The results of this study showed that over 60% of adult participants expressed their willingness to support the legalization of ULKD in Poland, and one in ten declared to voluntarily donate a kidney to a stranger. Their knowledge and attitudes regarding bone marrow transplantation or organ transplantation after death, organ transplantation from living donors, and the risk of organ trafficking were associated with support for the legalization of ULKD. Also, those viewing selfless donation of a kidney to a stranger as a positive act were more likely to support ULKD legalization compared to those who did not view donation in this manner. These data show that altruism is one of several variables to consider when approaching this topic for both Polish legislative change and ultimately UKLD promotion.
Compared to a similar, prior Polish study  our study indicates that support for ULKD is increasing. Namely, in 2006, Kowal et al. found only 0.2% of Poles supported ULKD, whereas 14 years later, we observed 10.4% supported ULKD. According to our study, nearly 80% (79.2%) of respondents would give a kidney to a close person. For comparison, in Denmark, 85.2% of respondents declared the readiness of living kidney donation to an identified person . In Singapore, 48% of respondents would be willing to donate a living kidney, while 13.9% of those under 40, 17.4% of those aged between 40 and 60 and 31.4% of those over 60 years of age would consider donating to a stranger . According research by Spital et al., 45% of respondents would donate a kidney to a stranger . In Turkey, the percentage of people who would donate a kidney to a stranger is 26.8%, while 67% of respondents would give a kidney to a loved one .
Historical increases in the willingness to donate organs after death led to the hypothesis that support for legalizing ULDK donation may also increase over time. In Poland, attitudes towards organ transplantation have changed over the last two decades. Our research shows that 76% of Poles over 18 years of age would agree to posthumous organ donation, whereas in 2010 such a declaration was made by 53% .
As the logistic regression shows, legalization of kidney donation for a stranger would be accepted by Poles who support organ donation after death or who are convinced that bone marrow donation is safe. This potentially signals the value of donation education and knowledge in donation preferences. Accordingly, efforts to legalize ULKD would need to include educational endeavors that would explain ULKD in lay language across Poland. Benchmarking with educational materials used in other countries and adapting these to Polish culture should be performed so that the materials would be ready for use alongside a legislative change permitting ULKD.
In Poland, the percentage of living donation is low. A 2019 study on the attitude of Poles towards transplantation conducted by the Medical University of Szczecin shows that 58% of Poles do not trust the health care system . According to 2010 data, 36% of Poles are afraid of manipulation on the human body . Similarly, Nordfalk et al. found that 12.7% of Danish respondents have fears about not actually being dead during organ donation, and they also conclude that bodily integrity may be a concern for some people who do not support organ donation .
Moreover, 17.7% of respondents to our survey believe that a possibility of ULKD will greatly contribute to organ trafficking, and 58% believe that ULKD could promote organ trafficking.
People afraid of increasing the risk of organ trafficking will likely not approve ULKD legislative initiatives, thus it is vital that the legislation be clear that organ trafficking is a crime with serious punishment. As Poland is a predominately Catholic country (70.6% of our respondents declared to be Catholic), educational efforts should also include the Papal support for living and deceased organ donation . Other potential concerns about ULKD such as donor screening and expenses, and the promotion of ULKD programs can be addressed by reflecting on best practices in high volume regions of the world [17, 29].
No statistically significant relationship was found between sociodemographic factors and support for legalizing ULKD in Poland (apart from living in certain voivodships), yet, there was a high level of support of the legalization of ULKD from those living in rural areas (66%). Perhaps rural Poles realize that the need for a kidney donor would be greater in their region (due to an inadequate supply of deceased donors or local living [donor] relatives. ULKD would provide a mechanism to clinically support the rural community who has end-stage renal disease, helping preserve the rural population. Notably, the West Pomeranian Voivodeship evidenced the strongest support for ULKD. This voivodeship is renowned for its wide array of health resorts and geothermal spas, as well as seven universities and one science-technology park – creating an environment that is clinically intellectual and innovative. There is an absence of such content in the Warmian-Masurian Voivodeship (lowest level of support for ULKD). The lowest level of ULKD support was noted amongst respondents who had no siblings. This may represent a generally pessimistic attitude about pursuit of transplant in the context of no family to rely on for support.
In 2010, only 27% of Poles surveyed declared knowledge of the law on organ transplantation . In 2016, more than half of the respondents (51%) did not know what regulations regarding organ transplantation were in force in Poland. Our study found 30.6% of respondents do not know who, according to Polish law, can become a living kidney donor. More than half of the respondents (55.7%) said that only blood-relatives can donate kidneys to each other. This is a strong indicator that public education efforts must include clinical concepts that inform about the suitability for non-relatives to be effective “clinical matches” for people in need of kidney transplantation. People will not support ULKD if they think it is scientifically or clinically incorrect. Additionally, educational materials should include content that decries organ trafficking as both unethical and illegal.
Chronic kidney disease is the second most common chronic disease in Poland, after arterial hypertension, currently affecting about 4.2 million people. End-stage renal disease requiring dialysis or transplant impacts approximately 6,500 Poles yearly (approximately 170 people per million inhabitants), and the number of patients receiving dialysis is increasing by approximately 1.8% annually. It is estimated that in Poland, the number of dialysis patients may exceed 30,000 by 2030 . Living kidney donation (including ULKD) is a viable clinical option to increase the number of kidney transplants and reduce dependence on costly and burdensome dialysis.
Implications for clinical practice
The positive trend of Polish support for ULKD is encouraging. This sets the stage for legalization of ULKD, as well as a receptive population to educate about the process of ULKD, and arranging robust ULKD screening and support programs for these donors. The end result will benefit Polish patients with end-stage renal disease, as well as benefit the Polish health system (as transplantation is ultimately more cost-effective than dialysis) [31, 32].
Our study, amongst others [33, 34] has shown that whilst altruism is a significant driver for UKLD, it is not enough to facilitate these donations. There is a need for actions aimed at increasing knowledge and awareness regarding donation and transplantation. Tools include social media campaigns, educational programmes in schools, and popular science programmes targeting a wide audience. Content can include pre- and post-transplant stories, as well as donation stories in order to make concepts real rather than theoretical. Additionally, educational material should be balanced, including content pertaining to the risks (physical, psychological, financial) of living organ donation, and there should be follow up and support services for all living donors to ensure their welfare.
Strengths and limitations
The strengths of the study is the large sample sizes. The structure of the sample was selected according to the representation in the population for gender, age and size of the place of residence. A minor study limitation is that the participant sample did not include other types of residents of Poland such as non-citizens (i.e., permanent residents); however, 99.2% of residents in Poland are Polish nationals . Long-time residents of Poland might consider themselves “Polish” and are able to be both organ donors and recipients, yet their views regarding UKLD were not solicited as they are not eligible to vote (to change existing organ donation law). Also, there is a small risk of sampling bias with any mass crowdsourced survey cohort in that there is a risk of a subpopulation of frequent survey takers who know how to manipulate survey-taking (thus lowering effect sizes). This risk can be reduced by excluding participants who are known high-responders; however, we did not include this as an exclusion criterion. The questionnaire used within this study was not validated, and therefore the results must be interpreted with this in mind.