Studies have shown that kidney donation is related to the possibility of increased proteinuria, but this is not directly related to these events. However, the same studies showed that the environmental situations that lead to these events have a greater impact on the post-transplant donor.
What are the measures taken to reduce this risk?
It is necessary that the donor has healthy life habits, avoiding risk situations such as: Hypertension, diabetes, obesity and smoking. It is these risk situations that start to increase the risks of ESRD, cardiovascular disease and death.
mai shawky
2 years ago
-living kidney donation still carries a risk of ESKD, Hypertension, increased protinuria with hyperfilteration injury after native nephrectomy. However, giving a kidney means giving a life.
– good selection of the donor and avoidance of diabetic and obese donors together with counseling about keeping healthy life style can preserve the kidney function and avoid post donation complications.
Naglaa Abdalla
2 years ago
In a study done by Hassan N. Ibrahim and others evaluating the long term consequences of kidney donation from November 1963 through December 2007, a total of 3698 nephroctomies in living donors were performed at the university of Minnesota.
They found that the survival of kidney donors was similar to that of controls who were matched for age, sex, and race or ethnic group. ESRD developed in 11 donors, a rate of 180 cases per million persons per year, as compared with a rate of 268 per million per year in the general population. At a mean (±SD) of 12.2±9.2 years after donation, 85.5% of the subgroup of 255 donors had a GFR of 60 ml per minute per 1.73 m2 of body surface area or higher, 32.1% had hypertension, and 12.7% had albuminuria. Older
age and higher body-mass index, but not a longer time since donation, were associated
with both a GFR that was lower than 60 ml per minute per 1.73 m2 and hypertension.
A longer time since donation, however, was independently associated with
albuminuria. Most donors had quality-of-life scores that were better than population
norms, and the prevalence of coexisting conditions was similar to that among controls
from the National Health and Nutrition Examination Survey (NHANES) who
were matched for age, sex, race or ethnic group, and body-mass index.
Conclusions:
Survival and the risk of ESRD in carefully screened kidney donors appear to be similar to those in the general population. Most donors who were studied had a preserved GFR, normal albumin excretion, and an excellent quality of life.
Mohamed Ghanem
2 years ago
Regarding Donor ESKD :
The prevalence of end stage kidney disease in live kidney donors appears to be equivalent to or lesser than that found in the random general population, despite a drop in glomerular filtration rate .
Over 15 years of follow-up, Muzaale evaluated the consequences of 96,000 renal donors who were matched with healthy controls . End-stage renal disease was expected to have a risk of 31/10000 15 years following donation, versus to 4 per 10,000 in matched non-donor groups .
The expected lifetime risk of end stage kidney disease among donors was Ninety per 10,000, in the general public it was 326 per 10,000, and in healthy matched controls it was fourteen per 10,000(22).
ESRD is thought to occur less frequently in kidney donors than in the general population. Compared to matched controls, the donors’ chance of having ESRD was much higher as considering that the vast bulk of donors were blood relatives, genetic factors may be a possible reason for the elevated risk in donors. Renal disease is more common in relatives of patients with chronic kidney disease, as is well known . Regarding donor’s mortality:
Three retrospective observational studies examined the mortality of healthy non-donors with living kidney donors . A decreased risk of death was found in donors compared to healthy non-donors in two studies while a possibly little increase was shown by the third study
On the other hand, Norwgian study 224 (out of 1901) kidney donors were died over the observation period, 68 (30.4%) of which were caused by cardiovascular disease. Among the 32,621 controls, there were 2425 deaths, 688 (28.4%) of which were caused by cardiovascular disease. No donors recently died during or immediately following the operation .
According to numerous studies, elevated blood pressure,albuminuria impaired renal function after nephrectomy in kidney donors are linked to a higher cause of cardiovascular mortality Cardiovascular evaluation before donation serves two objectives. First, it identifies potential donors who may not be a good match for donation because they have a greater than normal risk of peri-operative problems. Second, it offers a chance to evaluate a donor’s cardiovascular risk factors, take into account kidney donation’s long-term consequences, and take steps to slow the advancement of heart illness.
Recommendations:
There is no evidence to support the routine use of stress testing in the assessment of the potential donor at low cardiac risk
Potential kidney donors with a history of cardiovascular disease, an exercise capacity of of <4 metabolic equivalents (METS) or with risk factors for cardiovascular disease should undergo further evaluation before donation
Stress testing is advised for prospective donors who pose a higher risk using any locally available technique or CT calcium scoring
References :
Segev DL, Muzaale AD, Caffo BS, et al. Perioperative mortality and long-term survival following live kidney donation. JAMA 2010; 303: 959-66.
Muzaale AD, Massie AB, Wang MC, et al. Risk of end-stage renal disease following live kidney donation. JAMA 2014; 311: 579-86.
ahmed saleeh
2 years ago
Please substantiate your answer
The answer is that it depends on the risk factors already present in the donor as HTN , DM , CVS events and even if no risk factors in the donor , still there is a risk of CVS events and ESKD
Risk of ESRD in kidney donors:
Overall risk of ESKD in kidney donors is less than 1% . Yet , risk may be higher in young , African Americans.
Studies have shown that kidney donors have increased risk of ESRD as compared to
Risk of Cardiovascular disease in kidney donors:
Different studies on the issue of CVS disease in kidney donors yet CVS complications is very rare and most studies showed no difference in donors vs non donors.
What are the measures taken to reduce this risk?
Donor selection , correction of risk factors involving control of DM , HTN , body weight and life style modifications , as well as renal function tests including urea, creatinine, urine analysis and proteinuria.
Amna Khalifa
2 years ago
The National Kidney Foundation, based on several studies stated that the life expectancy will not change after living donation. Though one of the studies by kiberd BA 2017 reported that donation will reduce life expectancy by 0.5-1 year. This could be due to the long-term consequences. Which can be preventable by maintaining the healthy life style.
However, perioperative complication the patient may encounter injury to surrounding tissue or other organs, and even death are all.
However, in the current era the kidney transplant surgeries are becoming more common hence surgical techniques are advancing and the risks involved with living donation continue to decrease.
With regard to the complication as a consequence of kidney donation there might be a long-term risks including proteinuria and hypertension.
A meta-analysis using 48 studies , 5048 donors, were analyzed and looked at proteinuria, or glomerular filtration rate (GFR) post kidney donation, The authors came to the conclusion that kidney donation causes minor increases in urinary protein. GFR decreased initially, but this was not followed by accelerated losses over the next 15 years. AX Garg. (2006).
The donor is at higher risk if he develop high blood pressure, especially if the donor is old in age or obese or he is African American or Hispanic descent as reported by Ibrahim HN and colleagues in (2009). A metanalysis taking in to account 48 number of studies reported using 5145 donors that a rise of 5mm Hg in BP within 5 years after donation as compared to the anticipated BP with normal aging, however these were only after 5 years of follow ups , it might require longer time to look at the risk and long term morbidity. Boudville N et al (2006).
However, the risk of diabetes post donation is similar to general population with similar risk factors such as increasing weight. This considered another factor which could subsequently results in approaching ESRD.
It is found by Ibrahim HN and his colleagues that the donors who develop diabetes post donation will have higher rate of albuminuria than those nondiabetic donors, they attributed this to development of early diabetic kidney disease. However, they did not exhibit an increased risk of progressive kidney disease in the first decade of diabetes.
The authors emphasized on the fact that all kidney donors, particularly those with a positive family history for diabetes, should be strongly advised to maintain weight control. (Ibrahim et al 2010).
Based on a few articles, such as Ibrahim HN et al 2009, muzaale AD et al 2014, and kiberd BA et al 2017, there have been isolated reports of patients developing kidney failure after donation. Mjoen G et al 2014 confirmed that donors have higher long-term risks for ESRD, cardiovascular disease, and all-cause mortality when compared to a control group of non-donors who would have been eligible for donation.
The donor should be counselled regarding few points which will reduce the risk of developing the above mentioned complications, these measures are:
Avoiding Smoking and drinking alcohol as both can delay the recovery after the operation. It’s recommended to avoid smoking and drinking for at least the first several weeks after surgery. living a healthy lifestyle and protecting the remaining kidney. subsequently reducing cardiovascular risk as well.
The donor can live with a single kidney, as normal population, the other kidney will compensate and the kidney function (GFR) will improve gradually. Hence kidney donors can live a normal life after donation. However, he has to maintain healthy life style to avoid complications or subsequent adverse effect. Hence, he has to maintain the kidney functions by avoiding nephrotoxics such as NSAIDS and maintains weight, avoiding gaining excess weight and smoking.
Rahul Yadav rahulyadavdr@gmail.com
2 years ago
There is an increase in the long-term risk of ESRD, cardiovascular disease, and mortality after donation, as stated below:
ESRD: as attached(2)
Cardiovascular disease: Hazard ratio 1.4(1)
Peri-operative death:0.03%(2)
All cause mortality: Hazard ratio 1.3(1)
Measures to reduce risk post-donation:
Good residual function of remaining kidney by careful selection of donor
Healthy diet and lifestyle
At least 5 days a week 30-45 mins of exercise
Yearly check up for proteinuria, blood pressure and sugar
Yearly USG KUB and kidney function tests
Avoiding NSAIDs
Adequate fluids intake
Immediate consult in case of any medical illness
References:
Mjoen G, et al. Long-term risks for kidney donors. Kidney Int 2014; 86: 162-7.
Garg AX, Boidville N. End-stage renal disease in living kidney donors. Kidney Int. 2014 ;86(1):20-2.
Hinda Hassan
2 years ago
Donation and ESRD Kidney donors have lower long-term risk of ESRD compared to the general population. This has been attributed to the careful screening process that excludes candidates with pre-existing conditions from donation. However, two recent studies, one from Norway and one from the United States, examined ESRD risks for living donors compared to healthy non-donors (not the general population) (1,2). Consistent with prior studies, a low absolute risk of ESRD (< 0.5% at 15 years post kidney donation and the lifetime risk estimated at 0.9%) was reported (2). While the relative risk of ESRD in donors was less than the general population, donors have a relative risk of ESRD of between 8 to 11 times compared to healthy non-donors. All of the donors with ESRD in the Norwegian study were family members of the recipients, and most developed immune-mediated renal disease. Despite their limitations (3-6), these studies provide the best information to date on donor risks. A risk calculator has recently been developed for use in counseling potential kidney donors. Demographic and health characteristics may now be used to estimate the projected longterm pre-donation risk of ESRD in donor candidates. A post donation calculator is not available (7) . Donation and cardiovascular disease A retrospective population based matched cohort study in the province of Ontario, Canada, between 1992 and 2009 was done on 2028 donors and 20 280 matched non-donors followed for a median of 6.5 years .The risk of the primary outcome of death and major cardiovascular events was lower in donors than in non-donors (2.8 v 4.1 events per 1000 person years; hazard ratio 0.66, 95% confidence interval 0.48 to 0.90). The risk of major cardiovascular events censored for death was no different in donors than in non-donors (1.7 v 2.0 events per 1000 person years; 0.85, 0.57 to 1.27). Results were similar in all sensitivity analyses. Older age and lower income were associated with a higher risk of death and major cardiovascular events in both donors and non-donors when each group was analysed separately. The risk of major cardiovascular events in donors is no higher in the first decade after kidney donation compared with a similarly healthy segment of the general population. (8) Donation and death Kidney donor surgery has a 007% mortality rate, which means that on average, for every 100,000 living donor
surgeries, seven donors die.(9) A study of all first kidney-only transplant recipients from 1980 through 2018 from the Australia and New Zealand Dialysis and Transplant Registry. Of 23,210 recipients, 4765 died with a functioning graft. Risk of death declined over successive eras, at all periods post-transplant. Reductions in early deaths were most marked; however, recipients ≥10 years post-transplant were 20% less likely to die in the current era compared with preceding eras (2015–2018 versus 2005–2009, adjusted hazard ratio, 0.80; 95% confidence interval, 0.69 to 0.90). In 2015–2018, cardiovascular disease was the most common cause of death, particularly in months 0–3 post-transplant (1.18 per 100 patient-years). Cancer deaths were rare early post-transplant, but frequent at later time points (0.93 per 100 patient-years ≥10 years post-transplant). Among 3657 patients with first graft loss, 2472 died and were not retransplanted. Death was common in the first year after graft failure, and the cause was most commonly cardiovascular (50%).(10) Ref: 1.Mjoen G, Hallan S, Hartmann A, Foss A, Midtvedt K, Oyen O, et al. Long-term risks for kidney donors. Kidney international. 2014 Jul;86(1):162-7. PubMed PMID: 24284516. 2.Muzaale AD, Massie AB, Wang MC, Montgomery RA, McBride MA, Wainright JL, et al. Risk of end-stage renal disease following live kidney donation. JAMA : the journal of the American Medical Association. 2014 Feb 12;311(6):579-86. PubMed PMID: 24519297. 3.Lam NN, Lentine KL, Garg AX. End-stage renal disease risk in live kidney donors: what have we learned from two recent studies? Current opinion in nephrology and hypertension. 2014 Nov;23(6):592-6. PubMed PMID: 25160076. Pubmed Central PMCID: 4189686. 4.Kasiske BL. Outcomes after living kidney donation: what we still need to know and why. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2014 Sep;64(3):335-7. PubMed PMID: 24797521. 5. Gill JS, Tonelli M. Understanding rare adverse outcomes following living kidney donation. JAMA : the journal of the American Medical Association. 2014 Feb 12;311(6):577-9. PubMed PMID: 24519296. 6.Matas AJ, Wadstrom J, Ibrahim HN. Kidney donation and risk of ESRD. JAMA : the journal of the American Medical Association. 2014 Jul 2;312(1):92-3. PubMed PMID: 25058223. 7. http://www.transplantmodels.com/esrdrisk/ 8.Garg A X, Meirambayeva A, Huang A, Kim J, Prasad G V R, Knoll G et al. Cardiovascular disease in kidney donors: matched cohort studyBMJ 2012; 344 :e1203 doi:10.1136/bmj.e1203 9.Kidney Donation Risks – Donor Care Network,www.donorcarenet.org › Education 10.Death after Kidney Transplantation: An Analysis by Era and Time Post-Transplant Tracey Ying, Bree Shi, Patrick J. Kelly, Helen Pilmore, Philip A. Clayton, Steven J. Chadban JASN Dec 2020, 31 (12) 2887-2899; DOI: 10.1681/ASN.2020050566
Alyaa Ali
2 years ago
kidney donors are at increased long-term risk for ESRD, cardiovascular, and all-cause mortality.
Donor nephrectomy is associated with increased risk of end stage renal disease in comparison with well-matched healthy non donors, but the absolute risk is low.
A study compared a cohort of 96,217 kidney donors in the USA in the period (1994 to 2011) with participants of the Third National Health and Nutrition Examination Survey (NHANES III) showed that estimated risk of ESRD at 15 years after donation was 30.8 per 10,000 in kidney donors and 3.9 per 10,000 in well matched healthy non-donor (P < .001). but the absolute risk is small.
Muzaale AD, Massie AB, Wang MC, Montgomery RA, McBride MA, Wainright JL, Segev DL. Risk of end-stage renal disease following live kidney donation. JAMA. 2014 Feb 12;311(6):579-86.
Cardiovascular risk and death
All-cause mortality, cardiovascular mortality, and end-stage renal disease (ESRD) was identified in 1901 individuals who donated a kidney during 1963 through 2007 with a median follow-up of 15.1 years. A control group of 32,621 potentially eligible kidney donors was selected, with a median follow-up of 24.9 years. Hazard ratio for all-cause death was significantly increased to 1.30 (95% confidence interval 1.11-1.52) for donors compared with controls. There was a significant corresponding increase in cardiovascular death to 1.40 (1.03-1.91), while the risk of ESRD was greatly and significantly increased to 11.38 (4.37-29.6). The overall incidence of ESRD among donors was 302 cases per million and might have been influenced by hereditary factors. Immunological renal disease was the cause of ESRD in the donors. Thus, kidney donors are at increasedlong-term risk for ESRD, cardiovascular, and all-cause mortality compared with a control group of non-donors who would have been eligible for donation.
Mjøen G, Hallan S, Hartmann A et al.,Long-term risks for kidney donors.Kidney Int. 2014;86(1):162.
Batool Butt
2 years ago
Donors should be counseled in detail about the long term increase risk of ESRD by 0.5% as quoted by Muzaale AD et al and 11.38 times increase risk as mentioned by Mjen G et al in 2014. Black race, young age, male sex, high BMI and a family history of renal disease if present can further add on the risk of ESRD. Various calculators are present which can help in predicting lifetime risk of ESRD.
There is controversial data available in estimating cardiovascular risks and mortality post donation .Majority of the studies have revealed similar risk in donors and healthy non-donors. Few studies have contrary results .According to Segev DL, et al , cardiovascular events(MI and arrhythmia) or PE are responsible for perioperative mortality and it accounts for 3.1 in 10,000 .Few studies revealed increase urinary protein ,hypertension and reduce GFR are the risk factors which in the long term can increase cardiovascular morbidity and mortality. There are also chances of ischemic heart disease after donation according to one study .Another study stated 40% increase in cardiovascular mortality and post-transplant hypertension after a follow up of 15 years.
Multidisciplinary team should always be involved in careful assessment of kidney donors in order to reduce the risks .Patient’s GFR should be properly assessed as per guidelines for age and gender and risk factors lie obesity, hypertension ,young age and ethnicity also to be considered and counseled to adopt healthy lifestyle ,stop smoking ,exercise regularly and avoid nephrotoxic medications post donation with regularly monitoring of renal function test, blood pressure ,proteinuria.
REFERENCES:
1-Mjøen G, Hallan S, Hartmann A, Foss A, Midtvedt K, Øyen O, Reisæter A, Pfeffer P, Jenssen T, Leivestad T, Line PD, Øvrehus M, Dale DO, Pihlstrøm H, Holme I, Dekker FW, Holdaas H. Long-term risks for kidney donors. Kidney Int. 2014 Jul;86(1):162-7. doi: 10.1038/ki.2013.460. Epub 2013 Nov 27. PMID: 24284516.
2-Muzaale AD, Massie AB, Wang MC, et al. Risk of end-stage renal diseasefollowing live kidney donation. JAMA 2014; 311: 579-86
3-Lam NN, Lentine KL, Levey AS, Kasiske BL, Garg AX. Long-term medical risks to the living kidney donor. Nat Rev Nephrol. 2015 Jul;11(7):411-9. doi: 10.1038/nrneph.2015.58. Epub 2015 May 5. PMID: 25941060
4-Segev L et al. Perioperative Mortality and Long-term Survival Following Live Kidney Donation. JAMA, March 10, 2010—Vol 303, No. 10
Ramy Elshahat
2 years ago
Please substantiate your answer
living kidney donors considers the best source of organs that afford the best results regarding graft survival but still, we expose healthy individuals to the risk of operation and post-operative complications. in general population, decrease GFR and proteinuria are independent risk factors for cardiovascular disease but in kidney donors still have controversy. Donors are not like the general population as donors are healthy individuals has no risk factors like diabetes and hypertension. a single study showed an increase in CVD in kidney donors by 40% after 25y follow-ups in comparison to paired healthy individuals.
regarding the risk of ESRD also when compare donors with paired healthy individuals showed an increased risk of 8% and 11% after 15y and 25y of follow up respectively
Is donation associated with an increased risk of ESRD, cardiovascular disease or death?
· The risk of end-stage renal disease (ESRD) after the donation is no higher than that of the general population. However, there is a very small absolute increased lifetime risk of ESRD following donation for which the potential donor must be counselled. (D2). (1)
· Studies suggest that living kidney donors are at increased risk of developing end-stage renal disease relative to healthy nondonors, but the 15-year cumulative incidence remains <1%.
· All-cause mortality in the first decade after nephrectomy seems to be lower or no different among donors than among healthy nondonors; one study suggests that over 25 years, the incidence might increase by 5%. In the first decade after donation, the risk of all-cause mortality and cardiovascular events is no higher than in healthy nondonors. The risk of death-censored major cardiovascular events was similar among donors and nondonors. (2,3) What are the measures taken to reduce this risk?
Careful selection of the donors, with special post- and perioperative care, and good follow-up after donation.
Good counselling of the donor with lifestyle modification (regular exercise, maintaining ideal body weight, smoking cessation)
Future studies must clarify the lifetime incidence of long-term outcomes, particularly in relation to a donor’s age, race, and history of comorbidities. (1,2) References:
1. Association BTS. Guidelines for Living Donor Kidney Transplantation, Fourth Edition. Accessed from https//bts.org.uk/wp-content/uploads/2018/07/FINAL_LDKT-guidelines_June-2018.pdf 2/10/2020. 2018;(March).
2. Lam NN, Lentine KL, Levey AS, Kasiske BL, Garg AX. Long-term medical risks to the living kidney donor. Nat Rev Nephrol [Internet]. 2015;11(7):411–9. Available from: https://doi.org/10.1038/nrneph.2015.58
3. Lentine KL, Segev DL. Understanding and Communicating Medical Risks for Living Kidney Donors: A Matter of Perspective. J Am Soc Nephrol [Internet]. 2017 Jan 1;28(1):12 LP – 24. Available from: http://jasn.asnjournals.org/content/28/1/12.abstract
Hamdy Hegazy
2 years ago
3. Is donation associated with an increased risk of ESRD, cardiovascular disease or death?
Please substantiate your answer The risk of ESRD in renal living donors is higher than healthy non-donors, however the incidence was less than 1% after 15 years according to Lam et al 2015 and Muzaale et al 2013. it was higher in young African American donors. The relative risk to develop ESRD in donors was high but the absolute risk was low. Risk factors in donors that might precipitate ESRD include: African American/south Asian ethinicity, Hypertension, DM, and obesity. , other studies showed similar results between both groups. 1 Cardiovascular mortality risk is 40% higher in donors compared to healthy non-donors. 2 All cause mortality is similar between donors and healthy non donors within 10 years of follow up. However, after 25 years it has increased by 5 % higher in the donor group.
What are the measures taken to reduce this risk? 1- Selection of donors. 2- Post-operative care, prevent and manage complications. 3- Life style: Diet, Exercise, Weight reduction and smoking cessation. 4- Follow up and tight control for Hypertension, blood sugar, renal function, and proteinuria.
References: 1) Lam NN, Lentine KL, Levey AS, Kasiske BL, Garg AX. Long-term medical risks to the living kidney donor. Nat Rev Nephrol. 2015 Jul;11(7):411-9. doi: 10.1038/nrneph.2015.58. Epub 2015 May 5. PMID: 25941060. 2) Muzaale AD, Massie AB, Wang MC, Montgomery RA, McBride MA, Wainright JL, Segev DL. Risk of end-stage renal disease following live kidney donation. JAMA. 2014 Feb 12;311(6):579-86. doi: 10.1001/jama.2013.285141. PMID: 24519297; PMCID: PMC4411956. donation. JAMA. 2010 Mar 10;303(10):959-66. doi: 10.1001/jama.2010.237. PMID: 20215610. 3) British Transplantation Society. Renal Association Guidelines for Living Donor Kidney Transplantation, 4th ed.; British Transplantation Society: Macclesfield, UK, 2018; Available online: https//bts.org.uk/wp-content/uploads/2018/07/FINAL_LDKT-guidelines_June-2018.pdf (accessed on 14 September 2022).
Ahmed Fouad Omar
2 years ago
Please substantiate your answer
Risks of ESRD
ESRD is more common in donors compared to non-donors. Risk factors include black race, young age, male sex, high BMI and a family history of renal disease. Muzaale AD et al confirmed that donation can increase the risk of ESRD by 0.5% compared to the general population but Mjen G et al in a long term follow-up confirmed an 11.38 times increase in the risk of ESRD more than the control population eligible for donation, but mostly due to immunological causes. Therefore, donors need to be counseled and consented for these potential risks and risk calculators are available to predict life-time risk to ESRD.
Mortality Risk:
Donation may decrease life by 0.5-1 year and lifestyle modification including weight reduction, smoking cessation may alter this outcome. Segev DL, et al stated that the perioperative mortality was 3.1 in 10,000 and this is mainly attributed to cardiovascular events(MI and arrhythmia) or PE, however, there was no significant difference in the long term mortality between donors and the general population. On the contrary, Mjen G et al in a long term follow-up confirmed increased all-cause mortality (30%) and this happened only after the first 5-10 years.
Risks of Cardiovascular disease:
The risks of cardiovascular events has been shown to be similar in donors and healthy non-donors. Another study showed that the cardiovascular risks are similar to non-donors after a decade.
What are the measures taken to reduce this risk?
Careful selection of donor selection and evaluation by the multidiscipline team
Correct the modifiable risk factor like smoking , obesity , encourage healthy diet and exercise
Regular follow-up of renal functions, blood pressure and blood sugar.
References:
1. Mjen G et al. Long-term risks for kidney donors. Kidney International (2014) 86, 162–167
2. Kiberd BA and Tennankore KK. Lifetime risks of kidney donation: a medical decision analysis. BMJ Open 2017(7).
3. Muzaale AD et al., Risk of End-Stage Renal Disease Following Live Kidney Donation. JAMA. 2014 February 12; 311(6): 579–586
4. Segev L et al. Perioperative Mortality and Long-term Survival Following Live Kidney Donation. JAMA, March 10, 2010—Vol 303, No. 10
Nasrin Esfandiar
2 years ago
· Q1: Yes. Some studies showed increased risk of ESKD and CVD especially comparing healthy non-donors. However, lower ESKD risk compared to general population risk of CVD is increased in elderly group especially if became hypertensive.
· Q2: Donors should be evaluated by cardiologists to reduce and treat modifiable risk factors for CVD. In addition, donor follow up is recommended at least annually for overweight, RFT, hypertension, proteinuria or albuminuria, diabetes and life style modifications.
Ahmed Abd El Razek
2 years ago
Renal donation is not associated with increased risk of ESRD .The risk is similar to general population and it is usually of new disease onset of immunological background which would have affected both kidneys.
Donors who developed ESRD (mean age ± standard deviation [SD] at ESRD, 62.4 ± 14.1 years.
Risk is increased in male, younger age of donation, smoking, family history of comorbid conditions as HTN or DM.
Measures to reduce the risk:
Better selection of donor, younger age with higher eGFR, or older more healthy donors with accepted total GFR, nonsmokers , if smoker adopt smoking cessation programs to help them to quit smoking , healthy lifestyle is advisable , donors with family history of DM, HTN or CKD to be excluded especially young age , avoid NSAIDs abuse ,nephrotoxic medications , addiction ,plus regular annual monitoring of renal functions and renal ultrasound post transplantation is a must.
Balaji Kirushnan
2 years ago
The incidence of ESRD in living kidney donors is reassuringly low as compared to the general population although there is a decrease in the GFR post donation in donors initially1…..
Muzzale compared the outcome of 96000 kidney donors in USA and followed for 15 years..This was published in JAMA in 2014.. the donor population was 75% white race, 25% were obese and 20% had pre donation GFR < 80ml/min….the estimated risk of ESRD 15 years post donation was 31 per 10,000 compared to 4 per 10,000 in non donated matched controls…The estimated risk of ESRD was 90 per 10,000 donors as compared to 326 per 10,000 donors in general population2…Another study from Norway also compared the risk of ESRD in donors and healthy matched controls and said that there is an increased risk of ESRD after life time kidney donation….
Donors must be reassured, but be aware of a small absolute increase risk of creatinine or worsening of GFR <30ml/min/m2 is very minimal from this study…the life time risk of ESRD is more in young age donors, african american donors, or those with hypertension, diabetes…Individualized risk assessment of the donors are needed before making an informed decision
Segev DL, Muzaale AD, Caffo BS, et al. Perioperative mortality and long-term survival following live kidney donation. JAMA 2010; 303: 959-66.
Muzaale AD, Massie AB, Wang MC, et al. Risk of end-stage renal disease following live kidney donation. JAMA 2014; 311: 579-86
measures taken to reduce the risk are to prevent the occurrence of life style mediated diseases post renal donation namely diabetes, hypertension, to avoid smoking or getting obese…. Annual monitoring of kidney functions is recommended for all donors as per BTS guidelines
Tahani Ashmaig
2 years ago
◇ Please substantiate your answer
▪︎Live kidney donation may reduce life expectancy by 0.5–1 year in most donors. The development of ESRD in donors may not be the only measure of risk as most of the predicted loss of life predates ESRD [1].
▪︎ In the general population, reduced GFR and proteinuria are associated with CVD but it remains controversial if reduced renal function increases the risk of CVD in otherwise healthy kidney donors. A majority of studies have not identified an increased risk of CVD among kidney donors, however, a single study with a median follow-up of 15 years showed a 40% increased cardiovascular mortality in kidney donors when compared with a cohort of self-proclaimed healthy individuals [2].
◇ What are the measures taken to reduce this risk
By following donors and treating risk factors aggressively to prevent ESRD and to improve donor survival [2].
______________________
Ref:
[1] Bryce A Kiberd and Karthik K Tennankore Lifetime risks of kidney donation: a medical decision analysis.
[2] Philip Munch, et al. Is the risk of cardiovascular disease increased in living kidney donors? A Danish population-based cohort study
American Journal. 2020. V 21,p. 1857-1865.
Esraa Mohammed
2 years ago
Donor Risk
The continued success of living donation depends upon ensuring the safety and excellent long-term outcomes of the donor. In particular, donors must be reassured that the risk both of developing progressive CKD and of premature cardiovascular death remain low following nephrectomy
Donor Risk -CKD/ESRD-
Recommendations
• Counselling and consent of potential living kidney donors must include acknowledgement that the baseline risk of ESRD is increased by donation. (A1)
• Discussion with potential donors must be informed by those factors known to increase ESRD risk post-donation, including donor age, sex, race, BMI, and a family history of renal disease. (A1)
• Risk calculators predicting lifetime ESRD risk may help inform the consent process. (C2)
The lifetime risk of ESRD after kidney donation is low Less than 1:200 donors (0.5%)
•Donor Risk -Death Peri-Operative (90 days) – 1 in 3,000
Wee Leng Gan
2 years ago
End-stage kidney disease — When compared with well-matched, equally healthy controls, donor nephrectomy appears to increase the risk of end-stage kidney disease (ESKD), although the absolute risk is low.
Cardiovascular disease or death. In a study comparing 2028 living kidney donors in Ontario, Canada (1992 to 2009) with 20,280 healthy, demographically matched nondonors, the risk of death or major cardiovascular events over a median seven years follow-up (maximum 18 years) was lower in donors than in healthy nondonors (2.8 versus 4.1 events per 1000 person-years; hazard ratio [HR] 0.66, 95% CI 0.48-0.90) Reference :
W3 s3
Is donation associated with an increased risk of ESRD, cardiovascular disease or death?
Q1- Please substantiate your answer
Risk of end-stage renal disease (ESRD) in kidney donors has been compared with risk of the general population, but the general population is not a well matched comparable group . that sway the previus studies show no increase in the risk of ESRD in kidney donors . But to get amore accurate comparison we should compare the risk of ESRD in kidney donors with that of a healthy nondonors who are at equally low risk of renal disease .A comparison to similarly screened healthy nondonors would more properly estimate the sequelae of kidney donation.
Compared with a matched non donors, kidney donors had an increased risk of ESRD; but the magnitude of the absolute risk increase was small . (1)
As conclusion of another study , Survival and the risk of ESRD in carefully screened kidney donors appear to be similar to those in the general population .(2)
Previous studies have suggested that living kidney donors maintain long-term renal function and experience no increase in cardiovascular or all-cause mortality. However, most analyses have included control groups less healthy than the living donor population and have had reatively short follow-up periods. Hazard ratio for all-cause death and cardiovascular mortality was significantly increased for donors compared with controls , while the risk of ESRD was greatly and significantly increased and might be influenced by hereditary factors and Immunological .Thus, kidney donors are at increased long-term risk for ESRD, cardiovascular, and all-cause mortality compared with a control group . (3)
Q2- What are the measures taken to reduce this risk?
Recent data support that living donors may experience a small increased risk of severe CKD and ESRD compared with healthy nondonors. For most donors, the 15-year risk of kidney failure is <1%, but for certain populations, such as young, black men, this risk may be higher. New risk prediction tools that combine the effects of demographic and health factors, and innovations in genetic risk markers are improving kidney risk stratification. (4)
Therefore carefully assessing the donor will help to reducing the chance of developing the bad outcomes ,
Reference :
1- Muzaale AD, Massie AB, Wang MC, Montgomery RA, McBride MA, Wainright JL, Segev DL: Risk of end-stage renal disease following live kidney donation. JAMA 311: 579–586, 2014
2- Ibrahim HN, Foley R, Tan L, Rogers T, Bailey RF, Guo H, Gross CR, Matas AJ: Long-term consequences of kidney donation. N Engl J Med 360: 459–469, 2009
3- . Mjøen G, Hallan S, Hartmann A, Foss A, Midtvedt K, Øyen O, Reisaeter A, Pfeffer P, Jenssen T, Leivestad T, Line PD, Øvrehus M, Dale DO, Pihlstrøm H, Holme I, Dekker FW, Holdaas H: Long-term risks for kidney donors. Kidney Int 86: 162–167, 2014
4- Lentine KL, Lam NN, Segev DL. Risks of Living Kidney Donation Current State of Knowledge on Outcomes Important to Donors.Clin J Am Soc Nephrol 14: 597–608, April, 2019.
Mohamed Essmat
2 years ago
In the general population, reduced GFR and proteinuria are associated with cardiovascular disease ,but it remains controversial if reduced renal function increases the risk of CVD in otherwise healthy kidney donors.
A majority of studies have not identified an increased risk of CVD among kidney donors,however, a single study with a median follow-up of 15 years showed a 40% increased cardiovascular mortality in kidney donors when compared with a cohort of self-proclaimed healthy individuals.
Also, while chronic kidney disease and reduced GFR is associated with an increased risk of atrial fibrillation or flutter (AF) the effect of kidney donation on this risk has not been assessed. Furthermore, how living kidney donation affects the risk of hypertension is equivocal, however, two recently published studies identified increased risks of hypertension after living kidney donation.
Garg et al. followed 2028 donors with a median age of 43 years at donation for a median of 6.5 years. Fourteen donors were registered with MI during follow-up. They found the risk of a first cardiovascular event (including stroke and MI) to be lower in donors than controls after follow-up. However, it is not likely that kidney donation reduces cardiovascular risk. These results may instead reflect the fact that the control group may not have been healthy enough to serve as controls for kidney donors. In a large study with data from 2696 living donors, Rizvi et al. performed a subanalysis, selecting data from potential donors (evaluated and accepted but who did not proceed for non-medical reason) as a control group for real living donors. They found 90 non-donor siblings who could be paired with actual donors for age, sex and BMI. During a mean follow-up time of 5 years, only one person in each group was diagnosed with ischaemic heart disease. *Compared with matched healthy nondonors, kidney donors had an increased risk of ESRD over a median of 7.6 years; however, the magnitude of the absolute risk increase was small. These findings may help inform discussions with persons considering live kidney donation. *Cumulative incidence of ESRD was lowest among living donors with BMI <25 and highest among donors with BMI>30 and it was higher among donors who were first-degree biologically related to their recipient
References :
1-Segev DL, Muzaale AD, Caffo BS, Mehta SH, Singer AL, Taranto SE, McBride MA, Montgomery RA: Perioperative mortality and long-term survival following live kidney donation. JAMA 303: 959–966, 2010
2. Muzaale AD, Massie AB, Wang MC, Montgomery RA, McBride MA, Wainright JL, Segev DL: Risk of end-stage renal disease following live kidney donation. JAMA 311: 579–586, 2014
3. Mjøen G, Hallan S, Hartmann A, Foss A, Midtvedt K, Øyen O, Reisaeter A, Pfeffer P, Jenssen T, Leivestad T, Line PD, Øvrehus M, Dale DO, Pihlstrøm H, Holme I, Dekker FW, Holdaas H: Long-term risks for kidney donors. Kidney Int 86: 162–167, 2014
4. Ibrahim HN, Foley R, Tan L, Rogers T, Bailey RF, Guo H, Gross CR, Matas AJ: Long-term consequences of kidney donation. N Engl J Med 360: 459–469, 2009
5. Locke JE, Reed RD, Massie A, MacLennan PA, Sawinski D, Kumar V, Mehta S, Mannon RB, Gaston R, Lewis CE, Segev DL: Obesity increases the risk of end-stage renal disease among living kidney donors. Kidney Int 91: 699–703, 2017
Mahmud Islam
2 years ago
There is a risk of ESRD as shown by some studies but that was not very high. Older age was associated with 1.7 higher risk (Kiberd BA, Tennankore KK. Lifetime risks of kidney donation: a medical decision analysis. BMJ Open. 2017 Sep 1;7(8):e016490. doi: 10.1136/bmjopen-2017-016490. PMID: 28864484; PMCID: PMC5588992.). MBI was another factor.
We need to choose donors carefully and follow them after the nephrectomy. The loss of nephron mass has an effect that may not be predicted before operation.
Abhijit Patil
2 years ago
A linkage of national donor registry data to ESKD registry data for 125,427 living donors found that early postdonation ESKD was predominantly reported as due to glomerulnephritis (GN), whereas late postdonation ESKD was more frequently reported as due to diabetes or hypertensive kidney disease, the latter two consistent with the leading causes of ESKD in the United States general population
Lentine KL, Lam NN, Segev DL. Risks of Living Kidney Donation: Current State of Knowledge on Outcomes Important to Donors. Clin J Am Soc Nephrol. 2019 Apr 5;14(4):597-608. doi: 10.2215/CJN.11220918. Epub 2019 Mar 11. PMID: 30858158; PMCID: PMC6450354.
The hazard ratio for all-cause death was 1.3 for donors when compared to controls, 1.4 for cardiovascular death, and 11.38 for ESRD.
Mjoen G, Hallan S, Hartmann A, et al. Long-term risks for kidney donors. Kidney Int 2014; 86: 162-7.
Lifetime risk of ESRD after kidney donation is low, occurring in less than 1:200 donors (0.5%).
However, it appears clear that, for an individual at low baseline risk, donating a kidney does increase the risk of later developing ESRD.
This risk remains substantially less than that in the general (unscreened) population.
It is not clear that kidney donation has a detrimental effect on long-term cardiovascular or all-cause mortality, with conflicting results from the US and Norwegian studies.
Mjoen G, Hallan S, Hartmann A, et al. Long-term risks for kidney donors. Kidney Int 2014; 86: 162-7.
Segev DL, Muzaale AD, Caffo BS, et al. Perioperative mortality and long-term
survival following live kidney donation. JAMA 2010; 303: 959-66.
AMAL Anan
2 years ago
Post-donation projected risk of end-stage renal disease (after kidney donation):
Previous studies have estimated that the 15-year absolute increase in the risk of ESRD from kidney donation averages 0.27%4,5. This risk varies depending on a donor candidate’s demographic and health characteristics. At the present time we do not have data on the lifetime post-donation risk of ESRD according to a donor candidate’s characteristics.
References
1. Grams ME, Sang Y, Levey AS, Matsushita K, Ballew S, Chang AR et al. Kidney-Failure Risk Projection for the Living Kidney-Donor Candidate. NEJM 2015 (epub ahead of print)
2. Hsu CY, McCulloch CE, Iribarren C, Darbinian J, Go AS. Body mass index and risk for end-stage renal disease. Ann Intern Med 2006;144:21-8.
3. Vivante A, Golan E, Tzur D, et al. Body mass index in 1.2 million adolescents and risk for end-stage renal disease. Arch Intern Med 2012;172:1644-50.
4. Mjøen G, Hallan S, Hartmann A, et al. Long-term risks for kidney donors. Kidney Int 2014;86:162-7.
5. Muzaale AD, Massie AB, Wang MC, et al. Risk of end-stage renal disease following live kidney donation. JAMA 2014;311:579-86.
Last edited 2 years ago by AMAL Anan
Wadia Elhardallo
2 years ago
Please substantiate your answer
long prospective cohort was designed to assess long term risks of kidney donation, it demonstrated a significant increase in ESRD, cardiovascular, and all-cause mortality during long-term follow-up after living kidney donation compared with a selected population of non-donors who would have met the criteria for donation. Although Previous studies have suggested that living kidney donors maintain long-term renal function and experience no increase in cardiovascular or all-cause mortality. factors known to increase ESRD risk post-donation, including donor age, sex,race, BMI, and a family history of renal disease
What are the measures taken to reduce this risk?
Avoid risk factors
Early follow-up of the donor, within the first few weeks after surgery, to ensure that he or she is supported and is making appropriate progress following the operation. This includes the monitoring of kidney function and the early detection of problems such as infection and poor wound healing.
Ongoing Long-term annual follow-up
dina omar
2 years ago
*Although absolute risk of end-stage kidney disease is considered very low But ; if compared with well-matched, healthy controls, donor nephrectomy appears to increase the risk of end-stage kidney. Most donors 15-year risk of chronic renal failure is <1%, but the risk will be higher in younger black males. Minor perioperative complications occur in 10%–20% of donor nephrectomy cases, but major complications occur in <3%, and the risk of perioperative death is <0.03%.Over-all ,the more decreased GFR in general population associated with an increased risk of adverse long-term outcomes including ESRD, cardiovascular disease up to death especially with GFR 60-75 mL/min/1.73m2. *The measures taken to reduce this risk : good screening and proper donor selection including risk factors for CVD taking :DM, Hypertension , Family history, smoking. -Potential LKD should be counseled regarding risks of kidney donation and possible long term cardiovascular complications , should have proper diet control , stop smoking and counseling him regarding regular follow-up clinically and laboratory.
References:
1.Lam NN, Segev DL, etal. : Risks of Living Kidney Donation Current State of Knowledge on Outcomes Important to Donors. Clin J Am Soc Nephro.14: 597–608,2019. 2.BTS/RA Living Donor Kidney Transpl. Guidelines 2018
rindhabibgmail-com
2 years ago
Just after donation there is compensatory hypertrophy of the remaining kidney and increase in GFR up to 70%.
It was seen after donation that the donor has been more careful with regular checkup, follow up and more conscious about there health. according to literature there is no significant increase in renal failure compare to normal population may be <1%. Although, there increase risk of developing hypertension.
Every donor should be evaluated thoroughly for any psychological issue, genetic, renal stone disease, and other comorbidities. psychological counseling for drug adherence, risk of developing future hypertension and other comorbidities associated with metabolic syndrome.
So the donor selection should be very careful.
Regular follow up and life style modification is necessary.
Mahmoud Hamada
2 years ago
I can not find my previous answer on that scenario!
Alaa eddin salamah
2 years ago
Kidney donors have lower long-term risk of ESRD compared to the general population. This has been attributed to the careful screening process that excludes candidates with pre-existing conditions from donation. However, two recent studies, one from Norway and one from the United States, examined ESRD risks for living donors compared to healthy non-donors (not the general population). Consistent with prior studies, a low absolute risk of ESRD (< 0.5% at 15 years post kidney donation and the lifetime risk estimated at 0.9%) was reported . While the relative risk of ESRD in donors was less than the general population, donors have a relative risk of ESRD of between 8 to 11 times compared to healthy non-donors. All of the donors with ESRD in the Norwegian study were family members of the recipients, and most developed immune-mediated renal disease. Despite their limitations, these studies provide the best information to date on donor risks. A risk calculator has recently been developed for use in counseling potential kidney donors. Demographic and health characteristics may now be used to estimate the projected longterm pre-donation risk of ESRD in donor candidates. A post donation calculator is not available.
Nephrectomy does not appear to increase long-term mortality
Kidney donation does not increase the risk of cardiovascular disease for donors
Abubacarr Jagne
2 years ago
Renal transplant is best form of renal replacement. In its preparation, everything is done work on the safety of the donor. No procedure is without a risk. Donors have an increase risk of hypertension, diabetes,declining GFR and the procedure risk.
The best way of reducing these risk is due screening, and proper procedure and follow up post transport
Huda Al-Taee
2 years ago
Please substantiate your answer
Donor nephrectomy does not appear to increase long-term mortality compared with controls, nor does it increase ESRD risk among white donors. Within the donor population, the likelihood of post-donation chronic renal failure and medical comorbidities such as hypertension and diabetes appears to be relatively higher among some donor subgroups, such as African Americans and obese donors. Still, the impact of uninephrectomy on the lifetime risks of adverse events expected without nephrectomy in these subgroups has not yet been defined.
Recent data support that living donors may experience a small increased risk of severe CKD and ESRD compared with healthy non-donors. For most donors, the 15-year risk of kidney failure is <1%, but for certain populations, such as young black men, this risk may be higher. . Minor perioperative complications occur in 10%–20% of donor nephrectomy cases, but major complications occur in <3%, and the risk of perioperative death is <0.03%.
What are the measures taken to reduce this risk?
New risk prediction tools that combine the effects of demographic and health factors and innovations in genetic risk markers are improving kidney risk stratification and proper donor selection.
References:
Lentine KL, Patel A. Risks and Outcomes of Living Donation. Advances in CKD. 2012 July;19(4):220-228.
Lentine KL, Lam NN, Segev DL. Risks of Living Kidney Donation Current State of Knowledge on Outcomes Important to Donors.Clin J Am Soc Nephrol 14: 597–608, April, 2019.
Giulio Podda
2 years ago
Please substantiate your answer
Previous reports suggest increased risk of hypertension and cardiovascular mortality after kidney donation. Some study have investigated the incidence of IHD and CVD, diabetes and cancer in live kidney donors compared with healthy controls eligible for donation. In a recent study different diagnoses were assessed in 1029 kidney donors and 16 084 controls. Stratified logistic regression was used to estimate associations with various disease outcomes, adjusted for gender, age at follow-up, smoking, BMI at baseline, systolic blood pressure at baseline and time since the donation. The mean observation time was 11.3 years for donors and 16.4 years for controls. At follow-up the age was 56.1 years in donors and 53.5 years in controls and 44% of donors were males versus 39.3% in the controls. At follow-up, 3.5% of the donors had been diagnosed with IHD versus 1.7% of the controls. There were no significant differences for the risks of cerebrovascular disease, diabetes or cancer. This study showed an increased risk of IHD compared with healthy controls.
Based on current data, after donor nephrectomy peri-operative mortality is around 3 per 10,000 cases, and major and minor peri-operative complications affect about 3–6% and 22% of donors, respectively. Long-term mortality does not seem to increase after donor nephrectomy compared with controls, and ESRD risk does not seem to increase among white donors. The likelihood of post-donation chronic renal failure and medical comborbidities seems to be higher among some donor subgroups (eg African Americans, obese), but how uni-nephrectomy affects the lifetime risks of adverse events expected without nephrectomy in these sub-groups is not yet defined.
What are the measures taken to reduce this risk?
-Accurate selection of the potential living donor to reduce complication both in the short and long term. -Thorough evaluation of all risk factors for CVD (Family history, Diabetes, smoking, obesity etc)
-Potential live donor should receive a pre-transplant counseling in order to make them aware of the risks associated with living with one kidney (obesity, BP control, life style such as smoking etc). In that sense the perspective donors need a closed follow-up (urinalysis, monitor BP, Blood sugar etc).
References: –Increased risk of ischaemic heart disease after kidney donation Anders J Haugen, Stein Hallan, Nina E Langberg, Dag Olav Dahle, Hege Pihlstrøm, Kåre I Birkeland, Anna V Reisæter, Karsten Midtvedt, Anders Hartmann, Hallvard Holdaas. Nephrology Dialysis Transplantation, Volume 37, Issue 5, May 2022, Pages 928–936,
Please substantiate your answer A major concern post renal donation is the development of ESRD. Several studies showed that there was no increased in the risk of ESRD development among LKD when compared to general population, but the risk may be slightly increased when compared to selected healthy control, & this increased risk could be explained by several factors as black race, obesity, & genetic origin of renal diseases. Muzzaale et al found that there was a small increase in the risk of ESRD development among LKD when compared matched healthy non donor( 90/10000 vs 14/10000), but the risk still lower when compared to general population. The increased risk in this study was found more among biologically related recipients, obese, old age & African-American donors. The risk of reducing GRF <30ml/min/m2 or ESRD was very low <1% . CVD was found to be lower among LKD when compared to healthy matched population & this may be due to extensive & thorough investigation pre-donation & close medical follow-up post donation. CVD including stroke is the leading cause of death in general population, but in donors it was found to be the second leading cause of death ( first leading cause was cancer) According to the OPTN data. Risk of ESRD in Live kidney Donors
There can be reduction in GFR after donation , however the risk of end stage renal disease remains similar too general population. The causes of ESRD in such Some studies have shown higher risk of ESRD in kidney donors as compared to general population. This may be the case in high risk donors like young Africans, pre diabetics and hypertensives. There is higher relative risk of ESRD in donors but absolute risk is low.
Risk of cardiovascular disease in kidney donors
As regards the risk of cardiovascular disease and death due to donation, there is still some controversy. There is slight higher risk of cardiovascular events as compared to normal subjects.
What are the measures taken to reduce this risk?
1- good donor seslection
2- close follow up & monitoring
3- prevent & treat risk factors ( weight reduction , bl.p,control , avoid smoking , alcohol )
Ahmed Omran
2 years ago
Post donation risks:
To what extent living donor nephrectomy influences risk of CVD still controversial.
Kidney donors have increased risk of need for treatment for hypertension as shown by 2 studies.
All-cause mortality, CVS mortality, and ESRD were found in kidney donors
There was a significant corresponding increase in cardiovascular death to 1.40 while the risk of ESRD was greatly and significantly increased to 11.38 .
Overall incidence of ESRD in donors was 302 cases per million; could be influenced by hereditary factors.
_Risk reduction:
Good donor selection with full evaluation of all risk factors for CVD ( DM, smoking, obesity, F/H of CVD or kidney disease)
Follow-up of donors for enough time with healthy life style and avoidance of CVD risk factors.
References: Philip Munch,Christian et al .Is the risk of cardiovascular disease increased in living kidney donors? A Danish population-based cohort study.October 2020 American Journal of TransplantationVolume 21, Issue 5 p. 1857-1865.
amiri elaf
2 years ago
Is donation associated with an increased risk of ESRD, cardiovascular disease or death? # Please substantiate your answer
*Decreased GFR in the general population is associated with an increased risk of adverse outcomes including ESRD, cardiovascular disease and death. This increase becomes apparent with a GFR between 60-75 mL/min/1.73m2 as compared to GFR >90 mL/min/1.73m2 and rises exponentially thereafter.
*The incidence of ESRD in living kidney donors appears to be similar to or lower than
that seen in the unselected general population despite a reduction in GFR.
* Muzaale compared the outcome of 96,000 kidney donors in the USA over a maximum follow-up of 15 years with matched healthy controls. The donor population was 75% white, 25% obese and 22% had a pre-donation eGFR <80 mL/min. The estimated risk of ESRD 15 years post-donation was 31 per 10,000 compared to 4 per 10,000 in matched controls.
*The increased risk was far greater in high risk donor populations such as African American donors.
*A second Norwegian study demonstrated a similar increased risk of ESRD after kidney donation.
*Donors may be reassured that the absolute increase life time risk of GFR <30 mL/min/1.73m2 or ESRD is very small (<1%) for the populations included in this
study. The absolute risk for young donors over a lifetime, particularly with additional
risk factors for ESRD is likely to be more significant.
*Additional adverse factors associated with an increased lifetime risk ESRD include:
Measured GFR just below the guideline threshold
Ethnic groups at higher risk (African Caribbean or South Asian origin
Hypertension, obesity and/or (pre) diabetes
*A recent US study showed that the risk of ESRD was greatest for younger patients of black ethnicity. The absolute increased lifetime risk of ESRD may be helpful in counselling potential donors with risk factors including those below threshold GFR. The data also support donation from some older donors who have additional risk factors such as hypertension but whose lifetime risk of ESRD is low.
*Three retrospective observational studies compared mortality among living kidney two studies revealed a lower risk of death in donors compared to healthy non-donors whilst the third study suggested a possible small increase.
*Garg et al conducted that the risk of death and cardiovascular events was lower and the risk of death-censored cardiovascular events was the same in the donors as compared with the healthy matched population. The quality of the evidence is considered poor, and there is no clear evidence that donation reduces long-term survival.
# What are the measures taken to reduce this risk?
Perfect evaluation and donor selection.
Counseling them about the risk factors of donation.
Choose the donors with good estimation of GFR according to the guideline.
Advice them about the healthy life style.
Regular follow up to detect any co morbidities accelerate the development of ESRD
BTS/RA Living Donor Kidney Transplantation Guidelines 2018
abosaeed mohamed
2 years ago
generally , there is low risk of ESRD in kidney donors , espicially with good donor selection when compared to general population .
this risk increased with younger , high BMI , smoking , black & donors are genetically related to the recipient ) .
the donor should be counselled & consented for this
What are the measures taken to reduce this risk?
1- good donor seslection
2- close follow up & monitoring
3- prevent & treat risk factors ( weight reduction , bl.p,control , avoid smoking , alcohol )
Hussam Juda
2 years ago
Is donation associated with an increased risk of ESRD, cardiovascular disease or death?
This may be different according to the length of the study, age of donor or ethnic group.
Long-term risks: Mortality and cardiovascular disease
· More than one study found that survival after living kidney donation is the same as for similar matched individuals who did not donate, at least over approximately 10 to 18 years [1-4], including one study of donors older than 55 years [5]
· One long-term study of more than 80,000 living kidney donors, the risk of death over a median 6.3 years of follow-up (maximum 12 years) was the same for kidney donors and demographically matched [6]
· In a study comparing 2028 living kidney donors in Ontario, Canada (1992 to 2009) with 20,280 healthy, demographically matched nondonors, the risk of death or major cardiovascular events over a median seven-year follow-up (maximum 18 years) was lower in donors than in healthy nondonors [7]. The risk of death-censored major cardiovascular events was similar among donors and nondonors
· But one study with longer follow-up (a median follow-up of 15 years, maximum 25 years) compared cardiovascular and all-cause mortality in 1901 kidney donors with a control group of 32,621 healthy, found that There was a significant increase in ESRD, cardiovascular, and all-cause mortality during long-term follow-up after living kidney donation [8]
Long-term risks: End-stage kidney disease
· When compared with well-matched, equally healthy controls, donor nephrectomy appears to increase the risk of end-stage kidney disease (ESKD), although the absolute risk is low [3,9,10].
· In one study, 1901 kidney donors were compared with 32,621 healthy, demographically matched controls from a population-based survey carried out in Norway between 1984 and 1987 (HUNT I) [8]. Compared with controls, the risk of ESKD was higher among donors.
-ESKD among the Norwegian donors was mostly due to immunologic diseases, so it is possible that the increase in risk of ESKD was related to genetically determined immunologic factors rather than the nephrectomy itself [11]
· A number of studies support that the risk of ESKD after kidney donation does not exceed the risk in the general population [12-13,14].
What are the measures taken to reduce this risk?
1. Good evaluation and selection of living donor candidates to reduce short and long term complications.
*To improve the evaluation and selection of living donor candidates, a KDIGO work group formulating guidelines for the “Evaluation and Care of Living Kidney Donors” collaborated with the Chronic Kidney Disease-Prognosis Consortium (CKD-PC) to conduct a meta-analysis combined with an analysis of the incidence of ESKD in a low-risk segment of the United States population to produce a comprehensive risk-prediction model for ESKD in the absence of donation based on data for nearly five million healthy persons [15]
2. Good estimation for GFR before donation, even with split renal function if needed
3. Closed follow-up for donor Bp, sugar, urine analysis, to diagnose early HTN or DM
Transplantation from a living donor is associated with shorter waiting time and longer graft survival compared with deceased donor transplantation; however, it also involves potential increased risks for the otherwise healthy donor associated with the surgery and long-term consequences of removal of a kidney. Reduced renal function is associated with cardiovascular disease (CVD); however, how living donor nephrectomy affects the risk of CVD remains controversial.
In the general population, reduced GFR and proteinuria are associated with cardiovascular disease (CVD), but it remains controversial if reduced renal function increases the risk of CVD in otherwise healthy kidney donors Kidney donors had an increased risk of initiating treatment for hypertension. two recently published studies identified increased risks of hypertension after living kidney donation.
single study with a median follow-up of 15 years showed a 40% increased cardiovascular mortality in kidney donors when compared with a cohort of self-proclaimed healthy individuals.
All-cause mortality, cardiovascular mortality, and end-stage renal disease (ESRD) was identified in 1901 individuals who donated a kidney during 1963 through 2007 with a median follow-up of 15.1 years. A control group of 32,621 potentially eligible kidney donors was selected, with a median follow-up of 24.9 years.
Hazard ratio for all-cause death was significantly increased to 1.30 for donors compared with controls. There was a significant corresponding increase in cardiovascular death to 1.40 while the risk of ESRD was greatly and significantly increased to 11.38 . The overall incidence of ESRD among donors was 302 cases per million and might have been influenced by hereditary factors. Immunological renal disease was the cause of ESRD in the donors.
What are the measures taken to reduce this risk?
Proper selection if donor with full evaluation of all risk factors for CVD (smoking, obesity, family history of CVD or kidney disease,)
Follow-up of donors for longer time with instruction about healthy life style and avoid risk factors for CVD
Long-term risks for kidney donorsGeir Mjøen et al. Kidney Int. 2014 Jul.
Eusha Ansary
2 years ago
There is risk of reduction in GFR after donation , however the risk of end stage renal disease remains similar to general population. Some studies have shown higher risk of ESRD in kidney donors as compared to general population. This may be due to the high risk donors like young Africans, pre diabetes and hypertensives. To treat or prevent all risk factors aggressively.
Zahid Nabi
2 years ago
Studies suggest that, beyond the perioperative period, survival after living kidney donation is the same as for similar matched individuals who did not donate, at least over approximately 10 to 18 years .However, long-term follow-up data are limited. In a study comparing 2028 living kidney donors in Ontario, Canada (1992 to 2009) with 20,280 healthy, demographically matched nondonors, the risk of death or major cardiovascular events over a median seven years follow-up (maximum 18 years) was lower in donors than in healthy nondonors (2.8 versus 4.1 events per 1000 person-years; hazard ratio [HR] 0.66, 95% CI 0.48-0.90).up to date. This shows that data is bit conflicting but we can say that apparently there is no increased risk.
ESRD RISK
When compared with well-matched, equally healthy controls, donor nephrectomy appears to increase the risk of end-stage kidney disease (ESKD), although the absolute risk is low Consistent with recommendations of a 2015 American Society of Transplantation (AST) consensus statement and Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guidelines , OPTN policy requires informing donor candidates that the risk of ESKD after donation may exceed that of healthy nondonors with medical characteristics similar to living kidney donors
Donor selection is very important. To minimize the risk we have to select the appropriate donors Non smoker Non obese Not hypertensive Not diabetic Not hypercholestermic No albuminuria
Ajay Kumar Sharma
Admin
2 years ago
Many thanks Dr Manal Malik, Dr Sahar, Dr F Batista, and Dr Fakhriya Alalawi,
Let us move to week 4.
Ajay
Sahar elkharraz
2 years ago
The best option for ESRD is kidney transplant from deceased or living donor; because of increase waiting list for transplant from deceased donor the number of living donation increase among transplant and most of them are family members in first relative degree; So due to genetic distribution and role of immunological risk to develop ESRD to donated persons on long term.
Recent studies shows an increased relative risk of ESRD after kidney donation, the absolute risk for ESRD is still less than 0.5% at 15 years and 0.9% for lifetime risk compared to 3.2% for the general
Long-term studies of living kidney donors have reported low rates of mortality and ESRD in a national study of living kidney donors in the United States, we previously estimated overall ESRD risk to donors at 31 ESRD cases per 10,000 living kidney donors in the first 15 years postdonation.
Two large cohort studies of individuals who did donate recently reported higher risk of ESRD in living kidney donors compared with healthy nondonors.
Risk of ESRD in donation more in male, black, old age and BMI high and donor who are first degree relative to their recipient.
living kidney donation may be associated with increased risk of hypertension and initiation of anti hypertension medication; however, in this study not identify increased risks of CVD or death.
What are the measures taken to reduce this risk?
Proper selection of donor to avoid risk of ESRD and should inform donor regarding risk factors of ESRD and hypertension especially first degree relative and annually fallow up with control weight and blood pressure and blood sugar and hyperlipidemia to avoid risk of cardiovascular disease
References:
Allan B. Massie, Abimereki D. Muzaale, Xun Luo, Eric K.H. Chow, Jayme E. Locke, Anh Q. Nguyen, Macey L. Henderson, Jon J. Snyder and Dorry L. Segev: Quantifying Postdonation Risk of ESRD in Living Kidney Donors
Philip Munch, et al. : Is the risk of cardiovascular disease increased in living kidney donors? A Danish population-based cohort studyTransplant. Am J 2021 May.
Filipe Prohaska Batista
2 years ago
The issue of loss of donor function for the general population is very controversial. Most studies make comparisons with the general population, but the potential donor must be in good health and meet a series of goals to be eligible for the procedure. Another difficulty is the long-term follow-up of both groups, to understand the real impact on this specific group and on a control that was so well selected.
Pre-transplant counseling is crucial to understand the risks involved in living with only one kidney and the necessary care, especially blood pressure control, food (dyslipidemia), avoiding smoking, obesity and other situations with important metabolic changes.
Manal Malik
2 years ago
Please substantiate your answer
there are controversial regarding ,as some studies suggested that living kidney donors maintain long term renal function and experience no increase in CVS or cause mortality or ESRD, however there was study for 1901 individual who donate kidney during 1903 -to 2007 with follow up 24 years with control group 32,621 there was significant increase in CVS death while the risk of ESRD was greately and significant increase to 11.38 .might influence by heredatory factors
2-What are the measures taken to reduce this risk?
detect and treat HTN early ,all measurement decrese CVS should be applied such as quit smoking,treat any hyper lipdemi
169. 2. Middleton PF, Duffield M, Lynch SV et al. Living donor liver transplantation—adult donor outcomes: a systematic review. Liver Transpl 2006; 12: 24–30
fakhriya Alalawi
2 years ago
In a study analysis by Kiberd BA et al, showed that 1%–5% of average-age current live kidney donors might develop ESRD because of nephrectomy. The added risk of ESRD resulted in a loss of only 0.126–0.344 remaining life years. Most of the loss of life was predicted to be associated with chronic kidney disease (CKD) not ESRD. Most events occurred 25 or more years after donation. Reducing the increased risk of death associated with CKD had a modest overall effect on the per cent loss of remaining life years (0.72%–1.9%) and QALYs (0.58%–1.33%).
On the other hand, a recent meta-analysis of four studies published between 2009 and 2016 with a total of 4274 donors and 53 246 controls, and an average follow-up time ranging from 6 to 15 years, found no evidence of an increase in cardiovascular risk in donors [pooled-adjusted RR 1.11 (95% CI 0.64–1.70)].
Similarly in other studies involving kidney donors, the usual decline over time in GFR does not appear to happen. For example, in a prospective study of 203 donors and 205 carefully selected controls, donors did not experience any further decline in iohexol-measured GFR from 6 months to 9 years post-donation, whereas the GFR in controls declined by an average of 1.26 mL/min/1.73 m2 per year. Albuminuria did not increase in donors over this 9-year period either. Similar findings were also observed in a 5-year prospective study of kidney donors using isotopic GFR to measure renal function. In 48 donors studied 5 years post-donation, there had been no further decline in either eGFR or isotopically measured eGFR in donors, whereas the 45 healthy controls had an annual mean reduction in eGFR of 1 ± 2 mL/min/1.73 m2.
What are the measures taken to reduce this risk? To treat all risk factors aggressively to prevent ESRD and to improve donor survival.
References:
1. Kiberd BA, Tennankore KK. Lifetime risks of kidney donation: a medical decision analysis. BMJ Open. 2017 Sep 1;7(8):e016490. doi: 10.1136/bmjopen-2017-016490. PMID: 28864484; PMCID: PMC5588992.
2. O’Keeffe LM, Ramond A, Oliver-Williams C, Willeit P, Paige E, Trotter P, Evans J, Wadström J, Nicholson M, Collett D, Di Angelantonio E. Mid-and long-term health risks in living kidney donors: a systematic review and meta-analysis. Annals of internal medicine. 2018 Feb 20;168(4):276-84.
3. Ferro CJ, Townend JN. Risk for subsequent hypertension and cardiovascular disease after living kidney donation: is it clinically relevant?. Clinical Kidney Journal. 2022 Apr;15(4):644-56.
Huda Saadeddin
2 years ago
ESRD
Kidney donors have lower long-term risk of ESRD compared to the general population. This has been attributed to the careful screening process that excludes candidates with pre-existing conditions from donation. However, two recent studies, one from Norway and one from the United States, examined ESRD risks for living donors compared to healthy non-donors (not the general population) (1,2). Consistent with prior studies, a low absolute risk of ESRD (< 0.5% at 15 years post kidney donation and the lifetime risk estimated at 0.9%) was reported (2). While the relative risk of ESRD in donors was less than the general population, donors have a relative risk of ESRD of between 8 to 11 times compared to healthy non-donors. All of the donors with ESRD in the Norwegian study were family members of the recipients, and most developed immune-mediated renal disease. Despite their limitations (3-6), these studies provide the best information to date on donor risks
—————————————————————-
During long-term follow-up of kidney donors, we found an increased risk of ischaemic heart disease compared with healthy controls. This information may be important in the follow-up and selection process of living kidney donors.
——————-
However, long-term death rates did not exceed rates of matched control subjects from the National Health and Nutrition
Donor nephrectomy does not appear to increase long-term mortality compared with controls
———-
What are the measures taken to reduce this risk?
Addressing Traditional risk factors: immutable (age, gender, inheritance), variable (smoking, hyperlipidemia, hypertension, obesity, diabetes mellitus, physical activity, stress).
MDT for selection of suitable donor
Annual follow up
Careful treatment of any comorbedities following renal donation according to recent guidelines
Reference
JOURNAL ARTICLE
Increased risk of ischaemic heart disease after kidney donation
Anders J Haugen, Stein Hallan, Nina E Langberg, Dag Olav Dahle, Hege Pihlstrøm, Kåre I Birkeland, Anna V Reisæter, Karsten Midtvedt, Anders Hartmann, Hallvard Holdaas … Show more
Nephrology Dialysis Transplantation, Volume 37, Issue 5, May 2022, Pages 928–936, https://doi.org/10.1093/ndt/gfab054
Long-term risks for kidney donors
Author links open overlay panel
GeirMjøen1SteinHallan23AndersHartmann1AkselFoss1KarstenMidtvedt1OleØyen1AnnaReisæter1PerPfeffer1TrondJenssen1TorbjørnLeivestad4Pål- DagLine1MagnusØvrehus2Dag OlavDale1HegePihlstrøm1IngarHolme5Friedo W.Dekker6HallvardHoldaas1
Risks and Outcomes of Living Donation
Krista L. Lentine, MD, MS and Anita Patel, MD
Additional article information
Mohamed Fouad
2 years ago
Is donation associated with an increased risk of ESRD, cardiovascular disease or death?
Basically, living donor kidney transplantation is the preferred treatment for ESRD patients, because it is associated with improved graft and patient survival compared with transplantation from a deceased donors.
A lot of studies tried to explore the risk of kidney donation. Previous studies have suggested that living kidney donors maintain long-term renal function and experience no increase in cardiovascular or all-cause mortality. However, most analyses have included control groups less healthy than the living donor population and have had relatively short follow-up periods.
one of the recent studies is Long-term risks for kidney donors: compared long-term renal function, cardiovascular and all-cause mortality in living kidney donors compared with a control group of individuals who are eligible for kidney donation. All-cause mortality, cardiovascular mortality, and end-stage renal disease (ESRD) was identified in 1901 individuals who donated a kidney during 1963 through 2007 with a median follow-up time of 15.1 years. A control group of 32,621 potentially eligible kidney donors was selected, with a median follow-up time of 24.9 years. Hazard ratio for all-cause death was significantly increased to 1.30 for donors compared with controls. There was a significant corresponding increase in cardiovascular death to 1.40 (1.03–1.91), while the risk of ESRD was greatly and significantly increased to 11.38 (4.37–29.6). The overall incidence of ESRD among donors was 302 cases per million. Immunological renal disease was the cause of ESRD in the donors. So, kidney donors are at increased long-term risk for ESRD, cardiovascular, and all-cause mortality compared with a control group of non-donors who are eligible for kidney donation.
The risk of perioperative mortality during organ retrieval from living donors have been estimated to occur in 0.03% of kidney donors.
Kidney International (2014) 86, 162–167; doi:10.1038/ki.2013.460;
published online 27 November 2013
Ban Mezher
2 years ago
A major concern post renal donation is the development of ESRD. Several studies showed that there was no increased in the risk of ESRD development among LKD when compared to general population, but the risk may be slightly increased when compared to selected healthy control, & this increased risk could be explained by several factors as black race, obesity, & genetic origin of renal diseases.
Muzzaale et al found that there was a small increase in the risk of ESRD development among LKD when compared matched healthy non donor( 90/10000 vs 14/10000), but the risk still lower when compared to general population. The increased risk in this study was found more among biologically related recipients, obese, old age & African-American donors. The risk of reducing GRF <30ml/min/m2 or ESRD was very low <1%
.
CVD was found to be lower among LKD when compared to healthy matched population & this may be due to extensive & thorough investigation pre-donation & close medical follow-up post donation. CVD including stroke is the leading cause of death in general population, but in donors it was found to be the second leading cause of death ( first leading cause was cancer) According to the OPTN data.
Long term mortality post donation found to be not increased when the donors followed for 12 years, with comparable life span to general population.
Measures to reduce the risk include:
Proper selection of potential donors.
Informed the donor about the risk of donation
Encourage healthy life style ( e.g. exercise, no smoking).
Regular medical follow-up
References:
Muzzaale A., Massie A., Wang M., Montgomery R., McBride M., et al. Risk of End Stage Renal Disease Following Live Kidney Donation. JAMA, 2014; 311(6): 579-586.
BTS. 4th edition. 2018.
Lentine K., and Patel A. Risks and Outcomes of Living Donation. Adv.Chronic Kidney Dis.2012;19(4): 220-228.
Matas A., Berglund D., Fock D. and Ibrahim H. Causes and timing of end stage renal disease after living kidney donation. Am.J.Transplant.2018;18:1140-1150.
Asmaa Khudhur
2 years ago
An increased risk of adverse outcomes including ESRD, cardiovascular disease and death associated withDecreased GFR in the general population.
This increase becomes apparent with a GFR between 60-75 mL/min/1.73m2 as compared to GFR >90 mL/min/1.73m2 and rises exponentially thereafter .
The incidence of ESRD in living kidney donors appears to be similar to or lower than that seen in the unselected general population despite a reduction in GFR .This is reassuring but not unexpected.
Nephrologist are faced with advising potential donors how to deals when they have extra adverse factors associated with an increased lifetime risk ESRD.
Factors and compounding risks include:
1-Measured GFR just below the guideline threshold
2-Ethnic groups at higher risk (African Caribbean or South Asian origin
3-Hypertension, obesity and/or (pre) diabetes
The risk was higher for blacks compared with Caucasians and in men compared with women. The risk of ESRD was greatest for younger patients of black ethnicity. The absolute increased lifetime risk of ESRD may be helpful in counselling potential donors with risk factors including those below threshold GFR as defined above. The data also support donation from some older donors who have additional risk factors such as hypertension but whose lifetime risk of ESRD is low.
Three retrospective observational studies compared mortality among living kidney donors in comparison with healthy non-donors.these studies shows that The risk of death and cardiovascular events was lower and the risk of death-censored cardiovascular events was the same in the donors as compared with the healthy matched population. The quality of the evidence is considered poor. There is no clear evidence that donation reduces long-term survival .
Reference
BTS
Studies have shown that kidney donation is related to the possibility of increased proteinuria, but this is not directly related to these events. However, the same studies showed that the environmental situations that lead to these events have a greater impact on the post-transplant donor.
It is necessary that the donor has healthy life habits, avoiding risk situations such as: Hypertension, diabetes, obesity and smoking. It is these risk situations that start to increase the risks of ESRD, cardiovascular disease and death.
-living kidney donation still carries a risk of ESKD, Hypertension, increased protinuria with hyperfilteration injury after native nephrectomy. However, giving a kidney means giving a life.
– good selection of the donor and avoidance of diabetic and obese donors together with counseling about keeping healthy life style can preserve the kidney function and avoid post donation complications.
In a study done by Hassan N. Ibrahim and others evaluating the long term consequences of kidney donation from November 1963 through December 2007, a total of 3698 nephroctomies in living donors were performed at the university of Minnesota.
They found that the survival of kidney donors was similar to that of controls who were matched for age, sex, and race or ethnic group. ESRD developed in 11 donors, a rate of 180 cases per million persons per year, as compared with a rate of 268 per million per year in the general population. At a mean (±SD) of 12.2±9.2 years after donation, 85.5% of the subgroup of 255 donors had a GFR of 60 ml per minute per 1.73 m2 of body surface area or higher, 32.1% had hypertension, and 12.7% had albuminuria. Older
age and higher body-mass index, but not a longer time since donation, were associated
with both a GFR that was lower than 60 ml per minute per 1.73 m2 and hypertension.
A longer time since donation, however, was independently associated with
albuminuria. Most donors had quality-of-life scores that were better than population
norms, and the prevalence of coexisting conditions was similar to that among controls
from the National Health and Nutrition Examination Survey (NHANES) who
were matched for age, sex, race or ethnic group, and body-mass index.
Conclusions:
Survival and the risk of ESRD in carefully screened kidney donors appear to be similar to those in the general population. Most donors who were studied had a preserved GFR, normal albumin excretion, and an excellent quality of life.
Regarding Donor ESKD :
The prevalence of end stage kidney disease in live kidney donors appears to be equivalent to or lesser than that found in the random general population, despite a drop in glomerular filtration rate .
Over 15 years of follow-up, Muzaale evaluated the consequences of 96,000 renal donors who were matched with healthy controls . End-stage renal disease was expected to have a risk of 31/10000 15 years following donation, versus to 4 per 10,000 in matched non-donor groups .
The expected lifetime risk of end stage kidney disease among donors was Ninety per 10,000, in the general public it was 326 per 10,000, and in healthy matched controls it was fourteen per 10,000(22).
ESRD is thought to occur less frequently in kidney donors than in the general population. Compared to matched controls, the donors’ chance of having ESRD was much higher as considering that the vast bulk of donors were blood relatives, genetic factors may be a possible reason for the elevated risk in donors. Renal disease is more common in relatives of patients with chronic kidney disease, as is well known .
Regarding donor’s mortality:
Three retrospective observational studies examined the mortality of healthy non-donors with living kidney donors . A decreased risk of death was found in donors compared to healthy non-donors in two studies while a possibly little increase was shown by the third study
On the other hand, Norwgian study 224 (out of 1901) kidney donors were died over the observation period, 68 (30.4%) of which were caused by cardiovascular disease. Among the 32,621 controls, there were 2425 deaths, 688 (28.4%) of which were caused by cardiovascular disease. No donors recently died during or immediately following the operation .
According to numerous studies, elevated blood pressure,albuminuria impaired renal function after nephrectomy in kidney donors are linked to a higher cause of cardiovascular mortality
Cardiovascular evaluation before donation serves two objectives. First, it identifies potential donors who may not be a good match for donation because they have a greater than normal risk of peri-operative problems. Second, it offers a chance to evaluate a donor’s cardiovascular risk factors, take into account kidney donation’s long-term consequences, and take steps to slow the advancement of heart illness.
Recommendations:
There is no evidence to support the routine use of stress testing in the assessment of the potential donor at low cardiac risk
Potential kidney donors with a history of cardiovascular disease, an exercise capacity of of <4 metabolic equivalents (METS) or with risk factors for cardiovascular disease should undergo further evaluation before donation
Stress testing is advised for prospective donors who pose a higher risk using any locally available technique or CT calcium scoring
References :
Segev DL, Muzaale AD, Caffo BS, et al. Perioperative mortality and long-term survival following live kidney donation. JAMA 2010; 303: 959-66.
Muzaale AD, Massie AB, Wang MC, et al. Risk of end-stage renal disease following live kidney donation. JAMA 2014; 311: 579-86.
Please substantiate your answer
The answer is that it depends on the risk factors already present in the donor as HTN , DM , CVS events and even if no risk factors in the donor , still there is a risk of CVS events and ESKD
Risk of ESRD in kidney donors:
Overall risk of ESKD in kidney donors is less than 1% . Yet , risk may be higher in young , African Americans.
Studies have shown that kidney donors have increased risk of ESRD as compared to
Risk of Cardiovascular disease in kidney donors:
Different studies on the issue of CVS disease in kidney donors yet CVS complications is very rare and most studies showed no difference in donors vs non donors.
What are the measures taken to reduce this risk?
Donor selection , correction of risk factors involving control of DM , HTN , body weight and life style modifications , as well as renal function tests including urea, creatinine, urine analysis and proteinuria.
The National Kidney Foundation, based on several studies stated that the life expectancy will not change after living donation. Though one of the studies by kiberd BA 2017 reported that donation will reduce life expectancy by 0.5-1 year. This could be due to the long-term consequences. Which can be preventable by maintaining the healthy life style.
However, perioperative complication the patient may encounter injury to surrounding tissue or other organs, and even death are all.
However, in the current era the kidney transplant surgeries are becoming more common hence surgical techniques are advancing and the risks involved with living donation continue to decrease.
With regard to the complication as a consequence of kidney donation there might be a long-term risks including proteinuria and hypertension.
A meta-analysis using 48 studies , 5048 donors, were analyzed and looked at proteinuria, or glomerular filtration rate (GFR) post kidney donation, The authors came to the conclusion that kidney donation causes minor increases in urinary protein. GFR decreased initially, but this was not followed by accelerated losses over the next 15 years. AX Garg. (2006).
The donor is at higher risk if he develop high blood pressure, especially if the donor is old in age or obese or he is African American or Hispanic descent as reported by Ibrahim HN and colleagues in (2009). A metanalysis taking in to account 48 number of studies reported using 5145 donors that a rise of 5mm Hg in BP within 5 years after donation as compared to the anticipated BP with normal aging, however these were only after 5 years of follow ups , it might require longer time to look at the risk and long term morbidity. Boudville N et al (2006).
However, the risk of diabetes post donation is similar to general population with similar risk factors such as increasing weight. This considered another factor which could subsequently results in approaching ESRD.
It is found by Ibrahim HN and his colleagues that the donors who develop diabetes post donation will have higher rate of albuminuria than those nondiabetic donors, they attributed this to development of early diabetic kidney disease. However, they did not exhibit an increased risk of progressive kidney disease in the first decade of diabetes.
The authors emphasized on the fact that all kidney donors, particularly those with a positive family history for diabetes, should be strongly advised to maintain weight control. (Ibrahim et al 2010).
Based on a few articles, such as Ibrahim HN et al 2009, muzaale AD et al 2014, and kiberd BA et al 2017, there have been isolated reports of patients developing kidney failure after donation.
Mjoen G et al 2014 confirmed that donors have higher long-term risks for ESRD, cardiovascular disease, and all-cause mortality when compared to a control group of non-donors who would have been eligible for donation.
The donor should be counselled regarding few points which will reduce the risk of developing the above mentioned complications, these measures are:
Avoiding Smoking and drinking alcohol as both can delay the recovery after the operation. It’s recommended to avoid smoking and drinking for at least the first several weeks after surgery. living a healthy lifestyle and protecting the remaining kidney. subsequently reducing cardiovascular risk as well.
The donor can live with a single kidney, as normal population, the other kidney will compensate and the kidney function (GFR) will improve gradually. Hence kidney donors can live a normal life after donation. However, he has to maintain healthy life style to avoid complications or subsequent adverse effect. Hence, he has to maintain the kidney functions by avoiding nephrotoxics such as NSAIDS and maintains weight, avoiding gaining excess weight and smoking.
There is an increase in the long-term risk of ESRD, cardiovascular disease, and mortality after donation, as stated below:
Measures to reduce risk post-donation:
References:
Donation and ESRD
Kidney donors have lower long-term risk of ESRD compared to the general population. This has been attributed to the careful screening process that excludes candidates with pre-existing conditions from donation. However, two recent studies, one from Norway and one from the United States, examined ESRD risks for living donors compared to healthy non-donors (not the general population) (1,2). Consistent with prior studies, a low absolute risk of ESRD (< 0.5% at 15 years post kidney donation and the lifetime risk estimated at 0.9%) was reported (2). While the relative risk of ESRD in donors was less than the general population, donors have a relative risk of ESRD of between 8 to 11 times compared to healthy non-donors. All of the donors with ESRD in the Norwegian study were family members of the recipients, and most developed immune-mediated renal disease. Despite their limitations (3-6), these studies provide the best information to date on donor risks. A risk calculator has recently been developed for use in counseling potential kidney donors. Demographic and health characteristics may now be used to estimate the projected longterm pre-donation risk of ESRD in donor candidates. A post donation calculator is not available (7) .
Donation and cardiovascular disease
A retrospective population based matched cohort study in the province of Ontario, Canada, between 1992 and 2009 was done on 2028 donors and 20 280 matched non-donors followed for a median of 6.5 years .The risk of the primary outcome of death and major cardiovascular events was lower in donors than in non-donors (2.8 v 4.1 events per 1000 person years; hazard ratio 0.66, 95% confidence interval 0.48 to 0.90). The risk of major cardiovascular events censored for death was no different in donors than in non-donors (1.7 v 2.0 events per 1000 person years; 0.85, 0.57 to 1.27). Results were similar in all sensitivity analyses. Older age and lower income were associated with a higher risk of death and major cardiovascular events in both donors and non-donors when each group was analysed separately. The risk of major cardiovascular events in donors is no higher in the first decade after kidney donation compared with a similarly healthy segment of the general population. (8)
Donation and death
Kidney donor surgery has a 007% mortality rate, which means that on average, for every 100,000 living donor
surgeries, seven donors die.(9) A study of all first kidney-only transplant recipients from 1980 through 2018 from the Australia and New Zealand Dialysis and Transplant Registry. Of 23,210 recipients, 4765 died with a functioning graft. Risk of death declined over successive eras, at all periods post-transplant. Reductions in early deaths were most marked; however, recipients ≥10 years post-transplant were 20% less likely to die in the current era compared with preceding eras (2015–2018 versus 2005–2009, adjusted hazard ratio, 0.80; 95% confidence interval, 0.69 to 0.90). In 2015–2018, cardiovascular disease was the most common cause of death, particularly in months 0–3 post-transplant (1.18 per 100 patient-years). Cancer deaths were rare early post-transplant, but frequent at later time points (0.93 per 100 patient-years ≥10 years post-transplant). Among 3657 patients with first graft loss, 2472 died and were not retransplanted. Death was common in the first year after graft failure, and the cause was most commonly cardiovascular (50%).(10)
Ref:
1.Mjoen G, Hallan S, Hartmann A, Foss A, Midtvedt K, Oyen O, et al. Long-term risks for kidney donors. Kidney international. 2014 Jul;86(1):162-7. PubMed PMID: 24284516.
2.Muzaale AD, Massie AB, Wang MC, Montgomery RA, McBride MA, Wainright JL, et al. Risk of end-stage renal disease following live kidney donation. JAMA : the journal of the American Medical Association. 2014 Feb 12;311(6):579-86. PubMed PMID: 24519297.
3.Lam NN, Lentine KL, Garg AX. End-stage renal disease risk in live kidney donors: what have we learned from two recent studies? Current opinion in nephrology and hypertension. 2014 Nov;23(6):592-6. PubMed PMID: 25160076. Pubmed Central PMCID: 4189686.
4.Kasiske BL. Outcomes after living kidney donation: what we still need to know and why. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2014 Sep;64(3):335-7. PubMed PMID: 24797521.
5. Gill JS, Tonelli M. Understanding rare adverse outcomes following living kidney donation. JAMA : the journal of the American Medical Association. 2014 Feb 12;311(6):577-9. PubMed PMID: 24519296.
6.Matas AJ, Wadstrom J, Ibrahim HN. Kidney donation and risk of ESRD. JAMA : the journal of the American Medical Association. 2014 Jul 2;312(1):92-3. PubMed PMID: 25058223.
7. http://www.transplantmodels.com/esrdrisk/
8.Garg A X, Meirambayeva A, Huang A, Kim J, Prasad G V R, Knoll G et al. Cardiovascular disease in kidney donors: matched cohort study BMJ 2012; 344 :e1203 doi:10.1136/bmj.e1203
9. Kidney Donation Risks – Donor Care Network,www.donorcarenet.org › Education
10.Death after Kidney Transplantation: An Analysis by Era and Time Post-Transplant
Tracey Ying, Bree Shi, Patrick J. Kelly, Helen Pilmore, Philip A. Clayton, Steven J. Chadban
JASN Dec 2020, 31 (12) 2887-2899; DOI: 10.1681/ASN.2020050566
kidney donors are at increased long-term risk for ESRD, cardiovascular, and all-cause mortality.
Donor nephrectomy is associated with increased risk of end stage renal disease in comparison with well-matched healthy non donors, but the absolute risk is low.
A study compared a cohort of 96,217 kidney donors in the USA in the period (1994 to 2011) with participants of the Third National Health and Nutrition Examination Survey (NHANES III) showed that estimated risk of ESRD at 15 years after donation was 30.8 per 10,000 in kidney donors and 3.9 per 10,000 in well matched healthy non-donor (P < .001). but the absolute risk is small.
Muzaale AD, Massie AB, Wang MC, Montgomery RA, McBride MA, Wainright JL, Segev DL. Risk of end-stage renal disease following live kidney donation. JAMA. 2014 Feb 12;311(6):579-86.
Cardiovascular risk and death
All-cause mortality, cardiovascular mortality, and end-stage renal disease (ESRD) was identified in 1901 individuals who donated a kidney during 1963 through 2007 with a median follow-up of 15.1 years. A control group of 32,621 potentially eligible kidney donors was selected, with a median follow-up of 24.9 years. Hazard ratio for all-cause death was significantly increased to 1.30 (95% confidence interval 1.11-1.52) for donors compared with controls. There was a significant corresponding increase in cardiovascular death to 1.40 (1.03-1.91), while the risk of ESRD was greatly and significantly increased to 11.38 (4.37-29.6). The overall incidence of ESRD among donors was 302 cases per million and might have been influenced by hereditary factors. Immunological renal disease was the cause of ESRD in the donors. Thus, kidney donors are at increasedlong-term risk for ESRD, cardiovascular, and all-cause mortality compared with a control group of non-donors who would have been eligible for donation.
Mjøen G, Hallan S, Hartmann A et al.,Long-term risks for kidney donors.Kidney Int. 2014;86(1):162.
Donors should be counseled in detail about the long term increase risk of ESRD by 0.5% as quoted by Muzaale AD et al and 11.38 times increase risk as mentioned by Mjen G et al in 2014. Black race, young age, male sex, high BMI and a family history of renal disease if present can further add on the risk of ESRD. Various calculators are present which can help in predicting lifetime risk of ESRD.
There is controversial data available in estimating cardiovascular risks and mortality post donation .Majority of the studies have revealed similar risk in donors and healthy non-donors. Few studies have contrary results .According to Segev DL, et al , cardiovascular events(MI and arrhythmia) or PE are responsible for perioperative mortality and it accounts for 3.1 in 10,000 .Few studies revealed increase urinary protein ,hypertension and reduce GFR are the risk factors which in the long term can increase cardiovascular morbidity and mortality. There are also chances of ischemic heart disease after donation according to one study .Another study stated 40% increase in cardiovascular mortality and post-transplant hypertension after a follow up of 15 years.
Multidisciplinary team should always be involved in careful assessment of kidney donors in order to reduce the risks .Patient’s GFR should be properly assessed as per guidelines for age and gender and risk factors lie obesity, hypertension ,young age and ethnicity also to be considered and counseled to adopt healthy lifestyle ,stop smoking ,exercise regularly and avoid nephrotoxic medications post donation with regularly monitoring of renal function test, blood pressure ,proteinuria.
REFERENCES:
1-Mjøen G, Hallan S, Hartmann A, Foss A, Midtvedt K, Øyen O, Reisæter A, Pfeffer P, Jenssen T, Leivestad T, Line PD, Øvrehus M, Dale DO, Pihlstrøm H, Holme I, Dekker FW, Holdaas H. Long-term risks for kidney donors. Kidney Int. 2014 Jul;86(1):162-7. doi: 10.1038/ki.2013.460. Epub 2013 Nov 27. PMID: 24284516.
2-Muzaale AD, Massie AB, Wang MC, et al. Risk of end-stage renal diseasefollowing live kidney donation. JAMA 2014; 311: 579-86
3-Lam NN, Lentine KL, Levey AS, Kasiske BL, Garg AX. Long-term medical risks to the living kidney donor. Nat Rev Nephrol. 2015 Jul;11(7):411-9. doi: 10.1038/nrneph.2015.58. Epub 2015 May 5. PMID: 25941060
4-Segev L et al. Perioperative Mortality and Long-term Survival Following Live Kidney Donation. JAMA, March 10, 2010—Vol 303, No. 10
living kidney donors considers the best source of organs that afford the best results regarding graft survival but still, we expose healthy individuals to the risk of operation and post-operative complications. in general population, decrease GFR and proteinuria are independent risk factors for cardiovascular disease but in kidney donors still have controversy. Donors are not like the general population as donors are healthy individuals has no risk factors like diabetes and hypertension. a single study showed an increase in CVD in kidney donors by 40% after 25y follow-ups in comparison to paired healthy individuals.
regarding the risk of ESRD also when compare donors with paired healthy individuals showed an increased risk of 8% and 11% after 15y and 25y of follow up respectively
better evaluation and counseling preoperative and regular follow-up post-donation
Reference:
Philip Munch,Christian Fynbo Christiansen,Henrik Birn,Christian Erikstrup,Mette Nørgaard.Is the risk of cardiovascular disease increased in living kidney donors? A Danish population-based cohort study.October 2020
American Journal of TransplantationVolume 21, Issue 5 p. 1857-1865.
Long-term risks for kidney donorsGeir Mjøen et al. Kidney Int. 2014 Jul.
Is donation associated with an increased risk of ESRD, cardiovascular disease or death?
· The risk of end-stage renal disease (ESRD) after the donation is no higher than that of the general population. However, there is a very small absolute increased lifetime risk of ESRD following donation for which the potential donor must be counselled. (D2). (1)
· Studies suggest that living kidney donors are at increased risk of developing end-stage renal disease relative to healthy nondonors, but the 15-year cumulative incidence remains <1%.
· All-cause mortality in the first decade after nephrectomy seems to be lower or no different among donors than among healthy nondonors; one study suggests that over 25 years, the incidence might increase by 5%. In the first decade after donation, the risk of all-cause mortality and cardiovascular events is no higher than in healthy nondonors. The risk of death-censored major cardiovascular events was similar among donors and nondonors. (2,3)
What are the measures taken to reduce this risk?
Careful selection of the donors, with special post- and perioperative care, and good follow-up after donation.
Good counselling of the donor with lifestyle modification (regular exercise, maintaining ideal body weight, smoking cessation)
Future studies must clarify the lifetime incidence of long-term outcomes, particularly in relation to a donor’s age, race, and history of comorbidities. (1,2)
References:
1. Association BTS. Guidelines for Living Donor Kidney Transplantation, Fourth Edition. Accessed from https//bts.org.uk/wp-content/uploads/2018/07/FINAL_LDKT-guidelines_June-2018.pdf 2/10/2020. 2018;(March).
2. Lam NN, Lentine KL, Levey AS, Kasiske BL, Garg AX. Long-term medical risks to the living kidney donor. Nat Rev Nephrol [Internet]. 2015;11(7):411–9. Available from: https://doi.org/10.1038/nrneph.2015.58
3. Lentine KL, Segev DL. Understanding and Communicating Medical Risks for Living Kidney Donors: A Matter of Perspective. J Am Soc Nephrol [Internet]. 2017 Jan 1;28(1):12 LP – 24. Available from: http://jasn.asnjournals.org/content/28/1/12.abstract
3. Is donation associated with an increased risk of ESRD, cardiovascular disease or death?
Please substantiate your answer
The risk of ESRD in renal living donors is higher than healthy non-donors, however the incidence was less than 1% after 15 years according to Lam et al 2015 and Muzaale et al 2013. it was higher in young African American donors. The relative risk to develop ESRD in donors was high but the absolute risk was low. Risk factors in donors that might precipitate ESRD include: African American/south Asian ethinicity, Hypertension, DM, and obesity. , other studies showed similar results between both groups. 1
Cardiovascular mortality risk is 40% higher in donors compared to healthy non-donors. 2
All cause mortality is similar between donors and healthy non donors within 10 years of follow up. However, after 25 years it has increased by 5 % higher in the donor group.
What are the measures taken to reduce this risk?
1- Selection of donors.
2- Post-operative care, prevent and manage complications.
3- Life style: Diet, Exercise, Weight reduction and smoking cessation.
4- Follow up and tight control for Hypertension, blood sugar, renal function, and proteinuria.
References:
1) Lam NN, Lentine KL, Levey AS, Kasiske BL, Garg AX. Long-term medical risks to the living kidney donor. Nat Rev Nephrol. 2015 Jul;11(7):411-9. doi: 10.1038/nrneph.2015.58. Epub 2015 May 5. PMID: 25941060.
2) Muzaale AD, Massie AB, Wang MC, Montgomery RA, McBride MA, Wainright JL, Segev DL. Risk of end-stage renal disease following live kidney donation. JAMA. 2014 Feb 12;311(6):579-86. doi: 10.1001/jama.2013.285141. PMID: 24519297; PMCID: PMC4411956.
donation. JAMA. 2010 Mar 10;303(10):959-66. doi: 10.1001/jama.2010.237. PMID: 20215610.
3) British Transplantation Society. Renal Association Guidelines for Living Donor Kidney Transplantation, 4th ed.; British Transplantation Society: Macclesfield, UK, 2018; Available online: https//bts.org.uk/wp-content/uploads/2018/07/FINAL_LDKT-guidelines_June-2018.pdf (accessed on 14 September 2022).
Risks of ESRD
ESRD is more common in donors compared to non-donors. Risk factors include black race, young age, male sex, high BMI and a family history of renal disease. Muzaale AD et al confirmed that donation can increase the risk of ESRD by 0.5% compared to the general population but Mjen G et al in a long term follow-up confirmed an 11.38 times increase in the risk of ESRD more than the control population eligible for donation, but mostly due to immunological causes. Therefore, donors need to be counseled and consented for these potential risks and risk calculators are available to predict life-time risk to ESRD.
Mortality Risk:
Donation may decrease life by 0.5-1 year and lifestyle modification including weight reduction, smoking cessation may alter this outcome. Segev DL, et al stated that the perioperative mortality was 3.1 in 10,000 and this is mainly attributed to cardiovascular events(MI and arrhythmia) or PE, however, there was no significant difference in the long term mortality between donors and the general population. On the contrary, Mjen G et al in a long term follow-up confirmed increased all-cause mortality (30%) and this happened only after the first 5-10 years.
Risks of Cardiovascular disease:
The risks of cardiovascular events has been shown to be similar in donors and healthy non-donors. Another study showed that the cardiovascular risks are similar to non-donors after a decade.
Careful selection of donor selection and evaluation by the multidiscipline team
Correct the modifiable risk factor like smoking , obesity , encourage healthy diet and exercise
Regular follow-up of renal functions, blood pressure and blood sugar.
References:
1. Mjen G et al. Long-term risks for kidney donors. Kidney International (2014) 86, 162–167
2. Kiberd BA and Tennankore KK. Lifetime risks of kidney donation: a medical decision analysis. BMJ Open 2017(7).
3. Muzaale AD et al., Risk of End-Stage Renal Disease Following Live Kidney Donation. JAMA. 2014 February 12; 311(6): 579–586
4. Segev L et al. Perioperative Mortality and Long-term Survival Following Live Kidney Donation. JAMA, March 10, 2010—Vol 303, No. 10
· Q1: Yes. Some studies showed increased risk of ESKD and CVD especially comparing healthy non-donors. However, lower ESKD risk compared to general population risk of CVD is increased in elderly group especially if became hypertensive.
· Q2: Donors should be evaluated by cardiologists to reduce and treat modifiable risk factors for CVD. In addition, donor follow up is recommended at least annually for overweight, RFT, hypertension, proteinuria or albuminuria, diabetes and life style modifications.
Renal donation is not associated with increased risk of ESRD .The risk is similar to general population and it is usually of new disease onset of immunological background which would have affected both kidneys.
American Journal of Transplantation https://doi.org/10.1111/ajt.14671
Donors who developed ESRD (mean age ± standard deviation [SD] at ESRD, 62.4 ± 14.1 years.
Risk is increased in male, younger age of donation, smoking, family history of comorbid conditions as HTN or DM.
Measures to reduce the risk:
Better selection of donor, younger age with higher eGFR, or older more healthy donors with accepted total GFR, nonsmokers , if smoker adopt smoking cessation programs to help them to quit smoking , healthy lifestyle is advisable , donors with family history of DM, HTN or CKD to be excluded especially young age , avoid NSAIDs abuse ,nephrotoxic medications , addiction ,plus regular annual monitoring of renal functions and renal ultrasound post transplantation is a must.
The incidence of ESRD in living kidney donors is reassuringly low as compared to the general population although there is a decrease in the GFR post donation in donors initially1…..
Muzzale compared the outcome of 96000 kidney donors in USA and followed for 15 years..This was published in JAMA in 2014.. the donor population was 75% white race, 25% were obese and 20% had pre donation GFR < 80ml/min….the estimated risk of ESRD 15 years post donation was 31 per 10,000 compared to 4 per 10,000 in non donated matched controls…The estimated risk of ESRD was 90 per 10,000 donors as compared to 326 per 10,000 donors in general population2…Another study from Norway also compared the risk of ESRD in donors and healthy matched controls and said that there is an increased risk of ESRD after life time kidney donation….
Donors must be reassured, but be aware of a small absolute increase risk of creatinine or worsening of GFR <30ml/min/m2 is very minimal from this study…the life time risk of ESRD is more in young age donors, african american donors, or those with hypertension, diabetes…Individualized risk assessment of the donors are needed before making an informed decision
measures taken to reduce the risk are to prevent the occurrence of life style mediated diseases post renal donation namely diabetes, hypertension, to avoid smoking or getting obese…. Annual monitoring of kidney functions is recommended for all donors as per BTS guidelines
◇ Please substantiate your answer
▪︎Live kidney donation may reduce life expectancy by 0.5–1 year in most donors. The development of ESRD in donors may not be the only measure of risk as most of the predicted loss of life predates ESRD [1].
▪︎ In the general population, reduced GFR and proteinuria are associated with CVD but it remains controversial if reduced renal function increases the risk of CVD in otherwise healthy kidney donors. A majority of studies have not identified an increased risk of CVD among kidney donors, however, a single study with a median follow-up of 15 years showed a 40% increased cardiovascular mortality in kidney donors when compared with a cohort of self-proclaimed healthy individuals [2].
◇ What are the measures taken to reduce this risk
By following donors and treating risk factors aggressively to prevent ESRD and to improve donor survival [2].
______________________
Ref:
[1] Bryce A Kiberd and Karthik K Tennankore
Lifetime risks of kidney donation: a medical decision analysis.
[2] Philip Munch, et al. Is the risk of cardiovascular disease increased in living kidney donors? A Danish population-based cohort study
American Journal. 2020. V 21,p. 1857-1865.
Donor Risk
The continued success of living donation depends upon ensuring the safety and excellent long-term outcomes of the donor. In particular, donors must be reassured that the risk both of developing progressive CKD and of premature cardiovascular death remain low following nephrectomy
Donor Risk -CKD/ESRD-
Recommendations
• Counselling and consent of potential living kidney donors must include acknowledgement that the baseline risk of ESRD is increased by donation. (A1)
• Discussion with potential donors must be informed by those factors known to increase ESRD risk post-donation, including donor age, sex, race, BMI, and a family history of renal disease. (A1)
• Risk calculators predicting lifetime ESRD risk may help inform the consent process. (C2)
The lifetime risk of ESRD after kidney donation is low Less than 1:200 donors (0.5%)
•Donor Risk -Death Peri-Operative (90 days) – 1 in 3,000
End-stage kidney disease — When compared with well-matched, equally healthy controls, donor nephrectomy appears to increase the risk of end-stage kidney disease (ESKD), although the absolute risk is low.
Reference :
Cardiovascular disease or death.
In a study comparing 2028 living kidney donors in Ontario, Canada (1992 to 2009) with 20,280 healthy, demographically matched nondonors, the risk of death or major cardiovascular events over a median seven years follow-up (maximum 18 years) was lower in donors than in healthy nondonors (2.8 versus 4.1 events per 1000 person-years; hazard ratio [HR] 0.66, 95% CI 0.48-0.90)
Reference :
W3 s3
Is donation associated with an increased risk of ESRD, cardiovascular disease or death?
Q1- Please substantiate your answer
Risk of end-stage renal disease (ESRD) in kidney donors has been compared with risk of the general population, but the general population is not a well matched comparable group . that sway the previus studies show no increase in the risk of ESRD in kidney donors . But to get amore accurate comparison we should compare the risk of ESRD in kidney donors with that of a healthy nondonors who are at equally low risk of renal disease .A comparison to similarly screened healthy nondonors would more properly estimate the sequelae of kidney donation.
Compared with a matched non donors, kidney donors had an increased risk of ESRD; but the magnitude of the absolute risk increase was small . (1)
As conclusion of another study , Survival and the risk of ESRD in carefully screened kidney donors appear to be similar to those in the general population .(2)
Previous studies have suggested that living kidney donors maintain long-term renal function and experience no increase in cardiovascular or all-cause mortality. However, most analyses have included control groups less healthy than the living donor population and have had reatively short follow-up periods. Hazard ratio for all-cause death and cardiovascular mortality was significantly increased for donors compared with controls , while the risk of ESRD was greatly and significantly increased and might be influenced by hereditary factors and Immunological .Thus, kidney donors are at increased long-term risk for ESRD, cardiovascular, and all-cause mortality compared with a control group . (3)
Q2- What are the measures taken to reduce this risk?
Recent data support that living donors may experience a small increased risk of severe CKD and ESRD compared with healthy nondonors. For most donors, the 15-year risk of kidney failure is <1%, but for certain populations, such as young, black men, this risk may be higher. New risk prediction tools that combine the effects of demographic and health factors, and innovations in genetic risk markers are improving kidney risk stratification. (4)
Therefore carefully assessing the donor will help to reducing the chance of developing the bad outcomes ,
Reference :
1- Muzaale AD, Massie AB, Wang MC, Montgomery RA, McBride MA, Wainright JL, Segev DL: Risk of end-stage renal disease following live kidney donation. JAMA 311: 579–586, 2014
2- Ibrahim HN, Foley R, Tan L, Rogers T, Bailey RF, Guo H, Gross CR, Matas AJ: Long-term consequences of kidney donation. N Engl J Med 360: 459–469, 2009
3- . Mjøen G, Hallan S, Hartmann A, Foss A, Midtvedt K, Øyen O, Reisaeter A, Pfeffer P, Jenssen T, Leivestad T, Line PD, Øvrehus M, Dale DO, Pihlstrøm H, Holme I, Dekker FW, Holdaas H: Long-term risks for kidney donors. Kidney Int 86: 162–167, 2014
4- Lentine KL, Lam NN, Segev DL. Risks of Living Kidney Donation Current State of Knowledge on Outcomes Important to Donors.Clin J Am Soc Nephrol 14: 597–608, April, 2019.
In the general population, reduced GFR and proteinuria are associated with cardiovascular disease ,but it remains controversial if reduced renal function increases the risk of CVD in otherwise healthy kidney donors.
A majority of studies have not identified an increased risk of CVD among kidney donors,however, a single study with a median follow-up of 15 years showed a 40% increased cardiovascular mortality in kidney donors when compared with a cohort of self-proclaimed healthy individuals.
Also, while chronic kidney disease and reduced GFR is associated with an increased risk of atrial fibrillation or flutter (AF) the effect of kidney donation on this risk has not been assessed. Furthermore, how living kidney donation affects the risk of hypertension is equivocal , however, two recently published studies identified increased risks of hypertension after living kidney donation.
Garg et al. followed 2028 donors with a median age of 43 years at donation for a median of 6.5 years. Fourteen donors were registered with MI during follow-up. They found the risk of a first cardiovascular event (including stroke and MI) to be lower in donors than controls after follow-up. However, it is not likely that kidney donation reduces cardiovascular risk. These results may instead reflect the fact that the control group may not have been healthy enough to serve as controls for kidney donors.
In a large study with data from 2696 living donors, Rizvi et al. performed a subanalysis, selecting data from potential donors (evaluated and accepted but who did not proceed for non-medical reason) as a control group for real living donors. They found 90 non-donor siblings who could be paired with actual donors for age, sex and BMI. During a mean follow-up time of 5 years, only one person in each group was diagnosed with ischaemic heart disease.
*Compared with matched healthy nondonors, kidney donors had an increased risk of ESRD over a median of 7.6 years; however, the magnitude of the absolute risk increase was small. These findings may help inform discussions with persons considering live kidney donation.
*Cumulative incidence of ESRD was lowest among living donors with BMI <25 and highest among donors with BMI>30 and it was higher among donors who were first-degree biologically related to their recipient
References :
1-Segev DL, Muzaale AD, Caffo BS, Mehta SH, Singer AL, Taranto SE, McBride MA, Montgomery RA: Perioperative mortality and long-term survival following live kidney donation. JAMA 303: 959–966, 2010
2. Muzaale AD, Massie AB, Wang MC, Montgomery RA, McBride MA, Wainright JL, Segev DL: Risk of end-stage renal disease following live kidney donation. JAMA 311: 579–586, 2014
3. Mjøen G, Hallan S, Hartmann A, Foss A, Midtvedt K, Øyen O, Reisaeter A, Pfeffer P, Jenssen T, Leivestad T, Line PD, Øvrehus M, Dale DO, Pihlstrøm H, Holme I, Dekker FW, Holdaas H: Long-term risks for kidney donors. Kidney Int 86: 162–167, 2014
4. Ibrahim HN, Foley R, Tan L, Rogers T, Bailey RF, Guo H, Gross CR, Matas AJ: Long-term consequences of kidney donation. N Engl J Med 360: 459–469, 2009
5. Locke JE, Reed RD, Massie A, MacLennan PA, Sawinski D, Kumar V, Mehta S, Mannon RB, Gaston R, Lewis CE, Segev DL: Obesity increases the risk of end-stage renal disease among living kidney donors. Kidney Int 91: 699–703, 2017
There is a risk of ESRD as shown by some studies but that was not very high. Older age was associated with 1.7 higher risk (Kiberd BA, Tennankore KK. Lifetime risks of kidney donation: a medical decision analysis. BMJ Open. 2017 Sep 1;7(8):e016490. doi: 10.1136/bmjopen-2017-016490. PMID: 28864484; PMCID: PMC5588992.). MBI was another factor.
We need to choose donors carefully and follow them after the nephrectomy. The loss of nephron mass has an effect that may not be predicted before operation.
Lentine KL, Lam NN, Segev DL. Risks of Living Kidney Donation: Current State of Knowledge on Outcomes Important to Donors. Clin J Am Soc Nephrol. 2019 Apr 5;14(4):597-608. doi: 10.2215/CJN.11220918. Epub 2019 Mar 11. PMID: 30858158; PMCID: PMC6450354.
Mjoen G, Hallan S, Hartmann A, et al. Long-term risks for kidney donors. Kidney Int 2014; 86: 162-7.
Mjoen G, Hallan S, Hartmann A, et al. Long-term risks for kidney donors. Kidney Int 2014; 86: 162-7.
Segev DL, Muzaale AD, Caffo BS, et al. Perioperative mortality and long-term
survival following live kidney donation. JAMA 2010; 303: 959-66.
Post-donation projected risk of end-stage renal disease (after kidney donation):
Previous studies have estimated that the 15-year absolute increase in the risk of ESRD from kidney donation averages 0.27%4,5. This risk varies depending on a donor candidate’s demographic and health characteristics. At the present time we do not have data on the lifetime post-donation risk of ESRD according to a donor candidate’s characteristics.
References
1. Grams ME, Sang Y, Levey AS, Matsushita K, Ballew S, Chang AR et al. Kidney-Failure Risk Projection for the Living Kidney-Donor Candidate. NEJM 2015 (epub ahead of print)
2. Hsu CY, McCulloch CE, Iribarren C, Darbinian J, Go AS. Body mass index and risk for end-stage renal disease. Ann Intern Med 2006;144:21-8.
3. Vivante A, Golan E, Tzur D, et al. Body mass index in 1.2 million adolescents and risk for end-stage renal disease. Arch Intern Med 2012;172:1644-50.
4. Mjøen G, Hallan S, Hartmann A, et al. Long-term risks for kidney donors. Kidney Int 2014;86:162-7.
5. Muzaale AD, Massie AB, Wang MC, et al. Risk of end-stage renal disease following live kidney donation. JAMA 2014;311:579-86.
long prospective cohort was designed to assess long term risks of kidney donation, it demonstrated a significant increase in ESRD, cardiovascular, and all-cause mortality during long-term follow-up after living kidney donation compared with a selected population of non-donors who would have met the criteria for donation. Although Previous studies have suggested that living kidney donors maintain long-term renal function and experience no increase in cardiovascular or all-cause mortality. factors
known to increase ESRD risk post-donation, including donor age, sex, race, BMI, and a family history of renal disease
Avoid risk factors
Early follow-up of the donor, within the first few weeks after surgery, to ensure that he or she is supported and is making appropriate progress following the operation. This includes the monitoring of kidney function and the early detection of problems such as infection and poor wound healing.
Ongoing Long-term annual follow-up
*Although absolute risk of end-stage kidney disease is considered very low But ; if compared with well-matched, healthy controls, donor nephrectomy appears to increase the risk of end-stage kidney. Most donors 15-year risk of chronic renal failure is <1%, but the risk will be higher in younger black males. Minor perioperative complications occur in 10%–20% of donor nephrectomy cases, but major complications occur in <3%, and the risk of perioperative death is <0.03%.Over-all ,the more decreased GFR in general population associated with an increased risk of adverse long-term outcomes including ESRD, cardiovascular disease up to death especially with GFR 60-75 mL/min/1.73m2.
*The measures taken to reduce this risk : good screening and proper donor selection including risk factors for CVD taking :DM, Hypertension , Family history, smoking.
-Potential LKD should be counseled regarding risks of kidney donation and possible long term cardiovascular complications , should have proper diet control , stop smoking and counseling him regarding regular follow-up clinically and laboratory.
References:
1.Lam NN, Segev DL, etal. : Risks of Living Kidney Donation Current State of Knowledge on Outcomes Important to Donors. Clin J Am Soc Nephro.14: 597–608,2019.
2.BTS/RA Living Donor Kidney Transpl. Guidelines 2018
Just after donation there is compensatory hypertrophy of the remaining kidney and increase in GFR up to 70%.
It was seen after donation that the donor has been more careful with regular checkup, follow up and more conscious about there health. according to literature there is no significant increase in renal failure compare to normal population may be <1%. Although, there increase risk of developing hypertension.
Every donor should be evaluated thoroughly for any psychological issue, genetic, renal stone disease, and other comorbidities.
psychological counseling for drug adherence, risk of developing future hypertension and other comorbidities associated with metabolic syndrome.
So the donor selection should be very careful.
Regular follow up and life style modification is necessary.
I can not find my previous answer on that scenario!
Kidney donors have lower long-term risk of ESRD compared to the general population. This has been attributed to the careful screening process that excludes candidates with pre-existing conditions from donation. However, two recent studies, one from Norway and one from the United States, examined ESRD risks for living donors compared to healthy non-donors (not the general population). Consistent with prior studies, a low absolute risk of ESRD (< 0.5% at 15 years post kidney donation and the lifetime risk estimated at 0.9%) was reported . While the relative risk of ESRD in donors was less than the general population, donors have a relative risk of ESRD of between 8 to 11 times compared to healthy non-donors. All of the donors with ESRD in the Norwegian study were family members of the recipients, and most developed immune-mediated renal disease. Despite their limitations, these studies provide the best information to date on donor risks. A risk calculator has recently been developed for use in counseling potential kidney donors. Demographic and health characteristics may now be used to estimate the projected longterm pre-donation risk of ESRD in donor candidates. A post donation calculator is not available.
Nephrectomy does not appear to increase long-term mortality
Kidney donation does not increase the risk of cardiovascular disease for donors
Renal transplant is best form of renal replacement. In its preparation, everything is done work on the safety of the donor. No procedure is without a risk. Donors have an increase risk of hypertension, diabetes,declining GFR and the procedure risk.
The best way of reducing these risk is due screening, and proper procedure and follow up post transport
Donor nephrectomy does not appear to increase long-term mortality compared with controls, nor does it increase ESRD risk among white donors. Within the donor population, the likelihood of post-donation chronic renal failure and medical comorbidities such as hypertension and diabetes appears to be relatively higher among some donor subgroups, such as African Americans and obese donors. Still, the impact of uninephrectomy on the lifetime risks of adverse events expected without nephrectomy in these subgroups has not yet been defined.
Recent data support that living donors may experience a small increased risk of severe CKD and ESRD compared with healthy non-donors. For most donors, the 15-year risk of kidney failure is <1%, but for certain populations, such as young black men, this risk may be higher. . Minor perioperative complications occur in 10%–20% of donor nephrectomy cases, but major complications occur in <3%, and the risk of perioperative death is <0.03%.
New risk prediction tools that combine the effects of demographic and health factors and innovations in genetic risk markers are improving kidney risk stratification and proper donor selection.
References:
Previous reports suggest increased risk of hypertension and cardiovascular mortality after kidney donation. Some study have investigated the incidence of IHD and CVD, diabetes and cancer in live kidney donors compared with healthy controls eligible for donation.
In a recent study different diagnoses were assessed in 1029 kidney donors and 16 084 controls. Stratified logistic regression was used to estimate associations with various disease outcomes, adjusted for gender, age at follow-up, smoking, BMI at baseline, systolic blood pressure at baseline and time since the donation. The mean observation time was 11.3 years for donors and 16.4 years for controls. At follow-up the age was 56.1 years in donors and 53.5 years in controls and 44% of donors were males versus 39.3% in the controls. At follow-up, 3.5% of the donors had been diagnosed with IHD versus 1.7% of the controls. There were no significant differences for the risks of cerebrovascular disease, diabetes or cancer. This study showed an increased risk of IHD compared with healthy controls.
Based on current data, after donor nephrectomy peri-operative mortality is around 3 per 10,000 cases, and major and minor peri-operative complications affect about 3–6% and 22% of donors, respectively. Long-term mortality does not seem to increase after donor nephrectomy compared with controls, and ESRD risk does not seem to increase among white donors. The likelihood of post-donation chronic renal failure and medical comborbidities seems to be higher among some donor subgroups (eg African Americans, obese), but how uni-nephrectomy affects the lifetime risks of adverse events expected without nephrectomy in these sub-groups is not yet defined.
-Accurate selection of the potential living donor to reduce complication both in the short and long term.
-Thorough evaluation of all risk factors for CVD (Family history, Diabetes, smoking, obesity etc)
-Potential live donor should receive a pre-transplant counseling in order to make them aware of the risks associated with living with one kidney (obesity, BP control, life style such as smoking etc). In that sense the perspective donors need a closed follow-up (urinalysis, monitor BP, Blood sugar etc).
References:
–Increased risk of ischaemic heart disease after kidney donation
Anders J Haugen, Stein Hallan, Nina E Langberg, Dag Olav Dahle, Hege Pihlstrøm, Kåre I Birkeland, Anna V Reisæter, Karsten Midtvedt, Anders Hartmann, Hallvard Holdaas.
Nephrology Dialysis Transplantation, Volume 37, Issue 5, May 2022, Pages 928–936,
-Risks and Outcomes of Living Donation. Krista L. Lentine, MD, MS1 and Anita Patel, MD2. Adv Chronic Kidney Dis. Author manuscript; available in PMC 2015 May 28.
Please substantiate your answer
A major concern post renal donation is the development of ESRD. Several studies showed that there was no increased in the risk of ESRD development among LKD when compared to general population, but the risk may be slightly increased when compared to selected healthy control, & this increased risk could be explained by several factors as black race, obesity, & genetic origin of renal diseases.
Muzzaale et al found that there was a small increase in the risk of ESRD development among LKD when compared matched healthy non donor( 90/10000 vs 14/10000), but the risk still lower when compared to general population. The increased risk in this study was found more among biologically related recipients, obese, old age & African-American donors. The risk of reducing GRF <30ml/min/m2 or ESRD was very low <1%
.
CVD was found to be lower among LKD when compared to healthy matched population & this may be due to extensive & thorough investigation pre-donation & close medical follow-up post donation. CVD including stroke is the leading cause of death in general population, but in donors it was found to be the second leading cause of death ( first leading cause was cancer) According to the OPTN data.
Risk of ESRD in Live kidney Donors
There can be reduction in GFR after donation , however the risk of end stage renal disease remains similar too general population. The causes of ESRD in such Some studies have shown higher risk of ESRD in kidney donors as compared to general population. This may be the case in high risk donors like young Africans, pre diabetics and hypertensives. There is higher relative risk of ESRD in donors but absolute risk is low.
Risk of cardiovascular disease in kidney donors
As regards the risk of cardiovascular disease and death due to donation, there is still some controversy. There is slight higher risk of cardiovascular events as compared to normal subjects.
1- good donor seslection
2- close follow up & monitoring
3- prevent & treat risk factors ( weight reduction , bl.p,control , avoid smoking , alcohol )
Post donation risks:
To what extent living donor nephrectomy influences risk of CVD still controversial.
Kidney donors have increased risk of need for treatment for hypertension as shown by 2 studies.
All-cause mortality, CVS mortality, and ESRD were found in kidney donors
There was a significant corresponding increase in cardiovascular death to 1.40 while the risk of ESRD was greatly and significantly increased to 11.38 .
Overall incidence of ESRD in donors was 302 cases per million; could be influenced by hereditary factors.
_Risk reduction:
Good donor selection with full evaluation of all risk factors for CVD ( DM, smoking, obesity, F/H of CVD or kidney disease)
Follow-up of donors for enough time with healthy life style and avoidance of CVD risk factors.
References:
Philip Munch,Christian et al .Is the risk of cardiovascular disease increased in living kidney donors? A Danish population-based cohort study.October 2020
American Journal of TransplantationVolume 21, Issue 5 p. 1857-1865.
Is donation associated with an increased risk of ESRD, cardiovascular disease or death?
# Please substantiate your answer
*Decreased GFR in the general population is associated with an increased risk of adverse outcomes including ESRD, cardiovascular disease and death. This increase becomes apparent with a GFR between 60-75 mL/min/1.73m2 as compared to GFR >90 mL/min/1.73m2 and rises exponentially thereafter.
*The incidence of ESRD in living kidney donors appears to be similar to or lower than
that seen in the unselected general population despite a reduction in GFR.
* Muzaale compared the outcome of 96,000 kidney donors in the USA over a maximum follow-up of 15 years with matched healthy controls. The donor population was 75% white, 25% obese and 22% had a pre-donation eGFR <80 mL/min. The estimated risk of ESRD 15 years post-donation was 31 per 10,000 compared to 4 per 10,000 in matched controls.
*The increased risk was far greater in high risk donor populations such as African American donors.
*A second Norwegian study demonstrated a similar increased risk of ESRD after kidney donation.
*Donors may be reassured that the absolute increase life time risk of GFR <30 mL/min/1.73m2 or ESRD is very small (<1%) for the populations included in this
study. The absolute risk for young donors over a lifetime, particularly with additional
risk factors for ESRD is likely to be more significant.
*Additional adverse factors associated with an increased lifetime risk ESRD include:
Measured GFR just below the guideline threshold
Ethnic groups at higher risk (African Caribbean or South Asian origin
Hypertension, obesity and/or (pre) diabetes
*A recent US study showed that the risk of ESRD was greatest for younger patients of black ethnicity. The absolute increased lifetime risk of ESRD may be helpful in counselling potential donors with risk factors including those below threshold GFR. The data also support donation from some older donors who have additional risk factors such as hypertension but whose lifetime risk of ESRD is low.
*Three retrospective observational studies compared mortality among living kidney two studies revealed a lower risk of death in donors compared to healthy non-donors whilst the third study suggested a possible small increase.
*Garg et al conducted that the risk of death and cardiovascular events was lower and the risk of death-censored cardiovascular events was the same in the donors as compared with the healthy matched population. The quality of the evidence is considered poor, and there is no clear evidence that donation reduces long-term survival.
# What are the measures taken to reduce this risk?
Perfect evaluation and donor selection.
Counseling them about the risk factors of donation.
Choose the donors with good estimation of GFR according to the guideline.
Advice them about the healthy life style.
Regular follow up to detect any co morbidities accelerate the development of ESRD
BTS/RA Living Donor Kidney Transplantation Guidelines 2018
1- good donor seslection
2- close follow up & monitoring
3- prevent & treat risk factors ( weight reduction , bl.p,control , avoid smoking , alcohol )
Is donation associated with an increased risk of ESRD, cardiovascular disease or death?
This may be different according to the length of the study, age of donor or ethnic group.
Long-term risks: Mortality and cardiovascular disease
· More than one study found that survival after living kidney donation is the same as for similar matched individuals who did not donate, at least over approximately 10 to 18 years [1-4], including one study of donors older than 55 years [5]
· One long-term study of more than 80,000 living kidney donors, the risk of death over a median 6.3 years of follow-up (maximum 12 years) was the same for kidney donors and demographically matched [6]
· In a study comparing 2028 living kidney donors in Ontario, Canada (1992 to 2009) with 20,280 healthy, demographically matched nondonors, the risk of death or major cardiovascular events over a median seven-year follow-up (maximum 18 years) was lower in donors than in healthy nondonors [7]. The risk of death-censored major cardiovascular events was similar among donors and nondonors
· But one study with longer follow-up (a median follow-up of 15 years, maximum 25 years) compared cardiovascular and all-cause mortality in 1901 kidney donors with a control group of 32,621 healthy, found that There was a significant increase in ESRD, cardiovascular, and all-cause mortality during long-term follow-up after living kidney donation [8]
Long-term risks: End-stage kidney disease
· When compared with well-matched, equally healthy controls, donor nephrectomy appears to increase the risk of end-stage kidney disease (ESKD), although the absolute risk is low [3,9,10].
· In one study, 1901 kidney donors were compared with 32,621 healthy, demographically matched controls from a population-based survey carried out in Norway between 1984 and 1987 (HUNT I) [8]. Compared with controls, the risk of ESKD was higher among donors.
-ESKD among the Norwegian donors was mostly due to immunologic diseases, so it is possible that the increase in risk of ESKD was related to genetically determined immunologic factors rather than the nephrectomy itself [11]
· A number of studies support that the risk of ESKD after kidney donation does not exceed the risk in the general population [12-13,14].
1. Good evaluation and selection of living donor candidates to reduce short and long term complications.
*To improve the evaluation and selection of living donor candidates, a KDIGO work group formulating guidelines for the “Evaluation and Care of Living Kidney Donors” collaborated with the Chronic Kidney Disease-Prognosis Consortium (CKD-PC) to conduct a meta-analysis combined with an analysis of the incidence of ESKD in a low-risk segment of the United States population to produce a comprehensive risk-prediction model for ESKD in the absence of donation based on data for nearly five million healthy persons [15]
2. Good estimation for GFR before donation, even with split renal function if needed
3. Closed follow-up for donor Bp, sugar, urine analysis, to diagnose early HTN or DM
References
1. Segev DL, Muzaale AD, Caffo BS, et al. Perioperative mortality and long-term survival following live kidney donation. JAMA 2010; 303:959.
2. Delanaye P, Weekers L, Dubois BE, et al. Outcome of the living kidney donor. Nephrol Dial Transplant 2012; 27:41.
3. O’Keeffe LM, Ramond A, Oliver-Williams C, et al. Mid- and Long-Term Health Risks in Living Kidney Donors: A Systematic Review and Meta-analysis. Ann Intern Med 2018; 168:276.
4. Kim Y, Yu MY, Yoo KD, et al. Long-term Mortality Risks Among Living Kidney Donors in Korea. Am J Kidney Dis 2020; 75:919.
5. Reese PP, Bloom RD, Feldman HI, et al. Mortality and cardiovascular disease among older live kidney donors. Am J Transplant 2014; 14:1853.
6. Segev DL, Muzaale AD, Caffo BS, et al. Perioperative mortality and long-term survival following live kidney donation. JAMA 2010; 303:959.
7. Garg AX, Meirambayeva A, Huang A, et al. Cardiovascular disease in kidney donors: matched cohort study. BMJ 2012; 344:e1203.
8. Mjøen G, Hallan S, Hartmann A, et al. Long-term risks for kidney donors. Kidney Int 2014; 86:162.
9. Organ Procurement and Transplantation Network (OPTN)/United Network for Organ Sharing (UNOS). National data reports, transplants by donor type https://optn.transplant.hrsa.gov/data/view-data-reports/national-data/# (Accessed on March 13, 2018).
10. Muzaale AD, Massie AB, Wang MC, et al. Risk of end-stage renal disease following live kidney donation. JAMA 2014; 311:579.
11. Matas AJ. Transplantation: Increased ESRD and mortality risk for kidney donors? Nat Rev Nephrol 2014; 10:130.
12. Pabico RC, McKenna BA, Freeman RB. Renal function before and after unilateral nephrectomy in renal donors. Kidney Int 1975; 8:166.
13. Davison JM, Uldall PR, Walls J. Renal function studies after nephrectomy in renal donors. Br Med J 1976; 1:1050.
14. Cherikh WS, Young CJ, Kramer BF, et al. Ethnic and gender related differences in the risk of end-stage renal disease after living kidney donation. Am J Transplant 2011; 11:1650.
15. Grams ME, Sang Y, Levey AS, et al. Kidney-Failure Risk Projection for the Living Kidney-Donor Candidate. N Engl J Med 2016; 374:411.
Transplantation from a living donor is associated with shorter waiting time and longer graft survival compared with deceased donor transplantation; however, it also involves potential increased risks for the otherwise healthy donor associated with the surgery and long-term consequences of removal of a kidney.
Reduced renal function is associated with cardiovascular disease (CVD); however, how living donor nephrectomy affects the risk of CVD remains controversial.
In the general population, reduced GFR and proteinuria are associated with cardiovascular disease (CVD), but it remains controversial if reduced renal function increases the risk of CVD in otherwise healthy kidney donors
Kidney donors had an increased risk of initiating treatment for hypertension.
two recently published studies identified increased risks of hypertension after living kidney donation.
single study with a median follow-up of 15 years showed a 40% increased cardiovascular mortality in kidney donors when compared with a cohort of self-proclaimed healthy individuals.
All-cause mortality, cardiovascular mortality, and end-stage renal disease (ESRD) was identified in 1901 individuals who donated a kidney during 1963 through 2007 with a median follow-up of 15.1 years. A control group of 32,621 potentially eligible kidney donors was selected, with a median follow-up of 24.9 years.
Hazard ratio for all-cause death was significantly increased to 1.30 for donors compared with controls.
There was a significant corresponding increase in cardiovascular death to 1.40 while the risk of ESRD was greatly and significantly increased to 11.38 .
The overall incidence of ESRD among donors was 302 cases per million and might have been influenced by hereditary factors. Immunological renal disease was the cause of ESRD in the donors.
Proper selection if donor with full evaluation of all risk factors for CVD (smoking, obesity, family history of CVD or kidney disease,)
Follow-up of donors for longer time with instruction about healthy life style and avoid risk factors for CVD
Philip Munch,Christian Fynbo Christiansen,Henrik Birn,Christian Erikstrup,Mette Nørgaard.Is the risk of cardiovascular disease increased in living kidney donors? A Danish population-based cohort study.October 2020
American Journal of TransplantationVolume 21, Issue 5 p. 1857-1865.
Long-term risks for kidney donorsGeir Mjøen et al. Kidney Int. 2014 Jul.
There is risk of reduction in GFR after donation , however the risk of end stage renal disease remains similar to general population. Some studies have shown higher risk of ESRD in kidney donors as compared to general population. This may be due to the high risk donors like young Africans, pre diabetes and hypertensives.
To treat or prevent all risk factors aggressively.
Studies suggest that, beyond the perioperative period, survival after living kidney donation is the same as for similar matched individuals who did not donate, at least over approximately 10 to 18 years .However, long-term follow-up data are limited.
In a study comparing 2028 living kidney donors in Ontario, Canada (1992 to 2009) with 20,280 healthy, demographically matched nondonors, the risk of death or major cardiovascular events over a median seven years follow-up (maximum 18 years) was lower in donors than in healthy nondonors (2.8 versus 4.1 events per 1000 person-years; hazard ratio [HR] 0.66, 95% CI 0.48-0.90).up to date.
This shows that data is bit conflicting but we can say that apparently there is no increased risk.
ESRD RISK
When compared with well-matched, equally healthy controls, donor nephrectomy appears to increase the risk of end-stage kidney disease (ESKD), although the absolute risk is low Consistent with recommendations of a 2015 American Society of Transplantation (AST) consensus statement and Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guidelines , OPTN policy requires informing donor candidates that the risk of ESKD after donation may exceed that of healthy nondonors with medical characteristics similar to living kidney donors
Donor selection is very important. To minimize the risk we have to select the appropriate donors
Non smoker
Non obese
Not hypertensive
Not diabetic
Not hypercholestermic
No albuminuria
Many thanks Dr Manal Malik, Dr Sahar, Dr F Batista, and Dr Fakhriya Alalawi,
Let us move to week 4.
Ajay
The best option for ESRD is kidney transplant from deceased or living donor; because of increase waiting list for transplant from deceased donor the number of living donation increase among transplant and most of them are family members in first relative degree; So due to genetic distribution and role of immunological risk to develop ESRD to donated persons on long term.
Recent studies shows an increased relative risk of ESRD after kidney donation, the absolute risk for ESRD is still less than 0.5% at 15 years and 0.9% for lifetime risk compared to 3.2% for the general
Long-term studies of living kidney donors have reported low rates of mortality and ESRD in a national study of living kidney donors in the United States, we previously estimated overall ESRD risk to donors at 31 ESRD cases per 10,000 living kidney donors in the first 15 years postdonation.
Two large cohort studies of individuals who did donate recently reported higher risk of ESRD in living kidney donors compared with healthy nondonors.
Risk of ESRD in donation more in male, black, old age and BMI high and donor who are first degree relative to their recipient.
living kidney donation may be associated with increased risk of hypertension and initiation of anti hypertension medication; however, in this study not identify increased risks of CVD or death.
Proper selection of donor to avoid risk of ESRD and should inform donor regarding risk factors of ESRD and hypertension especially first degree relative and annually fallow up with control weight and blood pressure and blood sugar and hyperlipidemia to avoid risk of cardiovascular disease
References:
JASN September 2017, 28 (9) 2749-2755; DOI: https://doi.org/10.1681/ASN.2016101084
The issue of loss of donor function for the general population is very controversial. Most studies make comparisons with the general population, but the potential donor must be in good health and meet a series of goals to be eligible for the procedure. Another difficulty is the long-term follow-up of both groups, to understand the real impact on this specific group and on a control that was so well selected.
Pre-transplant counseling is crucial to understand the risks involved in living with only one kidney and the necessary care, especially blood pressure control, food (dyslipidemia), avoiding smoking, obesity and other situations with important metabolic changes.
169.2. Middleton PF, Duffield M, Lynch SV et al. Living donor livertransplantation—adult donor outcomes: a systematic review. LiverTranspl 2006; 12: 24–30
In a study analysis by Kiberd BA et al, showed that 1%–5% of average-age current live kidney donors might develop ESRD because of nephrectomy. The added risk of ESRD resulted in a loss of only 0.126–0.344 remaining life years. Most of the loss of life was predicted to be associated with chronic kidney disease (CKD) not ESRD. Most events occurred 25 or more years after donation. Reducing the increased risk of death associated with CKD had a modest overall effect on the per cent loss of remaining life years (0.72%–1.9%) and QALYs (0.58%–1.33%).
On the other hand, a recent meta-analysis of four studies published between 2009 and 2016 with a total of 4274 donors and 53 246 controls, and an average follow-up time ranging from 6 to 15 years, found no evidence of an increase in cardiovascular risk in donors [pooled-adjusted RR 1.11 (95% CI 0.64–1.70)].
Similarly in other studies involving kidney donors, the usual decline over time in GFR does not appear to happen. For example, in a prospective study of 203 donors and 205 carefully selected controls, donors did not experience any further decline in iohexol-measured GFR from 6 months to 9 years post-donation, whereas the GFR in controls declined by an average of 1.26 mL/min/1.73 m2 per year. Albuminuria did not increase in donors over this 9-year period either. Similar findings were also observed in a 5-year prospective study of kidney donors using isotopic GFR to measure renal function. In 48 donors studied 5 years post-donation, there had been no further decline in either eGFR or isotopically measured eGFR in donors, whereas the 45 healthy controls had an annual mean reduction in eGFR of 1 ± 2 mL/min/1.73 m2.
What are the measures taken to reduce this risk?
To treat all risk factors aggressively to prevent ESRD and to improve donor survival.
References:
1. Kiberd BA, Tennankore KK. Lifetime risks of kidney donation: a medical decision analysis. BMJ Open. 2017 Sep 1;7(8):e016490. doi: 10.1136/bmjopen-2017-016490. PMID: 28864484; PMCID: PMC5588992.
2. O’Keeffe LM, Ramond A, Oliver-Williams C, Willeit P, Paige E, Trotter P, Evans J, Wadström J, Nicholson M, Collett D, Di Angelantonio E. Mid-and long-term health risks in living kidney donors: a systematic review and meta-analysis. Annals of internal medicine. 2018 Feb 20;168(4):276-84.
3. Ferro CJ, Townend JN. Risk for subsequent hypertension and cardiovascular disease after living kidney donation: is it clinically relevant?. Clinical Kidney Journal. 2022 Apr;15(4):644-56.
ESRD
Kidney donors have lower long-term risk of ESRD compared to the general population. This has been attributed to the careful screening process that excludes candidates with pre-existing conditions from donation. However, two recent studies, one from Norway and one from the United States, examined ESRD risks for living donors compared to healthy non-donors (not the general population) (1,2). Consistent with prior studies, a low absolute risk of ESRD (< 0.5% at 15 years post kidney donation and the lifetime risk estimated at 0.9%) was reported (2). While the relative risk of ESRD in donors was less than the general population, donors have a relative risk of ESRD of between 8 to 11 times compared to healthy non-donors. All of the donors with ESRD in the Norwegian study were family members of the recipients, and most developed immune-mediated renal disease. Despite their limitations (3-6), these studies provide the best information to date on donor risks
—————————————————————-
During long-term follow-up of kidney donors, we found an increased risk of ischaemic heart disease compared with healthy controls. This information may be important in the follow-up and selection process of living kidney donors.
——————-
However, long-term death rates did not exceed rates of matched control subjects from the National Health and Nutrition
Donor nephrectomy does not appear to increase long-term mortality compared with controls
———-
What are the measures taken to reduce this risk?
Addressing Traditional risk factors: immutable (age, gender, inheritance), variable (smoking, hyperlipidemia, hypertension, obesity, diabetes mellitus, physical activity, stress).
MDT for selection of suitable donor
Annual follow up
Careful treatment of any comorbedities following renal donation according to recent guidelines
Reference
JOURNAL ARTICLE
Increased risk of ischaemic heart disease after kidney donation
Anders J Haugen, Stein Hallan, Nina E Langberg, Dag Olav Dahle, Hege Pihlstrøm, Kåre I Birkeland, Anna V Reisæter, Karsten Midtvedt, Anders Hartmann, Hallvard Holdaas … Show more
Nephrology Dialysis Transplantation, Volume 37, Issue 5, May 2022, Pages 928–936, https://doi.org/10.1093/ndt/gfab054
Long-term risks for kidney donors
Geir Mjøen 1 , Stein Hallan 2 , Anders Hartmann 1 , Aksel Foss 1 , Karsten Midtvedt 1 , Ole Øyen 1 , Anna Reisæter 1 , Per Pfeffer 1 , Trond Jenssen 1 , Torbjørn Leivestad 3 , Pål-Dag Line 1 , Magnus Øvrehus 4 , Dag Olav Dale 1 , Hege Pihlstrøm 1 , Ingar Holme 5 , Friedo W Dekker 6 , Hallvard Holdaas 1
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Long-term risks for kidney donors
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GeirMjøen1SteinHallan23AndersHartmann1AkselFoss1KarstenMidtvedt1OleØyen1AnnaReisæter1PerPfeffer1TrondJenssen1TorbjørnLeivestad4Pål- DagLine1MagnusØvrehus2Dag OlavDale1HegePihlstrøm1IngarHolme5Friedo W.Dekker6HallvardHoldaas1
Risks and Outcomes of Living Donation
Krista L. Lentine, MD, MS and Anita Patel, MD
Additional article information
Is donation associated with an increased risk of ESRD, cardiovascular disease or death?
Basically, living donor kidney transplantation is the preferred treatment for ESRD patients, because it is associated with improved graft and patient survival compared with transplantation from a deceased donors.
A lot of studies tried to explore the risk of kidney donation. Previous studies have suggested that living kidney donors maintain long-term renal function and experience no increase in cardiovascular or all-cause mortality. However, most analyses have included control groups less healthy than the living donor population and have had relatively short follow-up periods.
one of the recent studies is Long-term risks for kidney donors: compared long-term renal function, cardiovascular and all-cause mortality in living kidney donors compared with a control group of individuals who are eligible for kidney donation. All-cause mortality, cardiovascular mortality, and end-stage renal disease (ESRD) was identified in 1901 individuals who donated a kidney during 1963 through 2007 with a median follow-up time of 15.1 years. A control group of 32,621 potentially eligible kidney donors was selected, with a median follow-up time of 24.9 years. Hazard ratio for all-cause death was significantly increased to 1.30 for donors compared with controls. There was a significant corresponding increase in cardiovascular death to 1.40 (1.03–1.91), while the risk of ESRD was greatly and significantly increased to 11.38 (4.37–29.6). The overall incidence of ESRD among donors was 302 cases per million. Immunological renal disease was the cause of ESRD in the donors. So, kidney donors are at increased long-term risk for ESRD, cardiovascular, and all-cause mortality compared with a control group of non-donors who are eligible for kidney donation.
The risk of perioperative mortality during organ retrieval from living donors have been estimated to occur in 0.03% of kidney donors.
Kidney International (2014) 86, 162–167; doi:10.1038/ki.2013.460;
published online 27 November 2013
A major concern post renal donation is the development of ESRD. Several studies showed that there was no increased in the risk of ESRD development among LKD when compared to general population, but the risk may be slightly increased when compared to selected healthy control, & this increased risk could be explained by several factors as black race, obesity, & genetic origin of renal diseases.
Muzzaale et al found that there was a small increase in the risk of ESRD development among LKD when compared matched healthy non donor( 90/10000 vs 14/10000), but the risk still lower when compared to general population. The increased risk in this study was found more among biologically related recipients, obese, old age & African-American donors. The risk of reducing GRF <30ml/min/m2 or ESRD was very low <1%
.
CVD was found to be lower among LKD when compared to healthy matched population & this may be due to extensive & thorough investigation pre-donation & close medical follow-up post donation. CVD including stroke is the leading cause of death in general population, but in donors it was found to be the second leading cause of death ( first leading cause was cancer) According to the OPTN data.
Long term mortality post donation found to be not increased when the donors followed for 12 years, with comparable life span to general population.
Measures to reduce the risk include:
References:
An increased risk of adverse outcomes including ESRD, cardiovascular disease and death associated withDecreased GFR in the general population.
This increase becomes apparent with a GFR between 60-75 mL/min/1.73m2 as compared to GFR >90 mL/min/1.73m2 and rises exponentially thereafter .
The incidence of ESRD in living kidney donors appears to be similar to or lower than that seen in the unselected general population despite a reduction in GFR .This is reassuring but not unexpected.
Nephrologist are faced with advising potential donors how to deals when they have extra adverse factors associated with an increased lifetime risk ESRD.
Factors and compounding risks include:
1-Measured GFR just below the guideline threshold
2-Ethnic groups at higher risk (African Caribbean or South Asian origin
3-Hypertension, obesity and/or (pre) diabetes
The risk was higher for blacks compared with Caucasians and in men compared with women. The risk of ESRD was greatest for younger patients of black ethnicity. The absolute increased lifetime risk of ESRD may be helpful in counselling potential donors with risk factors including those below threshold GFR as defined above. The data also support donation from some older donors who have additional risk factors such as hypertension but whose lifetime risk of ESRD is low.
Three retrospective observational studies compared mortality among living kidney donors in comparison with healthy non-donors.these studies shows that The risk of death and cardiovascular events was lower and the risk of death-censored cardiovascular events was the same in the donors as compared with the healthy matched population. The quality of the evidence is considered poor. There is no clear evidence that donation reduces long-term survival .
Reference
BTS
I appreciate your logical reasoning, Dr Asma Khudur.