- Email: [email protected]
Veterinary Students' Attitude Toward Living Kidney Donation: A Multicenter Stratified Study From Spain
Accepted Manuscript Attitude Toward Living Kidney Donation: Are Veterinary Students In Favor? A Multicenter Stratified Study from Spain Laura Martínez-Alarcón, Antonio Ríos, Guillermo Ramis, Jaime Gómez-Laguna, Xavier Moll, Victoria Falceto, Fidel San Román-Acaso, Fidel San Román-Llorens, Juan José Quereda, Juan Manuel Herrero Medrano, Livia Mendonça, José Luis Martin-Barrasa, Olga María Fernández, Antonio Muñoz, Pablo Ramírez, Pascual Parrilla PII:
S0041-1345(18)30438-X
DOI:
10.1016/j.transproceed.2018.02.177
Reference:
TPS 28419
To appear in:
Transplantation Proceedings
Received Date: 15 January 2018 Accepted Date: 26 February 2018
Please cite this article as: Martínez-Alarcón L, Ríos A, Ramis G, Gómez-Laguna J, Moll X, Falceto V, San Román-Acaso F, San Román-Llorens F, Quereda JJ, Herrero Medrano JM, Mendonça L, Martin-Barrasa JL, Fernández OM, Muñoz A, Ramírez P, Parrilla P, Attitude Toward Living Kidney Donation: Are Veterinary Students In Favor? A Multicenter Stratified Study from Spain, Transplantation Proceedings (2018), doi: 10.1016/j.transproceed.2018.02.177. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
ATTITUDE TOWARD LIVING KIDNEY DONATION: ARE VETERINARY STUDENTS IN FAVOR? A MULTICENTER STRATIFIED STUDY FROM SPAIN
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Laura Martínez-Alarcón1-3, Antonio Ríos1-3, Guillermo Ramis2-4, Jaime Gómez-Laguna5, Xavier Moll6, Victoria Falceto7, Fidel San Román-Acaso8, Fidel San Román-Llorens8, Juan José Quereda9, Juan Manuel Herrero Medrano4, Livia Mendonça10, José Luis Martin-Barrasa11-12, Olga María Fernández2,13, Antonio Muñoz4, Pablo Ramírez1-3, Pascual Parrilla1-3.
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1.-"International Collaborative Donor Project", Murcia-España. 2.-Instituto Murciano de Investigación Biosanitaria (IMIB), Murcia-España. 3.-Servicio de Cirugía, Unidad de Trasplantes, Hospital Clínico Universitario Virgen de la Arrixaca. Murcia-España 4.-Departamento de Producción Animal. Facultad de Veterinaria. Universidad de MurciaEspaña. 5.-Departament of Anatomy and Comparative Pathology. University of Córdoba. Spain. 6.-Departamento de Medicina y Cirugía Animal. Facultad Veterinaria. Universitat Autonoma Barcelona (UAB) España. 7.-Universidad Zaragoza, España. 8.-Universidad Complutense de Madrid, España. 9.-Grupo Fisiopatología de la Reproducción. Departamento Producción y Sanidad Animal, Salud Pública Veterinaria y Ciencia y Tecnología de los Alimentos. Facultad de Veterinaria. Universidad Cardenal Herrera-CEU, CEU Universities Valencia. Spain. 10.-Escola de Veterinária e Zootecnia. Universidade Federal de Goiás, Goiania, Brazil. 11.-Experimental Animal Facility, Research Unit, Hospital Universitario de Gran Canaria, Dr. Negrín, Las Palmas de Gran Canaria, Spain. 12.-Animal Infectious Diseases and Ictiopatology, University Institute of Animal Health (IUSA), University of Las Palmas de Gran Canaria, Arucas, Spain. 13.- Animalario libre de Patógenos Arrixaca- IMIB. Murcia-España.
Email addresses of authors: Martínez-Alarcón: [email protected], Ríos: [email protected], Ramis: [email protected], Gomez-Laguna: [email protected], Moll: [email protected],
Falceto: [email protected], San-Román-Acaso:
[email protected], San Román-Llorens: [email protected], Quereda: [email protected], Herrero-
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Medrano: [email protected], Mendonça: [email protected], Martín-Barrasa: [email protected], Fernández: [email protected], Muñoz: [email protected], Ramírez: [email protected], Parrilla: [email protected]
Corresponding author: Dr. Antonio Ríos Zambudio, Avenida de la Libertad nº 208. 30007. Casillas.
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Murcia. ESPAÑA. E-mail: [email protected] Telephone: +34968.27.07.57 Fax: +34968.36.94.38
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Grant information: No grant support. "J. Gómez-Laguna is supported by a “Ramón y Cajal” contract of the Spanish Ministry of Economy and Competitiveness". Key words: Living kidney related donation; veterinary student; organ donation; attitude. Abbreviations: LKRD: living kidney related donations; ODT: organ donation and transplantation; DS/DK: Does not say/does not know. Tables: __1____ Figures: __0___ (color – Yes / No)
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ABSTRACT TITLE: ATTITUDE TOWARD LIVING KIDNEY DONATION: ARE VETERINARY STUDENTS IN FAVOR? A MULTICENTER STRATIFIED STUDY FROM SPAIN
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OBJECTIVES: Due to the current deficit of organs for transplantation, living kidney related donations (LKRD) should be promoted. The objective was to analyze the attitude of Spanish veterinary students toward LKRD because they may influence public opinion in the future, and to determine the factors that condition it.
METHODS: A sociological, interdisciplinary, multicenter and observational study was carried out in the Veterinary
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students enrolled in Spain (n=9000) in the university academic year 2010-2011. A sample of 2815 students was stratified by geographical area and academic year. Instrument used: The students' attitude toward LKRD was
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assessed using a psychosocial validated questionnaire (PCID-DVR RIOS) was self-administered and completed anonymously. Data collection procedure: Randomly selected veterinary schools. The questionnaire was applied to each academic year at compulsory sessions. Statistical analysis: Student´s t test, χ2 test and logistic regression analysis.
RESULTS: The completion rate was 95% (n=2683). 93% (n=2504) were in favor of related LKRD, and 36% (n=945)
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supported unrelated living kidney donation. The following variables were associated with having a more favorable attitude: 1) sex (p<0.001); 2) students of Southern universities had a more favorable attitude (p=0.029); 3) attitude toward deceased donation (p<0.001); 4) a father’s (p<0.001) or a mother’s (p<0.001) in favor to organ donation and
from a relative.
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5) having discussed the subject with friends (p=0.027) or family (p=0.016). However, only 60% would accept a kidney
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CONCLUSION: Spanish veterinary students have a favorable attitude toward LKRD. However, only 60% would accept a kidney from a relative.
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INTRODUCTION. Kidney transplantation, like other kinds of transplantation, is limited by the organ shortage. To promote living kidney related donations (LKRD) it is important to involve healthcare professionals because a negative predisposition of these professionals will generate distrust towards this kind of donation and this will
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create a barrier to developing this method of organ procurement [1]. Medical staff members play an important role in promoting organ donation, but it is necessary that the rest of the staff, including veterinarians, have a positive attitude toward LKRD. In this context, veterinarians of today are familiarized with health care topics and often hold
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decision-making positions in the public health care system or teach many university courses.
The attitude toward LKRD was studied in different subpopulations: kidney patients on the transplant waiting
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list [2,3], health care professionals [4], general public [5,6] and medical or journalism students [7,8]. However, only a study surveyed the attitude of the veterinary students toward LKRD in 2 universities [9]. Nowadays, future Spanish veterinarians have specific university courses about human organ donation, stem cells, and transplantation, and are familiarized with all of the pros and cons of LKRD. Moreover, these students often are involved in xenotransplantation research projects (possible future therapy). It would be interesting to determine the
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attitude of future veterinarians toward LKRD (current therapy), which has not yet been studied in comparison to their attitude toward xenotransplantation [10]. We believe it is important to study different population groups to identify subgroups that do not have a favorable attitude in order to promote awareness campaigns toward LKRD.
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The aim of this study was to analyze the attitude of Spanish veterinary students toward LKRD because they may influence public opinion in the future and to determine the factors that condition it.
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MATERIALS AND METHODS. Study Population: A sociological, interdisciplinary, multicentre, and observational study was performed in the academic year 2010–2011 on Veterinary students (n=9000) of Spain. Sample size: A sample of 2790 students was selected (99% confidence and a precision of ± 2%) stratified by geographical area and year of study. Instrument for measuring attitude: The measurement instrument used was a validated questionnaire of attitude toward organ donation and transplantation (ODT) (PCID-DVR RIOS: “International Collaborative Organ Donation Project about Organ Transplantation and Donation (Ríos y col.) [1,10-11]. This questionnaire includes questions distributed into four validated sub-scales or factors in the Spanish population, having a total explained variance of 63.203% and a confidence interval for Cronbach's alpha coefficient of: 0.834. It was self-administered 3
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and completed anonymously. Study variables: Attitude toward LKRD was used as the dependent variable. The following seven categories of independent variables were analyzed: 1) Socio-personal variables; 2) Academic variables; 3) Variables of attitude toward ODT and 4) Variables of social interaction. Statistical analysis: A
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descriptive statistical analysis was carried out on each of the variables, and for the comparison of the different variables Student's t-test was applied together with the χ2 test complemented by an analysis of the remainders. Fisher's exact test was applied when the contingency tables had cells with an expected frequency of <5. For the
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multivariate analysis a logistic regression test was used including the variables that were statistically significantly in the bivariate analysis. P values of less than 0.05 were considered statistically significant.
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RESULTS. Veterinary schools included and the response rate obtained: The 6 randomly selected veterinary schools agreed to take part in the study. Of the 2815 selected students (the 2790 selected plus the 0.9% per type of sample) 2683 correctly completed the questionnaire (a response rate of 95.31%). Attitude towards LKRD: The survey showed that 93% (n=2504) of respondents would donate a kidney to a relative who needed it and 36% (n=945) supported unrelated LKD. Factors affecting attitude toward LKRD: The following variables were
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associated with having a more favorable attitude: Socio-personal and academic variables: Regarding sex, the females had a more favorable attitude towards LKRD than the males (94 vs. 91%; p<0.001)(Table 1). With respect geographical location of University, students of Southern universities had a more favorable attitude (p=0.029).
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Variables of knowledge and attitude toward ODT and Social Interaction: those who had a father (p<0.001) or a mother (p<0.001) in favour to organ donation; those who had spoken about the subject with one's family (p=0.016)
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and friends (p=0.027); having a favorable attitude toward deceased donation (p<0.001); In addition, the respondents in favor of the donation of a family member’s organs had a more favorable attitude (p<0.001) and those who had interest in receiving a talk about ODT (p<0.001). However, only 60% would accept a kidney from a relative. DISCUSSION. In developed countries, there is a growing tendency to encourage living kidney donation [12]. Therefore, it is important to create a favorable social climate towards this kind of donation [13]. In Spain, studies of public attitude towards LKRD have shown that people are quite in favor [5,6,14]. However, it is also essential for opinion-generating groups, above all healthcare professionals, to have a favorable attitude so that they can be carriers of positive messages about this matter [15]. For these reasons, it is important for veterinary students, shortly 4
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to become professionals, to have a favorable attitude to help promote living donation. In our country, one of the first studies indicated a not very good level of acceptance among healthcare workers, because they believed that deceased donation was the best alternative [16], but recent studies have shown an improvement in this attitude [17].
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Our data show that veterinary students accept related LKRD to a high degree, being 93% of Spanish students in favor. This percentage is similar than the rate reported in Spanish medical students [7]. This attitude is more favorable than healthcare professionals and Spanish general public (83-87%)[1,4,6], but less favorable than of
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university students in health-related subjects (93-94%) [7,9] which is possibly due to the more advanced training provided to the latter. Therefore, the knowledge acquired during university training about living donation and related
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aspects will have a decisive influence on the professionals and the information they provide [7]. Some studies have emphasized that young people (students in particular) generally tend to be more in favor of donation than general population [7,18]. These are favorable data suggesting that with institutional support, and given the favorable situation, LKRD rates could increase. In Spain, it has already started to increase slightly in recent years [7]. An analysis of the factors affecting veterinary students' attitude towards LKRD has shown a close relationship
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between attitude towards deceased donation and LKRD [1, 4]. It has been observed that a favorable attitude towards deceased organ donation, a factor also reported in the general public, is a positive factor for promoting living kidney donation [5]. Also, a relationship is with variables of socio-familiar interaction [19]. In this regard, discussing the
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matter with one’s family and friends is very influential aspects of attitude towards donation. These are classical factors which have been reported as affecting attitude towards deceased organ donation [13], and their influence is
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also apparent in living donation. In this sense, as observed in the public, it is essential to encourage family dialogue about matters related to ODT, as this usually has a positive effect on attitude towards LKRD [20-21]. These favorable indices of attitude towards LKRD lead us to believe that living kidney donation rates could soon increase in Spain. This could provide a potential supply of organs that is much greater than that of deceased organs and which still needs to be developed [7]. However, we should not forget that only 60% would accept a kidney from a relative. It should be noted that the appropriate training of future veterinary in the ODT process will require a specific knowledge of those variables that affect their attitude towards donation from the stage that they become students. In
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fact, knowing the factors that determine their attitude towards donation will make it possible to optimize the resources invested in campaigns to promote ODT and to take more specific action. To conclude, the attitude of veterinary students from Spain toward LKRD is very favorable and it could boost
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donation rates in the future. These future professionals may play an important role in fostering public acceptance of this kind of transplantation. BIBLIOGRAPHY
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1.-Ríos A, Ramírez P, del Mar Rodríguez M, Martínez L, Montoya MJ, Lucas D, Alcaraz J, Parrilla P. Attitude of ancillary personnel faced with living kidney donation in a hospital with a living donor kidney transplant program. Transplantation. 2007; 83: 336-40.
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2.-Martínez-Alarcón L, Ríos A, Conesa C, Alcaraz J, González MJ, Ramírez P, et al. Attitude of kidney patients on the transplant waiting list toward related-living donation. A reason for the scarce development of living donation in Spain. Clin Transplant.2006; 20: 719-24 3.-Martínez-Alarcón L, Ríos A, Conesa C, Alcaraz J, González MJ, Montoya M, Fernández OM, Pons JA, Ramírez P, et al. Attitude toward living related donation of patients on the waiting list for a deceased donor solid organ transplant. Transplant Proc. 2005; 37: 3614-17. 4.-Ríos A, Ramírez P, Martínez L, García JA, Montoya MJ,et al. Attitude of personnel in hospital cadaveric organ transplant-related units
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faced with living kidney donation in a hospital with a living kidney donor transplantation program. Nephron Clin Pract.2008;108:c75-82 5.-Ríos A, Martínez-Alarcón L, Sánchez J, Jarvis N, 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; 23:1720-7
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6.-Ríos A, Martínez-Alarcón L, Sánchez J, Jarvis N, Guzmán D, Parrilla P, Ramírez P. Factors that influence the attitude of East European residents in Spain towards living kidney donation. Transpl Int. 2009; 22:707-16.
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7.-Ríos A, López-Navas A, López-López A, Gómez FJ, Iriarte J, Herruzo R, Blanco G, et al. Medical students faced with related and unrelated living kidney donation: a stratified and multicentre study in Spain. World J Urol. 2016; 34: 1673-1684. 8.-Martínez-Alarcón L, Ríos A, López MJ, Sánchez J, López-Navas A, Parrilla P, Ramírez P. The attitude of future journalists toward living donation. Transplant Proc. 2009; 41: 2055-9. 9.-Martínez-Alarcón L, Ramis G, Gómez-Laguna J, Quereda JJ, Herrero-Medrano JM, Mrowiec A, Mendonça L, López-Navas A, Ríos A. Attitude toward living kidney donation: differences between students from two Spanish universities. Transplant Proc. 2015; 47: 10-2
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10.-Martínez-Alarcón L, Ríos A, Ramis G, Quereda JJ, Herrero JM, Muñoz A, Parrilla P, Ramírez P. Are veterinary students in favor of xenotransplantation? An opinion study in a Spanish university with a xenotransplantation program. Transplant Proc. 2010; 42: 2130-33. 11.-Ríos A. International collaborative donor project. Cir Esp (In press)
Collective: A Scientific Registry for Living Donors. Am J Transplant. 2017; 17:3040-3048.
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12.-Kasiske BL, Asrani SK, Dew MA, Henderson ML, Henrich C, Humar A, Israni AK, Lentine KL, Matas AJ, Newell KA, et al. The Living Donor
13.-Ríos A, Cascales P, Martínez L, Sánchez J, Jarvis N, Parrilla P, Ramírez P. Emigration from the British Isles to south-eastern Spain:
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a study of attitudes toward organ donation. Am J Transplant 2007;7:2020–30.
14.-Ríos A, Martínez L, Sánchez J, Jarvis N, Guzmán D, et al. Attitude of the population of German origin in the South East of Spain
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toward living kidney donation. In search of favourable sub-groups for promoting living kidney donation in Spain. Nephron Clin Pract. 2008; 110:c133–c138
15.-Ríos A, López-Navas A, Ayala-García M, Sebastián MJ, Abdo-Cuza A, Alán J, et al. Level of awareness of personnel in hospital services related to the donation process: A Spanish and Latin American multicenter study. J Heart Lung Transplant. 2012; 31: 850-57. 16.-Arias M, de Felipe C. Trasplante renal de donante vivo: encuesta de opinión de los nefrólogos españoles. Nefrología. 1995; 15:523-28
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17.-Ríos A, López-Navas A, Ayala-García MA, Sebastián MJ, Abdo-Cuza A, Martínez-Alarcón L, Ramírez EJ, et al. A multicenter study in Spanish, Mexican and Cuban hospitals of attitude toward living kidney donation. Ann Transplant. 2014;19:96–103. 18.-Ge F, Kaczmarczyk G, Biller-Andorno N. Attitudes toward live and postmortem kidney donation: a survey of Chinese medical
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students. Exp Clin Transplant. 2014; 12: 506-9.
19.-Zambudio AR, Conesa C, Ramírez P, Galindo PJ, Martínez L, Rodríguez MM, Parrilla P. What is the attitude of hospital transplant-
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related personnel toward donation? J Heart Lung Transplant. 2006; 25: 972-76. 20.-Ríos A, López-Navas AI, Navalón JC, Martínez-Alarcón L, Ayala-García MA, Sebastián-Ruiz MJ, et al. The Latin American population in Spain and organ donation. Attitude toward deceased organ donation and organ donation rates. Transpl Int. 2015; 28:437-47. 21.-Ríos A, López-Navas A, García JA, Garrido G, Ayala MA, Sebastián MJ, Hernández A, Ramírez P, Parrilla P. The attitude of Latin American immigrants resident in Florida (USA) toward deceased organ donation. Transplant Int 2017; 30: 1020-1031.
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Table 1. Socio-personal variables of knowledge about LKRD and social interaction that affect attitude toward donation. In favor n=2504 (93%)
Not in favor n=179 (7%)
p
22 ± 2.9
21 ± 2
0.470
681 (91%) 1823 (94%)
68 (9%) 111 (5%)
0.002
654 (93%) 1840 (94%) 10
34 (6%) 35 (7%) 30 (6%) 37 (6%) 43 (7%)
111 (8%) 68 (6%)
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1342 (92%) 1162 (94%)
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0.902
486 (94%) 472 (93%) 455 (94%) 559 (94%) 532 (93%)
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0.029
47 (7%) 126 (6%) 6
0.785
30 (5%) 142 (7%) 7
0.275
755 (95%) 760 (92%) 41 (93%) 891 (94%) 57
37 (5%) 65 (8%) 3 (7%) 59 (6%) 15
0.069
1236 (96%) 1091 (92%) 107 (92%) 41 (89%) 29
53 (4%) 98 (8%) 10 (8%) 5 (11%) 13
<0.001
1428 (95%) 894 (93%) 120 (90%) 40 (78%) 22
69 (5%) 73 (7%) 13 (10%) 11 (22%) 13
<0.001
1654 (94%) 832 (92%) 18
99 (6%) 73 (8%) 7
0.016
1721 (94%) 762 (92%) 21
104 (6%) 66 (8%) 9
0.027
2098 (95%) 383 (87%) 23
109 (5%) 60 (13%) 10
<0.001
2261 (94%) 189 (83%) 54
133 (6%) 38 (17%) 8
<0.001
1790 (95%) 91 (76%) 598 (93%) 25
93 (5%) 29 (24%) 43 (7%) 14
<0.001
521 (95%) 1968 (93%) 15
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Variable N=2683 Socio-Personal and Academic Variables Mean age: 21 ± 2 years Sex: Male (n=749) Female (n=1934) Year at University: First (n=520) Second (n=507) Third (n=485) Fourth (n=596) Fifth (n=575) Geographical location: Northern (n=1453) Southern (n=1230) Variables of knowledge about ODT and Social Interaction Knowing a transplant patient: Yes (n=701) No (n=1966) DS/DK (n=16) Knowing a donor: Yes (n=551) No (n=2110) DS/DK (n=22) Knowing the attitude of one’s partner: Yes, favorable (n=792) Not known (n=825) Yes, against (n=44) Does not have a partner (n=950) DS/DK (n=72) Knowing the attitude of one’s father: Yes, favorable (n=1289) Not known (n=1189) Yes, against (n=117) Does not have father (n=46) DS/DK (n=42) Knowing the attitude of one’s mother: Yes, favorable (n=1497) Not known (n=967) Yes, against (n=133) Does not have mother (n=51) DS/DK (n=35) Family discussion about ODT: No (n=1753) Yes (n=905) DS/DK (n=25) Friends discussion about ODT: No (n=1825) Yes (n=828) DS/DK (n=30) Attitude toward deceased donation: In favor (n=2207) Not in favor (n=443) DK/NA (n=33) Donation the organs of a relative: Yes (n=2394) No (n=227) DS/DK (n=62) Interest in receiving a talk about ODT: Yes (n=1883) No (n=120) Doubts (n=641) DS/DK (n=39)
ODT: Organ Donation and Transplantation; DS/DK: Does not say/does not know
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ACCEPTED MANUSCRIPT Highlights Spanish veterinary students have a favorable attitude toward LKRD.
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Only 60% would accept a kidney from a relative.
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University students play an important role in promoting this type of organ donation.
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S0041-1345(18)30438-X
DOI:
10.1016/j.transproceed.2018.02.177
Reference:
TPS 28419
To appear in:
Transplantation Proceedings
Received Date: 15 January 2018 Accepted Date: 26 February 2018
Please cite this article as: Martínez-Alarcón L, Ríos A, Ramis G, Gómez-Laguna J, Moll X, Falceto V, San Román-Acaso F, San Román-Llorens F, Quereda JJ, Herrero Medrano JM, Mendonça L, Martin-Barrasa JL, Fernández OM, Muñoz A, Ramírez P, Parrilla P, Attitude Toward Living Kidney Donation: Are Veterinary Students In Favor? A Multicenter Stratified Study from Spain, Transplantation Proceedings (2018), doi: 10.1016/j.transproceed.2018.02.177. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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ATTITUDE TOWARD LIVING KIDNEY DONATION: ARE VETERINARY STUDENTS IN FAVOR? A MULTICENTER STRATIFIED STUDY FROM SPAIN
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Laura Martínez-Alarcón1-3, Antonio Ríos1-3, Guillermo Ramis2-4, Jaime Gómez-Laguna5, Xavier Moll6, Victoria Falceto7, Fidel San Román-Acaso8, Fidel San Román-Llorens8, Juan José Quereda9, Juan Manuel Herrero Medrano4, Livia Mendonça10, José Luis Martin-Barrasa11-12, Olga María Fernández2,13, Antonio Muñoz4, Pablo Ramírez1-3, Pascual Parrilla1-3.
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1.-"International Collaborative Donor Project", Murcia-España. 2.-Instituto Murciano de Investigación Biosanitaria (IMIB), Murcia-España. 3.-Servicio de Cirugía, Unidad de Trasplantes, Hospital Clínico Universitario Virgen de la Arrixaca. Murcia-España 4.-Departamento de Producción Animal. Facultad de Veterinaria. Universidad de MurciaEspaña. 5.-Departament of Anatomy and Comparative Pathology. University of Córdoba. Spain. 6.-Departamento de Medicina y Cirugía Animal. Facultad Veterinaria. Universitat Autonoma Barcelona (UAB) España. 7.-Universidad Zaragoza, España. 8.-Universidad Complutense de Madrid, España. 9.-Grupo Fisiopatología de la Reproducción. Departamento Producción y Sanidad Animal, Salud Pública Veterinaria y Ciencia y Tecnología de los Alimentos. Facultad de Veterinaria. Universidad Cardenal Herrera-CEU, CEU Universities Valencia. Spain. 10.-Escola de Veterinária e Zootecnia. Universidade Federal de Goiás, Goiania, Brazil. 11.-Experimental Animal Facility, Research Unit, Hospital Universitario de Gran Canaria, Dr. Negrín, Las Palmas de Gran Canaria, Spain. 12.-Animal Infectious Diseases and Ictiopatology, University Institute of Animal Health (IUSA), University of Las Palmas de Gran Canaria, Arucas, Spain. 13.- Animalario libre de Patógenos Arrixaca- IMIB. Murcia-España.
Email addresses of authors: Martínez-Alarcón: [email protected], Ríos: [email protected], Ramis: [email protected], Gomez-Laguna: [email protected], Moll: [email protected],
Falceto: [email protected], San-Román-Acaso:
[email protected], San Román-Llorens: [email protected], Quereda: [email protected], Herrero-
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Medrano: [email protected], Mendonça: [email protected], Martín-Barrasa: [email protected], Fernández: [email protected], Muñoz: [email protected], Ramírez: [email protected], Parrilla: [email protected]
Corresponding author: Dr. Antonio Ríos Zambudio, Avenida de la Libertad nº 208. 30007. Casillas.
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Murcia. ESPAÑA. E-mail: [email protected] Telephone: +34968.27.07.57 Fax: +34968.36.94.38
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Grant information: No grant support. "J. Gómez-Laguna is supported by a “Ramón y Cajal” contract of the Spanish Ministry of Economy and Competitiveness". Key words: Living kidney related donation; veterinary student; organ donation; attitude. Abbreviations: LKRD: living kidney related donations; ODT: organ donation and transplantation; DS/DK: Does not say/does not know. Tables: __1____ Figures: __0___ (color – Yes / No)
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ABSTRACT TITLE: ATTITUDE TOWARD LIVING KIDNEY DONATION: ARE VETERINARY STUDENTS IN FAVOR? A MULTICENTER STRATIFIED STUDY FROM SPAIN
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OBJECTIVES: Due to the current deficit of organs for transplantation, living kidney related donations (LKRD) should be promoted. The objective was to analyze the attitude of Spanish veterinary students toward LKRD because they may influence public opinion in the future, and to determine the factors that condition it.
METHODS: A sociological, interdisciplinary, multicenter and observational study was carried out in the Veterinary
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students enrolled in Spain (n=9000) in the university academic year 2010-2011. A sample of 2815 students was stratified by geographical area and academic year. Instrument used: The students' attitude toward LKRD was
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assessed using a psychosocial validated questionnaire (PCID-DVR RIOS) was self-administered and completed anonymously. Data collection procedure: Randomly selected veterinary schools. The questionnaire was applied to each academic year at compulsory sessions. Statistical analysis: Student´s t test, χ2 test and logistic regression analysis.
RESULTS: The completion rate was 95% (n=2683). 93% (n=2504) were in favor of related LKRD, and 36% (n=945)
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supported unrelated living kidney donation. The following variables were associated with having a more favorable attitude: 1) sex (p<0.001); 2) students of Southern universities had a more favorable attitude (p=0.029); 3) attitude toward deceased donation (p<0.001); 4) a father’s (p<0.001) or a mother’s (p<0.001) in favor to organ donation and
from a relative.
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5) having discussed the subject with friends (p=0.027) or family (p=0.016). However, only 60% would accept a kidney
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CONCLUSION: Spanish veterinary students have a favorable attitude toward LKRD. However, only 60% would accept a kidney from a relative.
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INTRODUCTION. Kidney transplantation, like other kinds of transplantation, is limited by the organ shortage. To promote living kidney related donations (LKRD) it is important to involve healthcare professionals because a negative predisposition of these professionals will generate distrust towards this kind of donation and this will
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create a barrier to developing this method of organ procurement [1]. Medical staff members play an important role in promoting organ donation, but it is necessary that the rest of the staff, including veterinarians, have a positive attitude toward LKRD. In this context, veterinarians of today are familiarized with health care topics and often hold
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decision-making positions in the public health care system or teach many university courses.
The attitude toward LKRD was studied in different subpopulations: kidney patients on the transplant waiting
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list [2,3], health care professionals [4], general public [5,6] and medical or journalism students [7,8]. However, only a study surveyed the attitude of the veterinary students toward LKRD in 2 universities [9]. Nowadays, future Spanish veterinarians have specific university courses about human organ donation, stem cells, and transplantation, and are familiarized with all of the pros and cons of LKRD. Moreover, these students often are involved in xenotransplantation research projects (possible future therapy). It would be interesting to determine the
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attitude of future veterinarians toward LKRD (current therapy), which has not yet been studied in comparison to their attitude toward xenotransplantation [10]. We believe it is important to study different population groups to identify subgroups that do not have a favorable attitude in order to promote awareness campaigns toward LKRD.
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The aim of this study was to analyze the attitude of Spanish veterinary students toward LKRD because they may influence public opinion in the future and to determine the factors that condition it.
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MATERIALS AND METHODS. Study Population: A sociological, interdisciplinary, multicentre, and observational study was performed in the academic year 2010–2011 on Veterinary students (n=9000) of Spain. Sample size: A sample of 2790 students was selected (99% confidence and a precision of ± 2%) stratified by geographical area and year of study. Instrument for measuring attitude: The measurement instrument used was a validated questionnaire of attitude toward organ donation and transplantation (ODT) (PCID-DVR RIOS: “International Collaborative Organ Donation Project about Organ Transplantation and Donation (Ríos y col.) [1,10-11]. This questionnaire includes questions distributed into four validated sub-scales or factors in the Spanish population, having a total explained variance of 63.203% and a confidence interval for Cronbach's alpha coefficient of: 0.834. It was self-administered 3
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and completed anonymously. Study variables: Attitude toward LKRD was used as the dependent variable. The following seven categories of independent variables were analyzed: 1) Socio-personal variables; 2) Academic variables; 3) Variables of attitude toward ODT and 4) Variables of social interaction. Statistical analysis: A
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descriptive statistical analysis was carried out on each of the variables, and for the comparison of the different variables Student's t-test was applied together with the χ2 test complemented by an analysis of the remainders. Fisher's exact test was applied when the contingency tables had cells with an expected frequency of <5. For the
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multivariate analysis a logistic regression test was used including the variables that were statistically significantly in the bivariate analysis. P values of less than 0.05 were considered statistically significant.
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RESULTS. Veterinary schools included and the response rate obtained: The 6 randomly selected veterinary schools agreed to take part in the study. Of the 2815 selected students (the 2790 selected plus the 0.9% per type of sample) 2683 correctly completed the questionnaire (a response rate of 95.31%). Attitude towards LKRD: The survey showed that 93% (n=2504) of respondents would donate a kidney to a relative who needed it and 36% (n=945) supported unrelated LKD. Factors affecting attitude toward LKRD: The following variables were
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associated with having a more favorable attitude: Socio-personal and academic variables: Regarding sex, the females had a more favorable attitude towards LKRD than the males (94 vs. 91%; p<0.001)(Table 1). With respect geographical location of University, students of Southern universities had a more favorable attitude (p=0.029).
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Variables of knowledge and attitude toward ODT and Social Interaction: those who had a father (p<0.001) or a mother (p<0.001) in favour to organ donation; those who had spoken about the subject with one's family (p=0.016)
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and friends (p=0.027); having a favorable attitude toward deceased donation (p<0.001); In addition, the respondents in favor of the donation of a family member’s organs had a more favorable attitude (p<0.001) and those who had interest in receiving a talk about ODT (p<0.001). However, only 60% would accept a kidney from a relative. DISCUSSION. In developed countries, there is a growing tendency to encourage living kidney donation [12]. Therefore, it is important to create a favorable social climate towards this kind of donation [13]. In Spain, studies of public attitude towards LKRD have shown that people are quite in favor [5,6,14]. However, it is also essential for opinion-generating groups, above all healthcare professionals, to have a favorable attitude so that they can be carriers of positive messages about this matter [15]. For these reasons, it is important for veterinary students, shortly 4
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to become professionals, to have a favorable attitude to help promote living donation. In our country, one of the first studies indicated a not very good level of acceptance among healthcare workers, because they believed that deceased donation was the best alternative [16], but recent studies have shown an improvement in this attitude [17].
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Our data show that veterinary students accept related LKRD to a high degree, being 93% of Spanish students in favor. This percentage is similar than the rate reported in Spanish medical students [7]. This attitude is more favorable than healthcare professionals and Spanish general public (83-87%)[1,4,6], but less favorable than of
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university students in health-related subjects (93-94%) [7,9] which is possibly due to the more advanced training provided to the latter. Therefore, the knowledge acquired during university training about living donation and related
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aspects will have a decisive influence on the professionals and the information they provide [7]. Some studies have emphasized that young people (students in particular) generally tend to be more in favor of donation than general population [7,18]. These are favorable data suggesting that with institutional support, and given the favorable situation, LKRD rates could increase. In Spain, it has already started to increase slightly in recent years [7]. An analysis of the factors affecting veterinary students' attitude towards LKRD has shown a close relationship
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between attitude towards deceased donation and LKRD [1, 4]. It has been observed that a favorable attitude towards deceased organ donation, a factor also reported in the general public, is a positive factor for promoting living kidney donation [5]. Also, a relationship is with variables of socio-familiar interaction [19]. In this regard, discussing the
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matter with one’s family and friends is very influential aspects of attitude towards donation. These are classical factors which have been reported as affecting attitude towards deceased organ donation [13], and their influence is
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also apparent in living donation. In this sense, as observed in the public, it is essential to encourage family dialogue about matters related to ODT, as this usually has a positive effect on attitude towards LKRD [20-21]. These favorable indices of attitude towards LKRD lead us to believe that living kidney donation rates could soon increase in Spain. This could provide a potential supply of organs that is much greater than that of deceased organs and which still needs to be developed [7]. However, we should not forget that only 60% would accept a kidney from a relative. It should be noted that the appropriate training of future veterinary in the ODT process will require a specific knowledge of those variables that affect their attitude towards donation from the stage that they become students. In
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fact, knowing the factors that determine their attitude towards donation will make it possible to optimize the resources invested in campaigns to promote ODT and to take more specific action. To conclude, the attitude of veterinary students from Spain toward LKRD is very favorable and it could boost
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donation rates in the future. These future professionals may play an important role in fostering public acceptance of this kind of transplantation. BIBLIOGRAPHY
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1.-Ríos A, Ramírez P, del Mar Rodríguez M, Martínez L, Montoya MJ, Lucas D, Alcaraz J, Parrilla P. Attitude of ancillary personnel faced with living kidney donation in a hospital with a living donor kidney transplant program. Transplantation. 2007; 83: 336-40.
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2.-Martínez-Alarcón L, Ríos A, Conesa C, Alcaraz J, González MJ, Ramírez P, et al. Attitude of kidney patients on the transplant waiting list toward related-living donation. A reason for the scarce development of living donation in Spain. Clin Transplant.2006; 20: 719-24 3.-Martínez-Alarcón L, Ríos A, Conesa C, Alcaraz J, González MJ, Montoya M, Fernández OM, Pons JA, Ramírez P, et al. Attitude toward living related donation of patients on the waiting list for a deceased donor solid organ transplant. Transplant Proc. 2005; 37: 3614-17. 4.-Ríos A, Ramírez P, Martínez L, García JA, Montoya MJ,et al. Attitude of personnel in hospital cadaveric organ transplant-related units
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faced with living kidney donation in a hospital with a living kidney donor transplantation program. Nephron Clin Pract.2008;108:c75-82 5.-Ríos A, Martínez-Alarcón L, Sánchez J, Jarvis N, 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; 23:1720-7
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6.-Ríos A, Martínez-Alarcón L, Sánchez J, Jarvis N, Guzmán D, Parrilla P, Ramírez P. Factors that influence the attitude of East European residents in Spain towards living kidney donation. Transpl Int. 2009; 22:707-16.
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7.-Ríos A, López-Navas A, López-López A, Gómez FJ, Iriarte J, Herruzo R, Blanco G, et al. Medical students faced with related and unrelated living kidney donation: a stratified and multicentre study in Spain. World J Urol. 2016; 34: 1673-1684. 8.-Martínez-Alarcón L, Ríos A, López MJ, Sánchez J, López-Navas A, Parrilla P, Ramírez P. The attitude of future journalists toward living donation. Transplant Proc. 2009; 41: 2055-9. 9.-Martínez-Alarcón L, Ramis G, Gómez-Laguna J, Quereda JJ, Herrero-Medrano JM, Mrowiec A, Mendonça L, López-Navas A, Ríos A. Attitude toward living kidney donation: differences between students from two Spanish universities. Transplant Proc. 2015; 47: 10-2
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10.-Martínez-Alarcón L, Ríos A, Ramis G, Quereda JJ, Herrero JM, Muñoz A, Parrilla P, Ramírez P. Are veterinary students in favor of xenotransplantation? An opinion study in a Spanish university with a xenotransplantation program. Transplant Proc. 2010; 42: 2130-33. 11.-Ríos A. International collaborative donor project. Cir Esp (In press)
Collective: A Scientific Registry for Living Donors. Am J Transplant. 2017; 17:3040-3048.
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12.-Kasiske BL, Asrani SK, Dew MA, Henderson ML, Henrich C, Humar A, Israni AK, Lentine KL, Matas AJ, Newell KA, et al. The Living Donor
13.-Ríos A, Cascales P, Martínez L, Sánchez J, Jarvis N, Parrilla P, Ramírez P. Emigration from the British Isles to south-eastern Spain:
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a study of attitudes toward organ donation. Am J Transplant 2007;7:2020–30.
14.-Ríos A, Martínez L, Sánchez J, Jarvis N, Guzmán D, et al. Attitude of the population of German origin in the South East of Spain
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toward living kidney donation. In search of favourable sub-groups for promoting living kidney donation in Spain. Nephron Clin Pract. 2008; 110:c133–c138
15.-Ríos A, López-Navas A, Ayala-García M, Sebastián MJ, Abdo-Cuza A, Alán J, et al. Level of awareness of personnel in hospital services related to the donation process: A Spanish and Latin American multicenter study. J Heart Lung Transplant. 2012; 31: 850-57. 16.-Arias M, de Felipe C. Trasplante renal de donante vivo: encuesta de opinión de los nefrólogos españoles. Nefrología. 1995; 15:523-28
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17.-Ríos A, López-Navas A, Ayala-García MA, Sebastián MJ, Abdo-Cuza A, Martínez-Alarcón L, Ramírez EJ, et al. A multicenter study in Spanish, Mexican and Cuban hospitals of attitude toward living kidney donation. Ann Transplant. 2014;19:96–103. 18.-Ge F, Kaczmarczyk G, Biller-Andorno N. Attitudes toward live and postmortem kidney donation: a survey of Chinese medical
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students. Exp Clin Transplant. 2014; 12: 506-9.
19.-Zambudio AR, Conesa C, Ramírez P, Galindo PJ, Martínez L, Rodríguez MM, Parrilla P. What is the attitude of hospital transplant-
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related personnel toward donation? J Heart Lung Transplant. 2006; 25: 972-76. 20.-Ríos A, López-Navas AI, Navalón JC, Martínez-Alarcón L, Ayala-García MA, Sebastián-Ruiz MJ, et al. The Latin American population in Spain and organ donation. Attitude toward deceased organ donation and organ donation rates. Transpl Int. 2015; 28:437-47. 21.-Ríos A, López-Navas A, García JA, Garrido G, Ayala MA, Sebastián MJ, Hernández A, Ramírez P, Parrilla P. The attitude of Latin American immigrants resident in Florida (USA) toward deceased organ donation. Transplant Int 2017; 30: 1020-1031.
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Table 1. Socio-personal variables of knowledge about LKRD and social interaction that affect attitude toward donation. In favor n=2504 (93%)
Not in favor n=179 (7%)
p
22 ± 2.9
21 ± 2
0.470
681 (91%) 1823 (94%)
68 (9%) 111 (5%)
0.002
654 (93%) 1840 (94%) 10
34 (6%) 35 (7%) 30 (6%) 37 (6%) 43 (7%)
111 (8%) 68 (6%)
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1342 (92%) 1162 (94%)
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0.902
486 (94%) 472 (93%) 455 (94%) 559 (94%) 532 (93%)
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0.029
47 (7%) 126 (6%) 6
0.785
30 (5%) 142 (7%) 7
0.275
755 (95%) 760 (92%) 41 (93%) 891 (94%) 57
37 (5%) 65 (8%) 3 (7%) 59 (6%) 15
0.069
1236 (96%) 1091 (92%) 107 (92%) 41 (89%) 29
53 (4%) 98 (8%) 10 (8%) 5 (11%) 13
<0.001
1428 (95%) 894 (93%) 120 (90%) 40 (78%) 22
69 (5%) 73 (7%) 13 (10%) 11 (22%) 13
<0.001
1654 (94%) 832 (92%) 18
99 (6%) 73 (8%) 7
0.016
1721 (94%) 762 (92%) 21
104 (6%) 66 (8%) 9
0.027
2098 (95%) 383 (87%) 23
109 (5%) 60 (13%) 10
<0.001
2261 (94%) 189 (83%) 54
133 (6%) 38 (17%) 8
<0.001
1790 (95%) 91 (76%) 598 (93%) 25
93 (5%) 29 (24%) 43 (7%) 14
<0.001
521 (95%) 1968 (93%) 15
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Variable N=2683 Socio-Personal and Academic Variables Mean age: 21 ± 2 years Sex: Male (n=749) Female (n=1934) Year at University: First (n=520) Second (n=507) Third (n=485) Fourth (n=596) Fifth (n=575) Geographical location: Northern (n=1453) Southern (n=1230) Variables of knowledge about ODT and Social Interaction Knowing a transplant patient: Yes (n=701) No (n=1966) DS/DK (n=16) Knowing a donor: Yes (n=551) No (n=2110) DS/DK (n=22) Knowing the attitude of one’s partner: Yes, favorable (n=792) Not known (n=825) Yes, against (n=44) Does not have a partner (n=950) DS/DK (n=72) Knowing the attitude of one’s father: Yes, favorable (n=1289) Not known (n=1189) Yes, against (n=117) Does not have father (n=46) DS/DK (n=42) Knowing the attitude of one’s mother: Yes, favorable (n=1497) Not known (n=967) Yes, against (n=133) Does not have mother (n=51) DS/DK (n=35) Family discussion about ODT: No (n=1753) Yes (n=905) DS/DK (n=25) Friends discussion about ODT: No (n=1825) Yes (n=828) DS/DK (n=30) Attitude toward deceased donation: In favor (n=2207) Not in favor (n=443) DK/NA (n=33) Donation the organs of a relative: Yes (n=2394) No (n=227) DS/DK (n=62) Interest in receiving a talk about ODT: Yes (n=1883) No (n=120) Doubts (n=641) DS/DK (n=39)
ODT: Organ Donation and Transplantation; DS/DK: Does not say/does not know
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Only 60% would accept a kidney from a relative.
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University students play an important role in promoting this type of organ donation.
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