1. A 45-year-old male with excellent kidney function offered a kidney to his brother, 111 mismatch, no DSA. He has mild diet-controlled DM. No evidence of haematuria, proteinuria or microalbuminuria.
- What do you manage this case?
- Substantiate your answer
Dear All
What did the guidelines suggest regarding mild DM and prediabetics?
Regarding diabetics :The eGFR and the rate of decline of eGFR were not significantly different between diabetic and matched non-diabetic donors
Consideration of a diabetic as a potential donor requires a thorough evaluation of the risks and benefits of donation and transplantation, for both the donor and recipient.
Specifically, a careful search should be made for any evidence of target organ damage and assessment of cardiovascular risk factors such as obesity, hypertension and hyperlipidaemia as well as critical fwctors like the age of the donor, donor GFR, and the relationship to the potential recipient.
Regarding prediabetics :
If there is an impaired glucose tolerance test, the annualised relative risk of a patient developing diabetes is 6 times higher compared to those with a normal test result and all cause mortality is 1.48 times higher.
References
BTS/RA Living Donor Kidney Transplantation Guidelines 2018
Hi Dr Mina,
I like the facts that you mentioned. It is decision time now. What is your decision?
Likewise Dr Ben,
I like the facts that you mentioned. It is decision time now. What is your decision?
The donor met most of the criteria except that the age is 45 and the guideline stated age > 60. I will not take him as a potential donor based on the BTS 2018 guidelines
BTS :
-All potential living kidney donors must have a fasting plasma glucose level checked. (B1)
-A fasting plasma glucose concentration between 6.1-6.9 mmol/L is indicative of an impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be undertaken. (B1)
-Prospective donors with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT. (B1) -If OGTT reveals a persistent impaired fasting glucose and/or an impaired glucose tolerance, then the risks of developing diabetes after donation must be carefully considered. (B1)
– Consideration should be given to the use of a diabetes risk calculator to inform the discussion of potential kidney donation. (B2)
-Consideration of patients with diabetes as potential kidney donors requires very careful evaluation of the risks and benefits. In the absence of evidence of target organ damage and having ensured that other cardiovascular risk factors such as obesity, hypertension or hyperlipidaemia are optimally managed, diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney. (Not graded)
KDIGO
Predonation metabolic and lifestyle factors
✓ Assess metabolic and lifestyle risk for CKD and/or cardiovascular disease
by obtaining the following prior to donation:
c Body mass index measurement
c History of diabetes mellitus and gestational diabetes and family history
of diabetes
c Fasting blood glucose and/or glycated hemoglobin (hemoglobin A1c)
c Fasting lipid profile, including total cholesterol, LDL-cholesterol,
HDL-cholesterol, and triglycerides
c Present and past use of tobacco products
Donor candidates with type 1 diabetes mellitus should not donate. The decision to approve donor candidates with prediabetes or type 2 diabetes
should be individualized based on demographic and health profile in relation to the transplant program’s acceptance threshold. Donor candidates with prediabetes and type 2 diabetes should be counseled that their condition may progress over time and may lead to end-organ complication
so in this case
young man with 111 mismatch with no DSA and diet controlled DM with excellent kidney function and no evidence of albuminuria, proteinuria or hematuria
after taking all detailed hx and physical examination
with discussion with MDT ( endocrine,nephro and surgeon )
after CVD evaluation and fasting glucose and OGTT all has done with no organ damage has been identified
i will accept him as donor and start on life style modification until time of surgery with regular follow up after the surgery
BTS guidelines and KDIGO
Hi Dr Farah,
I like your logical and structured approach.
Ajay
The guidelines suggest that a potential kidney donor with diabetes needs thorough assessment of cardiovascular risk factors( HT, dyslipidemia,and obesity, in addition to age, GFR and relation of donor to recipients. If no end organ damage & CVS is low, the donor should be informed about the long term risk of donation if he accept the risk we can precede with transplantation. IFG found to be comparable outcome to normal glucose after 10 years of follow up
HI Dr Ban,
What is your choice in this case, I know you have quote some guidelines.
According to BTS/RA Living Donor Kidney Transplantation Guidelines 2018
Traditional guidance has suggested that individuals with diabetes should not donate
a kidney. However, in an observational study of 444 donors from a single Japanese centre that has accepted subjects with an abnormal OGTT, including a small number
with diabetes, no difference was found in the rate of immediate post-operative
complications or survival at 20 years between the glucose tolerant and intolerant
groups. Through self-reporting of status at follow-up, no major diabetic
complications were observed in the glucose intolerant group
Consideration of a diabetic as a potential donor requires a thorough evaluation of
the risks and benefits of donation and transplantation, for both the donor and
recipient. Specifically, a careful search should be made for any evidence of target
organ damage and assessment of cardiovascular risk factors such as obesity,
hypertension and hyperlipidaemia. The age of the donor, donor GFR, and the
relationship to the potential recipient are critical factors. After exclusion of preexisting diabetic nephropathy, possibly including renal biopsy, the potential risk of
development of diabetic nephropathy should be discussed with the potential donor.
In a small study, 45 donors with impaired fasting glucose were matched with 45
donors with a normal fasting glucose at the time of donation and followed for a
median duration of 10.4 years. Those with IFG appeared to do well, when compared
with donors with a normal fasting glucose. Urine albumin excretion and MDRD
eGFR were similar in both groups. Almost 60% of the donors with IFG had a normal
fasting glucose at follow-up, but significantly more had developed diabetes (15.6%
vs 2.2%)
Hi Dr Eusha,
You have mentioned studies but there is no reference
Evaluation by OGTT or glycosylated HB in donor candidates with family history of DM elevated fasting blood glucose or history of gestational DM. Diabetics to be excluded from donation,( OPTN,2020). That exclusion is the recommended practice in many guidelines. A recommendation ;opinion based ,allows diabetics for donation with thorough assessment of lifetime risk of cardiovascular disease and progressive kidney disease,BTS,2011.No established strong exclusion criteria regarding prediabetics and diabetes risk factors. KIDIGO,2017 permits donation from pre diabetics or type 2 DM according to individualized demographic and health profile in the applied transplant program regarding the acceptable risk threshold .So, counselling these candidates regarding potential risk for progression to end organ damage is needed.
Hi Dr Omran,
What is your choice in this case, I know you have quote some guidelines.
What did the guidelines suggest regarding mild DM and prediabetics?
Hi Dr Alshaikh,
What is your choice in this case, I know you have quoted level of recommendations..
In this case i will perform OGTT, history of smoking and family history of diabetes should be taken, measure BMI, lipid profile, his age is important to further evaluate his cardiovascular risk and the screening process.
counsel him about the risk of progress in to diabetes and development of CKD, and the increased risk for cardiovascular diseases.
if OGTT is normal and no prediabetes or diabetes i’ll proceed , if he has either one i’ll refuse hi to be a donor.
thank you
Many thanks Dr Wadi for a comprehensive reply.
Ajay
Thank you alot Dr Ajay you are the best
Dear Dr Wadi, so nice of you to say that. As a doctor, when someone might say ‘I have nothing to learn’ that is the day for retirement. I have been learning from my academic elder brother Ahmed Halawa, and more recently from Prof Dawlat Belal. For that matter, we are learning from all my fellows and colleagues on this live ward round all the time.
With warm regards,
Ajay
All respect and appreciation to all of you, wishing you always success in your academic and family life, God willing
Dear prof Ahmed the guidelines can guide us and help us in making decisions but still, we can make our judgment case by case based on the expert view, center policy, and facilities, in addition to local center protocols, taking into consideration disease burden in the community like our gulf area the DM is the leading cause of ESRD and more than 60% of patients on dialysis due to DKD, black and Southeast Asia, those with positive FH or female with the previous GDM they are higher risk group to be taken in consideration. Most centers in the US including OPTN consider DM, in general, an absolute contraindication for donations. so this young donor will donate to his brother with a good match and excellent baseline renal function with no microalbuminuria, but still, I need to know if he is from minor ethnicity if he has strong FH of DM and DKD in the family, if any other metabolic risk factors like smoking, dyslipidemia, BMI so I will reject his as a donor after addressing all his medical risks and lifetime risk post donation with him and his recipient and I can refer him to independent living donor advocate that can help and explain independently his medical risk
according to the British transplant society
* diabetics could be donors after:
a. evaluation of other CVS risk and their management i.e HTN, obesity or hyperlipidemia
b. excluding target organ damage
c. assessment of the lifetime risk of CVS and progressive renal disease after donation
(evidence: not graded)
According to KDIGO 2018
Donation in patients with type2 DM is individualized based on the severity of illness and predicted long-term risk. Older age with well-controlled glycemia and without end-organ damage (including nephropathy, retinopathy, and CVS diseases) might be donors.
So for that donor, I would consider
-reviewing hid hgA1c, family history of DKD, smoking history, lipid profile and BMI
– consulting him that he might have an increased risk long-term complications for ESKD and then could be accepted as a donor
OGTT should be done; if it is revealed persistent impaired fasting and or impaired glucose tolerance, then the risk of DM should be carefully considered.
What do guidelines say:
BTS guidelines:
Prediabetes: Prospective donors with an increased risk of type 2 diabetes because
of family history, a history of gestational diabetes, ethnicity or obesity
should also undergo an OGTT. Consideration should be given to the use of a diabetes risk calculator to inform the discussion of potential kidney donation
Diabetes: Diabetics without any end organ injury and after exclusion of hypertension, obesity and dyslipidemias, they can be accepted as donors after a thorough assessment of lifetime cardiovascular disease.
KDIGO Guidelines:
Diabetics with well controlled glycemia with oral hypoglycemics, no need for insulin and without any end organ damage, can donate kidney.
This case:
This case look like donor has mild type 2 DM (as he is more than 30 years of age), no need for insulin and no end-organ damage, he can be accepted as donor. he should be counselled about increased chances of DM post donation. So, he needs to be in closer follow-up.
BTS :
-All potential living kidney donors must have a fasting plasma glucose level checked. (B1)
-A fasting plasma glucose concentration between 6.1-6.9 mmol/L is indicative of an impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be undertaken. (B1)
-Prospective donors with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT. (B1) -If OGTT reveals a persistent impaired fasting glucose and/or an impaired glucose tolerance, then the risks of developing diabetes after donation must be carefully considered. (B1)
– Consideration should be given to the use of a diabetes risk calculator to inform the discussion of potential kidney donation. (B2)
-Consideration of patients with diabetes as potential kidney donors requires very careful evaluation of the risks and benefits. In the absence of evidence of target organ damage and having ensured that other cardiovascular risk factors such as obesity, hypertension or hyperlipidaemia are optimally managed, diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney. (Not graded)
KDIGO
Predonation metabolic and lifestyle factors
✓ Assess metabolic and lifestyle risk for CKD and/or cardiovascular disease
by obtaining the following prior to donation:
c Body mass index measurement
c History of diabetes mellitus and gestational diabetes and family history
of diabetes
c Fasting blood glucose and/or glycated hemoglobin (hemoglobin A1c)
c Fasting lipid profile, including total cholesterol, LDL-cholesterol,
HDL-cholesterol, and triglycerides
c Present and past use of tobacco products
Donor candidates with type 1 diabetes mellitus should not donate. The decision to approve donor candidates with prediabetes or type 2 diabetes
should be individualized based on demographic and health profile in relation to the transplant program’s acceptance threshold. Donor candidates with prediabetes and type 2 diabetes should be counseled that their condition may progress over time and may lead to end-organ complication
so in this case
young man with 111 mismatch with no DSA and diet controlled DM with excellent kidney function and no evidence of albuminuria, proteinuria or hematuria
after taking all detailed hx and physical examination
with discussion with MDT ( endocrine,nephro and surgeon )
after CVD evaluation and fasting glucose and OGTT all has done with no organ damage has been identified
i will accept him as donor and start on life style modification until time of surgery with regular follow up after the surgery
BTS guidelines and KDIGO
Consideration of patients with diabetes as potential kidney donors
requires very careful evaluation of the risks and benefits. In the
absence of evidence of target organ damage and having ensured that
other cardiovascular risk factors such as obesity, hypertension or
hyperlipidaemia are optimally managed, diabetics can be considered
for kidney donation after a thorough assessment of the lifetime risk of
cardiovascular and progressive renal disease in the presence of a
single kidney. (Not graded) BTS/RA guidlines
According to American Society of Transplantation;2015:Prediabetes increases risk of diabetes associated kidney disease .
Proper life styling is recommended for potential donors with prediabetes to improve metabolism and decrease risk of DM development. Potential donors with DM are not candidates for donation per UNOS.
According to KDIGO 2017:
Type 1 DM potential donors to be excluded.
For both type 2 or prediabetic candidates, they need individualized decision according demographic and health condition based on the risk threshold in transplant program ,Additionally, counselling is needed as donor candidates condition may progress to end organ complications
If OGTT reveals a persistent impaired fasting glucose and/or an impaired glucose tolerance, then the risks of developing diabetes after donation must be carefully considered. (B1)
Consideration should be given to the use of a diabetes risk calculator to inform the discussion of potential kidney donation. (B2)
BTS/RA Living Donor Kidney Transplantation Guidelines 2018
BTS/RT LIVING DONOR KIDNEY TRANSPLANT2018
1- these donors can be accepted for donation.
2- they have a high chance of developing overt diabetes post transplantation.
3- graft survival is good .
4- GFR AND albumin excretion is not significantly differ from non diabetic.
5- if they are accepted as a donor they should be carefully assessed for future kidney and cardiovascular complication.
According to BTS 2018, T2DM are excluded from donation. If FBS is between 6.1-6.9 mmol/L, OGTT should be performed especially if the donor has positive familial history for DM, history of gestational diabetes, obesity, or is African-American or Hispanic. Other workups are: lipid profile, EKG and echocardiography. In the case of OGTT more that 200 mg/dL is precluded from donation.
According to the KD,GO guideline, the decision for donors with prediabetes or T2DM should be individualized and counseled that there is a high probability of progression over time and complications.
DM is not a contraindication for kidney transplantation. The donor would accept and the recipient should undergo strict control of risk factors for the development of post-transplant DM. Starting with the induction and maintenance of immunosuppression, we could evaluate the use of minimal doses or even their substitution. Subsequently, follow-up to control opportunistic infections and mainly maintenance of healthy lifestyle habits.
With regard to the donor, he should also be monitored, especially with regard to the development of proteinuria and hypertension in the future, which may lead to increased cardiovascular risk.
According to BTS guidelines:
If OGTT revealing impaired fasting glucose and or Impaired glucose tolerance so risks oF developing DM after donation should be considered .
If already known diabetic with no diabetic complications ,no other comorbidities ,no cardiovascular risk like obesity ,HTN.hyperlipidemia
Ask about family history of diabetes, obesity hypertension
Assessment of diabetes organ damage is important, cardiovascular risk, nervous system evaluation, retinal examination.
BTS recommendations:
Consideration should be given to the use of a diabetes risk calculator
to inform the discussion of potential kidney donation. (B2)
Consideration of patients with diabetes as potential kidney donors
requires very careful evaluation of the risks and benefits. In the
absence of evidence of target organ damage and having ensured that
other cardiovascular risk factors such as obesity, hypertension or
hyperlipidaemia are optimally managed, diabetics can be considered
for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a
single kidney. (Not graded)
In our country we do not accept diabetic donors
Risks should be assessed accurately including full history for the patient including gestational diabetes and FH of diabetes
Full examination and investigation to exclude micro or macrovascular complications of diabetes and proper risk evaluation for the patient.
Type 1 DM absolute CI to donation
Type 2 relative CI according to risk calculation as with impaired glucose tolerance.
In general this donor with a diet controlled DM is not a candidate for donation and should be discarded, yet according to KDIGO and BTS guidelines, if no other available donor and after discussing all possible complications that may arise from this donation and that although risk of developing ESKD post donation is very rare it might happen
If the donor still insists on donation.. We shall proceed
Type I DM is absolute contraindication
Type II DM
The perception of a danger of acquiring diabetes after donation and perhaps developing diabetic nephropathy that progresses to end-stage renal disease (ESRD) is what raises concerns regarding the acceptability of live kidney donors with impaired glucose metabolism
In these donors, one concern is that compensatory hyperfiltration from donating a kidney will combine with the hyperfiltration observed in DM and lead to a rapidly progressive deterioration of kidney function
Most transplant programs regard established diabetes mellitus as a contraindication to living donation, and many centers exclude individuals deemed high-risk
Individuals with IFG and IGT should be counseled on lifestyle modifications, including weight control, diet, exercise, and tobacco avoidance.
Donation is not advised for those who have mild or borderline IGT as well as additional risk factors Like HTN , Obesity , smoking and hyperlipidemia
or presence of end organ damage diabetic retinopathy , cardiac affection and peripheral blood vessels affections
So I will accept the donor after
Life style modification
Strict blood sugar control
Avoiding of any risk factors obesity , smoking and hypertension
excluding of end organ damage
Ref
BTS
Eligibility criteria for living kidney donors with preexisting type 2 diabetes mellitus as per the OPTN’s updated policy 2022. (1)
• Age >55*
• Non-insulin-dependent diabetes mellitus
• On maximum of 2 oral anti-diabetic medications*
• DM duration >3 years*
• Nonsmoker
• No HTN*
• Body mass index <30 kg/m2*
• Normal fundus exam with no evidence of other end-organ/diabetic complications
• Well-controlled hyperlipidemia within the past year
• Urine albumin-creatinine ratio <30 mg/g or urine protein-creatinine ratio <200 mg/g
• HbA1C <7% on at least three occasions within the past 2 years
*On a case-by-case basis, potential donors who slightly deviate from these suggested parameters but are still deemed suitable by the selection committee for donation will be evaluated and accepted.
Apart from above parameters, KDIGO and BTS guidelines suggest evaluation of cardiovascular system to find end organ damage ( ECG,ECHO and DSE).(2,3)
The potential donor in this instance is 45 years old, has diabetes under control and has normal other parameters. I’ll accept this as a donor.
He needs to be encouraged for
Reference:
Workup
1.Family history and physical examination to detect complications
2.fasting blood sugar, oral glucose tolerance test,HBA1c.
3.BMI
4.Assessment of presence of complication albumin/creatine ratio,fundus examination
,Cardiovascular evaluation and assessment of risk factors as hyperlipidemia, hypertension and obesity.
After that according to BTS guidelines
1.Type1 diabetes is absolute contraindication for kidney donation.
2.In type 2 diabetes, presence of hypertension,obesity or diabetic complications is a contraindication for kidney donation.
If there is no diabetic complication or other CV risk factor and GFR more than 80 ml/minute and age more than 60 ( relative contraindication)
and can be considered for donation after the assessment of the life time risk of CV and progressive kidney disease in the presence of a single kidney.
According to KDIGO : the decision for donation in pre-diabetic or type 2 DM should be individualized based on demographic and health profile in relation to the transplant program”s acceptable risk threshold
Donor candidates with pre-diabetes or type 2 diabetes should be counseled that their condition may progress over time and may lead to end organ complications.
impaired glucose tolerance test , the risk for developing diabetes after donation should be considered. the annual relative risk of a patient developing diabetes 6 times compared to whom with normal test.
Impaired glucose tolerance test is also associated with an increased risk of premature mortality and increased cardiovascular risk.
I will refuse this donor, his age below 60 years
Ø According to BTS guidelines consideration of patients with diabetes as potential kidney donors requires very careful evaluation of the risks and benefits. In the absence of evidence of target organ damage and having ensured that other cardiovascular risk factors such as obesity, hypertension or hyperlipidaemia are optimally managed, diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney.
Ø In this donor he is good immunological match but diabetic, so assessment of all cardiovascular risk factors, obesity, HTN, hyperlipidaemia is mandatory.
Ø After exclusion of preexisting diabetic nephropathy, possibly including renal biopsy, the potential risk of development of diabetic nephropathy should be discussed with the potential donor.
Reference:
BTS/RA Living Donor Kidney Transplantation Guidelines 2018
45 years old diabetic potential donor with no laboratory evidence of diabetic nephropathy.
1-According to BTS/RA Living Donor Kidney Transplantation Guidelines 2018
Consideration of patients with diabetes as potential kidney donors requires a very careful evaluation of the risks and benefits. In the absence of evidence of target organ damage and having ensured that other cardiovascular risk factors such as obesity, hypertension, or hyperlipidemia are optimally managed, diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney. (Not graded).
2-Laboratory investigations are not enough for the exclusion of diabetic nephropathy and still, kidney biopsy is the most sensitive investigation.
3-diabetic end-organ damage includes the kidney, heart, eye, and blood vessels. all of them need to be carefully evaluated before clearing this patient from diabetic-induced organ damage.
4-other risk factors complicating diabetes like hypertension, hyperlipidemia, smoking, and obesity should be evaluated and corrected
after assessment of the previous risk factors and counseling by MDT maybe this candidate accepted as a potential donor
in our center, we never accept diabetic patients as a potential donor
References:
BTS guidelines
I will accept this donor after screening for cardiovascular assessments , retina examination ,HbA1C and GTT
if he has well control type 2 diabetes with diet control only so we can proceed
· This donor requires very careful evaluation of the risk and benefits. She should be evaluated for target organ damage of diabetes and for CVD risk factors like HTN, smoking, obesity and hyperlipidemia. She needs lifestyle modification. HgA,C should be done and if it is more than 6.5% or if she has other risk factors, she should be precluded for donation and follow lifestyle modification advice.
According to BTS 2018, T2DM are excluded from donation. If FBS is between 6.1-6.9 mmol/L, OGTT should be performed especially if the donor has positive familial history for DM, history of gestational diabetes, obesity, or is African-American or Hispanic. Other workups are: lipid profile, EKG and echocardiography. In the case of OGTT more that 200 mg/dL is precluded from donation.
· According to the KD,GO guideline, the decision for donors with prediabetes or T2DM should be individualized and counseled that there is a high probability of progression over time and complications.
I wouldn’t accept this donor.
According british transplant society:
1- All donors must have a fasting plasma glucose level checked.
2- A fasting plasma glucose concentration between 6.1-6.9 mmol/L (110-125mg/dl) is indicative of an impaired fasting glucose state and t (OGTT) should be undertaken.
3- donors with an high risk of type 2 diabetes because of
o family history.
o a history of gestational diabetes.
o ethnicity .
o obesity.
should also undergo an OGTT.
4- diabetes as donors requires very careful evaluation
5- In the absence of evidence of target organ damage , and other cardiovascular risk factors such as obesity, hypertension or hyperlipidaemia are optimally managed,
diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease .
The American Diabetes Association ddefines impaired fasting glucose (IFG) as an intermediate state of hyperglycemia in which glucose levels do not meet criteria for diabetes but are too high to be considered normal . It defines IFG as a fasting plasma glucose of 100 to 125 mg/dL.
The term prediabetes is applied in the setting of impaired glucose tolerance or IFG and indicates a higher than normal risk of progression to type 2 diabetes mellitus (DM).
The detection of abnormal glucose metabolism in living donor raises concerns about the development of DM and potentially diabetic kidney disease in the future.
A strategy of excluding all prediabetic individuals from donation may lead to decrease the donor pool.
In one study they conclude that , that living kidney donors with IFG developed DM at a much higher rate than matched controls, but the majority remained with IFG or reverted to normal fasting glucose. Impaired fasting glucose donors had a preserved GFR, and their rates of albuminuria were similar to those of matched cotrols at 10 years. They did not have an excessive risk of ESRD
About the prediabetic donors :
· More than half of IFG donors had reverted to normal fasting glucose.
· These patients had a higher chance to develop DM.
· estimated glomerular filtration rate and albumin excretion are not higher in IFG and normal glucose donors.
1- According to above mentioned data diabetic (or pre diabetic ) patient can be accepted as a donor.
2- They will need thorough assessment for cardiovascular complication.
3- They have high chance of developing over diabetic and future diabetic complication.
4- Future risk of these complication should be discussed with the donor .
references:-
1- BTS gudelines .
2- Chandran et al ,Prediabetic Living Kidney Donors Have Preserved Kidney Function at 10 Years After Donation, Transplantation 97(7):p 748-754, April 15, 2014.
This is a 45-y old male with diet-controlled DM with normal GFR without proteinuria or hematuria wants to donate a kidney to his brother 111 mismatch and no DSA.
This potential donor needs the usual work up of any especially the following items:
1- Full detailed history.
2- Full clinical examination including fundus examination.
3- Routine blood tests including HbA1C and OGTT.
4- Radiological investigations as per center protocol.
Donors with DM II and those with pre-DM should be counselled that their disease may deteriorate over time after kidney donation and may lead to end-organ complications as per KDIGO 2017 guidelines, and BTS/RA 2018 guidelines.
I would accept him as a potential donor after proper counselling.
The donor is 45 years old with excellent functions of kidney but he has mild diet controlled diabetes mellitus however no haematuria, proteinuria or micro albuminuria. The patient should have fasting plasma glucose checked, in his case if its pre diabetic, the donor should do OGTT to reveal whether it’s impaired fasting glucose IFG and or an impaired glucose tolerance IGT then the donor will be regarded as high risk for developing DM.
IFG has 4.7 fold increased annual relative risk of developing DM than normal FBS. IGT associated with premature mortality and increased CV risk. IGT has 6 times higher risk of developing DM and 1.48 times higher for all cause mortality.
HbA1c also can used to diagnose DM (>6.5%) and 6-6.5% indicates 25-50% increased risk, 20 times higher risk of DM in 5 years compared to HbA1c of 5%.
QDiabetes risk calculator can be used to predict the risk of developing DM in future.
Diabetes was traditionally deferred from donating but studies emerged showed that OGTT, including mild DM had no difference in the rate of immediate post operative complications or survival at 20 years between glucose tolerant and intolerant group.
BTS suggested thorough evaluation of the risk and benefit of donation and transplantation for both donor and recipient. So donor need to be evaluated for target organ damage and risk of CV death. Diabetic nephropathy, possibility of renal biopsy should be considered.
KDIGO suggested older donor with well controlled glycaemia not requiring insulin and without end organ damage might be considered.
For the scenario, I would like to have extensive discussion with the donor and explore the possibility of complications and plan to evaluate the risk for CV death or all cause of mortality.
In my centre, diabetes is contraindication for donation. Prevalence of diabetes is high in my country and risk of developing DM is high. It’s a tough decision to make, but if QDiabest risk is low and extensive evaluation found that patient is fit to donate, I would consider him as donor.
References
BTS living donor guideline
KDIGO living donor guideline
references BTS/RT LIVING DONOR KIDNEY TRANSPLANT 2018
DM patients to be considered as potential kidney donors require very careful evaluation of the risks and benefits in the absence of evidence of target organ damage risk factors such as HTN, obesity, hyperlipidemia is optimal manage.
DM can be considered for kidney transplant donors after a thorough assessment of the lifetime risk of CVS and progressive renal disease in the presence of a single kidney.
as per kiddo guidelines type, 1 DM should not donate but for type 2 or pre-diabetes the donor should be counseled about donation and should be individual according to the transplant program.
type 2 or pre-diabetes should be counselled about the progress of kidney disease and end-organ failure.
.
regarding this donor will good match and no proteinuria and mild DM, need a multidisciplinary team approach and evaluation more other CVS risk factors obesity, and hyperlipidemia. I will accept this donor after counselling him about the risk of donation.
The given scenario is a type 2 diabetic donor with no microscopic hematuria or microalbuminuria. He has normal renal functions. Diabetes is also mild and is diet controlled with no medications. He is young aged diabetic donor.. He has come forward to donate to his brother with haplomatch and no DSA.
Traditionally diabetic donors are not taken up for organ donation… Due to increased pool of recipients and on going donor shortage there has been discussions about maximizing the donor pool among living donors… The Amesterdam Forum accepts hypertension with no organ damage, but diabetic are contraindicated from organ donation. The British Transplant Society in 2018 have clearly recommended the indications for organ donation in a diabetic
Those who are pre diabetics they recommend OGTT to diagnose diabetes along with other risk factor evaluation….
Those who are a diabetic BTS guidelines recommend organ donation after detailed discussion with the recipient and the donor after risk factors and other end organ damage are ruled out.. I would like to evaluate the associated cardiovascular system for any end organ damage in the donor…type 1 diabetes are not encouraged from organ donation due to the high incidence of proven end organ damage after 20 years….Type 2 Diabetic individuals with no end organ damage (that is no proteinuria, no retinopathy), no obesity, non smoking and normal cardiovascular status after evaluation can be encouraged for donation..
KDIGO 2017 also recommend the same as BTS 2018 guidelines…
The main concern is the donor who is a diabetic with single kidney progressing to ESRD in the future.. Once the kidney is transplanted into the recipient, the recipient mileu is the factor for allograft functioning..
In a Japanese’s cohort of 444 donors with abnormal OGTT and few with diabetes, the donors were followed up for overall survival and end organ damage..There was no difference between the glucose tolerant and the glucose intolerant groups..
Recent change in the OPTN policy published in CJASN in Nov 2022 list few criteria to select diabetic donors after exclusion of the factors … the list factors are
age>55 years, non insulin dependent, on maximum 2 OHA, diabetic duration > 3 years, non smoker, non hypertensive, BMI <30kg/m2, no microalbuminuria, no other end organ damage, HbA1c<7% within past 2 years..
Based on the above I will accept this donor after counselling
References:
BTS guidelines for living donor transplantation
Karim M. Soliman, Ahmed Daoud, Maria Aurora Posadas Salas, Teresa Rice, Genta Uehara, Rani Shayto, Tibor Fülöp, Derek DuBay, Michael J. Casey
CJASN Nov 2022, CJN.09460822; DOI: 10.2215/CJN.09460822
The donor is 45 years old male with excellent renal function and no structural abnormalities. No immunological barriers so far. The only drawback is the presence of diabetes. Despite it is diet controlled diabetes, this will affect both the recipient and the donor either through the development of frank diabetes in the donor later on or the appearance of diabetes in the recipient as his odds are high since his brother has diabetes. The Amsterdam Forum recommended exclusion of diabetic donors. They did not address the pre-diabetic patients. The Asian Pacific Society of Nephrology guidelines suggest OGTT for donors at risk of DM. Individuals with a history of diabetes or fasting blood glucose of ≥126mg/dl (7.0mmol/L) on at least two occasions (or 2-h glucose with OGTT ≥ 200mg/dl (11.1mmol/L)) should not donate. In USA ,most centers decline donors who have diabetes or impaired glucose tolerance. Regarding donors with impaired fasting glucose, they are accepted if they had normal 2-hour oral glucose tolerance test. The onset and frequency of diabetic nephropathy in those needs to be studied in the future. (3)
When diabetic donors were compared with non-diabetic donors, the former were more likely to have hypertension and proteinuria. Both had a similar serum creatinine. Following uni-nephrectomy, the GFR will increase by 70% which if occurred in the presence of a diabetic hyper-filteration will augment the damage to the kidney. Silveiro noticed higher rates of micro-albuminuria in diabetic donors when compared to non-diabetic donors or to two-kidney diabetics. Macro-albuminuria was also more in diabetic donor when compared to non-diabetic donors but the two-kidney diabetics has the same rates as diabetic donors. Again there was no noted difference in renal function among all three groups. (1).
Another study revealed that DM developed after 18 years post donation. The changes in annual eGFR were similar between non diabetic and diabetic donor in the 7 years before the development of DM. Diabetes was found to be associated with development of proteinuria and hypertension but not with ESRD. The decline in eGFR after the appearance of DM of diabetic donors only exceed the non-diabetic donors in cases of concomitant proteinuria and hypertension.(2) Framingham study revealed accelerated kidney damage in patients with IFG and IGT.
On the other hand , Chang study showed similar rates of kidney damage between type 1 diabetes who received a transplant (one kidney) with matched patients with type 1 diabetes (two kidneys). this study has a major draw back as there is no hyperfiltration due to cyclosporine use in the transplant recipients.In Japan, diabetic patients can donate if they have no mircoalbuminuria. Okamoto for 88 months found no ESRD in 27 diabetic donors and 44 donors with IGT and found that 7 out of 65 developed frank diabetes. A larger study population (3698 ) by Ibrahim were followed for a longer period . He observed higher frequency of hypertension and proteinuria in donors (predominantly white) who developed type 2 diabetes compared with those who did not. On the other hand there was no difference in the estimated GFR.11 donors developed ESRD (0.29%) but they had no diabetic nephropathy. Ibrahim declared that the diabetic donors have similar rates of kidney disease and so he suggested no to decline donors with family history of diabetes. So the hypothesis of the role of hyperfiltration, due to nephrectomy, in faster deterioration of kidney function has no evidence so far.
Donors with pre-diabetes or Diabetes are at an increased risk for CVD and this risk increase further with the decline in eGFR in CKD patients . Data regarding the risk of CVD in donors is still under study. One Canadian study found no increase in mortality or CVD in white donors with diabetes over 6 years.
Some information are needed such as the ethnicity as Black and Hispanics donors, as compared to white donors, had a greater risk of diabetes mellitus requiring drug therapy(4). The metabolic syndrome and obesity are predictors for developing diabetes later on. Younger donor with IFG has a higher risk for DM development .this will increase the cumulative lifetime risk for developing diabetes in the presence of other risk factors.(3)
Other risk factors need to be evaluated like FH, BMI of ≥30 kg/m2 and excessive alcohol use .These were found to be associated with more progression of kidney disease and micro-albuminuria. Simmons suggested four major predictors of future diabetes:
1. ethnic group
2. previous gestational diabetes(is not applied in this donor)
3. a high titer of islet cell antibody (for insulin-dependent diabetes mellitus)
4. impaired glucose tolerance.
Scores need to be used to assess the risk of diabetes. Finnish Diabetes Risk Score (FINDRISC) uses age, body mass index (BMI), central obesity, daily exercise, diet, drug-treated hypertension, history of high blood glucose, and family history. Diabetes Personal Health Decisions (PHD) risk includes ethnicity. Those scores predict the 30-year risks in the general population for the development of diabetes, myocardial infarction (MI), cerebrovascular accident, and renal failure. The use of them in the exclusion of donors is not validated. But we need to adopt them for the process of informed consent. (3)
This patient has no proteinuria so we can proceed with the OGTT and we need to consider ethnicity ,FH, lipid profile ,smoking, age , features of metabolic syndrome , his risk for diabetes and MI by age 60.
We need present these risks to this donor with stress upon the fact that long term outcomes were still under studies .
References:
(1)Ibrahim, H.N., Kukla, A., Cordner, G., Bailey, R., Gillingham, K. and Matas, A.J. (2010), Diabetes after Kidney Donation. American Journal of Transplantation, 10: 331-337. https://doi.org/10.1111/j.1600-6143.2009.02944.x
(2)Benjamin R. Morgan, Hassan N. Ibrahim,Long-term outcomes of kidney donors,Arab Journal of Urology,Volume 9, Issue 2,2011,Pages 79-84
(3)Christine Buchek Vigneault, William Stuart Asch, Neera Kanhouwa Dahl, Margaret Johnson Bia, Should Living Kidney Donor Candidates with Impaired Fasting Glucose Donate?CJASN Aug 2011, 6 (8) 2054-2059; DOI: 10.2215/CJN.03370411
(4)Benjamin R. Morgan, Hassan N. Ibrahim,Long-term outcomes of kidney donors,Arab Journal of Urology,Volume 9, Issue 2,2011,Pages 79-84
This donor 45 year old male with mild diet controlled DM with no evidence of haematuria or proteinuria or albuminuria need to be thoroughly investigated; BMI assessment ,duration of DM ,smoking , presence of HTN , retinopathy , peripheral neuropathy ,polyuria ,cardiological examination is a must ,by ECG ,ECHO , stress exercise testing, MYOVIEW Scan ,according to cardiological team recommendations, also diabetologist should be involved with further assessment of OGTT ,HBA1C.
Lipid profile should be optimum and accepted.
Good renal function may be due to hyperfiltration state on early DM presentation, further testing may be required as well as frequent close observation and monitoring.
The history of recipient’s original renal disease is necessary, family history of DM is against donation. The aetiology of recipient’s renal failure of diabetic kidney disease is against donation.
Type 1 DM is contraindicated for renal donation. Type 2 DM with controlled blood sugar by diet and lifestyle only can be eligible to donate with exclusion of any end organ affection, as well as normal eGFR and clearance from the endocrine team.
Prediabetics are allowed to donate after exclusion of any organ affection by DM, according to British Transplantation Society guidelines.
Adding to the previous data, the donor is still young to be exposed to long-term DM complications and to suffer the burden of the disease, it is not preferred for renal donation unless detailed counselling with all hazards of diabetic kidney disease progression, up to development of ESRD must be explained.
If the donor accepted to donate after all, meticulous follow up with close monitoring is mandatory lifelong with full discrimination between compensatory changes post donation versus early diabetic kidney disease development. Tight glycemic control is necessary post donation with adoption of healthy lifestyle regarding exercise, diet, and weight in addition to smoking cessation if coexists.
A donor with T2DM can donate if no micro and macrovascular complication.
T1DM contraindicated.
a patient should evaluated before proceeding to donation IFG, OGTT, HbA1c.
In this case can proceed for donation as there is no proteinuria, hematuria etc.
But should also be assessed for CVD, and other end organ damage.
BTS/KDIGO
It is a patient who, despite having type 2 diabetes, has glycemic control only with dietary care, without the need for drug treatment.
It is necessary to talk about the risks involved, after all, the donor is quite young and may have complications from a single kidney in the future. An investigation evaluating target organ damage, albuminuria, retinopathy, neuropathy, and fasting glucose is the first step.
Metabolic control, frequent physical exercises, body mass index below 30, avoidance of smoking need to be objectified, and frequent periodic examinations for evaluation.
I would proceed with the transplant if these points are reiterated, discussed, and objectified.
• Early education and discussion
• Recipient assessment
• Living donor coordinator
• Consultant led service
• Multidisciplinary input
• Final pre-operative discussion with Transplant Nephrologist and Surgeon
• Medical assessment – History – Clinical,Laboratory investigation
Assessment of renal functions
1)Screening for other target organ damage.
2)Assess cardiac function by ECG / ECHO +/- Myoview.
3)Assess donor risk of dyslipidaemia, smoking status, BMI, blood pressure control.
4) Review serial sugar profile/ HBA1C in diabetic clinic
Two-hour glucose tolerance testing or HbA1c should be performed in donor candidates with elevated fasting blood glucose, history of gestational diabetes, or family history of diabetes in a first-degree relative.
Donor candidates with type 1 diabetes mellitus should not donate.
The decision to approve donor candidates with prediabetes or type 2 diabetes should be individualized based on demographic and health profile in relation to the transplant program’s acceptance threshold.
Donor candidates with prediabetes and type 2 diabetes should be counseled that their condition may progress over time and may lead to end-organ complications.
Living Kidney Donor.KDIGO 2017.
How do you manage this case?
45 yrs donor with diet-controlled DM, III mismatch, No DSA, no hematuria, proteinuria, or microalbuminuria
the benefits should outweigh the risks. MDT (including diabetician) should decide the acceptance or not
we can accept this donor after a though assessment of cardiovascular risk (HTN, Obesity, hyperlipidemia), an assessment of target organ damage which seems to be not evident regarding the kidney, as no proteinuria, etc. needs to measure the e GFR
and informative counselling about the risk of progression to ESRD if risk factors did not manage appropriately like smoking, BMI, HTN, and DM.
according to guidelines, T1DM is a contraindication to donation
T2DM with no risk factors for cardiovascular disease like HTN, hyperlipidemia,smoking and obesity can donate, also those with no complications or any evidence of end-organ damage, e GFR > 80 ml/min/1.73m2, and older age 60 years.
*By history: This potential donor 45 years old male 111 mismatch , no DSA and diet controlled DM with excellent kidney function, with no evidence of haematuria, proteinuria or micro-albuminuria.
*1.T1DM donors should not be accepted , according to BTS: can be accepted if no target organ damage , no CVS risk and management of other risk factors as Hypertension, dyslipidemic while KDIGO 2018, informed that individualization of T2DM donors according to age and severity of Diabetes, no target organ damage.
2. pre diabetics if; young age can progression to frank diabetes with aging.
*So, I will accept this donor after counselling him regarding the risk of progression of kidney disease, and he has to be evaluated in a regular base to discover early possible complications, regular clinical and investigational follow-up ( HBA1c, OGTT , lipid profile , kidney function tests , electrolytes , urine analysis and 24 hours urinary proteins, A diabetes risk calculator should also be done ).
*Pre-diabetic donors increases the risk for diabetes-associated kidney disease. So, lifestyle modifications have to be done : diet control , exercise and BMI < 25 to reduce overt diabetes risk .
References:
1. S., Masharani, U., Webber,etal., : Pre-diabetic living kidney donors have preserved kidney function at 10 years after donation. Transpl.2014 ,97, 748–754.2.
2.British transplant society BTS/RA Living Donor Kidney Transplantation Guidelines 2018.
In our transplantation center , when the donor presented with pre diabetics and impaired glucose tolerance we ask him to do life style modification such as wt reduction , exercise stop smoking then to be re evaluated if he still has impaired glucose tolerance we do not accept him as potential donor .
In this patient we must evaluate for other risk factors such as obesity , dyslipidemia , smoking , family history of DM
careful assessment for end organ damage and CV risks
then we should do 2 Hr OGTT , if normal we can proceed with donation after explain the future risk of developing DM in the future , if OGTT still high i will not accept him as a donor
BTS guidelines:
Prediabetes: Prospective donors with an increased risk of type 2 diabetes because
of family history, a history of gestational diabetes, ethnicity or obesity
should also undergo an OGTT. Consideration should be given to the use of a diabetes risk calculator to inform the discussion of potential kidney donation
Diabetes: Diabetics without any end organ injury and after exclusion of hypertension, obesity and dyslipidemias, they can be accepted as donors after a thorough assessment of lifetime cardiovascular disease.
In this scenario a 45 y man with 111 mismatch , no DSA and diet controlled DM who has also excellent kidney function.
There are no evidence of haematuria, proteinuria or microalbuminuria.
Type 1 diabetic donors are refused ,pre diabetics especially young age are likely to have progression of there diabetic condition with aging with subsequent Cvd and renal complications.
I will counsel the donor regarding potential completion and risk of kidney disease.
If he still wishes to donate will do full evaluation of all risk factors for diabetic complications mainly CVS,renal complications, with calculations of the risk
-BMI
-smoking
– llifestyle
-OGTT,HBA1C
-fundus examination for diabetic changes
-blood pressure monitoring at af least 3 different times
-family history of diabetes, hypertension, renal disease
-lipid profile
UNOS requires that potential kidney donors with diabetes mellitus be excluded from donation, thus the potential donor who is not able to correct their pre-diabetes may be denied as a donor candidate.
A small study of kidney donors with pre-diabetes who went on to donation noted higher rates of progression to diabetes (15.6%) compared to donors with normal glucose levels (2.2%) for those with pre-diabetes but no difference in remaining kidney function over the first 10 years following donation.
A diabetes risk calculator is available to provide more accurate, personalized estimates of an individual’s risk for diabetes using information on age, waist circumference, history of gestational diabetes, height, race/ethnicity, hypertension, family history, and exercise.
Recommendations
1. The risk of diabetes mellitus in donors with pre-diabetes is higher than for a healthy donor with normal glucose metabolism.
Pre-diabetes increases the future risk for diabetes-associated kidney disease for the donor.
2. UNOS requires that potential donors with diabetes mellitus be excluded from donation. Potential donors with pre-diabetes need to make lifestyle changes including diet change, increased exercise and weight loss to normalize their glucose metabolism and reduce their risk for future diabetes. These changes will need to be continued over the long term.
If all investigations were normal i will accept him after informed consent, life style modification, weight loss,stop smoking, control of lipid profile, and regular exercise
And re assessment after 6 months.
References
1. USRDS accessed at http://www.usrds.org/2015/view/v2_01.aspx
2. UNOS donor evaluation policy accessed at http://optn.transplant.hrsa.gov/ContentDocuments/OPTN_Policies.pdf#nameddest=Policy_14
3. Chandran, S., Masharani, U., Webber, A. B. & Wojciechowski, D. M. Prediabetic living kidney donors have preserved kidney function at 10 years after donation. Transplantation 97, 748–754 (2014)
4. Heikes KE, Eddy DM, Arondekah B, Schlessinger L. Diabetes Risk Calculator: A simple tool for detecting undiagnosed diabetes and pre-diabetes. Diabetes Care, 2008; 31: 1040–1045.
The donor has good kidney function and has controlled DM without the need for medication.
KDIGO guidelines include 2 hour glucose tolerance testing, and counseling the donor on possibility of disease progression over time and potential end organ complications.
Fasting Blood glucose, HbA1c, lipid profile to check for dyslipidemia, cardiac evaluation – echocardiography.
BTS kidney transplantation guidelines recommend that live donors with diabetes can be accepted as long as there is absence of evidence of end organ damage, and that cardiovascular risk factors such as obesity, hypertension, and hyperlipidemia are optimally managed.
Lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney following kidney donation are to be thoroughly assessed and evaluated.
Donor education and counseling is paramount regarding lifestyle factors and modifications such as smoking abstinence, weight management, moderate exercise 3-5 days a week, and regular measurement and recording of blood glucose levels. Follow up is to be done on a longer basis and any evidence of cardiovascular abnormalities or kidney disturbances are to be evaluated and treated promptly to prevent complications.
References :
This patient has type 2 DM with diet control only
British guidelines:
Consideration of patients with diabetes as potential kidney donors requires very careful evaluation of the risks and benefits. In the absence of evidence of target organ damage and having ensured that other cardiovascular risk factors such as obesity, hypertension or
hyperlipidemia are optimally managed, diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney.
less than 1% of Europeans with type 2 diabetes develop ESRD but the incidence is higher in other ethnic groups. There is, however, a 50% cumulative incidence of proteinuria after type 2 diabetes has been present for 20 years which may become an issue for kidney donors who have
an above average life expectancy and who may expect to live into their 80s
KDIGO guidelines:
The decision to approve donor candidates with prediabetes or type 2 diabetes should be individualized based on demographic and health profile in relation to the transplant program’s acceptable risk threshold. Donor candidates with prediabetes or type 2 diabetes
should be counseled that their condition may progress
over time and may lead to end-organ complications.
My decision
I will accept him as a donor after
– Full cardiac assessment and ensure that no end organ damage
– Ensure that his blood sugar is well controlled by HbA1C
– Very clear explanation about the possibility of developing CKD and possible ESRD in future and also about the surgical risks
young man with 111 mismatch with no DSA and diet controlled DM with excellent kidney function and no evidence of albuminuria, proteinuria or hematuria
after taking all detailed hx and physical examination
with discussion with MDT ( endocrine,nephro and surgeon )
after CVD evaluation and fasting glucose and OGTT all has done with no organ damage has been identified
i will accept him as donor and start on life style modification until time of surgery with regular follow up after the surgery
BTS guidelines and KDIGO
This patient has diabetes (type II) which is mildly diet-controlled. In the absence of evidence of target organ damage and having ensured that other cardiovascular risk factors such as obesity, hypertension or hyperlipidaemia are optimally managed this patient may be considered suitable for transplantation. However before proceeding with kidney transplantation we should inform the patient about the risk of progressive renal disease and his cardiovascular risk after donation. Life style modifications and tight control of his diabetes are essential in order to control the risk factors.
KDIGO 2017
This patient has diabetes (type II) which is mildly diet-controlled. In the absence of evidence of target organ damage and having ensured that other cardiovascular risk factors such as obesity, hypertension or hyperlipidaemia are optimally managed this patient may be considered suitable for transplantation. However before proceeding with kidney transplantation we should inform the patient about the risk of progressive renal disease and his cardiovascular risk after donation. Life style modifications and tight control of his diabetes are essential in order to control the risk factors
Yes, I will accept this donor as donor extending criteria, if there is no other suitable donor but he need careful evaluation with MDT and counseling about suspected risk of DM and ESRD then a series of tests to check the overall health and make sure there aren’t any problems that would keep him from donating.
The evaluation ncluding:
·Ask about family medical history
·Check the weight and age
·Test blood for high levels of blood sugar and hemoglobin A1c
If the blood sugar level is higher than 110mg/dl, it means pre-diabetes.
.The lifestyle should be change by change eating habits and lose of weight in addition to exercise for daily life
If the blood sugar level is within normal range, he might be able to donate a kidney,
If blood sugar level is still high, he may not be able to donate, especially if he is young and have many years ahead when diabetes may develop
References
Chandran, S., Masharani, U., Webber, A. B. & Wojciechowski,D.M. Prediabetic living kidney donors have preserved kidneyfunction at 10 years after donation. Transplantation 97,748–754 (2014)
Heikes KE, Eddy DM, Arondekah B, Schlessinger L. DiabetesRisk Calculator: A simple tool for detecting undiagnoseddiabetes and pre-diabetes. Diabetes Care, 2008; 31: 1040–1045.
USRDS accessed at http://www.usrds.org/2015/view/v2_01.aspx
As both living and deceased donor transplant kidneys are in short supply, some transplant centres do accept donor with some risk factors termed ‘medically complex living donors’(1) a group which includes donors with prediabetes.
Living kidney donation is performed with the expectation that the risk for short- and long-term harm to the donor is minimal, although it is important to note that most published series have only included low-risk donors.
In the case of the medically complex living donor, however, insufficient data about long-term outcomes and lack of consensus regarding important risk factors.(2)
Though there are some risks to the donor that may be directly attributable to nephrectomy.
Several long-term follow-up studies in humans have suggested that hyperfiltration of the remaining kidney after unilateral donor nephrectomy was not associated with increased risks of adverse effects for more than 10 years(3)
A recent meta-analysis suggests that a 5 mm Hg increase in blood pressure occurs within 5–10 years after donation above that anticipated with normal aging (4).
a second meta-analysis reported a slightly increased risk of proteinuria but no increase in loss of kidney function in living kidney donors(5).
current guidelines suggest that proceeding with kidney donation in the patient with prediabetes is acceptable, provided the potential donor is aware of the potential risks and is thus able to make an informed decision. Nonetheless, prediabetic donors should likely be counseled to engage in activities that reduce their future risk of diabetes
references:
1-A potential living kidney donor with prediabetes Jiao Yang , Ajay K. Singh , Colm C. Magee , Merri L. Pendergrass and Sofia B. Ahmed,Kidney international. THE RENAL CONSULT| VOLUME 76, ISSUE 6, P673-677, SEPTEMBER 02, 2009
2-Creating a medical, ethical, and legal framework for complex living kidney donors. Reese P.P. Caplan A.L Kesselheim A.S. et al. Clin J Am Soc Nephrol. 2006; 1: 1148-1153
3- Renal outcome 25 years after donor nephrectomy. Goldfarb D.A. Matin S.F. Braun W.E. et al. J Urol. 2001; 166: 2043-2047
4- Meta-analysis: risk for hypertension in living kidney donors. Boudville N. Prasad G.V.Knoll G.et al.Ann Inter Med. 2006; 145: 185-196.
5- Proteinuria and reduced kidney function in living kidney donors: A systematic review, meta-analysis, and meta-regression. Garg A.X. Muirhead N. Knoll G. et al. Kidney Int. 2006; 70: 1801-1810
how i will manage this patient
As per BTG
will use a diabetes risk calculator to inform the discussion of potential kidney donation.
l will evaluate the donor for the risks
In the absence of evidence of target organ damage and having ensured that other cardiovascular risk factors such as obesity, hypertension or hyperlipidaemia are optimally managed.
i will consider him for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney.
the potential risk of development of diabetic nephropathy should be discussed with the potential donor.
diabetic nephropathy in a kidney donor is not common during the follow-up periods reported in the published literature. It is, however, quite possible that this may not be the case with longer follow-up, particularly in younger donors and in minority ethnic groups
references:
Steiner RW, Ix JH, Rifkin DE, Gert B. Estimating risks of de novo kidney diseases after living kidney donation. Am J Transplant 2014; 14: 538-44.
This is a case of low immunological kidney transplantation for the recipient. Kidney donor has diabetes probably type 2 as it is controlled with diet ( no insulin requirement). As reported patient does not have end organ damage, in regards to kidneys (hematuria and albuminuria), but should be also evaluated for diabetic retinopathy( end organ damage), as retinopathy prevents kidney donation. Potential donar shoulb be also evaluated for other risk factors of future cardiovascular complications, such as obesity, hypertension and diabetes ( for females also history of gestational diabetes).
In the absence of other associated risk factors, patients young age increases the future risk of worsening of DM status and subsequent higher risk of CVD, as donor still has many expected remaining life time years.
Patient should be counseled about his future risk of cardiovascular complications.
What do you manage this case?
Historically diabetes was considered as a contraindication for donation. However as KIDIGO guidelines such decisions can be individualized. This depends upon patient factors, demographics and individual transplant programme threshold .
While considering diabetic donors for donation a careful assessment is required. The focus is to assess the current disease status, any impact of disease like end organ damage , cardiovascular risks and other factors like age family history of ESRD. It is important to exclude diabetic nephropathy possibly by biopsy.
This 45 year old male is diet controlled diabetic with no evidence of Hematuria, proteinuria and microalbuminuria.
He will need more detailed assessment.
I will take a focussed history and do pertinent physical examination and arrange some investigations:
This will include.
Fasting sugar
HBA1C
Oral glucose tolerance
Check for microalbuminuria
Lipid profile
He will also need cardiac assessment in the form of ECG and Echo and a fundoscopy will be essential. I will arrange an endocrine and cardiology review.
After exclusion of diabetic nephropathy and other end organ damage he can potentially donate.
He should be educated and counselled about risk of ESRD, cardiovascular risks. He should be counselled that with single kidney and especially he is only 45 there will be higher risk of ESRD, cardiovascular risk and worsening of diabetes.
Post donation he will need strict follow up including diabetic control , watch for hyperlipdemia and cardiovascualr risks.
Follow up on new life style to modify risk factors
So in conclusion he can be considered for donation after proper education and counselling .
Substantiate your answer
BTS Living kidney donation guidelines 2018
KIDIGO guidelines 2017
Diabetes is one of challenges in kidney donation, but still it depends and varies from case to case ,I do agree with Farah in what she said .and I thinks such young donor with 111 mismatch and borderline diabetes but has no risk factorss fo CVD or obesity can donate his kidney after detailed discussion about the future possibility of developing overt diabetes and end organ damage
this decision need MDT approach ,
According to the BST:
-All potential living kidney donors must have a fasting plasma glucose level checked. (B1)
-A fasting plasma glucose concentration between 6.1-6.9 mmol/L is indicative of an impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be undertaken. (B1)
-Prospective donors with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT. (B1) -If OGTT reveals a persistent impaired fasting glucose and/or an impaired glucose tolerance, then the risks of developing diabetes after donation must be carefully considered. (B1)
– Consideration should be given to the use of a diabetes risk calculator to inform the discussion of potential kidney donation. (B2)
-Consideration of patients with diabetes as potential kidney donors requires very careful evaluation of the risks and benefits. In the absence of evidence of target organ damage and having ensured that other cardiovascular risk factors such as obesity, hypertension or hyperlipidaemia are optimally managed, diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney. (Not graded)
The donor is 45 years old male with excellent renal function and no structural abnormalities. No immunological barriers so far. The only drawback is the presence of diabetes. Despite it is diet controlled diabetes, this will affect both the recipient and the donor either through the development of frank diabetes in the donor later on or the appearance of diabetes in the recipient as his odds are high since his brother has diabetes. The Amsterdam Forum recommended exclusion of diabetic donors. They did not address the pre-diabetic patients. The Asian Pacific Society of Nephrology guidelines suggest OGTT for donors at risk of DM. Individuals with a history of diabetes or fasting blood glucose of ≥126mg/dl (7.0mmol/L) on at least two occasions (or 2-h glucose with OGTT ≥ 200mg/dl (11.1mmol/L)) should not donate. In USA ,most centers decline donors who have diabetes or impaired glucose tolerance. Regarding donors with impaired fasting glucose, they are accepted if they had normal 2-hour oral glucose tolerance test. The onset and frequency of diabetic nephropathy in those needs to be studied in the future. (3)
When diabetic donors were compared with non-diabetic donors, the former were more likely to have hypertension and proteinuria. Both had a similar serum creatinine. Following uni-nephrectomy, the GFR will increase by 70% which if occurred in the presence of a diabetic hyper-filteration will augment the damage to the kidney. Silveiro noticed higher rates of micro-albuminuria in diabetic donors when compared to non-diabetic donors or to two-kidney diabetics. Macro-albuminuria was also more in diabetic donor when compared to non-diabetic donors but the two-kidney diabetics has the same rates as diabetic donors. Again there was no noted difference in renal function among all three groups. (1).
Another study revealed that DM developed after 18 years post donation. The changes in annual eGFR were similar between non diabetic and diabetic donor in the 7 years before the development of DM. Diabetes was found to be associated with development of proteinuria and hypertension but not with ESRD. The decline in eGFR after the appearance of DM of diabetic donors only exceed the non-diabetic donors in cases of concomitant proteinuria and hypertension.(2) Framingham study revealed accelerated kidney damage in patients with IFG and IGT.
On the other hand , Chang study showed similar rates of kidney damage between type 1 diabetes who received a transplant (one kidney) with matched patients with type 1 diabetes (two kidneys). this study has a major draw back as there is no hyperfiltration due to cyclosporine use in the transplant recipients.In Japan, diabetic patients can donate if they have no mircoalbuminuria. Okamoto for 88 months found no ESRD in 27 diabetic donors and 44 donors with IGT and found that 7 out of 65 developed frank diabetes. A larger study population (3698 ) by Ibrahim were followed for a longer period . He observed higher frequency of hypertension and proteinuria in donors (predominantly white) who developed type 2 diabetes compared with those who did not. On the other hand there was no difference in the estimated GFR.11 donors developed ESRD (0.29%) but they had no diabetic nephropathy. Ibrahim declared that the diabetic donors have similar rates of kidney disease and so he suggested no to decline donors with family history of diabetes. So the hypothesis of the role of hyperfiltration, due to nephrectomy, in faster deterioration of kidney function has no evidence so far.
Donors with pre-diabetes or Diabetes are at an increased risk for CVD and this risk increase further with the decline in eGFR in CKD patients . Data regarding the risk of CVD in donors is still under study. One Canadian study found no increase in mortality or CVD in white donors with diabetes over 6 years.
Some information are needed such as the ethnicity as Black and Hispanics donors, as compared to white donors, had a greater risk of diabetes mellitus requiring drug therapy(4). The metabolic syndrome and obesity are predictors for developing diabetes later on. Younger donor with IFG has a higher risk for DM development .this will increase the cumulative lifetime risk for developing diabetes in the presence of other risk factors.(3)
Other risk factors need to be evaluated like FH, BMI of ≥30 kg/m2 and excessive alcohol use .These were found to be associated with more progression of kidney disease and micro-albuminuria. Simmons suggested four major predictors of future diabetes:
1. ethnic group
2. previous gestational diabetes(is not applied in this donor)
3. a high titer of islet cell antibody (for insulin-dependent diabetes mellitus)
4. impaired glucose tolerance.
Scores need to be used to assess the risk of diabetes. Finnish Diabetes Risk Score (FINDRISC) uses age, body mass index (BMI), central obesity, daily exercise, diet, drug-treated hypertension, history of high blood glucose, and family history. Diabetes Personal Health Decisions (PHD) risk includes ethnicity. Those scores predict the 30-year risks in the general population for the development of diabetes, myocardial infarction (MI), cerebrovascular accident, and renal failure. The use of them in the exclusion of donors is not validated. But we need to adopt them for the process of informed consent. (3)
This patient has no proteinuria so we can proceed with the OGTT and we need to consider ethnicity ,FH, lipid profile ,smoking, age , features of metabolic syndrome , his risk for diabetes and MI by age 60.
We need present these risks to this donor with stress upon the fact that long term outcomes were still under studies .
References:
(1)Ibrahim, H.N., Kukla, A., Cordner, G., Bailey, R., Gillingham, K. and Matas, A.J. (2010), Diabetes after Kidney Donation. American Journal of Transplantation, 10: 331-337. https://doi.org/10.1111/j.1600-6143.2009.02944.x
(2)Benjamin R. Morgan, Hassan N. Ibrahim,Long-term outcomes of kidney donors,Arab Journal of Urology,Volume 9, Issue 2,2011,Pages 79-84
(3)Christine Buchek Vigneault, William Stuart Asch, Neera Kanhouwa Dahl, Margaret Johnson Bia, Should Living Kidney Donor Candidates with Impaired Fasting Glucose Donate?CJASN Aug 2011, 6 (8) 2054-2059; DOI: 10.2215/CJN.03370411
(4)Benjamin R. Morgan, Hassan N. Ibrahim,Long-term outcomes of kidney donors,Arab Journal of Urology,Volume 9, Issue 2,2011,Pages 79-84
Patients with controlled type 2 DM are considered a relative contraindication to kidney donation. Mild diet-controlled DM will be very acceptable if the patient is over 60 years old, provided no complication is evident. Donation of diabetics of young age is not eligible, especially if accompanied by obesity, cigarette smoking etc. BTS 2018 guideline suggests evaluating prediabetics with a history of gestational DM, impaired FBG etc. by DM risk calculator to evaluate the risk of DM.
I need to evaluate his brother’s ESKD reason. If he is because of diabetic nephropathy, this is important to exclude this donor. Diet-controlled diabetes at a young age (here 45) may not predict the future, and renal function will depend on basal eGFR.
As explained in the lecture provided, patients over 60 with eGFR over 80 and without complications (DNP etc.) can be considered potential donors.
Prediabetics should have OGTT and should be evaluated for risk of DM, preferably by risk calculator (BTS guideline 2018)
HISTORY
we need good assesment and evaluation of the risk and benfits :
1- How many years have T2DM?
2- Diet
3- Physical activity
4- Smoking
5- Obese or no
6- Have diabetic retinopathy or no
7- Hyperlipidemia
8- And verey important HbA1C
9- Family history(DM,HTN,OBESITY,Metabolic syndrom,autoimmuno and cardiovascular disease).
10- WE known all
What do you manage this case?
The donor need more investigation and evaluation
1- CBC
2- U.analysis
3-ACR 3 time during 6 months
4- FBS
5- OTTG
6- KFT
7- Lipidprofil
8- elctrolyte
9- abdominal and pelvic u/s
10- ECG
11- Echocardiography
12- May be need cardic catheterzation and renal biopsy ??
follow up :
1- Contol blood sugar
2- Keep HbA1c values between 39 and 46 mmol/mol (5.7% and 6.4%)
3- Correct dyslipidemia if presnet
4- Stop smoking
5- Physical activity 150 min /week
6- Keep BMI between 25- 30
###We must explain to him about the surgery and the risks that may occur, and he must be presented to a social and psychological specialist before unilateral nephroectomy.
Substantiate your answer
What do you manage this case?
In this scenario of a potentially living, related kidney donor in which the immuonological risk is low ( as there is 111 mismatch and no DSA), and well controlled diabetes with diet only. There is no evidence of diabetic nephropathy (no proteinuria, hematuria, or microalbuminuria).
▪︎Accepting this donor or not must be done by a multidisciplinary approach.
We must:
1. Consult this patient and tell him about the risk of donation with diabetes.
2. See if his recipient has no other suitable donor.
When accepting this donor according to marginal donor criteria (MDs) ( MDs now include people of older age, people with hypertension (HTN), and those who are obese, have mild kidney dysfunction, or diabetes mellitus (DM)[1].
▪︎We must evaluate his medical and surgical risks and other micro vascular complication of DM need to be excluded ( diabetic nephropathy, neuropathy and retinopathy).
▪︎We shall assess other cardiovascular risk factors such as cigarette smoking, obesity, dyslipidemia, …etc
Note: that in our center until now we are not accepting diabetic donors. Most of our donors are young and relatives.
_______________________
Ref:
[1] Kasumi Y. et al. Feasible kidney donation with living marginal donors, including diabetes mellitus.
https://onlinelibrary.wiley.com/toc/20504527/2021/9/3
This case lies in the grey zone with need for individualized pattern of approach regarding long term medical risk following donation .Hyperfiltration due to DM will be augmented after donation. Other risk factors like dyslipidemia ,smoking ,hypertension and post donation expected proteinuria.
IKDA role is needed to facilitate medical, surgical evaluation with full psychological assessment.
I like your description, this case lies in ‘grey zone’, dear Dr Omran.
_ the current potential donor has type 2 DM, well controlled with diet, so he can be accepted as a donor but with the following precautions:
1. Proper counseling about the risk to develop post donation worsening of his diabetic state and incresaed risk of diabetic nephropathy and progression to ESKD (especially in such young recipient with expected long life span post donation to develop many complications).
2. Exclusion of target organ damage as fundus examination for retinopathy.
Color duplex on iliac vessels to exclude premature astherosclerotic changes plus Carotid intimal thickness .
3. Exclude other risk factors for worsening kindney function and Cardiovascular complications as obesity, hypertension, smoking and dyslipidemia.
4. Life style modifications and tight control of his diabetes state is essential.
5. Use of donor risk calculation can help in predicting risk of CKD in donor ( in the context of presence of multiple risk factors).
This is as per KDIGO 2017.
Many thanks Dr Shawky.
Ajay
Traditional guidance has suggested that individuals with diabetes should not donate
a kidney.
Consideration of a diabetic as a potential donor requires a thorough evaluation of
the risks and benefits of donation and transplantation, for both the donor and
recipient. Specifically, a careful search should be made for any evidence of target
organ damage and assessment of cardiovascular risk factors such as obesity,
hypertension and hyperlipidaemia. The age of the donor, donor GFR, and the
relationship to the potential recipient are critical factors. After exclusion of preexisting diabetic nephropathy, possibly including renal biopsy, the potential risk of
development of diabetic nephropathy should be discussed with the potential donor.
Appropriate counseling should be done regarding future risk .
Hi Dr Ansary,
I wish you could add MDT discussion to the ‘list to do’
Potential donor; 45y male, relative(brother) normal KFT with mild diet-controlled DM. No hematuria. No proteinuria.
Potential KTR; AM and no DSA.
The main issues in this pair are the DM in the potential donor( which is mild and controlled with diet) and the donor age, as he is still young and may have all the possible complications after donation in regard to his diet-controlled DM.
To accept the offer from this diabetic to his relative brother, a very careful evaluation of the risks and benefits is required, provided the absence of evidence of target organ damage and having ensured that other cardiovascular risk factors such as obesity, hypertension or hyperlipidaemia are optimally managed.
Diabetics can be considered for donation as per KDIGO and BTS guidelines, after thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney1.
Observations from a study in a Japanese center, including 444 patients supported the willingness of this relative to donate to his brother. Japanese found no difference in the rate of immediate post-operative complications or survival at 20y between the glucose tolerant and intolerant groups1.
The discrepancy of the significant impact of donor DM on graft outcome and the frequent absence of DN in diabetic donor kidneys noted, is of considerable interest. It suggests that donor DM adversely impacts graft outcome through mechanisms distinct from the renal tissue injury seen in DN2.
The potential KTR has an acceptable mismatch and no DSA to the index donor. After full counseling and detailed discussion to raise the awareness of the possible complications post-donation, I will go ahead with this potential donor provided his willingness to donate to his brother.
Reference
1. BTS/RA Living Donor Kidney Transplantation Guidelines 2018
2. Luan D. Truong, et al “Kidney Donors With Diabetes: Renal Biopsy Findings at Time of Transplantation and Their Significance”
Hi Dr Assafi,
I wish you could add MDT discussion to the ‘list to do’.
Ajay
BTS :
-All potential living kidney donors must have a fasting plasma glucose level checked. (B1)
-A fasting plasma glucose concentration between 6.1-6.9 mmol/L is indicative of an impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be undertaken. (B1)
-Prospective donors with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT. (B1) -If OGTT reveals a persistent impaired fasting glucose and/or an impaired glucose tolerance, then the risks of developing diabetes after donation must be carefully considered. (B1)
– Consideration should be given to the use of a diabetes risk calculator to inform the discussion of potential kidney donation. (B2)
-Consideration of patients with diabetes as potential kidney donors requires very careful evaluation of the risks and benefits. In the absence of evidence of target organ damage and having ensured that other cardiovascular risk factors such as obesity, hypertension or hyperlipidaemia are optimally managed, diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney. (Not graded)
KDIGO
Predonation metabolic and lifestyle factors
✓ Assess metabolic and lifestyle risk for CKD and/or cardiovascular disease
by obtaining the following prior to donation:
c Body mass index measurement
c History of diabetes mellitus and gestational diabetes and family history
of diabetes
c Fasting blood glucose and/or glycated hemoglobin (hemoglobin A1c)
c Fasting lipid profile, including total cholesterol, LDL-cholesterol,
HDL-cholesterol, and triglycerides
c Present and past use of tobacco products
Donor candidates with type 1 diabetes mellitus should not donate. The decision to approve donor candidates with prediabetes or type 2 diabetes
should be individualized based on demographic and health profile in relation to the transplant program’s acceptance threshold. Donor candidates with prediabetes and type 2 diabetes should be counseled that their condition may progress over time and may lead to end-organ complication
so in this case
young man with 111 mismatch with no DSA and diet controlled DM with excellent kidney function and no evidence of albuminuria, proteinuria or hematuria
after taking all detailed hx and physical examination
with discussion with MDT ( endocrine,nephro and surgeon )
after CVD evaluation and fasting glucose and OGTT all has done with no organ damage has been identified
i will accept him as donor and start on life style modification until time of surgery with regular follow up after the surgery
***** interesting article that i found about diabetic nephropathy in diabetic donors if biopsy has done before the surgery
DN is noted in a small percentage of diabetic donor kidneys. When this occurs, the DN is often mild and in early stages. After transplantation, DN in diabetic donor kidneys may stabilize or progress with a mild increase in severity and at a slow pace. In cases DN is not present in diabetic donor kidneys, DN often does not develop in posttransplant, even in diabetic recipients. This study suggests that diabetic donor kidneys with or without DN may not by itself impart significant adverse effect of graft survival
references :
BTS guidelines and KDIGO
Kidney Donors With Diabetes: Renal Biopsy Findings at Time of Transplantation and Their Significance
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6616142/
Yes Dr Farah,
I quote your reply, “I will accept him as donor and start on life style modification until time of surgery with regular follow up after the surgery”.
This has to consist of time-bound targets for our prospective donor to achieve and maintain those gains for significant duration of time.
A 45 years gentleman who came forward to potentially donate his kidney to his brother and whether he can be accepted for this donation.
Given data:
-111 mismatch with no DSA and diet controlled DM with excellent kidney function and no evidence of albuminuria, proteinuria or hematuria
BTS 2018 and KDIGO 2017 guide lines(1,2) accepted type 2 diabetic patients to donate their kidneys on individual bases if there is no evidence of target organ damage and after meticulous assessment of cardiovascular risks for progressive cardiovascular disease and renal disease with a single kidney. Additionally, a proper counseling to these potential donors that their condition may progress over time after donation and may lead to end organ complications However, Ibrahim et al found that the rate of decline of eGFR were not significantly different between diabetic and non-diabetic matched donors(3).
What do you manage this case?
1. This donor requires Risk assessment to exclude occult cardiovascular disease and exclude target organ damage
· History taking including family history of DM, smoking history
· Thorough clinical examination including checking of Bp, BMI and fundoscopy and examination for PVD
· Laboratory blood tests to check Hba1c, serum cholesterol and triglycerides
· ECG, ECHO
2. Assess his functional capacity :being diabetic; this donor CV risk score will be high and will require further investigations in liaise with the cardiology to check his functional capacity including stress test, MPS, CT CAC score and may need a CTCA or a formal coronary angiography.
Substantiate your answer?
After this careful assessment and counseling for this exceptional case, if this donor is still willing to donate his kidney, i will proceed for kidney donation (following the BTS and KGIGO guidelines) with close post donation follow up with emphasis on lifestyle modifications (4)
References:
========
Dear Dr Omar,
I quote your reply, “ i will proceed for kidney donation (following the BTS and KGIGO guidelines) with close post donation follow up with emphasis on lifestyle modifications (4).”
My approach in this regard:
This has to consist of time-bound targets for our prospective donor to achieve and maintain those gains for significant duration of time.
>>Substantiate your answer
type 2 diabetes can be considered for donation provided that :
1- no evidence of EOD
2- optimal management of other cardiovascular risk factors such as obesity, hypertension & hyperlipidaemia .
Hi Dr Mohamed,
I would go for MDT approach and advice would consist of time-bound targets for our prospective donor to achieve and maintain those gains for significant duration of time.
What do you manage this case ?
Substantiate your answer :
Hi Dr Omar,
I would go for MDT approach and advice would consist of time-bound targets for our prospective donor to achieve and maintain those gains for significant duration of time.
● How do you manage this case?
•I will proceed with him as a donar candidate.
●Substantiate the answer:
•Traditional guidelines have suggested that diabetics shall not donate a kidney, while the BTS goes on with an
an observational study of 444 donors from a single Japanese; that has accepted subjects with an abnormal OGTT, including a small number with diabetes; that there is no difference found in the rate of immediate post operative complications or survival at 20 years between the glucose tolerant and intolerant groups.
•Consideration of a diabetic as a potential donor requires a thorough evaluation of the risks and benefits of donation and transplantation, for both the donor and recipient. Specifically, a careful search should be made for any evidence of target organ damage and assessment of cardiovascular risk factors such as obesity, hypertension and hyperlipidaemia.
•In a large survey of living kidney donors in the United States, Ibrahim et al found that the self-reported prevalence of diabetes was 5.2% in the 2,954 patients who responded.
The vast majority of kidney donors where white, about 50% were genetically related to the recipient.
The eGFR and the rate of decline of eGFR were not significantly different between diabetic and matched non-diabetic donors. In this study, 11 donors developed ESRD requiring dialysis or transplantation, of which none were due to diabetic kidney disease.
References:
-BTS/RA Living Donor Kidney Transplantation Guidelines 2018
Hi Dr Mina,
I would go for MDT approach. This prospective should demonstrate that life-style gains are maintained for a significant duration of time.