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



  • 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).


      • The qualification, training requirement, and role of the ILDA set forth by the Organ Procurement Transplantation Network (OPTN) and the American Society of Transplantation (AST) Living Donor Community of Practice Committee1 are summarized in Table 5-1.


    • 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



          • image Donor GFR should be estimated from serum creatinine (eGFR[Cr]).


        • Confirmatory testing using one or more of the following measurements, depending on availability



          • image 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].)


          • image Measured creatinine clearance (mCrCl)


          • image Estimated GFR (eGFR) from the combination of serum creatinine and cystatin C (eGFR[Cr-Cys])


          • image 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).


      • KDIGO inclusion and exclusion criteria for donation2,3



        • image GFR ≥90 mL/min/1.73 m2: acceptable for kidney donation


        • image GFR <60 mL/min/1.73 m2: not acceptable for donation


        • image 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.


        • image 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



        • image GFR determination in all donor candidates


        • image Chronic kidney disease epidemiology collaboration equation (CKD-EPI) creatinine using standardized assays


        • image 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.



        • image 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)



        • image 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.


        • image 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



        • image Donor proteinuria should be measured as albuminuria, not total urine protein.


        • image Initial screening should be performed using urine albumin-to-creatinine ratio (ACR) in a random urine specimen.


        • image Albuminuria should be confirmed using albumin excretion rate (AER, mg/d) in a timed urine specimen. Repeat ACR if AER cannot be obtained.


        • image KDIGO inclusion and exclusion criteria for donation2



          • 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



        • image Albuminuria30 mg/d: donation not advisable (Historically, proteinuria >250 mg/d was used to preclude donation.)


    • Isolated microscopic hematuria

May 8, 2019 | Posted by in NEPHROLOGY | Comments Off on Living Donor Evaluation
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