Preoperative General and Urologic Evaluation for Laparoscopic Donor Nephrectomy

Laboratory tests (renal function/immunological compatibility)

Blood pressure

24-h urine collection to quantify creatinine clearance and measure proteinuria

Oral glucose tolerance test and HbA_1C if indicated

Metabolic workup if previous renal stones

Donor ABO typing

Complete blood count with platelet count and differential

Measurement of transaminases

Lipid profile

Complete coagulation studies

Urinalysis and culture

Electrocardiograph

Chest x-ray

Crossmatch performed

Human leukocyte antigen (HLA) typing of the donor may be done

Clinical history and physical examination

Initial interview with specific focus on renal disease and family history of renal disease

Completion of a detailed health questionnaire

Donor education and completion of evaluation of consent

Detailed history and physical examinations by transplant nephrologists and surgeons

Multiple complete vital signs

Detailed evaluation by mental health expert

Interview with independent living donor advocate

Assessment for transmissible infectious disease

Human immunodeficiency virus, hepatitis B and C

Rapid plasma reagin

Testing for tuberculosis (TB) – TB skin testing or QuantiFERON-TB Gold

Testing for Strongyloides, Trypanosoma cruzi, and West Nile virus for donors from endemic areas

Evaluation of renal anatomy with cross-sectional imaging

Age-appropriate health screening, including cancer screening

Prostate-specific antigen (recommendations based on donor age and family history)

Gynecologic examination with Papanicolaou smear

Colonoscopy

Mammogram

Pregnancy test if indicated

Echocardiography and cardiac stress testing as indicated

Pulmonary function studies and computed tomography scanning of the chest as indicated

2.3 Contraindications

General contraindications to living donation are [6] (Table 2.2):

The presence of vascular disease that precludes the arterial and venous anastomoses required for a technically successful transplant
Recent or current malignancy
Chronic illness with short life expectancy
Active substance abuse
Active infectious process
Coronary artery disease
Psychosocial factors that may hinder future adherence to medical treatment

Table 2.2

Contraindications

	Absolute	Relative
Age	Less than 18 years	Over 65 years (excluded in many programs)
Substance abuse	Active substance abuse	Abstinence from substance abuse with documented completion of rehabilitation
Hypertension	Multiple agents or high doses of single agents for control End-organ injury Additional strong risk factors for cardiovascular disease	Borderline or control with single agents
Diabetes	Diabetes mellitus	Impaired glucose tolerance
Obesity	Morbid obesity (BMI >35) or obesity (BMI >30) with comorbid conditions	Obesity
Renal disease	Evidence of renal disease, including a reduced creatinine clearance (GFR <80 mL/min), proteinuria (>250 mg), or hematuria	Borderline creatinine clearance, microscopic hematuria
Renal stones	Multiple or recurrent renal calculi of a metabolic condition that predisposes to the recurrence of renal calculi	Single renal stone
Infection	HIV, hepatitis B, hepatitis C	Hepatitis B core antibody
Cancer	Cancer, either current or treated but at significant risk for recurrence
Cardiovascular disease	Coronary or peripheral vascular disease Valvular heart disease
Renal anatomic abnormalities	Significant discrepancy in the kidney sizes	Vascular anomalies

As per guidelines patients with previous malignancies can undergo renal transplantation after a period of 2 years. It is not needed in cases of incidental renal carcinoma, in situ carcinoma, focal neoplasm low-grade bladder cancer, or basal cell skin cancer. A waiting time of more than 2 years is necessary in cases of melanoma, breast cancer, colorectal carcinoma, and uterine carcinoma [7].

2.4 Radiologic Evaluation

The optimal imaging modality remains a matter of debate. Angiography, the classic gold standard for defining renal anatomy, is now rarely used. Currently Computerized Tomography Angiography (CTA) or Magnetic Resonance Angiography (MRA) is used to evaluate the donor kidneys, define vascular anatomy, and assess donors for other abdominal anomalies or pathology [8]. These imaging modalities are particularly important for assessing anatomic variations affecting the renal arteries, veins, or ureters (Fig. 2.1), which are an important consideration in determining the suitability of an individual for living kidney donation. In providing precise information on the anatomy of the renal vasculature and possible variants and diseases prior to surgery, CTA has reduced the risks and complications during and after renal transplantation, improving the likelihood of a successful outcome [10]. MRA is, however, considered equally accurate in defining renal anatomy and detecting incidental findings that may influence the decision about an individual’s suitability to be a living kidney donor. While MRA has the advantage of avoiding ionizing radiation and potentially nephrotoxic contrast agents, it is much less sensitive in detecting small renal or ureteral stones [9]. Ultimately the choice of imaging modality should probably be based on local imaging expertise and specific protocols.

Fig. 2.1

The CTA gives us wealth of information on the arterial anatomy. It gives us an idea about the prehilar branching, the number of vessels, and the relation of splenic vessels to the upper pole

All potential donors should have a chest x-ray.

Knowledge of the surgical techniques performed and the exclusion criteria allows radiologists to write an accurate radiological report. The radiological arterial report must include renal artery atherosclerosis, aneurysms, arteriovenous malformations and arteriovenous fistulas, dissection, thrombosis, and fibromuscular dysplasia.

The venous report should include the venous variants of the inferior vena cava (duplication, left location, etc.) and the renal veins (retroaortic, circumaortic) and the location, number, diameter, and variants of gonadal, adrenal, and lumbar veins (Fig. 2.2). A delayed topogram acquired in the excretory phase, delayed CT images, or conventional abdominal radiography must be performed to evaluate the collecting system and ureters and screen for a possible duplication anomaly [11, 12].

Fig. 2.2

The venous anatomy is also well delineated with the triple-phase contrast CTA. As depicted in this picture the relation of the renal vein with the adrenal vein and the lumbar vein is clearly seen. This is of strategic importance in surgical planning

2.5 Specific Medical Evaluations

Factors that most commonly contribute to the medical complexity of living kidney donors are age, obesity, hypertension, and psychosocial issues.

2.5.1 Age

There is a clear trend toward accepting older individuals as donors. Registry data indicate that between 2000 and 2009, the mean age of living kidney donors increased from 39.6 to 41.3 years, while the percentage of living kidney donors in the 50- to 64-year-old age range increased from 18.1 to 25%, and the percentage of donors between 18 and 34 years of age declined from 33.2 to 30.3% [13]. With respect to the impact of increasing donor age on potential complications, despite the intuitive sense that older living kidney donors might be at increased risk, several groups have reported that the perioperative risk is not increased in older living donors [14, 15].

Only gold members can continue reading. Log In or Register to continue