Initial health screen: All prospective donors are screened over the phone or through an online, confidential, Web-based questionnaire to ensure there are no absolute contraindications to living donation. Typical screening questions include age, height and weight to determine body mass index (BMI), history of diabetes, hypertension (HTN), kidney stones, hypercoagulability, psychiatric illnesses and substance use, and significant family history of kidney disease among others.
Appointment for full evaluation: If the phone or online screen does not reveal any absolute contraindications, prospective donors are scheduled for a psychosocial, medical, and surgical evaluation at the transplant center.
Figure 5-1 summarizes the stepwise approach to the evaluation and workup of potential living kidney donors.
Psychosocial assessment: major components
Transplant programs are required to appoint an independent living donor advocate (ILDA) to support potential donors throughout the process and to promote donor understanding of the informed consent including the risks and benefits of donation.
The ILDA can be a social worker, nurse, psychologist, or physician (in many programs the social worker functions as the ILDA).
Psychosocial evaluation should be performed by the transplant center psychiatrist or social worker who has no personal or clinical relationship with the recipient.
Address protection of donor’s confidentiality.
Assess donor’s motivation and capacity:
Inform donor of option “not to donate” and ensure confidentiality.
Exclude coercion or secondary gain (eg, monetary or other secondary personal gain).
Figure 5-1 Stepwise Approach to the Evaluation and Workup of Potential Living Kidney Donors
CT, computed tomography. aPsychosocial and medical evaluation (1 and 2) can be performed the same day → If “cleared,” proceed to surgical evaluation (3). bSee Table 5-4.
Assess donor’s ability to make decision (confirm full capacity to give informed consent).
Assess donor’s accurate knowledge of
Recipient’s health risk (physical and mental benefits).
Donor’s health risk (physical and mental).
Donation process.
Evaluate sociodemographic history and current status:
Assess adequacy of social and financial support.
Explore history of substance abuse.
TABLE 5-1 Qualification, Training Requirement, and Role of the Independent Living Donor Advocate Set Forth by the Organ Procurement Transplantation Network and American Society of Transplantation Living Donor Community of Practice Committee
OPTN
AST Living Donor Community of Practice
Functions independently from the transplant candidate’s team
Advocates for the rights of the living donor
Reviews whether the living donor has received information on each of the following areas:
Informed consent
Evaluation process
Surgical procedure
Medical and psychosocial risks
Follow-up requirements
The ILDA must
Have a certain skill set rather than a specific profession.
Be educated and demonstrate competence in core knowledge components.
Assess components of informed consent.
Have a reporting structure outside the transplant center.
Integrate his or her role throughout the donor care continuum.
The ILDA role should include a narrow “veto power.”
Assists the donor in obtaining additional information from other professionals as needed
Centers must develop a transparent system to define ILDA independence.
Abbreviations: AST, American Society of Transplantation; ILDA, independent living donor advocate; OPTN, Organ Procurement Transplantation Network.
Evaluate underlying psychiatric disorders (stability, risk of recurrence after donation).
Discuss possible outcomes:
Psychological benefits after a successful transplantation (increased self-esteem)
Resentment and depression after an unsuccessful transplantation
Covert depression or anxiety with altruistic donor due to the lack of knowledge of transplant outcome
Psychosocial contraindications
Presence of any significant psychiatric problem
Possibility of coercion
Medical evaluation
Complete history and physical examination
Suggested routine evaluation and optional testing are listed in Table 5-2.
Absolute and relative contraindications to living kidney donation are shown in Table 5-3.
Glomerular filtration rate (GFR) evaluation: 2017 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guidelines2,3
Donor kidney function should be expressed as GFR and not as serum creatinine concentration.
GFR should be expressed in mL/min/1.73 m2 rather than mL/min.
Two-stage GFR testing in all donor candidates
Initial testing
Donor GFR should be estimated from serum creatinine (eGFR[Cr]).
Confirmatory testing using one or more of the following measurements, depending on availability
Measured GFR (mGFR) using an exogenous filtration marker, preferably urinary or plasma clearance of inulin, iothalamate, chromium-51 ethylenediaminetetraacetic acid (51Cr-EDTA), iohexol, or technetium-99m diethylenetriaminepentaacetic acid (99mTc-DTPA) (Currently, DTPA is rarely used and has been replaced by technetium-99m mercaptoacetyltriglycine [99mTc-MAG3].)
Measured creatinine clearance (mCrCl)
Estimated GFR (eGFR) from the combination of serum creatinine and cystatin C (eGFR[Cr-Cys])
Repeat eGFR from serum creatinine (eGFR[Cr])
If there are parenchymal, vascular, or urologic abnormalities, or asymmetry of kidney size on renal imaging, single-kidney GFR should be assessed using radionuclides or contrast agents that are excreted by glomerular filtration (eg, 99mTc-MAG3).
GFR ≥90 mL/min/1.73 m2: acceptable for kidney donation
GFR <60 mL/min/1.73 m2: not acceptable for donation
GFR 60 to 89 mL/min/1.73 m2: Decision should be individualized based on demographic and health profile in relation to the transplant center’s acceptance risk threshold.
When asymmetry in GFR, parenchymal abnormalities, vascular abnormalities, or urologic abnormalities are present but do not preclude donation, the more severely affected kidney should be used for donation.
Authors’ center
GFR determination in all donor candidates
Chronic kidney disease epidemiology collaboration equation (CKD-EPI) creatinine using standardized assays
Twenty-four-hour urine creatinine clearance in mL/min/1.73 m2 (may overestimate GFR because of creatinine secretion)
TABLE 5-2 Suggested Routine Evaluation and Optional Testinga
Laboratory tests
ABO blood group, HLA tissue typing, crossmatch testing
Urinalysis and urine culture
24-h urine for albumin, protein,b and creatinine clearance (or GFR determination by nuclear medicine test)
CBC with platelets, INR, and PTT
Comprehensive metabolic panel (electrolytes, transaminase levels, albumin, bilirubin, calcium, phosphorous, alkaline phosphatase, fasting blood glucose)
Fasting lipid profile
Serologies: hepatitis B (surface Ag, IgM and IgG core Ab, and surface Ab), HCV Ab screening (if positive, check PCR confirmatory test),c HIV1/HIV2 antibody screen,c CMV, EBV, HSV, West Nile antibodies (IgG and IgM), RPR or VDRL (FTA-ABS confirmatory test if positive RPR or VDRL), Strongyloides, stercoralis antibodies
Geographic residence or environmental exposure that may require additional testing: coccidioidomycosis, schistosomiasis, malaria, HHV-8, HHV-6, Trypanosoma cruzi
Women <55 y: human chorionic gonadotropin quantitative pregnancy test
Prospective donors >60 y: serum protein electrophoresis and serum immunofixation electrophoresis
African Americans: hemoglobin electrophoresis (to rule out sickle cell trait)
Other tests
Electrocardiogram
Chest x-ray
Pap smear appropriate for age similar to the general population
Mammogram appropriate for age similar to the general population
Renal imaging: spiral CT, CT angiogram, or magnetic resonance angiogram
Further testing depending on age, history, abnormal laboratory findings, family history
Cardiac screening: exercise treadmill or nuclear medicine stress test, echocardiogram
Colonoscopy for prospective donors ≥50 y
24-h ambulatory blood pressure monitoring
Renal biopsy
Cystoscopy
PPD skin test or QuantiFERON-TB Gold test
Screening for hypercoagulability
Oral glucose tolerance test in patients with family history of diabetes or in those with risk factors for diabetes (see text)
PSA screening for men with family history at the discretion of the clinician (routine screening may be more harmful than protective)
African Americans: screening for APOL1 G1/G2 mutation (see text)
Abbreviations: APOL1, apolipoprotein L1; CBC, complete blood count; CMV, cytomegalovirus; CT, computed tomography; EBV, Epstein-Barr virus; FTA-ABS, fluorescent treponemal antibody absorption test; GFR, glomerular filtration rate; HCV, hepatitis C virus; HHV-6, human herpesvirus 6; HHV-8, human herpesvirus 8; HLA, human leukocyte antigen; HSV, herpes simplex virus; IgG, immunoglobulin G; IgM, immunoglobulin M; INR, international normalized ratio; PCR, polymerase chain reaction; PPD, purified protein derivative; PSA, prostate-specific antigen; PTT, partial thromboplastin time; RPR, rapid plasma reagin; VDRL, Venereal Disease Research Laboratory test.
aCriteria may differ among centers.
b Kidney Disease: Improving Global Outcomes guidelines recommend that donor proteinuria should be measured as albuminuria, not total urine protein. In the authors’ opinion, both urine albumin and total protein should be measured because the former does not detect light chain immunoglobulins.
c Anti-HIV1/HIV2 antibody screen (or HIV antigen/antibody [Ag/Ab] combination assays) as close as possible but within 28 days prior to organ recovery and HCV RNA by nucleic acid testing (NAT) as close as possible but within 28 days prior to organ recovery.
TABLE 5-3 Absolute and Relative Contraindications to Living Kidney Donation (criteria may vary among centers)
Absolute contraindications (opinion based)
Relative contraindications
Evidence of kidney disease (GFR <80 mL/min/1.73 m2 and/or microalbuminuria ≥30 mg/24 h [or equivalent]) (see relative contraindication regarding KDIGO guideline). Historically, at the authors’ center overt proteinuria >250 mg/d was used to preclude donation.
Significant renal or urologic abnormalities
Transmissible infectious disease (HIV, hepatitis B or hepatitis C infection, Trypanosoma cruzi infection, or Chagas disease [see text])
Active malignancy
Chronic illness that places patient at significant risk of undergoing surgery
Poorly controlled psychiatric illness or active substance abuse
Cognitive deficit
Current pregnancy
Hypertension (clinically significant)
Diabetes mellitus
Recurrent nephrolithiasis or bilateral stones
History of thrombotic disorders with risk factors for future events or inherited hypercoagulable stress (eg, the presence of anticoagulant or anticardiolipin antibody, factor V Leiden, or prothrombin gene mutation FII-20210)
High suspicion for covert coercion
BMI >30-35 kg/m2 (center dependent)
Urologic abnormalities of donor kidney
Age <18 y (seldom performed) or >70 y (need to evaluate on a case-by-case basis)
Borderline or mild hypertension
Borderline urinary abnormalities in the absence of renal function impairment
Single prior episode of kidney stone without evidence of secondary risk (see text and Table 5-4)
Obesity (center dependent, generally defined as BMI >30 kg/m2)
Metabolic syndrome and fatty liver (must resolve or demonstrate significant improvement through lifestyle changes before donation)
Young donor with risk factors for future development of diabetes mellitus
Jehovah’s Witness
African Americans with two mutated alleles of APOL1 G1/G2
Sickle cell trait (Sickle cell trait is considered as an absolute contraindication to living donation at some centers.)
Cigarette smokers (must stop at least 4 wk prior to surgery to decrease pulmonary complications). At some centers, current cigarette smoking is considered a contraindication to donation.
KDIGO guidelines for GFR between 60 and 89 mL/min/1.73 m2 and/or AER between 30 and 100 mg/d: Decision should be individualized based on demographic and health profile in relation to the transplant center’s acceptance risk threshold.
T. cruzi infection (Chagas disease, see text)
Abbreviations: AER, albumin excretion rate; APOL1, apolipoprotein L1; BMI, body mass index; GFR, glomerular filtration rate; KDIGO, Kidney Disease: Improving Global Outcomes.
Exclusion criteria at the authors’ center (and at most transplant centers)
GFR of <80 mL/min/1.73 m2 (or inappropriately low for age or gender)
A projected postdonation GFR of <40 mL/min/1.73 m2 at 80 years of age
Proteinuria/albuminuria
Routine urinalysis dipstick (RUA) versus spot urine protein-to-creatinine ratio (UPC)
The use of RUA to detect proteinuria has limitations4:
RUA is sensitive in detecting tubular proteins and albumin but not light chain immunoglobulins.
The total protein concentration detected varies with the degree of urinary concentration, not necessarily the severity of proteinuria.
Spot UPC ratio detects all types of proteins and reduces variations due to urinary concentrating status. Patients with elevated UPC but negative albuminuria may have tubular proteinuria, light chain proteinuria, or urinary tract abnormalities.
Twenty-four-hour urine protein detects all types of proteins and remains the gold standard for quantitation of proteinuria. Concurrent measurement of urine creatinine is necessary to assess for collection adequacy (generally 20 mg/kg/d; ±5-10 mg/kg/d; adjustment may be estimated based on gender, age, and muscle mass).
Transient causes of proteinuria should be ruled out (eg, urinary tract infection [UTI], fevers, and vigorous exercise).
Orthostatic proteinuria (elevated urine protein with assumption of the upright posture and normal protein excretion during recumbency) is a benign condition that can be seen in adolescents and young adults. Its presence does not necessarily preclude donation and should be assessed on a case-by-case basis. The presence of microalbuminuria should preclude donation.
2017 KDIGO Clinical Practice Guidelines2
Donor proteinuria should be measured as albuminuria, not total urine protein.
Initial screening should be performed using urine albumin-to-creatinine ratio (ACR) in a random urine specimen.
Albuminuria should be confirmed using albumin excretion rate (AER, mg/d) in a timed urine specimen. Repeat ACR if AER cannot be obtained.
Urine AER <30 mg/d: acceptable for donation
Urine AER >100 mg/d: not acceptable for donation
AER 30 to 100 mg/d: Decision should be individualized based on demographic and health profile in relation to the transplant program’s acceptable risk threshold. The KDIGO expert panel has not excluded candidates solely on the basis of AER 30 to 100 mg/d because estimated projected predonation lifetime risk of end-stage kidney disease (ESKD) in older patients with AER in this range is very low in the absence of decreased GFR and other health risk factors.
Authors’ center
Albuminuria ≥30 mg/d: donation not advisable (Historically, proteinuria >250 mg/d was used to preclude donation.)
Isolated microscopic hematuria
Repeat and confirm urinalysis for hematuria:
Obtain clean catch specimen.
Obtain nonmenstruating specimen in nonmenopausal menstruating women.
False-positive dipstick for “blood” in the urine
Contaminated samples
Myoglobinuria
Hemoglobinuria
Medical history to consider: UTI (including tuberculosis), stones, tumors, and family history of renal disease
2012 American Urological Association recommendations for evaluation of asymptomatic microhematuria include
Assessment of risk factors for urinary tract malignancies (irritative voiding symptoms, chemical exposures, current or past tobacco use).
Radiologic evaluation (multiphasic computed tomography [CT] urography with and without contrast, or magnetic resonance urography) and cystoscopy in patients aged 35 years or older regardless of history of anticoagulation therapy.
Isolated microscopic hematuria without evidence of urologic, or renal function, or anatomical abnormalities is not an absolute contraindication to donation. Onethird of transplant centers surveyed in the United States are willing to accept prospective donor candidates with isolated microhematuria, a negative urologic evaluation (which may include cystoscopy), and a normal kidney biopsy.5
Young adults with isolated urinary abnormalities should be excluded from donation.
2017 KDIGO Clinical Practice Guidelines2
Donor candidates should be assessed for microscopic hematuria.
Donor candidates with persistent microscopic hematuria should undergo testing to identify possible causes, which may include
Urinalysis and urine culture to assess for infection.
Cystoscopy and imaging to assess for urinary tract malignancy.
Twenty-four-hour urine stone panel to assess for nephrolithiasis and/or microlithiasis.
Kidney biopsy to assess for glomerular disease (eg, thin basement membrane nephropathy [TBMN], early immunoglobulin A (IgA) nephropathy, and Alport syndrome).
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Living Donor Evaluation
Living Donor Evaluation
Phuong-Chi T. Pham
Phuong-Anh T. Pham
Julie M. Yabu
Michael S. Lee
H. Albin Gritsch
Phuong-Thu T. Pham
Living kidney donation for transplantation is currently common practice. This chapter provides general guidelines for evaluating a potential living donor candidate. Practice may vary among centers. However, the universal goals are to minimize immediate and future physical and psychosocial health risks to both the prospective donor and recipient.
GENERAL EVALUATION
