3. A 59-year-old male with excellent kidney function offered a kidney to his son who 31-year-old, 111 mismatch, no DSA. His blood pressure is well controlled by one agent. No evidence of proteinuria, haematuria, or microalbuminuria. His echocardiogram showed normal sized ventricles with no evidence of systolic or diastolic dysfunction
- What is your management plan?
- Would your management differ if the potential donor was on 3 antihypertensive agents?
Dear All
Our duty is to help these patients to improve their health. What will you do for this potential donor who is on 3 medications for his BP? Can you make him suitable for donation?
Also, define ‘end-organ damage”. Assume has clotting abnormality due to deficient factor 9. Will you consider this end-organ damage?
What will you do for this potential donor who is on 3 medications for his BP? Can you make him suitable for donation?
We can make him suitable by aggressive treatment for him hypertension and control other risk factors like obesity, hyperlipidemia , DM , stop smoking, daily exercise and eating healthy diet.
Define ‘end-organ damage:
The damage occurring in major organs fed by circulatory system (heart , kidneys , brain , eyes) usually referred to End -organ damage .
This damage can be sustained due to uncontrolled hypertension or hypotension or hypovolemia.
End organ damage in hypertension can be detected early, reflects accurately the hypertensive patient’s overall cardiovascular risk, and should be prevented and treated with antihypertensive treatment.
Hypertensive end organ damage can now be diagnosed early and reversed with specific and aggressive treatment.
Reference:
End Organ Damage In Hypertension
Roland E Schmieder, Prof. Dr. med.
I like your decision-making process Dr Asmaa Khudur . Ajay
Our duty is to help these patients to improve their health. What will you do for this potential donor who is on 3 medications for his BP? Can you make him suitable for donation?
I’ll counsel him about the increased risk for cardiovascular risk and the risk of life time incidence of ESRD. and let him know about the current guidelines and optimize his antihypertensive medications to keep blood pressure equal or less than 130/80 mmHg, and treat the comorbidities, ie obesity , OSA , dyslipidemia, and encourage smoking abstinence, special concern to life style modifications, ie low salt diet and encourage physical activity.
I would perform an ABPM to have more details about his hypertension status and the physiological dipping – if impaired this would raise the possibility of cardiovascular events -vascular decreased elasticity and stiffness.
a thorough history and physical exam to be sure he has no end organ damage (LHV, retinopathy, proteinuria, and previous cardiovascular events)
All the above measures after exclusion of secondary causes of elevated blood pressure from history and laboratories.
Also, define ‘end-organ damage”. Assume has clotting abnormality due to deficient factor 9. Will you consider this end-organ damage?
End organ damage is several hypertension-related pathologies, such as cardiac hypertrophy and fibrosis, hypertensive heart failure, renal fibrosis, kidney failure, retinopathy and hemorrhagic stroke. up to my knowledge clotting abnormality due to deficient factor 9 (hemophilia) is not an end organ damage.
Hi Dr Alshaeikh and Dr Ben,
The deficiency of factor 9 though not related to organ damage due to HT, would it affect your decision-making to go ahead with donor operation?
In the availability of factors at our center, it would not be a contraindication to donation, inspite of risk of bleeding, but he however should do viral screen for HCV , HBV and HIV
Thanks prof
Yes, the patient will requires factor 9 ready for replacement during the time of surgery
What will you do for this potential donor who is on 3 medications for his BP? Can you make him suitable for donation?
Diet control with low Salt diet and healthy food
Exercise
Weight loss
Stop smoking
Strict adherence to his medications and to keep BP less than 130/90
Define end-organ damage:
Affection of major organs as heart kidneys eyes and brain and if detected early can be reversed by strict control of blood pressure.
but abnormalities in clotting factor 9 not an end organ damage
The diagnosis of hypertensive end organ damage is of decisive importance. This is reflected in European and German guidelines:
life stlye modification ,exercise , stop smoking , salt restrection ,,decrease alcohol consumption , wieght loss all these things improve pressure controll.
Our duty is to help these patients to improve their health. What will you do for this potential donor who is on 3 medications for his BP? Can you make him suitable for donation?
The patient with 3 antihypertensive medications can be a donor but there must be life style modifications in other to achieve that result needed.
1) Avoid salty diet
2) Avoid stress
3) No toxic habits
4) Exercise may consider aerobic
5) Do routine check-ups with his physician.
6) others
Also, define ‘end-organ damage”. Assume has clotting abnormality due to deficient factor 9. Will you consider this end-organ damage?
End organ damage is referred to as damage that occurs in major organs of the body that is fed from the circulatory system due to uncontrolled HTN, hypotension and hypovolemia. The organs mostly at risk are the heart, the kidneys, eyes and brain. Mostly it is focus on high pressures. To ensure a patient doesn’t have it, proper studies must be done and follow-ups. It can be detected and treated once proper follow-ups are carried.
Factor 9 is not considered an end organ damage but a haematological pathology that is related to Factor 1X deficiency or haemophilia B which is an X-linked inherited bleeding disorder.
If he is on 3 drugs for HTN, I will advice him to modify his life style by wait reduction, regular exercise, alcohol intake reduction, and stop smoking. If drugs after that reduced to 2 antihypertensive he will be accepted for donation.
End-organ damage: Retinopathy, Proteinuria, LVH, previous cardiovascular disease
Factor 9 deficiency not end organ damage, but he needs pre-operative preparation and special consideration with preparing of clotting factor
Live donor transplantation is the best management for patient with ESRD, but due to shortage of donor pools accepting a donor with well controlled HT by 1 or 2 medications without end organ damage ( LVH & albuminuria) found to be associated with good graft & patient outcome without increased donor risk.
So this donor can be accepted for donation.
If the donor hypertension was controlled by 3 drugs he should be not accepted for donation, but if he is the only available donor for this patient he can be advised to achieve normal BMI, stop smoking, exercise & adopt healthy life style & reassess again if his blood pressure controlled by 1 or 2 drugs after change in life style then he can be accepted with emphasis on keep with healthy life style post donation to reduce the risk of CKD development.
References:.
patients on three ant hypertensive medication are not suitable donor and should be declined.
end organ damage are , LVH, coronary heart disease, retinopathy, proteinurea , CKD, CVA.
factor 9 deficieny is not considered as end organ damage.
Good control of BP, lipids, diabetes mellitus and weight is appropriate.
End-organ damage is defined as involvement of brain, renal, cardiac, eyes and vessels.
Hemophilia is not a hypertensive end-organ damage, but as a clotting disorder needs correction by factor replacement.
Despite normal kidney functions of the donor and absence of proteinuria and hematuria and he was controlled hypertension on one antihypertensive so I can accept the donor as
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.
If he was on 3 drugs : It is better to discard this donor as he is on high risk of CKD
Ref :
BTS guidlines
This donor presents itself as a great option for the recipient and also for himself, in the perspective of avoiding undesirable events of the nephrectomy in the long term. It would only require normal follow-up of habits, mainly monitoring proteinuria.
In this situation, the donation would be contraindicated, as the recommendation is for the donor to accept up to 2 antihypertensive agents. However, we can offer monitoring seeking to improve your life habits in order to improve your cardiovascular performance and perhaps acquire conditions for donation to your child.
The daily practice of exercises, in addition to a balanced diet, can be alternatives to improve your cardiovascular performance without putting you at greater health risk for a donation.
What is your management plan?
The donor is 59 year old hypertensive on one antihypertensive medication with no LVH (no target organ damage) so as per guidelines we shall proceed with transplantation.
Yet this donor should be counselled for proper control of BP, lifestyle changes as well as strict control of BP , diet , decrease salt intake , as well as follow up of predicted complications including micro and macrovascular complications.
Would your management differ if the potential donor was on 3 antihypertensive agents?
Donor with hypertension and on 3 anti-hypertensives should not be taken up as per the guidelines
However , if blood pressure was controlled on 2 or less BP medications, we shall proceed with the transplantation.
As per KDIGO guidelines, Donor candidates with hypertension that can be controlled to systolic blood pressure less than 140 mm Hg and diastolic blood pressure less than 90 mm Hg using 1 or 2 antihypertensive agents, who do not have evidence of target organ damage, may be acceptable for donation. The decision to approve donor candidates with hypertension should be individualized based on demographic and health profile in relation to the transplant program’s acceptable risk threshold.
Hence I will approve him as a donor as :
1- He is controlled on single antihypertensive.
2- He does not have end organ damage such as normal ventricles, no proteinuria.
However, I will counsel him that there is evidence that his BP might worsen after donation. He should live healthy life style to avoid worsening of his BP and worsening renal function, including avoiding smoking, stopping or reducing alcohol, maintain optimal weight. Avoid nephrotoxic. Ensure compliance to his antihypertensives.
If the donor on 3 antihypertensives , he will be rejected as adonor.
Although the age is not considered as limitation for donation, but we can expect some sclerosed renal cells from this old kidney with less graft survival .
The guideline does not permit donation from hypertensive patient controlled with 3 drugs
As per BTS and KDIGO guidelines
Potential contraindications for donation in hypertensive donors:
End organ damage in hypertension includes the following (1):
Living donors must be counselled for lifestyle modifications including moderate daily exercise, low salt intake, maintaining adequate weight, give up smoking, reducing alcohol intake, tight control of BP and avoid dyslipidemia
Because the potential donor in this case has no end organ damage and is controlled by a single drug, he is accepted as a donor. He must be encouraged to follow lifestyle modifications, as mentioned before.
A potential donor who is taking three antihypertensive medications is contraindicated for donation, according to most guidelines, but should be educated to follow the advice given to all hypertensive patients.
Reference:
What is your management plan?
A 59 year male with well controlled BP on one agent and no evidence of target organ damage is a suitable donor to his son according to BTS/RA 2018 guidelines.
Would your management differ if the potential donor was on 3 antihypertensive agents?
If the above patient is taking three drugs to control hypertension, then he should not be considered for donation,however, if he controls his blood pressure by smoking cessation ,adopting healthy lifestyle like taking low salt diet ,regularly exercise, and is on one or two anti-hypertensive and there is TOD then can be considered.
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
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 his blood pressure is controlled with one drug and there is no end organ damage so I will accept him as a potential donor
if this potential donor is controlled on 3 medications I will not accept him as a potential donor because his blood pressure control will be more difficult to be controlled post-donation and he will be exposed to higher risk.
Reference
BTS/RA Living Donor Kidney Transplantation Guidelines 2018
Living donation part 2 , by Roberto Cacciola
According to this donor age the BP controlled by just one agent and there’s no evidence of renal or Cardiovascular affection , so will proceed for donation.
if the BP controlled by 3 drugs so we need to investigate more for other organ affection
The donor has hypertension which is well controlled by one agent and there is no end organ damage , he can be considered for living kidney donation according to KDIGO guidelines.
If the potential donor was on 3 anti-hypertensive drugs and had no end organ damage ,
We can make him suitable after decreasing anti-hypertensive to 2 drugs after adjustment the drug dosage and life style modification (dietary salt restriction, weight loss,exercise,search for causes of secondary hypertension)
End organ damage related to hypertension.
Deficiency of factor 9, not end organ damage
As he is an HLA compatible donor and his one anti-hypertensive agent, without any end-organ damage,
he would be a good donor for his son.
If he was on 3 antihypertensive agents, he could not be accepted for donation duo to the risk of
worsening his HTN that could lead to ESKD and CVD.
What is your management plan?
Good donor with well controlled BP on one agent without evidence of end organ damage according to BTS/RA 2018 guidelines.
Would your management differ if the potential donor was on 3 antihypertensive agents?
Donors with hypertension on 3 agents are excluded from donation.
The target is to optimize his BP control by following healthy life style, weight loss, low salt diet, exercise, smoking cessation and avoidance of alcohol.
What is your management plan?
According to british transplant society guideline, donors with hypertension are excluded from donation if:
1. Blood pressure is not controlled to <140/90 mmHg on one or two antihypertensive drugs .
2. Evidence of end organ damage (retinopathy, left ventricular hypertrophy, proteinuria, previous cardiovascular disease) .
3. Unacceptable risk of future cardiovascular risk or lifetime incidence of ESRD .
4. All living kidney donors must be encouraged to
5. lifestyle measures including stopping smoking, reducing alcohol intake, frequent exercise and, weight loss.
6. Hypertension will develop in at least 30% of patients following unilateral nephrectomy
As this patient has hypertension controlled by single agent , and there is no signs of end organ damage , then I will accept him as a donor.
Would your management differ if the potential donor was on 3 antihypertensive agents?
Yes , a blood pressure which is controlled by three drugs are considered sever hypertension . Acording to above guidelines a hypertension needing three drug is excluded from donation.
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)
What is your management plan?
According to BTS/RA Living Donor Kidney Transplantation Guidelines 2018
This father with mild-moderate hypertension that is controlled to <140/90 mmHg (and/or 135/85 mmHg with ABPM or home monitoring) with one blood pressure medication can be accepted for donation if he has no evidence of end organ damage. The acceptance will be based on the assessment of his cardiovascular risks and local policy.
Would your management differ if the potential donor was on 3 antihypertensive agents?
Yes, if this donor was on 3 Bp medications, BTS/RA guide lines would exclude him from donation. However, if he underwent life style modification to control his Bp by weight loss , stoping smoking and alcohol intake , and salt restriction.
He may be reassessed later, and considered for donation if he managed to bring his Bp under control to accepted targets while receiving 1 or 2 drugs and without EOD
References:
BTS/RA Living Donor Kidney Transplantation Guidelines 2018
Our potential donor is :
-59 years old
-HTN well controlled on single antihypertensive medication with no evidence of end organ damage
According to the BTS guidelines this donor can be accepted but preoperative counseling should be done , life style modifications; avoiding smoking , diet control , weight control , follow up of blood pressure .
if our potential donor was on 3 antihypertensive medications he should be declines according to the current BTS guidelines .
This father poses a good candidate for renal donation for his son, being HTN, controlled on monotherapy with no evidence of end organ damage can be accepted after cardiological consultation and further evaluation if needed.
Smoking cessation, minimal salt intake, weight control and adopting healthy lifestyle with mandatory follow up frequently is recommended.
Management for those on triple antihypertensive agent would be totally different as they are excluded from donation from the start. He should be referred for cardiology team for further investigation and assessment as well as develop a good plan of care by then.
The donor is the father to the recipient who is his son…His blood pressure is controlled with single antihypertensive drugs…There is no retinopathy, nephropathy or LVH by Echo…..his blood pressure is well controlled…So according to BTS guidelines he can be taken up for surgery or kidney donation….
If the patient was on 3 antihypertensive drugs I will not accept the donor…I will stick continue to explore any end organ damage due to the blood pressure and also look for target organ damage…If there are no target organ damage, i will advice him for weight reduction, smoking cessation and cholesterol control..I would see if these changes reduce the requirement of the tablets…and then decide
*Regarding this candidate donor : old age, mild HTN controlled on 1 item with no target organ damage.
*I will accept this donor , According to the BTS/RA LKD Transplantation Guidelines 2018, that after assessment of cardiovascular risk and control BP < 140/90 mmHg, life style modification as diet control, cessation of smoking.
*Would your management differ if the potential donor was on 3 antihypertensive agents?
I will refuse this donor due to severe blood pressure which controlled on 3 medications , due to the increased incidence of end stage renal disease and cardiovascular complications, and according to BTS recommended that potential donors with hypertension are excluded from donation if: blood pressure more than 140/90 on dual anti-hypertensive medications or evidence of EOD as; (Retinopathy, LVH , proteinuria).
*But; I can give a trial of controlling modifiable risk factors as ; tight blood pressure control and other life style modifications stop smoking and alcohol, regular exercise , diet control due to shortage of donors and long patients waiting list.
References:
1.BTS/RA Living Donor Kidney Transplantation Guidelines 2018
1) Allow proceed for kidney donation if other pre transplant workout are normal.
2) Not suitable as kidney donor if this patient needed 3 antihypertensive agents. Cardiovascular and renal risk.
According to literature this is resistant hypertension we can not offer donation, there is risk of progression to development of renal disease.
End organ damage usually occurs due to consequences of on organ damage and causing the other organ damage, like uncontrolled hypertension, uncontrolled and long lasting diabetes, cardiovascular compromise and with low EF.
A patient who has resistant hypertension is risk of developing end organ damage, the first step is life style modification, smoking secession, weight reduction, role out secondary causes if any treat accordingly, last but not the least good BP control with anti- hypertensive medications to prevent END ORGAN DAMAGE.
This is an elderly father with blood pressure controlled with no evidence of proteinuria, hematuria, or microalbuminuria with normal 2D Echo.We can accept him as donor provided his BMI, DM and other lifestyle of favorable.
BTS/RA Living Donor Kidney Transplantation Guidelines 2018 state 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.”
“It is recommended that potential donors with hypertension are excluded from donation if blood pressure is not controlled to <140/90 mmHg on one or two antihypertensive drugs”
So, accepting donor with controlled Hypertension with three drugs would depend upon donor obesity, DM, cardiovascular risk, smoking and end-organ daamage.
If we accept him, then
Define end-organ damage:
Diagnosis of early hypertensive end organ damage
Schmieder RE. End organ damage in hypertension. Dtsch Arztebl Int. 2010 Dec;107(49):866-73. doi: 10.3238/arztebl.2010.0866. Epub 2010 Dec 10. PMID: 21191547; PMCID: PMC3011179.
# What is your management plan?
*This donor 59 year old ,with excellent kidney function, BP well controlled by one therapy, no evidence of(proteinuria, haematuria, microalbuminuria) and his Echocardiogram showed normal sized ventricles with no evidence of systolic or diastolic dysfunction (no end organ failure).
* According to the BTS/RA Living Donor Kidney Transplantation Guidelines 2018 Recommendations:
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. (C1).
* So, I will accept this potential donor.
# Would your management differ if the potential donor was on 3 antihypertensive agents?
*BTS recommended that potential donors with hypertension are excluded from donation if: (C1)
# Blood pressure is not controlled to <140/90 mmHg on one or two antihypertensive drugs.
# Evidence of end organ damage (retinopathy, left ventricular hypertrophy, proteinuria, previous cardiovascular disease).
# Unacceptable risk of future cardiovascular risk or lifetime incidence of ESRD.
* So, I will not accept this potential donor on 3 antihypertensive agents. But to increase the donor pool the donors must be encouraged to minimize 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)
BTS/RA Living Donor Kidney Transplantation Guidelines 2018
It is a patient who is at risk due to a history of hypertension controlled with medication. It does not appear to have target organ damage. We do not have other risk factors such as fasting glucose, body mass index, ethnicity, metabolic changes, and other findings that would increase cardiovascular risk.
I would talk about the risks involved in organ donation and the need for greater health care for a good post-nephrectomy evolution.
If the patient was using three medications for blood pressure control, I would strongly suggest non-pharmacological care and treatment of underlying diseases (as well as obesity, if applicable) for adequate metabolic control and would only proceed with the donation if blood pressure control was achieved with only two antihypertensive medications.
What is your management plan?
The patient’s BP is controlled on one agent with no e/o of end-organ damage (proteinuria, LVH, retinopathy), so he is suitable for kidney donation. Usually BP < 140/90mmHg is acceptable. However, we need to make sure that he will adhere healthy lifestyle post donation as hypertension is a known risk factor for CKD and ESKD in general population. It also has been shown that that pre-HTN is a risk factor for increasing the anti-hypertensive agents post-hypertension.
Also, pre-hypertension defined as systolic BP 120-139 and diastolic BP 80-89 according to JNC 8
Would your management differ if the potential donor was on 3 antihypertensive agents?
According to the British guidlelines, 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. Therefore, I would not accept a patient on 3 types of anti-hypertensive medications due to the increased risks of CKD, ESKD and cardiovascular event.
References:
· Sawinski D, Locke JE. Evaluation of kidney donors: core curriculum 2018. American Journal of Kidney Diseases. 2018 May 1;71(5):737-47.
· 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.
This patient is < 60 years, according to age accepted for donation, as inferior outcome expected in >60.
He has excellent kidney function with controlled Bp in one drug, with no target organ damage or proteinuria nor haematuria.
I would complete his pre-operation assessment and counselling about risk of progression of hypertension and possible complications and about life style modification.
Yes. If he is on 3 antihypertensive drugs he will be excluded from donation
What is your management plan?
this donor with hypertension that is well controlled with a single drug, and has no evidence of end-organ damage (no hematuria, proteinuria, or microalbuminuria) and normal LV by Echo.
he can be a suitable donor but we need to counsel him about the risk of CKD and high Bp after donation, so needs good follow-up in addition to lifestyle modification (exercise, low salt diet, cessation of smoking)
Would your management differ if the potential donor was on 3 antihypertensive agents?
yes, as this will be more likely to have an adverse event after donation and preoperatively. so this will preclude the donation.
This 59 year old male with known case of HTN , which is controlled by one medication with no evidence of end organ damage can proceed with donation work up and make attention about CV risk as he is more than 50 year and had HTN ( he should undergo ECG , MPS ) and risk of developing CKD or CVS disease should be discussed with him
according to KDIGO guide lines any patient with HTN needing 3 medication is unfit for donation
we should focus on modifiable risk factors
1- smoking cessation
2- weight reduction
3- exercise
4- low salt diet
And if the patient BP become less than 140\90 using 2 medication with no end organ damage we can proceed with donation work up after discussion and knowing the risk of CVD and CKD post donation
End organ damage usually refers to damage occurring in major organs fed by the circulatory system (heart, kidneys, brain, eyes) which can sustain damage due to uncontrolled hypertension, hypotension, or hypovolemia.
according to factor 9 deficiency , if the factors is available at the time of surgery we can proceed with donation surgery
thanks
The donor has history of hypertension (well controlled on one drug) but no evidence of end organ damage (no hematuria, no proteinuria and normal ECHO).
Mismatch is 111 and no DSA.
His age is not a contraindication for kidney donation but he should be informed about the increased risk of perioperative complications associated with reduced graft survival and function.
I would consider him a suitable candidate for kidney donation. However, we should advice life style (regular exercise, weight loss smoking cessation etc) and he will also require a regular follow up in view of his background history of hypertension. Indeed he will be at even higher risk of hypertension following a donation (single kidney has increased risk of hypertension)
If the patient is on three different antihypertensive medication I would consider the patient not suitable for donation. To be on three different antihypertensive drugs indicate that his BP has been poorly controlled therefore he will be at higher risk of rapid declining kidney function (hypertensive nephrosclerosis). Moreover his risk of hypertension will increase after nephrectomy.
▪︎What is your management plan?
This donor has hypertension that is well controlled on one drug,
Full evaluation revealed no long term complications of hypertension ,no data about how long he has been hypertensive but yet there is no proteinuria , hematuria,normal echocardiography and no evidence end organ damage so no contraindication for donation with close follow up of the donor with counselling regarding potential risk of rise in Bp aftet donation, and instructions about healthy life style, avoid obesity, smoking, tight control of lipid profile
There were 111 mismatch with no DSA so no contraindication to donation
▪︎Would your management differ if the potential donor was on 3 antihypertensive agents?
if he is on 3 antihypertensive medication then he will be excluded from donation
according to KDIGO and BTS guidelines ,
Due to higher incidence of Cardiovascular and renal complications.
And if he wishes to donate he must control all risk factors ( salt restoration, stop smoking, control weight ,dyslipidemia)
With trial to control his blood pressure by maximum doses of 2 agents if manged to control his Bp he would be considered for donation after counselling him about possible long term effect
A patient 31 years old with kidney failure is offered with a kidney that is 59 years old, hypertensive but controlled with only one medication with no urinary pathology, and with an ECHO revealing normal ventricular size with no systolic neither diastolic dysfunction. This patient is a good candidate as a donor but there are 2 factors one need to identify and take very good note. They are:
1) The donor age or the age differences. Although the guidelines may not totally consider a contraindication but when it comes to the longevity of the graft there could be a short function. The donor may also have increased risk of peri-operatory and post-operatory complications. So, the donor must be carefully evaluated and ensure all goes well as a donor,
2) The other aspect is the hypertension that is well controlled in this case with no cardiovascular complications. Which makes it a benefit for donor, but care must be taken to ensure BP doesn’t increase but remain controlled as to prevent complication to the donor and post-operative complications.
In light of a patient with 3 different antihypertensive medications he will not be considered a good candidate as a donor.
The guideline recommends a BP less than 140/90 with one or two medications with no end organ damages and no cardiovascular pathologies. To be a donor, there must be lifestyle modifications to decrease the risk of the complications of hypertension. Once that is met and the BP has improved with less medications needed and there is confirmed studies that there is no organ damage then the donor can proceed.
References
KDIGO guidelines 2017
BTS guidelines 2018
This patient is accepted kidney donor candidate as there are no contraindications as end organ damage or other risk factors & comorbidities .In addition, he needs full medical care as case of secondary hypertension.
In case of potential donors with 3 medications for hypertension, BP must be in accepted range with management of modifiable risk factors and comorbidities; life style, body weight , dyslipidemia, smoking, alcohol, dieting, and medications causing high blood pressure.
Potential kidney donors in need for three antihypertensive medications cannot be candidates for donation.
References:
KIDIGO guidelines 2017
1- this young 31 years old donor with well controlled HTN with one agent anti HTN medication with no evidence of proteinuria or haematuria with normal ECHO finding patient can precede for renal transplantation if there is no organ damage and no other risk factors or comorbidities
screen this young donors for any secondary cause for HTN.and control all other risk factors if exist.
donors with 3 anti HTN medication
make sure his BP control
any secondary cause can be found to be treated if possible.
A patient 31 years old with kidney failure is offered with a kidney that is 59 years old, hypertensive but controlled with only one medication with no urinary pathology, and with an ECHO revealing normal ventricular size with no systolic neither diastolic dysfunction. This patient is a good candidate as a donor but there are 2 factors one need to identify and take very good note. They are:
1) The donor age or the age differences. Although the guidelines may not totally consider a contraindication but when it comes to the longevity of the graft there could be a short function. The donor may also have increased risk of peri-operatory and post-operatory complications. So, the donor must be carefully evaluated and ensure all goes well as a donor,
2) The other aspect is the hypertension that is well controlled in this case with no cardiovascular complications. Which makes it a benefit for donor, but care must be taken to ensure BP doesn’t increase but remain controlled as to prevent complication to the donor and post-operative complications.
In light of a patient with 3 different antihypertensive medications he will not be considered a good candidate as a donor.
The guideline recommends a BP less than 140/90 with one or two medications with no end organ damages and no cardiovascular pathologies. To be a donor, there must be lifestyle modifications to decrease the risk of the complications of hypertension. Once that is met and the BP has improved with less medications needed and there is confirmed studies that there is no organ damage then the donor can proceed.
References
KDIGO guidelines 2017
BTS guidelines 2018
potential donors with hypertension are excluded from donation if:
• Blood pressure is not controlled to <140/90 mmHg on one or two antihypertensive drugs
• Evidence of end organ damage (retinopathy, left ventricular hypertrophy, proteinuria, previous cardiovascular disease)
• Unacceptable risk of future cardiovascular risk or lifetime incidence of ESRD
I will agree to receive kidney from this donor as his blood pressure is well controlled by one agent and no evidence of target organ damage
The British Hypertension Society define hypertension when daytime ABPM or average home blood pressure is >135/85 mmHg
All potential donors should be carefully assessed for the presence of hypertension which, if present, may exclude donation. However, donation may be possible in the presence of controlled hypertension with no evidence of end organ damage.
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.
If hypertension is confirmed in donor we should started non-pharmacological interventions
and drug treatment started if required.
If adequate blood pressure control is achieved or if the long-term cardiovascular risk is deemed acceptable by both patient and assessor, the donor may proceed to nephrectomy.
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.
All donors should be warned that blood pressure may rise after donation.
Blood pressure should be monitored regularly after donation and lifestyle should be modified to minimise the risk of hypertension and future cardiovascular disease.
Elevated blood pressure after donation may increase future cardiovascular risk or predicted lifetime incidence of ESRD above an acceptable level.
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.
Reference
Guidelines for Living Donor Kidney Transplantation Fourth Edition March 2018
BTS/RA Living Donor Kidney Transplantation Guidelines 2018 United Kingdom Guidelines
What is your management plan?
Hypertension is an important risk factor developing CKD and cardiovascular pathologies. It can decrease functional renal mass after donation. Therefore careful assessment is mandatory before considering donation.
As per KIDIGO guidelines kidney donation can be done if eGFR is >90 ml/s.
Kidney donation is contraindicated if eGFR is < 60ml/min
eGFR between 60-90 ml/s is an area which requires careful assessment to validate the suitability for kidney donation.
Regarding the index case- He is 59 with excellent kidney function with normal echo no sign of end organ damage, I will accept him for kidney donation .
Would your management differ if the potential donor was on 3 antihypertensive agents?
Those potential donors who are on 3 antihypertensive carry high risk of CKD and cardiovascular pathologies and are generally not suitable for donation as per guidelines.
Reference
BTS guielines in living kidney donation-https://bts.org.uk/wp-content/uploads/2018/07/FINAL_LDKT-guidelines_June-2018.pdf
I think he is a good candidate for kidney donation. As a well controlled hypertension with one medication and no evidence of complications is not a contraindication.
At this level he will not be suitable for donation due to high risk of CVS complications and ESRD.
Also, this patient must be assessed for secondary causes of hypertension as hard to control HTN with multiple drugs must be investigated. If the secondary cause is curable he may then be a candidate for donation.
What is your management plan?
No need for any further assessment in this case. After appropriate counseling, I would proceed for transplantation; the donor has a blood pressure that is well controlled on only one antihypertensive medication and there no any evidence of end-organ damage; so he is of low risk.
In the past, a BP reading >140/90 mm Hg &/or use of AHMs was considered as contraindications to donation. However, patients with easily controlled HTN with 1 or 2 agents & no evidence of target organ damage may be accepted as low-risk kidney donors on a case-by-case basis.
The KDIGO working group (2017) suggested that potential donors with HTN should be individualized in relation to the transplant program’s acceptable risk profile threshold & that they should be counseled that donation may accelerate the rise in BP & increase the need for more antihypertensive therapy. We would be more concerned in younger donors(the index case is 59), especially if they are overweight (BMI not mentioned in the case scenario) or have African ancestry (ethnicity of the index donor not mentioned), or both.
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Would your management differ if the potential donor was on 3 antihypertensive agents?
No consensus regarding donation in hypertensive individuals who need more than 2 antihypertensive mediations for the control of their blood pressure.
However, this donor is not young, his blood pressure is well controlled, and there is no any target organ damage; so one can individualize the decision of accepting him for donation after a well informed counseling regarding the possibility of progression of his hypertension after donation as well as the possibility of developing target organ damage.
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, strengthening the support for their inclusion into, and consequent expansion of, the living kidney donor pool.
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.
☆What is your management plan?
▪︎In this scenario of a 59 years old man with excellent kidney function and planned to donate his kidney for his son with good mismatch. This patient is hypertensive with good control. There is no evidence of haematuria, proteinuria or microalbuminuria. ▪︎In this Scenario this patient can be accepted as a kidney donor with low risk ▪︎Note that, in the past, a BP reading >140/90 mm Hg and/or use of antihypertensive medications (AHMs) was considered as contraindications to donation. However, patients with easily controlled hypertension with 1 or 2 agents and with no evidence of target organ damage may be accepted as low-risk kidney donors on a case-by-case basis [1].
▪︎ In this patient additional examinations and imaging studies may be considered to assess his qualification to donate.
☆Would your management differ if the potential donor was on 3 antihypertensive agents? Yes
▪︎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].
_________________________________________
Ref:
[1] Anjay Rastogi, et al. Blood Pressure and Living Kidney Donors: A Clinical Perspective. Transplant Direct. 2019 Oct; 5(10): e488.
our donor old age with controlled hHTN and no end organ damage so according to guideline I will accept him
>>>> Despite hypertension being a known risk factor for renal and cardiovascular disease,more and more transplant centers are relaxing their selection criteria to include donors with well-regulated hypertension in response to decreasing supply of donor organs and increasing demand for kidney transplants.
Some studies have found that donors with predonation hypertension have a decline in kidney function (evidenced by increasing serum creatinine and decreased estimated GFR),while others have maintained that there is no significant difference in kidney function between normotensive and hypertensive donors.
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, strengthening the support for their inclusion into, and consequent expansion of, the living kidney donor pool.
Development of Hypertension in Kidney Donors Postdonation
Even though kidney donation often leads to physiological alterations (kidney hyperfiltration, upregulation of renin-angiotensin-aldosterone system, and changes in vascular tone)28,29 that may elevate BP, it is not considered to be a risk factor in developing hypertension postdonation.
An important prospective study by Kasiske et al followed living kidney donors over a 3-year period.30 They observed systolic and diastolic BP increased slightly and significantly over time in both donors and controls, but there were no significant differences between the 2 groups; in addition, after 3 years, the 24-hour ABPM of both groups was not statistically significant either.
The KDIGO Clinical Practice Guidelines suggest that proper BP measurements should be performed annually as part of postdonation follow-up care.Hypertensive living kidney donors (whether the hypertension developed pre or postdonation) should be followed more frequently than the average, normotensive donor and to have regular BP, laboratory, and urinary albumin:creatinine ratio tests conducted. They should also have their other cardiovascular risk factors well controlled.
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*** Would your management differ if the potential donor was on 3 antihypertensive agents?
According to guidelines mentioned in previous case this absolutely contraindication to accept this potential donor .
Reference
Blood Pressure and Living Kidney Donors: A Clinical Perspective
Anjay Rastogi, MD, PhD, Stanley Yuan, MD, […], and Matthew R. Weir, MD
Many thanks Dr Huda.
What is your management plan?
This donor has excellent renal function and his blood pressure is well controlled by single anti hypertensive with no end organ damage. , so this pt is considered low risk and can be accepted for kidney donation with post donation regular follow up of his blood pressure
Would your management differ if the potential donor was on 3 antihypertensive agents?
First proper history for compliance or not on his medications , exclude white coated HTN , exclude secondary causes could make his bp uncontrolled
If proved that he really needs the triple antihypertensive medication , he will be excluded from donation.
-The donor is 59 y old with controlled HTN on one agent ,he has no end organ damage with excellent renal function, so he has to undergo further assessment as he is considered high cardiovascular risk score according to his age 59 y and gender as a male as older age donors are more liable to perioperative complications ,and decreased long term graft survival and function .
if cardiovascular risk score is>10 and screening for occult cardiovascular disease and functional capacity with METS score evaluation <4 then cardiological assessment will be needed.
In fact this donor acceptance will be dependent on overall assessment .
-If his BP is controlled on 3 medications he will be less likely to be accepted
Reference
Prof .Roberto Cacciola lecture
Thank you; how would this guy on 3 antihypertensive medications be a suitable donor then?
In this case I shall consider this young man as a donor, if no suitable alternative is available.
In my opinion donor on three antihypertensives can not be considered as donor.
Short answer. I’m sure you can do better than this
In this case I will consider him as a donor. He can donate kidney.
However, if he was on 3 anti hypertensive drug, he will not be accepted as a donor.
Short answer. I’m sure you can do better than this
· Management plan
Since this patient has well-controlled BP on 1 medication and with no organ damage, then he is a suitable donor.
· Management plan if this potential donor was on 3 antihypertensive:
Based on KDIGO guidelines, donor candidates with hypertension that can be con[1]trolled to systolic blood pressure less than 140 mm Hg and diastolic blood pressure less than 90 mm Hg using 1 or 2 antihypertensive agents, who do not have evidence of target organ damage, may be acceptable for do[1]nation. Hence this patient is on 3 medications I will reject him for donation.
2017-KDIGO-LD-GL.pdf , accessed on 21/9/22
Short answer. I’m sure you can do better than this. How would this guy on 3 antihypertensive medications be a suitable donor then?
This man is considered a candidate for donation as he is using only one anti-hypertensive medication with no end organ damage; therefore, we will do other routine assessment as a donor.
As per KDIGO guidelines, in this situation, he will be not a good candidate for donation as he will be at high risk to develop ESRD and cardiovascular complications
Thank you; how would this guy on 3 antihypertensive medications be a suitable donor then?
The patient is 59 years old (approaching 60) – age more than 60 years old has been associated with higher rate of postoperative grade I–II complications and presented lower eGFR at 1 year
Grade I–II complications such as:
Blood pressure is controlled by one anti- HTN agent- Donor candidates with hypertension that can be controlled to systolic blood pressure less than 140 mm Hg and diastolic blood pressure less than 90 mm Hg using 1 or 2 antihypertensive agents, who do not have evidence of target organ damage, may be acceptable for donation.
His echocardiogram showed normal sized ventricles with no evidence of systolic or diastolic dysfunction
This patient will be counselled for post donation hypertension and should be informed that blood pressure may rise with aging, and that donation may accelerate a rise in blood pressure and need for extra antihypertensive treatment over expectations with normal aging.
If patient agrees, will proceed for donor nephrectomy
If the potential donor was on 3 antihypertensive agents
we should asses the compliance of medications
Then should rule out white coat hypertension or inappropriate measurement of BP
Will do ABPM or office BP measurement to confirm the blood pressure
Will look for secondary causes of HTN such as Conn’s syndrome which can be controlled by spironolactone or removal of adrenal adenoma.
If still the BP control need 3 anti hypertensive, then he might not be suitable donor.
References
Gero, D., Dib, F., Matter, M. et al. Outcomes of Kidney Donors over 60 Years Old: A Single-Center Cohort Study. World J Surg 41, 2940–2948 (2017). https://doi.org/10.1007/s00268-017-4071-y
Hi Dr Marimutu,
I enjoyed reading the scientific content of your response. However, it is not easy to read because of:
(a) Syntax errors regarding usage of full stop and comma
(b) The first letter of a new sentence should be in capitals
(c) Why write single sentence paragraphs when the theme of the last 7 sentences is similar?
(d) Subject (noun) of many sentences is missing.
You might wonder why Ajay Sharma is being a ‘painful stickler’. One of our aims is for us to help you all to write good scientific write-ups.
With regards,
Ajay
What is your management plan?
The potential donor is hypertensive with controlled BP on single agent and nothing precludes or runs against donation. I will proceed with donor and accept his kidney donation.
Would your management differ if the potential donor was on 3 antihypertensive agents?
I will reject the potential donor.
If the potential donor BP is controlled with 3 agents, this rendered him as not suitable for donation. In the setting of uncontrolled BP or hypertensive medications exceeding 2 drugs the potential donor should be rejected.
Thank you; how would make this guy on 3 antihypertensive medications a suitable donor then?
Old age with well controlled hypertension by one agent and no evidence of end organ damage so he is suitable to donation to his son but should be counselling regarding complications post operative and should be encouraging life style modification about cessation of smoking and maintain his weight with healthy diet and regular exercise, close adherence to his anti hypertensive medication and regular fallow up his clinic and control lipid by anti lipid.
In this situation patient is not suitable for donation because uncontrolled hypertension and high risk of nephrosclerosis and ESRD.
Thank you, Sahar. Yes, we need to improve his heath and lifestyle. Well done
What is your management plan?
This case is reverse of patient with evidence of TOD ,he has well controlled hypertension
by one medication as per BTS guide ,he eligible to donate for his son.
BTS , suggest that potential donors with mild or moderate hypertension should be
considered suitable for nephrectomy, particularly if the blood pressure is controlled with
non-pharmacological methods and 1 or 2 antihypertensive agent.(1)
Advice and recommends lifestyle measures in kidney donors to reduce the risk of
hypertension and its consequences, including frequent exercise, smoking cessation, and
weight loss where appropriate.
Lifestyle modifications include healthy diet, smoking cessation, weight loss if
overweight, regular exercise.(2)
Follow-up arranged indefinitely of Donors with hypertension is critical for monitoring of
control in relation to targets and for monitoring and management of complications.
Would your management differ if the potential donor was on 3 antihypertensive agents:
patient on 3 hypertension medication should be excluded from donation, as
recommended by BTS.(1)
References:
1-BTS GUIDL 2018.
2-kdiqo guideline 2017
Thank you; how would make this guy on 3 antihypertensive medications a suitable donor then?