2. A 29-year-old male with excellent kidney function offered a kidney to his father who 61 years old, 111 mismatch, no DSA. His blood pressure is well controlled by 2 drugs. No evidence of proteinuria or haematuria. His echocardiogram showed mild concentric left ventricular hypertrophy, but no evidence of systolic or diastolic dysfunction
- What is your management?
Dear All
What is the risk for this patient developing CKD?
Is the risk of CKD or the risk of CVD or both that matter? Why
How can you reduce this risk?
Hypertension (HTN) and CKD are closely associated with an intermingled cause and effect relationship. Blood pressure (BP) typically rises with declines in kidney function, and sustained elevations in BP hasten progression of kidney disease. and also increase the risk for CVD[1&2].
The risk can be reduced by better control of blood pressure and associated comorbidities ie; obesity, hyperlipidemia, and smoking.and preventing end organ damage , ie LVH, retinopathy, proteinuria ..etc[1].
[1] Rastogi A, Yuan S, Arman F, Simon L, Shaffer K, Kamgar M, Nobakht N, Bromberg JS, Weir MR. Blood Pressure and Living Kidney Donors: A Clinical Perspective. Transplant Direct. 2019 Sep 19;5(10):e488. doi: 10.1097/TXD.0000000000000939. PMID: 31723583; PMCID: PMC6791603.
[2] Judd E, Calhoun DA. Management of hypertension in CKD: beyond the guidelines. Adv Chronic Kidney Dis. 2015 Mar;22(2):116-22. doi: 10.1053/j.ackd.2014.12.001. PMID: 25704348; PMCID: PMC4445132.
Yes, Dr Alshaaikh,
When I mention the relation between cardiovascular disease and a decline in kidney function I would not only include raised creatinine but proteinuria as well.
hypertension with end-organ damage can lead to both CVD and CKD and even cerebrovascular disease so both are important and patients should be under control and monitor for microalbuminuria with modification of other risk factors like dyslipidemia, Diabetes, smoking cessation, avoiding alcohol, and weight reduction,
hypertension is a risk factor for both CKD and CVD; the risk can be reduced by good control of BP, and control of proteinuria if present, in addition, other risk factors associated with hypertension should be controlled such as obesity, smoking, hyperlipidemia, diabetes, medications such as NSAIDs
Recent report showed donors may be at increased risk of ESRD as well as CVD risk. Both CKD and CVD risks are important. Risk reduction includes; self monitoring of BP, no smoking, weight reduction , control of BP and sugar.
presence of HTN is risk factor for both CKD and CVD and especially if uncontrolled or commented of one or more other risk factors such as DM ,smoking and high lipid profile, the risk can be reduced by controlled the BP and absence or control any other risk factors mention above
In some patients, the plasma creatinine concentration and degree of proteinuria continue to rise despite seemingly good control of the systemic blood pressure. Why such patients are susceptible to progressive kidney injury is not known
https://www.uptodate.com/contents/clinical-features-diagnosis-and-treatment-of-hypertensive-nephrosclerosis/abstract/5
Risk of CKD or CVD is important in this patient as he still young and has LVH, mostly he will progress with time.
To reduce the risk he is advised to well control Bp, stop smoking, reduce alcohol amount, exercise, and weight reduction.
Because this donor is young with hypertension associated with end organ damage (LVH), he should be declined from donation.
References:
hypertension is risk factor for cardiovascular disease at the same time he is a risk factor for developing chronic kidney disease .about 30% of CKD is caused by hypertension . the hypertension is closely related as a risk factor for development of cardiovascular complication. therefore hypertension carry a risk of both CKD and cardiovascular disease.
this patient is treated as
1- searching for underlying cause ( secondary hypertension)
2- life style modification ( diet, exercise >
3- medication to reduce BP to accepted target.
Hypertension is a major cause of CKD and as this donor has LVH, his kidneys may de involved too. So, he will be at risk of both CKD and CVD. His risk would be decreased by good control for BP, blood sugar, lipids, weight and cigarette quitting.
HTN is both a cause and effect of CKD and contributes to its progression.
Hypertension and CKD are both independent risk factors for CVD.
Reducing risk by good control of blood pressure
Despite normal kidney functions of the donor and absence of proteinuria and hematuria there was controlled hypertension
As he needs two drugs for control the hypertension with presence of target organ damage ( Ventricular hypertrophy )
So It is preferred to discard this donor.
BTS stated that :
Potential donors with mild-moderate hypertension that is controlled to
<140/90 mmHg (and/or 135/85 mmHg with ABPM or home monitoring)
with one or two antihypertensive drugs and who have no evidence of
end organ damage may be acceptable for donation. Acceptance will be
based on an overall assessment of cardiovascular risk and local policy.
Ref :
BTS
This donor is too young to have hypertension. As it is controlled, it would not be a contraindication to the donation, however, he also already has a target organ lesion (left ventricular hypertrophy) CONTRAINDICATING this donation.
Even this donor has a high risk of CKD and CVD, and must carry out strict control of blood pressure levels and proteinuria, in addition to lifestyle habits.
Donor is at high risk of developing CKD ,and better not to donate
better control of blood pressure ,avoid smoking ,lipid profile
What is your management?
29 year old donor presenting with HTN controlled on 2 drugs and complicated with Mild left ventricular hypertrophy ( target organ damage) so this donor according to guidelines should be discarded even with normal KFTs and no proteinuria.
Hypertension in the donor has shown in some studies that it can be responsible for further deterioration in renal function post donation by reducing renal compensatory mechanism and might result in ESRD. Okumura K et al 2019.
Boudville N and colleagues 2006, reported in a meta-analysis that hypertension can be one of the consequences of donation, which has been confirmed by other authors as well (Garg AX et al 2008). subsequently he might progresses to ESRD .
I will reject him as a donor, counsel him regarding compliance with his antihypertensives and maintaining healthy life style. He is young with 2 antihypertensive , I will refer him to the cardiologist to investigate him for secondary hypertension, and follow his LVH.
This patient now with single kidney and he is hypertensive which is well controlled.
Management plan:
life style modification regarding diet, exercise, smoking and stressful conditions
check of blood glucose level and follow up
lipid level and good control
renal profile and urine analysis follow up
Donor has hypertension and end organ damage(mild concentric LVH) at the age of 29.
Considering his young age, he has risk factors for developing CKD and CAD.
As per most of guidelines including KDIGO and BTS/RA Living Donor Kidney Transplantation Guidelines 2018, end organ damage is considered as a contraindication for donation and i will reject this donor.

Additionally, he should be advised for healthy lifestyle, moderate exercise daily, quit smoking(if present), maintain adequate weight, control BP and dyslipidemia ( if present)
According to BTS/RA Living Donor Kidney Transplantation Guidelines 2018
It is recommended that potential donors with hypertension are excluded from donation if: (C1)
This potential donor although his blood pressure is controlled with 2 drugs there is end organ damage in the form of mild concentric left ventricular hypertrophy so he should be excluded from organ donation and be investigated for the underlying cause of this hypertension in such a young patient,
Reference
BTS/RA Living Donor Kidney Transplantation Guidelines 2018
Living donation part 2 , by Roberto Cacciola
HTN is independent risk factor for end organ damage ,in this patient it controlled by two medication so the risk is higher
ECHO show just LVH but we need to screen for coronary arteries,check the lipid profile and screening for DM before to proceed
HTN is not considered an absolute contraindication for kidney living donation.
KDIGO guidelines recommend that living donor with hypertension that can be controlled with one or two medications to less than 140/90 mmHg and without end-organ damage could be considered for living kidney donation.
In this case , the donor is hypertensive and well controlled by two drugs, but he has an organ damage ( mild concentric LVH).
he should be excluded.
Donor’s hypertension is well controlled by 2 antihypertensive agents, but he has HTN end-organ damagein form of mild LVH.
Thus, according to KDIGO guideline, because of his end-organ damage and young age, he is contraindicated for donation.
Donor age 29, Hypertensive on 2 anti-hypertensive drugs with ECHO showing mild LVH with preserved RVF and LVF.
BTS/RA 2018 guidelines recommend to exclude donors if BP>140/90 on two anti-HTN medications or previous CV disease or evidence of end organ damage.
This donor is at high risk of CV events and CKD after donation, education and counselling is mandatory.
I would decline this donation offer.
According to birtish transplant society hypertensive donor managed as following
HYPERTENSION IN THE DONOR
Blood pressure must be assessed on at least 2 separate occasions.
Ambulatory BP monitoring or home monitoring is recommended if
Ø blood pressure is high,
Ø high normal or variable,
Ø If donor is on treatment for hypertension.
Ø a blood pressure of <140/90 mmHg is usually acceptable for donation.
Ø Prospective donors should be warned about the risk of post donation hypertension.
Ø donors BP should be monitored annually.
Ø donors with mild-moderate HT that is controlled to <140/90 mmHg (and/or 135/85 mmHg with ABPM or home monitoring) with one or two antihypertensive drugs and who have no evidence of end organ damage may be acceptable for donation.
donors with hypertension are excluded if:
Ø Blood pressure is not controlled to <140/90 mmHg on one or two antihypertensive drugs .
Ø Evidence of end organ damage (retinopathy, left ventricular hypertrophy, proteinuria, previous cardiovascular disease) .
Ø Unacceptable risk of future cardiovascular risk or lifetime incidence of ESRD .
All living kidney donors must be encouraged to
Ø lifestyle measures including stopping smoking, reducing alcohol intake, frequent exercise and, weight loss.
Ø Hypertension will develop in at least 30% of patients following unilateral nephrectomy
According to this guidelines this donor should be be declined .
1) Andrews PA et al. British Transplantation Society / Renal Association UK Guidelines for Living Donor Kidney Transplantation 2018: Summary of Updated Guidance. Transplantation. 2018 Jul;102(7)
Young donor, with history of hypertension controlled on 2 blood pressure medications. However, he has features of end organ damage(LVH) that would preclude him from kidney donation.
According to BTS, potential kidney donors with hypertension are excluded if they met any of the following:
– Uncontrolled blood pressure <140/90 with one or two anti-hypertensive medications.
– Evidence of end organ damage( retinopathy– proteinuria- LVH-previous cardiovascular diseases).
This patient has increased risk for future cardiovascular disease and life time incidence of chronic kidney disease.
This patient needs a detailed history(including a family history), thorough examination, laboratory and radiological investigations to exclude secondary causes of hypertension.
living kidney donors are encouraged to decrease their hypertensive risk through life style modification ( stopping smoking, reducing alcohol intakes, frequent exercise and weight loss).Moreover, if hypertension is diagnosed during pre-transplant work up or developed later to be managed according to the British Hypertension Society guidelines.
References:
1. Andrews PA et al. British Transplantation Society / Renal Association UK Guidelines for Living Donor Kidney Transplantation 2018: Summary of Updated Guidance. Transplantation. 2018 Jul;102(7)
2. Lecture of prof. Roberto Cacciola (assessment of living donations)
Our potential donor is 29 years old with hypertension that’s well controlled on 2 drugs but there is evidence of end organ damage in the form of left ventricular hypertrophy
According to the British society of transplantation this donor is at risk of post transplant morbidities and should be discarded
Although this son seems to be of good option for donation, however HTN patients with evidence of target end organ damage as LVH ,retinopathy or other manifestations are totally declined from donation .the risk of HTN predonation with other system affection carries rather comorbid outcomes ,accelerated HTN ,progressive cardiac events or even renal impairment.
The donor is a young male (29 years) with normal renal functions and is offered for kidney donation to his father who is a CKD V patient….The donor has Hypertension that is controlled by 2 drugs….Although he has no proteinuria or hematuria there is Left Centricular Hypertrophy which is an end organ damage…
According to the BTS guidelines of 2018, hypertensive donors can be taken up for surgery if they have well controlled blood pressure(<140/90mm) with less than 2 drugs and with no evidence of target end organ damage that is no proteinuria or hematuria or retinopathy or no LVH….
European best practice guidelines say that these donors can be re evaluated after good lifestyle modifications to see if these end organ damage disappears.. ..
KDIGO guidelines are similar to the BTS guidelines….
Given the young age of the donor and hypertension with 2 drugs and end organ damage with LVH I will reject this donor
Management of the donor will be find out a cause for the secondary hypertension as age is less than 30 years….there is no hematuria or proteinuria excluding an underlying glomerulonephritis as the cause of hypertension….the donor will need other tests namely potassium, urinary metanephrines, renin aldosterone ratio, serum cortisol levels etc
*This candidate young donor has hypertension controlled on 2 medications with mild LVH so has end organ damage , so ; he is not suitable for kidney donation.
*Management directed towards:
1.Diagnosis the cause of his hypertension in young age and asses family history ,causes of secondary hypertension( Renal duplex and KFT, lipid profile ,proteinuria should be followed regularly).
2.He should control risk factors as; obesity, tight control of blood pressure ,control lipid profile, stop smoking, low salt diet.
*This candidate donor has risk of developing CVD later on, risk of hypertensive kidney disease
References:
BTS/RA LKD Transplantation Guidelines 2018
This young man is not suitable for kidney donation as he needed 2 antihypertensive medications with mild LVH.
Management plan
1) counsel regarding the cardiovascular risk and renal risk of kidney donation in this case.
2) lifestyle modification. healthy lifestyle. dietary advice eg low salt diet
3) ensure good compliant to medication.
4)annual echo follow up.
I would reject this donor.
first of all, he has documented hypertension associated LVH which is a sign of cardiovascular affection.
Secondly, he is 29 years old with dual therapy hypertension, which make him more prone for developing CKD. thus , as per some guidelines(1), this patient should be excluded.
References
:
1- Andrews PA, Burnapp L. British Transplantation Society / Renal Association UK Guidelines for Living Donor Kidney Transplantation 2018: Summary of Updated Guidance. Transplantation. 2018 Jul;102(7):e307. doi: 10.1097/TP.0000000000002253. PMID: 29688993; PMCID: PMC7228639.
BTS/RA Living Donor Kidney Transplantation Guidelines 2018
“It is generally accepted that the presence of hypertensive end organ damage (left ventricular hypertrophy, retinopathy, proteinuria), uncontrolled hypertension, or hypertension that requires more than two drugs to achieve adequate control are contraindications to donor nephrectomy.”
European Renal Best Practice Guideline on kidney donor and recipient evaluation and perioperative care states that
“We suggest that these potential donors be re-evaluated for disappearance of this target organ damage after appropriate treatment”
So, we need to reassess this donor after
If there is reversal of the LVH, then he can be considered for donation.
in this case risk of CVD and CKD both matter as he is a young donor with end organ damage with two antihypertensive drugs.
Abramowicz D, Cochat P, Claas FH, Heemann U, Pascual J, Dudley C, Harden P, Hourmant M, Maggiore U, Salvadori M, Spasovski G, Squifflet JP, Steiger J, Torres A, Viklicky O, Zeier M, Vanholder R, Van Biesen W, Nagler E. European Renal Best Practice Guideline on kidney donor and recipient evaluation and perioperative care. Nephrol Dial Transplant. 2015 Nov;30(11):1790-7. doi: 10.1093/ndt/gfu216. Epub 2014 Jul 9. PMID: 25007790.
Probably he has essential hypertension, with initial end organ damage(LVH), as BP is well controlled with two drugs but possibility of needed further escalation after single Fx kidney, possible hyperfiltration and FSGS, proteinuria. current data shows association of hypertension and more>30% development of future renal failure.
Family showed be counselled thoroughly.
The risk can reduced if, Good blood pressure control,
weight control, more vigilant for routine check up.
*This potential donor 29 year old male, with excellent kidney function, the BP is well controlled with 2 drugs, no evidence of proteinuria or haematuria, the Echocardiogram showed mild concentric left ventricular hypertrophy but no evidence or systolic or diastolic dysfunction, no data about his body weight.
*It is recommended that potential donors with hypertension are excluded from donation if: (C1)
o Blood pressure is not controlled to <140/90 mmHg on one or two antihypertensive drugs
o Evidence of end organ damage (retinopathy, left ventricular hypertrophy, proteinuria, previous cardiovascular disease)
o Unacceptable risk of future cardiovascular risk or lifetime incidence of ESRD
*So, I will not accept this donor because his young, may developed end organ damage, CVD and ESRD.
*In our practice in my center in case of potential hypertensive donor we select only those with age > 50 years, e-FGR>80 ml/min, 24 hour urine albumin<30 mg/day and controlled with one or two drugs.
BTS/RA Living Donor Kidney Transplantation Guidelines 2018
He is a young patient, already hypertensive and in need of two drugs for blood pressure control, we do not have data on BMI and ethnicity to add other risk factors, but as he already has left ventricular hypertrophy we should not accept the donation.
The risk is quite high with so many factors added together. Obviously, we can proceed with an improved diet, metabolic control, and frequent and adequate exercise to improve your blood pressure and metabolic status.
It is recommended that potential donors with hypertension are excluded from donation if:
· Bp is not controlled to< 149/90mmHg on one or two antihypertensive drugs
· Evidence of end organ damage (retinopathy, left ventricle hypertrophy, proteinuria, previous cardiovascular disease)
· Unacceptable risk of future cardiovascular risk or lifetime incidence of ESRD
This donor has controlled Bp, no proteinuria, but has left ventricle hypertrophy. We don’t know if LVH is recent or old and improving with drugs.
He still young and progression of kidney disease is suspected due to possible progression of HTN post donation.
He should be encouraged to stop smoking( if he smokes), reduce alcohol intake, frequent exercise, and weight reduction.
this young man should be precluded from donation as he is a case of hypertension with end organ damage (LVH). Also, first, we must search for a secondary cause of hypertension in this man. manage the other risk factors like obesity, smoking etc
hypertension is associated with the risk of CKD and CVD especially if uncontrolled.
This patient is not the better candidate for donation
we should have full history and examination about the hypertension and as he is less than 30 we MUST R/O secondary cause of HTN
despite this patient BP is well controlled on 2 medications he has LVH which considered end organ damage
so its better to look for another donor as he has increased risk of both developing CKD and CVD post donation
about this person we should act on modifiable risk factor such as weight reduction , smoking secession, exercise encouragement , low salt diet , good control of BP lipid profile , prevention of protienurea
thanks
He is young with hypertension (well controlled on 2 antihypertensive) and evidence of LVH (though mild).
I would consider him not suitable for kidney donation even though he has a well controlled BP (on 2 antihypertensive) because he has already evidence of end organ damage (Mild LVH) and above all in view of life time incidence of end stage kidney disease and the risk for potential risk of future cardiovascular disease
This patient is young and should be fully investigated for hypertension even though he has likely an essential hypertension.
I would like to know if there is any family history of hypertension and in that case may need genetic study. We need to know his life style (e.g. smoking, weight, diabetes)
In terms of Investigation I would request: Cortisol, TFT, RAA, urinary catecholamine and I will arrange an MRA renal artery. He requires an ophtalmology review to exclude hypertensive retinopathy
I would also advice life style changes: stop smoking if patient is a smoker, reduce salt intake and physical activity.
That potential donor is not candidate for donation being of age less than 50,with BP on 2 medications ,end organ damage ;LVH. So, that offer cannot be accepted.
On the other hand, patient to be managed as a classic case of case of secondary hypertension including family history ,and investigations with accordingly necessary therapeutic actions..
References
Living Kidney Donor- KDIGO 2017
This scenario of young male with poorly controlled Bp as he had LVH at this age .
He should be declined from donation as he had end organ damage presented as concentric left ventricular hypertrophy.
being young age we must search for causes of secondary hypertension,he is also at higher risk for developing cardiovascular complications at older age and higher risk for developing hypertensive renal disease.
Proteinuria and kidney function must be checked regularly ,renal ultrasound and duplex, lipid profile ,thyroid profile all must be evaluated and he must be referred to cardiologist for follow-up.
Kidney donation will increase the risk for earlier CV and renal complications.
BTS/RA Living Donor Kidney Transplantation Guidelines 2018
young 29 years male want to donate kidney to his father ,HTN in this age need to be investigated for the cause, with no proteinuria or haematuria .
although his BP controlled but in 2 medication so we need to discuss with him that been at risk develop ckd and CVS ,especially if there is any more risk factor.
regarding the cause of HTN and searching about secondary causes of HTN and detailed family hx
Proper hx and clinical examination
Labs including serum lytes ,hormonal status ,urine analysis
Protein / creatinine ratio ….
Imaging renal ct angio , renal u/s
Also he needs life style modification,stop smoking ,and strict b/p control
Such patient with early HTN may progress to CKD if not managed well and again he is suitable for kidney donation
Current guideline exclude potential donors from donation if-
Blood pressure >140/90 mm Hg despite being on 1-2 antihypertensives.
Sign of end organ damage.
With this background I will council him that kidney donation can increase his risks of developing CKD and cardiovascular risks . This can lead to shorter longevity.
He has to continue antihypertensive medication and watch lipid profile along with lifestyle adjustments.
young 29 years male want to donate kidney to his father ,HTN in this age need to be investigated for the cause, with no proteinuria or haematuria .
although his BP controlled but in 2 medication so we need to discuss with him that been at risk develop ckd and CVS ,especially if there is any more risk factor.
The current BTS guidelines exclude donor with HTN if BP.140/90mmgh on 2 or more anti HTN or any organ damage
reference
kidigo guidlined2007
donors with well-controlled BP (BP <140/90 controlled with 1–2 antihypertensive drugs and no evidence of target organ damage) seem to be at minimal risk of developing worsening kidney function or hypertension
Yet, the available studies are of short duration, and there are phenotypes, such as obese, or people with African heritage who may be at more risk, and genotypes such as APOL1 which may confer more risk over time
medication regimen to control BP
make positive lifestyle changes, including weight control, modest dietary sodium reduction and regular exercise, smoking avoidance, and modest alcohol intake.11,49
They should also receive proper education on taking home BP for self-BP monitoring and management.

11. Lentine KL, Kasiske BL, Levey AS, et al. KDIGO clinical practice guideline on the evaluation and care of living kidney donors. Transplantation 2017101Suppl 1S1–S109 [Europe PMC free article] [Abstract] [Google Scholar]
48. Olyaei AJ, deMattos AM, Bennett WM. A practical guide to the management of hypertension in renal transplant recipients. Drugs 1999581011–1027 [Abstract] [Google Scholar]
49. Rossi AP, Vella JP. Hypertension, living kidney donors, and transplantation: where are we today? Adv Chronic Kidney Dis 201522154–164 [Abstract] [Google Scholar]
This patient has two risk factors
Hypertension with target organ damage including (CKD) – (CVD) both of them matter
Because existence both of them carries cumulative risk of reducing life expectancy
We can reduce the risk by well control BP
ABPM may benefit ?
Follow up the patient with BP measurement and microalbuminuria screening routinely is very important
Refer the patient to cardiologist for scheduling Echocardiogram
Avoiding other risks: smoking- BMI more than 30
What is your management?
This 29 year old potential donor has hypertension though the duration of hypertension is not mentioned .
There is left ventricular hypertrophy due to hypertension ( Sign of end organ damage).
LVH is sign of end organ damage indicating stress on cardiovascular system.
There is family history of CKD- Exact cause not mentioned.
I will like to investigate him further to rule out secondary causes of hypertension though we know that essential hypertension is the major cause of hypertension at his age.
With this background the is very young ( Still 29 years old) and kidney donation may be risky.
Kidney donation may increase his risk of developing CKD and higher cardiovascular risks. Cardiac risk assessment will be required.
Current guideline exclude potential donors from donation if-
Blood pressure >140/90 mm Hg despite being on 1-2 antihypertensives.
Sign of end organ damage.
With this background I will council him that kidney donation can increase his risks of developing CKD and cardiovascular risks . This can lead to shorter longevity.
He has to continue antihypertensive medication and watch lipid profile along with lifestyle adjustments.
Reference
KDIGO Guielines 2017
Although this donor has HTN with two medications used to to control his BP, there is evidence of cardiovascular complications with LVH. We can not accept him as a donor due to increased risk of CVS and renal function deterioration!
Screening for secondary hypertension is indicated if the patient is less than 30 years with no family history of HTN or obesity.
This young donor with hypertension likely uncontrolled in view of LVH ( end organ damage ) so as per KDIGO guidelines not accepted as a donor .
Also he needs to be investigated well for secondary causes of hypertension especially he is young
Otherwise , he needs life style modification , low salt diet , stop smoking , weight reduction
ï‚· What is your management?
Further assessment should include:
The degree of control of his blood pressure & the method of blood pressure measurement (some guidelines recommend that a 24-hour ABPM BP reading >140/90 mm Hg or use of AHMs be a contraindication to donation).
ACC/AHA guidelines exclude from donation those with an average office BP reading ≥160/100 mm Hg, evidence of end-organ damage (LVH, albuminuria), or are taking >2 antihypertensive medications.
This index case has LVH, though mild, and is taking 2 antihypertensive medications. The blood pressure readings are not mentioned in the scenario. So one would think of excluding him from donation; however, when hypertensive donors are allowed to donate, they do not seem to be at a significantly increased risk of developing renal or CVD.
If this patients average office BP reading <130/80 mm Hg over 3 measurements, then he could be considered for donation with appropriate individualization & counseling.
Lentine et al reported that pre-donation HTN was not associated with an increased risk of any peri-operative complications, such as gastrointestinal, bleeding, respiratory, & surgical injuries
Reference
Anjay Rastogi.Blood Pressure and Living Kidney Donors: A Clinical Perspective.Transplantation Direct 2019;5: e488; doi: 10.1097/TXD. 00000000 00000 939. Published online 19 September, 2019.
▪︎It is well known that hypertension has been one of the main exclusion criteria for living kidney donation, as it is a risk factor for renal and cardiovascular disease [1].
▪︎In this scenario; a 29 years old male, hyptensive (well controlled by two drugs), with excellent kidney function. He is planned to donate his kidney to his father with good miss match. Also, has mild concentric left ventricular hypertrophy. ▪︎The above picture make this young man not suitable for donation, because the most current living kidney donation guidelines state that: Donors with a BP >140/90 mm Hg with 1–2 antihypertensive medications or evidence of end-organ damage should be excluded from living kidney donation [1].
▪︎This pt also needs more evaluation regarding the cause of hypertension. He needs proper hystory, clinical examination and
Laboratory investigation.
________________________
Ref:
[1] Anjay Rastogi, et al.
Blood Pressure and Living Kidney Donors: A Clinical Perspective. Transplant Direct Direct. 2019 Oct; 5(10): e488.
Regarding donation, his male is not eligible for donation and should be excluded as he has end organ damage in the form of left ventricular hypertrophy.
His young age increases the risk of future cardiovascular complications and increase the risk for developing ESKD and this risk may be aggravated by nephrectomy.
Subclinical hypertensive nephrosclerosis may be present at time of donation and may increase the risk of cardiovascular complications and the possibility of ESRD.
Regarding his management, secondary causes of HTN should be excluded through hormonal assessment, renal artery duplex
Should be counseled about the necessity of proper control of BP to decrease the risk of hypertension related complications.
Life style modification as cessation of smoking, exercise, weight loss and avoiding alcohol intake.
BTS/RA Living Donor Kidney Transplantation Guidelines 2018
Living donor who is young 29 y/o good kidney functions and miss match but with hypertension controlled by 2 medications and mild concentric left ventricular hypertrophy make him not suitable for donation and needs more evaluation regarding the cause of HTN and searching about secondary causes of HTN and detailed family hx
Proper hx and clinical examination
Labs including serum lytes ,hormonal status ,urine analysis
Protein / creatinine ratio ….
Imaging renal ct angio , renal u/s
Also he needs life style modification,stop smoking ,and strict b/p control
Such patient with early HTN may progress to CKD if not managed well and again he is suitable for kidney donation
According to BTS/RA Living Donor Kidney Transplantation Guidelines 2018
It is recommended that potential donors with hypertension are excluded from donation if: (C1)
hypertrophy, proteinuria, previous cardiovascular disease)
All living kidney donors must be encouraged to minimise the risk of hypertension and its consequences before and after donation by lifestyle measures including stopping smoking, reducing alcohol intake, frequent exercise and, where appropriate, weight loss. (C1)
It is recommended that donors who are diagnosed with hypertension during assessment or who develop hypertension following donation are managed according to British Hypertension Society guidelines. (B1
Reference
BTS/RA Living Donor Kidney Transplantation Guidelines 2018
Living donation part 2 , by Roberto Cacciola
I like your decision-making process Dr Huda. Ajay
Thank you prof
This donor is 29 y old male ,he has hypertension controlled on 2 medications and has LVH seen by the echo denoting the long standing duration of HTN ,and end organ damage meanwhile cardiovascular risk assessment of the donor according to cardiovascular risk score , as well as functional capacity and METS score evaluation can be done if less than 4 further stress testing are needed along with cardiological ,and anaesthesiologist evaluation within a MDT team.
Hypertension if with end organ damage (LVH) is a common cause to decline donors due to the high risk of perioperative complications and severity of HTN after nephrectomy.
The etiology of his secondary hypertension has to be investigated as well.
So this donor better to be declined as he is HTN with end organ damage with high risk of long term complications due to his young including severe HTN ,ESRD ,cardiovascular complications.
Reference;
Professor Roberto Cacciola lecture
Thank You
See my QUESTION above. Your answer is not a complete answer.
I note that there is agreement that there is an unacceptable risk of future cardiovascular risk or lifetime incidence of ESRD in this index case.
This index case needs to be carefully looked after in HT clinic.
The proposed young donor is hypertensive under treatment with two drugs with LVH. It could be a case of secondary hypertension which demands further evaluation. I do not consider him as a donor.
Yes, Dr Ansary. I like your clear thought process. As you know, the probability of this proposed doner having essential hypertension (HT) is much higher than secondary HT, even though at this age we should consider looking for secondary HT (in any one younger than 35 or older 55 the age of diagnosis of HT).
In this case I will not consider him as a donor as he had end organ involvement (LVH). Rather he needs regular follow up.
Thank You
See my QUESTION above. Your answer is not a complete answer.
The patient is a 61 years old male, who needed a kidney, same was donated by his son and with ECHO showed mild concentric left ventricular hypertrophy with no evidence of systolic or diastolic dysfunctions, and managed with 2 antihypertensive drugs. Also no evidence of proteinuria and haematuria.
The candidate can still be a possible candidate as a donor. However, there are certain parameters that need to follow.
1) The donor blood pressure must be controlled and ensure there is adequate renal function.
2) Must be investigated to see if there is another organ that is involved or damaged.
3) There must be lifestyle modifications avoiding certain foods, toxic habits, etc.
Once the patient has been properly investigated and if there is the presence of organ damage and the blood pressure is not properly controlled he should not be a candidate for the donor but if all investigations and cardiovascular investigations are acceptable then I should believe that the transplantation can proceed. the patient is young and must be investigated for a secondary cause of elevated BP.
There is next factor I may consider is the age differences and duration of the donor’s kidney as it relates to the recipient’s age.
Post donor transplantation, the patient also is likely to develop worsening blood pressure and worsening cardiovascular diseases which can lead to kidney diseases.
Thank You
See my QUESTION above. Your answer is not a complete answer.
Though this patient apparently has no evidence of kidney disease, but he is 29 yrs old only and on 2 antihypertensive medications, he should be evaluated for secondary causes.
I don’t think he should be accepted for donation.
Thank You
See my QUESTION above. Your answer is not a complete answer.
This young patient with HTN, on 2 antihypertensive medications with the feature of end-organ damage; concentric LVH should not be accepted as a donor as per KDIGO guidelines otherwise he will be at risk of developing ESRD with cardiovascular complications.
We need to refer him to a cardiologist for further evaluation, management and to r/o any suspected secondary cause of hypertension
Thank You
See my QUESTION above. Your answer is not a complete answer.
Management plan
The potential kidney donor although having well controlled BP on 2 drugs, but he has concentric LVH on echocardiographic study, which is considered to be an indicative of end organ damage.
This potential donor should be counseled against donation and the potential recipient to be counseled also. Kidney donation should be rejected in the presence of feature indicative of an end organ damage1.
reference
1. BTS/RA Living Donor Kidney Transplantation Guidelines 2018
Thank You
See my QUESTION above. Your answer is not a complete answer.
This donor not suitable for donation because he is young with uncontrolled hypertension by evidence of LVH in echo and presence of 2 anti hypertensive medication.
He need good history regarding smoking and history to role out hormonal disturbance and family history of secondary hypertension
need good examination for his weight and cardiac and respiratory and lower limb to role out peripheral vascular disease and ophthalmologist to role out retinopathy.
laboratory studies for lipid profile and hormonal assay
lifestyle modification for tight control blood pressure and lipid, low salt diet and regular exercise. Control weight stop smoking
Short and sweet. Thank you
The available donor is 29 Y old male with history of hypertension well controlled by two anti-hypertensive medication , III mismatches and no DSA.Unine examination is free from haematuria or proteinuria. Echocardiography showed mild left ventricular hypertrophy.
*this donor needs further evaluation :
– family history to exclude secondary hypertension.
– labs, electrolytes and hormones.
– Doppler for renal arteries or MRA if Suggested..
I will not accept this donor.
According to recommendation for hypertension to potential kidney donor.
The potential kidney donors with hypertension will be excluded if met any of the followings.:
– blood pressure will not be controlled to be less than 140/90 with one or two anti-hypertensivemedications.
– there were any evidence of end organ damage( retinopathy- left ventricular hypertrophy – proteinuria- previous cardiovascular discases).
– patient had risk of future cardiovascular disease or life time incidence of end stage kidney diseases.
* living kidney donors should encourage to decrease their hypertensive risk by modification of their life style ( stopping smoking, reducing alcohol intakes, frequent exercise and weight loss).
* it is also recommended that potential living donors who diagnosed hypertension during pre-transplant work up or developed hypertension to be managed according t British Hypertension Society guidelines.
References:
Lecture of Roberto cacciola (assessment of living donations).
I appreciate the clarity of your thought process, Dr Amal Anan
Thank You for the excellent answer