ¼ .044). The following 3 variables persisted as significant in the multivariate analysis affecting attitude toward LKD: receiving information about ODT from the television (odds ratio [OR], 2.154) and from friends (OR, 10.389) and acceptance of an autopsy (OR, 2.268) (Table 1). Two variables remained significant in the multivariate analysis related to attitude toward LLD: receiving information about ODT from friends (OR, 10.939) and acceptance of an autopsy (OR, 2.443) (Table 1).
DISCUSSION
Living donation is a type of donation that is generally well accepted in our region in the general population [5] and in subgroups of the population (ie, teenagers [6], teachers [14], immigrants from different countries [7e10]). However, current data show that the percentage of living donation is still low [1]. Taking into account that more than half of donors are older than 60 years of age [1], it is important to find out the
OLDER PEOPLE AND LIVING DONATION
opinion of older people toward this kind of donation. In this study, it was noted that 88% to 89% of those aged > 65 years were willing to donate a kidney or part of a liver while alive to a family member, although only 3% would be prepared to donate to anyone (family or otherwise). The level of favorable attitude toward related living donation for a family member in other population groups is similar to that reported in other population studies [5e10,14]. Nevertheless, these studies have revealed that there was a favorable attitude toward unrelated donation of around 20% to 30%. These data reflect how the main concern of the older population could be emotional affiliation or social expectations, reasons described as being a priority in living donation [15]. In previous studies, it has been noted that social and family interaction regarding the subject of ODT could have an effect on this group [11], and these are variables that have also had an influence on living donation in other population groups [6e10,14]. In addition, other psychosocial variables that have classically affected attitude toward living donation in other studies did not have an influence on older people in this study. These variables include: sex [5e7,14], marital status [5,7,8], and religion [7,9,10] and variables related to knowledge of some aspects of ODT, such as previous experience of ODT [5,6,9,10] and a belief that one might need a transplant in the future [7,8] (as well as taking part in prosocial activities) [6,9]. There are, however, 2 factors that do appear to be related to a better predisposition toward this kind of donation according to the results of the present study: the acceptance of an autopsy and not being afraid of scars. This is a finding that has also been found in studies carried out on teenagers and some European immigrants [8,9]. In the present study, the fact of having received information about ODT is also related to a greater willingness to become a living donor. This point is important for creating educational intervention strategies in this group of the population, given that providing adequate information about the benefits of living donation, could help to maintain or even improve related and unrelated living donation. CONCLUSIONS
Older people are in favor of living donation, both of the kidneys and the liver, when it is a related kind of donation with a family member, and their attitudes are affected by information they receive about ODT. Therefore, it would be interesting to create educational strategies in this population group in an effort to provide adequate information about living donation.
3
REFERENCES [1] National Transplant Organization. Memorias e todos los documentos [Memories e all of the documents. http://www.ont.es/ infesp/Memorias/Forms/AllItems.aspx; 2019. [Accessed 24.03.19] [in Spanish]. [2] Reed RD, Sawinski D, Shelton BA, MacLennan PA, Hanaway M, Kumar V, et al. Population health, ethnicity, and rate of living donor kidney transplantation. Transplantation 2018;102: 2080e7. [3] Barnieh L, Collister D, Manns B, Lam NN, Shojai S, Lorenzetti D, et al. A scoping review for strategies to increase living kidney donation. Clin J Am Soc Nephrol 2017;12:1518e27. [4] Davis CL. How to increase living donation. Transpl Int 2011;24:344e9. [5] Conesa C, Ríos Zambudio A, Ramírez P, del Mar Rodríguez M, Rivas P, Parrilla P. Socio-personal factors influencing public attitude towards living donation in south-eastern Spain. Nephrol Dial Transplant 2004;19:2874e82. [6] Ríos A, Febrero B, López-Navas A, Martínez-Alarcón L, Sánchez J, Guzmán D, et al. Evaluation of attitude toward living organ donation among adolescents in Southeast Spain. Transplant Proc 2012;44:1489e92. [7] Ríos A, López-Navas A, Martínez-Alarcón L, Ramírez P, Parrilla P. Latin Americans in Spain and their attitude toward living kidney donation. Clin Transplant 2015;29:1054e62. [8] Ríos A, Martínez-Alarcón L, Sánchez J, Jarvis N, Guzmán D, Parrilla P, et al. Factors that influence the attitude of East European residents in Spain towards living kidney donation. Transpl Int 2009;22:707e16. [9] Ríos A, Martínez-Alarcón L, Sánchez J, Jarvis N, Garcia JA, Rodríguez JM, et al. The quest for favourable subgroups to encourage living kidney donation in Spain. an attitudinal study among British and Irish citizens resident in southeastern Spain. Nephrol Dial Transplant 2008;23:1720e7. [10] Ríos A, Martínez-Alarcón L, López-Navas A, Febrero B, Sánchez J, Ramis G, et al. Attitudes of Scottish residents in the southeast of Spain concerning living donation. Transplant Proc 2013;45:3575e8. [11] Febrero B, Almela-Baeza J, Febrero R, Ríos A, González MR, Gil PJ, et al. Importance for the elderly of discussion in the family and society about attitude toward organ donation. Transplant Proc 2018;50:523e5. [12] Ríos A, López-Navas AI, De-Francisco C, Sánchez Á, Hernández AM, Ramírez P, et al. Living kidney donation questionnaire (PCID-DVR-Ríos): validation and psychometric characteristics in a Spanish-speaking population. Transplant Proc 2018;50: 370e3. [13] Ríos A, López-Navas AI, De-Francisco C, Sánchez Á, Hernández AM, Ramírez P, et al. Validation of the attitude toward living liver donation questionnaire (PCID-DVH-Ríos) in Spanishspeaking populations: characteristics and psychometric properties. Transplant Proc 2018;50:2287e90. [14] Ríos A, Febrero B, Martínez-Alarcón L, López-Navas A, Sánchez J, Guzman D, et al. Evaluation of attitudes toward living organ donation: a multicenter study of compulsory secondary school education teachers. Transplant Proc 2010;42: 3106e8. [15] Papachristou C, Walter M, Dietrich K, Danzer G, Klupp J, Klapp BF, et al. Motivation for living-donor liver transplantation from the donor’s perspective: an in-depth qualitative research study. Transplantation 2004;78:1506e14.
Transplant Unit, General Surgery, Virgen de la Arrixaca University Hospital, Mucian Institute of Biomedical Investigations, Murcia, Spain; bDepartment of Surgery, Pediatrics, Gynecology and Obstetrics, University of Murcia School of Medicine, Murcia, Spain; c Faculty of Communication and Documentation, University of Murcia, Murcia, Spain; and dDepartment of Statistics, Mathematics and Informatics, University of Miguel Hernández, Elche, Spain
ABSTRACT Background. Living donation is a potential source of organs that could help to reduce the organ transplant deficit. Given that we have a worldwide aging population, it is important to assess the opinion of older people toward this type of donation. Objectives. To analyze the attitude of people aged > 65 years toward living kidney donation (LKD) and living liver donation (LLD) and to investigate the variables affecting their attitudes. Methods. A multicentric study was carried out using a representative sample of people > 65 years stratified by sex and geographic location in southeastern Spain (n ¼ 420). The measurement instrument was a validated questionnaire about LKD and LLD. Statistics were analyzed using SPSS version 21.0 (IBM Corp, Armonk, NY, United States) software. Descriptive analysis was carried out using Student t test, c2 test, and a multivariate analysis. Results. The questionnaire completion rate was 84% (n ¼ 351) with 88% (n ¼ 310) in favor of LKD, and 89% (n ¼ 311) in favor of LLD. Favorable attitude decreased to 3% when the donation under consideration was unrelated. Attitudes toward LKD and LLD were associated with having received information from the television (P ¼ .016 and P ¼ .045) and from friends (P ¼ .017 and P ¼ .03); accepting an autopsy after death (P ¼ .001 and P ¼ .002); and not being worried about scars (P ¼ .015 and P ¼ .044). In the multivariate analysis, the following variables continued to be significant: having received information from the television (odds ratio [OR], 2) and from friends (OR, 10.3); and the acceptance of an autopsy (OR, 2). Conclusions. Older people are in favor of both LKD and LLD, assuming it is a related donation. In addition, the information the elderly population receives regarding organ donation and transplantation affects their attitudes.
L
IVING donation still provides an important source of organs that should be taken into account when dealing with the current deficit in transplant organs, although in 2018, the number of transplants resulting from this type of donation only reached 6% of cases in Spain [1]. A recent study in the United States analyzed the factors that could be causing a decline in living donation, revealing how belonging to some subgroups of the population and socioeconomic level could be factors to take into account, among
ª 2020 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, XX, 1e3 (2020)
others [2]. In this sense, it is important to detect those groups of the population that are less aware of this type of organ donation in order to create targeted educational intervention strategies, which are one of the most important
*Address correspondence to Javier Almela-Baeza, Calle Campus Universitario, 8, 30100 Murcia, Spain. Tel: þ34691507629. E-mail: [email protected] 0041-1345/20 https://doi.org/10.1016/j.transproceed.2019.09.022
1
2
points to consider as measures for improving living donation rates [3,4]. The studies undertaken until now investigating the attitudes of the general public [5] and different subgroups of the population in our region (eg, teenagers [6] and immigrants [7e10]) have shown that there is a generally favorable attitude toward living donation. We are currently witnessing a worldwide aging of the population, and this is leading to a greater proportion of recipients and older donors. In the last year alone, 58% of donors in our region were older than 60 years, and 37% were older than 70 years [1]. In this regard, it is important to find out the opinion of older people toward this type of donation, taking into account that previous studies have shown that older donors might have a better general predisposition toward organ donation and transplantation (ODT) [5,11]. The objective of our study was to analyze the attitude of people > 65 years of age toward living kidney donation (LKD) and living liver donation (LLD) and the psychosocial variables affecting this attitude.
FEBRERO, ROS, ALMELA-BAEZA ET AL Table 1. A Multivariate Analysis of the Variables Affecting Attitude Toward LKD and LLD
LKD Variables
Receiving information about ODT from the television Receiving information about ODT from friends Acceptance of an autopsy Receiving information about ODT from friends Acceptance of an autopsy
Regression Coefficient (b)
SE
OR (95% CI)
P Value*
0.767
0.384 2.154 (1.016-4.567)
.045
2.341
1.084 10.389 (1.240-87.026) .031
0.819
0.364 2.268 (1.111-4.629)
2.392
1.079 10.939 (1.320-90.633) .027
1.515
0.358 2.443 (1.212-4.925)
.025
.013
Abbreviations: CI, confidence interval; LKD, living kidney donation; ODT, organ donation and transplantation; OR, odds ratio. *P < .05 indicates statistical significance.
METHODS An observational sociologic study was conducted. A multicentric study was carried out using a representative sample of people aged > 65 years stratified by sex and geographic location in southeastern Spain (n ¼ 420). The attitude was assessed using a validated questionnaire of attitude toward ODT. The questionnaire was designed by the International Collaborative Organ Donation project about LKD and LLD [12,13]. The questionnaire included items distributed into 3 subscales or factors, and they were validated in the Spanish population, having a total explained variance of 63.995% and a Cronbach a reliability coefficient of 0.778. The questionnaire was completed anonymously and self-administered.
Statistical Analysis The data were stored on a database and analyzed using a statistical package. Descriptive statistical analysis was carried out for the bivariate analysis. Student t test and the c2 test were complemented by an analysis of remainders. Fisher exact test was applied when the contingency tables had cells with an expected frequency of < 5. A multivariate analysis was applied to the variables that were significant in the bivariate analysis (P < .05).
RESULTS
The questionnaire completion rate was 84% (n ¼ 351). Eighty-five percent (n ¼ 300) of those aged > 65 years were in favor of related LKD: 3% (n ¼ 10) would donate a kidney to anyone; 8% (n ¼ 28) would not donate a living kidney; and 4% (n ¼ 13) were unsure. A favorable attitude toward LKD was related to a favorable attitude toward (1) the donation of a family member’s organs after death (92% vs 85%; P ¼ .031); (2) having received information about ODT from the television (94% vs 78%; P ¼ .016) and from friends (96% vs 86%; P ¼ .017); (3) having accepted an autopsy after death (93% vs 82%; P ¼ .001); and (4) not being worried about scars, compared to being worried about or having doubts about them (90% vs 77% vs 67%; P ¼ .015).
With regard to LLD, 86% (n ¼ 302) of the people > 65 years old would be in favor, although only if the donation was to a family member. A further 3% (n ¼ 9) would donate part of their liver while alive to anyone, 7% (n ¼ 24) would not donate it, and 4% (n ¼ 16) had doubts about donation. Having a favorable attitude toward LLD was related to having a favorable attitude toward the donation of a family member’s organs after death (92% vs 85%; P ¼ .045) and to the following factors: (1) having received information about ODT from the television (91% vs 80%; P ¼ .045) and from friends (96% vs 87%; P ¼ .03); (2) having accepted an autopsy after death (93% vs 83%; P ¼ .002); and (3) not being worried about scars (90% vs 81% vs 67%; P ¼ .044). The following 3 variables persisted as significant in the multivariate analysis affecting attitude toward LKD: receiving information about ODT from the television (odds ratio [OR], 2.154) and from friends (OR, 10.389) and acceptance of an autopsy (OR, 2.268) (Table 1). Two variables remained significant in the multivariate analysis related to attitude toward LLD: receiving information about ODT from friends (OR, 10.939) and acceptance of an autopsy (OR, 2.443) (Table 1).
DISCUSSION
Living donation is a type of donation that is generally well accepted in our region in the general population [5] and in subgroups of the population (ie, teenagers [6], teachers [14], immigrants from different countries [7e10]). However, current data show that the percentage of living donation is still low [1]. Taking into account that more than half of donors are older than 60 years of age [1], it is important to find out the
OLDER PEOPLE AND LIVING DONATION
opinion of older people toward this kind of donation. In this study, it was noted that 88% to 89% of those aged > 65 years were willing to donate a kidney or part of a liver while alive to a family member, although only 3% would be prepared to donate to anyone (family or otherwise). The level of favorable attitude toward related living donation for a family member in other population groups is similar to that reported in other population studies [5e10,14]. Nevertheless, these studies have revealed that there was a favorable attitude toward unrelated donation of around 20% to 30%. These data reflect how the main concern of the older population could be emotional affiliation or social expectations, reasons described as being a priority in living donation [15]. In previous studies, it has been noted that social and family interaction regarding the subject of ODT could have an effect on this group [11], and these are variables that have also had an influence on living donation in other population groups [6e10,14]. In addition, other psychosocial variables that have classically affected attitude toward living donation in other studies did not have an influence on older people in this study. These variables include: sex [5e7,14], marital status [5,7,8], and religion [7,9,10] and variables related to knowledge of some aspects of ODT, such as previous experience of ODT [5,6,9,10] and a belief that one might need a transplant in the future [7,8] (as well as taking part in prosocial activities) [6,9]. There are, however, 2 factors that do appear to be related to a better predisposition toward this kind of donation according to the results of the present study: the acceptance of an autopsy and not being afraid of scars. This is a finding that has also been found in studies carried out on teenagers and some European immigrants [8,9]. In the present study, the fact of having received information about ODT is also related to a greater willingness to become a living donor. This point is important for creating educational intervention strategies in this group of the population, given that providing adequate information about the benefits of living donation, could help to maintain or even improve related and unrelated living donation. CONCLUSIONS
Older people are in favor of living donation, both of the kidneys and the liver, when it is a related kind of donation with a family member, and their attitudes are affected by information they receive about ODT. Therefore, it would be interesting to create educational strategies in this population group in an effort to provide adequate information about living donation.
3
REFERENCES [1] National Transplant Organization. Memorias e todos los documentos [Memories e all of the documents. http://www.ont.es/ infesp/Memorias/Forms/AllItems.aspx; 2019. [Accessed 24.03.19] [in Spanish]. [2] Reed RD, Sawinski D, Shelton BA, MacLennan PA, Hanaway M, Kumar V, et al. Population health, ethnicity, and rate of living donor kidney transplantation. Transplantation 2018;102: 2080e7. [3] Barnieh L, Collister D, Manns B, Lam NN, Shojai S, Lorenzetti D, et al. A scoping review for strategies to increase living kidney donation. Clin J Am Soc Nephrol 2017;12:1518e27. [4] Davis CL. How to increase living donation. Transpl Int 2011;24:344e9. [5] Conesa C, Ríos Zambudio A, Ramírez P, del Mar Rodríguez M, Rivas P, Parrilla P. Socio-personal factors influencing public attitude towards living donation in south-eastern Spain. Nephrol Dial Transplant 2004;19:2874e82. [6] Ríos A, Febrero B, López-Navas A, Martínez-Alarcón L, Sánchez J, Guzmán D, et al. Evaluation of attitude toward living organ donation among adolescents in Southeast Spain. Transplant Proc 2012;44:1489e92. [7] Ríos A, López-Navas A, Martínez-Alarcón L, Ramírez P, Parrilla P. Latin Americans in Spain and their attitude toward living kidney donation. Clin Transplant 2015;29:1054e62. [8] Ríos A, Martínez-Alarcón L, Sánchez J, Jarvis N, Guzmán D, Parrilla P, et al. Factors that influence the attitude of East European residents in Spain towards living kidney donation. Transpl Int 2009;22:707e16. [9] Ríos A, Martínez-Alarcón L, Sánchez J, Jarvis N, Garcia JA, Rodríguez JM, et al. The quest for favourable subgroups to encourage living kidney donation in Spain. an attitudinal study among British and Irish citizens resident in southeastern Spain. Nephrol Dial Transplant 2008;23:1720e7. [10] Ríos A, Martínez-Alarcón L, López-Navas A, Febrero B, Sánchez J, Ramis G, et al. Attitudes of Scottish residents in the southeast of Spain concerning living donation. Transplant Proc 2013;45:3575e8. [11] Febrero B, Almela-Baeza J, Febrero R, Ríos A, González MR, Gil PJ, et al. Importance for the elderly of discussion in the family and society about attitude toward organ donation. Transplant Proc 2018;50:523e5. [12] Ríos A, López-Navas AI, De-Francisco C, Sánchez Á, Hernández AM, Ramírez P, et al. Living kidney donation questionnaire (PCID-DVR-Ríos): validation and psychometric characteristics in a Spanish-speaking population. Transplant Proc 2018;50: 370e3. [13] Ríos A, López-Navas AI, De-Francisco C, Sánchez Á, Hernández AM, Ramírez P, et al. Validation of the attitude toward living liver donation questionnaire (PCID-DVH-Ríos) in Spanishspeaking populations: characteristics and psychometric properties. Transplant Proc 2018;50:2287e90. [14] Ríos A, Febrero B, Martínez-Alarcón L, López-Navas A, Sánchez J, Guzman D, et al. Evaluation of attitudes toward living organ donation: a multicenter study of compulsory secondary school education teachers. Transplant Proc 2010;42: 3106e8. [15] Papachristou C, Walter M, Dietrich K, Danzer G, Klupp J, Klapp BF, et al. Motivation for living-donor liver transplantation from the donor’s perspective: an in-depth qualitative research study. Transplantation 2004;78:1506e14.