Multiple studies find that kidney patients are uncomfortable asking potential living donors to donate, but less is known about the specific reasons why not. This mixed methods study examined reasons why recipients don't ask qualitatively, then determined the most salient predictors of being unwilling to ask.

We surveyed 750 patients presenting for kidney transplant in St. Louis, MO about their attitudes toward pursuing living donor kidney transplant (LDKT). Patients who reported being unwilling to ask then answered an open-ended question as to why not. These qualitative reasons were coded into themes and the percent of answers within each was calculated. Using the entire sample, we identified survey questions about patients' decision-making that were similar to each theme and conducted multivariable logistic regression to predict being unwilling to ask based on demographic, clinical, and decision-making factors.

Forty-four percent of patients were unwilling to ask someone to be a living donor, with 78% of these stating they "would not" ask and 22% stating they "could not" ask. The majority of the recipients unwilling to ask reported experiencing high levels of psychological distress about asking. In addition, some had no eligible living donors or volunteers. In multivariable logistic regression, we found that patients who feared pressuring a potential living donor (Odds ratio: 2.09; 95% CI: 1.37-3.19), did not perceive that a donor would benefit from LDKT (1.88; 95% CI: 1.35-2.62), felt they were too old to benefit from LDKT (1.53; 95% CI: 1.06-2.18), were White (2.35; 95% CI: 1.60-3.37), and had polycystic kidney disease (1.78; 1.08-2.92) were more unwilling to ask.

Within LDKT educational programs, either finding a way to support patients in combating the anxiety and stress about asking or working around it by having transplant champions make the requests instead may help more patients pursuit LDKT.

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