http://informahealthcare.com/rnf ISSN: 0886-022X (print), 1525-6049 (electronic) Ren Fail, 2014; 36(4): 489–494 ! 2014 Informa Healthcare USA, Inc. DOI: 10.3109/0886022X.2013.875814
CLINICAL STUDY
The attitude toward living kidney donation among personnel from units related to donation and transplantation in Spain, Mexico and Cuba Antonio Rı´os1,2,3,4, Ana Lo´pez-Navas2,5, Marco Antonio Ayala-Garcı´a6,7, Marı´a Jose´ Sebastia´n8, Anselmo Abdo-Cuza9, Laura Martı´nez-Alarco´n1,2,3, Ector Jaime Ramı´rez10, Gerardo Mun˜oz11, Gerardo Palacios8, Juliette Sua´rez-Lo´pez12, Ricardo Castellanos9, Beatriz Gonza´lez6,10, Miguel Angel Martı´nez13, Ernesto Dı´az6,7, Pablo Ramı´rez1,2,3,4, and Pascual Parrilla3,4 1
Proyecto Colaborativo Internacional Donante, ‘‘International Collaborative Donor Project’’, Murcia, Spain, 2Regional Transplant Center, Consejerı´a de Sanidad y Consumo de la Regio´n de Murcia, Spain, 3Transplant Unit, Surgery Service, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain, 4 Department of Surgery, University of Murcia, Murcia, Spain, 5Department of Psychology, Universidad Cato´lica San Antonio, UCAM, Murcia, Spain, 6 Hospital Regional de Alta Especialidad del Bajı´o, Leo´n, Guanajuato, Mexico, 7HGSZ No. 10 del Instituto Mexicano del Seguro Social Delegacio´n Guanajuato, Mexico, 8Transplant Coordination Center, UMAE Hospital de Especialidades N 25 IMSS, Monterrey, Mexico, 9Surgical Medical Research Center, Cuba, 10Department of Medicine, University of Guanajuato, Mexico, 11The 21st Century National Medical Center, Mexican Institute of Social Security, Mexico, 12Hermanos Ameijeiras Hospital, Cuba, and 13State Public Health Institute of Guanajuato, Mexico Abstract
Keywords
Background: Living kidney donation (LKD) is becoming increasingly necessary as a treatment option for reducing the deficit in transplant organs. Hospital personnel in services related to donation and transplantation play a key role in promoting this kind of donation. Objective: To analyze the attitude toward LKD among hospital workers in services related to donation and transplantation in Spain and Latin America. Methods: Eight hospitals in the ‘‘International Collaborative Donor Project’’ were selected (Spain–Mexico–Cuba). A random sample was taken which was stratified according to the type of service and job category, in transplant-related services. Results: Of the 878 respondents, 90% were in favor of related LKD, and 28% were in favor if the LKD was not related. Attitude was more favorable among Latin Americans workers compared to the Spanish (p ¼ 0.014). Other factors associated to attitude included: age (p ¼ 0.004); an attitude in favor of deceased donation and living liver donation (p50.001); and acceptance of a kidney from a donor (p50.001). Conclusions: The attitude toward related LKD was very favorable among hospital personnel in units related to the donation and transplantation process in Spain and Latin America, which means that they could contribute to its promotion particularly at the current time when living kidney donation needs to be expanded.
Attitude, hospital personnel, living kidney donation, transplant-related services
Dialysis has been one of the greatest advances in the management of chronic kidney failure because it has made it possible to drastically reduce mortality in these patients.1 Following this, kidney transplantation has become the treatment of choice, allowing kidney patients to resume their daily activities with an excellent quality of life, similar to that of an individual without any kind of pathology.2,3 Currently, kidney transplantation is carried out using both deceased and living donors. Deceased kidney donation is the most utilized in Spain, although, it no longer provides sufficient organs to cover the demand for kidney transplantation.4 Living kidney donation (LKD) involves low morbidity
Address correspondence to Dr. Antonio Rı´os Zambudio, Avenida de la Libertad n 208, Casillas, 30007 Murcia, Spain. Tel: 968 27 07 57; Fax: 968.36.97.16; E-mail: [email protected]
Received 24 August 2013 Revised 22 November 2013 Accepted 4 December 2013 Published online 5 February 2014
and has few after effects in the donor, with better results than those obtained with deceased donors.5–7 However, in many countries, especially in Spanish speaking countries, it is used very infrequently.4 In Spain, for instance, the LKD rate is 5 p.m.p. (in 2009), in Mexico it is 16 p.m.p. (in 2010) and in Cuba 2.5 p.m.p. in the 2008.4,8 The implication and involvement of healthcare personnel whose work is related with these activities, clearly affects the development of this type of transplantation in areas where it is least used.9–12 It is notable that although most of the groups surveyed are in favor of this activity,12 in the Spanish speaking areas the data show that they are not always in favor of this type of donation.11 In spite of the different circumstances faced by each country, there is no doubt that in all of them there is a deficit of kidney transplant organs and the need for more organs is growing. Many governments and healthcare institutions have prioritized donation programs in order to try to
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Introduction
History
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increase the number of transplants. Without a doubt, kidney transplantation from living donors requires the immediate and active participation of society, especially in families. Given this situation, the attitude of hospital workers who carry out their job activity in services related to the donation and transplant process is important: an unfavorable attitude could become a barrier to the development of this way of procuring organs and vice versa: a positive attitude will enhance donor procurement.9,10 The latest data available in the Spanish speaking world and provided by our own group, show that attitude is favorable toward living kidney donation among personnel from units related with the donation and transplantation process.9 However, these data are limited to just one hospital and there are no further data to make us think these could be representative of attitude in all geographical areas.11,13 The objective of this study is to analyze the attitude toward living kidney donation among hospital workers in transplant-related services from Spain and Latin America (Mexico and Cuba), and to analyze the variables affecting this attitude.
Material and methods Study population Eight hospitals in the ‘‘International Donor Collaboration Project’’ were selected; three in Spain, three in Mexico and two in Cuba. In these hospitals a random sample was taken and stratified according to service and job category (physicians, nurses, healthcare assistants and non-healthcare personnel) among transplant-related services. These services were grouped into three categories: (1) donor procurement units (intensive care units, postoperative recovery unit, and neurosurgery unit); (2) transplant units (general surgery and digestive apparatus service, urology service, and cardiovascular surgery service); and transplant patient follow-up units (internal medicine of the digestive apparatus, nephrology and cardiology). Opinion survey and study variables Attitude toward living kidney donation was assessed using a survey of the psychosocial aspects of organ donation and transplantation which was validated in our geographical area.9,10,14,15 For the distribution of these questionnaires contact was made with the head of service for the physicians’ questionnaire, with the nursing coordinator for the nursing personnel and an administrator for non-healthcare personnel, who were each given an explanation of the study and were made responsible for handing out the survey in selected work shifts. The survey was completed anonymously and was self-administered. Attitude toward related and unrelated LKD was analyzed as the dependent variable. The independent variables were grouped into: (1) Demographic: Country; (2) Socio-personal: Age, sex and marital status; (3) Job: Type of clinical service, type of hospital, service according to its relationship with transplantation, type of personnel, job category and job situation; (4) Knowledge of and attitude toward organ donation and transplantation: Personal experience of organ
Ren Fail, 2014; 36(4): 489–494
donation and transplantation, attitude toward deceased donation, a belief in the possibility of needing a transplant oneself in the future, attitude toward living liver donation, and acceptance of a kidney from a living donor if one were needed; (5) Social interaction and pro-social behavior: Discussion with the family about donation and transplantation, a partner’s opinion toward donation and transplantation and toward carrying out pro-social type activities; (6) Religious: The respondent’s religion and knowledge of the attitude of his or her religion toward donation and transplantation; and (7) Attitude toward the body: Concern about mutilation after donation. Statistical analysis The data were stored on a database and analyzed using the SPSS 15.0 statistical package (SPSS Inc., Chicago, IL). A descriptive statistical analysis was carried out on each of the variables, and to compare the different variables Student’s ttest and the 2 test was applied, complemented by an analysis of remainders. In order to determine and evaluate the multiple risks, logistic regression was carried out using the variables which had a statistically significant association in the bivariate analysis. In all cases, only p values of less than 0.05 were considered as statistically significant.
Results Attitude toward LKD A total of 878 workers were surveyed; 354 from Spain, 386 from Mexico and 138 from Cuba. 90% (n ¼ 790) were in favor of related LKD, 4% (n ¼ 32) were against and 6% (n ¼ 56) undecided. Attitude was less favorable among Cubans at 95% (n ¼ 131) in favor, followed by Mexicans at 91% (n ¼ 352) and the Spanish at 87% (n ¼ 307) (p ¼ 0.014). When unrelated LKD was considered, only 28% (n ¼ 242) were in favor. Attitude was most favorable among Cubans, where 41% (n ¼ 57) were in favor, followed by Mexicans where 34% (n ¼ 130) were in favor, and finally the Spanish with 16% (n ¼ 55) in favor (p50.001). Factors affecting attitude toward LKD Demographic variable According to the respondents’ country, attitude was more favorable among Cubans at 95% (n ¼ 131) in favor, followed by the Mexicans at 91% (n ¼ 352) and the Spanish at 87% (n ¼ 307) (p ¼ 0.014) (Table 1). Socio-personal variables The only differences found depended on age. It was found that those who were in favor of related LKD tended to have a younger mean age than those who were not in favor (37 ± 10 years versus 40 ± 11 years; p ¼ 0.004) (Table 1). Job variables No relevant relationships were found between attitude toward LKD and job variables (Table 1).
Living kidney donation
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Table 1. Demographic, socio-personal and job variables which affect attitude toward related LKD among personnel from hospital services directly related to the organ donation and transplantation process in Spain and Latin America. Variable Demographic Country: Spain (n ¼ 354) Mexico (n ¼ 386) Cuba (n ¼ 138) Socio-personal Age: (37 ± 10 years) Sex: Male (n ¼ 339) Female (n ¼ 531) DK/NA (n ¼ 8) Marital status: Single (n ¼ 306) Married (n ¼ 495) Widowed, separated, divorced (n ¼ 66) DK/NA (n ¼ 11) Job Type of service in which he or she works: Surgical (n ¼ 382) Medical (n ¼ 496) Type of hospital: Transplant Hospital (n ¼ 736) Procurement Hospital (n ¼ 142) Service according to its relationship with transplantation: Donor Procurement Units (n ¼ 367) Transplant Units (n ¼ 375) Transplant Follow-up Units (n ¼ 136) Type of personnel: Healthcare personnel (n ¼ 771) Non-healthcare personnel (n ¼ 107) Job category: Physician (n ¼ 310) Nursing (n ¼ 356) Healthcare Assistant (n ¼ 105) Non-healthcare personnel (n ¼ 107) Job situation: Permanent position (n ¼ 377) Temporary, contracted (n ¼ 461) DK/NA (n ¼ 40)
In favor (n ¼ 790; 90%) Not in favor (n ¼ 88; 10%)
p
307 (87%) 352 (91%) 131 (95%)
47 (13%) 34 (9%) 7 (5%)
0.014
37 ± 10 an˜os
40 ± 11 years
0.004
306 (90%) 480 (90%) 4
33 (10%) 51 (10%) 4
0.950
279 (91%) 448 (90%) 58 (88%) 5
27 (9%) 47 (10%) 8 (12%) 6
0.708
347 (91%) 443 (89%)
35 (9%) 53 (11%)
0.456
658 (89%) 132 (93%)
78 (11%) 10 (7%)
0.196
327 (89%) 341 (91%) 122 (90%)
40 (11%) 34 (9%) 14 (10%)
0.703
690 (89%) 100 (93%)
81 (11%) 7 (7%)
0.201
283 315 92 91
(91%) (88%) (88%) (93%)
27 (9%) 41 (12%) 13 (12%) 7 (7%)
0.313
342 (91%) 411 (89%) 37
35 (9%) 50 (11%) 3
0.456
Notes: Bold values represent statistical significance. DK/NA = Does not know/No answer.
Variables of knowledge of and attitude toward organ donation and transplantation When the respondent considered that they might need a transplant in the future, this may have also positively affected acceptance of LKD, specially in comparison with those who did not consider this option (94% vs. 79%; p50.001) (Table 2). It was found that a favorable attitude toward other types of donation favored acceptance of LKD. For example, those who were in favor of deceased organ donation had a more favorable attitude toward LKD compared to those who were not in favor (93% vs. 80%; p50.001). This was also the case for those who were prepared to accept living liver donation compared to those who were not (99% vs. 50%; p50.001). Similarly those who would accept a kidney from a living donor, if one were needed, were more in favor than those who were undecided about accepting a kidney (97% vs. 71%; p50.001). Social interaction and pro-social behavior variables A positive association has been found between attitude toward LKD and being prepared to carry out pro-social activities,
above all compared to those who had no intention of participating in these kinds of social activities (92% vs. 80%; p ¼ 0.007) (Table 2). Religious variables No relevant relationships have been found between religious variables and attitude toward LKD (Table 3). Variables of attitude toward the body No associations have been found between the variables and attitude toward LKD (Table 3). Multivariate analysis On carrying out the multivariate analysis for assessing the variables with most weight affecting attitude toward LKD we found that statistical significance persists in both of the following variables (Table 4): (1) a favorable attitude toward living liver donation (Odds Ratio ¼ 58.823; p50.001); and (2) being prepared to accept a kidney from a living donor if one were needed (OR ¼ 8.771; p50.001).
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Table 2. Variables of knowledge about and attitude toward organ donation and transplantation, and of social interaction and pro-social behavior affecting attitude toward related LKD among personnel from hospital services directly related with the organ donation and transplantation process in Spain and Latin America. Variable Knowledge of and attitude toward organ donation and transplantation Personal experience of donation and transplantation: Yes (n ¼ 299) No (n ¼ 579) Attitude toward deceased donation: In Favor (n ¼ 686) Against – Undecided (n ¼ 192) Possibility of needing a transplant: Yes (n ¼ 424) No (n ¼ 14) Doubts (n ¼ 440) Attitude toward living liver donation: Yes (n ¼ 196) Yes, only related (n ¼ 524) Never (n ¼ 90) Undecided (n ¼ 68) Acceptance of living kidney donation if it was needed: Yes (n ¼ 579) No (n ¼ 81) Doubts (n ¼ 218) SOCIAL INTERACTION AND PRO-SOCIAL BEHAVIOR Family discussion about donation and transplantation: Yes (n ¼ 677) No (n ¼ 201) The respondent’s partner’s opinion about donation and transplantation: Yes, in favor (n ¼ 450) I do not know it (n ¼ 179) Yes, against (n ¼ 44) I do not have a partner (n ¼ 142) DK/NA (n ¼ 63) Carrying out pro-social activities: Yes (n ¼ 223) No (n ¼ 54) No, but I would like to (n ¼ 566) DK/NA (n ¼ 35)
In favor (n ¼ 790; 90%)
Not in favor (n ¼ 88; 10%)
p
265 (89%) 525 (91%)
34 (11%) 54 (9%)
0.339
636 (93%) 154 (80%)
50 (7%) 38 (10%)
50.001
400 (94%) 11 (79%) 379 (86%)
24 (6%) 3 (21%) 61 (14%)
50.001
194 517 63 16
(99%) (99%) (70%) (23%)
2 (1%) 7 (1%) 27 (30%) 52 (77%)
50.001
563 (97%) 72 (89%) 155 (71%)
16 (3%) 9 (11%) 63 (29%)
50.001
615 (91%) 175 (87%)
62 (9%) 26 (13%)
0.117
(96%) (93%) (93%) (92%) 22
20 (4%) 13 (7%) 3 (7%) 11 (8%) 41
0.348
197 (88%) 43 (80%) 521 (92%) 29
26 (12%) 11 (20%) 45 (8%) 6
0.007
430 166 41 131
Notes: Bold values represent statistical significance. DK/NA ¼ Does not know/No answer.
Table 3. Religious variables and variables of attitude toward the body which affect attitude toward related LKD among personnel form hospital services directly related with the organ donation and transplantation process in Spain and Latin America.
Variable Religious A respondent’s religion: Catholic (n ¼ 664) Other religions (n ¼ 22) Atheist/agnostic (n ¼ 142) DK/NA (n ¼ 50) Knowledge of the attitude of one’s religion toward donation and transplantation: Yes, in favor (n ¼ 388) Yes, against (n ¼ 12) I do not know it (n ¼ 276) DK/NA (n ¼ 10) Attitude toward the body Concern about mutilation after donation: I am concerned (n ¼ 110) I am not concerned (n ¼ 699) DK/NA (n ¼ 69)
In favor Not in favor (n ¼ 790; 90%)(n ¼ 88; 10%) p
626 (94%) 21 (96%) 134 (94%) 9
38 (6%) 1 (4%) 8 (6%) 41
0.973
363 (94%) 10 (83%) 264 (96%) 10
25 (6%) 2 (17%) 12 (4%) –
0.137
103 (94%) 663 (95%) 24
7 (6%) 36 (5%) 45
0.598
Note: DK/NA ¼ Does not know/No answer.
Discussion There was a high level of acceptance of living kidney donation by employees working in units related to organ donation and transplantation in the Spanish speaking world. It is notable, however, that the attitude was somewhat less positive in Spain compared to that found in Mexico or Cuba. It is possible that the great development of deceased donation in the Spanish territory has made the development of living donation difficult, as shown in other studies11 because, until recently, it was well known that this activity was practically non-existent in Spain. The data found, which is very favorable, show that living donation rates could be increased in all the countries with adequate institutional support. In fact, in Spain, in recent years, they have already started to rise.4 In Mexico, the proportion is completely the other way round, given that more than three quarters of kidney transplants performed each year are from living donors and there has been a limited development in deceased donation programs in general. Here the essential problem is the continued reduction in the number of transplants carried out compared to those demanded and the impossibility of providing this treatment to everyone who needs it. Many healthcare institutions have included this objective in their
Living kidney donation
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Table 4. Variables affecting attitude toward related LKD among personnel from hospital services directly related to the organ donation and transplantation process in Spain and Latin America (multivariate study).
Variable
Regression coefficient (b)
Standard error
4.060
0.406
2.170 0.868
0.371 0.546
Attitude toward living liver donation: Not in favor (n ¼ 158) In favor (n ¼ 720) Acceptance of living kidney donation if it were necessary: Doubts (n ¼ 218) Yes (n ¼ 579) No (n ¼ 81)
Odds ratio (confidence interval) 1 58.823 (125–26.315) 1 8.771 (18.181–4.237) 2.380 (6.944–0.817)
p
50.001 50.001 0.111
Note: Bold values represent statistical significance.
priority programs for the coming years, with the aim of notably decreasing the number of patients on dialysis treatment who are in favor of transplantation. When dealing with unrelated donation, Cuban and Mexican workers had a much more favorable attitude than the Spanish (41% and 34% vs. 16%). It would seem that for the Spanish, family and emotional ties are more essential elements than they are for Latin American workers. These data could be explained by the closeness of the United States, where there are high rates of unrelated living donation, with donors precisely of Latin American origin16 and where the economic incentives are possibly a factor to take into account.17,18 In the last decade, with the corresponding legal adjustments, several countries have begun strengthening and promoting unrelated living donation13,18 as a way of alleviating the organ deficit. This could begin to favor hidden trading in organs. Perhaps, a more realistic policy with better perspectives in terms of results would be focused on the promotion of deceased donation at all levels in these countries, because the rates are far from being at an acceptable level.4 We cannot overlook the fact that although living kidney donation has a very low morbidity and mortality level and therefore involves a very low risk, it leads to a growing percentage of the healthy population with one kidney.19 An inadequate lifestyle, combined with genetic and/or cultural factors, could negatively affect this population group in the distant future. Unlike the situation in attitude toward deceased organ donation20,21 no differences have been found in terms of job category or other variables of this nature, but they have emotional and other factors related directly or indirectly with donation and transplantation.22,23 As shown in Table 2, a favorable attitude toward deceased organ donation is a factor which encourages a positive attitude toward living donation. However, it is worth noting that although they are workers in services directly related with the deceased organ donation and transplantation process, only 78% (n ¼ 215) are in favor of donating their own organs after death. This seems to be a contradictory piece of data and although we had already reported it previously9 it does not fail to cause amazement. It should be noted that this is not a one-off event but quite a generalized situation across other non-hospital worker groups, at least in Spanish speaking countries. This also leads us to reflect on our findings, because it is clear that the attitude of the personnel involved, on its own, does not guarantee success. In this way, if we provide the example of Spain, deceased donation has been a
great success and only 78% of the workers involved would donate their organs, whereas living kidney donation is regarded as a ‘‘failure’’ and yet 87% are in favor. More of the factors involved will have to be identified and institutional and political support will need to be provided.24 Attitude toward living liver donation, among other factors, has a strong association with attitude toward living kidney donation. Generally, the main problem with living donation is its acceptance; accepting that the extraction of a living organ from a healthy person is an ethically correct therapeutic option when the risk for the donor is low enough to be reasonably assumed.23,25 Finally, it remains to be seen that when the respondents report being in favor of receiving or accepting a kidney from a living donor if one were needed, they are also more in favor of the living donation of that organ. In a certain sense, as in deceased donation,23,25 the arguments of solidarity and reciprocity continue to be very important in all these acts of donation, that is, doing to others what we would like to be done to ourselves if we needed an organ.26–28 In the light of the results obtained, and above all, in the circumstances of daily life, LKD is expected to keep increasing both in Spain as well as in Latin American countries in the coming years. Most transplant centers have a living kidney program and the number of patients on the waiting list is ever increasing.4 The favorable attitude and motivation of personnel involved is of enormous importance, together with having institutional support for its development in many countries. To conclude, hospital personnel from units related to the donation and transplantation in Spain and Latin America had a very favorable attitude toward LKD, which could give them a key role for promoting donation at the current time when LKD is being encouraged. In order to achieve this, it is necessary to achieve social, political and economic support, and also the active involvement of nephrologists, without which living kidney donation would not be possible.
Declaration of interest This study was not sponsored by any entity. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Contribution to the study by the authors (1) Conception and design: Rı´os A (2) Acquisition of a subtantial portion of data: Rı´os A, Lo´pez-Navas A, Ayala-Garcı´a MA, Sebastia´n MJ,
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(4) (5)
(6) (7) (8) (9)
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Abdo-Cuza A, Martı´nez-Alarco´n L, Ramı´rez EJ, Mun˜oz G, Sua´rez-Lo´pez J, Castellanos R, Ramı´rez R, Gonza´lez B, Martı´nez MA, Dı´az E, Palacios G Analysis and interpretation of data: Rı´os A, Lo´pez-Navas A, Ayala-Garcı´a MA, Sebastia´n MJ, Abdo-Cuza A, Ala´n J, Ramı´rez P, Parrilla P Drafting of the manuscript: Rı´os A Critical revision of the manuscript for important intellectual content: Rı´os A, Lo´pez-Navas A, Ayala-Garcı´a MA, Sebastia´n MJ, Abdo-Cuza A Statistical expertise: Rı´os A, Lo´pez-Navas A Obtaining funding for this project or study: Rı´os A Supervision: Rı´os A, Lo´pez-Navas A Final approval of the version to be published: Rı´os A, Lo´pez-Navas A, Ayala-Garcı´a MA, Sebastia´n MJ, AbdoCuza A, Ala´n J, Martı´nez-Alarco´n L, Ramı´rez EJ, Mun˜oz G, Sua´rez-Lo´pez J, Castellanos R, Ramı´rez R, Gonza´lez B, Martı´nez MA, Dı´az E, Ramı´rez P, Parrilla P
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11. Arias M, de Felipe C. Trasplante renal de donante vivo: encuesta de opinio´n de los nefro´logos espan˜oles. Nefrologı´a. 1995;15:523–528. 12. Cunningham J, Cass A, Anderson K, et al. Australian nephrologists’ attitudes towards living kidney donation. Nephrol Dial Transplant. 2006;21:1178–1183. 13. Alvarez M, Martin E, Garcia A, et al. Encuesta de opinio´n sobre la donacio´n de vivo renal. Nefrologia. 2005;25:57–61. 14. Rı´os A, Conesa C, Ramı´rez P, et al. Attitude survey of hospital workers in the surgical services toward living kidney donation. Transplant Proc. 2005;37:3621–3625. 15. Conesa C, Rı´os A, Ramı´rez P, et al. Attitude of primary care nurses toward living kidney donation. Transplant Proc. 2005;37: 3626–3630. 16. Klein AS, Messersmith EE, Ratner LE, et al. Organ donation and utilization in the United States, 1999–2008. Am J Transplant. 2010; 10:973–986. 17. Gaston RS, Danovitch GM, Epstein RA, et al. Limiting financial disincentives in live organ donation: a rational solution to the kidney shortage. Am J Transplant. 2006;6:2548–2555. 18. Van Buren MC, Massey EK, Maasdam L, et al. For love or money? Attitudes toward financial incentives among actual living kidney donors. Am J Transplant. 2010;10:2488–2492. 19. Dols LF, Ijzermans JN, Wentink N, et al. Long-term follow-up of a randomized trial comparing laparoscopic and mini-incision open live donor nephrectomy. Am J Transplant. 2010;10:2481–2487. 20. Rı´os A, Ramı´rez P, Martı´nez L, et al. Are personnel in transplant hospitals in favor of cadaveric organ donation? Multivariate attitudinal study in a hospital with a solid organ transplant program. Clin Transplant. 2006;20:743–754. 21. Rı´os A, Ramı´rez P, Galindo PJ, et al. Primary health care personnel faced with cadaveric organ donation: a multicenter study in southeastern Spain. Clin Transplant. 2008;22:657–663. 22. Rı´os A, Martı´nez-Alarco´n L, Sa´nchez J, 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;23:1720–1727. 23. Rı´os A, Cascales P, Martı´nez L, et al. Emigration from the British Isles to south-eastern Spain: a study of attitudes toward organ donation. Am J Transplant. 2007;7:2020–2030. 24. Hilhorst MT, Kranenburg LW, Zuidema W, et al. Altruistic living kidney donation challenges psychosocial research and policy: a response to previous articles. Transplantation. 2005;79:1470–1474. 25. Conesa C, Rı´os A, Ramı´rez P, et al. Estudio multivariante de los factores psicosociales que influyen en la actitud poblacional hacia la donacio´n de o´rganos. Nefrologı´a. 2005;25:684–697. 26. Rı´os A, Martı´nez-Alarco´n L, Sa´nchez J, et al. German citizens in southeastern Spain: a study of attitude toward organ donation. Clin Transplant. 2010;24:349–357. 27. Rı´os A, Martinez L, Sa´nchez J, et al. Factors that influence the attitude of East European residents in Spain toward living kidney donation. Transplant Int. 2009;22:707–716. 28. Rı´os A, Ramı´rez P, Rodrı´guez MM, et al. Attitude of hospital personnel faced with living liver donation in a Spanish center with a living donor liver transplant program. Liver Transplant. 2007;13: 1049–1056.
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CLINICAL STUDY
The attitude toward living kidney donation among personnel from units related to donation and transplantation in Spain, Mexico and Cuba Antonio Rı´os1,2,3,4, Ana Lo´pez-Navas2,5, Marco Antonio Ayala-Garcı´a6,7, Marı´a Jose´ Sebastia´n8, Anselmo Abdo-Cuza9, Laura Martı´nez-Alarco´n1,2,3, Ector Jaime Ramı´rez10, Gerardo Mun˜oz11, Gerardo Palacios8, Juliette Sua´rez-Lo´pez12, Ricardo Castellanos9, Beatriz Gonza´lez6,10, Miguel Angel Martı´nez13, Ernesto Dı´az6,7, Pablo Ramı´rez1,2,3,4, and Pascual Parrilla3,4 1
Proyecto Colaborativo Internacional Donante, ‘‘International Collaborative Donor Project’’, Murcia, Spain, 2Regional Transplant Center, Consejerı´a de Sanidad y Consumo de la Regio´n de Murcia, Spain, 3Transplant Unit, Surgery Service, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain, 4 Department of Surgery, University of Murcia, Murcia, Spain, 5Department of Psychology, Universidad Cato´lica San Antonio, UCAM, Murcia, Spain, 6 Hospital Regional de Alta Especialidad del Bajı´o, Leo´n, Guanajuato, Mexico, 7HGSZ No. 10 del Instituto Mexicano del Seguro Social Delegacio´n Guanajuato, Mexico, 8Transplant Coordination Center, UMAE Hospital de Especialidades N 25 IMSS, Monterrey, Mexico, 9Surgical Medical Research Center, Cuba, 10Department of Medicine, University of Guanajuato, Mexico, 11The 21st Century National Medical Center, Mexican Institute of Social Security, Mexico, 12Hermanos Ameijeiras Hospital, Cuba, and 13State Public Health Institute of Guanajuato, Mexico Abstract
Keywords
Background: Living kidney donation (LKD) is becoming increasingly necessary as a treatment option for reducing the deficit in transplant organs. Hospital personnel in services related to donation and transplantation play a key role in promoting this kind of donation. Objective: To analyze the attitude toward LKD among hospital workers in services related to donation and transplantation in Spain and Latin America. Methods: Eight hospitals in the ‘‘International Collaborative Donor Project’’ were selected (Spain–Mexico–Cuba). A random sample was taken which was stratified according to the type of service and job category, in transplant-related services. Results: Of the 878 respondents, 90% were in favor of related LKD, and 28% were in favor if the LKD was not related. Attitude was more favorable among Latin Americans workers compared to the Spanish (p ¼ 0.014). Other factors associated to attitude included: age (p ¼ 0.004); an attitude in favor of deceased donation and living liver donation (p50.001); and acceptance of a kidney from a donor (p50.001). Conclusions: The attitude toward related LKD was very favorable among hospital personnel in units related to the donation and transplantation process in Spain and Latin America, which means that they could contribute to its promotion particularly at the current time when living kidney donation needs to be expanded.
Attitude, hospital personnel, living kidney donation, transplant-related services
Dialysis has been one of the greatest advances in the management of chronic kidney failure because it has made it possible to drastically reduce mortality in these patients.1 Following this, kidney transplantation has become the treatment of choice, allowing kidney patients to resume their daily activities with an excellent quality of life, similar to that of an individual without any kind of pathology.2,3 Currently, kidney transplantation is carried out using both deceased and living donors. Deceased kidney donation is the most utilized in Spain, although, it no longer provides sufficient organs to cover the demand for kidney transplantation.4 Living kidney donation (LKD) involves low morbidity
Address correspondence to Dr. Antonio Rı´os Zambudio, Avenida de la Libertad n 208, Casillas, 30007 Murcia, Spain. Tel: 968 27 07 57; Fax: 968.36.97.16; E-mail: [email protected]
Received 24 August 2013 Revised 22 November 2013 Accepted 4 December 2013 Published online 5 February 2014
and has few after effects in the donor, with better results than those obtained with deceased donors.5–7 However, in many countries, especially in Spanish speaking countries, it is used very infrequently.4 In Spain, for instance, the LKD rate is 5 p.m.p. (in 2009), in Mexico it is 16 p.m.p. (in 2010) and in Cuba 2.5 p.m.p. in the 2008.4,8 The implication and involvement of healthcare personnel whose work is related with these activities, clearly affects the development of this type of transplantation in areas where it is least used.9–12 It is notable that although most of the groups surveyed are in favor of this activity,12 in the Spanish speaking areas the data show that they are not always in favor of this type of donation.11 In spite of the different circumstances faced by each country, there is no doubt that in all of them there is a deficit of kidney transplant organs and the need for more organs is growing. Many governments and healthcare institutions have prioritized donation programs in order to try to
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Introduction
History
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increase the number of transplants. Without a doubt, kidney transplantation from living donors requires the immediate and active participation of society, especially in families. Given this situation, the attitude of hospital workers who carry out their job activity in services related to the donation and transplant process is important: an unfavorable attitude could become a barrier to the development of this way of procuring organs and vice versa: a positive attitude will enhance donor procurement.9,10 The latest data available in the Spanish speaking world and provided by our own group, show that attitude is favorable toward living kidney donation among personnel from units related with the donation and transplantation process.9 However, these data are limited to just one hospital and there are no further data to make us think these could be representative of attitude in all geographical areas.11,13 The objective of this study is to analyze the attitude toward living kidney donation among hospital workers in transplant-related services from Spain and Latin America (Mexico and Cuba), and to analyze the variables affecting this attitude.
Material and methods Study population Eight hospitals in the ‘‘International Donor Collaboration Project’’ were selected; three in Spain, three in Mexico and two in Cuba. In these hospitals a random sample was taken and stratified according to service and job category (physicians, nurses, healthcare assistants and non-healthcare personnel) among transplant-related services. These services were grouped into three categories: (1) donor procurement units (intensive care units, postoperative recovery unit, and neurosurgery unit); (2) transplant units (general surgery and digestive apparatus service, urology service, and cardiovascular surgery service); and transplant patient follow-up units (internal medicine of the digestive apparatus, nephrology and cardiology). Opinion survey and study variables Attitude toward living kidney donation was assessed using a survey of the psychosocial aspects of organ donation and transplantation which was validated in our geographical area.9,10,14,15 For the distribution of these questionnaires contact was made with the head of service for the physicians’ questionnaire, with the nursing coordinator for the nursing personnel and an administrator for non-healthcare personnel, who were each given an explanation of the study and were made responsible for handing out the survey in selected work shifts. The survey was completed anonymously and was self-administered. Attitude toward related and unrelated LKD was analyzed as the dependent variable. The independent variables were grouped into: (1) Demographic: Country; (2) Socio-personal: Age, sex and marital status; (3) Job: Type of clinical service, type of hospital, service according to its relationship with transplantation, type of personnel, job category and job situation; (4) Knowledge of and attitude toward organ donation and transplantation: Personal experience of organ
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donation and transplantation, attitude toward deceased donation, a belief in the possibility of needing a transplant oneself in the future, attitude toward living liver donation, and acceptance of a kidney from a living donor if one were needed; (5) Social interaction and pro-social behavior: Discussion with the family about donation and transplantation, a partner’s opinion toward donation and transplantation and toward carrying out pro-social type activities; (6) Religious: The respondent’s religion and knowledge of the attitude of his or her religion toward donation and transplantation; and (7) Attitude toward the body: Concern about mutilation after donation. Statistical analysis The data were stored on a database and analyzed using the SPSS 15.0 statistical package (SPSS Inc., Chicago, IL). A descriptive statistical analysis was carried out on each of the variables, and to compare the different variables Student’s ttest and the 2 test was applied, complemented by an analysis of remainders. In order to determine and evaluate the multiple risks, logistic regression was carried out using the variables which had a statistically significant association in the bivariate analysis. In all cases, only p values of less than 0.05 were considered as statistically significant.
Results Attitude toward LKD A total of 878 workers were surveyed; 354 from Spain, 386 from Mexico and 138 from Cuba. 90% (n ¼ 790) were in favor of related LKD, 4% (n ¼ 32) were against and 6% (n ¼ 56) undecided. Attitude was less favorable among Cubans at 95% (n ¼ 131) in favor, followed by Mexicans at 91% (n ¼ 352) and the Spanish at 87% (n ¼ 307) (p ¼ 0.014). When unrelated LKD was considered, only 28% (n ¼ 242) were in favor. Attitude was most favorable among Cubans, where 41% (n ¼ 57) were in favor, followed by Mexicans where 34% (n ¼ 130) were in favor, and finally the Spanish with 16% (n ¼ 55) in favor (p50.001). Factors affecting attitude toward LKD Demographic variable According to the respondents’ country, attitude was more favorable among Cubans at 95% (n ¼ 131) in favor, followed by the Mexicans at 91% (n ¼ 352) and the Spanish at 87% (n ¼ 307) (p ¼ 0.014) (Table 1). Socio-personal variables The only differences found depended on age. It was found that those who were in favor of related LKD tended to have a younger mean age than those who were not in favor (37 ± 10 years versus 40 ± 11 years; p ¼ 0.004) (Table 1). Job variables No relevant relationships were found between attitude toward LKD and job variables (Table 1).
Living kidney donation
DOI: 10.3109/0886022X.2013.875814
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Table 1. Demographic, socio-personal and job variables which affect attitude toward related LKD among personnel from hospital services directly related to the organ donation and transplantation process in Spain and Latin America. Variable Demographic Country: Spain (n ¼ 354) Mexico (n ¼ 386) Cuba (n ¼ 138) Socio-personal Age: (37 ± 10 years) Sex: Male (n ¼ 339) Female (n ¼ 531) DK/NA (n ¼ 8) Marital status: Single (n ¼ 306) Married (n ¼ 495) Widowed, separated, divorced (n ¼ 66) DK/NA (n ¼ 11) Job Type of service in which he or she works: Surgical (n ¼ 382) Medical (n ¼ 496) Type of hospital: Transplant Hospital (n ¼ 736) Procurement Hospital (n ¼ 142) Service according to its relationship with transplantation: Donor Procurement Units (n ¼ 367) Transplant Units (n ¼ 375) Transplant Follow-up Units (n ¼ 136) Type of personnel: Healthcare personnel (n ¼ 771) Non-healthcare personnel (n ¼ 107) Job category: Physician (n ¼ 310) Nursing (n ¼ 356) Healthcare Assistant (n ¼ 105) Non-healthcare personnel (n ¼ 107) Job situation: Permanent position (n ¼ 377) Temporary, contracted (n ¼ 461) DK/NA (n ¼ 40)
In favor (n ¼ 790; 90%) Not in favor (n ¼ 88; 10%)
p
307 (87%) 352 (91%) 131 (95%)
47 (13%) 34 (9%) 7 (5%)
0.014
37 ± 10 an˜os
40 ± 11 years
0.004
306 (90%) 480 (90%) 4
33 (10%) 51 (10%) 4
0.950
279 (91%) 448 (90%) 58 (88%) 5
27 (9%) 47 (10%) 8 (12%) 6
0.708
347 (91%) 443 (89%)
35 (9%) 53 (11%)
0.456
658 (89%) 132 (93%)
78 (11%) 10 (7%)
0.196
327 (89%) 341 (91%) 122 (90%)
40 (11%) 34 (9%) 14 (10%)
0.703
690 (89%) 100 (93%)
81 (11%) 7 (7%)
0.201
283 315 92 91
(91%) (88%) (88%) (93%)
27 (9%) 41 (12%) 13 (12%) 7 (7%)
0.313
342 (91%) 411 (89%) 37
35 (9%) 50 (11%) 3
0.456
Notes: Bold values represent statistical significance. DK/NA = Does not know/No answer.
Variables of knowledge of and attitude toward organ donation and transplantation When the respondent considered that they might need a transplant in the future, this may have also positively affected acceptance of LKD, specially in comparison with those who did not consider this option (94% vs. 79%; p50.001) (Table 2). It was found that a favorable attitude toward other types of donation favored acceptance of LKD. For example, those who were in favor of deceased organ donation had a more favorable attitude toward LKD compared to those who were not in favor (93% vs. 80%; p50.001). This was also the case for those who were prepared to accept living liver donation compared to those who were not (99% vs. 50%; p50.001). Similarly those who would accept a kidney from a living donor, if one were needed, were more in favor than those who were undecided about accepting a kidney (97% vs. 71%; p50.001). Social interaction and pro-social behavior variables A positive association has been found between attitude toward LKD and being prepared to carry out pro-social activities,
above all compared to those who had no intention of participating in these kinds of social activities (92% vs. 80%; p ¼ 0.007) (Table 2). Religious variables No relevant relationships have been found between religious variables and attitude toward LKD (Table 3). Variables of attitude toward the body No associations have been found between the variables and attitude toward LKD (Table 3). Multivariate analysis On carrying out the multivariate analysis for assessing the variables with most weight affecting attitude toward LKD we found that statistical significance persists in both of the following variables (Table 4): (1) a favorable attitude toward living liver donation (Odds Ratio ¼ 58.823; p50.001); and (2) being prepared to accept a kidney from a living donor if one were needed (OR ¼ 8.771; p50.001).
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Table 2. Variables of knowledge about and attitude toward organ donation and transplantation, and of social interaction and pro-social behavior affecting attitude toward related LKD among personnel from hospital services directly related with the organ donation and transplantation process in Spain and Latin America. Variable Knowledge of and attitude toward organ donation and transplantation Personal experience of donation and transplantation: Yes (n ¼ 299) No (n ¼ 579) Attitude toward deceased donation: In Favor (n ¼ 686) Against – Undecided (n ¼ 192) Possibility of needing a transplant: Yes (n ¼ 424) No (n ¼ 14) Doubts (n ¼ 440) Attitude toward living liver donation: Yes (n ¼ 196) Yes, only related (n ¼ 524) Never (n ¼ 90) Undecided (n ¼ 68) Acceptance of living kidney donation if it was needed: Yes (n ¼ 579) No (n ¼ 81) Doubts (n ¼ 218) SOCIAL INTERACTION AND PRO-SOCIAL BEHAVIOR Family discussion about donation and transplantation: Yes (n ¼ 677) No (n ¼ 201) The respondent’s partner’s opinion about donation and transplantation: Yes, in favor (n ¼ 450) I do not know it (n ¼ 179) Yes, against (n ¼ 44) I do not have a partner (n ¼ 142) DK/NA (n ¼ 63) Carrying out pro-social activities: Yes (n ¼ 223) No (n ¼ 54) No, but I would like to (n ¼ 566) DK/NA (n ¼ 35)
In favor (n ¼ 790; 90%)
Not in favor (n ¼ 88; 10%)
p
265 (89%) 525 (91%)
34 (11%) 54 (9%)
0.339
636 (93%) 154 (80%)
50 (7%) 38 (10%)
50.001
400 (94%) 11 (79%) 379 (86%)
24 (6%) 3 (21%) 61 (14%)
50.001
194 517 63 16
(99%) (99%) (70%) (23%)
2 (1%) 7 (1%) 27 (30%) 52 (77%)
50.001
563 (97%) 72 (89%) 155 (71%)
16 (3%) 9 (11%) 63 (29%)
50.001
615 (91%) 175 (87%)
62 (9%) 26 (13%)
0.117
(96%) (93%) (93%) (92%) 22
20 (4%) 13 (7%) 3 (7%) 11 (8%) 41
0.348
197 (88%) 43 (80%) 521 (92%) 29
26 (12%) 11 (20%) 45 (8%) 6
0.007
430 166 41 131
Notes: Bold values represent statistical significance. DK/NA ¼ Does not know/No answer.
Table 3. Religious variables and variables of attitude toward the body which affect attitude toward related LKD among personnel form hospital services directly related with the organ donation and transplantation process in Spain and Latin America.
Variable Religious A respondent’s religion: Catholic (n ¼ 664) Other religions (n ¼ 22) Atheist/agnostic (n ¼ 142) DK/NA (n ¼ 50) Knowledge of the attitude of one’s religion toward donation and transplantation: Yes, in favor (n ¼ 388) Yes, against (n ¼ 12) I do not know it (n ¼ 276) DK/NA (n ¼ 10) Attitude toward the body Concern about mutilation after donation: I am concerned (n ¼ 110) I am not concerned (n ¼ 699) DK/NA (n ¼ 69)
In favor Not in favor (n ¼ 790; 90%)(n ¼ 88; 10%) p
626 (94%) 21 (96%) 134 (94%) 9
38 (6%) 1 (4%) 8 (6%) 41
0.973
363 (94%) 10 (83%) 264 (96%) 10
25 (6%) 2 (17%) 12 (4%) –
0.137
103 (94%) 663 (95%) 24
7 (6%) 36 (5%) 45
0.598
Note: DK/NA ¼ Does not know/No answer.
Discussion There was a high level of acceptance of living kidney donation by employees working in units related to organ donation and transplantation in the Spanish speaking world. It is notable, however, that the attitude was somewhat less positive in Spain compared to that found in Mexico or Cuba. It is possible that the great development of deceased donation in the Spanish territory has made the development of living donation difficult, as shown in other studies11 because, until recently, it was well known that this activity was practically non-existent in Spain. The data found, which is very favorable, show that living donation rates could be increased in all the countries with adequate institutional support. In fact, in Spain, in recent years, they have already started to rise.4 In Mexico, the proportion is completely the other way round, given that more than three quarters of kidney transplants performed each year are from living donors and there has been a limited development in deceased donation programs in general. Here the essential problem is the continued reduction in the number of transplants carried out compared to those demanded and the impossibility of providing this treatment to everyone who needs it. Many healthcare institutions have included this objective in their
Living kidney donation
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Table 4. Variables affecting attitude toward related LKD among personnel from hospital services directly related to the organ donation and transplantation process in Spain and Latin America (multivariate study).
Variable
Regression coefficient (b)
Standard error
4.060
0.406
2.170 0.868
0.371 0.546
Attitude toward living liver donation: Not in favor (n ¼ 158) In favor (n ¼ 720) Acceptance of living kidney donation if it were necessary: Doubts (n ¼ 218) Yes (n ¼ 579) No (n ¼ 81)
Odds ratio (confidence interval) 1 58.823 (125–26.315) 1 8.771 (18.181–4.237) 2.380 (6.944–0.817)
p
50.001 50.001 0.111
Note: Bold values represent statistical significance.
priority programs for the coming years, with the aim of notably decreasing the number of patients on dialysis treatment who are in favor of transplantation. When dealing with unrelated donation, Cuban and Mexican workers had a much more favorable attitude than the Spanish (41% and 34% vs. 16%). It would seem that for the Spanish, family and emotional ties are more essential elements than they are for Latin American workers. These data could be explained by the closeness of the United States, where there are high rates of unrelated living donation, with donors precisely of Latin American origin16 and where the economic incentives are possibly a factor to take into account.17,18 In the last decade, with the corresponding legal adjustments, several countries have begun strengthening and promoting unrelated living donation13,18 as a way of alleviating the organ deficit. This could begin to favor hidden trading in organs. Perhaps, a more realistic policy with better perspectives in terms of results would be focused on the promotion of deceased donation at all levels in these countries, because the rates are far from being at an acceptable level.4 We cannot overlook the fact that although living kidney donation has a very low morbidity and mortality level and therefore involves a very low risk, it leads to a growing percentage of the healthy population with one kidney.19 An inadequate lifestyle, combined with genetic and/or cultural factors, could negatively affect this population group in the distant future. Unlike the situation in attitude toward deceased organ donation20,21 no differences have been found in terms of job category or other variables of this nature, but they have emotional and other factors related directly or indirectly with donation and transplantation.22,23 As shown in Table 2, a favorable attitude toward deceased organ donation is a factor which encourages a positive attitude toward living donation. However, it is worth noting that although they are workers in services directly related with the deceased organ donation and transplantation process, only 78% (n ¼ 215) are in favor of donating their own organs after death. This seems to be a contradictory piece of data and although we had already reported it previously9 it does not fail to cause amazement. It should be noted that this is not a one-off event but quite a generalized situation across other non-hospital worker groups, at least in Spanish speaking countries. This also leads us to reflect on our findings, because it is clear that the attitude of the personnel involved, on its own, does not guarantee success. In this way, if we provide the example of Spain, deceased donation has been a
great success and only 78% of the workers involved would donate their organs, whereas living kidney donation is regarded as a ‘‘failure’’ and yet 87% are in favor. More of the factors involved will have to be identified and institutional and political support will need to be provided.24 Attitude toward living liver donation, among other factors, has a strong association with attitude toward living kidney donation. Generally, the main problem with living donation is its acceptance; accepting that the extraction of a living organ from a healthy person is an ethically correct therapeutic option when the risk for the donor is low enough to be reasonably assumed.23,25 Finally, it remains to be seen that when the respondents report being in favor of receiving or accepting a kidney from a living donor if one were needed, they are also more in favor of the living donation of that organ. In a certain sense, as in deceased donation,23,25 the arguments of solidarity and reciprocity continue to be very important in all these acts of donation, that is, doing to others what we would like to be done to ourselves if we needed an organ.26–28 In the light of the results obtained, and above all, in the circumstances of daily life, LKD is expected to keep increasing both in Spain as well as in Latin American countries in the coming years. Most transplant centers have a living kidney program and the number of patients on the waiting list is ever increasing.4 The favorable attitude and motivation of personnel involved is of enormous importance, together with having institutional support for its development in many countries. To conclude, hospital personnel from units related to the donation and transplantation in Spain and Latin America had a very favorable attitude toward LKD, which could give them a key role for promoting donation at the current time when LKD is being encouraged. In order to achieve this, it is necessary to achieve social, political and economic support, and also the active involvement of nephrologists, without which living kidney donation would not be possible.
Declaration of interest This study was not sponsored by any entity. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Contribution to the study by the authors (1) Conception and design: Rı´os A (2) Acquisition of a subtantial portion of data: Rı´os A, Lo´pez-Navas A, Ayala-Garcı´a MA, Sebastia´n MJ,
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(3)
(4) (5)
(6) (7) (8) (9)
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Abdo-Cuza A, Martı´nez-Alarco´n L, Ramı´rez EJ, Mun˜oz G, Sua´rez-Lo´pez J, Castellanos R, Ramı´rez R, Gonza´lez B, Martı´nez MA, Dı´az E, Palacios G Analysis and interpretation of data: Rı´os A, Lo´pez-Navas A, Ayala-Garcı´a MA, Sebastia´n MJ, Abdo-Cuza A, Ala´n J, Ramı´rez P, Parrilla P Drafting of the manuscript: Rı´os A Critical revision of the manuscript for important intellectual content: Rı´os A, Lo´pez-Navas A, Ayala-Garcı´a MA, Sebastia´n MJ, Abdo-Cuza A Statistical expertise: Rı´os A, Lo´pez-Navas A Obtaining funding for this project or study: Rı´os A Supervision: Rı´os A, Lo´pez-Navas A Final approval of the version to be published: Rı´os A, Lo´pez-Navas A, Ayala-Garcı´a MA, Sebastia´n MJ, AbdoCuza A, Ala´n J, Martı´nez-Alarco´n L, Ramı´rez EJ, Mun˜oz G, Sua´rez-Lo´pez J, Castellanos R, Ramı´rez R, Gonza´lez B, Martı´nez MA, Dı´az E, Ramı´rez P, Parrilla P
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