Dear professor Ahmed, can we change in the graded recommendations, or just copy paste?
Wee Leng Gan
2 years ago
Transplant Legal framework in UK
The Human Tissue Act 2004 applies in England, Wales and Northern Ireland.
The Human Tissue (Scotland) Act 2006, applies in Scotland.
Types of Living Donation Permitted by the Legislation
1)Direct donation ( genetically related donation, Emotionally related donation )
2)Paired or pool donation. Donor-recipient pairs are involved in a linked exchange.
3)Non-directed altruistic donation. organ is donated by a healthy person to an unknown recipient.
4)Directed altruistic donation. Contact has been establish between donor and recipient. Both maybe either genetically related or not related.
All living organ donation must meet the following criteria
1) No rewards for donor.
2) Obtained consent for the purpose of transplantation.
3) Independent assessor for donor and recipient.
4)strict prohibition of commercial organ trafficking.
5)Children is defined as those below the age of 18 year old. In Scotland, living donation of solid organs from children is not permitted. In England and Wales, both parental consent and court approval must obtained before living organ donation from the children.
6) Living organ donation for mental incapable adults is not permitted in Scotland. In England, Wales and Northern Ireland, living organ donation from adult who lacks the capacity to consent requires court approval.
In Malaysia. The Ministry of Health regulating Living Donor Kidney Transplantation.
An individual willing to donate organ must be :
a. An adult legally able to give consent
b. Aware of all risks that can occur
c. Physically and mentally fit
d. Fully aware of the decision he/she is making
e. Able to fully evaluate and understand all information given to him/her
f. Not have received any coercion or any advice or opinions from sources other then the institution which is planning the transplantation.
g.Living unrelated donors must have access to all available information before signing the consent form. Enough time must be given for such consent. The doctor involved must ensure that the freedom to give consent is not hampered. The potential donor and the recipient or the recipient’s family should not be known each other to avoid any financial transaction.
h.Organ donation from unrelated donors is primarily not accepted unless in special circumstances. Such special circumstance may prevail when there is no suitable related living donor or a cadaveric donor for liver transplant. In such situations, application should be made for approval from the Unrelated Transplant Approval Committee (UTAC).
Asmaa Khudhur
2 years ago
SUPPORTING AND INFORMING THE POTENTIAL DONOR
Recommendations
* The best environment must be provided for the live donor to decide to donate in a voluntary and informed manner. Primary legislation mandates that the donor and recipient be evaluated independently.
* The parameters of anonymity must be outlined and agreed at the outset in order to obtain the best results for donor, recipient, and transplant. The receiver should ideally talk to their donor about pertinent details or agree to them being provided.
* The best practice is to have separate clinical teams for the donor and recipient; but, in order to guarantee good communication and coordination of the transplant procedure without jeopardizing the independence of either donor or recipient, healthcare professionals must collaborate. The donation/transplantation process includes support for the potential donor, recipient, and family.
Confidentiality:
The relationship between the donor and recipient’s respective doctors should be private.
Informing the Potential Donor:
When requesting informed consent, registered doctors have a duty to act responsibly, according to the General Medical Council (GMC).
Informed Consent for Living Kidney Donation:
Summary of Key Points to be Discussed with a Potential Donor:
General points about process, consent and confidentiality:
1. Living donors must be adequately informed of both the general hazards (applied to all donors) and any unique, personal dangers in order to provide permission for donation that is legitimate (for them)
2. Prior to moving on to any stage of the pathway, informed consent must be obtained.
3. Information about what will be shared between the transplant team and the GP must be provided.
4. Information about what will not be disclosed to the prospective recipient, unless express consent is given to do so, must be provided.
5. It should be made clear that unexpected results from the tests could emerge, which may or may not be related to kidney donation. These findings might include:
A description of the recipient’s genetic relationship.
b. Anatomical or medical findings with ambiguous significance that may call for additional evaluation or referral to a different field of study.
6. It should be emphasized that the donor has the right to revoke consent at any time before the procedure.
Specific points about process and possible outcomes:
1. Risks of donation (generic and specific).
2. Nature of surgical procedure and length of stay in hospital.
3. Potential graft loss in the recipient.
4. Requirement for HTA assessment.
5. Reimbursement of expenses.
6. Requirement for annual review.
Understanding what is Involved:
The need for valid consent for kidney donation must be explained to the potential donor.
Information about Likely Outcomes for the Kidney:
Despite the fact that the nephrectomy’s surgical risks are unrelated to the recipient’s identification, the donor’s decision to contribute or not may be influenced by the possibility that the transplant would be successful. A crucial component of the consent procedure is disclosing information regarding the chances of success. The likelihood of a successful transplant must be realistically estimated for the potential living donor.
Independence of Decision:
The clinician in charge of obtaining consent must be certain that the potential donor has the capacity to make a competent and rational decision. Valid consent for surgery must be freely provided and informed.
The Responsibility of the Donor Surgeon:
Under the terms of his or her duty of care, the surgeon performing the living donor nephrectomy has a special obligation to make sure that the donor is fully aware of any possible dangers and the long-term repercussions of the procedure.
Donor Identity:
There is substantial discussion surrounding the importance of donor identity in the context of informed consent. During the living donor transplant work-up, details about a donor’s identity and genetic relationship with the potential receiver of their contribution may become known.
Patient Advocacy:
The UK regulatory framework reflects the long-held belief that the possible donor should be given the chance to meet separately with a party who is independent of the transplant team.
Independent Translators:
Within the UK, there is a wide range of cultures and ethnicities, and a sizable portion of donors do not speak English as their first language.
Psychological Issues:
Psychological issues are rare after donation, and most donors report higher self-esteem while their relationships with both donors and recipients improve.
Death and Transplant Failure:
For patients with higher baseline comorbidity, LDKT is becoming more widely regarded as the preferred course of treatment. The effective managing of expectations is a crucial component of the pre-transplant preparation for all parties involved because of the higher risk of post-operative co-morbidity, transplant failure, and death that is likely.
DONOR EVALUATION: SUMMARY
Recommendations
* Before beginning the donor assessment process in cases of directed donation (to a known recipient), it is necessary to determine the probable recipient’s likely suitability for transplantation. Avoid unnecessary delays if extra recipient assessment is necessary. This step allows for the non-invasive evaluation of the donor. Donor evaluation is designed to cause them as little inconvenience as possible and to remove any unnecessary obstacles to moving forward. Flexibility in scheduling appointments, attending investigations, and choosing a surgery date is beneficial.
* Donor evaluation needs to be organized in order to be clear, rational, and cogent. A designated co-ordinator should oversee the planning of the evaluation process to ensure good communication with the donor and participation of the larger multidisciplinary team. The results of the inquiry must be communicated to the potential donor accurately and effectively. At the earliest possible point in the assessment process, unsuitable donors must be found. When a potential donor is determined to be unfit to donate, a policy must be in place, and the proper follow-up and support must be made available. According on manpower and resource availability, donor evaluation centers will have different organizational characteristics, but all donors are subject to the same general guidelines. an agreed-upon donor evaluation
Summary of Key Points of Importance in the Medical +/- Family History of a Potential Kidney Donor
Haematuria/proteinuria/urinary tract infection
Difficulty in passing urine, including urgency, frequency, dysuria
History of peripheral oedema
Gout
Nephrolithiasis
Hypertension
Diabetes mellitus, including family history
Ischaemic heart disease/peripheral vascular disease/other atherosclerosis Cardiovascular risk factors
Thromboembolic disease
Sickle cell and other haemoglobinopathies
Weight change
Change in bowel habit
Previous jaundice
Previous or current malignancy
Systemic disease which may involve the kidney
Chronic infection such as tuberculosis
Family history of a renal condition that may affect the donor
Smoking
Current or prior alcohol or drug dependence
Mental health history
Obstetric history
Residence abroad
Previous medical assessment e.g. for life insurance
Previous anaesthetic problem
History of back or neck pain and trauma
Results of national screening programme tests e.g. cervical smear, mammography,
colorectal screening
History with respect to Transmissible Infection
Previous illnesses
Jaundice or hepatitis
Malaria
Previous blood transfusion Tuberculosis / atypical mycobacterium Family history of tuberculosis
Family history of Creutzfeldt-Jakob disease, previous treatment with natural growth hormone, or undiagnosed degenerative neurological disorder
Specific geographical risk factors: e.g. fungi and parasites, tuberculosis, hepatitis, malaria, worms
Increased risk of HIV, HTLV1 and HTLV2, Hepatitis B and C infection
Haemophiliac or sexual partner of haemophiliac High risk sexual behaviour
History of infectious hepatitis or syphilis
History of intravenous drug use
Tattoo or skin piercing within last 6 months
Sexual partner of an individual with positive serology Sexual partner of drug addict.
Points of Particular Importance when Undertaking Clinical Examination of a Potential Kidney Donor
Abdominal fat distribution
Blood pressure
Body mass index
Dipstick urinalysis
Evidence of self-harm
Examination for abdominal masses or herniae
Examination for scars or previous surgery
Examination for lymphadenopathy
Examination / history of regular self-examination of the breasts Examination / history of regular self-examination of the testes Examination of the cardiovascular and respiratory systems Mental health
Routine Screening Investigations for the Potential Donor
Urine
Dipstick for protein, blood and glucose (at least twice) Microscopy, culture and sensitivity (at least twice) Measurement of protein excretion rate (ACR or PCR)
Blood
Haemoglobin and blood count
Coagulation screen (PT and APTT) Thrombophilia screen (where indicated) Sickle cell trait (where indicated) Haemoglobinopathy screen (where indicated) G6PD deficiency (where indicated)
Creatinine, urea and electrolytes
Isotopic or other reference test for measurement of GFR
Liver function tests
Bone profile (calcium, phosphate, albumin and alkaline phosphatase)
Urate
Fasting plasma glucose
Glucose tolerance test (if family history of diabetes or fasting plasma glucose >5.6 mmol/L)
Fasting lipid screen (if indicated)
Thyroid function tests (if strong family history)
Pregnancy test (if indicated)
Virology and infection screen
Hepatitis B and C
HIV
HTLV1 and 2 (if appropriate)
Cytomegalovirus
Epstein-Barr virus
Toxoplasma
Syphilis
Varicella zoster virus (where recipient seronegative)
HHV8 (where indicated)
Malaria (where indicated) Trypanosoma cruzi (where indicated) Schistosomiasis (where indicated)
Cardiorespiratory system
Chest X-ray
ECG
ECHO (where indicated)
Cardiovascular stress test (as routine or where indicated)
ASSESSMENT OF RENAL FUNCTION
The estimated glomerular filtration rate (eGFR), calculated from a creatinine assay calibrated to the International Reference Standard, should be used as the initial evaluation criterion for donor candidates.
A reference measured method (mGFR), such as the clearance of 51Cr-EDTA, 125iothalamate, or Iohexol, must then be used to determine GFR. These procedures must be carried out in accordance with the British Society of Nuclear Medicine’s published recommendations.
Differential kidney function, determined by 99mTcDMSA scanning is recommended where there is >10% variation in kidney size or significant renal anatomical abnormality.
DONOR AGE
Recommendations:
* Although elderly age alone is not a strict no-no for donation, older donors must undergo more stringent medical screening to ensure they are suitable. It is important to inform both the donor and the recipient that the function and potentially even the long-term survival of the graft may be affected and that the older donor may be more susceptible to postoperative problems. This is especially clear with donors who are older than 60.
DONOR OBESITY
Recommendations:
Patients who are overweight but otherwise in good health (BMI 25–30 kg/m2) can donate kidneys without risk.
Patients with moderate obesity (BMI 30-35 kg/m2) should have a thorough pre-operative evaluation to rule out cardiovascular, respiratory, and kidney disease.
Patients with moderate obesity (BMI 30-35 kg/m2) should receive advice about the increased risk of peri-operative complications based on extrapolation of outcome data from very obese donors (BMI >35 kg/m2).
Patients who are moderately obese (BMI 30-35 kg/m2) must be informed of the long-term risk of kidney disease and given advice on how to maintain their optimum weight both before and after donation. Donation should be discouraged in those who are extremely obese (BMI >35 kg/m2) due to the lack of information on the safety of kidney donation.
HYPERTENSION IN THE DONOR Recommendations
* At least two different occasions must be used to measure blood pressure. If blood pressure is high, high normal, fluctuating, or the potential donor is receiving therapy for hypertension, ambulatory blood pressure monitoring or home monitoring are advised. We advise that blood pressure readings of less than 140/90 mmHg are typically suitable for donation. Especially if they are in a high-risk group, prospective donors need to be informed about the possibility of developing hypertension connected to donation. Annual donor monitoring includes taking blood pressure readings.
* Potential donors may be accepted for donation if they have mild to moderate hypertension that is under control at 140/90 mmHg (or 135/85 mmHg with ABPM or home monitoring) and show no signs of end organ damage. Acceptance will be determined by a general evaluation of cardiovascular risk and regional regulations. Potential donors with hypertension should be discouraged from giving if:
o Blood pressure is not controlled to <140/90 mmHg on one or two antihypertensive drugs
o Evidence of end organ damage (retinopathy, left ventricular hypertrophy, proteinuria, previous cardiovascular disease)
o Unacceptable risk of future cardiovascular risk or lifetime incidence of ESRD
* All living kidney donors must be urged to take lifestyle steps, such as quitting smoking, consuming less alcohol, exercising frequently, and, when necessary, losing weight, to reduce their risk of hypertension and its effects both before and after donation.
* It is advised that donors who are found to have hypertension during evaluation or who experience hypertension after donation be treated in accordance with British Hypertension Society recommendations.
DIABETES MELLITUS
Recommendations
* Fasting plasma glucose levels must be assessed for all possible living kidney donors. An oral glucose tolerance test (OGTT) should be performed when the fasting plasma glucose level is between 6.1-6.9 mmol/L, which indicates an impaired fasting glucose status. Prospective donors should additionally have an OGTT if they have a higher risk of type 2 diabetes due to family history, a history of gestational diabetes, ethnicity, or obesity.
* If OGTT results show a persistently impaired fasting glucose and/or impaired glucose tolerance, it is important to carefully weigh the risks of developing diabetes after donation. The usage of a diabetes risk calculator should be taken into account while having the conversation about future kidney donation. Diabetes patients must have their risks and benefits carefully weighed before being considered as kidney donors. After a thorough evaluation of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney, diabetics can be considered for kidney donation in the absence of evidence of target organ damage and after ensuring that other cardiovascular risk factors like obesity, hypertension, or hyperlipidaemia are optimally managed.
CARDIOVASCULAR EVALUATION Recommendations
* The routine use of stress testing to evaluate potential donors with low cardiac risk is not supported by any data. Before donating, potential kidney donors having a history of cardiovascular disease, an exercise capacity of less than 4 metabolic equivalents (METS), or with cardiovascular disease risk factors should be given more scrutiny. Stress testing by whichever method is locally accessible or by CT calcium scoring is advised for higher risk potential donors. As part of the clinical evaluation of donors with increased cardiovascular and peri-operative risk, discussion with and/or review by cardiologists, anesthesiologists, and the transplant MDT is advised.
PROTEINURIA
Recommendations
* The amount of protein excreted in the urine from all potential living donors must be measured.
* The recommended screening test is a urine albumin/creatinine ratio (ACR) carried out on a spot urine sample, while urine protein/creatinine ratio (PCR) is a suitable substitute.
* Absolute contraindications to donation include ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day, and protein excretion >500 mg/day.
* The impact of somewhat elevated proteinuria (PCR 15-50 mg/mmol or 24-hour urine protein 150-500 mg/day) and albuminuria (ACR 3-30 mg/mmol) has not been thoroughly examined in living kidney donors. However, these levels indicate a relative contraindication to donation because the risk of CKD and cardiovascular morbidity rises steadily with rising albuminuria or proteinuria.
NON-VISIBLE HAEMATURIA
Recommendations
* Reagent strip (dipstick) urinalysis must be conducted on all prospective living donors at least twice. Persistent non-visible haematuria is defined as having two or more positive tests, even if they are only trace positive (PNVH).
* Perform a urine culture and renal imaging if PNVH is present to rule out common urologic reasons include infection, nephrolithiasis, and urothelial cancer. Perform a cystoscopy on patients older than 40 to rule out bladder pathology if no reason is discovered. If the donor still wants to donate but there is no indication of a cause, a kidney biopsy is advised if the haematuria on the dipstick test is 1+ or higher.
Donation is prohibited by glomerular pathology, with the probable exception of thin basement membrane disease. A kidney biopsy and referral to a clinical geneticist are advised for donors who have persistent asymptomatic non-visible haematuria (PANVH) and a family history of the condition or the X-linked Alport syndrome.
PYURIA
Statement of Recommendation
* Prospective donors who are discovered to have pyuria will only be taken into consideration for donation if it can be shown that the pyuria is brought on by a treatable condition, such as a simple urinary tract infection.
INFECTION IN THE PROSPECTIVE DONOR Recommendations
* It is crucial to check for infections in potential donors in order to determine the risks of infection transmission to the recipient as well as any potential concerns for the donor from past or present infections. Donors with active viral replication may be considered in specific situations, but active HBV and HCV infection in the donor is typically a contraindication to living donor kidney donation. HIV infection or infection with the human T lymphotrophic virus (HTLV) is an absolute contraindication to living donation.
Within 30 days of donation, screening for HBV, HCV, and HIV infection must be repeated. All prospective donors should receive dietary recommendations for preventing HEV infection, and within 30 days of donation, nucleic acid testing should be done to check for HEV viraemia. Prior to transplantation, the CMV status of the donor and recipient must be established. The potential of post-transplant CMV illness must be discussed with the donor and recipient when the donor is CMV positive and the recipient is CMV negative. Prior to transplantation, the EBV status of the donor and recipient must be ascertained. The possibility of developing Post Transplant Lymphoproliferative Disease must be discussed with the donor and recipient when the donor is EBV positive and the recipient is EBV negative.
NEPHROLITHIASIS
Recommendations
* Potential donors with a limited history of prior kidney stones or minor renal stone(s) on imaging may still be regarded as potential kidney donors in the absence of a major metabolic problem. Both the donor and the receiver must receive complete counseling, and the donor must have access to the proper long-term donor follow-up.
* Potential donors should speak with a renal stone disease expert if metabolic problems were found during screening.
* If vascular anatomy and split kidney function allow, it may be possible to donate the stone-bearing kidney from suitable donors who have unilateral kidney stones such that they will receive a kidney free of stones following the donation.
Hinda Hassan
2 years ago
These are the bts guidelines. It has started with ethical consideration regarding ensuring a a voluntary and informed choice about donation and independent assessment of the donor and recipient. Evaluation should be undertaken within an 18 week pathway, assuming there are no logistical issues such as donor unavailability. Having a compatible ABO blood group and human leucocyte antigen provides high chance of success. Otherwise, alternative options like paired/pooled donation and antibody incompatible transplantation should be discussed and performed in experienced center.
Renal function should be evaluated through estimated glomerular filtration rate followed by measured methods. 99mTcDMSA scanning should be considered when there is >10% variation in kidney size or significant renal anatomical abnormality. Pre-donation mGFR should be such that the predicted post-donation GFR remains within the gender and age-specific normal range.Donors need to be offered lifelong annual assessment of renal function. Age alone is not an absolute contraindication to donation but both donor and recipient must be aware that the older donor may be at greater risk of peri-operative complications and less graft survival. BMI 25-30 kg/m2can safely proceed to kidney donation but BMI 30-35 kg/m2need careful preoperative evaluation and counseling regarding weight reduction. BMI >35 kg/m2 should be discouraged. BP should be assessed on at least 2 separate occasions and use ambulatory / home monitoring if blood pressure is high, high normal or variable, or the potential donor is on treatment for hypertension. The target is <140/90 mmHg and all donors need to utilize all the measures needed to minimize the HTN risk.. Donors need to be warned about the risk of developing donation-related hypertension. Donors with controlled mild/moderate hypertension with one or two antihypertensive drugs and who have no evidence of end organ damage may be acceptable for donation after full assessment of cardiovascular risk. Otherwise they should be excluded.
fasting plasma glucose need to be checked and oral glucose tolerance test (OGTT) should be undertaken if FBG 6.1-6.9 mmol/L , presence of DM2 risk , family history, a history of gestational diabetes, ethnicity or obesity . if this is abnormal,then the risks of developing diabetes after donation must be carefully considered through use of a diabetes risk calculator.
Cardiac risk need to be assessed and reviewed with cardiologists and anaesthetists and further evaluation is needed in cases with a history of cardiovascular disease, an exercise capacity of <4 metabolic equivalents (or with risk factors for cardiovascular disease. Stress tests are applied to high risk potential donors.
Urine protein excretion quantification is recommended in all potential living donors through ACR or PCR initially. if ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day or protein excretion >500 mg/day ,this is an absolute contraindications to donation. Levels below this and above normal are a relative contraindication to donation.
All potential living donors must have reagent strip urinalysis performed on at least two separate occasions. In case of two or more positive tests, including trace positive, persistent non-visible haematuria, urine culture and renal imaging need to be done to exclude common urologic causes. If those are negative, perform cystoscopy in patients age >40 years.If no cause is found and the donor still wishes to donate, then a kidney biopsy is recommended if haematuria is 1+ or greater on dipstick testing. Glomerular pathology precludes donation, with the possible exception of thin basement membrane disease. For donors with persistent asymptomatic non-visible haematuria and a family history of haematuria or X-linked Alport syndrome, a renal biopsy and referral to a clinical geneticist are recommended.
Presence of pyuria if due to a reversible cause,is not a contraindication for donation. Infections need to be screened to identify potential risks for the donor from previous or current infection and to assess the risks of transmission of infection to the recipient and screening for HBV, HCV,HEV and HIV infection must be repeated within 30 days of donation. Active HBV and HCV infection in the donor are usually contraindications to living donor kidney donation; however, donors with evidence of active viral replication may be considered under some circumstances. HIV or human T lymphotrophic virus infection is an absolute contraindication to living donation. If the donor has CMV or EBV, and the recipient is CMV or EBV negative, the donor and recipient must be counselled about the risk of post-transplant CMV or EBV respectively. travel or abroad residence history need to be assessd to avoid risk of endemic infections.
Donors with PMH of stones may still be considered as potential kidney donors after full counselling and appropriate long-term donor follow up. If metabolic abnormalities were detected on screening, they should be discussed with a specialist in renal stone disease. In appropriate donors with unilateral kidney stone(s) the stone-bearing kidney can be considered for donation (if vascular anatomy and split kidney function permit) in order to leave the donor with a stone-free kidney after donation.
Donor anaemia needs to be investigated and treated before donation and if non Northern European heritage or if indicated, haemoglobinopathy screen must be carried out. Consultant haematologist advice is recommended.
detailed family history of kidney disease is mandatory and if the recipient has an inherited condition, appropriate tests are recommended in the potential donor.
Exclude donor malignancy through history, clinical examination and investigation.Active malignant disease is a contraindication to living donation but donors with certain types of successfully treated low-grade tumour may be considered after careful evaluation and discussion. Accidental renal mass lesion must be diagnosed, managed, referred to a Urology Specialist and appropriate images are recommended. An incidental, unilateral solitary AML <4 cm with typical characteristic CT criteria does not usually preclude donation. A kidney with an AML <1 cm may be considered for donation or left in situ in the donor’s remaining kidney. Kidneys containing a single AML between 1 and 4 cm can be considered for donation depending on its position, consideration of whether ex vivo excision of the AML is straightforward, or whether it can be left in situ in the recipient and followed with serial ultrasound imaging.
Surgery work-up for living kidney donation may include direct or indicative evaluation of split renal function with the kidney with poorer function selected for nephrectomy irrespective of vascular anatomy and it must include detailed imaging confirming the vascular anatomy of both donor kidneys and information about the renal parenchyma and collecting systems. Either CTA or MRA can be used as current evidence indicates little difference in accuracy. Multiple renal arteries or kidneys with anatomical anomalies are not absolute contraindications to donation. Decisions must be made on an individual basis as part of a multi-disciplinary team evaluation.
All living donors must receive adequate thromboprophylaxis and appropiate compression devices.
All living donor surgery must be performed or directly supervised by a Consultant surgeon with appropriate training in the technique. Laparoscopic donor surgery is the preferred technique and Mini-incision surgery is preferable to standard open surgery.hydration pre- and peri-operative intravenous fluid replacement with Hartmann’s solution is preferred to 0.9% Saline.
histocompatibility status assessment through an evidence-based protocol is recommended at an early stage of work-up with antibodies screening particularly for recipients with high potential of immunosuppression reduction or withdrawal. The histocompatibility laboratory must issue an interpretive report stating the donor and recipient HLA mismatch, recipient sensitisation status and crossmatch results, and define the associated immunological risk for all living donor-recipient pairs Post-transplant antibody monitoring must be undertaken according to the BSHI/BTS guidelines. When possible, the partners/offspring HLA types, for a female recipients who have had previous pregnancies should be determined. A 14 days pre-transplant serum sample collected must be tested in a sensitive antibody screening and donor crossmatch assay and transplantation should not usually be performed if the crossmatch test is positive, unless the antibody is shown to be indicative of acceptable immunological risk. Any changes in immunosuppression during the transplant work-up must be notified to the histocompatibility laboratory. HLA matching may be preferred when there is an option of selecting between living donors, particularly to reduce the possibility of subsequent sensitisation. For patients with an ABO/HLA incompatible and/or a poorly HLA matched living donor, consideration should be given to entry into the UK living kidney sharing scheme (UKLKSS) to identify a more suitable donor. To maximise transplant opportunities within the UKLKSS, donors and recipients must only be included in a matching run if:
1. Their clinical assessment and histocompatibility screening are complete and up to date.
2. If matched, they are available to attend for crossmatch testing and proceed to surgery within the designated timeframes.
3. Relevant complex donor considerations identified in the ‘prerun’ and donor HLA and age preferences have been discussed and agreed with the recipient.
4. They understand their roles and responsibilities with respect to other donors and recipient pairs in the schemes with whom they may be matched.
Donors need to be informed about the risk of donation and women must be informed of a greater risk of pregnancy-induced hypertension following kidney donation. Close monitoring of blood pressure, creatinine and foetal well-being is advisable in kidneys donors during pregnancy. Kidney donors may be offered Aspirin 75 mg daily for pre-eclampsia prophylaxis.
For recurrent diseases, the consequences for transplant function, and the time-course of any deterioration must all be considered. A discussion of the effects of immunosuppression and transplant failure on morbidity and mortality may also be appropriate, it is high in FSGS and MCGN.
Pre-emptive living related, from a blood group compatible well-matched donor, renal transplantation is the gold standard therapy for children with minimising HLA mismatches. they should be assessed by a multi-disciplinary team, and children who are ≥10 kg in weight are suitable to receive a kidney from an adult living donor.
Our local guidelines follows most of the recommendations except that we do not usually do invasive measures to donors.
CARLOS TADEU LEONIDIO
2 years ago
This guideline is intended for the entire transplant community and aims to provide guidance on how to maintain the health and well-being of the living donor, including ethical and medico-legal principles regarding donor selection and preoperative medical evaluation. from the donor.
LEGAL FRAMEWORK:
All living donor transplants must comply with relevant UK legislation, highlighting the withdrawal consent that must comply with the requirements of the Human Tissue Act 2004 and the Mental Capacity Act 2005 and have evidence of non-commercial negotiation of human material.
Living donations can be:
– Targeted: known recipient, with pre-existing emotional or genetic relationship
– Paired: formation of donor-receiver pairs where a “linked exchange” is involved.
– Altruistic – Undirected: This is an unspecified donation to an unknown recipient.
– Altruistic – directed: this is a donation where the donor has the desire to donate and there is no relationship with the receiver prior to the decision to donate, but is built during the process.
ETHIC:
Ensuring the well-being and safety of the donor is a cornerstone, followed by independence between the medical teams responsible for the evaluation and preparation of the donor and recipient. Ethical principles such as: Autonomy, Beneficence, Dignity, Non-maleficence, Reciprocity and Confidentiality must be remembered throughout the process, both from the point of view of the donor and the recipient. And the Right to Information on specific points of the process and possible results is also a central commitment throughout the process.
DONOR EVALUATION:
Refers to clinical and psychosocial assessments that identify weaknesses that may contraindicate donation or identify clinical risks to the donor that need to be managed in the pre- and postoperative period. It is important to remember the possibility of requesting a second opinion throughout the process.
The following are important clinical conditions to be evaluated in potential donors:
A – Evaluation is the renal function and its risk of deterioration, with the establishment of the GRF limits that must be adopted and also the monitoring of the donor after the donation. Where aging with the natural loss of GFR and the development of comorbidities that may impair renal function are closely monitored. It is noteworthy that the incidence of end-stage renal disease is lower in this population than the incidence in the unselected general population.
B – Senility alone is not a contraindication for donation. It encompasses a higher risk of surgical complications and that long-term graft function and survival will be more compromised.
C – Obesity is a risk factor for surgical complications and is involved with a greater number of comorbidities (cardiovascular, respiratory and renal) that may harm the donor, with donation being contraindicated in very obese patients.
D – Hypertension: pre-donation management and warning about the possibility of development after donation.
E – Diabetes: just like hypertension, pre-donation management is carried out, with a thorough assessment of target organ damage and risk assessment using calculators.
F – Pre-donation cardiovascular assessment
G – Proteinuria: because it is a predictor of chronic kidney disease and cardiovascular mortality
H – Non-visible hematuria: after ruling out urological causes (lithiasis, infection and urothelial carcinoma), it is necessary to exclude bladder disease, so that we can assess glomerular disease. Persistent hematuria will prompt biopsy.
I – Pyuria: reversible disease must be evidenced – infectious condition – for approval of the donation.
J – Infections: the presence of active infections suspends the donation. Mandatory screening for Hepatitis (A, B and E), HIV, HTLV, CMV, EBV, fungal and parasitic infections, prion disease. Bacterial diseases deserve special attention due to the possibility of donation when good treatment is performed. Mycobacteria prevent transplantation.
L – Nephrolithiasis: patients with a limited history of previous renal lithiasic disease and small renal calculi, with no serious metabolic disease
M – Haematological disease: hemoglobinopathies need to be excluded.
N – Familial kidney disease: must be excluded both in the donor and in the recipient.
O – Donor malignancy: screening mainly for those living donors over 50 years old. It leads to suspension of the donation, except when there are low-grade tumors that have been successfully treated.
SURGERY: ethical and technical aspects, donor risks
Detailed imaging examination should be performed for vascular and anatomical evaluation (renal parenchyma and collecting systems), with no absolute contraindication if there is any problem. Thromboprophylaxis and preoperative hydration to improve cardiovascular stability are mandatory to reduce perioperative mortality, which is low.
The importance of multimodal strategies to improve recovery after nephrectomy should be valued (decreased preoperative fasting, epidural analgesia, preoperative psychology, preoperative fluid infusion)
HISTOCOMPATIBILITY TEST
Early stage to be performed to avoid unnecessary clinical investigation. The first action is the exclusion of clinically relevant antibodies to ensure optimal donor selection and graft survival. Adequacy between transplant units and histocompatibility laboratories is essential for following an established protocol.
Mahmud Islam
2 years ago
Living kidney donation outcomes are always better than the deceased donation. Donors were well investigated before surgery and evaluated systematically. The transplant MDT should inform the donor with sufficient information regarding the risks and benefits. In the last years, there has been a trend to extend the donor pool. Minors younger than 18 years should rarely if ever accepted as donors. Donors should have the opportunity of independence of decision. The information needs to be comprehensive with honest. Donors need to be evaluated by a multidisciplinary team to determine the eligibility and risk of donation. Routine screening includes urine, blood test for CBC, biochemistry, and infectious agents evaluation in addition to systemic evaluation with special stress on cardiovascular evaluation. Each donor candidate should have at least basic ECO, CXr, ECHO and stress test (when indicated). Assessment of renal function includes eGFR and evaluation for proteinuria and hematuria. Differential eGFR with radio nuclear studies may be needed (combined EDTA and DMSA). Age itself is. Ot an absolute contraindicartion. Both recipient and donor should be aware of benefits vs risks. Blood pressure is important to evaluate. Donors are suggested to be excluded in case of evidence of end-organ damage and/or uncontrolled HT (target <140/90) with one or two medications. Concomitant risk factors like obesity and smoking should be minimized. DM is a well-known risk factor for CKD. Donors with DM should be evaluated for the lifetime risk of CKD before being considered for donation. Fasting blood glucose of more than 7 mmol/L of A1c>6.5 in addition to OGTT may be used. (QDiabetes®-2015 risk calculator: http://qdiabetes.org) maybe useful in evaluation. CVS evaluation is critical. Stress test is not usually routine but should be used in certain circumstances. CT calcium score is recommended for high-risk patients. Proteinurea is important. PCR or 24 hours quantitative measures may be used. ACR>30 mg/mmol or 300mg/day, and PCR>50 or 500mg/day are absolute contraindications for kidney donation. Non-visible hematuria should be evaluated, and cystoscopy is done when needed. Except for thin basement membranes, glomerular pathologies preclude donation. Active infection, active HBV, or HCV viral infections are contraindications. HIV and HTLV are also contraindications for donation. CMV positivity should be evaluated, and the risk of post-transplant CMV infection should be explained, especially in case the recipient is CMV-negative. This applies to EBV as well. In absence of metabolic reasons for kidney stones, donors may be accepted with the preference of donating kidneys with stones as long as split renal function allows. Some are incidental. Hematologic disease and evaluation of anaemias for hemoglobinopathies may need to be carefully considered.
Mohammed Sobair
2 years ago
Donor’s types and donor perceptive:
LRKT improved donation pool.
Welfare and safety of donor must be seeked.
Though compliance with both legal and medical act by transplantation center.
Donor give valid consent, without duress or coercion, and that reward is not a factor in the donation.
Understand potential risk of transplantation.
Donors can receive reimbursement of expenses, such as travel costs and loss of earnings result from donation of an organ.
. Types of Living Donation:
Directed donation, Paired or pool donation, Non-directed altruistic donation and directed altruistic donation.
Donor is not allowed for children below 18years and person without mental capacity (only by court). Ethics:
Should be observed by all transplant team.
Independent assessment team is required for donors and recipient.
Psychiatric/psychological services must be available for donors/recipients requiring referral. Confidentiality:
Should be maintained at outset and information shared decided at the start.
Donor advocacy and psychological services should be provided to donors.
Evaluation of donors:
Multi-disciplinary team and
Agreed, evidence-based protocol.
A logical sequence.
Option of a second opinion must always be available to donors and recipients if donor not found suitable. Time of evaluation:
Variable, whenever recipient is ready for transplant.
Discussion with potential donors and recipients will usually be started when the recipient eGFR is approximately 20 mL/min or when the recipient is expected to require renal replacement therapy within 12-18 months. Duration of evaluation:
Evaluation of a potential donor should be undertaken within an 18 WEEEKS
Evaluation should be planned.
An agreed donor assessment protocol must be in place. A flow chart:
Early:
Early education & discussion with all potential transplant recipients +/- potential donors about optimal options for transplantation.
Establish recipient fit for transplantation & start appropriate pre-transplant assessment. Weeks 0-2:
Donor identified, LD coordinator facilitates initial discussion with potential donor(s) +/- recipient & other family members as appropriate. Most appropriate should be identified, taking into account possible social, psychological and medical risk factors. Weeks 2-4:
Primary contra-indications identified from donor(s) past and present medical history
ABO compatibility +/- HLA sensitization.
. Routine blood & urinalysis tests. Weeks 4-8:
Donor evaluation is planned with the prospective donor, in a timely manner, to an agreed protocol & in accordance with the availability of local resources. Weeks 8-10:
Results review by members of the MDT & feedback to the donor. Weeks 11:
Suitable donor & recipient pair:
Referred for final preoperative discussion with Consultant Nephrologist and Transplant Surgeon.
Final cross match within the 7-10 days before transplantation and routine pre-op investigations,
Pre-admission visit. Week 18:
OPERATION.
LD coordinator maintains contact with donor & facilitates life-long follow-up arrangements
If donor unsuitable, follow-up arranged.
How these guidelines are different from the guidelines you follow at your workplace?
In our centers less split test i used to assess donor kidney function.
Hamdy Hegazy
2 years ago
Please summarize these guidelines in your own words
Requirements before transplantation: 1- Consent. 2- No reward or organ purchasing. 3- Independent assessor of donor and recipient. Types of donors: 1- Directed to a specific recipient. 2- Non-directed. 3- Directed altruistic donation. 4- Paired donation. The donors should be assessed for their mental health and physical safety for donation. They should be provided with information about the procedure, outcomes and complications. Albuminuria occurs after donation with a slight increase in the risk of ESRD in donors. The risk of ESRD increase in current or former smoker, obese, diabetic, African- American and patients with albuminuria or renal impairment. assessment of donor kidney functions is preferred by estimated GFR using serum creatinine (CKD-EPI) this is to exclude donors with CKD , this test should be confirmed by measuring creatinine clearance using 24 hours urine. Safe threshold level for kidney donation is ≥ 80 mL/min for donors ≥ 30 years and ≥ 90 mL/min/1.73 m2 for those <30 years old. Split kidney function helps assess the function of each kidney to donate the lower functioning kidney. it can be best done using 99mTcDMSA scanning. Old age > 60 years is not a contraindication to donation. Donors should be evaluated and donor and recipient should be informed with the increase in risk of perioperative complications Obese with BMI 25-30 kg/m2 can proceed to donation safely, those with BMI 30-35 kg/m2 can proceed to donation if they accept the peri-operative and long term risk associated with obesity and are willing to lose weight, patients with BMI >35 kg/m2 should be excluded form donation Evaluation of BP before kidney donation
Clinic BP: at least 2 separate visits, using calibrated BP device, proper sized cuff, by trained staff, after resting 5 min, and taking 3 readings at least 1 min apart
Home BP: Clinic BP reading should be confirmed with home BP evaluation.
Ambulatory 24 hours BP monitoring: is indicated if the clinic BP is ≥ 130/85, variable BP measurements or if the patient is on antihypertensive medications
Guidelines for safe donation (regarding BP) Donors with clinic BP ≺ 140/90 mm Hg (Home BP or AMBP ≺135/85 mmHg) on no antihypertensive medications: donate safely. Donors with clinic BP ≺ 140/90 mm Hg (home BP or AMBP ≺135/85 mmHg) on 1 or 2 antihypertensive medications: can proceed safely to kidney donation if there is no evidence of end organ damage. Donors with clinic BP ≥ 140/90 mm Hg on 2 antihypertensive medications: should be excluded from donation Donors receiving more than 2 antihypertensive medications or having end organ damage should be excluded from donation. Treatment of hypertension post donation as per British hypertension society guidelines. All donors should be screened for proteinuria, if ACR > 30 mg/mmol or PCR> 50 mg/mmol and proteinuria> 500 mg/day –à excluded from donation. All donors should be screened for hematuria in 2 separate occasions, if positive, they should be evaluated by urine culture, scanning and cystoscopy, renal biopsy can be done, if it reveals thin basement disease, the donor can proceed for the procedure. Recipients are worked up for transplantation once GFR is below 20 ml/min/m2 and expected initiation of dialysis is within 1-1.5 years. Donor evaluation: includes discussion, history, examination, investigations, planning, feedback of the donor, final pre-operative discussion, final cross match and routine peri-operative investigations. Donors should be screened for infection as per protocol. Especially CMV status, EBV status. Donors with renal stones can donate if not recurrent, if unilateral. They should donate the kidney with stones. Vascular anatomy of the kidney should be assessed before donation using CTA or MRA. If ABO and HLA incompatible-à kidney paired donation or desensitization should be done in expert center. Cardiovascular assessment: non-invasive tests. If +ve coronary CT angiography, refer to cardiology for further evaluation and possible coronary angiography. Risk of recurrence of original kidney disease should be discussed with both donor and recipient. How these guidelines are different from the guidelines you follow at your workplace? In my center, we deal with living related donation, all donors should have split renal function test by renal isotopic scan, kidneys with stone or masses are excluded from donation.
Nasrin Esfandiar
2 years ago
Ⅰ-comprehensive history and the physical exam:
1) The history of hypertension, diabetes, urinary tract infection (UTI), urinary symptoms, proteinuria or hematuria, nephrolithiasis, cardiovascular disease and its risk factors, thromboembolic events, gestational diabetes (GDM), low birth weight (if possible), birth weight of offspring(s), history of blood transfusion, and any significant medical conditions such as infectious diseases.
2) Female candidates with history of GDM in the past 10 years are excluded from
donation.
3) A history of alcohol abuse, smoking history, substance abuse, and NSAIDs usage should be taken.
4) Family history of diabetes, renal disease (Nephrolithiasis, ADPKD, IgA
nephropathy, SLE), and infectious diseases should be taken.
5) History of pregnancy or planning for pregnancy.
6) Body mass index should be calculated.
7) Blood pressure should be measured in office or by ABPM if indicated.
.
8) Signs of heart disease, lung disease, lymphadenopathy, hepatomegaly, and splenomegaly should be examined.
9) The vascular system (abdominal, femoral, carotid bruits) should be evaluated. Ⅱ-Then laboratory investigations are necessary which include:
1) Blood group, Rh
2) Complete Blood Count (CBC), Differential
a) The potential donor with anemia must be evaluated for the etiology.
3) FBS
a) FBS ≥ 126 mgr/dl or post prandial glucose with oral GTT≥ 200 mg/dl or Hb A1c ≥ 6.5% preclude donation.
b) FBS between 100-126 mgr/dl with the history of diabetes in 1° relatives or obesity or gestational diabetes should be assessed by OGTT
4) BUN, Creatinine
a) Serum Creatinine level would be used to estimate GFR based on CKD-EPI
equation.
5) A comprehensive panel (Electrolytes, Lipid profile)
6) Uric acid
7) Liver function tests
8) PT, PTT, INR.
9) ESR, CRP
10) Urine analysis includes dipstick and microscopic evaluation and culture, protein excretion rate (ACR or PCR) must be done in all potential donors.
11) All the female prospective donors during the childbearing age should be tested for beta HCG.
12) Thrombophilia screen, the sickle cell trait, Hemoglobinopathy screen and G6PD (if indicated) III. ASSESSMENT FOR LATENT AND ACTIVE INFECTIONS
1(VDRL or RPR
2) Wright’s test to detect brucellosis.
3) PPD with CXR
4) An antibody screening for HIV-1 and HIV-2.
5) HBsAg, HBsAb titer and HBcAb (IgM,IgG)
6) Anti-HCV Antibody (ELISA).
7) CMV antibodies (IgM, IgG).
8) EBV antibodies (IgM, IgG).
9) Anti-HSV Antibodies (IgM,IgG)
10) Anti HTLV1,2 antibodies.
11) Anti toxoplasma antibodies (IgM, IgG). IV. HYPERTENSION
1) Donors should have at least 2 office blood pressure measurements less than 140/90 mm Hg. V. OBESITY
1) Measurement of BMI is recommended. VI. DIABETES MELLITUS
1) Donors with a positive history for diabetes or FBS equal or more than126 mg/dL on at least two occasions or post prandial and OGTT ≥ 200 mg/dL or HbA1c ≥ 6.5% are excluded. VI. CARDIOVASCULAR EVALUATION
1) All potential donors need an electrocardiogram and a CXR and echocardiography prior to surgery. VII. PULMONARY EVALUATION
1) It is advised to quit smoking 4 weeks before the transplantation.
2) The pulmonary function test and pulmonary evaluation should be done in donors with a history of chronic lung disease or pulmonary symptoms. VIII. MALIGANACY SCREENING
1) Age related malignancy screening should be done for prospective donors.
2) All the sexually active female donors should have a pap smear. IX. RENAL FUNCTION
1) Estimating glomerular filtration (GFR) by CKD-EPI equation and measured GFR by EDTA are performed for donor evaluation. Safe GFRs for donation are according the following table (2, 24).
Ahmed Abd El Razek
2 years ago
Summary
This guidance applies only to living donor kidney transplantation.
Type of donation:
1. Directed donation: (Genetically related donation &Emotionally related donation)
2. Paired or pool donation
3. Non-directed altruistic donation
4. Directed altruistic donation
Donor evaluation
The main target of donor evaluation is to confirm the convenience of the donor as well as minimization the risk of donation.
The confidentiality of the donor should be respected in addition to maintaining a strict separation of the mutual interests of the donor and recipient. In order to achieve this; two separate clinical teams assess the donor and recipient before donation.
A compatible ABO blood group and human leucocyte antigen (HLA) transplant offers the best opportunity for success
A full past and present medical history must be taken. A thorough clinical examination must be performed. A psychosocial assessment is recommended for all donors.
Crucial items concerning both the Medical and Family History of a candidate Potential Kidney Donor are:
Haematuria/proteinuria/urinary tract infection
Difficulty in passing urine, including urgency, frequency, dysuria
History of peripheral oedema
Gout
Nephrolithiasis
Hypertension
Diabetes mellitus, including family history
Ischemic heart disease/peripheral vascular disease/other atherosclerosis
Cardiovascular risk factors
Thromboembolic disease
Sickle cell and other haemoglobinopathies
Weight change
Change in bowel habit
Previous jaundice
Previous or current malignancy
Systemic disease which may involve the kidney
Chronic infection such as tuberculosis
Family history of a renal condition that may affect the donor
Smoking
Current or prior alcohol or drug dependence
Previous anaesthetic problem
History of back or neck pain and trauma
History with respect to Transmissible Infection
Previous illnesses: Jaundice or hepatitis, Malaria, Previous blood transfusion, Tuberculosis.
Increased risk of HIV, HTLV1 and HTLV2, Hepatitis B and C infection: Haemophiliac or sexual partner of haemophiliac, High risk sexual behaviour, History of infectious hepatitis or syphilis, History of intravenous drug use, Tattoo or skin piercing within last 6 months, Sexual partner of an individual with positive serology, Sexual partner of drug addict.
On Clinical Examination highlight the following:
Abdominal fat distribution
Blood pressure
Body mass index
Dipstick urinalysis
Evidence of self-harm
Examination for abdominal masses or herniae
Examination for scars or previous surgery
Examination for lymphadenopathy
Examination / history of regular self-examination of the breasts
Examination / history of regular self-examination of the testes
Examination of the cardiovascular and respiratory systems
Mental health Routine Screening Investigations
Urine
Dipstick for protein, blood and glucose (at least twice)
Microscopy, culture and sensitivity (at least twice)
Measurement of protein excretion rate (ACR or PCR)
Blood
Haemoglobin and blood count
Coagulation screen (PT and APTT)
Thrombophilia screen
Creatinine, urea and electrolytes
Isotopic or other reference test for measurement of GFR
Liver function tests
Fasting plasma glucose
Virology and infection screen
Hepatitis B and C
HIV
Cytomegalovirus
Epstein-Barr virus
Toxoplasma
Cardiorespiratory system
Chest X-ray
ECG
ECHO
ASSESSMENT OF RENAL FUNCTION
Measurement of Renal Function:Initial evaluation by using estimated glomerular filtration rate (eGFR), in terms of mL/min/1.73m2 in a creatinine assay, followed by assessment by another reference measured method (mGFR) as clearance of 51Cr-EDTA, 125iothalamate or Iohexol.
Split renal function, evaluated by 99mTcDMSA scanning is recommended if there is >10% variation in kidney size or significant renal anatomical abnormality.
GFR Thresholds for Donation
Pre-donation mGFR ought to be within the gender and age-specific normal range. The potential donor must be consented for probability of increased lifetime risk of ESRD following donation. Monitoring of Kidney Donor should be lifelong annual assessment of renal function at least serum creatinine, estimation of urine protein excretion and blood pressure measurement.
GFR in this normal population remains stable in both sexes until aged around 40 years and then declines each decade at a rate of 6.6 mL/min/1.73m2 for men and 7.7 mL/min/1.73m2 in women.
Increased lifetime risk ESRD in kidney donors is similar to the general population with exception of the presence of Hypertension, obesity and prediabetes.
A threshold GFR >80 mL/min/1.73m2 appears safe for donation in the 35 year and above age range. A threshold for donation of >90 mL/min/1.73m2 is set for those <30 years.
DONOR AGE
The older donor may be at greater risk of peri-operative complications and possibly the long-term survival of the graft may be affected which is apparent in cases with donors >60 years of age.
Pre-donation cardio-respiratory function should be carefully assessed in older donors. Most centres perform a stress echocardiogram and/or myocardial perfusion scan if indicated. Respiratory function tests are indicated in smokers and those with airway disease.
Screening of serum PSA is mandatory in males above 55 years.
Younger donors can develop later on diabetes, hypertension, obesity, immunologically mediated disease or other renal risk factors, and have more time for these risk factors to progress to CKD and finally ESRD.
Moderately obese patients (BMI 30-35 kg/m2) necessitate careful preoperative assessment to exclude cardiovascular, respiratory and kidney disease as well as counselling about the increased risk of peri-operative complications. These donors must be advised to lose weight prior to donation and to maintain their ideal weight following donation. Obese donors have substantial increased risk of hypertension, hypercholesterolemia, insulin resistance and diabetes, heart disease, stroke, sleep apnoea and certain cancers. Obesity is considered a relative contra-indication to living kidney donation as there is a high increased risk for surgical complications.
Laparoscopic donor nephrectomy is an increasingly recommended safe procedure in the candidate healthy obese kidney donor and does not result in a high rate of major peri-operative complications.
HYPERTENSION IN THE DONOR
Blood pressure must be assessed on at least two separate occasions.
Ambulatory blood pressure monitoring or home monitoring is requested when blood pressure is high, high normal or variable, or the potential donor is on treatment for hypertension.
Blood pressure <140/90 mmHg is usually acceptable for donation.
Potential donors with mild-moderate hypertension that is controlled to <140/90 mmHg with one or two antihypertensive drugs and who have no evidence of end organ damage may be acceptable for donation.
DIABETES MELLITUS
Fasting plasma glucose concentration between 6.1-6.9 mmol/L is indicative of an impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be done.
CARDIOVASCULAR EVALUATION
Potential kidney donors with a history of cardiovascular disease, an exercise capacity of <4 metabolic equivalents (METS) or with risk factors for cardiovascular disease should undergo further evaluation prior to donation.
Cardiologists, anaesthetists and the transplant MDT is recommended as part of the clinical assessment of donors with higher cardiovascular and peri-operative risk.
CT coronary calcium scoring may be an alternative way of stratifying coronary risk.
PROTEINURIA
ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day or protein excretion >500 mg/day represent absolute contraindications for donation.
Orthostatic proteinuria should not be considered as a contraindication to donation.
NON-VISIBLE HAEMATURIA
All potential living donors must have reagent strip (dipstick) urinalysis performed on at least two separate occasions. Two or more positive tests, including trace positive, is considered as persistent non-visible haematuria (PNVH). If PNVH is present, perform urine culture and renal imaging to exclude common urologic causes including infection, nephrolithiasis and urothelial carcinoma. If no cause is found, perform cystoscopy in patients age >40 years to exclude bladder pathology.
The possible exception of Glomerular pathology is thin basement membrane disease. Renal biopsy may be needed. INFECTION IN THE PROSPECTIVE DONOR
The presence of HIV or human T lymphotrophic virus (HTLV) infection is an absolute contraindication to living donation. Screening for HBV, HCV and HIV infection must be repeated within 30 days of donation. Active HBV and HCV infection in the donor are contraindications to living donor kidney donation.
The CMV status of donor and recipient must be determined before transplantation. When the donor is CMV positive and the recipient is CMV negative, the donor and recipient must be counselled about the risk of post-transplant CMV disease.
NEPHROLITHIASIS
In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as kidney donors.
In appropriate donors with unilateral kidney stone(s) the stone-bearing kidney can be considered for donation (if vascular anatomy and split kidney function permit) in order to leave the donor with a stone-free kidney post donation.
Follow Up these donors post donation by maintaining a high fluid intake for life (at least 2.5 litres of fluid per day) as well as regular follow-up imaging e.g. annual renal ultrasound and assessment of the metabolic profile should be considered.
ADPKD
A negative renal ultrasound beyond the age of 40 years excludes disease. Between the ages of 20-40 years, a negative ultrasound should be followed by a CT or MRI scan.
Our centre applies the British transplantation guidelines .
Abdul Rahim Khan
2 years ago
Please summarise these guidelines in your own words
Prerequisites:
There are three pre requisites before transplantation that include a proper consent from donor, it should be reward less, and acceptance report of donor and recipient should be assessed by an independent assessor.
Donors are either directed or non-directed. A directed altruistic donation could be the one in which A donor and recipient either know each other but have no blood relation between each other .A non-directed donation is the one in which the donor and recipient never met before or they go into go into paired donation
Mental health of potential altruistic donors should have a capacity to consent and that should be assessed by an experienced clinician.
Donor safety is the first priority and should be considered ,regardless of recipient benefit. He should be explained in detail about procedure , out come and safety
Donor Confidentiality should be ensured
If a donor does not meet centre specific criteria he/she should be offered a second opinion by other transplant centre.
Transplant recipient should be assessed first to be eligible for transplant and then donor should be evaluated as early as possible so that next donor can be screened in case of first donor failure.
Time of initiation of transplant workup
Once eGFR of the recipients is below 20 mL/min or if the recipient is expected to have a RRT within 1-1.5 years discussion between recipient and donor should be started.
Donor evaluation : it roughly takes around 18 weeks, discussion for first 2 weeks,, evaluation in next 2 weeks that includes history, examination, investigations including HLA typing and ABO, cross matching. 1 month for time planning, 2 weeks are given to donor for feedback , 6 weeks for final preoperative discussion. Last one week is just before transplantation 1 week before transplantation and a final repeat final cross match and routine preoperative investigations are done. Operation is done in 18th week.
Donor Education: every donor should be educated to minimize and control risks to prevent ESRD. Young child bearing age donors educated about gestational HTN and preeclampsia. An appropriate follow up plan after donation should be offered to all and if not fit they should be informed as soon as possible
To achieve best results ABO and HLA compatibility is a must. For ABO or HLA incompatibility the patient have options like KPD or desensitization which is done only in experienced centres.
Albuminuria –post operative is more common in donor and there is a slight increase in the risk of ESRD observed in donors. The risk of ESRD is more in current or former smoker, obese, diabetic, African- American and patients with albuminuria or renal impairment
It is always important to assess kidney functions pre operatively in donor by measuring estimated GFR using serum creatinine (CKD-EPI). This will help to exclude donors with evident CKD. Further confirmation is done by measuring creatinine clearance using 24 hours urine.
Safe threshold level for kidney donation is the least GFR at which the patient can safely donate his kidney if there is no other contraindications. This is ≥ 80 mL/min for donors ≥ 30 years and ≥ 90 mL/min/1.73 m2 for those <30 years old.
Donor with lower functioning kidney: Split Kidney Functions are done to assess the function of each kidney using 99mTcDMSA scanning which is indicated if there is >10% variation in kidney size or abnormal renal anatomy detected by CT.
If donor age > 60 years he/she should be evaluated rigorously and donor and recipient should be informed with the increase in risk of perioperative complications. But age above 60 is no contra indication.
Donors with BMI 25-30 kg/m2 can donate safely, those with BMI 30-35 kg/m2 can only donate if they accept the peri-operative and long term risk associated with obesity and are willing to lose weight, patients with BMI >35 kg/m2 should be excluded form donation.
HTN after kidney donation will develop if higher BP before donation, African American and Hispanic ethnicity and obesity, Elderly, these patients should be educated about the risk of developing hypertension after donation
Regarding Glycaemic control all donors should have fasting BG.If there are risk factors such as obesity, positive family history of DM, history of gestational DM, African-American OGTT is performed. HBA1c can identify the donor as normal, impaired fasting, IGT or diabetic.
Donors with impaired fasting or IGT need to be educated about the risk of developing DM while having single kidney and after addressing all cardiovascular risk factors (smoking, hyperlipidemia, hypertension) and if they understand the outcomes they should proceed for donation
Potential donors with DM can donate once fully educated about post donation outcome , provided cardiovascular system is controlled and no target end-organ damage is observed.
Potential donors with Low risk can proceed for kidney donation after normal resting ECG, ECHO
Potential donors with High Cardiovascular risk factors:This needs to be evaluated by non-invasive testing. This can be stress echo or cardiac scintigraphy. Sometimes if needed CT angiography and if positive, patient should be referred for cardiology evaluation and possible angiography
Proteinuria in donors:
Screening for prorienuria is done with urine ACR or PCR, and if abnormal , 24 hours urinary protein test is done to confirm proteinuria.
Hematuria in donor Urine:
Urine analysis is done in 2 separate occasionsin all potential donors to screen Hematuria , if both tests positive it is considered a case of positive non visible Hematuria (PNVH).
PNVH positive non visible Hematuria (PNVH).
This is further evaluated by urine culture and imaging. Cystoscopy should be done if donor is above 40 years and culture is negative. If Imaging is ,renal biopsy should be done. If any form of glomerulonephritis is found it becomes a contraindication to transplantation except TBMD.
Persistent sterile pyuria is a contraindication for donation, while transient pyuria due to UTI can donate.
Donor virology and serology
HBV, HCV, HIV and virology should be done pre operatively and then repeated after 1 month of donation. Active HBV, HCV infection, presence of HIV or HTLV are considered contraindications to donation
If the donor isCMV positive, recipient should be informed about the risk of CMV activation and the prophylaxis regimen should be explained with possible side effects.
If the donor is EBV positive and the recipient is negative, recipient should be informed about the risk of PTLD post transplantation
Renal stones: Nephrolithiasis if not recurrent due to metabolic abnormality does not stop one from donation. In case of unilateral nephrolithiasis It is recommended to donate the kidney containing stone.
Anaemic patient,anemia needs proper workup and cause identified and treated. In case of haemoglobinopathies the decision for donation is made on the type and its long-term effect.
Family History: Detailed family history of renal disease, especially if the donor and recipient are genetically related needs to be obtained.
Active malignancy :
It should be excluded before donation, certain low grade malignancy need to be treated successfully before kidney donation. All donors >50 years need to be screened for occult malignancy.
Renal mass should be diagnosed using US, CT with contrast or MRI
ANGIOMYOLIPOMA:
The presence of incidental bilateral or unilateral AML >4 cm are contraindication to donation,
Unilateral AML 1-4 cm can be considered for donation with or without excision
Patient with AML <1 cm can donate without excision
Renal cell carcinoma:
Unilateral RCC <4 cm can donate their kidney after complete excision of the mass and reconstruction.
Abnormal Renal Vasculature:
Before donation vascular anatomy of the donor kidney should be evaluated using CTA or MRA. Case of donor kidney with multiple renal arteries or with abnormal, anatomy is not considered absolute contraindication but such case need to be discussed individually.
Donor surgical management:
Intra and post- operative hydration of donor is mandatory using normal saline. Thromboprophylaxis in the form of intraoperative bothmechanical compression stocking and pharmacological with LMWH.
Laparoscopic kidney retrieval is the best choice and if open surgery is indicated mini-incision surgery is recommended. Haem-o-lok clips are not recommended to be used for securing the renal artery
Post operatively enhanced recoveryprotocols after surgery (ERAS) are associated with better outcome.
Cautions for pregnant ladies:
Rt or Lt kidney in a female in child bearing period can be donated without any added risk of hydronephrosis . In pregnant female with unilateral kidney it is important to closely monitor BP, creatinine and foetus , and aspirin 75 mg can be given to prevent preeclampsia
The risk of recurrence of original kidney disease should be discussed with the recipient and donor. These are the conditions associated with more chances of recurrence of original disease. Primary FSGS, Type 1 p Oxaluria etc
End stage renal disease in a child:
The the gold standardtherapy for ESRD in a child is pre-emptive matched living related renal transplantation. If a child weight is ≥10 kg he/she can receive an adult kidney.
How these guidelines are different from the guidelines you follow at your workplace?
Use HBA1c in assessment of glucose intolerance BMI> 30- Exclude from donation ERAS is used in our practice No practice on HLAi/ABOi We do split kidney function Donor with anatomical abnormalities are excluded
Abhijit Patil
2 years ago
LEGAL FRAMEWORK
All transplants performed from living donors must comply with the requirements of the primary legislation (Human Tissue Act 2004 and Human Tissue (Scotland) Act 2006), which regulate transplantation and organ donation across the United Kingdom. (Not graded)
Consent for the removal of organs from living donors, for the purposes of transplantation, must comply with the requirements of the Human Tissue Act 2004, and the Mental Capacity Act 2005 in England and Wales, and the Mental Capacity Act 2016 in Northern Ireland.
DONOR EVALUATION: SUMMARY
ASSESSMENT OF RENAL FUNCTION
Initial evaluation of donor candidates should be using estimated glomerular filtration rate (eGFR)
GFR must subsequently be assessed by a reference measured method (mGFR) such as clearance of 51Cr-EDTA, 125iothalamate or Iohexol
Differential kidney function, determined by 99mTcDMSA scanning is recommended where there is >10% variation in kidney size or significant renal anatomical abnormality. (C1)
Pre-donation mGFR should be such that the predicted post-donation GFR remains within the gender and age-specific normal range within the donor’s lifetime.
The risk of end-stage renal disease (ESRD) after 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 consented. (D2)
Donor Age
Old age alone is not an absolute contraindication to donation but the medical work-up of older donors must be particularly rigorous to ensure they are suitable. (A1)
Both donor and recipient must be made aware that the older donor may be at greater risk of peri-operative complications and that the function and possibly the long-term survival of the graft may be compromised. This is particularly evident with donors >60 years of age. (B1)
DONOR OBESITY
Otherwise healthy overweight patients (BMI 25-30 kg/m2) may safely proceed to kidney donation. (B1)
Moderately obese patients (BMI 30-35 kg/m2) must undergo careful preoperative evaluation to exclude cardiovascular, respiratory and kidney disease. (C2)
Moderately obese patients (BMI 30-35 kg/m2) must be counselled about the increased risk of peri-operative complications based on extrapolation of outcome data from very obese donors (BMI >35 kg/m2).
Moderately obese patients (BMI 30-35 kg/m2) must be counselled about the long-term risk of kidney disease and be advised to lose weight before donation and to maintain their ideal weight following donation.
kidney donation in the very obese (BMI >35 kg/m2) –> donation should be discouraged. (C1)
HYPERTENSION IN THE DONOR
Blood pressure must be assessed on at least two separate occasions.
Ambulatory blood pressure monitoring or home monitoring is recommended if blood pressure is high, high normal or variable, or the potential donor is on treatment for hypertension. (C2)
We suggest that a blood pressure <140/90 mmHg is usually acceptable for donation. (C1)
Blood pressure measurement is part of annual donor monitoring. (C1)
Potential donors with mild-moderate hypertension that is controlled to <140/90 mmHg (and/or 135/85 mmHg with ABPM or home monitoring) with one or two antihypertensive drugs and who have no evidence of end organ damage may be acceptable for donation.
It is recommended that potential donors with hypertension are excluded from donation if: (C1)
o Blood pressure is not controlled to <140/90 mmHg on one or two
antihypertensive drugs
o Evidence of end organ damage (retinopathy, left ventricular
hypertrophy, proteinuria, previous cardiovascular disease)
o Unacceptable risk of future cardiovascular risk or lifetime
incidence of ESRD
All living kidney donors must be encouraged to minimise the risk of hypertension and its consequences before and after donation by lifestyle measures including stopping smoking, reducing alcohol intake, frequent exercise and, where appropriate, weight loss. (C1)
DIABETES MELLITUS
All potential living kidney donors must have a fasting plasma glucose level checked. (B1)
A fasting plasma glucose concentration between 6.1-6.9 mmol/L is indicative of an impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be undertaken. (B1)
Prospective donors with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT. (B1)
If OGTT reveals a persistent impaired fasting glucose and/or an impaired glucose tolerance, then the risks of developing diabetes after donation must be carefully considered. (B1)
In the absence of evidence of target organ damage and having ensured that other cardiovascular risk factors such as obesity, hypertension or hyperlipidaemia are optimally managed, diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney. (Not graded)
CARDIOVASCULAR EVALUATION
There is no evidence to support the routine use of stress testing in the assessment of the potential donor at low cardiac risk. (C2)
Potential kidney donors with a history of cardiovascular disease, an exercise capacity of <4 metabolic equivalents (METS) or with risk factors for cardiovascular disease should undergo further evaluation before donation. (C2)
For higher risk potential donors, stress testing is recommended by whichever method is locally available or by CT calcium scoring. (C2)
PROTEINURIA
Urine protein excretion needs to be quantified in all potential living donors. (B1)
A urine albumin/creatinine ratio (ACR) performed on a spot urine sample is the recommended screening test, although urine protein/creatinine ratio (PCR) is an acceptable alternative. (A1)
ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day or protein excretion >500 mg/day represent absolute contraindications to donation. (C2)
The significance of moderately increased albuminuria (ACR 3-30 mg/mmol) and proteinuria (PCR 15-50 mg/mmol or 24-hour urine protein 150-500 mg/day) has not been fully evaluated in living kidney donors.
However, since the risk of CKD and cardiovascular morbidity increase progressively with increasing albuminuria or proteinuria such levels are a relative contraindication to donation. (C2)
NON-VISIBLE HAEMATURIA
All potential living donors must have reagent strip (dipstick) urinalysis performed on at least two separate occasions. (B1)
Two or more positive tests, including trace positive, is considered as persistent non-visible haematuria (PNVH). (B1)
If PNVH is present, perform urine culture and renal imaging to exclude common urologic causes including infection, nephrolithiasis and urothelial carcinoma. (A1)
If no cause is found, perform cystoscopy in patients age >40 years to exclude bladder pathology. (B1)
If no cause is found and the donor still wishes to donate, then a kidney biopsy is recommended if haematuria is 1+ or greater on dipstick testing. (B1)
Glomerular pathology precludes donation, with the possible exception of thin basement membrane disease. (B1)
For donors with persistent asymptomatic non-visible haematuria (PANVH) and a family history of haematuria or X-linked Alport syndrome, a renal biopsy (B1) and referral to a clinical geneticist are recommended. (B2)
INFECTION IN THE PROSPECTIVE DONOR
Screening for infection in the prospective donor is essential to identify potential risks for the donor from previous or current infection and to assess the risks of transmission of infection to the recipient. (B1)
Active HBV and HCV infection in the donor are usually contraindications to living donor kidney donation; however, donors with evidence of active viral replication may be considered under some circumstances. (B1)
The presence of HIV or human T lymphotrophic virus (HTLV) infection is an absolute contraindication to living donation. (B1)
Screening for HBV, HCV and HIV infection must be repeated within 30 days of donation. (Not graded)
The CMV status of donor and recipient must be determined before transplantation. When the donor is CMV positive and the recipient is CMV negative, the donor and recipient must be counselled about the risk of post-transplant CMV disease. (B1)
When the donor is EBV positive and the recipient is EBV negative, the donor and recipient must be counselled about the risk of developing Post Transplant Lymphoproliferative Disease. (B1)
NEPHROLITHIASIS
In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as potential kidney donors.
In appropriate donors with unilateral kidney stone(s) the stone-bearing kidney can be considered for donation (if vascular anatomy and split kidney function permit) in order to leave the donor with a stone-free kidney after donation. (C2)
FAMILIAL RENAL DISEASE
When the cause of kidney failure in the recipient is due to an inherited condition, appropriate tests – including genetic testing if available – are recommended to exclude genetic disease in the potential donor. (A1)
DONOR MALIGNANCY
Active malignant disease is a contraindication to living donation but donors with certain types of successfully treated low-grade tumour may be considered after careful evaluation and discussion. (B1)
Donors with an incidental renal mass lesion must have this diagnosed and managed on its own merit (out with discussion of kidney donation) with appropriate referral to a Urology Specialist in line with the ‘2-week wait’ pathway. (A1)
Contrast enhanced renal CT scan, ultrasound and / or MRI can usually distinguish between benign lesions such as angiomyolipoma (AML) or malignancy such as renal cell carcinoma (RCC).
Bilateral AML and AML >4 cm generally preclude living kidney donation although occasionally unilateral large (>4 cm) AML can be used if ex vivo excision of the AML appears to be straightforward.
An incidental, unilateral solitary AML <4 cm with typical characteristic CT criteria does not usually preclude donation.
A kidney with an AML <1 cm may be considered for donation or left in situ in the donor’s remaining kidney.
Kidneys containing a single AML between 1 and 4 cm can be considered for donation depending on its position, consideration of whether ex vivo excision of the AML is straightforward, or whether it can be left in situ in the recipient and followed with serial ultrasound imaging. (C1)
Donors with an incidental small (<4 cm) renal mass that appears on imaging to be a RCC must be seen in a specialist Urology clinic and be offered standard of care treatment options, including partial and radical nephrectomy.
Renal function permitting, if the person wishes to consider radical nephrectomy, ex-vivo excision of the small renal mass with subsequent donation of the reconstructed kidney can be considered on an individual basis with specific caveats, full MDM discussion and appropriate informed consent from the donor and recipient. (D2)
Tahani Ashmaig
2 years ago
Guidelines For Living Donor Kidney Transplantations
1. Introduction:
▪︎In these guidelines, the GRADE system has been used to rate the quality of evidence and the strength of recommendations. ▪︎This approach is consistent with that adopted by KDIGO in its recent guidance relating to renal transplantation, and also with guidelines from the European Best Practice Committee, and from the Renal Association. ▪︎For each recommendation the quality of evidence has been graded as one of: A (high) B (moderate) C (low) D (very low) ▪︎For each recommendation, the strength of recommendation has been indicated as one of: Level 1 (recommended) Level 2 (suggested) Not graded (where there is not enough evidence to allow formal grading)
▪︎These guidelines represent consensus opinion from experts in the field of transplantation in the United Kingdom. They represent a snapshot of the evidence available at the time of writing. It is recognised that recommendations are made even when the evidence is weak. It is felt that this is helpful to clinicians in daily practice and is similar to the approach adopted by KDIGO . 2. LEGAL FRAMEWORK Recommendations · All transplants performed from living donors must comply with the requirements of the primary legislation which regulate transplantation & organ donation across the United Kingdom. (Not graded) · All transplant centres performing living organ donation must be licensed by the Human Tissue Authority in line with the requirements of the European Union Organ Donation Directive which sets out the minimum requirements for the Quality and Safety of Organs for Transplantation. (Not graded) · Consent for the removal of organs from living donors, for the purposes of transplantation, must comply with the requirements of the Human Tissue Act 2004, and the Mental Capacity Act 2005 in England and Wales, and the Mental Capacity Act 2016 in Northern Ireland. Consent in Scotland must comply with the Human Tissue (Scotland) Act 2006 and the Adults with Incapacity (Scotland) Act 2000. (Not graded) 3. ETHICS Recommendations · All health professionals involved in living donor kidney transplantation must acknowledge the wide range of complex moral issues in this field and ensure that good ethical practice consistently underpins clinical practice. The BTS has an Ethics Committee to provide additional support and advice if required. (Not graded) · Regardless of potential recipient benefit, the safety and welfare of the potential living donor must always take precedence over the needs of the potential transplant recipient. (Not graded) · Independence is recommended between the clinicians responsible for the assessment and preparation of the donor and the recipient, in addition to the Independent Assessor for the Human Tissue Authority. (Not graded)
4. SUPPORTING AND INFORMING THE POTENTIAL DONOR Recommendations · The living donor must be offered the best possible environment for making a voluntary and informed choice about donation. The transplant team must provide generic information that is relevant to all donors as well as specific information that is material to the person intending to donate. This includes information about the assessment process and the benefits and risks of donation to the individual donor. (B1) · Independent assessment of the donor and recipient is required by primary legislation (Human Tissue Act 2004). (Not graded) · To achieve the best outcome for donor, recipient and transplant, the boundaries of confidentiality must be specified and discussed at the outset. Relevant information about the recipient can only be shared with the donor if the recipient has given consent and vice versa. Both the recipient and donor must be informed that it is necessary and usual for all relevant clinical information to be shared across the transplant team in order to optimise the chance of a successful outcome for the transplant. (B1) · Ideally, the recipient will discuss relevant information with their donor, or allow it to be shared. If the recipient is not willing to disclose information, then the transplant team must decide whether it is possible to communicate the risks and benefits of donating adequately, without needing to disclose specific medical details. (Not graded) · Separate clinical teams for donor and recipient are considered best practice but healthcare professionals must work together to ensure effective communication and co-ordination of the transplant process without compromising the independence of either donor or recipient. It is essential that an informed health professional who is not directlyinvolved with the care of the recipient acts as the donor advocate in addressing any outstanding questions, anxieties or difficult issues, and assists the donor in making a truly autonomous decision. (B1) · Support for the prospective donor, recipient and family is an integral part of the donation/transplantation process. Psychological needs must be identified at an early stage in the evaluation to ensure that appropriate support and/or intervention is initiated. Access to specialist psychiatric/psychological services must be available for donors/recipients requiring referral. (B1) 5. DONOR EVALUATION: 5.2 Recommendations · In cases of directed donation (to a known recipient) the likely suitability of the potential recipient for transplantation must be established before starting donor assessment. If additional recipient assessment is required, unnecessary delay should be avoided. Non-invasive assessment of the donor may be undertaken in this phase. (Not graded) · As far as possible, donor assessment is planned to minimise inconvenience to him/her and to avoid unnecessary barriers to proceeding. Flexibility in terms of timescales, planning consultations, attending for investigations and date of surgery is helpful. (Not graded) · Donor assessment must be planned to ensure that it is focused, logical & coherent. Good communication with the donor and involvement of the wider multi-disciplinary team is essential and is achieved most effectively if a designated co-ordinator leads the organisation of the assessment process. The results of investigations must be relayed accurately and efficiently to the potential donor. Unsuitable donors must be identified at the earliest possible stage of assessment. (Not graded) · A policy must be in place to manage prospective donors who are found to be unsuitable to donate and appropriate follow-up and support must be made available. (Not graded) · The organisational aspects for donor evaluation will vary between centres, according to available resources and personnel, but the same principles apply for all donors. An agreed donor assessment protocol must be in place that is tailored to the needs of the individual. (Not graded) · To facilitate pre-emptive transplantation, donor evaluation must start sufficiently early to allow time for more than one donor to be assessed if required. Information must be provided at an early stage and discussion with potential donors and recipients will usually be started when the recipient eGFR is approximately 20 mL/min or when the recipient is expected to require renal replacement therapy within 12-18 months. Recipient and donor assessment can then be tailored according to the rate of decline of recipient renal function, disease specific considerations and individual circumstances. (B2) · The evaluation of a potential donor should be undertaken within an 18 week pathway, assuming there are no logistical issues such as donor unavailability. There may, of course, be pauses if the recipient’s transplant assessment is complicated or if the recipient’s renal function remains satisfactory. 5.3. ABO BLOOD GROUPING AND CROSSMATCH TESTING Recommendations · A compatible ABO blood group and human leucocyte antigen (HLA) transplant offers the best opportunity for success. (A1) · Where ABO or HLA incompatibility is present, alternative options for transplantation must be discussed with the donor and recipient, including paired/pooled donation and antibody incompatible transplantation. Antibody incompatibletransplantation must only be performed in a transplant centre with the relevant experience and appropriate support. (A1) 5.5. ASSESSMENT OF RENAL FUNCTION Recommendations Measurement of Renal Function · Initial evaluation of donor candidates should be using eGFR, expressed as mL/min/1.73m2 computed from a creatinine assay standardised to the International Reference Standard. (B1) · GFR must subsequently be assessed by a reference measured method (mGFR) such as clearance of 51Cr-EDTA, 125iothalamate or Iohexol performed according to guidelines published by the British Society of Nuclear Medicine. (B1) · Differential kidney function, determined by 99mTcDMSA scanning is recommended where there is >10% variation in kidney size or significant renal anatomical abnormality. (C1 Advisory GFR Thresholds for Donation · Pre-donation mGFR should be such that the predicted post-donation GFR remains within the gender and age-specific normal range within the donor’s lifetime. (B1) · The risk of end-stage renal disease (ESRD) after 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 consented. (D2) · The decision to approve donor candidates whose renal function is below the advisory GFR threshold or who have additional risk factors for the development of ESRD should be individualised and based on the predicted lifetime incidence of ESRD. (D2) · The renal function requirements of the intended recipient, based upon the absolute GFR of the donor, are relevant to the decision to donate (in a directed donation) and to the acceptance of a kidney offer from a non-directed donor or within the UK Living Kidney Sharing Schemes. (Not Graded) Monitoring of Kidney Donor · The donor must be offered lifelong annual assessment of renal function including serum creatinine, estimation of urine protein excretion and blood pressure measurement. (B1) 5.6. DONOR AGE Recommendations · Old age alone is not an absolute contraindication to donation but the medical work-up of older donors must be particularly rigorous to ensure they are suitable. (A1) · Both donor and recipient must be made aware that the older donor may be at greater risk of peri-operative complications and that the function and possibly the long-term survival of the graft may be compromised. This is particularly evident with donors >60 years of age. (B1)
5.7. DONOR OBESITY Recommendations · Otherwise healthy overweight patients (BMI 25-30 kg/m2) may safely proceed to kidney donation. (B1) · Moderately obese patients (BMI 30-35 kg/m2) must undergo careful preoperative evaluation to exclude cardiovascular, respiratory and kidney disease. (C2) · Moderately obese patients (BMI 30-35 kg/m2) must be counselled about the increased risk of peri-operative complications based on extrapolation of outcome data from very obese donors (BMI >35 kg/m2). (B1) · Moderately obese patients (BMI 30-35 kg/m2) must be counselled about the long-term risk of kidney disease and be advised to lose weight before donation and to maintain their ideal weight following donation. (B1) · Data on the safety of kidney donation in the very obese (BMI >35 kg/m2) are limited and donation should be discouraged. (C
5.8. HYPERTENSION IN THE DONOR Recommendations · Blood pressure must be assessed on at least two separate occasions. Ambulatory blood pressure monitoring or home monitoring is recommended if blood pressure is high, high normal or variable, or thepotential donor is on treatment for hypertension. (C2) · We suggest that a blood pressure <140/90 mmHg is usually acceptable for donation. (C1) · Prospective donors must be warned about the risk of developing donation-related hypertension, particularly if in a high-risk group. Blood pressure measurement is part of annual donor monitoring. (C1) · Potential donors with mild-moderate hypertension that is controlled to <140/90 mmHg (and/or 135/85 mmHg with ABPM or home monitoring) with one or two antihypertensive drugs and who have no evidence of end organ damage may be acceptable for donation. Acceptance will be based on an overall assessment of cardiovascular risk and local policy. (C1) · It is recommended that potential donors with hypertension are excluded from donation if: (C1) o Blood pressure is not controlled to <140/90 mmHg on one or two antihypertensive drugs o Evidence of end organ damage (retinopathy, left ventricularhypertrophy, proteinuria, previous cardiovascular disease) o Unacceptable risk of future cardiovascular risk or lifetime incidence of ESRD · All living kidney donors must be encouraged to minimise the risk of hypertension and its consequences before and after donation by lifestyle measures including stopping smoking, reducing alcohol intake, frequent exercise and, where appropriate, weight loss. (C1) BTS/RA Living Donor Kidney Transplantation Guidelines 2018 91 · It is recommended that donors who are diagnosed with hypertension during assessment or who develop hypertension following donation are managed according to British Hypertension Society guidelines. (B1) 5.9. DIABETES MELLITUS Recommendations · All potential living kidney donors must have a fasting plasma glucose level checked. (B1) · A fasting plasma glucose concentration between 6.1-6.9 mmol/L is indicative of an impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be undertaken. (B1) · Prospective donors with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT. (B1) · If OGTT reveals a persistent impaired fasting glucose and/or an impaired glucose tolerance, then the risks of developing diabetes after donation must be carefully considered. (B1) · Consideration should be given to the use of a diabetes risk calculator to inform the discussion of potential kidney donation. (B2) · Consideration of patients with diabetes as potential kidney donors requires very careful evaluation of the risks and benefits. In the absence of evidence of target organ damage and having ensured that other cardiovascular risk factors such as obesity, hypertension or hyperlipidaemia are optimally managed, diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney. (Not graded) 5.10. CARDIOVASCULAR EVALUATION Recommendations · There is no evidence to support the routine use of stress testing in the assessment of the potential donor at low cardiac risk. (C2) · Potential kidney donors with a history of cardiovascular disease, an exercise capacity of <4 metabolic equivalents (METS) or with risk factors for cardiovascular disease should undergo further evaluation before donation. (C2) · For higher risk potential donors, stress testing is recommended by whichever method is locally available or by CT calcium scoring . (C2) · Discussion with and/or review by cardiologists, anaesthetists and the transplant MDT is recommended as part of the clinical assessment of donors with higher cardiovascular and peri-operative risk. (D2) 5.11. PROTEINURIA Recommendations · Urine protein excretion needs to be quantified in all potential living donors. (B1) · A urine albumin/creatinine ratio (ACR) performed on a spot urine sample is the recommended screening test, although urine protein/creatinine ratio (PCR) is an acceptable alternative. (A1) · ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day or protein excretion >500 mg/day represent absolute contraindications to donation. (C2) · The significance of moderately increased albuminuria (ACR 3-30 mg/mmol) and proteinuria (PCR 15-50 mg/mmol or 24-hour urine protein 150-500 mg/day) has not been fully evaluated in living kidney donors. However, since the risk of CKD and cardiovascular morbidity increase progressively with increasing albuminuria or proteinuria such levels are a relative contraindication to donation. (C2) 5.12. NON-VISIBLE HAEMATURIA Recommendations · All potential living donors must have reagent strip (dipstick) urinalysis performed on at least two separate occasions. (B1) · Two or more positive tests, including trace positive, is considered as persistent non-visible haematuria (PNVH). (B1) · If PNVH is present, perform urine culture and renal imaging to exclude common urologic causes including infection, nephrolithiasis & urothelial carcinoma. (A1) · If no cause is found, perform cystoscopy in patients age >40 years to exclude bladder pathology. (B1) · If no cause is found and the donor still wishes to donate, then a kidney biopsy is recommended if haematuria is 1+ or greater on dipstick testing. (B1) · Glomerular pathology precludes donation, with the possible exception of TMD. (B1) · For donors with persistent asymptomatic non-visible haematuria (PANVH) and a family history of haematuria or X-linked Alport syndrome, a renal biopsy (B1) and referral to a clinical geneticist are recommended. (B2) 5.13. PYURIA
Statement of Recommendation
· Prospective donors found to have pyuria can only be considered for donation if it can be demonstrated that the pyuria is due to a reversible cause, such as an uncomplicated urinary tract infection. (C1) 5.14. INFECTION IN THE PROSPECTIVE DONOR Recommendations · Screening for infection in the prospective donor is essential to identify potential risks for the donor from previous or current infection and to assess the risks of transmission of infection to the recipient. (B1) · Active HBV and HCV infection in the donor are usually contraindications to living donor kidney donation; however, donors with evidence of active viral replication may be considered under some circumstances. (B1) · The presence of HIV or human T lymphotrophic virus (HTLV) infection is an absolutecontraindication to living donation. (B1) · Screening for HBV, HCV and HIV infection must be repeated within 30 days of donation. (Not graded) · All potential donors should be provided with dietary advice regarding avoidance of HEV infection, and screening should be undertaken for HEV viraemia by nucleic acid testing within 30 days of donation. (Not graded) · The CMV status of donor and recipient must be determined before transplantation. When the donor is CMV positive and the recipient is CMV negative, the donor and recipient must be counselled about the risk of post-transplant CMV disease. (B1) · The EBV status of donor and recipient must be determined before transplantation. When the donor is EBV positive and the recipient is EBV negative, the donor and recipient must be counselled about the risk of developing Post Transplant Lymphoproliferative Disease. (B1) · Potential donors must be screened by history for travel or residence abroad to assess their potential risk for having acquired endemic BTS/RA Living Donor Kidney Transplantation Guidelines 2018 126 infections and appropriate microbiological investigations instigated if indicated. (Not graded) 5.15. NEPHROLITHIASIS Recommendations · In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as potential kidney donors. Full counselling of donor and recipient is required along with access to appropriate long-term donor follow up. (C2) · Potential donors with metabolic abnormalities detected on screening should be discussed with a specialist in renal stone disease. (C2) · In appropriate donors with unilateral kidney stone(s) the stone-bearing kidney can be considered for donation (if vascular anatomy and split kidney function permit) in order to leave the donor with a stone-free kidney after donation. (C2) 5.16. HAEMATOLOGICAL DISEASE Recommendations · Donor anaemia needs to be investigated and treated before donation. (A1) · A haemoglobinopathy screen must be carried out in patients with nonNorthern European heritage or if indicated by the full blood count. (A1) · Careful consideration needs to be given to the use of potential donors with haemoglobinopathies. (B1) · Advice from a consultant haematologist is recommended for haematological conditions not covered in this guideline. (Not graded 5.17. FAMILIAL RENAL DISEASE
Recommendations
· All potential transplant recipients must have a detailed family history recorded and confirmation where possible of the diagnosis in other family members with known kidney disease. This may aid diagnosis for the recipient, clarify any mode of inheritance and identify at risk relatives. (A1) · When the cause of kidney failure in the recipient is due to an inherited condition, appropriate tests – including genetic testing if available – are recommended to exclude genetic disease in the potential donor. (A1) · Many inherited kidney diseases are rare, so involvement of clinical and laboratory genetics services must be considered at an early stage to assess likely risks to family members and the appropriate use of molecular genetic testing. (B1) 5.18. DONOR MALIGNANCY Recommendations · Careful history taking, clinical examination and investigation of potential donors are essential to exclude occult malignancy before kidney donation, particularly in older (age >50 years) donors. (B1) · Active malignant disease is a contraindication to living donation but donors with certain types of successfully treated low-grade tumour may be considered after careful evaluation and discussion. (B1) · Donors with an incidental renal mass lesion must have this diagnosed and managed on its own merit (out with discussion of kidney donation) with appropriate referral to a Urology Specialist in line with the ‘2-week wait’ pathway. (A1) · Contrast enhanced renal CT scan, ultrasound and / or MRI can usually distinguish between benign lesions such as angiomyolipoma (AML) or malignancy such as renal cell carcinoma (RCC). Review by a specialist uroradiologist is recommended. (C1) · Bilateral AML and AML >4 cm generally preclude living kidney donation although occasionally unilateral large (>4 cm) AML can be used if ex vivo excision of the AML appears to be straightforward. · An incidental, unilateral solitary AML <4 cm with typical characteristic CT criteria does not usually preclude donation. · A kidney with an AML <1 cm may be considered for donation or left in situ in the donor’s remaining kidney. · Kidneys containing a single AML between 1 and 4 cm can be considered for donation depending on its position, consideration of whether ex vivo excision of the AML is straightforward, or whether it BTS/RA Living Donor Kidney Transplantation Guidelines 2018 160 can be left in situ in the recipient and followed with serial ultrasound imaging. (C1) · Donors with an incidental small (<4 cm) renal mass that appears on imaging to be a RCC must be seen in a specialist Urology clinic and be offered standard of care treatment options, including partial and radical nephrectomy. Renal function permitting, if the person wishes to consider radical nephrectomy, ex-vivo excision of the small renal mass with subsequent donation of the reconstructed kidney can be considered on an individual basis with specific caveats, full MDM discussion and appropriate informed consent from the donor and recipient. (D2) 6. SURGERY: TECHNICAL ASPECTS, DONOR RISK AND PERI-OPERATIVE CARE Recommendations · Work-up for living kidney donation may include direct or indicative evaluation of split renal function with the kidney with poorer function selected for nephrectomy irrespective of vascular anatomy (see Chapter 5.5). (C2) · Work-up for living kidney donation must include detailed imaging confirming the vascular anatomy of both donor kidneys and information about the renal parenchyma and collecting systems. Either CTA or MRA can be used as current evidence indicates little difference in accuracy. (B1) · Multiple renal arteries or kidneys with anatomical anomalies are not absolute contraindications to donation. Decisions must be made on an individual basis as part of a multi-disciplinary team evaluation. (B2) · All living donors must receive adequate thromboprophylaxis. Intraoperative mechanical compression and post-operative compression stockings, along with low molecular weight heparin, are recommended. (A2) · All living donor surgery must be performed or directly supervised by a Consultant surgeon with appropriate training in the technique. (C1) · Pre-operative hydration with an overnight infusion and/or a fluid bolus during surgery improves cardiovascular stability during laparoscopic donor nephrectomy. (B2) · Pre- and peri-operative intravenous fluid replacement with Hartmann’s solution is preferred to 0.9% Saline. (B2) · Laparoscopic donor surgery (fully laparoscopic or hand-assisted) is the preferred technique for living donor nephrectomy, offering a BTS/RA Living Donor Kidney Transplantation Guidelines 2018 172 quicker recovery, shorter hospital stay and less pain. Mini-incision surgery is preferable to standard open surgery. (B1) · Haem-o-lok clips are not to be used to secure the renal artery during donor nephrectomy following a report of an adverse event involving this technique.(C2) · Patients undergoing living donor nephrectomy are likely to benefit from the management approaches widely used in “enhanced recovery after surgery” (ERAS) programmes. (D2) 7. HISTOCOMPATIBILITY TESTING FOR LIVING DONOR KIDNEY TRANSPLANTATION Recommendations · Initial assessment of donor and recipient histocompatibility status must be undertaken at an early stage in living donor kidney transplant work-up to avoid unnecessary and invasive clinical investigation. (B2) · Screening of potential living donor kidney transplant recipients for clinically relevant antibodies is important for ensuring optimal donor selection and graft survival. (A1) · Antibody screening is especially important when potential living donor transplant recipients undergo reduction or withdrawal of immunosuppression. (B2) · Post-transplant antibody monitoring must be undertaken according to the BSHI/BTS guidelines. (B1) · Transplant units and histocompatibility laboratories must agree an evidence-based protocol to define antibody screening and crossmatch results that constitute a high immunological risk to transplantation. (B2) · When possible, the HLA type(s) of partners/offspring of female recipients who have had previous pregnancies should be determined to aid immunological risk assessment for repeat paternal HLA mismatches in women with low level DSA. (B1) · A pre-transplant serum sample collected within 14 days of the planned date for transplantation must be tested in a sensitive antibody screening and donor crossmatch assay and transplantation should not usually be performed if the crossmatch test is positive, unless the antibody is shown to be indicative of acceptable immunological risk. (A1) BTS/RA Living Donor Kidney Transplantation Guidelines 2018 192 · Changes in immunosuppression during the transplant work-up must be notified to the histocompatibility laboratory and additional antibody screening and donor-recipient crossmatch tests must be undertaken as indicated. (B1) · HLA matching may be preferred when there is an option of selecting between living donors, particularly to reduce the possibility of subsequent sensitisation. This is important for younger recipients where repeat transplantation may be required. However, it is recognised that other donor factors will be taken into account. (B1) · For patients with an ABO/HLA incompatible and/or a poorly HLA matched living donor, consideration should be given to entry into the UK living kidney sharing scheme (UKLKSS) to identify a more suitable donor. (B2) · The histocompatibility laboratory must issue an interpretive report stating the donor and recipient HLA mismatch, recipient sensitisation status and crossmatch results, and define the associated immunological risk for all living donor-recipient pairs. (A1) 8. EXPANDING THE DONOR POOL Recommendations · Coherent organisational and clinical practices are essential between transplant centres to optimise the UK Living Kidney Sharing Schemes (UKLKSS) and to maximise the number of potential transplants that proceed. (B1) · To maximise transplant opportunities within the UKLKSS, donors and recipients must only be included in a matching run if: o Their clinical assessment and histocompatibility screening are complete and up to date. (B1) o If matched, they are available to attend for crossmatch testing and proceed to surgery within the designated timeframes. (B1) o Relevant complex donor considerations identified in the ‘prerun’ and donor HLA and age preferences have been discussed and agreed with the recipient. (B1) o They understand their roles and responsibilities with respect to other donors and recipient pairs in the schemes with whom they may be matched. (B1) · The default for all non-directed altruistic kidney donors (NDADs) is to donate into an altruistic donor chain (ADC) within the UKLKSS provided that there is no higher priority patient on the national transplant list. (B1) · All altruistic donors (non-directed and directed) must undergo formal mental health assessment with a mental health professional before donation. (C1) · Living kidney donors who are antibody incompatible with their recipient must have all the options and risks explained to them, including donation into the UKLKSS and antibody removal. (C1)
amiri elaf
2 years ago
*This guidance relates only to living donor kidney transplantation and reflects a growing body of evidence, incorporating aspects of clinical practice that are relevant
to both adult and paediatric settings.
# Ethics Recommendations
* All health professionals involved in living donor kidney transplantation
must acknowledge the wide range of complex moral issues in this field
and ensure that good ethical practice consistently underpins clinical practice.
* Regardless of potential recipient benefit, the safety and welfare of the potential living donor must always take precedence over the needs of the potential transplant recipient.
* Independence is recommended between the clinicians responsible for
the assessment and preparation of the donor and the recipient, in addition to the Independent Assessor for the Human Tissue Authority.
*a living donor kidney transplant would almost always be the preferred option, with better transplant and patient survival than for deceased donation.
*Donating a kidney involves a detailed process of investigation, major surgery, and
a significant period of recovery.
The collective transplant MDT is responsible for informing the potential donor of the
risks associated with living kidney donation.
# SUPPORTING AND INFORMING THE POTENTIAL DONOR
*The living donor must be offered the best possible environment for making a voluntary and informed choice about donation.
* Independent assessment of the donor and recipient is required by primary legislation.
*To achieve the best outcome for donor, recipient and transplant, the boundaries of confidentiality must be specified and discussed at the outset. Relevant information about the recipient can only be shared with the donor if the recipient has given consent and vice versa.
* Ideally, the recipient will discuss relevant information with their donor, or allow it to be shared. If the recipient is not willing to disclose information, then the transplant team must decide whether it is possible to communicate the risks and benefits of donating adequately, without needing to disclose specific medical details.
*Separate clinical teams for donor and recipient are considered best practice but healthcare professionals must work together to ensure effective communication and co-ordination of the transplant process without compromising the independence of either donor or recipient.
*It is essential that an informed health professional who is not directly.
*Psychological problems are infrequent after donation and most donors experience
increased self-esteem, whilst donor and recipient relationships are enhanced.
# Death and Transplant Failure
*LDKT is increasingly considered the treatment of choice for recipients with higher
baseline comorbidity.
* An increased risk of post-operative co-morbidity, transplant failure and death is likely and the appropriate management of expectations is an essential part of the pre-transplant preparation for all parties concerned.
# DONOR EVALUATION
*The primary goal of the donor evaluation process is to ensure the suitability of the
donor and to minimise the risk of donation.
* In cases of directed donation the likely suitability of the potential recipient for transplantation must be established before starting donor assessment. If additional recipient assessment is required, unnecessary delay should be avoided. Non invasive assessment of the donor may be undertaken in this phase. (Not graded)
* As far as possible, donor assessment is planned to minimize inconvenience to him/her and to avoid unnecessary barriers to proceeding. Flexibility in terms of timescales, planning consultations, attending for investigations and date of surgery is helpful. (Not graded)
* Donor assessment must be planned to ensure that it is focused, logical and coherent. Good communication with the donor and involvement of
the wider multi-disciplinary team is essential and is achieved most
effectively if a designated co-ordinator leads the organisation of the
4l8assessment process. The results of investigations must be relayed
accurately and efficiently to the potential donor. Unsuitable donors
must be identified at the earliest possible stage of assessment. (Not graded)
* A policy must be in place to manage prospective donors who are found
to be unsuitable to donate and appropriate follow-up and support must
be made available. (Not graded)
*The organisational aspects for donor evaluation will vary between centres, according to available resources and personnel, but the same
principles apply for all donors. An agreed donor assessment protocol
must be in place that is tailored to the needs of the individual.
*To facilitate pre-emptive transplantation, donor evaluation must start sufficiently early to allow time for more than one donor to be assessed if required. Information must be provided at an early stage and discussion with potential donors and recipients will usually be started when the recipient eGFR is approximately 20 mL/min or when the recipient is expected to require renal replacement therapy within 12-18 months. Recipient and donor assessment can then be tailored according to the rate of decline of recipient renal function, disease specific considerations and individual circumstances. (B2)
*The evaluation of a potential donor should be undertaken within an 18 week pathway, assuming there ar/e no logistical issues such as donor unavailability.
#ABO BLOOD GROUPING AND CROSSMATCH TESTING
* A compatible ABO blood group and human leucocyte antigen (HLA) transplant offers the best opportunity for success. (A1)
* Where ABO or HLA incompatibility is present, alternative options for transplantation must be discussed with the donor and recipient, including paired/pooled donation and antibody incompatible transplantation. Antibody incompatible transplantation must only be performed in a transplant centre with the relevant experience and appropriate support.
# MEDICAL ASSESSMENT
*It is important to manage the expectations of the donor from the outset and to be clear about the difference between a healthy individual and a suitable donor.
*A full past and present medical history must be taken. A psychosocial assessment is recommended for all donors with appropriate referral to a mental health professional as requiredThe EPAT tool provides a structured approach to initial psychosocial assessment which can be performed by any member of the multi-disciplinary team and which can help to identify potential areas of concern.
*Donor assessment will usually be arranged by a specialist transplant/living donation
nurse, supported by a clinician.
#Summary of Key Points of Importance in the Medical +/- Family History of a
Potential Kidney Donor
Haematuria/proteinuria/urinary tract infection/ Difficulty in passing urine, including urgency, frequency, dysuria/ History of peripheral oedema/ Gout/ Nephrolithiasis
Hypertension/ Diabetes mellitus/ including family history Ischaemic heart disease/peripheral vascular disease/other atherosclerosis
Cardiovascular risk factors/ Thromboembolic disease/ Sickle cell and other haemoglobinopathies/ Weight change/ Change in bowel habit/ Previous jaundice
Previous or current malignancy/ Systemic disease which may involve the kidney
Chronic infection such as tuberculosis/ Family history of a renal condition that may affect the donor/ Smoking/ Current or prior alcohol or drug dependence/ Mental health history/ Obstetric history/ Residence abroad/ Previous medical assessment e.g. for life insurance/ Previous anaesthetic problem/ History of back or neck pain and trauma/ Results of national screening programme tests e.g. cervical smear, mammography,/ colorectal screening.
# Points of Particular Importance when Undertaking Clinical Examination of a
Potential Kidney Donor
Abdominal fat distribution/ Blood pressure/ Body mass index/Dipstick urinalysis
Evidence of self-harm/ Examination for abdominal masses or hernia/ Examination for scars or previous surgery/ Examination for lymphadenopathy/ Examination / history of regular self-examination of the breasts/ Examination / history of regular self/ examination of the testes/ Examination of the cardiovascular and respiratory systems
Mental health.
# Routine Screening Investigations for the Potential Donor
Haemoglobin and blood count/ Coagulation screen (PT and APTT)/ Thrombophilia screen (where indicated)/ Sickle cell trait (where indicated)/ Haemoglobinopathy screen (where indicated)/ G6PD deficiency (where indicated)/ Creatinine, urea and electrolytes/ Isotopic or other reference test for measurement of GFR/Liver function tests/ Bone profile (calcium, phosphate, albumin and alkaline phosphatase)/ Urate
Fasting plasma glucose/ Glucose tolerance test (if family history of diabetes or fasting plasma glucose/ >5.6 mmol/L)/ Fasting lipid screen (if indicated)/ Thyroid function tests (if strong family history)/ Pregnancy test (if indicated)/Hepatitis B and C
HIV/ HTLV1 and 2 (if appropriate)/ Cytomegalovirus/ Epstein-Barr virus/ Toxoplasma
Syphilis/ Varicella zoster virus (where recipient seronegative)/ HHV8 (where indicated)/ Malaria (where indicated)/ Trypanosoma cruzi (where indicated)/ Schistosomiasis (where indicated)/ Chest X-ray/ ECG/ ECHO (where indicated)/ Cardiovascular stress test (as routine or where indicated)
# ASSESSMENT OF RENAL FUNCTION
Measurement of Renal Function
* Initial evaluation of donor candidates should be using (eGFR), expressed as mL/min/1.73m2 computed from a creatinine assay standardised to the International
Reference Standard. (B1)
* GFR must subsequently be assessed by a reference measured method (mGFR) such as clearance of 51Cr-EDTA, 125iothalamate or Iohexol performed according to guidelines published by the British Society of Nuclear Medicine. (B1)
*Differential kidney function, determined by 99mTcDMSA scanning is recommended where there is >10% variation in kidney size or significant renal anatomical abnormality. (C1)
# Advisory GFR Thresholds for Donation
* Pre-donation mGFR should be such that the predicted post-donation GFR remains within the gender and age-specific normal range within the donors lifetime.
* The risk of end-stage renal disease (ESRD) after donation is no higher than that of the general population. However, there is a very small absolute increased lifetimerisk of ESRD following donation for which the potential donor must be consented. (D2)
* The decision to approve donor candidates whose renal function is below the advisory GFR threshold or who have additional risk factors for the development of ESRD should be individualised and based on the predicted lifetime incidence of ESRD. (D2)
* The renal function requirements of the intended recipient, based upon the absolute GFR of the donor, are relevant to the decision to donate (in a directed donation) and to the acceptance of a kidney offer from a non-directed donor or within the UK Living Kidney Sharing Schemes. (Not Graded)
# Monitoring of Kidney Donor
*The donor must be offered lifelong annual assessment of renal function including serum creatinine, estimation of urine protein excretion and blood pressure measurement. (B1)
# HYPERTENSION IN THE DONOR
* Blood pressure must be assessed on at least two separate occasions. Ambulatory blood pressure monitoring or home monitoring is recommended if blood pressure is high, high normal or variable, or the potential donor is on treatment for hypertension. (C2)
*We suggest that a blood pressure <140/90 mmHg is usually acceptable for donation. (C1)
* Prospective donors must be warned about the risk of developing donation-related hypertension, particularly if in a high-risk group. Blood pressure measurement is part of annual donor monitoring. (C1)
* Potential donors with mild-moderate hypertension that is controlled to <140/90 mmHg (and/or 135/85 mmHg with ABPM or home monitoring) with one or two antihypertensive drugs and who have no evidence of end organ damage may be acceptable for donation. Acceptance will be based on an overall assessment of cardiovascular risk and local policy.(C1)
*It is recommended that potential donors with hypertension are excluded from donation if: (C1)
o Blood pressure is not controlled to <140/90 mmHg on one or two antihypertensive drugs
o Evidence of end organ damage (retinopathy, left ventricular hypertrophy, proteinuria, previous cardiovascular disease)
o Unacceptable risk of future cardiovascular risk or lifetime incidence of ESRD
* All living kidney donors must be encouraged to minimise the risk of hypertension and its consequences before and after donation by lifestyle measures including stopping smoking, reducing alcohol intake, frequent exercise and, where appropriate, weight loss. (C1)
*It is recommended that donors who are diagnosed with hypertension during assessment or who develop hypertension following donation are managed according to British Hypertension Society guidelines. (B1)
# DIABETES MELLITUS
* All potential living kidney donors must have a fasting plasma glucose level checked. (B1)
* A fasting plasma glucose concentration between 6.1-6.9 mmol/L is indicative of an impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be undertaken. (B1)
* Prospective donors with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT. (B1)
*If OGTT reveals a persistent impaired fasting glucose and/or an impaired glucose tolerance, then the risks of developing diabetes after donation must be carefully considered. (B1)
* Consideration should be given to the use of a diabetes risk calculator to inform the discussion of potential kidney donation. (B2)
*Consideration of patients with diabetes as potential kidney donors requires very careful evaluation of the risks and benefits. In the absence of evidence of target organ damage and having ensured that other cardiovascular risk factors such as obesity, hypertension or hyperlipidaemia are optimally managed, diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney. (Not graded)
# CARDIOVASCULAR EVALUATION
* There is no evidence to support the routine use of stress testing in the assessment of the potential donor at low cardiac risk. (C2)
* Potential kidney donors with a history of cardiovascular disease, an exercise capacity of <4 metabolic equivalents (METS) or with risk factors for cardiovascular disease should undergo further evaluation before donation. (C2)
* For higher risk potential donors, stress testing is recommended by whichever method is locally available or by CT calcium scoring . (C2)
* Discussion with and/or review by cardiologists, anaesthetists and the transplant MDT is recommended as part of the clinical assessment of donors with higher cardiovascular and peri-operative risk. (D2)
# PROTEINURIA
* Urine protein excretion needs to be quantified in all potential living donors. (B1)
* A urine albumin/creatinine ratio (ACR) performed on a spot urine sample is the recommended screening test, although urine protein/creatinine ratio (PCR) is an acceptable alternative. (A1)
* ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day or protein excretion >500 mg/day represent absolute contraindications to donation. (C2)
*The significance of moderately increased albuminuria (ACR 3-30 mg/mmol) and proteinuria (PCR 15-50 mg/mmol or 24-hour urine protein 150-500 mg/day) has not been fully evaluated in living kidney donors. However, since the risk of CKD and cardiovascular morbidity increase progressively with increasing albuminuria or proteinuria such levels are a relative contraindication to donation. (C2)
# NON-VISIBLE HAEMATURIA
Recommendations
* All potential living donors must have reagent strip (dipstick) urinalysis performed on at least two separate occasions. (B1)
*Two or more positive tests, including trace positive, is considered as persistent non-visible haematuria (PNVH). (B1)
* If PNVH is present, perform urine culture and renal imaging to exclude common urologic causes including infection, nephrolithiasis and urothelial carcinoma. (A1)
*If no cause is found, perform cystoscopy in patients age >40 years to exclude bladder pathology. (B1)
* If no cause is found and the donor still wishes to donate, then a kidney biopsy is recommended if haematuria is 1+ or greater on dipstick testing. (B1)
* Glomerular pathology precludes donation, with the possible exception of thin basement membrane disease. (B1)
* For donors with persistent asymptomatic non-visible haematuria (PANVH) and a family history of haematuria or X-linked Alport syndrome, a renal biopsy (B1) and referral to a clinical geneticist are recommended. (B2)
# PYURIA
* Prospective donors found to have pyuria can only be considered for donation if it can be demonstrated that the pyuria is due to a reversible cause, such as an uncomplicated urinary tract infection. (C1)
# INFECTION IN THE PROSPECTIVE DONOR
* Screening for infection in the prospective donor is essential to identify potential risks for the donor from previous or current infection and to assess the risks of transmission of infection to the recipient. (B1)
* Active HBV and HCV infection in the donor are usually contraindications to living donor kidney donation; however, donors
with evidence of active viral replication may be considered under some circumstances. (B1)
* The presence of HIV or human T lymphotrophic virus (HTLV) infection is an absolute contraindication to living donation. (B1)
* Screening for HBV, HCV and HIV infection must be repeated within 30 days of donation. (Not graded)
* All potential donors should be provided with dietary advice regarding avoidance of HEV infection, and screening should be undertaken for HEV viraemia by nucleic acid testing within 30 days of donation. (Not graded)
* The CMV status of donor and recipient must be determined before transplantation. When the donor is CMV positive and the recipient is CMV negative, the donor and recipient must be counselled about the risk of post-transplant CMV disease. (B1)
* The EBV status of donor and recipient must be determined before transplantation. When the donor is EBV positive and the recipient is
EBV negative, the donor and recipient must be counselled about the risk of developing Post Transplant Lymphoproliferative Disease. (B1)
* Potential donors must be screened by history for travel or residence abroad to assess their potential risk for having acquired endemicinfections and appropriate microbiological investigations instigated if indicated. (Not graded)
# NEPHROLITHIASIS
* In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as potential kidney donors. Full counselling of donor and recipient is required along with access to appropriate long-term donor follow up. (C2)
* Potential donors with metabolic abnormalities detected on screening should be discussed with a specialist in renal stone disease. (C2)
* In appropriate donors with unilateral kidney stone(s) the stone-bearing kidney can be considered for donation (if vascular anatomy and split kidney function permit) in order to leave the donor with a stone-free kidney after donation. (C2)
# HAEMATOLOGICAL DISEASE
* Donor anaemia needs to be investigated and treated before donation. (A1)
* A haemoglobinopathy screen must be carried out in patients with non- Northern European heritage or if indicated by the full blood count. (A1)
*Careful consideration needs to be given to the use of potential donors with haemoglobinopathies. (B1)
* Advice from a consultant haematologist is recommended for haematological conditions not covered in this guideline. (Not graded)
# FAMILIAL RENAL DISEASE
* All potential transplant recipients must have a detailed family history recorded and confirmation where possible of the diagnosis in other family members with known kidney disease. This may aid diagnosis for the recipient, clarify any mode of inheritance and identify at risk relatives. (A1)
* When the cause of kidney failure in the recipient is due to an inherited condition, appropriate tests – including genetic testing if available – are recommended to exclude genetic disease in the potential donor. (A1)
* Many inherited kidney diseases are rare, so involvement of clinical and laboratory genetics services must be considered at an early stage to assess likely risks to family members and the appropriate use of molecular genetic testing. (B1)
# DONOR MALIGNANCY
* Careful history taking, clinical examination and investigation of potential donors are essential to exclude occult malignancy before kidney donation, particularly in older (age >50 years) donors. (B1)
* Active malignant disease is a contraindication to living donation but donors with certain types of successfully treated low-grade tumour may be considered after careful evaluation and discussion. (B1)
* Donors with an incidental renal mass lesion must have this diagnosed and managed on its own merit (out with discussion of kidney donation) with appropriate referral to a Urology Specialist in line with the 2-week wait pathway. (A1)
* Contrast enhanced renal CT scan, ultrasound and / or MRI can usually distinguish between benign lesions such as angiomyolipoma (AML) or malignancy such as renal cell carcinoma (RCC). Review by a specialist uroradiologist is recommended. (C1)
* Bilateral AML and AML >4 cm generally preclude living kidney donation although occasionally unilateral large (>4 cm) AML can be used if ex vivo excision of the AML appears to be straight forward.
* An incidental, unilateral solitary AML <4 cm with typical characteristic CT criteria does not usually preclude donation.
* A kidney with an AML <1 cm may be considered for donation or left in situ in the donors remaining kidney.
* Kidneys containing a single AML between 1 and 4 cm can be considered for donation depending on its position, consideration of whether ex vivo excision of the AML is straightforward, or whether it can be left in situ in the recipient and followed with serial ultrasound imaging. (C1)
* Donors with an incidental small (<4 cm) renal mass that appears on imaging to be a RCC must be seen in a specialist Urology clinic and be offered standard of care treatment options, including partial and radical nephrectomy. Renal function permitting, if the person wishes to consider radical nephrectomy, ex-vivo excision of the small renal mass with subsequent donation of the reconstructed kidney can be
considered on an individual basis with specific caveats, full MDM discussion and appropriate informed consent from the donor and recipient. (D2)
# SURGERY: TECHNICAL ASPECTS, DONOR RISK AND PERI-OPERATIVE CARE
* Work-up for living kidney donation may include direct or indicative evaluation of split renal function with the kidney with poorer function selected for nephrectomy irrespective of vascular anatomy(C2)
* Work-up for living kidney donation must include detailed imaging confirming the vascular anatomy of both donor kidneys and information about the renal parenchyma and collecting systems. Either CTA or MRA can be used as current evidence indicates little difference in accuracy. (B1)
* Multiple renal arteries or kidneys with anatomical anomalies are not absolute contraindications to donation. Decisions must be made on an individual basis as part of a multi-disciplinary team evaluation. (B2)
* All living donors must receive adequate thromboprophylaxis. Intraoperative mechanical compression and post-operative compression stockings, along with low molecular weight heparin, are recommended. (A2)
* All living donor surgery must be performed or directly supervised by a Consultant surgeon with appropriate training in the technique. (C1)
* Pre-operative hydration with an overnight infusion and/or a fluid bolus during surgery improves cardiovascular stability during laparoscopic donor nephrectomy. (B2)
* Pre- and peri-operative intravenous fluid replacement with Hartmanns solution is preferred to 0.9% Saline. (B2)
* Laparoscopic donor surgery (fully laparoscopic or hand-assisted) is the preferred technique for living donor nephrectomy, offering aquicker recovery, shorter hospital stay and less pain. Mini-incision surgery is preferable to standard open surgery. (B1)
* Haem-o-lok clips are not to be used to secure the renal artery during donor nephrectomy following a report of an adverse event involving this technique.(C2)
# HISTOCOMPATIBILITY TESTING FOR LIVING DONOR KIDNEY TRANSPLANTATION
* Initial assessment of donor and recipient histocompatibility status must be undertaken at an early stage in living donor kidney transplant work-up to avoid unnecessary and invasive clinical investigation. (B2)
* Screening of potential living donor kidney transplant recipients for clinically relevant antibodies is important for ensuring optimal donor selection and graft survival. (A1)
* Antibody screening is especially important when potential living donor transplant recipients undergo reduction or withdrawal of immunosuppression. (B2)
* Post-transplant antibody monitoring must be undertaken according to the BSHI/BTS guidelines. (B1)
* Transplant units and histocompatibility laboratories must agree an evidence-based protocol to define antibody screening and crossmatch results that constitute a high immunological risk to transplantation. (B2)
* When possible, the HLA type(s) of partners/offspring of female recipients who have had previous pregnancies should be determined to aid immunological risk assessment for repeat paternal HLA mismatches in women with low level DSA. (B1)
* A pre-transplant serum sample collected within 14 days of the planned date for transplantation must be tested in a sensitive antibody screening and donor crossmatch assay and transplantation should not usually be performed if the crossmatch test is positive, unless the antibody is shown to be indicative of acceptable immunological risk. (A1)
#Changes in immunosuppression during the transplant work-up must be notified to the histocompatibility laboratory and additional antibody
screening and donor-recipient crossmatch tests must be undertaken
as indicated. (B1)
*HLA matching may be preferred when there is an option of selecting between living donors, particularly to reduce the possibility of subsequent sensitisation. This is important for younger recipients where repeat transplantation may be required. However, it is recognised that other donor factors will be taken into account. (B1)
* For patients with an ABO/HLA incompatible and/or a poorly HLA matched living donor, consideration should be given to entry into the UK living kidney sharing scheme (UKLKSS) to identify a more suitable donor. (B2)
*The histocompatibility laboratory must issue an interpretive report stating the donor and recipient HLA mismatch, recipient sensitization status and crossmatch results, and define the associated immunological risk for all living donor-recipient pairs. (A1)
# Recommendations (Not graded)
* Antibody incompatible transplantation (AIT) should only be undertaken after prior consideration of entry of the donor-recipient pair into the UK Living Kidney Sharing Schemes (UKLKSS) (see Chapter 8).
* AIT should be considered as part of an ongoing structured programmers, and should not be performed on an occasional basis.
*To initiate a programme, a unit should be able to demonstrate a demand of at least five cases a year and appropriate support from clinical transplant, plasmapheresis and histocompatibility teams. An AIT programme requires funding for additional staff and consumables, and all programmes should receive Commissioner support.
* There is insufficient evidence to make precise recommendations for treatment protocols, but units should have a written protocol based on best published practice. This should include recommendations on prevention, diagnosis and treatment of antibody mediated rejection.
*Protocols that follow the above can be regarded as established treatment and do not require Ethics Committee approval as research procedures. However, the standard of consent should include detailed written information which describes the risks of the procedure. The transplant donor should receive equivalent information to the
recipient, so they are aware of the risks of the procedure to the recipient, whether it results in a transplant or not. Potential recipients and donors should be aware of their treatment choices, especially the option of exchange (pooled/paired) transplantation.
* Laboratories should be able to define antibodies to the standard defined in the BSHI/BTS document Guidelines for the Detection and
# Characterisation of Clinically Relevant Antibodies in Solid Organ Transplantation’. Sensitive and rapid techniques for the measurement of donor-specific HLA antibody levels must be available.
*If ABOi transplantation is to be performed, blood group antibody titres need to be measured, with differentiation between A1 and A2 subgroups of recipient blood group A (when appropriate) and discrimination between IgG- and IgM-specific ABO antibodies. In living donor transplantation, a 7 day per week service with same day turnaround time is required.
* AIT results in an improved quality of life when compared to dialysis. Additionally, many patients receiving antibody incompatible transplants may have no other chance of a transplant. Transplantation is cost effective over time with a saving of about £15,000 per annum compared to dialysis when averaged over a 10 year period
* Every patient undergoing AIT should be audited on a local and national basis, with the national audit through the AIT Registry.
*The UK AIT Registry will define the optimal dataset to be collected, and will be able to report AIT activity against benchmark outcome data from international reports and the national dataset of renal transplantation.
# EXPANDING THE DONOR POOL
* Coherent organisational and clinical practices are essential between transplant centres to optimise the UK Living Kidney Sharing Schemes (UKLKSS) and to maximise the number of potential transplants that proceed. (B1)
* To maximise transplant opportunities within the UKLKSS, donors and recipients must only be included in a matching run if:
o Their clinical assessment and histocompatibility screening are complete and up to date. (B1)
o If matched, they are available to attend for crossmatch testing and proceed to surgery within the designated timeframes. (B1)
o Relevant complex donor considerations identified in the prerun and donor HLA and age preferences have been discussed and agreed with the recipient. (B1)
o They understand their roles and responsibilities with respect to other donors and recipient pairs in the schemes with whom they may be matched. (B1)
* The default for all non-directed altruistic kidney donors (NDADs) is to donate into an altruistic donor chain (ADC) within the UKLKSS provided that there is no higher priority patient on the national transplant list. (B1)
* All altruistic donors (non-directed and directed) must undergo formal mental health assessment with a mental health professional before donation. (C1)
* Living kidney donors who are antibody incompatible with their recipient must have all the options and risks explained to them, including donation into the UKLKSS and antibody removal. (C1)
# Which potential donors should be referred?
* There is clear, emphatic consensus among mental health clinicians working in the field that ALL potential altruistic donors should be referred for mental health assessment.
# Who should undertake assessments?
* Mental health assessments of potential altruistic donors can be undertaken by any suitably qualified and sufficiently senior mental health clinician (whether psychiatrist, psychologist, social worker, counsellor or nurse specialist) who is sufficiently familiar with transplant procedures, risk and outcomes, ideally because they are
embedded within or affiliated to transplant services.
Centres with access to more than one type of clinician can direct
referrals accordingly (for example preferring that potential donors with a history of mental disorder treated by medication see a psychiatrist, rather than psychologist, initially). Some cases may require assessment by more than one professional.
# At what stage of work-up?
* Referral for mental health assessment of potential altruistic donors should be made after initial screening, clinical assessment, and provision of information by the transplant team, but before any investigations which carry risk. However, to avoid delay in the assessment process and in discussion with the donor, it may be
appropriate to perform mental health assessment in parallel with physical assessment.
# With what information to hand?
*Referral information should include, at a minimum, a clear description of any specific mental health concerns or a statement that there are none. Where concerns relate to past episodes of treatment, available details obtained from the GP should be forwarded to the referee. Mental health clinicians receiving referrals should be free to gather further information directly if they judge it relevant, either on referral or after interview. Potential donors should be advised by the referrer that this gathering and sharing of information will happen (just as it would if they had a cardiac history and were being referred for cardiology assessment), and should be asked to agree to it.
# What is the purpose of assessment?
*The multiple potential purposes of mental health assessment listed above should be acknowledged, together with their overlap with each other and with the IA role. Referral should, where possible, clarify the purpose(s) for which referral is made. Mental health clinicians should clarify the specific purpose(s) they have addressed in their assessment.
# How should it be undertaken?
* The nature of the assessment should be tailored to the referral question, the clinical circumstances, and the professional background of the assessor. Repeat interviews, third party interviews, standardized questionnaires and structured assessments may all be necessary, but the only element of assessment required in all cases is a clinical interview
# To whom should the assessment report be sent?
*As a minimum, the assessment report should go to the referring clinician in the transplant team, the GP, and any mental health services with which the potential donor is in (or may foreseeably require) follow up. Reports may also go directly to the patient, where this is consonant with practice in local mental health and renal services. The report should also be forwarded to the HTA-IA in due course. The patient should be informed about, and consent to, this dissemination of information.
# What are the follow-up requirements for those who go on to donate, and for those who are declined on mental health grounds?
*Assessing clinicians should identify routes to mental health follow-up for those who may need it in the short- or long-term after donation. For potential donors who are declined there should be direct liaison with relevant mental health services and the GP.
# LOGISTICAL CONSIDERATIONS
* Wherever possible, the aim is to ensure that the financial impact on the living donor is cost neutral by the reimbursement of legitimate expenses incurred as a direct result of the preparation for and/or act of donation. There are clear policies across the four UK countries to ensure that claims are settled in full and in a timely manner (B1)
* Donors who are non-UK residents present unique logistical challenges. To ensure that the process is clinically effective and to comply with Visa and Immigration requirements, there is an agreed entry visa application process and maximum duration of stay in the UK (six months) for the donor. Visa extensions will only be considered in exceptional or unforeseen circumstances. (B1)
#DONOR FOLLOW-UP AND LONG-TERM OUTCOME
* 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 risk of ESRD in living donors mandates lifelong follow-up after donor nephrectomy. For donors who are resident in the UK, this can be offered locally or at the transplant centre according to the wishes of the donor, but such arrangements must secure the collection of data for submission to the UK Living Donor Registry. (B1)
* Donors who are non UK residents and travel to the UK to donate (privately or to a NHS entitled recipient) are not entitled to NHS followup but must be given advice about appropriate follow-up before returning to their country of origin. (C1)
* Potential donors who are unable to proceed to donation must be appropriately followed up and referred for further investigation and management as required. (B1)
* Women must be informed of a greater risk of pregnancy-induced hypertension following kidney donation. (A1)
* Close monitoring of blood pressure, creatinine and foetal well-being is advisable in kidneys donors during pregnancy. (C1)
* Kidney donors may be offered Aspirin 75 mg daily for pre-eclampsia prophylaxis. (D2)
* There is no evidence to support the benefits of right or left nephrectomy to prevent pregnancy induced hydronephrosis. (Not graded)
*Births after kidney donation should be reported to the Living Donor Registry as a significant medical event at each annual review. (Not graded)
# RECIPIENT OUTCOME AFTER LIVING DONOR KIDNEY TRANSPLANTATION IN ADULTS
* Graft and patient survival after living donor kidney transplantation should be within the national range of expected outcomes. (A1)
* Transplant centres should regularly audit secondary outcomes and should reappraise practice if their results are not comparable with other units. (B1)
* Where a recipient is considered to be at high risk, transplantation should only proceed if, in the view of the team of professionals involved, there is an expectation that the patient is likely to survive with a functioning transplant for more than 2 years. (C2)
* Patients at higher risk of complications and a poor outcome, due to immunological status or co-morbidities, should be considered for transplantation when the clinical team regard the risk / benefit ratio to be favourable. Due process will include careful consideration of the likely outcome for that individual without transplantation. The potential donor must be fully appraised of the issues. A summary of these discussions (between the clinical team and the donor-recipient pair) should be documented in the clinical records and a copy should also be given to the donor and recipient. (C2)
#RECURRENT RENAL DISEASE
* A wide range of diseases that cause renal failure may recur in a transplanted kidney. This is important to consider when determining the optimal treatment strategy for a recipient and when counseling both donor and recipient on the relative risks and benefits of living donor transplantation. The risks of recurrence, the consequences for transplant function, and the time-course of any deterioration must all be considered. A discussion of the effects of immunosuppression and transplant failure on morbidity and mortality may also be appropriate. (B1)
* The risks of recurrent disease are high in FSGS and MCGN. In these diseases, the presence of specific adverse clinical features may indicate living donor transplantation should be avoided, even where a donor is available. This will require careful assessment and deliberation with all interested parties. (B2)
* In atypical HUS potential de novo disease in a related donor needs to be addressed directly. The risks of recurrent disease in the recipient need to be mitigated through regulated approval and consideration of the use of an inhibitor of complement activation, currently eculizumab. (A1)
* In patients with risks related to underlying activity such as SLE or systemic vasculitis, adequate disease control and an appropriate
period of quiescence are important to ensure optimal outcomes. (B1)
* Recommendations for individual diseases follow in the following text. Type 1 and type 2 diabetes are not contraindications to living donor transplantation, irrespective of whether they are the underlying cause of renal failure. Both the donor and recipient should be counseled regarding the increased risks associated with surgery.
Living donor kidney transplantation is a reasonable option in patients with primary FSGS. Both the donor and recipient need to be specifically counselled about the risk of recurrent disease, which may occur early and result in rapid graft loss. In those in whom a genetic aetiology has been established the risk of recurrent disease is low but not absent. A potential living related donor must also be investigated for evidence of the same genetic abnormality.
Transplantation in an individual with unequivocal evidence of graft loss secondary to recurrent disease constitutes a high risk of subsequent failure such that some centers consider this a contraindication to repeat transplantation. In this context, living donor transplantation should be considered only in special circumstances and after careful discussion between the multi professional team, the donor and the recipient. Equally it is incumbent upon that team to assess the circumstances of the original graft failure with absolute rigor. The risk of recurrence is low when the previous graft did not fail due to recurrent disease.
*The risk of recurrent disease does not contraindicate living donor transplantation in IgA nephropathy. Both the donor and recipient should be counselled regarding the risks of recurrent disease.
* This risk of recurrent disease does not contraindicate living donor transplantation in membranous nephropathy. Both the donor and recipient should be counselled regarding the risks of recurrent disease.
*Patients with amyloidosis should be discussed with the National Amyloidosis Centre before progressing to living donor transplantation.
Patients with AA amyloidosis should have effective disease control before surgery
*The overall risks associated with recurrent disease are small in SLE and living donor transplantation is safe in quiescent disease. Both the donor and recipient should be counselled regarding the risks of recurrent disease. (B2)
* The risks associated with recurrent disease are small and the outcomes of transplantation good, therefore AASV does not contraindicate living donor transplantation if the aforementioned criteria are met. Both the donor and recipient should be counseled regarding the risks of recurrent disease.
* The risks associated with recurrent disease are small and the outcomes of transplantation good, therefore Goodpasture’s disease does not contraindicate living donor transplantation if the aforementioned criteria are met. Both the donor and recipient should be counselled regarding the risks of recurrent disease.
* The overall risks associated with Alport syndrome are small and the outcomes of transplantation good, therefore Alport syndrome does not contraindicate living donor transplantation. Both the donor and recipient should be counselled regarding the risks of de novo anti-GBM disease. (B2)
* Type I and II MCGN do not contraindicate living donor transplantation. However, the risk of recurrent disease and subsequent graft loss is sufficiently high that transplantation should only be undertaken following careful discussion between the multi-professional team, the donor and the recipient. This is particularly the case if there is an identified abnormality of a soluble complement regulatory protein.
* Transplantation in an individual with unequivocal evidence of graft loss secondary to recurrent C3 glomerulopathy constitutes a high risk of subsequent failure such that some centres consider this a contraindication to repeat transplantation
* Among patients with genetic abnormalities in complement proteins or with an unknown cause of C3 glomerulopathy, a comparison with atypical HUS suggests that consideration should be given to avoiding living related donors in whom similar genetic mutations may predispose to the future development of C3 glomerulopathy afternephrectomy
* Living related renal transplantation should be avoided in atypical HUS unless the cause of the disease in the recipient is known and this has
been excluded in the donor. Even then related donors may be at a greater risk of aHUS and should be warned of this risk.
* In patients in whom the underlying cause has unequivocally been attributed to Shiga-toxin, the recurrence rate of HUS is low and living donor transplantation may be considered.
* In appropriately selected cases, living donor kidney transplantation is a reasonable treatment option in primary hyperoxaluria. Both the donor and recipient should be counselled regarding the risks of recurrent disease.
* Cystinosis is not a contra-indication to living donor transplantation. However, both donor and recipient should be counselled regarding the long-term extra-renal complications related to disease progression.
# LIVING DONOR KIDNEY TRANSPLANTATION IN CHILDREN
* Pre-emptive living related renal transplantation is the gold standard therapy for children with end-stage renal disease. (2C)
* The aim should be for children to receive a renal transplant from a blood group compatible well-matched donor, although ABO and/or HLA incompatible renal transplantation is feasible in children. (2C)
* Every effort should be made to minimise HLA mismatches (especially with common antigens) to reduce the risk of future sensitisation. (2D)
* All children with stage 4 and 5 chronic kidney disease should be assessed by a multi-disciplinary team, including a paediatric nephrologist, transplant surgeon, anaesthetist and urologist (where appropriate) prior to renal transplantation. (Not graded)
* In general, children who are ≥10 kg in weight are suitable to receive a kidney from an adult living donor. (2C)
Abdullah Raoof
2 years ago
Guidelines for Living Donor Kidney Transplantation
1- Please summarise these guidelines in your own words.
Donor considered unsuitable because they:
1. when there is absolute contraindication to donation.
2. Have a relative contraindication to donation.
3. Do not meet transplant centre-specific criteria for acceptance .
DONOR EVALUATION: SUMMARY
Recommendations
Ø For directdonation the likely suitability of the potential recipient for transplantation must be established before starting donor assessment.
Ø donor assessment is planned to minimize inconvenience to patient .
Ø Donor assessment must be planned to ensure that it is focused, logical and coherent and involvement of multi-disciplinary team is important . Unsuitable donors must be identified at the earliest possible stage of assessment.
Ø donor evaluation steps may vary between centers , but the principles apply for all donors are the same .
Ø pre-emptive transplantation, donor evaluation must start sufficiently early to allow time for more than one donor to be assessed if required. It is usually started when the recipient eGFR is approximately 20 mL/min or when the recipient is expected to require R R T within 12-18 months .
Ø The evaluation of a potential donor should be undertaken within an 18 week pathway, assuming there are no logistical issues such as donor unavailability.
Ø To promote planned, pre-emptive LD transplantation as the treatment ,To minimise time on dialysis .
ABO BLOOD GROUPING AND CROSSMATCH TESTING
Ø A compatible ABO and (HLA) transplant offers the best chance of success.
Ø If ABO or HLA incompatibility is present, the alternative is paired donation and antibody incompatible transplantation.
5.5 ASSESSMENT OF RENAL FUNCTION
Ø Initial evaluation of donor candidates should be using estimated(eGFR), expressed as mL/min/1.73m2 .
Ø GFR must subsequently be assessed by measured (mGFR) such as clearance of 51Cr-EDTA, 125iothalamate or Iohexol .
Ø Differential kidney function, estimated by 99mTcDMSA scanning is recommended in
o When there is >10% variation in kidney size or
o significant renal anatomical abnormality.
Ø Pre-donation mGFR should be such that the predicted post-donation GFR remains within the gender and age-specific normal range within the donor’s lifetime.
Ø The risk of (ESRD) after donation is not higher than that of the general population. But , there is a very small absolute increased lifetime risk of ESRD following .
Ø The donor must be offered lifelong annual assessment of renal function including serum creatinine, estimation of urine protein excretion and blood pressure measurement.
DONOR AGE
Ø Old age alone is not an absolute contraindication to donation .
Ø The donor and recipient must be made aware that
o Are at greater risk of peri-operative complications and that
o the function and survival of the graft may be compromised especially in those above 60 years .
Ø in Most centers do not consider donors aged <18 years and consider an age of 18-21 years as a relative contraindication to donation.
Summary
Most transplant programs are more flexible in older donors. Younger donors should be subjected to stringent exclusion criteria .
DONOR OBESITY
Ø overweight patients (BMI 25-30 kg/m2) may safely go to kidney donation.
Ø Moderately obese patients (BMI 30-35 kg/m2) should be assessed carefully preoperative
to exclude cardiovascular, respiratory and kidney disease.
– must be counselled aboutthe increased risk of peri-operative complications .
– must be counselled about the long-term risk of kidney disease
– advised to lose weight and to maintain their ideal weight following donation.
Ø kidney donation in the very obese (BMI >35 kg/m2) should be discouraged.
5.8 HYPERTENSION IN THE DONOR
Ø B p must be assessed on at least 2 separate occasions.
Ambulatory BP monitoring or home monitoring is recommended if
v blood pressure is high,
v high normal or variable,
v If donor is on treatment for hypertension.
Ø a blood pressure of <140/90 mmHg is usually acceptable for donation.
Ø Prospective donors should be warned about the risk of post donation hypertension.
Ø donors BP should be monitored annually.
Ø donors with mild-moderate HT that is controlled to <140/90 mmHg (and/or 135/85 mmHg with ABPM or home monitoring) with one or two antihypertensive drugs and who have no evidence of end organ damage may be acceptable for donation.
Ø donors with hypertension are excluded if:
v Blood pressure is not controlled to <140/90 mmHg on one or two antihypertensive drugs .
v Evidence of end organ damage (retinopathy, left ventricular hypertrophy, proteinuria, previous cardiovascular disease) .
v Unacceptable risk of future cardiovascular risk or lifetime incidence of ESRD .
Ø All living kidney donors must be encouraged to
v lifestyle measures including stopping smoking, reducing alcohol intake, frequent exercise and, weight loss.
Ø Hypertension will develop in at least 30% of patients following unilateral nephrectomy
DIABETES MELLITUS
Ø All donors must have a fasting plasma glucose level checked.
Ø A fasting plasma glucose concentration between 6.1-6.9 mmol/L (110-125mg/dl) is indicative of an impaired fasting glucose state and t (OGTT) should be undertaken.
Ø donors with an high risk of type 2 diabetes because of
o family history,
o a history of gestational diabetes,
o ethnicity or
o obesity
should also undergo an OGTT.
Ø diabetes as donors requires very careful evaluation
v In the absence of evidence of target organ damage
v other cardiovascular risk factors such as obesity, hypertension or hyperlipidaemia are optimally managed,
diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease .
CARDIOVASCULAR EVALUATION
Ø There is no need use of stress testing in the assessment of donor at low cardiac risk.
Ø Potential kidney donors with
v a history of cardiovascular disease,
v an exercise capacity of <4 metabolic equivalents (METS) or
v with risk factors for cardiovascular disease
should undergo further evaluation before donation.
Ø For higher risk potential donors, stress testing is recommended by Which ever method is locally available or by CT calcium scoring .
Ø The choice of stress test will be influenced by local service provision.
Ø CT coronary calcium scoring may be an alternative way of stratifying coronary risk.
PROTEINURIA
Ø Urine protein excretion should be assessed in all living donors.
Ø A urine albumin/creatinine ratio (ACR) is the recommended screening test, urine protein/creatinine ratio (PCR) is an alternative method .
Ø ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day or protein excretion >500 mg/day represent absolute contraindications to donation .
Ø The significance of moderately increased albuminuria (ACR 3-30 mg/mmol) and proteinuria (PCR 15-50 mg/mmol or 24-hour urine protein 150-500 mg/day) has not been fully evaluated in living kidney donors.
Ø since the risk of CKD and cardiovascular morbidity increase progressively with increasing albuminuria or proteinuria such levels are a relative contraindication to donation.
NON-VISIBLE HAEMATURIA
Ø All donors must have (dipstick) urinalysis performed on at least two occasions.
Ø Two or more positive tests, including trace positive, is considered as persistent non-visible haematuria (PNVH).
Ø If PNVH is present, we need to exclude
o infection,
o nephrolithiasis and
o urothelial carcinoma.
Ø If no cause is found, cystoscopy is indicated in patients >40 years to exclude bladder pathology. (B1)
Ø If cystoscopy is normal then a kidney biopsy is recommended if haematuria is 1+ or greater on dipstick testing.
Ø Glomerular pathology prevent donation, exception of thin basement membrane disease.
Ø With a family history of haematuria or X-linked Alport syndrome, a renal biopsy and referral to a clinical geneticist are recommended.
PYURIA
Ø donors found with pyuria can only be considered for donation if it is due to a reversible cause, such as an uncomplicated urinary tract infection.
INFECTION IN THE PROSPECTIVE DONOR
Ø Screening for infection in the donor is essential .
Ø Active HBV and HCV infection in the donor are usually contraindications .
Ø HIV or human T lymphotrophic virus (HTLV) infection is an absolute contraindication to living donation.
Ø Screening for HBV, HCV and HIV infection must be repeated within 3 days of donation.
Ø All donors should be provided with dietary advice regarding avoidance of HEV infection, and screening should be undertaken for HEV viraemia by nucleic acid testing within 30 days of donation.
Ø The CMV status of donor and recipient must be determined before transplantation.
Ø The EBV status of donor and recipient must be tested before transplantation.
NEPHROLITHIASIS
Ø In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging , may still be considered as potential kidney donors.
Ø Potential donors with metabolic abnormalities detected on screening should be discussed with a specialist in renal stone disease.
Ø In appropriate donors with unilateral kidney stone(s) the stone-bearing kidney can be considered for donation .
HAEMATOLOGICAL DISEASE
Ø Donor anaemia needs to be investigated and treated before donation.
Ø A haemoglobinopathy screen must be carried out if indicated by the full blood count.
Ø Careful consideration needs to be given to the use of potential donors with haemoglobinopathies .
FAMILIAL RENAL DISEASE
Ø All potential transplant recipients must have a detailed family history recorded .
Ø When the cause of kidney failure in the recipient is due to an inherited condition, appropriate tests are recommended to exclude genetic disease .
DONOR MALIGNANCY
Ø history taking, clinical examination and investigation of donors are essential to exclude occult malignancy , in older (age >50 years) .
Ø Active malignant disease is a contraindication to donation .
Ø Contrast enhanced renal CT scan, ultrasound and / or MRI can usually distinguish between benign or malignant lesion .
Ø Bilateral AML and AML >4 cm generally preclude living kidney donation .
Ø An incidental, unilateral solitary AML <4 cm with typical characteristic CT criteria does not usually preclude donation.
Ø A kidney with an AML <1 cm may be considered for donation or left in situ in the donor’s remaining kidney.
Ø Kidneys containing a single AML between 1 and 4 cm can be considered for donation.
Ø Donors with an incidental small (<4 cm) renal mass suggesting a RCC must be offer partial and radical nephrectomy.
Ø Renal function permitting ,the reconstructed kidney can be Considered for donation .
Q2 How these guidelines are different from the guidelines you follow at your workplace?
Actually I did not compare with others , therefore I donot know .
Eusha Ansary
2 years ago
Summary:
Donor evaluation:
In cases of directed donation the likely suitability of the potential recipient for transplantation must be established before starting donor assessment.
As far as possible, donor assessment is planned to minimize inconvenience to him/her and to avoid unnecessary barriers to the proceeding.
Donor assessment must be planned to ensure that it is focused, logical and coherent.
ABO BLOOD GROUPING AND CROSSMATCH TESTING
Compatible ABO blood group and HLA transplant offer the best opportunity for success.
Where ABO or HLA incompatibility is present, alternative options for transplantation must be discussed with the donor and recipient, including paired/pooled donation and antibody incompatible transplantation. Antibody incompatible transplantation must only be performed in a transplant center with the relevant experience and appropriate support.
ASSESSMENT OF RENAL FUNCTION
Measurement of Renal Function:
Initial evaluation of donor candidates should be using estimated glomerular filtration rate (eGFR), expressed as mL/min/1.73m2 computed from a creatinine assay standardised to the International Reference Standard.
GFR must subsequently be assessed by a reference measured method (mGFR) such as clearance of 51Cr-EDTA, 125 iothalamates or Iohexol performed according to guidelines published by the British Society of Nuclear Medicine.
Differential kidney function, determined by 99mTcDMSA scanning is recommended where there is >10% variation in kidney size or a significant renal anatomical abnormality.
DONOR AGE
Old age alone is not an absolute contraindication to donation but the medical work-up of older donors must be particularly rigorous to ensure they are suitable.
Both donor and recipient must be made aware that the older donor may be at greater risk of peri operative complications and that the function and possibly the long-term survival of the graft may be compromised. This is particularly evident with donors >60 years of age.
DONOR OBESITY
Otherwise healthy overweight patients (BMI 25-30 kg/m2 ) may safely proceed to kidney donation.
Moderately obese patients (BMI 30-35 kg/m2 ) must undergo a careful preoperative evaluation to exclude cardiovascular, respiratory and kidney disease.
Moderately obese patients (BMI 30-35 kg/m2 ) must be counselled about the increased risk of peri-operative complications based on extrapolation of outcome data from very obese donors (BMI >35 kg/m2 ).
Moderately obese patients (BMI 30-35 kg/m2 ) must be counselled about the long-term risk of kidney disease and be advised to lose weight before donation and to maintain their ideal weight following donation.
Data on the safety of kidney donation in the very obese (BMI >35 kg/m2 ) are limited, and the donation should be discouraged.
HYPERTENSION IN THE DONOR
Blood pressure must be assessed on at least two separate occasions. Ambulatory blood pressure monitoring or home monitoring is recommended if blood pressure is high, high normal or variable, or the potential donor is on treatment for hypertension.
We suggest that a blood pressure <140/90 mmHg is usually acceptable for donation.
Prospective donors must be warned about the risk of developing donation-related hypertension, particularly if in a high-risk group. Blood pressure measurement is part of annual donor monitoring.
Potential donors with mild-moderate hypertension that is controlled to <140/90 mmHg (and/or 135/85 mmHg with ABPM or home monitoring) with one or two antihypertensive drugs and who have no evidence of end-organ damage may be acceptable for donation. Acceptance will be based on an overall cardiovascular risk assessment and local policy.
DIABETES MELLITUS
All potential living kidney donors must have a fasting plasma glucose level checked.
A fasting plasma glucose concentration between 6.1-6.9 mmol/L indicates an impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be undertaken.
Prospective donors with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT. (B1) If OGTT reveals persistent impaired fasting glucose and/or impaired glucose tolerance, the risk of developing diabetes after donation must be carefully considered.
Consideration should be given to using a diabetes risk calculator to inform the discussion of potential kidney donation.
Consideration of patients with diabetes as potential kidney donors requires carefully evaluating the risks and benefits.
CARDIOVASCULAR EVALUATION
There is no evidence to support the routine use of stress testing in assessing the potential donor at low cardiac risk.
Potential kidney donors with a history of cardiovascular disease, an exercise capacity of <4 metabolic equivalents (METS) or risk factors for cardiovascular disease should undergo further evaluation before donation.
For higher-risk potential donors, stress testing is recommended by whichever method is locally available or by CT calcium scoring.
Discussion with and/or review by cardiologists, anaesthetists and the transplant MDT is recommended as part of the clinical assessment of donors with higher cardiovascular and peri-operative risk.
PROTEINURIA
Urine protein excretion needs to be quantified in all potential living donors.
A urine albumin/creatinine ratio (ACR) performed on a spot urine sample is the recommended screening test, although urine protein/creatinine ratio (PCR) is an acceptable alternative.
ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day or protein excretion >500 mg/day represent absolute contraindications to donation.
The significance of moderately increased albuminuria (ACR 3-30 mg/mmol) and proteinuria (PCR 15-50 mg/mmol or 24-hour urine protein 150-500 mg/day) has not been fully evaluated in living kidney donors. However, since the risk of CKD and cardiovascular morbidity increase progressively with increasing albuminuria or proteinuria, such levels are a relative contraindication to donation.
NON-VISIBLE HAEMATURIA
All potential living donors must have reagent strip (dipstick) urinalysis performed on at least two separate occasions.
Two or more positive tests, including trace positive, is considered as persistent non-visible haematuria (PNVH).
Giulio Podda
2 years ago
Please summarise these guidelines in your own words
This guidance relates to living donor kidney transplantation and includes the ethical and medico-legal aspects of donor selection, medical and pre-operative donor evaluation,Identification of high risk donors, the management of complications, and expected Outcome. The guidance also includes antibody incompatible transplantation, recurrent disease and Transplantation in the context of other co-morbidities.
LEGAL FRAMEWORK:
All transplants performed from living donors must comply with the Human Tissue Act 2004 and Human Tissue (Scotland) Act 2006). Transplant centres performing living organ donation must be licensed by the Human Tissue Authority according with the requirements of the European Union Organ Donation Directive. Consent for the removal of organs from living donors, must comply with the requirements of the Human Tissue Act 2004, and the Mental Capacity Act 2005 in England and Wales, and the Mental Capacity Act 2016 in Northern Ireland. Consent in Scotland must comply with the Human Tissue (Scotland) Act 2006 and the Adults with Incapacity (Scotland) Act 2000.
ETHICS: complex moral issues in this field and good ethical practice in living donor kidney transplantation should be owned by all health professional involved. Safety and welfare of the potential living donor should always take priority. Altruism, Autonomy, Beneficence, Dignity, Non-maleficence and Reciprocity are the Ethical Principles of Living Donor Transplantation.
SUPPORTING AND INFORMING THE POTENTIAL DONOR: The living donor should receive the best possible environment for making a voluntary and informed choice about donation. Donor and recipient require an Independent assessment (primary legislation Human Tissue Act 2004). Confidentiality must be specified and discussed at the beginning. Relevant information about the recipient can only be shared with the donor if the recipient has given consent and vice versa.
Psychological needs must be identified to ensure that appropriate support and/or intervention is initiated. An informed health professional not directly
involved with the care of the recipient acts as the donor advocate in
addressing any outstanding questions, and assists the donor in making an autonomous decision
ABO BLOOD GROUPING AND CROSSMATCH TESTING:
Compatible ABO blood group and HLA transplant offers the best opportunity the best outcome. Alternative options for transplantation must be discussed with the donor and recipient, If ABO or HLA incompatibility is present. Alternative options for transplantation include paired/pooled donation and antibody incompatible
transplantation. Antibody incompatible transplantation should be
performed in a centres with relevant experience.
DONOR EVALUATION
The process of donor evaluation is to ensure the suitability of the donor and to minimise the risk of donation. Potential donors must be assessed following evidence-based protocol. Donor evaluation will start only when the suitability of the potential recipient for transplantation has been established.
For pre-emptive transplantation in order to maximize and avoid unnecessary delay where the probability of recipient contraindications is low, it may be appropriate to start the donor work-up in parallel to the recipient assessment.
Routine Screening Investigations for the Potential Donor
Urine
Dipstick for protein, blood and glucose, Microscopy, culture and sensitivity,
Measurement of urine ACR or PCR
Blood
Haemoglobin and blood count, Coagulation screen (PT and APTT), Thrombophilia screen,
Sickle cell trait, Haemoglobinopathy screen, G6PD deficiency, Creatinine, urea and electrolytes, Isotopic or other reference test for measurement of GFR, LFT’s, Bone profile
Urate, Fasting plasma glucose, Glucose tolerance test (if family history of diabetes or fasting plasma glucose >5.6 mmol/L), Fasting lipid screen (if indicated), Thyroid function tests (if strong family history), Pregnancy test (if indicated)
Virology and infection screen (see section 5.14)
Hepatitis B and C, HIV, HTLV1 and 2 (if appropriate),CMV, EBV, Toxoplasma, Syphilis
Varicella zoster virus (where recipient seronegative), HHV8 (where indicated), Malaria (where indicated), Trypanosoma cruzi (where indicated), Schistosomiasis (where indicated)
Cardiorespiratory system
Chest X-ray, ECG, ECHO
Cardiovascular stress test (Where indicated)
Renal Function evaluation:
Initial assessment of renal function in living kidney donors is by measurement of serum creatinine which is usually performed by an estimate GFR using the CKD- Epidemiology Collaboration. Measurement of GFR using a clearance of inulin, 51Cr-EDTA, 125I-iothalamate or iohexol offer a more detailed assessment of potential donor function. These measurement are used to inform potential donors of the long-term risks of donation and potential recipients of the anticipated level of kidney function being transplanted. The mean age at donation of the cohorts has been around 45 years and the lower threshold for donation a GFR >80 mL/min/1.73m2. If the patient age is equal or more than 35 year old eGFR should be greater than 80 ml/min. If patient age is less than 30 year old eGFR should be greater than 90 ml/min.
In the general population a decreased GFR is associated with an increased risk of Adverse outcomes, ESRD, cardiovascular disease and death.
In the presence of >10% variation in kidney size or anatomical abnormality of the kidneys Split kidney function need to be evaluated.
Old age is not a contraindication to donation. However, donor and recipient need be aware that the older donor (particularly evident with donors >60 years of age) are at higher risk of peri-operative complications. Moreover the function and the long-term survival of the graft may be compromised.
Patients with BMI 30-35 kg/m2need a preoperative assessment to exclude cardiovascular, respiratory and kidney disease. Moreover they shsould be informed
Of the increased risk of peri-operative complications and the long-term risk of kidney disease. Moderately obese patients should be advised to lose weight before donation and to maintain their ideal weight following donation
Blood pressure <140/90 mmHg is usually acceptable for donation. A patient with BP < 140/90 mmHg (and or 135/85 mmHg with ABPM or Home monitoring) controlled with one or two antihypertensive drugs and no evidence of end organ damage may be considered for donation. Potential donor should be excluded if Blood pressure is not controlled ( <140/90 mmHg) while on one or two antihypertensive drugs and if there is evidence of end organ damage. Patient with high risk of future cardiovascular risk or lifetime incidence of ESRD should be excluded from donation.
Fasting plasma glucose (FPG) must be checked in all potential living donors. A FPG concentration between 6.1-6.9 mmol/L indicate an impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be performed. Donors with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT. The risks of developing diabetes after donation should be considered if OGTT reveals a persistent IFG or an IGT
Patients with diabetes may be considered as potential kidney donors if target organ damage has been excluded and other cardiovascular risk factors are optimally managed.
Potential donors should undergo cardiac evaluation before donation if they have history of cardiovascular disease, risk factors for cardiovascular disease and an exercise capacity of <4 metabolic equivalents. Stress testing or CT calcium scoring should be doen For higher risk potential donors. Donors with higher cardiovascular and peri-operative risk should be discussed in the transplant MDT and reviewed by cardiologists and anaesthetists.
Proteinuria is a contraindication for transplant (ACR > 30 mg/mmol and PCR > 50 mg/mmol). Albumin excretion >300 mg/day or protein excretion >500 mg/day represent absolute contraindications to donation.
Urinalysis should be performed on at least two separate occasions to exclude non visible haematuria. Two or more positive tests (including trace positive), is considered as persistent non-visible haematuria (PNVH). If PNVH is present, potential donor should have a urine culture and renal imaging to exclude common urologic causes such as infection, nephrolithiasis and urothelial carcinoma and if no cause is found, in patients age above 40 years, a cystoscopy should be done to exclude bladder pathology. If donor still wishes to donate and no cause is found then a kidney biopsy is recommended (haematuria of 1+ or greater on dipstick testing. Glomerular pathology is a contraindication for donation with the exception of thin basement membrane disease.
Donors found to have pyuria can be considered for donation if the pyuria is due to a reversible cause (uncomplicated urinary tract infection)
Potential donor should be screened for infection in order to identify potential risks for the donor from previous or current infection and to assess the risks of transmission of infection to the recipient. Active HBV and HCV infection in the donor are usually contraindications to living donor kidney donation. Screening for HBV, HCV and HIV infection must be repeated within 30 days of donation. Active HBV and HCV infection in the donor are usually contraindications to living donor kidney donation. The CMV status of donor and recipient need to be determined before transplantation. If the donor is CMV positive and the recipient is CMV negative, the donor and recipient should be informed about the risk of posttransplant CMV disease. If the donor is EBV positive and the recipient is EBV negative, the donor and recipient must be informed about the risk of developing Post Transplant Lymphoproliferative Disease.
Donors with no significant metabolic abnormalities or with a little history of previous kidney stones, or small renal stone on imaging, may still be considered for donation. Potential donors with metabolic abnormalities should be discussed with a specialist in renal stone disease.
Potential donor with anaemia needs to be investigated and treated before donation.
Perspective donors with haemoglobinopathies should receive a careful consideration (Haematology evaluation) In case of congenital conditions genetic testing and family historyry should be done.
In age >50 years malignancy should be excluded. Active cancer is a contraindication to organ donation. If donors have some treated low-grade tumors or unilateral renal mass less than 4 cm (if AML, without excision; and if RCC, with excision and renal reconstruction).can be considered eligible for donation.
In regard to technical aspects of the surgery the necessary assessments include: Direct or indirect evaluation of split renal function, vascular anatomy, renal parenchyma and collecting system imaging using CTA or MRA needs to be arranged. Pre- and post-operative adequate hydration is crucial. All patients should receive thromboprophylaxis. It is preferable to provide donors with laparoscopics nephrectomy. Enhanced recovery after surgery programs and long term follow up post donation should be offered. In case of pregnancy post donation close monitoring of BP, creatinine, foetal evaluation and pre-eclampsia prophylaxis (aspirin 75 mg) are needed.
Patients should receive counselling about the risks of recurrence of the disease.
It is highly recommended in children with ESRD to carry out pre-emptive transplant with a compatible blood group and minimal HLA mismatches. Adult living donor kidney can be received by all who weigh more than 10kg.
How these guidelines are different from the guidelines you follow at your workplace?
We use the same criteria
hussam juda
2 years ago
· Kidney transplantation from a living donor is recommended for most ESKD patients, particularly complex recipients.
· About 1 in 3 kidney transplants performed in the UK are from living donors
· For each recommendation of the guideline the quality of evidence has been graded as one of:
A (high) B (moderate) C (low) D (very low)
· For each recommendation, the strength has been indicated as one of:
Level 1 (we recommend) Level 2 (we suggest) Not graded (where there is not enough evidence to allow formal grading)
The Human Tissue Authority (HTA)
· is responsible for assessing all applications for organ donation from living people
· ensure that the donor has given valid consent, and gives approval for the living donation The European Union Organ Donation Directive(EUODD)
· It is the first pan-European regulatory framework governing the donation and transplantation of organs from the living and deceased and responsible about follow-up of living donors across the EU
· The HTA is the Competent Authority for the UK under the EUODD Consent for the Removal of Organs from Living Donors
· treating clinician is responsible to get the consent for the removal of organs from living donors
· The clinician responsible for the living donor is required to confirm to the HTA that the donor understands all risks of donation Types of Living Donation Permitted by the Legislation
1. Directed donation
(i) Genetically related donation: blood relative
(ii) Emotionally related donation: for example, spouse, partner, or close friend;
2.Paired or pool donation:
· The donors are not genetically related or known to their respective recipients.
· ‘Paired donations’ involve two pairs in an exchange
· ‘pooled donations’ include a series of paired donations, each of which is linked to another in the same series
3.Non-directed altruistic donation: an organ is donated by a healthy person to an unknown recipient
4.Directed altruistic donation:
(i) Genetic relationship and no established emotional relationship
(ii) No pre-existing relationship between donor and recipient before the need for a transplant
Requirements for Transplants Involving a Living Donor
· To give approval HTA want to be sure that
1. No reward has been, or will be, given;
2. Consent to removal for the purpose of transplantation has been given
3. An Independent Assessor (IA) has performed separate interviews with the donor and the recipient
and offer a report of their assessment to the HTA.
· In cases of directed genetically or emotionally related donation, the HTA needs a conformation about the relationship
· higher regulatory risk needs at least 3 members of HTA, this may include:
1. Paired and pooled donation
2. Non-directed altruistic living donation
3. Directed altruistic donation cases where the donor is non-resident in the UK
4. Certain directed donation cases where the donor has an economic
5. dependence on the recipient
6. If the organ donor is a child
7. If the organ donor is an adult who lacks capacity
Exceptional Circumstances Children
· a person under 18 years old
· The use of a living organ from a child can only proceed with Court approval followed by approval from an HTA panel Adults without Mental Capacity
· Donation requires court approval, then approval from HTA panel
· In Scotland, living donation from adults without mental capacity is not permitted under the Human Tissue
ETHICS: Recommendations
· All health professionals involved in living donor kidney transplantation should have good knowledge about ethical issues related to this field
· The priority is for donor safety over recipient benefit.
· Independence is recommended between the clinicians responsible for the assessment and preparation of the donor and the recipient
SUPPORTING AND INFORMING THE POTENTIAL DONOR
· The living donor must be offered the best possible environment for making a voluntary and informed choice about donation. The transplant team must provide generic information that is relevant to all donors as well as specific information that is material to the person intending to donate. This includes information about the assessment process and the benefits and risks of donation to the individual donor. (B1)
· Independent assessment of the donor and recipient is required by primary legislation (Human Tissue Act 2004). (Not graded)
· To achieve the best outcome for donor, recipient and transplant, the boundaries of confidentiality must be specified and discussed at the outset. Relevant information about the recipient can only be shared with the donor if the recipient has given consent and vice versa. Both the recipient and donor must be informed that it is necessary and usual for all relevant clinical information to be shared across the transplant team in order to optimise the chance of a successful outcome for the transplant. (B1)
· Ideally, the recipient will discuss relevant information with their donor, or allow it to be shared. If the recipient is not willing to disclose information, then the transplant team must decide whether it is possible to communicate the risks and benefits of donating adequately, without needing to disclose specific medical details. (Not graded)
· Separate clinical teams for donor and recipient are considered best practice but healthcare professionals must work together to ensure effective communication and co-ordination of the transplant process without compromising the independence of either donor or recipient. It is essential that an informed health professional who is not directly involved with the care of the recipient acts as the donor advocate in addressing any outstanding questions, anxieties or difficult issues, and assists the donor in making a truly autonomous decision. (B1)
· Support for the prospective donor, recipient and family is an integral part of the donation/transplantation process. Psychological needs must be identified at an early stage in the evaluation to ensure that appropriate support and/or intervention is initiated. Access to specialist psychiatric/psychological services must be available for donors/recipients requiring referral. (B1)
A Summary of Key Points to be Discussed with a Potential Donor
General points about process, consent and confidentiality:
1. For a living donor to give valid consent for donation, he/she must be properly
informed about the generic risks (for all donors) and any specific, individual
risks (for them) (see section 4.3.5 and Chapter 2).
2. Informed consent must be sought before progressing to each stage of the
pathway.
3. Information must be given about what will be shared amongst the transplant
team and the GP.
4. Information must be given about what will not be shared with the potential
recipient, unless explicit consent is given to do so.
5. It should be explained that the tests might throw up unexpected findings that
may or may not be relevant to donating a kidney. These findings might
include:
a. Information about the genetic relationship with the recipient.
b. Medical or anatomical findings of uncertain significance that might
require further assessment or referral to another specialty.
6. It should be emphasised that the donor can withdraw from the process at
any time up until the time of surgery.
Specific points about process and possible outcomes:
1. Risks of donation (generic and specific).
2. Nature of surgical procedure and length of stay in hospital.
3. Potential graft loss in the recipient.
4. Requirement for HTA assessment.
5. Reimbursement of expenses.
6. Requirement for annual review.
DONOR EVALUATION
· In cases of directed donation (to a known recipient) the likely suitability of the potential recipient for transplantation must be established before starting donor assessment. If additional recipient assessment is required, unnecessary delay should be avoided. Non-invasive assessment of the donor may be undertaken in this phase. (Not graded)
· As far as possible, donor assessment is planned to minimize inconvenience to him/her and to avoid unnecessary barriers to proceeding. Flexibility in terms of timescales, planning consultations, attending for investigations and date of surgery is helpful. (Not graded)
· Donor assessment must be planned to ensure that it is focused, logical and coherent. Good communication with the donor and involvement of the wider multi-disciplinary team is essential and is achieved most effectively if a designated coordinator leads the organization of the assessment process. The results of investigations must be relayed accurately and efficiently to the potential donor. Unsuitable donors must be identified at the earliest possible stage of assessment. (Not graded)
· A policy must be in place to manage prospective donors who are found to be unsuitable to donate and appropriate follow-up and support must be made available. (Not graded)
· The organizational aspects for donor evaluation will vary between centers, according to available resources and personnel, but the same principles apply for all donors. An agreed donor assessment protocol must be in place that is tailored to the needs of the individual
· To facilitate pre-emptive transplantation, donor evaluation must start sufficiently early to allow time for more than one donor to be assessed if required. Information must be provided at an early stage and discussion with potential donors and recipients will usually be started when the recipient eGFR is approximately 20 mL/min or when the recipient is expected to require renal replacement therapy within 12-18 months. Recipient and donor assessment can then be tailored according to the rate of decline of recipient renal function, disease specific considerations and individual circumstances. (B2)
· The evaluation of a potential donor should be undertaken within an 18-week pathway, assuming there are no logistical issues such as donor unavailability. There may, of course, be pauses if the recipient’s transplant assessment is complicated or if the recipient’s renal function remains satisfactory
ABO BLOOD GROUPING AND CROSSMATCH TESTING
· A compatible ABO blood group and human leucocyte antigen (HLA) transplant offers the best opportunity for success. (A1)
· Where ABO or HLA incompatibility is present, alternative options for transplantation must be discussed with the donor and recipient, including paired/pooled donation and antibody incompatible transplantation.
· Antibody incompatible transplantation must only be performed in a transplant centre with the relevant experience and appropriate support. (A1)
Summary of Key Points of Importance in the Medical +/- Family History of a Potential Kidney Donor
Haematuria/proteinuria/urinary tract infection
Difficulty in passing urine, including urgency, frequency, dysuria
History of peripheral oedema
Gout
Nephrolithiasis
Hypertension
Diabetes mellitus, including family history
Ischaemic heart disease/peripheral vascular disease/other atherosclerosis
Cardiovascular risk factors
Thromboembolic disease
Sickle cell and other haemoglobinopathies
Weight change
Change in bowel habit
Previous jaundice
Previous or current malignancy
Systemic disease which may involve the kidney
Chronic infection such as tuberculosis
Family history of a renal condition that may affect the donor
Smoking
Current or prior alcohol or drug dependence
Mental health history
Obstetric history
Residence abroad
Previous medical assessment e.g. for life insurance
Previous anaesthetic problem
History of back or neck pain and trauma
Results of national screening programme tests e.g. cervical smear, mammography,
colorectal screening History with respect to Transmissible Infection
Previous illnesses
Jaundice or hepatitis
Malaria
Previous blood transfusion
Tuberculosis / atypical mycobacterium
Family history of tuberculosis
Family history of Creutzfeldt-Jakob disease, previous treatment with natural growth
hormone, or undiagnosed degenerative neurological disorder
Specific geographical risk factors: e.g. fungi and parasites, tuberculosis, hepatitis,
malaria, worms
Increased risk of HIV, HTLV1 and HTLV2, Hepatitis B and C infection
Haemophiliac or sexual partner of haemophiliac
High risk sexual behaviour
History of infectious hepatitis or syphilis
History of intravenous drug use
Tattoo or skin piercing within last 6 months
Sexual partner of an individual with positive serology
Sexual partner of drug addict
Points of Particular Importance when Undertaking Clinical Examination of a Potential Kidney Donor
Abdominal fat distribution
Blood pressure
Body mass index
Dipstick urinalysis
Evidence of self-harm
Examination for abdominal masses or herniae
Examination for scars or previous surgery
Examination for lymphadenopathy
Examination / history of regular self-examination of the breasts
Examination / history of regular self-examination of the testes
Examination of the cardiovascular and respiratory systems
Mental health
Routine Screening Investigations for the Potential Donor Urine
Dipstick for protein, blood and glucose (at least twice)
Microscopy, culture and sensitivity (at least twice)
Measurement of protein excretion rate (ACR or PCR) Blood
Haemoglobin and blood count
Coagulation screen (PT and APTT)
Thrombophilia screen (where indicated)
Sickle cell trait (where indicated)
Haemoglobinopathy screen (where indicated)
G6PD deficiency (where indicated)
Creatinine, urea and electrolytes
Isotopic or other reference test for measurement of GFR
Liver function tests
Bone profile (calcium, phosphate, albumin and alkaline phosphatase)
Urate
Fasting plasma glucose
Glucose tolerance test (if family history of diabetes or fasting plasma glucose
>5.6 mmol/L)
Fasting lipid screen (if indicated)
Thyroid function tests (if strong family history)
Pregnancy test (if indicated) Virology and infection screen
Hepatitis B and C
HIV
HTLV1 and 2 (if appropriate)
Cytomegalovirus
Epstein-Barr virus
Toxoplasma
Syphilis
Varicella zoster virus (where recipient seronegative)
-HHV8, Malaria, Trypanosoma cruzi, Schistosomiasis (where indicated) Cardiorespiratory system
Chest X-ray
ECG
ECHO (where indicated)
Cardiovascular stress test (as routine or where indicated)
ASSESSMENT OF RENAL FUNCTION Measurement of Renal Function
· Initial evaluation of donor candidates should be using estimated glomerular filtration rate (eGFR), expressed as mL/min/1.73m2 computed from a creatinine assay standardised to the International Reference Standard. (B1)
· GFR must subsequently be assessed by a reference measured method (mGFR) such as clearance of 51Cr-EDTA, 125iothalamate or Iohexol performed according to guidelines published by the British Society of Nuclear Medicine. (B1)
· Differential kidney function, determined by 99mTcDMSA scanning is recommended where there is >10% variation in kidney size or significant renal anatomical abnormality. (C1) Advisory GFR Thresholds for Donation
· Pre-donation mGFR should be such that the predicted post-donation GFR remains within the gender and age-specific normal range within the donor’s lifetime.
· The risk of end-stage renal disease (ESRD) after 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 consented. (D2)
· The decision to approve donor candidates whose renal function is below the advisory GFR threshold or who have additional risk factors for the development of ESRD should be individualised and based on the predicted lifetime incidence of ESRD. (D2)
· The renal function requirements of the intended recipient, based upon the absolute GFR of the donor, are relevant to the decision to donate (in a directed donation) and to the acceptance of a kidney offer from a non-directed donor or within the UK Living Kidney Sharing Schemes. (Not Graded)
Monitoring of Kidney Donor
· The donor must be offered lifelong annual assessment of renal function including serum creatinine, estimation of urine protein excretion and blood pressure measurement. (B1)
Divided Renal Function
· measured by combining 51Cr-EDTA and 99mTc-DMSA
· indicated if there is a size disparity between the two kidneys (>10%) in a potential donor, if renal function is close to the acceptable threshold for donation, or when there is anatomical abnormality or complexity.
· the kidney with lower function is usually donated.
· Some centres choose to perform split function testing routinely on all donors What is a Safe Threshold Level of Kidney Function to Donate?
The mean age at donation of the cohorts has been around 45 years and the lower threshold for donation a GFR >80 mL/min/1.73m2 Normal Kidney Function & Change in Kidney Function with Aging
· renal function corrected for BSA is significantly higher for men than women after age 40 years.
· GFR remains stable in both sexes until aged around 40 years and then declines each decade at a rate of 6.6 mL/min/1.73m2 for men and 7.7 mL/min/1.73m2 in women Early changes to Renal Function Following Living Kidney Donation
· By three months, remnant kidney clearance increases to a mean GFR of around 65-75% of pre-donation renal function.
· the average decrement in GFR after donation was 26 mL/min/1.73m2 Long-Term Loss of GFR in Kidney Donors
The recommended age-related GFR thresholds for donation ensure that predicted renal function will remain within the lower limit of normal GFR with aging. Is Donation Associated with an Increased Risk of End-Stage Renal Disease, Cardiovascular Disease or Death?
· 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
· The absolute risk for young donors over a lifetime, particularly with additional risk factors for ESRD is likely to be more significant Individualization in Discussion of the Risks of ESRD factors associated with an increased lifetime risk ESRD:
· Measured GFR just below the guideline threshold
· Ethnic groups at higher risk (African Caribbean or South Asian origin (by inference))
· Hypertension, obesity and/or (pre) diabetes Advisory Threshold Measured GFR Considered Safe for Donation
· A threshold GFR >80 mL/min/1.73m2 appears safe for donation in the 35 year and above age range
· A threshold for donation of >90 mL/min/1.73m2 has been set for those <30 years
DONOR AGE
· Old age alone is not an absolute contraindication to donation but the medical work-up of older donors must be particularly rigorous to ensure they are suitable. (A1)
· Both donor and recipient must be made aware that the older donor may be at greater risk of peri-operative complications and that the function and possibly the long-term survival of the graft may be compromised. This is particularly evident with donors >60 years of age. (B1) The Young Donor
· Most programmes do not consider donors aged <18 years and
· age of 18-21 years considered a relative contraindication to donation
· Younger donors, may still develop diabetes, hypertension, obesity, immunologically mediated disease or other renal risk factors, and have more time for these risk factors to progress to CKD and ultimately ESRD The Older Donor
· In the last five years there has been a significant increase in the number of living donations in the UK from the 60-69 and >70 year groups
· Donors above 60 years of age have:
– increased risk of peri-operative complications,
-existing comorbidities and residual function post-donation,
-long-term transplant outcome in the recipient associated with reduced donor GFR and potential donor vasculopathy
Donor Complication Rates Related to Age
· peri-operative outcomes such as operative time, blood loss and length of stay are shown in some recent studies to be no different from younger donors in carefully selected donors above 60 years.
· Pre-donation cardio-respiratory function should be carefully assessed in older donors Graft Outcome from Older Donors
· Renal function declines progressively with age and kidneys from older living donors have reduced function
· the use of older kidney donors appears to be an equivalent or beneficial alternative to awaiting deceased donor kidneys Long Term Risk for Older Donors
· Older donors with potential risk factors for kidney disease, are less likely than younger donors to have enough time for such risk factors to lead to progressive kidney diseas DONOR OBESITY
· Otherwise healthy overweight patients (BMI 25-30 kg/m2 ) may safely proceed to kidney donation. (B1)
· Moderately obese patients (BMI 30-35 kg/m2 ) must undergo careful pre[1]operative evaluation to exclude cardiovascular, respiratory and kidney disease. (C2)
· Moderately obese patients (BMI 30-35 kg/m2 ) must be counselled about the increased risk of peri-operative complications based on extrapolation of outcome data from very obese donors (BMI >35 kg/m2 ). (B1)
· Moderately obese patients (BMI 30-35 kg/m2 ) must be counselled about the long-term risk of kidney disease and be advised to lose weight before donation and to maintain their ideal weight following donation. (B1)
· Data on the safety of kidney donation in the very obese (BMI >35 kg/m2 ) are limited and donation should be discouraged. (C1)
HYPERTENSION IN THE DONOR
· Blood pressure must be assessed on at least two separate occasions. Ambulatory blood pressure monitoring or home monitoring is recommended if blood pressure is high, high normal or variable, or the potential donor is on treatment for hypertension. (C2)
· We suggest that a blood pressure <140/90 mmHg is usually acceptable for donation. (C1)
· Prospective donors must be warned about the risk of developing donation-related hypertension, particularly if in a high-risk group. Blood pressure measurement is part of annual donor monitoring. (C1)
· Potential donors with mild-moderate hypertension that is controlled to <140/90 mmHg (and/or 135/85 mmHg with ABPM or home monitoring) with one or two antihypertensive drugs and who have no evidence of end organ damage may be acceptable for donation. Acceptance will be based on an overall assessment of cardiovascular risk and local policy. (C1)
· It is recommended that potential donors with hypertension are excluded from donation if: (C1)
o Blood pressure is not controlled to <140/90 mmHg on one or two antihypertensive drugs
o Evidence of end organ damage (retinopathy, left ventricular hypertrophy, proteinuria, previous
cardiovascular disease)
o Unacceptable risk of future cardiovascular risk or lifetime incidence of ESRD
· All living kidney donors must be encouraged to minimise the risk of hypertension and its consequences before and after donation by lifestyle measures including stopping smoking, reducing alcohol intake, frequent exercise and, where appropriate, weight loss. (C1)
· It is recommended that donors who are diagnosed with hypertension during assessment or who develop hypertension following donation are managed according to British Hypertension Society guidelines. (B1)
DIABETES MELLITUS
· All potential living kidney donors must have a fasting plasma glucose level checked. (B1)
· A fasting plasma glucose concentration between 6.1-6.9 mmol/L is indicative of an impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be undertaken. (B1)
· Prospective donors with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT. (B1)
· If OGTT reveals a persistent impaired fasting glucose and/or an impaired glucose tolerance, then the risks of developing diabetes after donation must be carefully considered. (B1)
· Consideration should be given to the use of a diabetes risk calculator to inform the discussion of potential kidney donation. (B2)
· Consideration of patients with diabetes as potential kidney donors requires very careful evaluation of the risks and benefits. In the absence of evidence of target organ damage and having ensured that other cardiovascular risk factors such as obesity, hypertension or hyperlipidaemia are optimally managed, diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney. (Not graded)
HbA1c
· HbA1c >6.5% is sufficient to diagnose diabetes if confirmed by repeat testing
· An HbA1c <6.5% may be used to predict the future likelihood of developing diabetes
· HbA1c result of 6.0-6.5% indicates a 5-year incidence risk of diabetes of 25-50%, 20 times higher than that associated with a HbA1c of 5%
· OGTT should be strongly considered when the HbA1c is in the range 6.0-6.5
Risk of Type 1 Diabetes
· Type 1 diabetes presents predominantly in childhood and early adulthood and 50% of cases have presented by the age of 20 years
· The incidence of type 1 diabetes in adults is less than 1 in 10,000
· First degree relatives of an individual with type 1 diabetes have a 15-fold increased risk of developing the disease
· As a working definition, type 1 diabetes is characterised by onset below the age of 30 years and a requirement for insulin treatment from the time of diagnosis Risk of Type 2 Diabetes
· Individuals who have a family history (first degree relative) of type 2 diabetes are at higher risk of developing the disease
· The combination of a positive family history and obesity (BMI >30 kg/m2 ) places an individual at very high risk of diabetes in later life
· A history of gestational diabetes is an independent risk factor for later diabetes. Risk Calculators
· use data for a particular individual to give an estimated risk for that individual for the development of diabetes over the subsequent 10 years
· Such calculators may usefully be used in the assessment of kidney donors and discussion of the results may be part of the assessment process Impaired Fasting Glucose and Kidney Donation
· Those with IFG appeared to do well, when compared with donors with a normal fasting glucose. Urine albumin excretion and MDRD eGFR were similar in both groups Risk of Diabetes Causing ESRD in Living Kidney Donors
· There is a sharp increase in the incidence of type 2 diabetes after the age of 50 and the median age at diagnosis is around 60 years
· Less than 1% of Europeans with type 2 diabetes develop ESRD but the incidence is higher in other ethnic groups
CARDIOVASCULAR EVALUATION
· There is no evidence to support the routine use of stress testing in the assessment of the potential donor at low cardiac risk. (C2)
· Potential kidney donors with a history of cardiovascular disease, an exercise capacity of <4 metabolic equivalents (METS) or with risk factors for cardiovascular disease should undergo further evaluation before donation. (C2)
· For higher risk potential donors, stress testing is recommended by whichever method is locally available or by CT calcium scoring. (C2)
· Discussion with and/or review by cardiologists, anaesthetists and the transplant MDT is recommended as part of the clinical assessment of donors with higher cardiovascular and peri-operative risk. (D2) PROTEINURIA
· Urine protein excretion needs to be quantified in all potential living donors. (B1)
· A urine albumin/creatinine ratio (ACR) performed on a spot urine sample is the recommended screening test, although urine protein/creatinine ratio (PCR) is an acceptable alternative. (A1)
· ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day or protein excretion >500 mg/day represent absolute contraindications to donation. (C2)
· The significance of moderately increased albuminuria (ACR 3-30 mg/mmol) and proteinuria (PCR 15-50 mg/mmol or 24-hour urine protein 150-500 mg/day) has not been fully evaluated in living kidney donors. However, since the risk of CKD and cardiovascular morbidity increase progressively with increasing albuminuria or proteinuria such levels are a relative contraindication to donation. (C2) NON-VISIBLE HAEMATURIA
· All potential living donors must have reagent strip (dipstick) urinalysis performed on at least two separate occasions. (B1)
· Two or more positive tests, including trace positive, is considered as persistent non-visible haematuria (PNVH). (B1)
· If PNVH is present, perform urine culture and renal imaging to exclude common urologic causes including infection, nephrolithiasis and urothelial carcinoma. (A1)
· If no cause is found, perform cystoscopy in patients age >40 years to exclude bladder pathology. (B1)
· If no cause is found and the donor still wishes to donate, then a kidney biopsy is recommended if haematuria is 1+ or greater on dipstick testing. (B1)
· Glomerular pathology precludes donation, with the possible exception of thin basement membrane disease. (B1)
· For donors with persistent asymptomatic non-visible haematuria (PANVH) and a family history of haematuria or X-linked Alport syndrome, a renal biopsy (B1) and referral to a clinical geneticist are recommended. (B2) PYURIA
· Prospective donors found to have pyuria can only be considered for donation if it can be demonstrated that the pyuria is due to a reversible cause, such as an uncomplicated urinary tract infection. (C1) INFECTION IN THE PROSPECTIVE DONOR
· Screening for infection in the prospective donor is essential to identify potential risks for the donor from previous or current infection and to assess the risks of transmission of infection to the recipient. (B1)
· Active HBV and HCV infection in the donor are usually contraindications to living donor kidney donation; however, donors with evidence of active viral replication may be considered under some circumstances. (B1)
· The presence of HIV or human T lymphotrophic virus (HTLV) infection is an absolute contraindication to living donation. (B1)
· Screening for HBV, HCV and HIV infection must be repeated within 30 days of donation. (Not graded)
· All potential donors should be provided with dietary advice regarding avoidance of HEV infection, and screening should be undertaken for HEV viraemia by nucleic acid testing within 30 days of donation. (Not graded)
· The CMV status of donor and recipient must be determined before transplantation. When the donor is CMV positive and the recipient is CMV negative, the donor and recipient must be counselled about the risk of post-transplant CMV disease. (B1)
· The EBV status of donor and recipient must be determined before transplantation. When the donor is EBV positive and the recipient is EBV negative, the donor and recipient must be counselled about the risk of developing Post Transplant Lymphoproliferative Disease. (B1)
· Potential donors must be screened by history for travel or residence abroad to assess their potential risk for having acquired endemic infections and appropriate microbiological investigations instigated if indicated. (Not graded)
NEPHROLITHIASIS
· In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as potential kidney donors. Full counselling of donor and recipient is required along with access to appropriate long-term donor follow up. (C2)
· Potential donors with metabolic abnormalities detected on screening should be discussed with a specialist in renal stone disease. (C2)
· In appropriate donors with unilateral kidney stone(s) the stone-bearing kidney can be considered for donation (if vascular anatomy and split kidney function permit) in order to leave the donor with a stone-free kidney after donation. (C2)
Incidence, Natural History and Management of Renal Stones
· 5% of potential kidney donors have asymptomatic small kidney stones detected by non-contrast CT scan
· 75% of renal stones are composed mainly of calcium oxalate, and a metabolic abnormality (e.g. hypercalciuria, hyperoxaluria, or hypocitraturia) may be detected in over 50%
· 25% of stones are composed of uric acid, pure calcium phosphate, cysteine or struvite (magnesium ammonium phosphate stones)
· Uric acid stones are often associated with a history of gout, ileostomy, diarrhoea or with the metabolic syndrome (acidic urine)
· people with Cystine stones should not donate a kidney
· people with Infection stones (with an anatomical abnormality) should not donate a kidney unless the anatomical abnormality is easily correctable
· asymptomatic stone formers may lack the co-morbidities found in symptomatic stone formers
· Patients with large or staghorn stones should not be considered as donors Assessment of Potential Donors
· a non-contrast CT KUB is advisable to determine the number, size and location of suspected stones
· A DMSA scan is useful if renal scarring is suspected and will give an estimate of split renal function
· before donation 24-hour urine collections for calcium, oxalate, citrate and urate, and early morning pH assessment should be done for a potential donors with a history of stone disease Proceeding to Donation
· If a significant and uncorrectable metabolic abnormality is identified then kidney donation is contra-indicated
· donation may be considered in potential donors with minor or correctable metabolic abnormalities e.g., isolated hypocitraturia, isolated hypercalciuria, isolated hyperuricosuria
· In potential donors who have a history of previous stones but no metabolic abnormality, proceeding with donation should be considered providing the number, size and frequency of previous stones has been low
· If donation proceeds, it is preferable to remove the kidney containing the suspected calculus.
· People with bilateral kidney stones should in general not be considered as kidney donors Follow Up
· Donor with a stone bearing kidney should be counselled about symptoms of renal colic and anuria
· Donors should drink a high fluid intake for life (at least 2.5 litres of fluid per day) and to continue any specific drug for stones
HAEMATOLOGICAL DISEASE
· Donor anaemia needs to be investigated and treated before donation. (A1)
· A haemoglobinopathy screen must be carried out in patients with non-Northern European heritage or if indicated by the full blood count. (A1)
· Careful consideration needs to be given to the use of potential donors with haemoglobinopathies. (B1)
· Advice from a consultant hematologist is recommended for hematological conditions not covered in this guideline. (Not graded) Anaemia
· WHO classification Hb <130 g/L for men and <120 g/L for women Sickle cell disease and sickle cell trait
· Sickle cell disease is an absolute contraindication to living kidney donation, due to higher risk of progressive CKD and general anaesthetic.
· in potential donors with sickle call trait (SCT):
1. There is a high incidence of urine concentrating abnormalities
2. visible and non-visible haematuria are well described
3. could be associated with a higher risk of progression to end stage renal disease, a higher incidence of CKD and albuminuria, and a more rapid deterioration in renal function
4. the peri-operative risks may be higher including complications such as venous thromboembolism
5. Individuals with SCT are also at increased risk of renal medullary carcinoma.
· SCT should not be an absolute contraindication to kidney donation Thalassaemia. Categories:
1. transfusion dependent thalassaemia (TDT)
2. non-transfusion dependent thalassaemia (NTDT) (including haemoglobin H disease)
3. thalassaemia trait (thalassaemia carriers).
– Only patients with thalassaemia trait can be considered for living kidney donation
– There have been a few reports of minor tubular dysfunction in some patients with thalassaemia trait
Red cell membrane disorders
· These include hereditary spherocytosis and hereditary eliptocytosis, inherited haemolytic anaemias of variable severity
· organ donation is acceptable in mild forms White Cell Disorders
· Monoclonal gammopathy of uncertain significance (MGUS)
MGUS per se does not cause end organ disease and individuals with this condition could with caution be considered as living kidney donors
· Myelodysplasia
– The presence of MDS should be considered a strong contraindication to donation. Clotting Disorders
· Patients with a history of VTE have a relative contraindication to donation
FAMILIAL RENAL DISEASE
· All potential transplant recipients must have a detailed family history recorded and confirmation where possible of the diagnosis in other family members with known kidney disease. This may aid diagnosis for the recipient, clarify any mode of inheritance and identify at risk relatives. (A1)
· When the cause of kidney failure in the recipient is due to an inherited condition, appropriate tests – including genetic testing if available – are recommended to exclude genetic disease in the potential donor. (A1)
· Many inherited kidney diseases are rare, so involvement of clinical and laboratory genetics services must be considered at an early stage to assess likely risks to family members and the appropriate use of molecular genetic testing. (B1)
Conditions in which renal dysfunction may be inherited and transplantation indicated for renal replacement therapy include the following:
· Autosomal dominant: ADPKD; Renal cysts and diabetes; Von Hippel Lindau disease; Familial haemolytic uraemic syndrome; Familial FSGS; Tuberose sclerosis complex; UMOD associated nephropathy (autosomal dominant tubulointerstitial disease); Nail patella syndrome
· Autosomal recessive: ARPKD; Alport syndrome; Familial nephrotic syndrome, renal ciliopathies including nephronophthisis
· X-linked: Alport syndrome; Fabry disease; Dent disease
· Polygenic: VUR; FSGS, IgA nephropathy
– In the majority of these conditions, the presence of disease in the potential donor precludes transplantation. ADPKD
· The most common inherited renal disease, affects 1:1000-1:2000 individuals and is responsible for ~10% of UK patients receiving renal replacement therapy
· The diagnosis is based on the following recently revised ultrasound criteria:
1. Three or more unilateral or bilateral cysts in individuals aged 15-39 years
2. At least two cysts in each kidney for individuals aged 40 to 59 years
3. At least four cysts in each kidney for individuals aged >60 years
· A negative renal ultrasound beyond the age of 40 years excludes disease
· Between the ages of 20-40 years, a negative ultrasound should be followed by a CT or MRI scan
· Criteria for the diagnosis or exclusion of disease using CT or MRI have recently been published with a total of >10 cysts being sufficient for diagnosis and
· genetic testing for ADPKD is more accurate to exclude disease in donors
Reflux Nephropathy
· family studies show a high sibling recurrence risk and significant risk of inheritance
· affects around 1-2% of infants and is one of the most common reasons for transplantation in young adults
· A careful search for evidence of reflux or its consequences should be undertaken in relatives being considered as donors
· A history of childhood enuresis or urinary tract infection is common in affected individuals.
· Nuclear medicine scanning can detect renal scars and this may indicates reflux in potential donors
DONOR MALIGNANCY: Recommendations
· Careful history taking, clinical examination and investigation of potential donors are essential to exclude occult malignancy before kidney donation, particularly in older (age >50 years) donors. (B1)
· Active malignant disease is a contraindication to living donation but donors with certain types of successfully treated low-grade tumour may be considered after careful evaluation and discussion. (B1)
· Donors with an incidental renal mass lesion must have this diagnosed and managed on its own merit (out with discussion of kidney donation) with appropriate referral to a Urology Specialist in line with the ‘2-week wait’ pathway. (A1)
· Contrast enhanced renal CT scan, ultrasound and / or MRI can usually distinguish between benign lesions such as angiomyolipoma (AML) or malignancy such as renal cell carcinoma (RCC). Review by a specialist uroradiologist is recommended. (C1)
· Bilateral AML and AML >4 cm generally preclude living kidney donation although occasionally unilateral large (>4 cm) AML can be used if ex vivo excision of the AML appears to be straightforward.
· An incidental, unilateral solitary AML <4 cm with typical characteristic CT criteria does not usually preclude donation.
· A kidney with an AML <1 cm may be considered for donation or left in situ in the donor’s remaining kidney.
· Kidneys containing a single AML between 1 and 4 cm can be considered for donation depending on its position, consideration of whether ex vivo excision of the AML is straightforward, or whether it can be left in situ in the recipient and followed with serial ultrasound imaging. (C1)
· Donors with an incidental small (<4 cm) renal mass that appears on imaging to be a RCC must be seen in a specialist Urology clinic and be offered standard of care treatment options, including partial and radical nephrectomy. Renal function permitting, if the person wishes to consider radical nephrectomy, ex-vivo excision of the small renal mass with subsequent donation of the reconstructed kidney can be considered on an individual basis with specific caveats, full MDM discussion and appropriate informed consent from the donor and recipient. (D2) Two types of donor-derived malignancies are possible:
· inadvertent transfer of tumour tissue (donor transmitted)
· de-novo malignancy arising after transplantation in donor-derived tissue (donor derived) Previous Cancer and Fitness for Living Donation Strong or absolute contraindication: · Malignant melanoma · Testicular cancer · Renal cell carcinoma >3 cm · Choriocarcinoma · Haematological malignancy · Lung cancer · Breast cancer · Sarcoma Possible donation
Treated cancer with high probability of cure after 5-10 years e.g.
· Colon cancer (Dukes’ A >5 years ago) · non-melanoma skin cancer · Carcinoma-in-situ of the cervix or vulva · Localised low grade prostate cancer with curative treatment, minimum cancer-free period of 5 years · Renal cell carcinoma
SURGERY: TECHNICAL ASPECTS, DONOR RISK AND PERI-OPERATIVE CARE Recommendations
· Work-up for living kidney donation may include direct or indicative evaluation of split renal function with the kidney with poorer function selected for nephrectomy irrespective of vascular anatomy (C2)
· Work-up for living kidney donation must include detailed imaging confirming the vascular anatomy of both donor kidneys and information about the renal parenchyma and collecting systems. Either CTA or MRA can be used as current evidence indicates little difference in accuracy. (B1)
· Multiple renal arteries or kidneys with anatomical anomalies are not absolute contraindications to donation. Decisions must be made on an individual basis as part of a multi-disciplinary team evaluation. (B2)
· All living donors must receive adequate thromboprophylaxis. Intra-operative mechanical compression and post-operative compression stockings, along with low molecular weight heparin, are recommended. (A2)
· All living donor surgery must be performed or directly supervised by a Consultant surgeon with appropriate training in the technique. (C1)
· Pre-operative hydration with an overnight infusion and/or a fluid bolus during surgery improves cardiovascular stability during laparoscopic donor nephrectomy. (B2)
· Pre- and peri-operative intravenous fluid replacement with Hartmann’s solution is preferred to 0.9% Saline. (B2)
· Laparoscopic donor surgery (fully laparoscopic or hand-assisted) is the preferred technique for living donor nephrectomy, offering a quicker recovery, shorter hospital stays and less pain. Mini-incision surgery is preferable to standard open surgery. (B1)
· Haem-o-lok clips are not to be used to secure the renal artery during donor nephrectomy following a report of an adverse event involving this technique. (C2)
· Patients undergoing living donor nephrectomy are likely to benefit from the management approaches widely used in “enhanced recovery after surgery” (ERAS) programmes. (D2) Peri-operative Fasting and Insulin Resistance
· Guidelines surrounding peri-operative fasting in non-emergency surgical cases recommend fasting for six hours for solids (including milk in tea or coffee) and two hours for clear liquids
· Reversing the ‘fasting’ state of the patient by administration of an oral carbohydrate drink pre-operatively can increase insulin sensitivity by 50%, a state which continues into the post-operative period
· pre-operative carbohydrate loading in patients undergoing donor nephrectomy is considered( Nutricia 4 x 200 mL cartons between 9 pm and midnight before the operation with a further 2 x 200 mL 2 hours pre-operatively)
HISTOCOMPATIBILITY TESTING FOR LIVING DONOR KIDNEY TRANSPLANTATION Recommendations
· Initial assessment of donor and recipient histocompatibility status must be undertaken at an early stage in living donor kidney transplant work-up to avoid unnecessary and invasive clinical investigation. (B2)
· Screening of potential living donor kidney transplant recipients for clinically relevant antibodies is important for ensuring optimal donor selection and graft survival. (A1)
· Antibody screening is especially important when potential living donor transplant recipients undergo reduction or withdrawal of immunosuppression. (B2)
· Post-transplant antibody monitoring must be undertaken according to the BSHI/BTS guidelines. (B1)
· Transplant units and histocompatibility laboratories must agree an evidence-based protocol to define antibody screening and crossmatch results that constitute a high immunological risk to transplantation. (B2)
· When possible, the HLA type(s) of partners/offspring of female recipients who have had previous pregnancies should be determined to aid immunological risk assessment for repeat paternal HLA mismatches in women with low level DSA. (B1)
· A pre-transplant serum sample collected within 14 days of the planned date for transplantation must be tested in a sensitive antibody screening and donor crossmatch assay and transplantation should not usually be performed if the crossmatch test is positive, unless the antibody is shown to be indicative of acceptable immunological risk. (A1)
· Changes in immunosuppression during the transplant work-up must be notified to the histocompatibility laboratory and additional antibody screening and donor-recipient crossmatch tests must be undertaken as indicated. (B1)
· HLA matching may be preferred when there is an option of selecting between living donors, particularly to reduce the possibility of subsequent sensitisation. This is important for younger recipients where repeat transplantation may be required. However, it is recognised that other donor factors will be taken into account. (B1)
· For patients with an ABO/HLA incompatible and/or a poorly HLA matched living donor, consideration should be given to entry into the UK living kidney sharing scheme (UKLKSS) to identify a more suitable donor. (B2)
· The histocompatibility laboratory must issue an interpretive report stating the donor and recipient HLA mismatch, recipient sensitisation status and crossmatch results, and define the associated immunological risk for all living donor-recipient pairs. (A1)
Assessment of Donor-Recipient HLA Mismatch Status
· The level of donor and recipient HLA compatibility is usually expressed as an HLA-A, -B and -DR mismatch grade determined from the number of donor HLA specificities at each locus that are absent in the recipient
· A donor and recipient with no HLA-A, -B, -DR incompatibilities is denoted ‘0.0.0’, whereas a fully mismatched combination is denoted ‘2.2.2’
Identification and Characterisation of Alloantibodies Pre-transplant antibody screening
· Immunological sensitisation can be due to: transfusion of blood products, pregnancy, and previous transplantation.
· HLA-specific alloantibodies can also arise naturally through cross[1]reactivity with pathogens, when they are termed idiopathic antibodies.
· low-level donor HLA-specific antibodies in patients previously exposed to that same HLA specificity through previous transplantation or, in female patients, pregnancy( could have risk for response refractory to baseline induction immunosuppression)
· Recipient serum samples must be obtained for HLA-specific antibody screening at least every three months, and additional samples collected at 14 and 28 days after transfusion of any blood products
· For patients with a failing/failed transplant, consideration should be given to the potential benefits of immunosuppression reduction/withdrawal and the risks of developing de novo HLA-specific allosensitisation that could severely restrict future options for transplantation
· In cases where HLA-DP-specific antibodies are detected in recipient serum, donor-recipient HLA-DP status and potential HLA-DP-specific antibody incompatibility should be determined Post-transplant antibody screening. can provide:
· prognostic information for the diagnosis of antibody-mediated rejection
· guide post-transplant rejection treatment,
· antibody reduction therapy
· choice of maintenance immunosuppressive therapy Pre-transplant Donor-Recipient Crossmatch Test
· performed to confirm the presence or absence of donor HLA-specific alloantibodies
· If donor HLA-specific antibodies are present in recipient serum, the crossmatch test can provide information about antibody levels and the associated immunological risk
· Pre-formed donor HLA-specific antibodies present in recipient serum can cause hyperacute and acute rejection
· Living donor crossmatch testing is usually carried out at the time of first referral.
· The final crossmatch must always be undertaken using a serum sample obtained within 14 days of the planned operation date
· It is recommended that allosensitised recipients with pre-formed HLA class I- and/or class II-specific alloantibodies and recipients awaiting repeat transplantation should undergo donor T lymphocyte (for HLA class I sensitised patients) or T and B lymphocyte (for HLA class II sensitised patients) flow cytometric crossmatching as a minimum
· A positive donor lymphocyte crossmatch test performed using DTT treated sera by CDC carries a high immunological risk of hyperacute and acute humoral rejection and constitutes a veto to transplantation, unless an effective HLAi strategy is used to minimise the risk of graft failure
· Patients with a previous failed or failing kidney transplant that remains in situ often reduce or withdraw immunosuppressive drugs. This is frequently associated with the development of de novo HLA-specific antibodies to the allograft which cause a previously unexpected positive crossmatch and which then preclude future transplantation from an HLA- mismatched living donor
· A reduction or stopping of immunosuppression within one month of the planned operation date is contraindicated and may delay or preclude transplantation
Selection of Suitable D
Last edited 2 years ago by Hussam Juda
Theepa Mariamutu
2 years ago
All health professionals involved in LDKT must ensure that good ethical practice consistently followed in clinical practice.
Safety and welfare of the potential living donor must always take precedence over the needs of the potential transplant recipient.
Key Ethical Principles in LDKT are
· Altruism,
· Autonomy,
· Beneficence,
· Dignity,
· Non-maleficence
· Reciprocity.
Potential living donor should be informed about all the possible risks to give valid consent
and can withdraw from the transplant process at any time.
Information about processes involved and possible outcomes must be clarified:
· Risks of donation (generic and specific). Nature of surgical procedure and length of stay in hospital. Potential graft loss in the recipient. Requirement for HTA assessment. Reimbursement of expenses. Requirement for annual review.
· full psychological or psychiatric assessment has been importanrt part of donor workup to ensure firstly volunteer willing for donation and is essential to identify pre-existing or potential mental health issues that might arise later.
DONOR EVALUATION
The primary is to ensure the suitability of the donor and to minimise the risk of donation. This involves identifying contraindications to donation and potential physical and psychosocial risks.
The evaluation should be comprehensive, potential donors must be assessed according to evidence-based protocol which includes multi-disciplinary input and discussion.
Detailed history and clinical examination followed by relevant laboratory and radiological investigating should be done
Initiate assessment with ABO compatibility +/- HLA sensitisation, primary contra-indications identified from donor(s) past and present medical history, routine blood & urinalysis tests.
Routine Screening Investigations for the Potential Donor
Urine: Dipstick for protein, blood, and glucose (minimum twice), Microscopy, culture and sensitivity (minimum twice), Measurement of protein excretion rate (ACR or PCR)
Blood:
· Full blood count
· Coagulation screen
· Thrombophilia screen (if indicated)
· Sickle cell trait (if indicated)
· Haemoglobinopathy screen (if indicated)
· G6PD deficiency (if indicated)
· Renal profile and electrolytes
· measurement of GFR
· Liver function tests
· Bone profile (calcium, phosphate, albumin, and alkaline phosphatase)
· Uric acid
· Fasting plasma glucose
· Glucose tolerance test (family history of diabetes or fasting blood sugar >5.6 mmol/L)
· Fasting lipid screen
· Thyroid function tests (if strong family history)
· Pregnancy test for female at fertility age
Virology and infection screen:
Hepatitis B and C, HIV. HTLV1 and 2 (if appropriate)
· Cytomegalovirus
· Epstein-Barr virus
· Toxoplasma, Syphilis
· Varicella zoster virus (if recipient seronegative), HHV8 (if indicated)
· Malaria (if indicated), Trypanosoma cruzi (if indicated), Schistosomiasis (if indicated)
Cardiorespiratory system:
· Chest X-ray
· ECG
· ECHO
· Cardiovascular stress test
Assessment of Renal Function:
· Initial evaluation of donor candidates should be using estimated glomerular filtration rate (eGFR), expressed as mL/min/1.73m2 using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation
· Pre-donation mGFR should be such that the predicted post-donation GFR remains within the gender and age-specific normal range within the donor’s lifetime. A threshold GFR >80 mL/min/1.73m2 appears safe for donation more than 35 years old.
Donor Age:
· Old age is not an absolute contraindication to donation but the rigorous medical work-up of older donors must be done.
· Donors aged <18 years is contraindicated while in most centres an age of18-21 years consider as a relative contraindication to donation.
· Older donors are more likely than younger donors to be excluded from donating based on problems discovered during the medical evaluation. However, each case should be considered on individual basis.
Donor Obesity:
Healthy BMI 25-30 kg/m2 may safely undergoes kidney donation. Obesity grade 1 must be counselled about the increased risk of peri-operative complications and advise to lose weight, Data on the safety of kidney donation in BMI >35 kg/m2 are limited and donation should be discouraged
Hypertension in the Donor:
It is recommended potential donors with hypertension are excluded from donation if:
· Blood pressure is not controlled to <140/90 mmHg on one or two antihypertensive
· Evidence of end organ damage (retinopathy, LVH, proteinuria, previous cardiovascular disease)
· Unacceptable risk of future cardiovascular risk
Diabetes Mellitus:
· FBS must done and concentration between 6.1-6.9 mmol/L is indicative of an impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be done
· Donor with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT, Diabetes may also be diagnosed based upon HbA1c criteria, a result 6.5% being sufficient to diagnose diabetes and confirmatory test should be done.
Cardiovascular Evaluation:
· There is no evidence to support the routine use of stress testing in the assessment of the potential donor at low cardiac risk
· For higher risk potential donors, stress testing is recommended by whichever method is locally available or by CT calcium scoring .
Proteinuria:
Urine protein excretion needs to be quantified in all potential living donors. ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day or protein excretion >500 mg/day represent absolute contraindications to donation.
Non-Visible Haematuria
· Two or more positive tests, including trace positive, is considered as persistent non-visible haematuria
· If PNVH is present, perform urine culture and renal imaging to exclude common urologic causes including infection, nephrolithiasis and urothelial carcinoma. If no cause is found, perform cystoscopy in patients age >40 years to exclude bladder pathology. Glomerular pathology precludes donation, except for thin basement membrane disease
Pyuria:
pyuria can only be considered for donation if it can be demonstrated that the pyuria is due to a reversible cause, such as an uncomplicated urinary tract infection
Infection in the Prospective Donor:
· Active HBV and HCV infection in the donor are usually contraindications to living donor kidney donation; however, donors with evidence of active viral replication may be considered under some circumstances. While The presence of HIV or human T lymphotropic virus (HTLV) infection is an absolute contraindication to living donation.
· The CMV status of donor and recipient must be determined before transplantation. When the donor is CMV positive and the recipient is CMV negative, the donor and recipient must be counselled about the risk of post-transplant CMV disease
Nephrolithiasis:
In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone on imaging, may still be considered as potential kidney donors.
Haematological Disease: Careful consideration needs to be given to the use of potential donors with haemoglobinopathies.
Donor Malignancy: Careful history taking, clinical examination and investigation of potential donors are essential to exclude occult malignancy before kidney donation, particularly in older (age >50 years) donors. Active malignant disease is a contraindication to living donation.
Work-up for living kidney donation must include detailed imaging confirming the vascular anatomy of both donor kidneys and information about the renal parenchyma and collecting systems. Either CTA or MRA can be used as current evidence indicates little difference in accuracy. Multiple renal arteries or kidneys with anatomical anomalies are not absolute contraindications to donation.
Last edited 2 years ago by Theepa Mariamutu
Huda Al-Taee
2 years ago
Summary:
Legal framework:
Recommendations:
All transplants performed from living donors must comply with the requirements of the primary legislation. (Not graded)
All transplant centres performing living organ donation must be licensed by the Human Tissue Authority (Not graded)
Consent for the removal of organs from living donors must comply with the requirements of the Human Tissue Act 2004 (Not graded)
Ethics:
Recommendations:
All health professionals involved in living donor kidney transplantation must acknowledge the wide range of complex moral issues in this field and ensure that good ethical practice consistently underpins clinical practice. (Not graded)
Regardless of potential recipient benefit, the safety and welfare of the potential living donor must always take precedence over the needs of the potential transplant recipient. (Not graded)
Independence is recommended between the clinicians responsible for the assessment and preparation of the donor and the recipient, in addition to the Independent Assessor for the Human Tissue Authority. (Not graded)
Donor evaluation:
Recommendations:
In cases of directed donation the likely suitability of the potential recipient for transplantation must be established before starting donor assessment. (Not graded)
As far as possible, donor assessment is planned to minimise inconvenience to him/her and to avoid unnecessary barriers to the proceeding. (Not graded)
Donor assessment must be planned to ensure that it is focused, logical and coherent. (Not graded)
A policy must be in place to manage prospective donors who are found to be unsuitable to donate and appropriate follow-up and support must be made available. (Not graded) The organisational aspects for donor evaluation will vary between centres, according to available resources and personnel, but the same principles apply to all donors. An agreed donor assessment protocol must be in place that is tailored to the needs of the individual. (Not graded)
To facilitate pre-emptive transplantation, donor evaluation must start sufficiently early to allow time for more than one donor to be assessed if required. . (B2)
The evaluation of a potential donor should be undertaken within an 18-week pathway, assuming there are no logistical issues such as donor unavailability.
ABO BLOOD GROUPING AND CROSSMATCH TESTING
Recommendations:
A compatible ABO blood group and HLA transplant offer the best opportunity for success. (A1).
Where ABO or HLA incompatibility is present, alternative options for transplantation must be discussed with the donor and recipient, including paired/pooled donation and antibody incompatible transplantation. Antibody incompatible transplantation must only be performed in a transplant centre with the relevant experience and appropriate support.
ASSESSMENT OF RENAL FUNCTION
Recommendations
Measurement of Renal Function:
Initial evaluation of donor candidates should be using estimated glomerular filtration rate (eGFR), expressed as mL/min/1.73m2 computed from a creatinine assay standardised to the International Reference Standard. (B1)
GFR must subsequently be assessed by a reference measured method (mGFR) such as clearance of 51Cr-EDTA, 125 iothalamates or Iohexol performed according to guidelines published by the British Society of Nuclear Medicine. (B1)
Differential kidney function, determined by 99mTcDMSA scanning is recommended where there is >10% variation in kidney size or a significant renal anatomical abnormality. (C1)
Monitoring of Kidney Donor:
The donor must be offered a lifelong annual assessment of renal function including serum creatinine, estimation of urine protein excretion and blood pressure measurement. (B1)
DONOR AGE
Recommendations
Old age alone is not an absolute contraindication to donation but the medical work-up of older donors must be particularly rigorous to ensure they are suitable. (A1)
Both donor and recipient must be made aware that the older donor may be at greater risk of peri-operative complications and that the function and possibly the long-term survival of the graft may be compromised. This is particularly evident with donors >60 years of age. (B1)
DONOR OBESITY
Recommendations:
Otherwise healthy overweight patients (BMI 25-30 kg/m2 ) may safely proceed to kidney donation. (B1)
Moderately obese patients (BMI 30-35 kg/m2 ) must undergo a careful preoperative evaluation to exclude cardiovascular, respiratory and kidney disease. (C2)
Moderately obese patients (BMI 30-35 kg/m2 ) must be counselled about the increased risk of peri-operative complications based on extrapolation of outcome data from very obese donors (BMI >35 kg/m2 ). (B1)
Moderately obese patients (BMI 30-35 kg/m2 ) must be counselled about the long-term risk of kidney disease and be advised to lose weight before donation and to maintain their ideal weight following donation. (B1)
Data on the safety of kidney donation in the very obese (BMI >35 kg/m2 ) are limited, and the donation should be discouraged. (C1)
HYPERTENSION IN THE DONOR
Recommendations:
Blood pressure must be assessed on at least two separate occasions. Ambulatory blood pressure monitoring or home monitoring is recommended if blood pressure is high, high normal or variable, or the potential donor is on treatment for hypertension. (C2)
We suggest that a blood pressure <140/90 mmHg is usually acceptable for donation. (C1)
Prospective donors must be warned about the risk of developing donation-related hypertension, particularly if in a high-risk group. Blood pressure measurement is part of annual donor monitoring. (C1)
Potential donors with mild-moderate hypertension that is controlled to <140/90 mmHg (and/or 135/85 mmHg with ABPM or home monitoring) with one or two antihypertensive drugs and who have no evidence of end-organ damage may be acceptable for donation. Acceptance will be based on an overall cardiovascular risk assessment and local policy. (C1)
It is recommended that potential donors with hypertension are excluded from donation if: (C1) o Blood pressure is not controlled to
DIABETES MELLITUS
Recommendation:
All potential living kidney donors must have a fasting plasma glucose level checked. (B1)
A fasting plasma glucose concentration between 6.1-6.9 mmol/L indicates an impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be undertaken. (B1)
Prospective donors with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT. (B1) If OGTT reveals persistent impaired fasting glucose and/or impaired glucose tolerance, the risk of developing diabetes after donation must be carefully considered. (B1)
Consideration should be given to using a diabetes risk calculator to inform the discussion of potential kidney donation. (B2)
Consideration of patients with diabetes as potential kidney donors requires carefully evaluating the risks and benefits. (Not graded)
CARDIOVASCULAR EVALUATION
Recommendations
There is no evidence to support the routine use of stress testing in assessing the potential donor at low cardiac risk. (C2)
Potential kidney donors with a history of cardiovascular disease, an exercise capacity of <4 metabolic equivalents (METS) or risk factors for cardiovascular disease should undergo further evaluation before donation. (C2)
For higher-risk potential donors, stress testing is recommended by whichever method is locally available or by CT calcium scoring. (C2)
Discussion with and/or review by cardiologists, anaesthetists and the transplant MDT is recommended as part of the clinical assessment of donors with higher cardiovascular and peri-operative risk. (D2)
PROTEINURIA
Recommendations:
Urine protein excretion needs to be quantified in all potential living donors. (B1)
A urine albumin/creatinine ratio (ACR) performed on a spot urine sample is the recommended screening test, although urine protein/creatinine ratio (PCR) is an acceptable alternative. (A1)
ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day or protein excretion >500 mg/day represent absolute contraindications to donation. (C2)
The significance of moderately increased albuminuria (ACR 3-30 mg/mmol) and proteinuria (PCR 15-50 mg/mmol or 24-hour urine protein 150-500 mg/day) has not been fully evaluated in living kidney donors. However, since the risk of CKD and cardiovascular morbidity increase progressively with increasing albuminuria or proteinuria, such levels are a relative contraindication to donation. (C2)
NON-VISIBLE HAEMATURIA
Recommendations:
All potential living donors must have reagent strip (dipstick) urinalysis performed on at least two separate occasions. (B1)
Two or more positive tests, including trace positive, is considered as persistent non-visible haematuria (PNVH). (B1)
If PNVH is present, perform urine culture and renal imaging to exclude common urologic causes including infection, nephrolithiasis and urothelial carcinoma. (A1)
If no cause is found, perform cystoscopy in patients age >40 years to exclude bladder pathology. (B1)
If no cause is found and the donor still wishes to donate, then a kidney biopsy is recommended if haematuria is 1+ or greater on dipstick testing. (B1)
Glomerular pathology precludes donation, with the possible exception of thin basement membrane disease. (B1)
For donors with persistent asymptomatic non-visible haematuria (PANVH) and a family history of haematuria or X-linked Alport syndrome, a renal biopsy (B1) and referral to a clinical geneticist are recommended. (B2)
PYURIA
Recommendation
Prospective donors found to have pyuria can only be considered for donation if it can be demonstrated that the pyuria is due to a reversible cause, such as an uncomplicated urinary tract infection. (C1)
INFECTION IN THE PROSPECTIVE DONOR
Recommendations
Screening for infection in the prospective donor is essential to identify
potential risks for the donor from previous or current infection and to
assess the risks of transmission of infection to the recipient. (B1)
Active HBV and HCV infection in the donor are usually
contraindications to living donor kidney donation; however, donors
with evidence of active viral replication may be considered under some
circumstances. (B1)
The presence of HIV or human T lymphotropic virus (HTLV) infection
is an absolute contraindication to living donation. (B1)
Screening for HBV, HCV and HIV infection must be repeated within 30
days of donation. (Not graded)
All potential donors should be provided with dietary advice regarding
avoidance of HEV infection, and screening should be undertaken for
HEV viraemia by nucleic acid testing within 30 days of donation. (Not
graded)
The CMV status of the donor and recipient must be determined before
transplantation. When the donor is CMV positive and the recipient is
CMV negative, the donor and recipient must be counselled about the
risk of post-transplant CMV disease. (B1)
The EBV status of donor and recipient must be determined before
transplantation. When the donor is EBV positive and the recipient is
EBV negative, the donor and recipient must be counselled about the
risk of developing Post Transplant Lymphoproliferative Disease. (B1)
Potential donors must be screened by history for travel or residence
abroad to assess their potential risk of acquiring endemic infections and appropriate microbiological investigations instigated if indicated. (Not graded)
NEPHROLITHIASIS
Recommendations:
In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as potential kidney donors. Full counselling of donor and recipient is required along with access to appropriate long-term donor follow-up. (C2)
Potential donors with metabolic abnormalities detected on screening should be discussed with a specialist in renal stone disease. (C2)
Inappropriate donors with a unilateral kidney stone(s) the stone-bearing kidney can be considered for donation (if vascular anatomy and split kidney function permit) to leave the donor with a stone-free kidney after donation. (C2)
HAEMATOLOGICAL DISEASE
Recommendations
Donor anaemia needs to be investigated and treated before donation. (A1)
A haemoglobinopathy screen must be carried out in patients with non Northern European heritage or if indicated by the full blood count. (A1)
Careful consideration needs to be given to the use of potential donors with haemoglobinopathies. (B1)
Advice from a consultant haematologist is recommended for haematological conditions not covered in this guideline. (Not graded)
FAMILIAL RENAL DISEASE
Recommendations
All potential transplant recipients must have a detailed family history recorded and confirmation where possible of the diagnosis in other family members with known kidney disease. This may aid diagnosis for the recipient, clarify any mode of inheritance and identify at-risk relatives. (A1)
When the cause of kidney failure in the recipient is due to an inherited condition, appropriate tests – including genetic testing if available – are recommended to exclude genetic disease in the potential donor. (A1)
Many inherited kidney diseases are rare, so involvement of clinical and laboratory genetics services must be considered early to assess likely risks to family members and the appropriate use of molecular genetic testing. (B1)
HISTOCOMPATIBILITY TESTING FOR LIVING DONOR KIDNEY TRANSPLANTATION Recommendations
Initial assessment of donor and recipient histocompatibility status must be undertaken early. (B2)
Screening of potential living donor kidney transplant recipients for clinically relevant antibodies is important for ensuring optimal donor selection and graft survival. (A1) Antibody screening is especially important when potential living donor transplant recipients undergo reduced or withdrawn immunosuppression. (B2)
Post-transplant antibody monitoring must be undertaken according to the BSHI/BTS guidelines. (B1)
Transplant units and histocompatibility laboratories must agree an evidence-based protocol to define antibody screening and crossmatch results that constitute a high immunological risk to transplantation. (B2)
When possible, the HLA type(s) of partners/offspring of female recipients who have had previous pregnancies should be determined to aid immunological risk assessment for repeat paternal HLA mismatches in women with low level DSA. (B1)
A pre-transplant serum sample collected within 14 days of the planned date for transplantation must be tested in a sensitive antibody screening and donor crossmatch assay and transplantation should not usually be performed if the crossmatch test is positive unless the antibody is shown to be indicative of acceptable immunological risk. (A1)
Changes in immunosuppression during the transplant work-up must be notified to the histocompatibility laboratory and additional antibody screening and donor-recipient crossmatch tests must be undertaken as indicated. (B1)
HLA matching may be preferred when there is an option of selecting between living donors, particularly to reduce the possibility of subsequent sensitisation. This is important for younger recipients where repeat transplantation may be required. However, it is recognised that other donor factors will be taken into account. (B1)
For patients with an ABO/HLA incompatible and/or a poorly HLA matched living donor, consideration should be given to entry into the UK living kidney sharing scheme to identify a more suitable donor. (B2)
The histocompatibility laboratory must issue an interpretive report stating the donor and recipient HLA mismatch, recipient sensitisation status and crossmatch results, and define the associated immunological risk for all living donor-recipient pairs. (A1)
How these guidelines are different from the guidelines you follow at your workplace?
At my workplace, we usually follow KDIGO guidelines.
Shereen Yousef
2 years ago
▪︎LEGAL FRAMEWORK
• All transplants from living donors must follow requirements of the primary legislation.•
•Written Consent must comply with the requirements of the corresponding authority organs.
▪︎ETHICS Recommendations
• All health professionals must acknowledge the wide range of complex moral issues in this field and ensure that good ethical practice.
• the safety of the potential living donor must always take precedence over the needs of the potential transplant recipient.
• Independence is recommended between the clinicians responsible for the assessment and preparation of the donor and the recipient, in addition to the Independent Assessor for the Human Tissue Authority.
▪︎SUPPORTING AND INFORMING THE POTENTIAL DONOR
• The living donor must be free and at comfort environment for making a voluntary and informed choiceato donate .
• Independent assessment of the donor and recipient is required by primary legislation
• boundaries of confidentiality must be specified and discussed at the outset.
•Separate clinical teams for donor and recipient are considered best practice but healthcare professionals must work together to ensure effective communication and co-ordination of the transplantation process .
• Support for the prospective donor, recipient and family is an integral part of the donation/transplantation process. Psychological needs must be identified at an early stage in the evaluation to ensure that appropriate support and/or intervention is initiated.
▪︎ BLOOD GROUPING AND CROSSMATCH TESTING
• A compatible ABO blood group and human leucocyte antigen (HLA) transplant offers the best opportunity for success. (A1)
• if ABO or HLA incompatibility is present, alternative options for transplantation must be discussed with the donor and recipient, as paired/pooled donation and antibody incompatible transplantation.
▪︎Evaluation OF Kidney FUNCTION
Measurement of RenalFunction Initial evaluation of donor candidates should be using estimated glomerular filtration rate (eGFR), expressed as mL/min/1.73m2 computed from a creatinine assay.
• GFR must subsequently be assessed by a reference measured method (mGFR) such as clearance of 51Cr-EDTA, 125iothalamate or Iohexol.
•Differential kidney function, determined by 99mTcDMSA scanning is recommended where there is >10% variation in kidney size or significant renal anatomical abnormality. (C1)
• Pre-donation mGFR should be such that the predicted post-donation GFR remains within the gender and age-specific normal range within the donor’s lifetime.
• The risk of end-stage renal disease (ESRD) after 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 consented. (D2)
• The decision to approve donor candidates whose renal function is below recommended GFR threshold or who have additional risk factors for the development of ESRD should be individualised and based on the predicted lifetime incidence of ESRD. (D2).
▪︎DONOR AGE
• Old age alone is not an absolute contraindication to donation but the more medical work-up . (A1)
• Both donor and recipient must be made aware that the older donor may be at greater risk of peri-operative complications and that the function and possibly the long-term survival of the graft may be compromised especially in donors >60 years of age. (B1).
▪︎DONOR OBESITY
• healthy overweight patients (BMI 25-30 kg/m2 ) may safely proceed to kidney donation. (B1) •
•Moderately obese patients (BMI 30-35 kg/m2 ) must undergo careful preoperative evaluation to exclude cardiovascular, respiratory and kidney disease. (C2) .
• Moderately obese patients (BMI 30-35 kg/m2 ) must be counselled about the increased risk of peri-operative complications based on extrapolation of outcome data from very obese donors (BMI >35 kg/m2 ). (B1)
• Moderately obese patients (BMI 30-35 kg/m2 ) must be counselled about the long-term risk of kidney disease and be advised to lose weight before donation and to maintain their ideal weight following donation. (B1)
• Data on the safety of kidney donation in the very obese (BMI >35 kg/m2 ) are limited and donation should be discouraged. (C1)
▪︎HYPERTENSION IN THE DONOR
• Blood pressure must be assessed on at least two separate occasions.
Ambulatory blood pressure monitoring or home monitoring is recommended if blood pressure is high, high normal or variable, or the potential donor is on treatment for hypertension. (C2)
• that a blood pressure <140/90 mmHg is usually acceptable for donation. (C1)•
•donors must know about the risk of developing donation-related hypertension, particularly if in a high-risk group. Blood pressure measurement is part of annual donor monitoring.
• Potential donors with mild-moderate hypertension that is controlled to <140/90 mmHg with one or two antihypertensive drugs and who have no evidence of end organ damage may be acceptable for donationC1).
• potential donors are excluded from donation if: (C1)o Blood pressure is not controlled to <140/90 mmHg on one or two antihypertensive drug or if there us evidence of end organ damage (retinopathy, left ventricular hypertrophy, proteinuria, previous cardiovascular disease).
• All living kidney donors must be encouraged to avoid risk factors by lifestyle measures including stopping smoking, reducing alcohol intake, frequent exercise and, weight loss. (C1).
▪︎DIABETES MELLITUS
• All potential living kidney donors must have a fasting plasma glucose level checked. (B1) .
if there is impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be undertaken. (B1)
• Prospective donors with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT. (B1) •
If OGTT reveals a persistent impaired fasting glucose and/or an impaired glucose tolerance, then the risks of developing diabetes after donation must be carefully considered. (B1) •
• patients with diabetes as potential kidney donors requires careful evaluation of the risks and benefits. In the absence of evidence of target organ damage diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney. (Not graded)
▪︎CARDIOVASCULAR EVALUATION
• kidney donors with a history of cardiovascular disease, an exercise capacity of <4 metabolic equivalents (METS) or with risk factors for cardiovascular disease should undergo further evaluation before donation. (C2)•
•For higher risk potential donors, stress testing is recommended by methods available or by CT calcium scoring . (C2)•
•Discussion with and/or review by cardiologists, anaesthetists and the transplant MDT is recommended as part of the clinical assessment of donors with higher cardiovascular and peri-operative risk. (D2)
▪︎NON-VISIBLE HAEMATURIA
• All potential living donors must have dipstick urinalysis performed on at least two separate occasions. (B1) •
Two or more positive tests, including trace positive, is considered as persistent non-visible haematuria (PNVH). (B1)
•If PNVH is present, perform urine culture and renal imaging to exclude common urologic causes including infection, nephrolithiasis and urothelial carcinoma. (A1•
•If no cause is found, perform cystoscopy in patients age >40 years to exclude bladder pathology. (B1)
• If no cause is found and the donor still wishes to donate, then a kidney biopsy is recommended if haematuria is 1+ or greater on dipstick testing. (B1)
• Glomerular pathology precludes donation, with the possible exception of thin basement membrane disease. (B1)•
▪︎PYURIA
• donors found to have pyuria can only be considered for donation if pyuria is due to a reversible cause, such as an uncomplicated urinary tract infection. (C1)
▪︎INFECTION IN THE PROSPECTIVE DONOR
• Screening for infection in the donor is essential to identify potential risks for the donor from previous or current infection and to assess the risks of transmission of infection to the recipient.
• Active HBV and HCV infection in the donor are usually contraindications to living donor kidney donation; however, donors with evidence of active viral replication may be considered under some circumstances. (B1) •
•The presence of HIV or human T lymphotrophic virus (HTLV) infection is an absolute contraindication to living donation. (B1) •
•The CMV status of donor and recipient must be determined before transplantation. When the donor is CMV positive and the recipient is CMV negative, the donor and recipient must be counselled about the risk of post-transplant CMV disease. (B1)
• The EBV status of donor and recipient must be determined before transplantation. When the donor is EBV positive and the recipient is EBV negative, the donor and recipient must be counselled about the risk of developing Post Transplant Lymphoproliferative Disease. (B1) •
▪︎NEPHROLITHIASIS
• In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as potential kidney donors.
• donors with metabolic abnormalities detected on screening should be discussed with a specialist in renal stone disease. (C2)
• In appropriate donors with unilateral kidney stone(s) the stone-bearing kidney can be considered for donation (if vascular anatomy and split kidney function permit) in order to leave the donor with a stone-free kidney after donation. (C2)
▪︎HAEMATOLOGICAL DISEASE
• Donor anaemia needs to be investigated and treated before donation. (A1)
• Careful consideration needs to be given to the use of donors with haemoglobinopathies. (B1)
▪︎FAMILIAL RENAL DISEASE
• All transplant recipients must have a detailed family history recorded if possible of the diagnosis in other family members with known kidney disease. This may aid diagnosis for the recipient, clarify any mode of inheritance and identify at risk relatives. (A1) •
When the cause of kidney failure in the recipient is due to an inherited condition, tests and genetic testing are recommended to exclude genetic disease in the donor. (A1)
▪︎DONOR MALIGNANCY
• Careful history taking, clinical examination and investigation of donors are essential to exclude occult malignancy before kidney donation, particularly in older (age >50 years) donors. (B1)
• Active malignant disease is a contraindication to living donation .
• Donors with an incidental renal mass lesion must be diagnosed and managed
• Contrast enhanced renal CT scan, ultrasound and / or MRI can usually distinguish between benign lesions such as angiomyolipoma (AML) or malignancy such as renal cell carcinoma (RCC).
• Bilateral AML and AML >4 cm generally preclude living kidney donation although occasionally unilateral.
• An incidental, unilateral solitary AML <4 cm with typical characteristic CT criteria does not usually preclude donation.
• A kidney with an AML <1 cm may be considered for donation or left in situ in the donor’s remaining kidney.
• Kidneys containing a single AML between 1 and 4 cm can be considered for donation depending on its position, consideration of whether ex vivo excision of the AML is straightforward, or whether it can be left in situ in the recipient and followed with serial ultrasound imaging. (C1)
• Donors with an incidental small (<4 cm) renal mass that appears on imaging to be a RCC must be seen in a specialist Urology clinic and be offered standard of care treatment options, including partial and radical nephrectomy. Renal function permitting, if the person wishes to consider radical nephrectomy, ex-vivo excision of the small renal mass with subsequent donation of the reconstructed kidney can be considered on an individual basis.
▪︎SURGERY: TECHNICAL ASPECTS, DONOR RISK AND PERI-OPERATIVE CARE
• Work-up for living kidney donation may include direct or indicative evaluation of split renal function with the kidney with poorer function selected for donation .
• Work-up for living kidney donation must include detailed imaging confirming the vascular anatomy of both donor kidneys and information about the renal parenchyma and collecting systems.
• Multiple renal arteries or kidneys with anatomical anomalies are not absolute contraindications to donation.
•All living donors must receive adequate thromboprophylaxis. Intraoperative mechanical compression and post-operative compression stockings, along with low molecular weight heparin, are recommended.
• • Pre- and peri-operative hydration and intravenous fluid replacement with Hartmann’s solution is preferred to 0.9% Saline. (B2) •
•Laparoscopic donor surgery (fully laparoscopic or hand-assisted) is the preferred technique
• Patients undergoing living donor nephrectomy are likely to benefit from the management approaches widely used in “enhanced recovery after surgery” (ERAS) programmes. (D2)
▪︎HISTOCOMPATIBILITY TESTING FOR LIVING DONOR KIDNEY TRANSPLANTATION
• Initial assessment of donor and recipient histocompatibility status must be undertaken at an early stage in living donor kidney transplant work-up to avoid unnecessary and invasive clinical investigation. (B2)
• Screening of recipients for clinically relevant antibodies is important for ensuring optimal donor selection and graft survival. (A1)
• Antibody screening is especially important when recipients undergo reduction or withdrawal of immunosuppression. (B2)
• Post-transplant antibody monitoring must be undertaken according to the BSHI/BTS guidelines. (B1)
• When possible, the HLA type(s) of partners/offspring of female recipients who have had previous pregnancies should be determined to aid immunological risk assessment for repeat paternal HLA mismatches in women with low level DSA. (B1)
• A pre-transplant serum sample collected within 14 days of the planned date for transplantation must be tested in a sensitive antibody screening and donor crossmatch assay .
Transplantation should not usually be performed if the crossmatch test is positive, unless the antibody is shown to be indicative of acceptable immunological risk. (A1)
• HLA matching may be preferred when there is an option of selecting between living donors, particularly to reduce the possibility of subsequent sensitisation.
• The histocompatibility laboratory must issue an interpretive report stating the donor and recipient HLA mismatch, recipient sensitisation status and crossmatch results, and define the associated immunological risk for all living donor-recipient pairs. (A1)
▪︎DONOR FOLLOW-UP AND LONG-TERM OUTCOME
• Counselling and consent of potential living kidney donors must include acknowledgement that the baseline risk of ESRD is increased by donation .
• 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
• Risk calculators predicting lifetime ESRD risk may help inform the consent process.
• The risk of ESRD in living donors mandates lifelong follow-up after donor nephrectomy.
• Potential donors who are unable to proceed to donation must be appropriately followed up and referred for further investigation and management as required. (B1)
• Women must be informed of a greater risk of pregnancy-induced hypertension following kidney donation. (A1)
• Close monitoring of blood pressure, creatinine and foetal well-being is advisable in kidneys donors during pregnancy. (C1)
• Kidney donors may be offered Aspirin 75 mg daily for pre-eclampsia prophylaxis. (D2) .
▪︎RECIPIENT OUTCOME AFTER LIVING DONOR KIDNEY TRANSPLANTATION IN ADULTS
• Graft and patient survival after living donor kidney transplantation should be within the national range of expected outcomes. (A1)
• Where a recipient is considered to be at high risk, transplantation should only proceed if, in the view of the team of professionals involved, there is an expectation that the patient is likely to survive with a functioning transplant for more than 2 years. (C2) •
▪︎RECURRENT RENAL DISEASE
The risks of recurrence, the consequences for transplant function, and the time-course of any deterioration must all be considered.
A discussion of the effects of immunosuppression and transplant failure on morbidity and mortality may also be appropriate. (B1)
• The risks of recurrent disease are high in FSGS and MCGN.
In these diseases, the presence of specific adverse clinical features may indicate living donor transplantation should be avoided.
• In atypical HUS potential de novo disease in a related donor needs to be addressed directly. The risks of recurrent disease in the recipient need to be mitigated through regulated approval and consideration of the use of an inhibitor of complement activation, currently eculizumab. (A1)
• In patients with risks related to underlying activity such as SLE or systemic vasculitis, adequate disease control and an appropriate period of quiescence are important to ensure optimal outcomes. (B1)
▪︎LIVING DONOR KIDNEY TRANSPLANTATION IN CHILDREN
• Pre-emptive living related renal transplantation is the gold standard therapy for children with end-stage renal disease.
• The aim should be for children to receive a renal transplant from a blood group compatible well-matched donor, although ABO and/or HLA incompatible renal transplantation is feasible in children.
• Every effort should be made to minimise HLA mismatches (especially with common antigens) to reduce the risk of future sensitisation.
• All children with stage 4 and 5 chronic kidney disease should be assessed by a multi-disciplinary team, including a paediatric nephrologist, transplant surgeon, anaesthetist and urologist prior to renal transplantation.
• In general, children who are ≥10 kg in weight are suitable to receive a kidney from an adult living donor.
abosaeed mohamed
2 years ago
LEGAL FRAMEWORK
Recommendations
· All transplants performed from living donors must comply with the requirements of the primary legislation (Human Tissue Act 2004 and Human Tissue (Scotland) Act 2006), which regulate transplantation and organ donation across the United Kingdom. (Not graded)
· All transplant centres performing living organ donation must be licensed by the Human Tissue Authority in line with the requirements of the European Union Organ Donation Directive which sets out the minimum requirements for the Quality and Safety of Organs for Transplantation. (Not graded)
· Consent for the removal of organs from living donors, for the purposes of transplantation, must comply with the requirements of the Human Tissue Act 2004, and the Mental Capacity Act 2005 in England and Wales, and the Mental Capacity Act 2016 in Northern Ireland. Consent in Scotland must comply with the Human Tissue (Scotland) Act 2006 and the Adults with Incapacity (Scotland) Act 2000. (Not graded)
ETHICS
Recommendations
· All health professionals involved in living donor kidney transplantation must acknowledge the wide range of complex moral issues in this field and ensure that good ethical practice consistently underpins clinical practice. The BTS has an Ethics Committee to provide additional support and advice if required. (Not graded)
· Regardless of potential recipient benefit, the safety and welfare of the potential living donor must always take precedence over the needs of the potential transplant recipient. (Not graded)
· Independence is recommended between the clinicians responsible for the assessment and preparation of the donor and the recipient, in addition to the Independent Assessor for the Human Tissue Authority. (Not graded)
SUPPORTING AND INFORMING THE POTENTIAL DONOR
Recommendations
· The living donor must be offered the best possible environment for making a voluntary and informed choice about donation. The transplant team must provide generic information that is relevant to all donors as well as specific information that is material to the person intending to donate. This includes information about the assessment process and the benefits and risks of donation to the individual donor. (B1)
· Independent assessment of the donor and recipient is required by primary legislation (Human Tissue Act 2004). (Not graded)
· To achieve the best outcome for donor, recipient and transplant, the boundaries of confidentiality must be specified and discussed at the outset. Relevant information about the recipient can only be shared with the donor if the recipient has given consent and vice versa. Both the recipient and donor must be informed that it is necessary and usual for all relevant clinical information to be shared across the transplant team in order to optimise the chance of a successful outcome for the transplant. (B1)
· Ideally, the recipient will discuss relevant information with their donor, or allow it to be shared. If the recipient is not willing to disclose information, then the transplant team must decide whether it is possible to communicate the risks and benefits of donating adequately, without needing to disclose specific medical details. (Not graded)
· Separate clinical teams for donor and recipient are considered best practice but healthcare professionals must work together to ensure effective communication and co-ordination of the transplant process without compromising the independence of either donor or recipient. It is essential that an informed health professional who is not directly BTS/RA Living Donor Kidney Transplantation Guidelines 2018 33 involved with the care of the recipient acts as the donor advocate in addressing any outstanding questions, anxieties or difficult issues, and assists the donor in making a truly autonomous decision. (B1)
· Support for the prospective donor, recipient and family is an integral part of the donation/transplantation process. Psychological needs must be identified at an early stage in the evaluation to ensure that appropriate support and/or intervention is initiated. Access to specialist psychiatric/psychological services must be available for donors/recipients requiring referral. (B1)
DONOR EVALUATION
Donor and/or recipient may be considered unsuitable because they:
1. Have an absolute contraindication to donation/transplantation according to UK Guidelines (i.e. general comorbidity or kidney specific issue)
2. Have a relative contraindication to donation/transplantation according to UK Guidelines
3. Do not meet transplant centre-specific criteria for acceptance of referral (e.g. age; comorbidity; complex anatomy; body mass index; immunological risk)
If donor and/or recipient unsuitable, decision discussed:
1. At transplant multi-disciplinary meeting (in collaboration with the transplant centre if referral originates in referring nephrology unit, according to type of contraindication +/- donor/recipient preferences)
2. With donor and/or recipient and second opinion offered: · Routinely if categories 2 or 3 apply · Exceptionally if category 1 applies (depending upon type of contraindication +/- donor/recipient preferences
Recommendations
· In cases of directed donation (to a known recipient) the likely suitability of the potential recipient for transplantation must be established before starting donor assessment. If additional recipient assessment is required, unnecessary delay should be avoided. Non-invasive assessment of the donor may be undertaken in this phase. (Not graded)
· As far as possible, donor assessment is planned to minimise inconvenience to him/her and to avoid unnecessary barriers to proceeding. Flexibility in terms of timescales, planning consultations, attending for investigations and date of surgery is helpful. (Not graded)
· Donor assessment must be planned to ensure that it is focused, logical and coherent. Good communication with the donor and involvement of the wider multi-disciplinary team is essential and is achieved most effectively if a designated co-ordinator leads the organisation of the assessment process. The results of investigations must be relayed accurately and efficiently to the potential donor. Unsuitable donors must be identified at the earliest possible stage of assessment. (Not graded)
· A policy must be in place to manage prospective donors who are found to be unsuitable to donate and appropriate follow-up and support must be made available. (Not graded)
· The organisational aspects for donor evaluation will vary between centres, according to available resources and personnel, but the same principles apply for all donors. An agreed donor assessment protocol must be in place that is tailored to the needs of the individual. Table 5.2.1 shows a suggested best practice model with an audit standard for donor evaluation. (Not graded) BTS/RA Living Donor Kidney Transplantation Guidelines 2018 53
· To facilitate pre-emptive transplantation, donor evaluation must start sufficiently early to allow time for more than one donor to be assessed if required. Information must be provided at an early stage and discussion with potential donors and recipients will usually be started when the recipient eGFR is approximately 20 mL/min or when the recipient is expected to require renal replacement therapy within 12-18 months. Recipient and donor assessment can then be tailored according to the rate of decline of recipient renal function, disease specific considerations and individual circumstances. (B2)
· The evaluation of a potential donor should be undertaken within an 18 week pathway, assuming there are no logistical issues such as donor unavailability. There may, of course, be pauses if the recipient’s transplant assessment is complicated or if the recipient’s renal function remains satisfactory.
ABO BLOOD GROUPING AND CROSSMATCH TESTING
Recommendations
· A compatible ABO blood group and human leucocyte antigen (HLA) transplant offers the best opportunity for success. (A1)
· Where ABO or HLA incompatibility is present, alternative options for transplantation must be discussed with the donor and recipient, including paired/pooled donation and antibody incompatible transplantation. Antibody incompatible transplantation must only be performed in a transplant centre with the relevant experience and appropriate support. (A1)
Points of Particular Importance when Undertaking Clinical Examination of a Potential Kidney Donor
– Abdominal fat distribution
– Blood pressure
– Body mass index
– Dipstick urinalysis
– Evidence of self-harm
– Examination for abdominal masses or herniae
– Examination for scars or previous surgery
– Examination for lymphadenopathy
– Examination / history of regular self-examination of the breasts
– Examination / history of regular self-examination of the testes
– Examination of the cardiovascular and respiratory systems
– Mental health
Routine Screening Investigations for the Potential Donor
Urine
Dipstick for protein, blood and glucose (at least twice)
Microscopy, culture and sensitivity (at least twice)
Measurement of protein excretion rate (ACR or PCR)
Blood
Haemoglobin and blood count
Coagulation screen (PT and APTT)
Thrombophilia screen (where indicated)
Sickle cell trait (where indicated)
Haemoglobinopathy screen (where indicated)
G6PD deficiency (where indicated)
Creatinine, urea and electrolytes
Isotopic or other reference test for measurement of GFR
Liver function tests
Bone profile (calcium, phosphate, albumin and alkaline phosphatase)
Urate
Fasting plasma glucose
Glucose tolerance test (if family history of diabetes or fasting plasma glucose
>5.6 mmol/L)
Fasting lipid screen (if indicated)
Thyroid function tests (if strong family history)
Pregnancy test (if indicated)
Virology and infection screen (see section 5.14)
Hepatitis B and C
HIV
HTLV1 and 2 (if appropriate)
Cytomegalovirus
Epstein-Barr virus
Toxoplasma
Syphilis
Varicella zoster virus (where recipient seronegative)
BTS/RA Living Donor Kidney Transplantation Guidelines 2018 65
HHV8 (where indicated)
Malaria (where indicated)
Trypanosoma cruzi (where indicated)
Schistosomiasis (where indicated)
Cardiorespiratory system (see section 5.10)
Chest X-ray
ECG
ECHO (where indicated)
Cardiovascular stress test (as routine or where indicated
ASSESSMENT OF RENAL FUNCTION
Recommendations
Measurement of Renal Function · Initial evaluation of donor candidates should be using estimated glomerular filtration rate (eGFR), expressed as mL/min/1.73m2 computed from a creatinine assay standardised to the International Reference Standard. (B1)
· GFR must subsequently be assessed by a reference measured method (mGFR) such as clearance of 51Cr-EDTA, 125iothalamate or Iohexol performed according to guidelines published by the British Society of Nuclear Medicine. (B1)
· Differential kidney function, determined by 99mTcDMSA scanning is recommended where there is >10% variation in kidney size or significant renal anatomical abnormality. (C1) Advisory GFR Thresholds for Donation
· Pre-donation mGFR should be such that the predicted post-donation GFR remains within the gender and age-specific normal range within the donor’s lifetime. Recommended threshold levels are defined in Table 5.5.2. (B1)
· The risk of end-stage renal disease (ESRD) after 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 consented. (D2)
· The decision to approve donor candidates whose renal function is below the advisory GFR threshold or who have additional risk factors for the development of ESRD should be individualised and based on the predicted lifetime incidence of ESRD. (D2) BTS/RA Living Donor Kidney Transplantation Guidelines 2018 67
· The renal function requirements of the intended recipient, based upon the absolute GFR of the donor, are relevant to the decision to donate (in a directed donation) and to the acceptance of a kidney offer from a non-directed donor or within the UK Living Kidney Sharing Schemes. (Not Graded) Monitoring of Kidney Donor
· The donor must be offered lifelong annual assessment of renal function including serum creatinine, estimation of urine protein excretion and blood pressure measurement. (B1)
DONOR AGE
Recommendations
– Old age alone is not an absolute contraindication to donation but the
medical work-up of older donors must be particularly rigorous to
ensure they are suitable. (A1)
– Both donor and recipient must be made aware that the older donor may
be at greater risk of peri-operative complications and that the function
and possibly the long-term survival of the graft may be compromised.
This is particularly evident with donors >60 years of age. (B1)
DONOR OBESITY
Recommendations
– Otherwise healthy overweight patients (BMI 25-30 kg/m2) may safely
proceed to kidney donation. (B1)
– Moderately obese patients (BMI 30-35 kg/m2) must undergo careful pre[1]operative evaluation to exclude cardiovascular, respiratory and kidney
disease. (C2)
– Moderately obese patients (BMI 30-35 kg/m2) must be counselled about
the increased risk of peri-operative complications based on
extrapolation of outcome data from very obese donors (BMI >35 kg/m2). (B1)
– Moderately obese patients (BMI 30-35 kg/m2) must be counselled about the long-term risk of kidney disease and be advised to lose weight before donation and to maintain their ideal weight following donation. (B1)
– Data on the safety of kidney donation in the very obese (BMI >35 kg/m2) are limited and donation should be discouraged. (C1)
–HYPERTENSION IN THE DONOR
Recommendations
– Blood pressure must be assessed on at least two separate occasions.
– Ambulatory blood pressure monitoring or home monitoring is recommended if blood pressure is high, high normal or variable, or the potential donor is on treatment for hypertension. (C2)
– We suggest that a blood pressure <140/90 mmHg is usually acceptable for donation. (C1)
– Prospective donors must be warned about the risk of developing donation-related hypertension, particularly if in a high-risk group.
– Blood pressure measurement is part of annual donor monitoring. (C1)
– Potential donors with mild-moderate hypertension that is controlled to <140/90 mmHg (and/or 135/85 mmHg with ABPM or home monitoring) with one or two antihypertensive drugs and who have no evidence of end organ damage may be acceptable for donation. Acceptance will be based on an overall assessment of cardiovascular risk and local policy. (C1)
– It is recommended that potential donors with hypertension are excluded from donation if: (C1) Blood pressure is not controlled to <140/90 mmHg on one or two antihypertensive drugs , Evidence of end organ damage (retinopathy, left ventricular hypertrophy, proteinuria, previous cardiovascular disease)
– Unacceptable risk of future cardiovascular risk or lifetime incidence of ESRD
– All living kidney donors must be encouraged to minimise the risk of hypertension and its consequences before and after donation by lifestyle measures including stopping smoking, reducing alcohol intake, frequent exercise and, where appropriate, weight loss. (C1) BTS/RA Living Donor Kidney Transplantation Guidelines 2018 91
– It is recommended that donors who are diagnosed with hypertension during assessment or who develop hypertension following donation are managed according to British Hypertension Society guidelines.(B1)
DIABETES MELLITUS
– Recommendations
– · All potential living kidney donors must have a fasting plasma glucose level checked. (B1)
– · A fasting plasma glucose concentration between 6.1-6.9 mmol/L is indicative of an impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be undertaken. (B1)
– · Prospective donors with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT. (B1)
– · If OGTT reveals a persistent impaired fasting glucose and/or an impaired glucose tolerance, then the risks of developing diabetes after donation must be carefully considered. (B1)
– · Consideration should be given to the use of a diabetes risk calculator to inform the discussion of potential kidney donation. (B2)
– · Consideration of patients with diabetes as potential kidney donors requires very careful evaluation of the risks and benefits. In the absence of evidence of target organ damage and having ensured that other cardiovascular risk factors such as obesity, hypertension or hyperlipidaemia are optimally managed, diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney. (Not graded)
CARDIOVASCULAR EVALUATION
Recommendations
– There is no evidence to support the routine use of stress testing in the
– assessment of the potential donor at low cardiac risk. (C2)
– Potential kidney donors with a history of cardiovascular disease, an exercise capacity of <4 metabolic equivalents (METS) or with risk factors for cardiovascular disease should undergo further evaluation before donation. (C2)
– For higher risk potential donors, stress testing is recommended by whichever method is locally available or by CT calcium scoring . (C2)
– Discussion with and/or review by cardiologists, anaesthetists and the transplant MDT is recommended as part of the clinical assessment of donors with higher cardiovascular and peri-operative risk. (D2)
PROTEINURIA
Recommendations
· Urine protein excretion needs to be quantified in all potential living donors. (B1)
· A urine albumin/creatinine ratio (ACR) performed on a spot urine sample is the recommended screening test, although urine protein/creatinine ratio (PCR) is an acceptable alternative. (A1)
· ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day or protein excretion >500 mg/day represent absolute contraindications to donation. (C2)
· The significance of moderately increased albuminuria (ACR 3-30 mg/mmol) and proteinuria (PCR 15-50 mg/mmol or 24-hour urine protein 150-500 mg/day) has not been fully evaluated in living kidney donors. However, since the risk of CKD and cardiovascular morbidity increase progressively with increasing albuminuria or proteinuria such levels are a relative contraindication to donation. (C2)
NON-VISIBLE HAEMATURIA
Recommendations
· All potential living donors must have reagent strip (dipstick) urinalysis performed on at least two separate occasions. (B1)
· Two or more positive tests, including trace positive, is considered as persistent non-visible haematuria (PNVH). (B1)
· If PNVH is present, perform urine culture and renal imaging to exclude common urologic causes including infection, nephrolithiasis and urothelial carcinoma. (A1)
· If no cause is found, perform cystoscopy in patients age >40 years to exclude bladder pathology. (B1)
· If no cause is found and the donor still wishes to donate, then a kidney biopsy is recommended if haematuria is 1+ or greater on dipstick testing. (B1)
· Glomerular pathology precludes donation, with the possible exception of thin basement membrane disease. (B1)
· For donors with persistent asymptomatic non-visible haematuria (PANVH) and a family history of haematuria or X-linked Alport syndrome, a renal biopsy (B1) and referral to a clinical geneticist are recommended. (B2)
PYURIA
Recommendation
· Prospective donors found to have pyuria can only be considered for donation if it can be demonstrated that the pyuria is due to a reversible cause, such as an uncomplicated urinary tract infection. (C1)
INFECTION IN THE PROSPECTIVE DONOR
Recommendations
· Screening for infection in the prospective donor is essential to identify potential risks for the donor from previous or current infection and to assess the risks of transmission of infection to the recipient. (B1)
· Active HBV and HCV infection in the donor are usually contraindications to living donor kidney donation; however, donors with evidence of active viral replication may be considered under some circumstances. (B1)
· The presence of HIV or human T lymphotrophic virus (HTLV) infection is an absolute contraindication to living donation. (B1)
· Screening for HBV, HCV and HIV infection must be repeated within 30 days of donation. (Not graded)
· All potential donors should be provided with dietary advice regarding avoidance of HEV infection, and screening should be undertaken for HEV viraemia by nucleic acid testing within 30 days of donation. (Not graded)
· The CMV status of donor and recipient must be determined before transplantation. When the donor is CMV positive and the recipient is CMV negative, the donor and recipient must be counselled about the risk of post-transplant CMV disease. (B1)
· The EBV status of donor and recipient must be determined before transplantation. When the donor is EBV positive and the recipient is EBV negative, the donor and recipient must be counselled about the risk of developing Post Transplant Lymphoproliferative Disease. (B1)
· Potential donors must be screened by history for travel or residence abroad to assess their potential risk for having acquired endemic BTS/RA Living Donor Kidney Transplantation Guidelines 2018 126 infections and appropriate microbiological investigations instigated if indicated. (Not graded)
Serological Testing of Donor
Routine tests for all donors
HbsAg and HBcAb HCV IgG HIV 1/2 Ab / HIV Ag combination assay (minimum 4th generation assay) HTLV 1/2 Ab Treponema pallidum Ab CMV IgG EBV IgG Toxoplasma gondii IgG Consider in selected cases
*Coccidiomycosis antibody *Malaria blood film *Schistosomiasis antibody, urine microscopy *Trypanosoma cruzi antibody *Strongyloides stercoralis antibody *West Nile Virus antibody/RNA
NEPHROLITHIASIS
Recommendations
· In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as potential kidney donors. Full counselling of donor and recipient is required along with access to appropriate long-term donor follow up. (C2)
· Potential donors with metabolic abnormalities detected on screening should be discussed with a specialist in renal stone disease. (C2)
· In appropriate donors with unilateral kidney stone(s) the stone-bearing kidney can be considered for donation (if vascular anatomy and split kidney function permit) in order to leave the donor with a stone-free kidney after donation. (C2)
HAEMATOLOGICAL DISEASE
Recommendations
· Donor anaemia needs to be investigated and treated before donation. (A1)
· A haemoglobinopathy screen must be carried out in patients with non Northern European heritage or if indicated by the full blood count. (A1)
· Careful consideration needs to be given to the use of potential donors with haemoglobinopathies. (B1)
· Advice from a consultant haematologist is recommended for haematological conditions not covered in this guideline. (Not graded)
FAMILIAL RENAL DISEASE
Recommendations
· All potential transplant recipients must have a detailed family history recorded and confirmation where possible of the diagnosis in other family members with known kidney disease. This may aid diagnosis for the recipient, clarify any mode of inheritance and identify at risk relatives. (A1)
· When the cause of kidney failure in the recipient is due to an inherited condition, appropriate tests – including genetic testing if available – are recommended to exclude genetic disease in the potential donor. (A1)
· Many inherited kidney diseases are rare, so involvement of clinical and laboratory genetics services must be considered at an early stage to assess likely risks to family members and the appropriate use of molecular genetic testing. (B1)
DONOR MALIGNANCY
Recommendations
· Careful history taking, clinical examination and investigation of potential donors are essential to exclude occult malignancy before kidney donation, particularly in older (age >50 years) donors. (B1) · Active malignant disease is a contraindication to living donation but donors with certain types of successfully treated low-grade tumour may be considered after careful evaluation and discussion. (B1)
· Donors with an incidental renal mass lesion must have this diagnosed and managed on its own merit (out with discussion of kidney donation) with appropriate referral to a Urology Specialist in line with the ‘2-week wait’ pathway. (A1)
· Contrast enhanced renal CT scan, ultrasound and / or MRI can usually distinguish between benign lesions such as angiomyolipoma (AML) or malignancy such as renal cell carcinoma (RCC). Review by a specialist uroradiologist is recommended. (C1)
· Bilateral AML and AML >4 cm generally preclude living kidney donation although occasionally unilateral large (>4 cm) AML can be used if ex vivo excision of the AML appears to be straightforward
. · An incidental, unilateral solitary AML <4 cm with typical characteristic CT criteria does not usually preclude donation.
– A kidney with an AML <1 cm may be considered for donation or left in
situ in the donor’s remaining kidney.
– Kidneys containing a single AML between 1 and 4 cm can be considered for donation depending on its position, consideration of whether ex vivo excision of the AML is straightforward, or whether it can be left in situ in the recipient and followed with serial ultrasound imaging. (C1)
– Donors with an incidental small (<4 cm) renal mass that appears on imaging to be a RCC must be seen in a specialist Urology clinic and be offered standard of care treatment options, including partial and radical nephrectomy. Renal function permitting, if the person wishes to consider radical nephrectomy, ex-vivo excision of the small renal mass with subsequent donation of the reconstructed kidney can be considered on an individual basis with specific caveats, full MDM discussion and appropriate informed consent from the donor and recipient. (D2) :
– Cancers with Strong or absolute contraindication :
· Malignant melanoma
· Testicular cancer
· Renal cell carcinoma >3 cm
· Choriocarcinoma
· Haematological malignancy
· Lung cancer
· Breast cancer
· Sarcoma
– Cancers with Possible donation : Treated cancer with high probability of cure after 5-10 years (favourable classification and staging)
· Colon cancer (Dukes’ A >5 years ago)
· Non-melanoma skin cancer
· Carcinoma-in-situ of the cervix or vulva
· Localised low grade prostate cancer with curative treatment, minimum cancer-free period of 5 years
· Renal cell carcinoma
SURGERY: TECHNICAL ASPECTS, DONOR RISK AND PERI-OPERATIVE CARE
Recommendations
· Work-up for living kidney donation may include direct or indicative evaluation of split renal function with the kidney with poorer function selected for nephrectomy irrespective of vascular anatomy (C2)
· Work-up for living kidney donation must include detailed imaging confirming the vascular anatomy of both donor kidneys and information about the renal parenchyma and collecting systems. Either CTA or MRA can be used as current evidence indicates little difference in accuracy. (B1)
· Multiple renal arteries or kidneys with anatomical anomalies are not absolute contraindications to donation. Decisions must be made on an individual basis as part of a multi-disciplinary team evaluation. (B2)
· All living donors must receive adequate thromboprophylaxis. Intraoperative mechanical compression and post-operative compression stockings, along with low molecular weight heparin, are recommended. (A2)
· All living donor surgery must be performed or directly supervised by a Consultant surgeon with appropriate training in the technique. (C1)
· Pre-operative hydration with an overnight infusion and/or a fluid bolus during surgery improves cardiovascular stability during laparoscopic donor nephrectomy. (B2)
· Pre- and peri-operative intravenous fluid replacement with Hartmann’s solution is preferred to 0.9% Saline. (B2)
· Laparoscopic donor surgery (fully laparoscopic or hand-assisted) is the preferred technique for living donor nephrectomy, offering a BTS/RA Living Donor Kidney Transplantation Guidelines 2018 172 quicker recovery, shorter hospital stay and less pain. Mini-incision surgery is preferable to standard open surgery. (B1)
· Haem-o-lok clips are not to be used to secure the renal artery during donor nephrectomy following a report of an adverse event involving this technique.(C2)
· Patients undergoing living donor nephrectomy are likely to benefit from the management approaches widely used in “enhanced recovery after surgery” (ERAS) programmes. (D2) HISTOCOMPATIBILITY TESTING FOR LIVING DONOR KIDNEY TRANSPLANTATION Recommendations
· Initial assessment of donor and recipient histocompatibility status must be undertaken at an early stage in living donor kidney transplant work-up to avoid unnecessary and invasive clinical investigation. (B2)
· Screening of potential living donor kidney transplant recipients for clinically relevant antibodies is important for ensuring optimal donor selection and graft survival. (A1)
· Antibody screening is especially important when potential living donor transplant recipients undergo reduction or withdrawal of immunosuppression. (B2)
· Post-transplant antibody monitoring must be undertaken according to the BSHI/BTS guidelines. (B1)
· Transplant units and histocompatibility laboratories must agree an evidence-based protocol to define antibody screening and crossmatch results that constitute a high immunological risk to transplantation. (B2)
· When possible, the HLA type(s) of partners/offspring of female recipients who have had previous pregnancies should be determined to aid immunological risk assessment for repeat paternal HLA mismatches in women with low level DSA. (B1)
· A pre-transplant serum sample collected within 14 days of the planned date for transplantation must be tested in a sensitive antibody screening and donor crossmatch assay and transplantation should not usually be performed if the crossmatch test is positive, unless the antibody is shown to be indicative of acceptable immunological risk. (A1)
· Changes in immunosuppression during the transplant work-up must be notified to the histocompatibility laboratory and additional antibody screening and donor-recipient crossmatch tests must be undertaken as indicated. (B1)
· HLA matching may be preferred when there is an option of selecting between living donors, particularly to reduce the possibility of subsequent sensitisation. This is important for younger recipients where repeat transplantation may be required. However, it is recognised that other donor factors will be taken into account. (B1)
· For patients with an ABO/HLA incompatible and/or a poorly HLA matched living donor, consideration should be given to entry into the UK living kidney sharing scheme (UKLKSS) to identify a more suitable donor. (B2)
· The histocompatibility laboratory must issue an interpretive report stating the donor and recipient HLA mismatch, recipient sensitisation status and crossmatch results, and define the associated immunological risk for all living donor-recipient pairs. (A1)
EXPANDING THE DONOR POOL Recommendations
· Coherent organisational and clinical practices are essential between transplant centres to optimise the UK Living Kidney Sharing Schemes (UKLKSS) and to maximise the number of potential transplants that proceed. (B1)
· To maximise transplant opportunities within the UKLKSS, donors and recipients must only be included in a matching run if: o Their clinical assessment and histocompatibility screening are complete and up to date. (B1) o If matched, they are available to attend for crossmatch testing and proceed to surgery within the designated timeframes. (B1) o Relevant complex donor considerations identified in the ‘prerun’ and donor HLA and age preferences have been discussed and agreed with the recipient. (B1) o They understand their roles and responsibilities with respect to other donors and recipient pairs in the schemes with whom they may be matched. (B1)
· The default for all non-directed altruistic kidney donors (NDADs) is to donate into an altruistic donor chain (ADC) within the UKLKSS provided that there is no higher priority patient on the national transplant list. (B1)
· All altruistic donors (non-directed and directed) must undergo formal mental health assessment with a mental health professional before donation. (C1)
· Living kidney donors who are antibody incompatible with their recipient must have all the options and risks explained to them, including donation into the UKLKSS and antibody removal. (C1)
· As a minimum, donors must be made aware that a compatible transplant has the best chance of success and direct antibody incompatible transplant is associated with higher short- and long-term risk, if that is what is proposed. (C1)
Marius Badal
2 years ago
I. Guidelines for Living Donor Kidney Transplantation
Please summarise these guidelines in your own words
How these guidelines are different from the guidelines you follow at your workplace?
Introduction: The guidelines are indeed fascinating. It includes various sections and firstly it started with an introduction that speaks about kidney transplants from living donors. Many patients have the problem of developing kidney failure, and the best treatment is a renal transplant. It is the most popular choice and most available one. Therefore, in the UK they have expanded the kidney door pool. Since the presence of UKLKSS, there have been changes to the guidelines to ensure that there is an expansion of the potential donor pool. With all the improvements of the guidelines, the donor remains at risk and must be vigilant before reducing renal function. The scope of the guidelines relates only to living donor kidney transplantation. It also reflects the evidence and incorporates aspects of clinical practice that are relevant to the groups to transplant. Its deals with the ethical and medico-legal aspects of donor selections. It also deals with the other part of transplantation like the complications, outcomes, etc. The process of writing and methodology of the UK guidelines for living donor kidney transplantation was commissioned by the British Transplantation Society and the Renal Association. The guidelines went through different scrutinize to ensure all aspects were covered in detail and at the end of March 2018 was the final document posted. The editorial committee was formed by different experts in the field of transplantation. There were also contributing authors. The guideline used the GRADE system to grade and ensure the quality of the guidelines was up to date and errorless. The guidelines were made of a legal framework, and it deals with the human tissue act of 2004, the human tissue authority (HTA), the European Union organ donation directive, and consent for the removal of organs from living donors. The types of living donation permitted by the legislation that was established in September 2012 help to specify the types of relationships that allows transplant between living donors and recipients. It involves: 1) Directed donation entails a specific donation where a healthy person donates an organ or part of one. 2) Paired or pool donation that involves donor-recipient pairs are involved in a linked exchange. 3) Non-directed altruistic donation is an unspecific donation where a healthy person donates to an unknown person 4) Directed altruistic donation the donor provides an organ donation to a recipient that has been introduced too. The requirements for transplants involving a living donor require that every living donation must be approved by the HTA before the donation can proceed. There are laws for the prohibition of commercial dealings in human materials based on the ACT 2004 that prevents individuals from commercial dealings. Also, the ACT 2004 allows donors to receive reimbursement for all the expenses they went through. Based on the guidelines, there are exceptional circumstances where organ donation must be careful and may not be accepted unless proven otherwise. They are: 1) In children especially under 18 years of age. 2) Adults without mental capacity The human tissue Act 2006 in Scotland stipulates that organs must not be removed unless the required conditions have been met by the constitution. The other important aspect of this guideline is the concept of Ethics. Since the living donor transplantation started, many ethical issues have been questioned and as such, it was considered in this guideline. They are: 1) The key ethical principles in living donor transplantation deal with: a) Altruism where an organ is given without remuneration b) Autonomy is the personal right to donate c) Beneficence is the promotion to ensure the well-being of all d) Dignity deals with a special status where dignity and monetary terms are not compatible. e) Non-maleficence is not harming anyone f) Reciprocity has to do with giving benefits to others who have helped 2) The recipient’s perspective. The LDKT risk and benefits are being protected. Living donors’ kidneys are of better organ quality and the expectancy or survival of the graft is excellent when compared with other forms. 3) The donor perspective. Donating a kidney involves risks and complications that can lead the patient to death. In this regard, donor rights are being protected to ensure there is no ill-treatment and ensure all benefits are granted. 4) The transplant team perspective. The team that is the MDT ensures that the donor’s right is protected and once the team has identified any issues, the donation can be canceled. 5) Expanding the living donor pool. As the program develops and grows, the legal framework ensures all the ethical criteria be followed. 6) The child or young person as a living donor. Protecting the right of minors are important and must not be overseen. 7) The British transplant society (BTS) ethics committee. Supporting and informing the potential donor: 1) Confidentiality: this is important since it protects the right of the donor and recipient. 2) Informing the potential donor. The GMC ensures doctors are registered for proper consent and coverage 3) Informed consent for living kidney donation. 4) Understanding what is involved. The process of donation must be explained in detail to the donor. 5) Information about likely outcomes for the kidney. All possible complications must be explained to the donor so that a clear decision can be made. 6) Independence of decision. The donor must decide on their own. 7) The responsibility of the donor surgeon. The surgeon must explain to the donor all the possible complications of the procedure. 8) Donor identity. 9) Primary advocacy. The donor must be given an opportunity to meet an independent party to hear their advice. 10) Independent translator. Individuals must be given a translator to better understand what they are dealing with and there are no discrepancies. 11) Psychology issues. 12) Death and transplant failure. Patients must know all the possible complications and the worse is death. Donor Evaluation The goal of donor evaluation is to ensure that the donor is comfortable and there is minimal risk. The donors must be assessed based on protocol and include MDT input. The assessment will vary based on the clinical circumstances of the patient. The donor evaluation includes: 1) initiating a second opinion for a living donor or recipient of a living donor kidney transplant. 2) Donor evaluation: summary and organizational chart with questionnaires 3) ABO blood grouping and crossmatch testing. 4) Medical assessment that involves: a) a summary of the key points of importance in the medical and family history potential kidney donor. b) A history with respect to transmissible infection c) Points of particular importance when undertaking a clinical examination of a potential kidney donor d) Routine screen investigation for the potential donor 5) Assessment of renal function that includes: a) Initial assessment of donor renal function b) Divided renal function and what is a safe threshold level of kidney function to donate. c) Normal kidney function and change in the kidney function with aging d) Early changes to renal function following living kidney donation e) Long-term loss of GFR in kidney donors f) Is donation associated with an increased risk of end-stage renal disease, cardiovascular disease, or death g) Individualisation in a discussion of the risks of ESRD. The risk factors can be measured as GFR, ethnic groups and HTN, obesity, and DM h) Advisory threshold measured GFR considered safe for donation 6) Donor age: a) Includes the young donor: less than 18 years old not considered donor and 18-21 relative contraindication. b) The older donor: above 60 years old should be carefully considered c) Donor complication rates related to age. d) Graft outcomes from older donors e) Long-term risk for older donors 7) Donor obesity: BMI 25-30 kg/m2 can be donated safely, BMI 30-35 KG/M2 must be carefully evaluated, and BMI 35 or more should be discouraged. 8) Hypertension in the donor, BP LESS THAN 140/90 IS USUALLY ACCEPTABLE 9) DM: patient fasting plasma glucose level must be checked and glucose of 6.1-6.9 mmol/l is impaired. An oral glucose tolerance test must be measured. 10) Cardiovascular evaluation must be considered before transplant and the test can be EKG, CT CORONARY CALCIUM, ETC. 11) Proteinuria both ACR and PCR can be done 12) Nonvisible haematuria and must be investigated for glomerulopathies 13) Pyuria must be investigated, and it is defined as having more than 10 white cells/mm2 14) Infection in the prospective donor and screening for infections must be investigated like HBV, HCV, ETC 15) NEPHROLITHIASIS must be investigated. Once the donor has met all the criteria, the patient must start to be processed and follow-ups. It must be noted that hematological diseases must be investigated like anemia, hemoglobinopathies, etc. Donor malignancy is also of interest and if suspected must be investigated. The surgical techniques must be explained to the donor, the risk, and possible complications. Other investigations needed are the group and crossmatch with HLA. As the transplant program develops and continues growing the transplant pool must be extended and carefully addressed. Summary; the guideline is about the preparation of donors for donation and ensuring all the necessary protocols be followed to avoid litigations. At my workplace currently, I don’t have any program for transplantation.
Wadia Elhardallo
2 years ago
Key General ethics and principles:
All health professionals involved in living donor kidney transplantationmustensure that good ethical practice consistently underpins clinicalpractice.
Safety and welfare of the potential living donor must always take precedence over the needs of the potential transplant recipient.
Key Ethical Principles in Living Donor Transplantation are: Altruism, Autonomy, Beneficence, Dignity, Non-maleficence and Reciprocity.
Potential living donor should be informed about all the possible risks in order to give valid consent for donation, and to feel free If they wish to withdraw from the transplant process at any time.
Specific points about process and possible outcomes must be clarify:
Risks of donation (generic and specific). Nature of surgical procedure and length of stay in hospital. Potential graft loss in the recipient. Requirement for HTA assessment. Reimbursement of expenses. Requirement for annual review.
full psychological or psychiatric assessment is important part of donor workup to ensure firstly volunteer willing for donation and is essential to identify pre-existing or potential mental health issues that might arise later on.
DONOR EVALUATION
The primary goal of the donor evaluation process is to ensure the suitability of the donor and to minimise the risk of donation. This involves identifying contraindications to donation and potential clinical (physical and psychosocial) risks.
The evaluation is comprehensive, potential donors must be assessed according to an agreed, evidence-based protocol which includes multi-disciplinary input and discussion.
Detailed history and clinical examination followed by relevant laboratory and radiological investigating .
Initiate assessment with ABO compatibility +/- HLA sensitisation , Primary contra-indications identified from donor(s) past and present medical history, Routine blood & urinalysis tests.
Routine Screening Investigations for the Potential Donor Urine: Dipstick for protein, blood and glucose (at least twice), Microscopy, culture and sensitivity (at least twice), Measurement of protein excretion rate (ACR or PCR) Blood Haemoglobin and blood count
Coagulation screen (PT and APTT)
Thrombophilia screen (where indicated)
Sickle cell trait (where indicated)
Haemoglobinopathy screen (where indicated)
G6PD deficiency (where indicated)
Creatinine, urea and electrolytes
Isotopic or other reference test for measurement of GFR
Liver function tests
Bone profile (calcium, phosphate, albumin and alkaline phosphatase)
Urate
Fasting plasma glucose
Glucose tolerance test (if family history of diabetes or fasting plasma glucose >5.6 mmol/L)
Fasting lipid screen (if indicated)
Thyroid function tests (if strong family history)
Pregnancy test (if indicated) Virology and infection screen : Hepatitis B and C, HIV. HTLV1 and 2 (if appropriate)
Cytomegalovirus
Epstein-Barr virus
Toxoplasma, Syphilis
Varicella zoster virus (where recipient seronegative),HHV8 (where indicated)
Malaria (where indicated),Trypanosoma cruzi (where indicated),Schistosomiasis (where indicated) Cardiorespiratory system : Chest X-ray
ECG
ECHO (where indicated)
Cardiovascular stress test (as routine or where indicated) Assessment of Renal Function :
Initial evaluation of donor candidates should be using estimatedglomerular filtration rate (eGFR), expressed as mL/min/1.73m2 using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and employing a creatinine assay
Pre-donation mGFR should be such that the predicted post-donation GFR remains within the gender and age-specific normal range within the donor’s lifetime. A threshold GFR >80 mL/min/1.73m2 appears safe for donation in the 35 year and
above age range.
Donor Age :
Old age alone is not an absolute contraindication to donation but the medical work-up of older donors must be particularly rigorous to ensure they are suitable. donors aged <18 years is contraindicated while in most centres an age of18-21 years consider as a relative contraindication to donation.
Older donors are more likely than younger donors to be excluded from donating on the basis of problems discovered during the medical evaluation. However, each case should be considered on individual basis .
Donor Obesity:
Otherwise healthy overweight patients (BMI 25-30 kg/m2) may safely proceed to kidney donation. (BMI 30-35 kg/m2) must be counselled about the increased risk of peri-operative complications and advise to lose weight, Data on the safety of kidney donation in the very obese (BMI >35 kg/m2) are limited and donation should be discouraged
Hypertension in the Donor:
It is recommended potential donors with hypertension are excluded from donation if:
o Blood pressure is not controlled to <140/90 mmHg on one or two antihypertensive
o Evidence of end organ damage (retinopathy, left ventricular hypertrophy, proteinuria, previous cardiovascular disease)
o Unacceptable risk of future cardiovascular risk or lifetime incidence of ESRD
Diabetes Mellitus:
a fasting plasma glucose must be level checked, concentration between 6.1-6.9 mmol/L isindicative of an impaired fasting glucose state and an oral glucose
tolerance test (OGTT) should be undertaken.
Prospective donors with an increased risk of type 2 diabetes because
of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT, Diabetes may also be diagnosed based upon HbA1c criteria, a result >48 mmol/mol (6.5%) being sufficient to diagnose diabetes if confirmed by repeat testing.
Cardiovascular Evaluation:
There is no evidence to support the routine use of stress testing in the
assessment of the potential donor at low cardiac risk
For higher risk potential donors, stress testing is recommended by
whichever method is locally available or by CT calcium scoring .
Proteinuria:
Urine protein excretion needs to be quantified in all potential living
or protein excretion >500 mg/day represent absolute contraindications to donation.
Non-Visible Haematuria
Two or more positive tests, including trace positive, is considered as
persistent non-visible haematuria, If PNVH is present, perform urine culture and renal imaging to exclude common urologic causes including infection, nephrolithiasis and
urothelial carcinoma. If no cause is found, perform cystoscopy in patients age >40 years to exclude bladder pathology. Glomerular pathology precludes donation, with the possible exception of thin basement membrane disease
Pyuria:
Prospective donors found to have pyuria can only be considered for
donation if it can be demonstrated that the pyuria is due to a reversible
cause, such as an uncomplicated urinary tract infection
Infection in the Prospective Donor :
Active HBV and HCV infection in the donor are usually
contraindications to living donor kidney donation; however, donors
with evidence of active viral replication may be considered under some
circumstances. While The presence of HIV or human T lymphotrophic virus (HTLV) infection is an absolute contraindication to living donation.
The CMV status of donor and recipient must be determined before
transplantation. When the donor is CMV positive and the recipient is
CMV negative, the donor and recipient must be counselled about the
risk of post-transplant CMV disease
Nephrolithiasis:
In the absence of a significant metabolic abnormality, potential donors
with a limited history of previous kidney stones, or small renal stone
on imaging, may still be considered as potential kidney donors.
Haematological Disease: Careful consideration needs to be given to the use of potential donorswith haemoglobinopathies.
Donor Malignancy: Careful history taking, clinical examination and investigation of
potential donors are essential to exclude occult malignancy before
kidney donation, particularly in older (age >50 years) donors. Active malignant disease is a contraindication to living donation.
Work-up for living kidney donation must include detailed imaging
confirming the vascular anatomy of both donor kidneys and
information about the renal parenchyma and collecting systems. Either
CTA or MRA can be used as current evidence indicates little difference
in accuracy. Multiple renal arteries or kidneys with anatomical anomalies are not
absolute contraindications to donation.
How these guidelines are different from the guidelines you follow at your workplace?
No major differences in the guidelines and our local protocol * some tests are not availabe
Mohammed Sobair
2 years ago
Please summarise these guidelines in your own words
Donor’s types and donor perceptive:
LRKT improved donation pool.
Welfare and safety of donor must be seeked.
Though compliance with both legal and medical act by transplantation center.
Donor give valid consent, without duress or coercion, and that reward is not a factor in
the donation.
Understand potential risk of transplantation.
Donors can receive reimbursement of expenses, such as travel costs and loss of
earnings result from donation of an organ.
Types of Living Donation:
Directed donation, Paired or pool donation, Non-directed altruistic donation and
directed altruistic donation.
Donor is not allowed for children below 18years and person without mental capacity
(only by court).
Ethics:
Should be observed by all transplant team.
Independent assessment team is required for donors and recipient
.
Psychiatric/psychological services must be available for donors/recipients requiring
referral.
Confidentiality:
Should be maintained at outset and information shared decided at the start.
Donor advocacy and psychological services should be provided to donors.
Evaluation of donors:
Multi-disciplinary team and
Agreed, evidence-based protocol.
A logical sequence.
Option of a second opinion must always be available to donors and recipients if donor
not found suitable.
Time of evaluation:
Variable, whenever recipient is ready for transplant.
Discussion with potential donors and recipients will usually be started when the recipient
eGFR is approximately 20 mL/min or when the recipient is expected to require renal
replacement therapy within 12-18 months.
Duration of evaluation:
Evaluation of a potential donor should be undertaken within an 18 WEEEKS
Evaluation should be planned.
An agreed donor assessment protocol must be in place.
A flow chart:
Early:
Early education & discussion with all potential transplant recipients and potential donors
about optimal options for transplantation.
Establish recipient fit for transplantation & start appropriate pre-transplant assessment.
Weeks 0-2:
Donor identified, LD coordinator facilitates initial discussion with potential donor,
recipient & other family members as appropriate. Most appropriate should be identified,
taking into account possible social, psychological and medical risk factors.
Weeks 2-4:
Primary contra-indications identified from donor, past and present medical history
ABO compatibility +/- HLA sensitization.
. Routine blood & urinalysis tests.
Weeks 4-8:
Donor evaluation is planned with the prospective donor, in a timely manner, to an agreed
protocol & in accordance with the availability of local resources.
Weeks 8-10:
Results review by members of the MDT & feedback to the donor.
Weeks 11:
Suitable donor & recipient pair:
Referred for final preoperative discussion with Consultant Nephrologist and Transplant
Surgeon.
Final cross match within the 7-10 days before transplantation and routine pre-op
investigations.
Pre-admission visit.
Week 18:
OPERATION.
LD coordinator maintains contact with donor & facilitates life-long follow-up
arrangements
If donor unsuitable, follow-up arranged.
How these guidelines are different from the guidelines you follow at your workplace?
Approach to donor evaluation is similar in different center ,with donor centered
approach .Time frame for us is more longer and legal issue is less stringent
Amit Sharma
2 years ago
Please summarise these guidelines in your own words
The guidelines involve adult kidney transplantation with respect to legal and ethical framework, supporting and informing the potential donor, the donor evaluation, blood group and histocompatibility testing, the surgical aspects including donor risk and peri-operative care, measures to increase the donor pool, donor follow-up and long-term outcomes, recipient outcomes and recurrent renal diseases, in addition to paediatric transplantation.
Legal framework: All renal transplantation should be as per the Human Tissue Act 2004. The consent for organ donation from the donor should be obtained after explaining the generic and specific material risks of donation. The donor could be either direct (genetically or emotionally related to the recipient); paired or pool donor; or directed or non-directed altruistic donor. There should be no reward (or commercial dealing) for donation and an independent assessor should assess both the donor and recipient. The donor can receive reimbursement of expenses and loss of earnings attributable to donation.
Ethical considerations: The safety and welfare of the donor is the priority.
Donor support and information: The donor should be provided generic and specific information material with respect to donation. Confidentiality must be maintained. A donor advocate, not directly involved with care of recipient can assist the donor in taking a truly autonomous decision. Access to psychological support should be present. A full psychological assessment of the donor should be performed if there is a concern regarding the mental health of the donor.
Donor evaluation: It should be done to identify potential contraindications and risks, by following an agreed, evidence-based protocol. It should be started after ensuring suitability of the recipient for transplantation, although it can be started early if the chances of finding recipient unsuitability are low. Option of second opinion must be given to both the donor and the recipient. In case of a pre-emptive transplant, donor evaluation should start early, when eGFR is approximately 20 ml/min, or when the recipient is expected to need renal replacement therapy in next 12-18 months. Donor evaluation should take place within 18 weeks (2 weeks for discussion, 2 weeks for history, examination and routine investigations including ABO and HLA compatibility, 4 weeks for detailed donor evaluation, 2 weeks for review by MDT members, 6-7 week for final pre-operative discussions, 1 week for pre-transplant cross-match and other investigations, and transplant in the 18th week).
ABO and HLA compatibility testing: Blood group and HLA compatible transplants have best results. Screening for donor specific antibodies is important for optimal donor selection and graft survival. Post-transplant antibody monitoring must be done in the recipient as per protocol. In presence of incompatibility, options like ABO incompatible transplant, kidney paired donation and desensitization should be discussed and offered only in an experienced centre.
Detailed donor evaluation:
Donor renal function should be estimated initially using serum creatinine and then measured using 51Cr-EDTA, 125Iothalamte or Iohexol. It should be more than the threshold levels recommended (>80 ml/min in aged 35 or more and >90 ml/min for age <30 years). If the renal function is below threshold level, decision should be taken on individual basis after assessing lifetime risk of ESRD in the specific donor. Split kidney function to be assessed only in presence of >10% variation in kidney size or anatomical abnormality of the kidneys.
Donors should be offered long-term annual assessment in form of serum creatinine, proteinuria, and blood pressure measurement.
Donor with age >60 years can also donate after detailed assessment and making both the donor and recipient aware of the risks and complications involved as well as the graft outcomes in such cases.
Donor with BMI >35 should be discouraged. Donors with BMI 30-35 must be taken up after detailed evaluation and counselling regarding risks involved.
Donors should be warned about risks of developing hypertension post-donation, especially in high-risk groups like African-Americans, Hispanics obese and presence of hypertension. Those with BP <140/90 (or <135/85 with ABPM or home monitoring), on 1-2 antihypertensives and no target organ damage (LVH, albuminuria, retinopathy etc) and without unacceptable future cardiovascular/ ESRD risk can be taken up for donation. The donors should be encouraged to follow a healthy lifestyle to minimized risk of hypertension. Hypertension should be treated using both non-pharmacological and pharmacological methods.
Donors should be checked for fasting blood glucose levels. If FBS is between 6.1-6.9 mmol/L, or there is history of gestational diabetes, family history of type 2 diabetes, obesity or African-American ethnicity, then the donor should under OGTT. Donors with IFG of IGT can donate after counselling and explaining the risks of developing diabetes after donating, and taking care of risk factors like obesity, dyslipidemia and hypertension.
Those with diabetes, and without any target organ damage, can be taken up as a donor after thorough assessment of lifetime risks of CV disease and ESRD, and management of risk factors.
Cardiovascular assessment for low-risk donors includes ECG and ECHO. Detailed evaluation is required in patients with history of cardiovascular disease and risks of CV disease. High risk donors should be evaluated by stress testing or CT calcium scoring and need multidisciplinary team evaluation.
Proteinuria assessment includes urinary albumin creatinine ratio (ACR) or protein creatinine ratio (PCR). ACR > 30 mg/mmol and PCR>50mg/mmol are contraindications for renal donation.
Urinary dipstick testing should be done twice to detect non-visible hematuria, and if present twice, then urine culture and imaging should be performed to exclude infection, nephrolithiasis, and urothelial carcinoma. Cystoscopy should be performed in age >40 years to rule out bladder pathology. A kidney bippsy should be performed before donation if no cause is found. Glomerular pathology prohibit donation, except presence of thin basement disease.
Presence of pyuria is a contraindication, unless it is due to a reversible cause like uncomplicated UTI.
Screening for HBV, HCV, HIV, CMV and EBV should be done and HIV, HBV and HCV testing should be repeated 1-month post-donation. Risks of CMV infection and PTLD in recipient should be explained in case of donor positive, recipient negative pairs of CMV and EBV.
Donor with small renal stone, or past history of renal stone, in absence of any metabolic abnormality can donate after counselling and offer of long-term follow-up post-donation. In unilateral stone, kidney with stone should be transplanted.
Donor with anemia should be evaluated for cause and treated. A hematologist should be involved decision-making in presence of hemoglobinopathies.
Detailed family history and genetic testing, in case of inherited conditions, should be undertaken.
Detailed evaluation (history, clinical examination, and investigation) to exclude malignancy, especially in age >50 years should be done. Active malignancy is a contraindication. Donors with certain treated low-grade tumors can be taken up. Donors with unilateral renal mass less than 4 cm, can be taken as donor (if AML, without excision; and if RCC, with excision and renal reconstruction).
Technical aspects of the surgery: Direct or indirect evaluation of split renal function, detailed vascular anatomy, renal parenchyma and collecting system imaging using CTA or MRA. Pre- and post-operative adequate hydration is essential. Adequate thromboprophylaxis should be provided. Laparoscopic donor nephrectomy is preferred and donors may benefit with ‘enhanced recovery after surgery’ programmes. Donors should be offered long-term follow-up post-donation. Pregnancy post-donation requires close monitoring of BP, creatinine, and fetal evaluation and pre-eclampsia prophylaxis (aspirin 75 mg).
Risks of basic disease recurrence post-transplant should be assessed and the patient should be counselled regarding the same.
In children with ESRD, pre-emptive transplant with a blood group compatible and minimal HLA mismatches is best. Those weighing more than 10 Kg can receive an adult living donor kidney.
How these guidelines are different from the guidelines you follow at your workplace?
Ours is a living related donor kidney transplant program. We do not take up donors with diabetes (excluded on the basis of FBS, PPBS, HbA1c and OGTT). Split kidney function is performed in all donors. ABO incompatible transplants and kidney paired donation transplants are performed in our unit. Donors with multiple vessels and anatomical variations like dual ureters are taken up. Donors with BMI>30 are excluded. Enhanced recovery after surgery protocol is not followed in our unit. We do not perform HLA incompatible and pediatric transplants.
Huda Mazloum
2 years ago
● Direct transplantation
First assesst patient suitability to transplantation
● Flexibility in terms of timescales, planning consultations, attending for investigations and date of surgery
● Ensure that donor is focused , logical and coherent
● Involve MDT in assessment donor
● In pre-emptive transplantation assessment of donor and recipient must start when eGFR 20 ml/min or the expected period to RRT is 12 – 18 weeks
● Where ABO or HLA incompatibity is pesent other options had to discuss as paired/pooled donation or antibody incopatible transplantation
● important points in medical and family history of donor
UTIs , hematuria , proteinuria , dysuria , urgency , frequency , gout , nephrotithiasis , hypertention , DM , IHD , PVD , smoking , malignancy , jaundice , bowel habit , weight change , thromboembolic disease , TB , systemic disease alcohol or drug dependenceobstetric history , residence abroad , previous medical and anaesthetic assessment
● History of transmissible infection : Hepatitis , malaria , TB , blood transfusion ,
● Increased risk of HIV , HTLV1 , HTLV2 , HBV , HCV
haemophiliac or high risk sexual behaviour and history of syphilis or intravenous drug use , tattoo sexual partner with positive serology and drug addict
● Points of Particular Importance when Undertaking Clinical Examination of Donor
Abdominal fat distribution , Bp , BMI , Dipstick urinalysis , Evidence of self-harm, abdominal masses or herniae , scars or previous surgery , lymphadenopathy , examination of the breasts , testes , and cardiovascular and respiratory systems , Mental health
● Routine Screening Investigations for the Potential Donor
Urine
** Dipstick for protein, blood and glucose , Microscopy, culture and sensitivity (at least twice)
** (ACR or PCR)
Blood
** CBC , (PT and APTT)
** Thrombophilia screen , Sickle cell trait , Haemoglobinopathy screen , G6PD deficiency (where indicated)
** Creatinine, urea and electrolytes
** measurement of GFR
** LFT
** Bone profile (Ca, P, ALB , ALP)
** Urate
** FBG
** GTT
** Fasting lipid screen , pregnancy test (if indicated)
** Thyroid function tests (if strong family history)
** Virology and infection screen ( Hepatitis B and C , HIV , HTLV1 and 2 , CMV , EBV , Toxoplasma , Syphilis , VZV
** HHV8 , Malaria , Trypanosoma cruzi , Schistosomiasis (where indicated)
** Cardiorespiratory system ( Chest X-ray , ECG , ECHO (where indicated) Cardiovascular stress test (as routine or where indicated)
● ASSESSMENT OF RENAL FUNCTION
** Initial test is (eGFR), expressed as mL/min/1.73m2
** subsequently be assessed by (mGFR) such as clearance of 51Cr-EDTA, 125iothalamate or Iohexol
** Differential kidney function, determined by 99mTcDMSA scanning is recommended where there is >10% variation in kidney size or significant renal anatomical abnormality
● Advisory GFR Thresholds for Donation
Pre-donation mGFR should be such that the predicted post-donation
● GFR remains within the gender and age-specific normal range within the donor’s lifetime.
● Risk of (ESRD) after donation is no higher than that of the general population. But is a very small absolute increased lifetime risk of ESRD following donation
● Monitoring of Kidney Donor
lifelong annual assessment of renal function including serum creatinine, estimation of urine protein excretion and blood pressure measurement.
● Donation Associated with an Increased Risk of End-Stage Renal Disease, Cardiovascular Disease and Death
● Old age alone is not an absolute contraindication to donation but may be at greater risk of peri-operative complications
particularly evident with donors >60 years of age.
● Younger potential with borderline risk factors should be subjected to stringent exclusion criteria
● Healthy overweight patients (BMI 25-30 kg/m2) may safely proceed to kidney donation. But Moderately obese patients (BMI 30-35 kg/m2) must undergo careful preoperative evaluation to exclude cardiovascular, respiratory and kidney disease and counselled about the increased risk of perioperative complications and the long-term risk of kidney disease and be advised to lose weight before and after donation
● very obese (BMI >35 kg/m2 )donors should be excluded
● Blood pressure must be assessed on at least two separate occasions.
● Ambulatory blood pressure monitoring or home monitoring is recommended if blood pressure is high, high normal or variable, or the potential donor is on treatment for hypertension.
● We suggest that a blood pressure <140/90 mmHg is usually acceptable for donation.
● Prospective donors must be warned about the risk of developing donation-related hypertension 30 % particularly if in a high-risk group.
● Blood pressure measurement is part of annual donor monitoring.
● Potential donors with mild-moderate hypertension that is controlled to <140/90 mmHg (and/or 135/85 mmHg with ABPM or home monitoring) with one or two antihypertensive drugs and who have no evidence of end organ damage may be acceptable for donation based on an overall assessment of cardiovascular risk and local policy.
● It is recommended that potential donors with hypertension are excluded from donation if:
o Blood pressure is not controlled to <140/90 mmHg on one or two
antihypertensive drugs
o Evidence of end organ damage (retinopathy, left ventricular hypertrophy, proteinuria, previous cardiovascular disease)
o Unacceptable risk of future cardiovascular risk or lifetime incidence of ESRD
● All living kidney donors must be encouraged to minimise the risk of hypertension and its consequences before and after donation by lifestyle measures including stopping smoking, reducing alcohol intake, frequent exercise and, where appropriate, weight loss.
● It is recommended that donors who are diagnosed with hypertension during assessment or who develop hypertension following donation are managed according to British Hypertension Society guidelines.
● All potential living kidney donors must have a fasting plasma glucose level checked
● A fasting plasma glucose concentration between 6.1-6.9 mmol/L is indicative of an impaired fasting glucose state
● (OGTT) should be done in donors with ** ** family history of type 2 diabetes
** a history of gestational diabetes
** ethnicity
** obesity
● If OGTT reveals a persistent impaired fasting glucose and/or an impaired glucose tolerance, then the risks of developing diabetes after donation must be carefully considered.
● Consideration should be given to the use of a diabetes risk calculator to inform the discussion of potential kidney donation
● Consideration of patients with diabetes as potential kidney donors requires very careful evaluation of the risks and benefits. ● In the absence of evidence of target organ damage and having ensured that other cardiovascular risk factors such as obesity, hypertension or hyperlipidaemia are optimally managed, diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney.
● Stress or invasive test is unnecessary in donor at low cardiac risk.
● Donors with
** a history of cardiovascular disease,
** an exercise capacity of <4 metabolic equivalents (METS)
** risk factors for cardiovascular disease should undergo further evaluation by method is locally available or by CT calcium scoring
● Discussion with and/or review by cardiologists, anaesthetists and the transplant MDT is recommended as part of the clinical assessment of donors with higher cardiovascular and peri-operative risk.
● Urine protein excretion needs to be quantified in all potential living donors.
●A urine albumin/creatinine ratio (ACR) performed on a spot urine sample is the recommended screening test although urine protein/creatinine ratio (PCR) is an acceptable alternative.
● ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day or protein excretion >500 mg/day represent absolute contraindications to donation.
● The significance of moderately increased albuminuria (ACR 3-30 mg/mmol) and proteinuria (PCR 15-50 mg/mmol or 24-hour urine protein 150-500 mg/day) has not been fully evaluated in living kidney donors.
● since the risk of CKD and cardiovascular morbidity increase progressively with increasing albuminuria or proteinuria such levels are a relative contraindication to donation.
● All potential living donors must have reagent strip (dipstick) urinalysis performed on at least two separate occasions.
● Two or more positive tests, including trace positive,not related to fever, menstruation or exercise. is considered as persistent non-visible haematuria (PNVH)
● If PNVH is present, perform urine culture and renal imaging to exclude common urologic causes including infection, nephrolithiasis and urothelial carcinoma.
● If no cause is found, perform cystoscopy in patients age >40 years to exclude bladder pathology.
● If no cause is found and the donor still wishes to donate, then a kidney biopsy is recommended if haematuria is 1+ or greater on dipstick testing.
● Glomerular pathology precludes donation, with the possible exception of thin basement membrane disease
● For donors with persistent asymptomatic non-visible haematuria (PANVH) and a family history of haematuria or X-linked Alport syndrome, a renal biopsy and referral to a clinical geneticist are recommended.
● Prospective donors found to have pyuria can only be considered for donation if it can be demonstrated that the pyuria is due to a reversible cause, such as an uncomplicated urinary tract infection
● Active HBV and HCV infection in the donor are usually contraindications to living donor kidney donation; donors with evidence of active viral replication may be considered undersome circumstances
● Screening for HBV, HCV and HIV infection must be repeated within 30 days of donation
● The presence of HIV or human T lymphotrophic virus (HTLV) infection is an absolute contraindication to living donation
● All potential donors should be provided with dietary advice regarding avoidance of HEV infection, and screening should be undertaken for HEV viraemia by nucleic acid testing within 30 days of donation.
● The CMV status of donor and recipient must be determined before transplantation. When the donor is CMV positive and the recipient is CMV negative, the donor and recipient must be counselled about the risk of post-transplant CMV disease
● The EBV status of donor and recipient must be determined before transplantation. When the donor is EBV positive and the recipient is EBV negative, the donor and recipient must be counselled about the risk of developing Post Transplant Lymphoproliferative Disease
● Potential donors must be screened by history for travel or residence abroad to assess their potential risk for having acquired endemic infections and appropriate microbiological investigations instigated if indicated.
● In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as potential kidney donors. Full counselling of donor and recipient is required along with access to appropriate long-term donor follow up
● Potential donors with metabolic abnormalities detected on screening should be discussed with a specialist in renal stone disease
● In appropriate donors with unilateral kidney stone(s) the stone-bearing kidney can be considered for donation (if vascular anatomy and split kidney function permit) in order to leave the donor with a stone-free kidney after donation
● Donor anaemia needs to be investigated and treated before donation.
● A haemoglobinopathy screen must be carried out in patients with nonNorthern European heritage or if indicated by the full blood count
● Careful consideration needs to be given to the use of potential donors with haemoglobinopathies
● All potential transplant recipients must have a detailed family history recorded and confirmation where possible of the diagnosis in other family members with known kidney disease. This may aid diagnosis for the recipient, clarify any mode of inheritance and identify at risk relatives
● When the cause of kidney failure in the recipient is due to an inherited condition, appropriate tests – including genetic testing if available – are recommended to exclude genetic disease in the potential donor
● Many inherited kidney diseases are rare, so involvement of clinical and laboratory genetics services must be considered at an early stage to assess likely risks to family members and the appropriate use of molecular genetic testing
● Careful history taking, clinical examination and investigation of potential donors are essential to exclude occult malignancy before kidney donation, particularly in older (age >50 years) donors
● Active malignant disease is a contraindication to living donation but donors with certain types of successfully treated low-grade tumour may be considered after careful evaluation and discussion
● Donors with an incidental renal mass lesion must have this diagnosed and managed on its own merit (out with discussion of kidney donation) with appropriate referral to a Urology Specialist in line with the ‘2-week wait’ pathway
● Contrast enhanced renal CT scan, ultrasound and / or MRI can usually distinguish between benign lesions such as angiomyolipoma (AML) or malignancy such as renal cell carcinoma (RCC). Review by a specialist uroradiologist is recommended
● Bilateral AML and AML >4 cm generally preclude living kidney donation although occasionally unilateral large (>4 cm) AML can be used if exvivo excision of the AML appears to be straightforward.
● An incidental, unilateral solitary AML <4 cm with typical characteristic CT criteria does not usually preclude donation.
● A kidney with an AML <1 cm may be considered for donation or left in situ in the donor’s remaining kidney
● Kidneys containing a single AML between 1 and 4 cm can be considered for donation depending on its position, consideration of whether ex vivo excision of the AML is straightforward, or whether it
can be left in situ in the recipient and followed with serial ultrasound imaging
● Donors with an incidental small (<4 cm) renal mass that appears on imaging to be a RCC must be seen in a specialist Urology clinic and be offered standard of care treatment options, including partial and radical nephrectomy. Renal function permitting, if the person wishes to consider radical nephrectomy, ex-vivo excision of the small renal mass with subsequent donation of the reconstructed kidney can be considered on an individual basis with specific caveats, full MDM discussion and appropriate informed consent from the donor and recipient
● Work-up for living kidney donation may include direct or indicative evaluation of split renal function with the kidney with poorer function selected for nephrectomy irrespective of vascular anatomy
● Work-up for living kidney donation must include detailed imaging confirming the vascular anatomy of both donor kidneys and information about the renal parenchyma and collecting systems. Either CTA or MRA can be used as current evidence indicates little difference in accuracy
● Multiple renal arteries or kidneys with anatomical anomalies are not absolute contraindications to donation. Decisions must be made on an individual basis as part of a multi-disciplinary team evaluation
● All living donors must receive adequate thromboprophylaxis. Intraoperative mechanical compression and post operative compression stockings, along with low molecular weight heparin, are recommended
● All living donor surgery must be performed or directly supervised by a Consultant surgeon with appropriate training in the technique
● Pre-operative hydration with an overnight infusion and/or a fluid bolus during surgery improves cardiovascular stability during laparoscopic donor nephrectomy
● Pre- and peri-operative intravenous fluid replacement with Hartmann’s solution is preferred to 0.9% Saline.
● Laparoscopic donor surgery (fully laparoscopic or hand-assisted) is the preferred technique for living donor nephrectomy, offering a quicker recovery, shorter hospital stay and less pain.
● Mini-incision surgery is preferable to standard open surgery
● Haem-o-lok clips are not to be used to secure the renal artery during donor nephrectomy following a report of an adverse event involving this technique
● Patients undergoing living donor nephrectomy are likely to benefit from the management approaches widely used in “enhanced recovery after surgery” (ERAS) programmes.
● Initial assessment of donor and recipient histocompatibility status must be undertaken at an early stage in living donor kidney transplant work-up to avoid unnecessary and invasive clinical investigation
● Screening of potential living donor kidney transplant recipients for clinically relevant antibodies is important for ensuring optimal donor selection and graft survival
● Antibody screening is especially important when potential living donor transplant recipients undergo reduction or withdrawal of immunosuppression.
● Post-transplant antibody monitoring must be undertaken according to the BSHI/BTS guidelines
● Transplant units and histocompatibility laboratories must agree an evidence-based protocol to define antibody screening and crossmatch results that constitute a high immunological risk to transplantation.
● When possible, the HLA type(s) of partners/offspring of female recipients who have had previous pregnancies should be determined to aid immunological risk assessment for repeat paternal HLA mismatches in women with low level DSA.
● A pre-transplant serum sample collected within 14 days of the planned date for transplantation must be tested in a sensitive antibody screening and donor crossmatch assay and transplantation should not غusually be performed if the crossmatch test is positive, unless the antibody is shown to be indicative of acceptable immunological risk.
● Changes in immunosuppression during the transplant work-up must be notified to the histocompatibility laboratory and additional antibody screening and donor-recipient crossmatch tests must be undertaken as indicated
● HLA matching may be preferred when there is an option of selecting between living donors, particularly to reduce the possibility of subsequent sensitisation. This is important for younger recipients where repeat transplantation may be required. However, it is recognised that other donor factors will be taken into account.
● For patients with an ABO/HLA incompatible and/or a poorly HLA matched living donor, consideration should be given to entry into the UK living kidney sharing scheme (UKLKSS) to identify a more suitable donor.
● The histocompatibility laboratory must issue an interpretive report stating the donor and recipient HLA mismatch, recipient sensitisation status and crossmatch results, and define the associated immunological risk for all living donor-recipient pairs
● Antibody incompatible transplantation (AIT) should only be undertaken after prior consideration of entry of the donor-recipient
● AIT should be considered as part of an ongoing structured programme, and should not be performed on an occasional basis
● To initiate a programme, a unit should be able to demonstrate a demand of at least five cases a year and appropriate support from clinical transplant, plasmapheresis and histocompatibility teams. An
AIT programme requires funding for additional staff and consumables, and all programmes should receive Commissioner support.
● There is insufficient evidence to make precise recommendations for treatment protocols, but units should have a written protocol based on best published practice. This should include recommendations on prevention, diagnosis and treatment of antibody mediated rejection.
● Protocols that follow the above can be regarded as established treatment and do not require Ethics Committee approval as research procedures. However, the standard of consent should include detailed written information which describes the risks of the procedure. The transplant donor should receive equivalent information to the recipient, so they are aware of the risks of the procedure to the recipient, whether it results in a transplant or not. Potential recipients and donors should be aware of their treatment choices, especially the option of exchange (pooled/paired) transplantation.
● Laboratories should be able to define antibodies to the standard defined in the BSHI/BTS document ‘Guidelines for the Detection and Characterisation of Clinically Relevant Antibodies in Solid Organ Transplantation’. Sensitive and rapid techniques for the measurement of donor-specific HLA antibody levels must be available.
● If ABOi transplantation is to be performed, blood group antibody titres need to be measured, with differentiation between A1 and A2 subgroups of recipient blood group A (when appropriate) and discrimination between IgG- and IgM-specific ABO antibodies. In living donor transplantation, a 7 day per week service with same day turn-around time is required.
● AIT results in an improved quality of life when compared to dialysis.
Additionally, many patients receiving antibody incompatibletransplants may have no other chance of a transplant. Transplantation is cost effective over time with a saving of about £15,000 per annum compared to dialysis when averaged over a 10 year period
● Every patient undergoing AIT should be audited on a local and national basis, with the national audit through the AIT Registry.
● All altruistic donors (non-directed and directed) must undergo formal mental health assessment with a mental health professional before donation
● Donors and recipients must only be included in a matching run if:
o Their clinical assessment and histocompatibility screening are complete and up to date. (B1)
o If matched, they are available to attend for crossmatch testing and proceed to surgery within the designated timeframes.
o Relevant complex donor considerations identified in the ‘pre-run’ and donor HLA and age preferences have been discussed and agreed with the recipient.
o They understand their roles and responsibilities with respect to other donors and recipient pairs in the schemes with whom they may be matched.
● Living kidney donors who are antibody incompatible with their recipient must have all the options and risks explained to them, including donation into the UKLKSS and antibody removal.
● As a minimum, donors must be made aware that a compatible transplant has the best chance of success and direct antibody incompatible transplant is associated with higher short- and long-term risk, if that is what is proposed
● The UKLKSS enables kidneys donated from living donors to be shared across the UK to maximise the number of transplant opportunities and include:
* Paired/pooled donation
* Altruistic donor chains
● Specific Considerations in Directed and Non-directed Altruistic Donation
◇ Psychosocial assessment
◇ Age
◇ Donor motivation
◇ Social support
◇ Anonymity
◇ Donor expectations
◇ Donors with terminal illnesses
◇ Logistical considerations
● Options for antibody incompatible living donor pairs
☆ Deceased donor transplantation
☆ Entry of the pair into the UKLKSS
☆ Direct antibody incompatible transplantation
☆ Acceptance of a lower risk antibody incompatible transplant
● There is clear, emphatic consensus among mental health clinicians working in the field that ALL potential altruistic donors should be referred for mental health assessment.
● 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
● Women must be informed of a greater risk of pregnancy-induced hypertension following kidney donation.Close monitoring of blood pressure, creatinine and foetal well-being is advisable in kidneys donors during pregnancy
● Kidney donors may be offered Aspirin 75 mg daily for preeclampsia prophylaxis
● There is no evidence to support the benefits of right or left nephrectomy to prevent pregnancy induced hydronephrosis
● Births after kidney donation should be reported to the Living Donor Registry as ‘a significant medical event’ at each annual review
● Patients at higher risk of complications and a poor outcome, due to immunological status or co-morbidities, should be considered for transplantation when the clinical team regard the risk / benefit ratio to be favourable. Due process will include careful consideration of the likely outcome for that individual without transplantation. The potential donor must be fully appraised of the issues
● The risks of recurrent disease are high in FSGS and MCGN. In these diseases, the presence of specific adverse clinical features may indicate living donor transplantation should be avoided, even where a donor is available. This will require careful assessment and deliberation with all interested parties
● In atypical HUS potential de novo disease in a related donor needs to be addressed directly. The risks of recurrent disease in the recipient need to be mitigated through regulated approval and consideration of the use of an inhibitor of complement activation, currently eculizumab.
● In patients with risks related to underlying activity such as SLE or systemic vasculitis, adequate disease control and an appropriate period of quiescence are important to ensure optimal outcomes
● Type 1 and type 2 diabetes are not contraindications to living donor transplantation, irrespective of whether they are the underlying cause of renal failure.
● The risk of recurrent disease does not contraindicate living donor transplantation in IgA nephropathy and membranous nephropaty
● Patients with amyloidosis should be discussed with the National Amyloidosis Centre before progressing to living donor transplantation. Patients with AA amyloidosis should have effective disease control before surgery.
● The overall risks associated with recurrent disease are small in SLE and living donor transplantation is safe in quiescent disease.
● The risks associated with recurrent disease are small and the outcomes of transplantation good, therefore AASV does not contraindicate living donor transplantation if the aforementioned criteria are met.
● The risks associated with recurrent disease are small and the outcomes of transplantation good, therefore Goodpasture’s disease does not contraindicate living donor transplantation if the aforementioned criteria are met
● The overall risks associated with Alport syndrome are small and the outcomes of transplantation good, therefore Alport syndrome does not contraindicate living donor transplantation.
● Type I and II MCGN do not contraindicate living donor transplantation. However, the risk of recurrent disease and subsequent graft loss is sufficiently high that transplantation should only be undertaken following careful discussion between the multi-professional team, the donor and the recipient. This is particularly the case if there is an identified abnormality of a soluble complement regulatory protein.
● Transplantation in an individual with unequivocal evidence of graft loss secondary to recurrent C3 glomerulopathy constitutes a high risk of subsequent failure such that some centres consider this a contraindication to repeat transplantation
● Among patients with genetic abnormalities in complement proteins or with an unknown cause of C3 glomerulopathy, a comparison with atypical HUS suggests that consideration should be given to avoiding living related donors in whom similar genetic mutations may predispose to the future development of C3 glomerulopathy after nephrectomy
● Living related renal transplantation should be avoided in atypical HUS unless the cause of the disease in the recipient is known and this has been excluded in the donor. Even then related donors may be at a greater risk of aHUS and should be warned of this risk.
● In patients in whom the underlying cause has unequivocally been attributed to Shiga-toxin, the recurrence rate of HUS is low and living donor transplantation may be considered.
● In appropriately selected cases, living donor kidney transplantation is a reasonable treatment option in primary hyperoxaluria
● Cystinosis is not a contra-indication to living donor transplantation. However, both donor and recipient should be counselled regarding the long-term extra-renal complications related to disease progression
● Pre-emptive living related renal transplantation is the gold standard therapy for children with end-stage renal disease
● The aim should be for children to receive a renal transplant from a blood group compatible well-matched donor, although ABO and/or HLA incompatible renal transplantation is feasible in children.
● In general, children who are ≥10 kg in weight are suitable to receive a kidney from an adult living donor
Mohamad Habli
2 years ago
LEGAL FRAMEWORK
Recommendations
• All transplants performed from living donors must comply with the requirements of the primary legislation.
• All transplant centres performing living organ donation must be licensed by the Human Tissue Authority in line with the requirements of the European Union Organ Donation Directive.
• Consent for the removal of organs from living donors, for the purposes of transplantation, must comply with the requirements of the corresponding authority organs.
ETHICS
Recommendations
• All health professionals involved in living donor kidney transplantation must acknowledge the wide range of complex moral issues in this field and ensure that good ethical practice consistently underpins clinical practice.
• Regardless of potential recipient benefit, the safety and welfare of the potential living donor must always take precedence over the needs of the potential transplant recipient. (Not graded)
• Independence is recommended between the clinicians responsible for the assessment and preparation of the donor and the recipient, in addition to the Independent Assessor for the Human Tissue Authority. (Not graded)
SUPPORTING AND INFORMING THE POTENTIAL DONOR
Recommendations
• The living donor must be offered the best possible environment for making a voluntary and informed choice about donation. The transplant team must provide generic information that is relevant to all donors as well as specific information that is material to the person intending to donate.
• Independent assessment of the donor and recipient is required by primary legislation .
• To achieve the best outcome for donor, recipient and transplant, the boundaries of confidentiality must be specified and discussed at the outset.
• Ideally, the recipient will discuss relevant information with their donor, or allow it to be shared. If the recipient is not willing to disclose information, then the transplant team must decide whether it is possible to communicate the risks and benefits of donating adequately, without needing to disclose specific medical details. (Not graded)
• Separate clinical teams for donor and recipient are considered best practice but healthcare professionals must work together to ensure effective communication and co-ordination of the transplant process without compromising the independence of either donor or recipient.
• Support for the prospective donor, recipient and family is an integral part of the donation/transplantation process. Psychological needs must be identified at an early stage in the evaluation to ensure that appropriate support and/or intervention is initiated.
ABO BLOOD GROUPING AND CROSSMATCH TESTING
Recommendations
• A compatible ABO blood group and human leucocyte antigen (HLA) transplant offers the best opportunity for success. (A1)
• Where ABO or HLA incompatibility is present, alternative options for transplantation must be discussed with the donor and recipient, including paired/pooled donation and antibody incompatible transplantation.
ASSESSMENT OF RENAL FUNCTION
Recommendations
Measurement of Renal Function
• Initial evaluation of donor candidates should be using estimated glomerular filtration rate (eGFR), expressed as mL/min/1.73m2 computed from a creatinine assay.
• GFR must subsequently be assessed by a reference measured method (mGFR) such as clearance of 51Cr-EDTA, 125iothalamate or Iohexol performed according to guidelines published by the British Society of Nuclear Medicine.
• Differential kidney function, determined by 99mTcDMSA scanning is recommended where there is >10% variation in kidney size or significant renal anatomical abnormality. (C1) Advisory GFR Thresholds for Donation
• Pre-donation mGFR should be such that the predicted post-donation GFR remains within the gender and age-specific normal range within the donor’s lifetime. Recommended threshold levels are defined in Table 5.5.2. (B1)
• The risk of end-stage renal disease (ESRD) after 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 consented. (D2)
• The decision to approve donor candidates whose renal function is below the advisory GFR threshold or who have additional risk factors for the development of ESRD should be individualised and based on the predicted lifetime incidence of ESRD. (D2)
DONOR AGE
Recommendations
• Old age alone is not an absolute contraindication to donation but the medical work-up of older donors must be particularly rigorous to ensure they are suitable. (A1)
• Both donor and recipient must be made aware that the older donor may be at greater risk of peri-operative complications and that the function and possibly the long-term survival of the graft may be compromised. This is particularly evident with donors >60 years of age. (B1)
DONOR OBESITY
Recommendations
• Otherwise healthy overweight patients (BMI 25-30 kg/m2 ) may safely proceed to kidney donation. (B1)
• Moderately obese patients (BMI 30-35 kg/m2 ) must undergo careful preoperative evaluation to exclude cardiovascular, respiratory and kidney disease. (C2)
• Moderately obese patients (BMI 30-35 kg/m2 ) must be counselled about the increased risk of peri-operative complications based on extrapolation of outcome data from very obese donors (BMI >35 kg/m2 ). (B1)
• Moderately obese patients (BMI 30-35 kg/m2 ) must be counselled about the long-term risk of kidney disease and be advised to lose weight before donation and to maintain their ideal weight following donation. (B1)
• Data on the safety of kidney donation in the very obese (BMI >35 kg/m2 ) are limited and donation should be discouraged. (C1)
HYPERTENSION IN THE DONOR
Recommendations
• Blood pressure must be assessed on at least two separate occasions. Ambulatory blood pressure monitoring or home monitoring is recommended if blood pressure is high, high normal or variable, or the potential donor is on treatment for hypertension. (C2)
• We suggest that a blood pressure <140/90 mmHg is usually acceptable for donation. (C1)
• Prospective donors must be warned about the risk of developing donation-related hypertension, particularly if in a high-risk group. Blood pressure measurement is part of annual donor monitoring. (C1)
• Potential donors with mild-moderate hypertension that is controlled to <140/90 mmHg with one or two antihypertensive drugs and who have no evidence of end organ damage may be acceptable for donationC1).
• It is recommended that potential donors with hypertension are excluded from donation if: (C1)
o Blood pressure is not controlled to <140/90 mmHg on one or two antihypertensive drugs
o Evidence of end organ damage (retinopathy, left ventricular hypertrophy, proteinuria, previous cardiovascular disease)
o Unacceptable risk of future cardiovascular risk or lifetime incidence of ESRD.
• All living kidney donors must be encouraged to minimise the risk of hypertension and its consequences before and after donation by lifestyle measures including stopping smoking, reducing alcohol intake, frequent exercise and, where appropriate, weight loss. (C1)
• It is recommended that donors who are diagnosed with hypertension during assessment or who develop hypertension following donation are managed according to British Hypertension Society guidelines. (B1)
DIABETES MELLITUS
Recommendations
• All potential living kidney donors must have a fasting plasma glucose level checked. (B1)
• A fasting plasma glucose concentration between 6.1-6.9 mmol/L is indicative of an impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be undertaken. (B1)
• Prospective donors with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT. (B1)
• If OGTT reveals a persistent impaired fasting glucose and/or an impaired glucose tolerance, then the risks of developing diabetes after donation must be carefully considered. (B1)
• Consideration should be given to the use of a diabetes risk calculator to inform the discussion of potential kidney donation. (B2)
• Consideration of patients with diabetes as potential kidney donors requires very careful evaluation of the risks and benefits. In the absence of evidence of target organ damage and having ensured that other cardiovascular risk factors such as obesity, hypertension or hyperlipidaemia are optimally managed, diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney. (Not graded)
CARDIOVASCULAR EVALUATION
Recommendations
• There is no evidence to support the routine use of stress testing in the assessment of the potential donor at low cardiac risk. (C2)
• Potential kidney donors with a history of cardiovascular disease, an exercise capacity of <4 metabolic equivalents (METS) or with risk factors for cardiovascular disease should undergo further evaluation before donation. (C2)
• For higher risk potential donors, stress testing is recommended by whichever method is locally available or by CT calcium scoring . (C2)
• Discussion with and/or review by cardiologists, anaesthetists and the transplant MDT is recommended as part of the clinical assessment of donors with higher cardiovascular and peri-operative risk. (D2)
NON-VISIBLE HAEMATURIA
Recommendations
• All potential living donors must have reagent strip (dipstick) urinalysis performed on at least two separate occasions. (B1)
• Two or more positive tests, including trace positive, is considered as persistent non-visible haematuria (PNVH). (B1)
• If PNVH is present, perform urine culture and renal imaging to exclude common urologic causes including infection, nephrolithiasis and urothelial carcinoma. (A1)
• If no cause is found, perform cystoscopy in patients age >40 years to exclude bladder pathology. (B1)
• If no cause is found and the donor still wishes to donate, then a kidney biopsy is recommended if haematuria is 1+ or greater on dipstick testing. (B1)
• Glomerular pathology precludes donation, with the possible exception of thin basement membrane disease. (B1)
• For donors with persistent asymptomatic non-visible haematuria (PANVH) and a family history of haematuria or X-linked Alport syndrome, a renal biopsy (B1) and referral to a clinical geneticist are recommended. (B2)
PYURIA Statement of Recommendation
• Prospective donors found to have pyuria can only be considered for donation if it can be demonstrated that the pyuria is due to a reversible cause, such as an uncomplicated urinary tract infection. (C1)
INFECTION IN THE PROSPECTIVE DONOR
Recommendations
• Screening for infection in the prospective donor is essential to identify potential risks for the donor from previous or current infection and to assess the risks of transmission of infection to the recipient. (B1)
• Active HBV and HCV infection in the donor are usually contraindications to living donor kidney donation; however, donors with evidence of active viral replication may be considered under some circumstances. (B1)
• The presence of HIV or human T lymphotrophic virus (HTLV) infection is an absolute contraindication to living donation. (B1)
• Screening for HBV, HCV and HIV infection must be repeated within 30 days of donation. (Not graded)
• All potential donors should be provided with dietary advice regarding avoidance of HEV infection, and screening should be undertaken for HEV viraemia by nucleic acid testing within 30 days of donation. (Not graded)
• The CMV status of donor and recipient must be determined before transplantation. When the donor is CMV positive and the recipient is CMV negative, the donor and recipient must be counselled about the risk of post-transplant CMV disease. (B1)
• The EBV status of donor and recipient must be determined before transplantation. When the donor is EBV positive and the recipient is EBV negative, the donor and recipient must be counselled about the risk of developing Post Transplant Lymphoproliferative Disease. (B1)
• Potential donors must be screened by history for travel or residence abroad to assess their potential risk for having acquired endemic infections and appropriate microbiological investigations instigated if indicated. (Not graded)
NEPHROLITHIASIS
Recommendations
• In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as potential kidney donors. Full counselling of donor and recipient is required along with access to appropriate long-term donor follow up. (C2)
• Potential donors with metabolic abnormalities detected on screening should be discussed with a specialist in renal stone disease. (C2)
• In appropriate donors with unilateral kidney stone(s) the stone-bearing kidney can be considered for donation (if vascular anatomy and split kidney function permit) in order to leave the donor with a stone-free kidney after donation. (C2)
HAEMATOLOGICAL DISEASE
Recommendations
• Donor anaemia needs to be investigated and treated before donation. (A1)
• A haemoglobinopathy screen must be carried out in patients with nonNorthern European heritage or if indicated by the full blood count. (A1)
• Careful consideration needs to be given to the use of potential donors with haemoglobinopathies. (B1)
• Advice from a consultant haematologist is recommended for haematological conditions not covered in this guideline. (Not graded)
FAMILIAL RENAL DISEASE
Recommendations
• All potential transplant recipients must have a detailed family history recorded and confirmation where possible of the diagnosis in other family members with known kidney disease. This may aid diagnosis for the recipient, clarify any mode of inheritance and identify at risk relatives. (A1)
• When the cause of kidney failure in the recipient is due to an inherited condition, appropriate tests – including genetic testing if available – are recommended to exclude genetic disease in the potential donor. (A1)
• Many inherited kidney diseases are rare, so involvement of clinical and laboratory genetics services must be considered at an early stage to assess likely risks to family members and the appropriate use of molecular genetic testing. (B1)
DONOR MALIGNANCY
Recommendations
• Careful history taking, clinical examination and investigation of potential donors are essential to exclude occult malignancy before kidney donation, particularly in older (age >50 years) donors. (B1)
• Active malignant disease is a contraindication to living donation but donors with certain types of successfully treated low-grade tumour may be considered after careful evaluation and discussion. (B1)
• Donors with an incidental renal mass lesion must have this diagnosed and managed on its own merit (out with discussion of kidney donation) with appropriate referral to a Urology Specialist in line with the ‘2-week wait’ pathway. (A1)
• Contrast enhanced renal CT scan, ultrasound and / or MRI can usually distinguish between benign lesions such as angiomyolipoma (AML) or malignancy such as renal cell carcinoma (RCC). Review by a specialist uroradiologist is recommended. (C1)
• Bilateral AML and AML >4 cm generally preclude living kidney donation although occasionally unilateral large (>4 cm) AML can be used if ex vivo excision of the AML appears to be straightforward.
• An incidental, unilateral solitary AML <4 cm with typical characteristic CT criteria does not usually preclude donation.
• A kidney with an AML <1 cm may be considered for donation or left in situ in the donor’s remaining kidney.
• Kidneys containing a single AML between 1 and 4 cm can be considered for donation depending on its position, consideration of whether ex vivo excision of the AML is straightforward, or whether it can be left in situ in the recipient and followed with serial ultrasound imaging. (C1)
• Donors with an incidental small (<4 cm) renal mass that appears on imaging to be a RCC must be seen in a specialist Urology clinic and be offered standard of care treatment options, including partial and radical nephrectomy. Renal function permitting, if the person wishes to consider radical nephrectomy, ex-vivo excision of the small renal mass with subsequent donation of the reconstructed kidney can be considered on an individual basis with specific caveats, full MDM discussion and appropriate informed consent from the donor and recipient. (D2)
SURGERY: TECHNICAL ASPECTS, DONOR RISK AND PERI-OPERATIVE CARE
Recommendations
• Work-up for living kidney donation may include direct or indicative evaluation of split renal function with the kidney with poorer function selected for nephrectomy irrespective of vascular anatomy (see Chapter 5.5). (C2)
• Work-up for living kidney donation must include detailed imaging confirming the vascular anatomy of both donor kidneys and information about the renal parenchyma and collecting systems. Either CTA or MRA can be used as current evidence indicates little difference in accuracy. (B1)
• Multiple renal arteries or kidneys with anatomical anomalies are not absolute contraindications to donation. Decisions must be made on an individual basis as part of a multi-disciplinary team evaluation. (B2)
• All living donors must receive adequate thromboprophylaxis. Intraoperative mechanical compression and post-operative compression stockings, along with low molecular weight heparin, are recommended. (A2)
All living donor surgery must be performed or directly supervised by a Consultant surgeon with appropriate training in the technique. (C1)
• Pre-operative hydration with an overnight infusion and/or a fluid bolus during surgery improves cardiovascular stability during laparoscopic donor nephrectomy. (B2)
• Pre- and peri-operative intravenous fluid replacement with Hartmann’s solution is preferred to 0.9% Saline. (B2)
• Laparoscopic donor surgery (fully laparoscopic or hand-assisted) is the preferred technique for living donor nephrectomy, offering a quicker recovery, shorter hospital stay and less pain. Mini-incision surgery is preferable to standard open surgery. (B1)
• Haem-o-lok clips are not to be used to secure the renal artery during donor nephrectomy following a report of an adverse event involving this technique.(C2)
• Patients undergoing living donor nephrectomy are likely to benefit from the management approaches widely used in “enhanced recovery after surgery” (ERAS) programmes. (D2)
HISTOCOMPATIBILITY TESTING FOR LIVING DONOR KIDNEY TRANSPLANTATION Recommendations
• Initial assessment of donor and recipient histocompatibility status must be undertaken at an early stage in living donor kidney transplant work-up to avoid unnecessary and invasive clinical investigation. (B2)
• Screening of potential living donor kidney transplant recipients for clinically relevant antibodies is important for ensuring optimal donor selection and graft survival. (A1)
• Antibody screening is especially important when potential living donor transplant recipients undergo reduction or withdrawal of immunosuppression. (B2)
• Post-transplant antibody monitoring must be undertaken according to the BSHI/BTS guidelines. (B1)
• Transplant units and histocompatibility laboratories must agree an evidence-based protocol to define antibody screening and crossmatch results that constitute a high immunological risk to transplantation. (B2)
• When possible, the HLA type(s) of partners/offspring of female recipients who have had previous pregnancies should be determined to aid immunological risk assessment for repeat paternal HLA mismatches in women with low level DSA. (B1)
• A pre-transplant serum sample collected within 14 days of the planned date for transplantation must be tested in a sensitive antibody screening and donor crossmatch assay and transplantation should not usually be performed if the crossmatch test is positive, unless the antibody is shown to be indicative of acceptable immunological risk. (A1)
• Changes in immunosuppression during the transplant work-up must be notified to the histocompatibility laboratory and additional antibody screening and donor-recipient crossmatch tests must be undertaken as indicated. (B1)
• HLA matching may be preferred when there is an option of selecting between living donors, particularly to reduce the possibility of subsequent sensitisation. This is important for younger recipients where repeat transplantation may be required. However, it is recognised that other donor factors will be taken into account. (B1)
• For patients with an ABO/HLA incompatible and/or a poorly HLA matched living donor, consideration should be given to entry into the UK living kidney sharing scheme (UKLKSS) to identify a more suitable donor. (B2)
• The histocompatibility laboratory must issue an interpretive report stating the donor and recipient HLA mismatch, recipient sensitisation status and crossmatch results, and define the associated immunological risk for all living donor-recipient pairs. (A1)
EXPANDING THE DONOR POOL
Recommendations
• Coherent organisational and clinical practices are essential between transplant centres to optimise the UK Living Kidney Sharing Schemes (UKLKSS) and to maximise the number of potential transplants that proceed. (B1)
• To maximise transplant opportunities within the UKLKSS, donors and recipients must only be included in a matching run if:
o Their clinical assessment and histocompatibility screening are complete and up to date. (B1)
o If matched, they are available to attend for crossmatch testing and proceed to surgery within the designated timeframes. (B1)
o Relevant complex donor considerations identified in the ‘prerun’ and donor HLA and age preferences have been discussed and agreed with the recipient. (B1)
o They understand their roles and responsibilities with respect to other donors and recipient pairs in the schemes with whom they may be matched. (B1)
• The default for all non-directed altruistic kidney donors (NDADs) is to donate into an altruistic donor chain (ADC) within the UKLKSS provided that there is no higher priority patient on the national transplant list. (B1)
• All altruistic donors (non-directed and directed) must undergo formal mental health assessment with a mental health professional before donation. (C1)
• Living kidney donors who are antibody incompatible with their recipient must have all the options and risks explained to them, including donation into the UKLKSS and antibody removal. (C1)
• As a minimum, donors must be made aware that a compatible transplant has the best chance of success and direct antibody incompatible transplant is associated with higher short- and long-term risk, if that is what is proposed. (C1)
LOGISTICAL CONSIDERATIONS
Recommendations
• Wherever possible, the aim is to ensure that the financial impact on the living donor is cost neutral by the reimbursement of legitimate expenses incurred as a direct result of the preparation for and/or act of donation. There are clear policies across the four UK countries to ensure that claims are settled in full and in a timely manner (B1)
• Donors who are non-UK residents present unique logistical challenges. To ensure that the process is clinically effective and to comply with Visa and Immigration requirements, there is an agreed entry visa application process and maximum duration of stay in the UK (six months) for the donor. Visa extensions will only be considered in exceptional or unforeseen circumstances. (B1)
DONOR FOLLOW-UP AND LONG-TERM OUTCOME
Recommendations
• Counselling and consent of potential living kidney donors must include acknowledgement that the baseline risk of ESRD is increased by donation (see also section 5.5). (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 (see also sections 5.6- 5.9). (A1)
• Risk calculators predicting lifetime ESRD risk may help inform the consent process. (C2)
• The risk of ESRD in living donors mandates lifelong follow-up after donor nephrectomy. For donors who are resident in the UK, this can be offered locally or at the transplant centre according to the wishes of the donor, but such arrangements must secure the collection of data for submission to the UK Living Donor Registry. (B1)
• Donors who are non UK residents and travel to the UK to donate (privately or to a NHS entitled recipient) are not entitled to NHS followup but must be given advice about appropriate follow-up before returning to their country of origin. (C1)
• Potential donors who are unable to proceed to donation must be appropriately followed up and referred for further investigation and management as required. (B1)
• Women must be informed of a greater risk of pregnancy-induced hypertension following kidney donation. (A1)
• Close monitoring of blood pressure, creatinine and foetal well-being is advisable in kidneys donors during pregnancy. (C1)
• Kidney donors may be offered Aspirin 75 mg daily for pre-eclampsia prophylaxis. (D2)
• There is no evidence to support the benefits of right or left nephrectomy to prevent pregnancy induced hydronephrosis. (Not graded)
• Births after kidney donation should be reported to the Living Donor Registry as ‘a significant medical event’ at each annual review. (Not graded)
RECIPIENT OUTCOME AFTER LIVING DONOR KIDNEY TRANSPLANTATION IN ADULTS Recommendations
• Graft and patient survival after living donor kidney transplantation should be within the national range of expected outcomes. (A1)
• Transplant centres should regularly audit secondary outcomes and should reappraise practice if their results are not comparable with other units. (B1)
• Where a recipient is considered to be at high risk, transplantation should only proceed if, in the view of the team of professionals involved, there is an expectation that the patient is likely to survive with a functioning transplant for more than 2 years. (C2)
• Patients at higher risk of complications and a poor outcome, due to immunological status or co-morbidities, should be considered for transplantation when the clinical team regard the risk / benefit ratio to be favourable. Due process will include careful consideration of the likely outcome for that individual without transplantation. The potential donor must be fully appraised of the issues. A summary of these discussions (between the clinical team and the donor-recipient pair) should be documented in the clinical records and a copy should also be given to the donor and recipient. (C2)
RECURRENT RENAL DISEASE
Summary of Recommendations
• A wide range of diseases that cause renal failure may recur in a transplanted kidney. This is important to consider when determining the optimal treatment strategy for a recipient and when counselling both donor and recipient on the relative risks and benefits of living donor transplantation. The risks of recurrence, the consequences for transplant function, and the time-course of any deterioration must all be considered. A discussion of the effects of immunosuppression and transplant failure on morbidity and mortality may also be appropriate. (B1)
• The risks of recurrent disease are high in FSGS and MCGN. In these diseases, the presence of specific adverse clinical features may indicate living donor transplantation should be avoided, even where a donor is available. This will require careful assessment and deliberation with all interested parties. (B2)
• In atypical HUS potential de novo disease in a related donor needs to be addressed directly. The risks of recurrent disease in the recipient need to be mitigated through regulated approval and consideration of the use of an inhibitor of complement activation, currently eculizumab. (A1)
• In patients with risks related to underlying activity such as SLE or systemic vasculitis, adequate disease control and an appropriate period of quiescence are important to ensure optimal outcomes. (B1)
• Recommendations for individual diseases follow in the following text.
LIVING DONOR KIDNEY TRANSPLANTATION IN CHILDREN
Recommendations
• Pre-emptive living related renal transplantation is the gold standard therapy for children with end-stage renal disease. (2C)
• The aim should be for children to receive a renal transplant from a blood group compatible well-matched donor, although ABO and/or HLA incompatible renal transplantation is feasible in children. (2C)
• Every effort should be made to minimise HLA mismatches (especially with common antigens) to reduce the risk of future sensitisation. (2D)
• All children with stage 4 and 5 chronic kidney disease should be assessed by a multi-disciplinary team, including a paediatric nephrologist, transplant surgeon, anaesthetist and urologist (where appropriate) prior to renal transplantation. (Not graded)
• In general, children who are ≥10 kg in weight are suitable to receive a kidney from an adult living donor. (2C)
Ramy Elshahat
2 years ago
This guideline was established by British society of transplantation on 2018, it includes
Objectives.
Legal framework.
Ethics.
Supporting information for potential kidney donors.
Donor evaluation.
Surgery.
Histocompatibility transplant testing.
Expanding donor pool.
Logistic consideration for living kidney donation.
Donor follow-up and long-term outcome.
Recipient outcome post-transplantation in adults.
Recurrent renal disease.
living donor transplantation in children.
2-legal framework -All transplants in the UK should be judged by (tissue evaluation organizations which include (The human tissue Act 2004 and the Human Tissue (Scotland) Act 2006).
-All consent removal of kidney transplants should be under guide by (tissue and mental evaluation) requirement of Human tissue 2004, and mental capacity act 2005 in England and Wales, and mental capacity Act in north Ireland 2016. The Human Tissue Authority (HTA) is responsible for assessing all applications for organ donation from living people. -All donors and recipients see an Independent Assessor (IA) who is trained and accredited by the HTA and acts on behalf of the HTA to ensure that the donor has given valid consent without duress or coercion and that reward is not a factor in the donation. If the HTA is satisfied with these matters, then approval for the living donation will be given. Types of living donation permitted by the legislation include:
Directed donation
Paired pool donation
Non-directed altruistic donation (offered one of their kidneys anonymously to someone on the National Transplant List.)
Directed altruistic donation (offered one of their kidneys to a specific patient)
The key ethical principles in living donation include:
Altruism
Autonomy
Beneficence
Dignity
Non-Maleficence
Reciprocity
3-Ethics:
All health professionals in LDKT should have full moral issues and good ethical experience.
Donor safety must be equally concerned, as recipient benefit.
Independence should be fully authorized between the recipient team and the donor team.
4-Supporting and informing the potential donor; -Living donors must be offered a good environment for a voluntary decision about donation.
–Independence evaluation of donor and recipient, must be judged by primary legislation.
–Confidentiality must be offered, to both, donor and recipient, and shared information must be done with consent.
–Separate clinician’s team for donor and recipient is better, but health care professionals should work together without breaking confidentiality.
–All aspects of support should be offered to donors, recipients, and families.
5-Donor evaluation; –recipient evaluation should be done before donor evaluation and the Plan for assessment of the donor should be done before counseling him, to reduce inconvenience, and avoid unnecessary barriers. -all lab results should be reflected by the donor, accurately by a multidisciplinary team. -for preemptive kidney transplantation recipient evaluation should be offered as early as GFR are 20 ml/min and acceleration of the process of transplantation is needed, donor assets should be started as early as possible to allow more time for discussion for transplantation Surgery.
– after a split evaluation of kidney functions by split kidney function, Nephrectomy is done to the lower kidney in GFR irrespective of vascular anatomy. –If a donor’s labs showed mild increased albuminuria or proteinuria, they are disqualified from being donors. -If a donor’s labs showed microscopic hematuria needs extensive evaluation including 2 cultures, cystoscopy, and possibly even a kidney biopsy.
-potential donors with active malignancy are not allowed to donate. Patients who have had malignant melanoma, and cancers of the breast, lung, and colon (Dukes stages B or C) are barred from the donation.
-potential donors with non-melanoma skin cancers and treated cancers with no risk of recurrence can be allowed to become donors but will require extensive workup and oncology evaluation before proceeding.
-Patients with renal masses will require referral to a specialist uro-radiologist to confirm if the masses are benign or malignant
–donor cardiac evaluation, a 12 lead ECG will suffice unless if the donor is at high risk for CVD – then referral to a cardiologist is required.
–Appropriate imaging to assess vascular tree, parenchyma, and collecting system should be offered to the donor’s kidneys. if there are anatomical anomalies, multiple vasculatures should be evaluated by a transplant surgeon and are not an absolute contraindication to transplantation.
–LMWH is recommended as thromboprophylaxis is offered by surgeons.
–All transplantation surgery must be done under a consultant surgeon
6-Histocompatibility testing for living donation for transplantation; -for donor evaluation, blood group and Histocompatibility testing should be done before any invasive investigation after screening for the recipient blood group and antibody panel, to optimize donor selection and graft survival.
–Post transplantation antibody monitoring, must be undertaken to the BSHI/BTS, guidelines.
-for female recipients with previous pregnancies, HLA typing for partner and offspring should be determined to avoid more immunological risks.
–Pre-transplant screen samples must be tested for antibody screening and donor crossmatch, so transplantation should be delayed unless positive crossmatch is within the accepted titer. -HLA matched donor is preferred especially for the younger recipients with the possible future need for re-transplantation to avoid sensitization.
-Recipient with ABO/HLA incompatible, and /or poorly HLA mismatch, the live donor should enter paired kidney donation program.
-The histocompatibility result report should be stating (donor, recipient HLA mismatch, recipient sensitization status, crossmatch result, and associated immunological risk for recipient and donor).
7-Expanding donor pool by UKLKSS; The UK Living Kidney Sharing Scheme is to maximize the number of transplantations. -The default, non-directed altruistic donors are to donate and be directed within UKLKSS.
-All altruistic donors if directed or not must have a formal mental health assessment before transplantation.
-all incompatible donors should be directed to UKLKSS.
-Donors should aware that; compatibility is always associated with success, while incompatibility is not.
8-Donor follow-up and long-term outcome; -the risk of ESKD post donation is related to multiple risk factors including age, sex, race, BMI, and history of renal disease so, follow-up post nephrectomy must be informed to all donors, especially females for increased risks and events with pregnancy including hypertension and pre-eclampsia, 9-Recipient outcome after live donor transplant in adult; -Graft and recipient survival, after transplantation of living donor, should be within range of expected outcome for high-risk patients’ expectation of recipient and graft functioning should be at least for 2 yrs. –All transplant centers must do regular audits and Graft and patient survival after living donor kidney transplantation should be within the national range of expected outcomes. They should also do audits for secondary outcomes and compare them to other transplant centers.
10-Recurrent renal disease:
there is a wide range of recurrent diseases of Glomerular disease post-transplantation, so the risk of recurrence and graft survival should be discussed with both donor and recipient.
-for diseases with a high recurrence rate like atypical HUS, living donors are not preferred and the diseased donor is preferred -Recipient risk of SLE or systemic vasculitis, needs adequate disease control time.
11-Living donor transplant in children; -Pre-emptive related transplant is the gold standard transplant for children. -children with CKD stage IV and V should be assessed by a multidisciplinary team. -Children > 10 kg is suitable to receive a kidney from an adult donor.
Doaa Elwasly
2 years ago
-All transplants done from living donors must fulfil the requirements of the primary legislation with all it’s aspects
-The different legalised living donation types include directed either genetically or emotionally related ,paired, Non-directed altruistic donation, directed altruistic donation.
– HTA must approve the living donations for organ transplantation before processing.
– Health care givers involved in living donor kidney transplantation must recognize the wide range of complex moral issues and make sure that good ethical practice is provided also ethical committe can be available for support.
-Multidisciplinary team must explain to the possible donor about all aspects and risks on the short and long term perspective ,ensuring to fulfil the wrights and needs of the recipient and the donor.
-The donor surgeon is responsible of ensuring that the donor understands all the process and approves with his own unpressurised will to proceed and give written and verbal consent.
-Potential donors must be evaluated according to an agreed, evidence-based protocol involving a multi-disciplinary
input including psychological assessment and discussion covering all aspects for the donor’s benefit.
-Second opinion can be taken for the appropriateness of the donor and enough work up time frame for the donor need to be available.
-directed donor /recipient pair evaluation includes early education and discussion with both parties then identification of suitable recipient ,then potential donor within 2 weeks .
Primary contraindications for donors are detected through history and investigations and screening questionnaire then ABO and HLA compitability can be tested from week 2-4
Week 4-8 ,the suitable donor is enrolled in gold standard investigation and further evaluation by MDT .
Week 8-10 results are reviewed and feedback given to donor
Week 11 if donor is not fit ,follow up and further needed ttt need to be provided
If fit for transplant both donor and recipient discuss with MDT team for legalisation of the process and signing the consents.
7-10 days before the surgery day another final crossmatch and preoperative further investigations can be carried out
Week 18 the operation can be done
Followed by postoperative follow up and LD coordinator has to facilitate long term arrangements for long term care provided by the facility to the donor.
-ABO or HLA are incompatible other options as paired/pooled donation and antibody incompatible transplantation has to be discussed with the donor and the recipient.
-Some specifically important pointes need to be clarified in donor’s history regarding hematuria ,proteinuria , UTI , frequency ,urgency, oedema ,DM ,HTN ,cardiac history, malignancy history , smoking as well as exposure to certain infections as TB , malaria , hepatitis B, C ,HIV and drug abuse history others
– for the clinical exam ,some points need to be highlightended along with general detailed exam as mental status ,BP,BMI ,abdominal fat , scars, Lymph node exam,breast or testicular exam, chest and cvs exam.
-Investigations involve routine tests including urine analysis and albumin /creatinine ratio blood count, coagulation profile ,thrombophilia screen ,sickle cell screen, kidney function tests , isotope or other investigation for measuring GFR,liver function, urate , blood glucose measuring tests, thyroid function, lipid profile and pregnancy tests and virology and infection screening as well as cardiorespiratory evaluation by chest xray ,ECG and echo.
– Initial assessment of renal function by eGFR computed from a creatinine assay standardised to the International Reference Standard.
-Then GFR need further evaluation by a measured reference method as clearance of 51Cr-EDTA, 125iothalamate or Iohexol.
– Differential kidney function using 99mTcDMSA scanning is
adviced when there is >10% variation in kidney size or
renal anatomical anomaly.
– Pre-donation m GFR need to be considered in order that predicted post-donation GFR remains within the gender and age-specific normal range
-ESRD post donation risk is similar to general population but slight higher risk can occur for which donor have not be consented.
-The acceptance of donors with GFR below the recommended threshold or with comorbides need to be individualised
-Early postdonation compensatory increase of renal function of the remaining kidney occurs and nearly post 3 momths the eGFR increases 65-70% of the predonation level.Some studies mentioned decrease of GFR post donation by average of 26 mL/min/1.73m2
-On long term bases the rate of decline of GFR post donation is not higher than that for matched general population.
– ESRD incidence for living kidney donors is similar to or lower than that in the unselected general population inspite of reduction in GFR opposing other studies which published that donors compared with healthy matched controls had an increased risk of ESRD postdonation and absolute risk is higher for younger donors specially with black ethnicity.
– The cardiovascular and life expectancy risk for donors compared to matched controls is debatable .
– Long term study revaled a minor increase in risk of ESRD for donors with mGFR >80 mL/min/1.73m2 with mean age at donation was 40-50 years.
– A threshold for donation of >90 mL/min/1.73m2 was set for those <30 years, and candidates >45 years the threshold renal function is predicated on post-donation GFR as (75% of pre-donation function) staying above the lower limit of the age and gender-specific normal range.
-Old age is not n absolute contraindication for donation if medically fit meanwhile they will be more liable to perioperative complications and the graft long term outcome can be compromised.
-Candidates < 18 y must not be considered for donation and those 18-21 y are relative contraindication as most of them can develop comorbidities and OPTN data showed that most donors of this age group experienced ESRD 15 y postdonation.
-Donors with BMI 25-30 can proceed to donation ,those with BMI 30-35 need further cardiovascular, respiratory evaluation ,as well as explanation of the high risk of perioperative complications and long term outcomes ,therefore they will need to loose weight .Donors with BMI>35 are declined .Obese candidates are more liable to perioperative complications and post nephrectomy more prone to develop proteinuria and ESRD .
-Donors with high normal ,high or variable BP and on antihypertensive therapy need ABPM or multiple home BP monitoring. BP <140/90 can be acceptable for donation, candidates with moderate HTN controlled on antihypertensives can be accepted according to overall cardiovascular assessment, while those with uncontrolled hypertension ,evidence of end organ damage and high risk of future cardiovascular complications are declined.
-Donors with impaired fasting glucose state , family history of type 2 DM, a history of gestational diabetes, ethnicity or obesity need to undergo an oral glucose tolerance test (OGTT) because if there is impaired glucose tolerance test ,the risk of developing DM postdonation will be high, consideration of risk and benefit will be needed before accepting diabetic candidate as a potential donor
-Risk calculators use data for a donor to give an estimated risk for the development of diabetes over the subsequent 10 years
-potential kidney donors with high cardiovascular risk factor or with exercise capacity <4 METS can be evaluated by stress test or CT Ca scoring along with MDT assessment.
-Potential donors screened by ACR if >30mg/mmol ,they shall be declined due to increased risk of CKD and cardiovascular morbidity.
-Potential donors need to have dipstick urine testing at least twice if PNVPH was detected further urinary cultures and imaging will be needed if non conclusive , cystoscopy will be needed for those>40 y old if non conclusive with hematuria +1 , renal biopsy can be done ,meanwhile thin basement membrane can donate but it has to be distinguished from Alport syndrome which is contraindicated to donate .
-Possible donors with pyuria will not be considered except after proving that pyuria is due to reversible cause as uncomplicated UTI.
-Screening of the potential donor for infection is essential as candidates with active hepatitis B,C ,HIV ,HTLV is contraindication also CMV and EBV status need to be known and both parties counselled specially if positive donors are donating to negative recipients .
-Donors without significant metabolic anomalies with limited renal stone history can be included after counselling and further assessment, if a suitable candidate with unilateral renal stone, the kidney with the stone can be donated if the split renal function and vascular anatomy allows donation.
-Donors with anemia has to be investigated and treated ,also cases with hemoglobinopathies needs further assessment and hematological evaluation.
-Recipients with inherited disease need to have genetic testing which will also aid in excluding relatives at risk to the same genetic disease to be excluded.
-Screening for occult malignancy in donors>50 Y is essential as active malignancy is a contraindication for donation, meanwhile some treated low grade tumours can be accepted after precise evaluation.
-potential donors can need evaluation of split renal function selecting the kidney with less function as well as imaging for vascular anatomy and renal parenchyma, thromboprophylaxis is needed ,adequate hydration is applied , laparoscopic nephrectomy is preferred, ERAS program application is beneficial
-Initial evaluation of HLA compatibility is done early to avoid unnecessary tests besides antibody screening followed by post transplant monitoring to decide for the immunosuppression regimen guided by certain protocol ,if 2 parties are incompatible they can be enrolled into the UK living kidney sharing scheme to identify a more compatible candidate. An interpretative detailed report need to be issued by histocompatibility lab.
-AIT can be performed after entry of the couple to the UKLKSS including a specific experienced program including plasma pharesis, if ABOi transplantation will be done specific protocol need to be followed.
-To enhance transplant opportunities within the UKLKSS, for Paired/pooled donation and altruistic donor chains donors and recipients must be involved according to specific considerations.
-Altruistic kidney donors need to be psychologically and mentally assessed in addition to other routine tests .
– Living Donor Expenses need to be reimbursed
– The risk of ESRD in living donors necessitates lifelong follow-up .
– The risks of recurrent disease are high post transplantation as in FSGS and MCGN so living donor better to be avoided after MDT evaluation.
– children with body weight ≥10 kg are suitable to receive a
kidney from an adult living donor after evaluation of MDT.
Hadeel Badawi
2 years ago
Kidney transplantation from a living donor, when available, is the treatment of choice or most patients with ESRD.
This guidance relates only to living donor kidney transplantation and reflects a growing body of evidence.
ETHICS
All health professionals involved in LDT must be familiar with the general principles of ethical practice; altruism, autonomy, Beneficence, Dignity, Non-maleficence, and Reciprocity
DONOR EVALUATION
-During evaluation of potential donor contraindication and unsuitability of donors must be identified at the earliest possible stage of assessment.
-It may be appropriate to start the donor work-up in parallel to the recipient assessment to maximize the chance of pre-emptive transplantation and avoid unnecessary delay.
ABO BLOOD GROUPING AND CROSSMATCH TESTING
– A compatible ABO blood group and HLA transplant offers the best opportunity for success. (A1) – Where ABO or HLA incompatibility is present, alternative options for transplantation must be discussed with the donor and recipient,. (A1)
MEDICAL ASSESSMENT
-A full past and present medical history must be taken to identify any risk of latent or current infection in the donor that could be transmitted to the recipient by a kidney allograft
-A thorough clinical examination must be performed, taking particular account of the cardiovascular and respiratory systems.
-A psychosocial assessment is recommended for all donors with appropriate referral to a mental health professional as required.
– Routine Screening Investigations for the Potential Donor: Urine (at least twice): Dipstick Microscopy, culture and sensitivity and ACR or PCR.
Blood:
CBC, Coagulation screen (PT and APTT)
Thrombophilia screen (where indicated)
Sickle cell trait (where indicated)
Haemoglobinopathy screen (where indicated)
G6PD deficiency (where indicated)
Creatinine, urea and electrolytes
Isotopic or other reference test for measurement of GFR
Liver function tests
Bone profile (calcium, phosphate, albumin and alkaline phosphatase)
Urate
Fasting plasma glucose
Glucose tolerance test (if family history of diabetes or fasting plasma glucose
>5.6 mmol/L)
Fasting lipid screen (if indicated)
Thyroid function tests (if strong family history)
Pregnancy test (if indicated)
Virology and infection screen:
Hepatitis B and C
HIV
HTLV1 and 2 (if appropriate)
Cytomegalovirus
Epstein-Barr virus
Toxoplasma
Syphilis
Varicella zoster virus (where recipient seronegative)
HHV8 (where indicated)
Malaria (where indicated)
Trypanosoma cruzi (where indicated)
Schistosomiasis (where indicated)
Cardiorespiratory system
Chest X-ray
ECG
ECHO (where indicated)
Cardiovascular stress test (as routine or where indicated)
ASSESSMENT OF RENAL FUNCTION – eGFR (CKD-EPI) expressed as mL/min/1.73m2 computed from a creatinine assay standardized to the International Reference Standard. (B1)
– GFR must subsequently be assessed by a reference measured method (mGFR) Cr-EDTA, iothalamate or Iohexol (B1)
– Differential kidney function, determined by 99mTcDMSA scanning is recommended where there is >10% variation in kidney size or significant renal anatomical abnormality. (C1)
– GFR Thresholds for donation defined based on the gender and age-specific normal range within the donor’s lifetime (B1)
– Donor whose renal function is below the GFR threshold or who have additional risk factors for ESRD should be individualized. (D2)
– The donor must be offered lifelong annual assessment of renal function including serum creatinine, estimation of UPC and BP measurement. (B1)
– The risk of ESRD after 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 consented. (D2)
– The risk of death and cardiovascular events was lower and the risk of death-censor cardiovascular events was the same in the donors as compared with the healthy matched population.
DONOR AGE – Old age alone is not an absolute contraindication to donation, they need careful consideration.(A1) – The older donor may be at greater risk of perioperative complications and that the function and possibly the long-term survival of the graft may be compromised. This is particularly evident with donors >60 years of age. (B1) – Most programs do not consider donors aged <18 year.
DONOR OBESITY – Otherwise healthy with (BMI 25-30 kg/m2) may safely proceed to donation. (B1) – Moderately obese donors (BMI 30-35 kg/m2): Need to exclude CVD, respiratory and kidney disease. (C2), counselled about the increased risk of perioperative complications (B1). Counselled about the long-term risk of kidney disease and be advised to lose weight before donation and to maintain their ideal weight following donation. (B1) – Limited data on the safety of kidney donation in the very obese (BMI >35 kg/m2) and should be discouraged. (C1)
HYPERTENSION IN THE DONOR – BP must be assessed on at least two separate occasions. – ABPM or home monitoring is recommended if BP is high, high normal or variable, or the potential donor is on treatment for hypertension. (C2) – BP <140/90 mmHg is usually acceptable for donation. (C1) – Donors must be warned about the risk of developing donation-related hypertension, particularly if in a high-risk group. – BP measurement is part of annual donor monitoring. (C1) – Donors with HTN controlled on medications (1 or 2) , no evidence of EOD may be acceptable for donation. Acceptance will be based on an overall assessment of cardiovascular risk and local policy. (C1) – All LKD must be encouraged to adapt lifestyle measures including stopping smoking, reducing alcohol intake, frequent exercise and, where appropriate, weight loss, to decrease the risk of hypertension. – Donors who are diagnosed with HTN pre- or post-donation are managed according to BHS (B1)
DIABETES MELLITUS – FBG in all donors (B1), if indicate an impaired fasting glucose state and an OGTT should be undertaken. (B1) – Donors with an increased risk of T2DM because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT. (B1) – If OGTT reveals a persistent impaired fasting glucose and/or an impaired glucose tolerance, then the risks of developing diabetes after donation must be carefully considered. (B1) – Use of a diabetes risk calculator to inform the discussion of potential kidney donation. (B2) – Diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney. (Not graded)
CARDIOVASCULAR EVALUATION – Routine use of stress testing in the assessment of donors at low cardiac risk, is not indicated (C2) – Donors with a history of CVD, an exercise capacity of <4 metabolic equivalents (METS) or with risk factors for CVD should undergo further evaluation before donation. (C2) – Higher risk donors, stress testing is recommended or by CT calcium scoring . (C2) – MDT discussion is recommended as part of the clinical assessment of donors with higher cardiovascular and peri-operative risk. (D2)
PROTEINURIA – Urine protein excretion needs to be quantified in all living donors. (B1) – Urine ACR is the recommended screening test, although urine PCR is an acceptable alternative. (A1) – ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day protein excretion >500 mg/day represent absolute contraindications to donation. (C2) – The significance of moderately increased albuminuria and proteinuria has not been fully evaluated in living kidney donors. However, since the risk of CKD and cardiovascular morbidity increase progressively with increasing albuminuria or proteinuria such levels are a relative contraindication to donation. (C2)
NON-VISIBLE HAEMATURIA – All living donors must have (dipstick) urinalysis on at least two separate occasions. (B1) – 2 or more positive tests (including trace), is considered as persistent non-visible haematuria (PNVH). (B1) – If PNVH is present, urine culture and renal imaging to exclude common urologic causes (A1) – If no cause is found, perform cystoscopy in patients age >40 years to exclude bladder pathology. (B1) – If no cause is found and the donor still wishes to donate, then a kidney biopsy is recommended if haematuria is 1+ or greater on dipstick testing. (B1) – Glomerular pathology precludes donation, with the possible exception of thin basement membrane disease. (B1) – For donors with persistent asymptomatic (PANVH) and a family history of haematuria or X-linked Alport syndrome, a renal biopsy (B1) and referral to a clinical geneticist are recommended. (B2)
PYURIA –Donors with pyuria can only be considered for donation if it is due to a reversible cause, such as an uncomplicated urinary tract infection.
INFECTION IN THE PROSPECTIVE DONOR – Screening to identify potential risks of donor infection and transmission to the recipient. (B1) – Active HBV and HCV infection in the donor are usually contraindications to living kidney donation; however, donors with evidence of active viral replication may be considered under some circumstances. (B1) – HIV or HTLV infection is an absolute contraindication to living donation. (B1) – Screening for HBV, HCV and HIV infection must be repeated within 30 days of donation. (Not graded) – All donors should be provided with dietary advice regarding avoidance of HEV infection, and screening by nucleic acid testing within 30 days of donation. (Not graded) – The CMV status of donor and recipient must be determined before transplantation. When the donor is CMV positive and the recipient is CMV negative, the donor and recipient must be counselled about the risk of post-transplant CMV disease. (B1) – The EBV status of donor and recipient must be determined before transplantation. When the donor is EBV positive and the recipient is EBV negative, the donor and recipient must be counselled about the risk of developing PTLD. (B1)
-Potential donors must be screened by history for travel or residence abroad to assess their potential risk for having acquired endemic infections and appropriate microbiological investigations instigated if indicated. (Not graded)
NEPHROLITHIASIS – In the absence of a significant metabolic abnormality, donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as potential kidney donors. Full counselling of donor and recipient is required along with access to appropriate long-term donor follow up. (C2) – Donors with metabolic abnormalities detected on screening should be discussed with a specialist in renal stone disease. (C2) – In appropriate donors with unilateral kidney stone(s) the stone-bearing kidney can be considered for donation (if vascular anatomy and split kidney function permit) in order to leave the donor with a stone-free kidney after donation. (C2)
HAEMATOLOGICAL DISEASE – Donor anemia needs to be investigated and treated before donation. (A1) – A haemoglobinopathy screen must be carried out in patients with non-Northern European heritage or if indicated by the full blood count. (A1) – Careful consideration needs to be given to the use of donors with haemoglobinopathies. (B1) – Advice from a hematologist is recommended for hematological conditions not covered in this guideline. (Not graded)
FAMILIAL RENAL DISEASE – All transplant recipients must have a detailed family history recorded and confirmation where possible of the diagnosis in other family members with known kidney disease. This may aid diagnosis for the recipient, clarify any mode of inheritance and identify at risk relatives. (A1) – When the cause of ERSD in the recipient is due to an inherited condition, appropriate tests – including genetic testing if available – are recommended to exclude genetic disease in the potential donor. (A1) – Many inherited kidney diseases are rare, so involvement of clinical and laboratory genetics services must be considered at an early stage to assess likely risks to family members and the appropriate use of molecular genetic testing. (B1)
DONOR MALIGNANCY – Careful H&E and investigation of donors are essential to exclude occult malignancy, particularly in older (age >50 years) donors. (B1) – Active malignant disease is a contraindication to LD but donors with certain types of successfully treated low-grade tumour may be considered (B1) – Donors with an incidental renal mass lesion to be evaluated by Urologist (A1) – Contrast enhanced renal CT scan, ultrasound and / or MRI can usually distinguish between benign lesions such as AML) or malignancy as RCC. Review by a specialist uroradiologist is recommended. (C1) – Bilateral AML and AML >4 cm generally preclude living kidney donation – AML <1 cm may be considered for donation or left in situ in the donor’s remaining kidney. – Single AML (1-4 cm) can be considered for donation depending on its position, consideration of excision of the AML is straightforward, or whether it can be left in situ in the recipient and followed with serial ultrasound imaging. (C1) – Donors with an incidental small (<4 cm) renal mass that appears on imaging to be RCC must be seen in a specialist Urology clinic and be offered standard of care treatment (D2)
SURGERY: TECHNICAL ASPECTS, DONOR RISK ANDPERI-OPERATIVE CARE – Evaluation of split renal function with the kidney with poorer function selected for nephrectomy irrespective of vascular anatomy (C2) -Detailed imaging (CTA or MRA) confirming the vascular anatomy of both donor kidneys and information about the renal parenchyma and collecting system. (B1) – Multiple renal arteries or kidneys with anatomical anomalies are not absolute contraindications to donation. (B2) – All living donors must receive adequate thromboprophylaxis A2) – Pre-operative hydration with an overnight infusion and/or a fluid bolus during surgery improves cardiovascular stability during laparoscopic donor nephrectomy. (B2) – Laparoscopic donor surgery (fully laparoscopic or hand-assisted) is the preferred technique for living donor nephrectomy.(C2) – “enhanced recovery after surgery” (ERAS) programs for all patient undergoing the surgery. (D2) HISTOCOMPATIBILITY TESTING FOR LIVING DONOR KIDNEY TRANSPLANTATION – Initial assessment of HLA status must be undertaken at an early stage in living donor kidney transplant work-up to avoid unnecessary and invasive clinical investigation. (B2) – Screening of recipients for clinically relevant antibodies is important for ensuring optimal donor selection and graft survival. (A1) – Antibody screening is especially important when recipients undergo reduction or withdrawal of immunosuppression. (B2) – Post-transplant antibody monitoring must be undertaken according to the BSHI/BTS guidelines. (B1) – Transplant units and histocompatibility laboratories must agree an evidence-based protocol to define antibody screening and crossmatch results that constitute a high immunological risk to transplantation. (B2) – When possible, the HLA type(s) of partners/offspring of female recipients who have had previous pregnancies should be determined to aid immunological risk assessment for repeat paternal HLA mismatches in women with low level DSA. (B1) – A pre-transplant serum sample collected within 14 days of the planned date for transplantation must be tested in a sensitive antibody screening and donor crossmatch assay and transplantation should not usually be performed if the crossmatch test is positive, unless the antibody is shown to be indicative of acceptable immunological risk. (A1) – Changes in immunosuppression during the transplant work-up must be notified to the histocompatibility laboratory and additional antibody screening and donor-recipient crossmatch tests must be undertaken as indicated. (B1) – HLA matching may be preferred to reduce the possibility of subsequent sensitization. However, it is recognized that other donor factors will be taken into account. (B1) – For patients with an ABO/HLA incompatible and/or a poorly HLA matched living donor, consideration should be given to entry into the UKLKSS to identify a more suitable donor. (B2) – The histocompatibility laboratory must issue an interpretive report stating the donor and recipient HLA mismatch, recipient sensitization status and crossmatch results, and define the associated immunological risk for all living donor-recipient pairs. (A1)
RECURRENT RENAL DISEASE – This is important to consider the risks of recurrence, the consequences for transplant function, and the time-course of any deterioration must all be considered. A discussion of the effects of immunosuppression and transplant failure on morbidity and mortality may also be appropriate. (B1)
LIVING DONOR KIDNEY TRANSPLANTATION IN CHILDREN – Pre-emptive living related renal transplantation is the gold standard therapy for children with ESRD. (2C) – In general, children who are ≥10 kg in weight are suitable to receive a kidney from an adult living donor. (2C) – The aim should be transplant from a blood group compatible well-matched donor, although ABO and/or HLA incompatible renal transplantation is feasible in children. (2C) – Effort should be made to minimize HLA mismatches (especially with common antigens) to reduce the risk of future sensitization. (2D) – All children with ERSD should be assessed by a MDT prior to renal transplantation. (Not graded)
Ghalia sawaf
2 years ago
BTS guideline has comprehensive recommendations which contain these headlined:
1- donor evaluation
2- surgery technique
3- histocompatibility test
4 expanding to donor pool
5- Logistical considerations
6- Donor Follow up
7- recipient outcome
8- recurrent renal disease
9- living donor kidney transplant in children
I will try to highlight some important recommendations from each topic
Old age now it’s not contraindication for donation but we should be careful especially about period operative complications
Also, graft survival from old donor( > 59 y ) is lower notably after 5 years
On the other hand most program refuse donor younger than 18 years because of risk of (CVD- DM……) development
Obesity is one of risk factors for both donor and recipient
Donation with BMI > 35 should be discouraged
They’d rather donor with BMI (20-30)
Donor with BMI (30- 35) needs per- transplant consultation to rule out risk factor ( CVD- BP- respiratory functions)
BTS guideline explains in details the (definition – methods of BP measurement) and identifies acceptable criteria;
Diabetic nephropathy development after donation is not common ( comparing to general population- and need long time follow up)
All donors must have a fasting plasma glucose test , if positive , OGTT should be performed or if family history of DM , a history of gestational diabetes, ethnicity or obesity is positive
In the absence of evidence of target organ damage and having ensured that other cardiovascular risk factors such as obesity, hypertension or hyperlipidaemia are optimally managed, diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney.
Cardiac evaluation
All patient should perform echocardiogram to screen cardiomyopathy or past ischemia
Stress test not recommended routinely in low risk donor
But in the presence of risk factors CT calcium scanning or other available test
Multidisciplinary teamwork is preferred
Proteinuria more than 500 mg per day is an absolute contraindication for renal transplantation
Proteinuria 150- 500 mg a day is a relative contraindication
All living donors must perform (dipstick) urinalysis on at least two separate occasions to rule out non visible hematuria , if positive, in donor older than 40years, perform cystoscopy to exclude bladder pathology.
Kidney biopsy is recommended to exclude glomerular disease which may preclude donation, with the exception of thin basement membrane
If x linked Alport syndrome is suspected genetic test should be done
Active HBV- HCV and HIV infection in the donor are usually contraindications
CMV/EBV status of donor and recipient must be determined before transplantation. When the donor is CMV/EBV positive and the recipient is CMV/EBV negative, the donor and recipient must be counselled about the risk of post-transplant CMV/EBV disease
Metabolic cause for lithiasis consider a specialist
Kidney bearing stones maybe considered for donation
Anemia should be interpreted and treated with hematologist
Active malignant is contraindication for donor recipient
ECHO- CT OR MRI have well valuation for AML OR RCC
Donor with AML OR RCC should consult urologists
Bilateral and usually > 4 cm unilateral AML preclude donation
Donor with AML < 1 cm unilateral AML can undergo procedure
UKLKSS is exit for patients with an ABO/HLA incompatible and/or a poorly HLA matched living donor
To initiate a programme of AIT, a unit should be able to demonstrate a demand of at least five cases a year and appropriate support from clinical transplant, plasmapheresis and histocompatibility teams
Sensitive and rapid techniques for the measurement of DSA levels must be available
If ABOi transplantation is to be performed, blood group antibody titres need to be measured, with differentiation between A1 and A2 subgroups of recipient blood group A (when appropriate) and discrimination between IgG- and IgM-specific ABO antibodies.
SURGERY: TECHNICAL ASPECTS, DONOR RISK AND PERI-OPERATIVE CARE
Work-up for direct or indicative evaluation of split renal function
poorer function kidney selected for nephrectomy
detailed imaging confirming the vascular anatomy – renal parenchyma and collecting systems. Either CTA or MRA can be used
Multiple renal arteries or kidneys with anatomical anomalies are not absolute contraindications to donation.
All living donors must receive adequate thromboprophylaxis. low molecular weight heparin, are recommended.
All living donor surgery must be performed by a Consultant surgeon with appropriate training in the technique
. Pre-operative hydration with an overnight infusion and/or a fluid bolus during surgery improves cardiovascular stability during laparoscopic donor nephrectomy.
Hartmann’s solution is preferred to 0.9% Saline.
Laparoscopic donor surgery is the preferred technique for living donor nephrectomy,
Haem-o-lok clips are not to be used to secure the renal artery during donor nephrectomy
After living donor nephrectomy , it is better to undergo “enhanced recovery after surgery” (ERAS) programmes.
LIVING DONOR KIDNEY TRANSPLANTATION IN CHILDREN
• Pre-emptive
• living related donor
• blood group compatible well-matched donor,
• minimise HLA mismatches to reduce the risk of future sensitisation.
• multi-disciplinary team, prior to renal transplantation
• children who are ≥10 kg in weight are suitable to receive a kidney from an adult living donor.
BTS guideline discusses recurrent disease with some considerations
IgA nephropathy
membranous nephropathy
ANCA vasculitis
Goodpasture
SLE
cystinosis
Primary hyperoxaluria (selected cases)
Not contraindication for LD RTX
We should avoid living related donor in Atypical HUS
Primary FSGS AND Type I and II MCGN do not contraindicate living donor transplantation.
But graft loss secondary to recurrent C3 glomerulopathy is a contraindication to repeat transplantation
Alport Syndrome
not contraindicate LD transplantation. But should be careful about the risks of de novo anti-GBM disease
For amyloidosis we should control disease before transplant
Last edited 2 years ago by Ghalia sawaf
Abdulrahman Ishag
2 years ago
Ethical consideration ;
Donating a kidney involves a detailed process of investigation, major surgery, and a significant period of recovery. Whilst there are documented overall benefits for the individual donor and wider society, living donor surgery entails risk, which includes
a small risk of death
Donor medical assessment ;
1-History and examination
2-Basic laboratory investigation , in addition to screening for viral infection and common transmitted disease .
Assessment of donor renal function ;
1-Estimate the GFR using the CKD-EPI equation .
2-Split renal function, measured by combining 51Cr-EDTA and 99mTc-DMSA, can be helpful when there is anatomical abnormality or complexity.
3-Age and Gender-Specific GFR based is recommended for Safe Threshold Level of Kidney Function to Donate .
Donor age ;
1-Old age is not absolutely contraindication to donate .
2- Donors aged <18 are not allowed to donate in most o the transplant program and an age of 18-21 years considered as a relative contraindication to donation.
Obesity ;
BMI 25-30 kg/m2) may safely proceed to kidney donation.
BMI 30-35 kg/m2) must be counseled about the long-term risk of kidney disease and be advised to lose weight before donation and to maintain their ideal weight following donation.
The very obese (BMI >35 kg/m2) are limited and donation should be discouraged.
HYPERTENSION IN THE DONOR;
1- a blood pressure of <140/90 mmHg is usually acceptable for donation.
2-mild-moderate hypertension that is controlled to <140/90 mmHg (and/or 135/85 mmHg with ABPM or home monitoring) with one or two antihypertensive drugs and who have no evidence of end organ damage may be acceptable for donation.
DIABETES MELLITUS;
1-All potential living kidney donors must have a fasting plasma glucose level checked.
2-an OGTT should be performed to potential donor with IGF and those with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity .
ARDIOVASCULAR EVALUATION;
1. No evidence to support the routine use of stress testing in the assessment of the potential donor at low cardiac risk.
2. For higher risk potential donors, stress testing is recommended by whichever method is locally available or by CT calcium scoring.
3. MDT is recommended.
PROTEINUR;
1- ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day or protein excretion >500 mg/day represent absolute contraindications to donation.
NON-VISIBLE HAEMATUR;
1-If PNVH is present, perform urine culture and renal imaging to exclude common urologic causes including infection, nephrolithiasis and urothelial carcinoma.
2-If no cause is found, perform cystoscopy in patients age >40 years to exclude bladder pathology.
3- If no cause is found and the donor still wishes to donate, then a kidney biopsy is recommended if haematuria is 1+ or greater on dipstick testing.
PYURI;
pyuria can only be considered for donation if it can be demonstrated that the pyuria is due to a reversible cause, such as an uncomplicated urinary tract infection
INFECTION IN THE PROSPECTIVE DONOR;
1-Active HBV and HCV infection in the donor are usually contraindications to living donor kidney donation; however, donors with evidence of active viral replication may be considered under some circumstances.
2- The presence of HIV or human T lymphotrophic virus (HTLV) infection is an absolute contraindication to living donation.
3- When the donor is CMV positive and the recipient is CMV negative, the donor and recipient must be counselled about the risk of post-transplant CMV disease.
4- When the donor is EBV positive and the recipient is EBV negative, the donor and recipient must be counselled about the risk of developing Post Transplant Lymphoproliferative Disease.
NEPHROLITHIAS ;
1-In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as potential kidney donors.
HAEMATOLOGICAL DISEA;
1- Donor anaemia needs to be investigated and treated before donation.
2- A haemoglobinopathy screen must be carried out in patients with non- Northern European heritage or if indicated by the full blood count.
DONOR MALIGNANCY;
1-It is essential to exclude occult malignancy before kidney donation, particularly in older (age >50 years) donors.
2- Active malignant disease is a contraindication to living donation but donors with certain types of successfully treated low-grade tumour may be considered after careful evaluation and discussion.
3- Donors with an incidental renal mass lesion must have this diagnosed and managed on its own merit (out with discussion of kidney donation) with appropriate referral to a Urology Specialist in line with the ‘2-week wait’ pathway.
3- Contrast enhanced renal CT scan, ultrasound and / or MRI can usually distinguish between benign lesions such as angiomyolipoma (AML) or malignancy such as renal cell carcinoma (RCC). Review by a specialist uroradiologist is recommended.
4- Bilateral AML and AML >4 cm generally preclude living kidney donation .
5- A kidney with an AML <1 cm may be considered for donation or left in situ in the donor’s remaining kidney.
6-Kidneys containing a single AML between 1 and 4 cm can be considered for donation depending on its position, consideration of whether ex vivo excision of the AML is straightforward, or whether it
How these guidelines are different from the guidelines you follow at your workplace?
These guidelines do not differ from the guidelines used in our transplant center.
Tropical diseases (schisosomiasis and urinary tract tuberculosis )is apart of work up
Isaac Abiola
2 years ago
SUMMARY
Introduction:
Kidney transplantation, particularly from a living donor does not only shorten the waiting time of patients with ESRD but offers better graft and patient survival. Disease donor is not readily available and for those that might even want a preemptive kidney transplant, this may be very difficult to achieve with disease donor and hence the UK living kidney sharing scheme (UKLKSS) has been of a tremendous help in allocating quality and better matched kidney to different recipient. In UK, living donor poor has been on the rise in the last 20 years as 1 in every 3-kidney transplant done in UK now a living donor
Legal Framework
all transplantation done in UK must comply with Human Tissue Act 2004 and Human Tissue (Scotland) Act 2006
all transplant centre must be licensed with minimum requirement to perform surgery by European Union Organ Donation Directives
consent must be obtained from the donor before removing an organ
Types of Living Donation Permitted by Legislation
Direct relation: could be genetically or emotionally related
Paired or pooled donation
Non direct altruistic donation
Direct altruistic donation
Ethics
As the pool and the number of those involved in living kidney donor is growing, every health worker must be up to date on the complex ethical issues that arise in the course of this process. The need for them to be very professional and independent is expected of them, the following guidelines must be carefully followed to avoid been caught up in the complexity of organ donation,
Altruism
Autonomy
Beneficence
Dignity
No-maleficence
Reciprocity
Donor Evaluation:
The evaluation of a donor is part of the critical steps to achieve successful kidney transplantation. The aim is ensured suitability and reduce the possible risk that may come with donation and each of the sages of the test must be discussed well with donor and an agreement reached before proceeding on those investigations. It is also important to do test in stages to prevent unnecessary exposure to some test that may not be needed if there is lack of suitability in the preliminary tests. The donor GP should be contacted for possible past medical history that may be of help. Furthermore, both the donor and recipient should be free to seek for a second opinion on tests conducted on them.
Routine Screening Test for the Donor.
Urine
Blood
Virology and infection screening
Cardiorespiratory systems
Assessments of kidney function
Immunological assessment
a) HLA mismatch status
b) identification of alloantibodies
c) donor-recipient antibody
Donor above the age of 60 years has been increasing now in UK and they must counsel on the need to do more detailed work up and possibility of perioperative complication. Also, the outcome of the graft function after the surgery must be explained to the recipient because of the physiologically expected decline in kidney function as one gets older. Furthermore, donors with peculiar situation like hypertension, obesity, impaired glycemic control or DM, proteinuria, hematuria must be subjected to more intense investigation, proper counselling, and risk assessment before surgery.
Surgery and Perioperative Care:
Living kidney donation is a major surgery that involves multidisciplinary team that must be lead and done by surgeon. Patient needs to be put through all the stages of the surgery with possible complications and how to manage if it arises. There should be a written documented protocol on pre-operative, perioperative and post-transplant care which must be regularly updated based on current evidence. Inform consent about the surgery, site on the body to be marked and the whether right or left kidney will be harvested for the surgery should well spelt out. DVT prophylaxis should be used since is a major surgery and an antibiotic cover with analgesic for pain control.
Donor Follow up and long-Term Outcome
The main pillar of a continue positive outcome in kidney donor surgery is to maintain safety and long term follow up of patient. Studies in USA and Sweden have reported a reduction in the occurrence of ESRD and cardiovascular disease among donor compared to the genral population. Also, some other studies have demonstrated a lower rate of ESRD among younger donors compared to old donors. However, every transplant centre should have their respective standard of operation on follow up of patient for early detection of any untoward complications like recurrent of native disease
The above is different from my centre in term of the more extensive investigations that are not readily available in the developing am practicing especially the genetic studies and some radiological studies like split renal function
Ibrahim Omar
2 years ago
it is too long, sir. how can I summarize 295 pages.
Assafi Mohammed
2 years ago
Guidelines for Living Donor Kidney Transplantation Summary Key ethical principals in living donor transplantation:
· Altruism.
· Autonomy.
· Beneficence.
· Dignity.
· Non-maleficence.
· Reciprocity. Key Points to be Discussed with a Potential Donor
1. Valid consent for donation.
2. There should be confidentiality(Both the donor and recipient have a right to a confidential relationship with their respective clinicians).
3. The donor should be informed about process and possible outcomes:
a) Risks of donation (generic and specific).
b) Nature of surgical procedure and length of stay in hospital.
c) Potential graft loss in the recipient.
d) Requirement for Human Tissue Authority (HTA) assessment.
e) Reimbursement of expenses.
f) Requirement for annual review. Donor Evaluation
1. Identify contraindications to donation and potential clinical (physical and psychosocial) risks.The donor should be assessed medically and psychologically.
2. ABO blood grouping and crossmatch testing.
Summary of Key Points of Importance in the Medical +/- Family History of a Potential Kidney Donor:
· Haematuria/proteinuria/urinary tract infection.
· Difficulty in passing urine, including urgency, frequency, dysuria.
· History of peripheral oedema.
· Gout.
· Nephrolithiasis.
· Hypertension.
· Diabetes mellitus, including family history.
· Ischaemic heart disease/peripheral vascular disease/other atherosclerosis.
· Cardiovascular risk factors.
· Thromboembolic disease.
· Sickle cell and other haemoglobinopathies.
· Weight change.
· Change in bowel habit.
· Previous jaundice.
· Previous or current malignancy.
· Systemic disease which may involve the kidney.
· Chronic infection such as tuberculosis.
· Family history of a renal condition that may affect the donor.
· Smoking.
· Current or prior alcohol or drug dependence.
· Mental health history.
· Obstetric history.
· Residence abroad.
· Previous medical assessment e.g. for life insurance.
· Previous anaesthetic problem.
· History of back or neck pain and trauma.
· Results of national screening programme tests e.g. cervical smear, mammography, colorectal screening History with respect to Transmissible Infection
1. Previous illnesses
2. Jaundice or hepatitis
3. Malaria.
4. Previous blood transfusion.
5. Tuberculosis / atypical mycobacterium Family history of tuberculosis
6. Family history of Creutzfeldt-Jakob disease, previous treatment with natural growth hormone, or undiagnosed degenerative neurological disorder
7. Specific geographical risk factors: e.g. fungi and parasites, tuberculosis, hepatitis, malaria, worms
8. Increased risk of HIV, HTLV1 and HTLV2, Hepatitis B and C infection:
i) Haemophiliac or sexual partner of haemophiliac.
ii) High risk sexual behaviour.
iii) History of infectious hepatitis or syphilis.
iv)History of intravenous drug use
v) Tattoo or skin piercing within last 6 months.
vi)Sexual partner of an individual with positive serology.
vii) Sexual partner of drug addict. The important Points in the Clinical Examination of a Potential Kidney Donor
Abdominal fat distribution
Blood pressure
Body mass index
Dipstick urinalysis
Evidence of self-harm
Examination for abdominal masses or herniae
Examination for scars or previous surgery
Examination for lymphadenopathy
Examination / history of regular self-examination of the breasts Examination / history of regular self-examination of the testes Examination of the cardiovascular and respiratory systems Mental health
Routine Screening Investigations for the Potential Donor
1. Urine
· Dipstick for protein, blood and glucose (at least twice)
· Microscopy, culture and sensitivity (at least twice)
· Measurement of protein excretion rate (ACR or PCR)
2. Blood : CBC, Coagulation screen (PT and APTT), Thrombophilia screen (where indicated), Sickle cell trait (where indicated), Haemoglobinopathy screen (where indicated), G6PD deficiency (where indicated) 3. KFT, Bone profile and LFT.
4. Isotopic or other reference test for measurement of GFR
5. Fasting plasma glucose and Glucose tolerance test (if family history of diabetes or fasting plasma glucose >5.6 mmol/L), Fasting lipid screen (if indicated), Thyroid function tests (if strong family history), Pregnancy test (if indicated)
6. Virology and infection screen;Hepatitis B and C, HIV, HTLV1 and 2 (if appropriate), Cytomegalovirus, Epstein-Barr virus, T oxoplasma, Syphilis, Varicella zoster virus (where recipient seronegative), HHV8 (where indicated), Malaria (where indicated), Trypanosoma cruzi (where indicated), Schistosomiasis (where indicated).
7. Cardiorespiratory system: Chest X-ray, ECG, ECHO (where indicated), Cardiovascular stress test (as routine or where indicated).
The selection criteria for donation, GFR >80 mL/min/1.73m2. Recently the current practice relies on the age and gender-specific GFRs that are considered safe to donate. Advisory Threshold GFR Levels Considered Acceptable for Living Kidney Donation DONOR AGE
· The younger donor Age > 18 y.
· Donors above 60 years of age need careful consideration with respect to the increased risk of peri-operative complications, existing comorbidities and residual function post-donation, and also the long-term transplant outcome in the recipient associated with reduced donor GFR and potential donor vasculopathy. DONOR OBESITY
1. BMI 25-30 kg/m2: healthy overweight patient may safely proceed to kidney donation.
2. BMI 30-35 kg/m2: Moderately obese patients
a) must undergo careful pre-operative evaluation to exclude cardiovascular, respiratory and kidney disease.
b) must be counselled about the increased risk of peri-operative complications based on extrapolation of outcome data from very obese donors (BMI >35 kg/m2).
c) must be counselled about the long-term risk of kidney disease and be advised to lose weight before donation and to maintain their ideal weight following donation.
3. BMI >35 kg/m2 : Data on the safety of kidney donation in the very obese are limited and donation should be discouraged.
HYPERTENSION IN THE DONOR
1. Blood pressure must be assessed on at least two separate occasions.
2. Ambulatory blood pressure monitoring or home monitoring is recommended if blood pressure is high, high normal or variable, or the potential donor is on treatment for hypertension.
3. Blood pressure <140/90 mmHg is usually acceptable for donation.
4. Potential donors with hypertension are excluded from donation if:
a) Blood pressure is not controlled to <140/90 mmHg on one or two antihypertensive drugs.
b) Evidence of end organ damage.
c) Unacceptable risk of future cardiovascular risk or lifetime incidence of ESRD. DIABETES MELLITUS
1. All potential living kidney donors must have a fasting plasma glucose level checked. FPG between 6.1-6.9 mmol/L is indicative of an impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be undertaken.
2. Prospective donors with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT.
3. Diabetics can be considered for kidney donation after a thorough assessment:
a) No end organ damage.
b) Optimally managed cardiovascular risk factors(HTN, obesity and hyperlipidemia). CARDIOVASCULAR EVALUATION
1. No evidence to support the routine use of stress testing in the assessment of the potential donor at low cardiac risk.
2. For higher risk potential donors, stress testing is recommended by whichever method is locally available or by CT calcium scoring.
3. MDT is recommended. PROTEINURIA
1. Urine protein excretion needs to be quantified in all potential living donors.
2. A urine albumin/creatinine ratio (ACR) performed on a spot urine sample is the recommended screening test, although urine protein/creatinine ratio (PCR) is an acceptable alternative.
3. ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day or protein excretion >500 mg/day represent absolute contraindications to donation.
4. Moderate proteinuria(ACR 3- 30 mg/mmol, PCR 15-50 mg/mmol, 24 h UrPr 150-500 mg) is a relative contraindication to donation. NON-VISIBLE HAEMATURIA
1. All potential living donors must have reagent strip (dipstick) urinalysis performed on at least two separate occasions.
2. Two or more positive tests, including trace positive, is considered as persistent non-visible haematuria (PNVH).
3. If PNVH is present, perform urine culture and renal imaging to exclude common urologic causes including infection, nephrolithiasis and urothelial carcinoma.
4. If no cause is found, perform cystoscopy in patients age >40 years to exclude bladder pathology.
5. If no cause is found and the donor still wishes to donate, then a kidney biopsy is recommended if haematuria is 1+ or greater on dipstick testing.
6. Glomerular pathology precludes donation, with the possible exception of thin basement membrane disease.
7. For donors with persistent asymptomatic non-visible haematuria (PANVH) and a family history of haematuria or X-linked Alport syndrome, a renal biopsy and referral to a clinical geneticist are recommended.
PYURIA
· Prospective donors with pyuria can only be considered for donation if it can be demonstrated that the pyuria is due to a reversible cause, such as an uncomplicated urinary tract infection. INFECTION IN THE PROSPECTIVE DONOR
1. Screening for HBV, HCV and HIV infection must be repeated within 30 days of donation.
2. Contraindication to LDKT: Active HBV and HCV infection(donors with evidence of active viral replication may be considered under some circumstances), HIV or human T lymphotrophic virus (HTLV) infection.
3. The CMV and EBV status must be determined before transplantation. NEPHROLITHIASIS
1. The potential donor with limited history of previous stone or small stone in the absence of metabolic abnormality, can be considered for donation.
2. In unilateral small kidney stone, stone-bearing kidney can be considered for donation if vascular anatomy and split kidney function permit. HAEMATOLOGICAL DISEASE
1. Donor anaemia needs to be investigated and treated before donation.
2. A haemoglobinopathy screen must be carried out if indicated by the full blood count. Careful consideration needs to be given to the use of potential donors with haemoglobinopathies.
i) SCD and transfusion dependent thalassaemia (TDT) are an absolute contraindication to LDKT.
ii) Compound heterozygote with Hb S (e.g; Hb SC, Hb ES, etc): Such patients behave like patients with sickle cell disease and therefore should not be accepted as living kidney donors.
iii) non-transfusion dependent thalassaemia (NTDT) can be considered for living kidneydonation.
iv) LKD is acceptable in mild form of red cell membrane disorder (spherocytosis, elliptocytosis and inherited hemolytic anemia).
v) MGUS per se with caution can be considered as living kidney donors.
vi) MDS should be considered a strong contraindication to donation.
vii) VTE and clotting disorder represent a relative contraindication to donation. FAMILIAL RENAL DISEASE
1. When the cause of ESRD is an inherited condition, genetic testing if available are recommended.
2. Genetic testing may aid the prediction of the likelihood of disease recurrence in the transplanted kidney(e.g. aHUS and SRNS).
3. Alport syndrome(AR); carriers with no renal abnormality by age 45 might be considered as donors in a similar manner to X-linked Alport syndrome. DONOR MALIGNANCY
1. Active malignant disease is a contraindication to living donation.
2. Bilateral AML and AML >4 cm generally preclude living kidney donation. SURGERY: TECHNICAL ASPECTS, DONOR RISK AND PERI-OPERATIVE CARE 1. Work-up for living kidney donation must include detailed imaging confirming the vascular anatomy of both donor kidneys and information about the renal parenchyma and collecting systems. Either CTA or MRA can be used as current evidence indicates little difference in accuracy. 2. Multiple renal arteries or kidneys with anatomical anomalies are not absolute contraindications to donation. 3. Pre- and peri-operative intravenous fluid replacement with Hartmann’s solution is preferred to 0.9% Saline. 4. Laparoscopic donor surgery (fully laparoscopic or hand-assisted) is the preferred technique for living donor nephrectomy. HISTOCOMPATIBILITY TESTING FOR LIVING DONOR KIDNEY TRANSPLANTATION 1. The initial assessment of donor and recipient histocompatibility status must be undertaken at an early stage in living donor kidney transplant work-up to avoid unnecessary and invasive clinical investigation. 2. Antibody screening is especially important when potential living donor transplant recipients undergo reduction or withdrawal of immunosuppression. How these guidelines are different from the guidelines you follow at your workplace?
In ourpractice we do not routinely screen for :
· HTLV 1/2 Ab
· Treponema pallidum Ab
· EBV IgG
· Toxoplasma gondii IgG The split kidney function is not considered in the workup of KT as potential donor with questionable kidney size or function will be excluded from donation list. The split kidney function can be performed in the general nephrology practice to help diagnosing and treating patients in regards to possible surgical intervention.
Rihab Elidrisi
2 years ago
This is comprehensive guidance for kidney donation.This include full assessment for the donor for medical, surgical and immunological .
Also it include Quality of evidence and reads recommendation as for KDIGO guidelines.
We need to conduct full donor assessment in MDT along with full investigation better to avoid the invasive procedure until final step-in parallel with the recipient.
Donor assessment should start early better preemptive when the recipient expected to begin RRT. Most center go for ABO and HLA compatibility .
Kidney function assessment by eGFR and mGFR equation ,the consent should include possibility of small risk ESRD in the future .
Young donor <18 years can be in rare and exceptional situation ,as no valid consent and autonomy.
Older donor is accepted provided they are fully assessed for pre operative risk .
Obesity: BMI 25to 30kg/m2 can donate .
BMI 30 to 35 kg/m2counselled about the risk of kidney disease ,CVD,respectively.
HTN; possible donation case of no end organ damage and on 1 or 2 anti HTN but he will need regular BP post donation as there is risk of 7% of HTN post donation.Lifestyle modification to reduce the risk of CVD post donation.
Diabetes: if high fasting of high risk for diabetes need to do OGTT. he can proceed with donation provided he is not obese,HTN,or hyperlipedeamic.
CVS;LOW RISK NO NEED for stress test while high risk need stress testing and Cardiology assessment .
Spot urine albumin/creatinine ration:
ACR>30mg/mmol or PCR>50mg/mmol absolute contraindication for donation.
Persistent hematuria in two occasion urine samples will need for further urological assessment including cystoscopy if he is above 40 years .if no clear cause ,the kidney biopsy is recommended.
Kidney ston: unilateral and uncomplicated in the absence of metabolic abnormality not prevent donation. Split eGFR May be need it
Anemia: should be investigated thoroughly .
Genetice and family history of kidney disease need. full assessment before donation
Active malignancy is absolute contraindication.
The donor should have detailed peri and post operative periods ,and he needs to be under regular longterm follow up
Mohammad Alshaikh
2 years ago
Please summarise these guidelines in your own words:
===============================================
The evaluation of potential living donors is systemic and multi resources approach for the sake of their general health and safety, and for better out come for the recipient.
ABO Blood Grouping and Crossmatching Test
ABO blood grouping is the first to be done to identify people can donate to specific recipient, and to proceed for evaluation of donor and recipient as well.
After getting the compatible ABO group, Human leucocyte antigen (HLA) transplant offers the best opportunity for success.
In cadaveric and paired exchange donation, these tests can afford better allocation of the kidney to the specific donors.
Medical Assessment:
Medical history including drug history , blood transfusion history and infectious history.
special concern to urological and renal history , hematuria , proteinurea incontinance, renal stones… etc.
Cardiac history, exercise tolerence, LL edema, PNDS, hypertension, orthopnea… etc.
Family history of renal disease , DM, renal stones.. etc.
History of hemoglobinopathies , sickle thalassemia, spherocytosis .. etc.
Endocrine evaluation, thyroid, calcium-phosphate metabolism. obesity and its complications.
GI- history of PUD, GI bleeding, change in bowel habit, yelllowish discoloration of sclera, alcoholic history… etc.
Malignancy- special concern to this history and the course of this history should be taken, and the cure status.
Rheumatological, vasculitis history should be documented, as well any musculoskeletal history.
Chronic infections, TB , HIV, Hepatitis B and C (course and treatmentof the disease and discussing each case with GI specialist regarding pre and post donation course and managment).
Travel history.
Previous anesthesia events.
Vaccination history.
History for illegal relationship and the risk of sexually transmitted diseases, if there is history of these diseases what was the course.
Points of Particular Importance when Undertaking Clinical Examination of a Potential Kidney Donor
Blood pressure, Pulses.
Hight and weight , BMI.
Head and neck exam including lymphnode exam.
Cardio-respiratory exam.
Abdominal exam
Musculoskeletal exam.
Examination / history of regular self-examination of the breasts.
Mental health evaluation and assessment.
Routine Screening Investigations for the Potential Donor
Urine:
Dipstick for protein, blood and glucose, Microscopy, culture and sensitivity (twice at least)
Evaluation for protein excretion (protein and albumin/creatinine ratio spot urine or by 24 hours urine protein excretion), If ACR >30 mg/mmol, PCR >50 mg/mmol, or protein excretion >500 mg/day the donor should be excluded form donation.
If ACR 3-30mg/mmol, PCR 15-50 mg/mmol or 24-hour urine protein 150-500 mg/day, the donor should be informed that there may be a risk of increased albuminuria after donation.
Evaluation of hematuria:(should be repeated twice) by urine dipstick (B1), if present, urine C/S & renal imaging to exclude infection, stone and cancer. (A1)
Bladder pathology should be excluded by cystoscopy if age >40. (B1)
Kidney biopsy considered if +ve dipstick and no cause is found. (B1)
Glomerular disease other than TBM disease is a contraindication for donation. (B1)
FH of haematuria or X-linked Alport syndrome, biopsy (B1) & genetic consultation recommended. (B2).
24-hr urine for creatinine clearance.
Blood:
CBC , coagulation profile( PT,APTT,INR), in some cases after taking the history can do work up for thrombophilia, blood film .. etc
Kidney function test and serum electrolytes:
Creatinine serum, eGFR, and creatinine clearance, Na, K, Ca, Po4, uric acid and magnesium.
Liver function test:
ALT,AST, Alkaline phosphatase, albumin…etc
Fasting glucose and lipid profile and HbA1C Thyroid function test, and pregnancy test if needed.
Virology and infection screen
Hepatitis B and C, HIV, Cytomegalovirus, Epstein-Barr virus, Toxoplasma, Syphilis
Varicella zoster virus (if recipient seronegative)…etc
Cardiorespiratory system
Chest X-ray
ECG
ECHO (where indicated
Cardiovascular stress test (if indicated)
Assessment of Donor Renal Function
Estimate glomerular filtration rate (eGFR) using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI).
The safe eGFR at which the patient can donate his kidney is ≥ 80 mL/min/1.73m2 for donors ≥ 30 years and ≥ 90 mL/min/1.73 m2 for those <30 years old.
Splet function evaluation help to assess the function of each kidney for the purpose of donation of the lower functioning kidney , it can be best done using 99mTcDMSA scanning which is indicated if there is >10% variation in kidney size or abnormal renal anatomy detected by CT scan .
Donor Age
Old age alone is not an absolute contraindication to donation, but they usually need a thorough medical evaluation to ensure they are suitable. (A1)
Both donor and recipient must be aware that older donor may be at greater risk of peri-operative complications and the graft survival may be less, particularly evident with donors >60 years of age. (B1).
DONOR OBESITY
Healthy overweight (BMI 25-30 kg/m2) accepted as donors. (B1)
Moderate obesity (BMI 30-35 kg/m2) carefully evaluated for CV, respiratory & kidney disease. (C2), should be counseled for higher perioperative risk. (B1), and informed about the risk of kidney disease, advise to lose weight before and after donation. (B1)
Donation prohibited in morbidly obese (BMI >35 kg/m2). (C1)
Hypertension in the donor
Blood pressure must be checked on a minimum of 2 occasions, ABPM or home monitoring if any high reading BP or the donor is on antihypertension. (C2)
BP<140/90 mmHg is accepted for donation. (C1)
Donors must be aware of risk of donation-related HTN. Annual BP measurment is a must, (C1)
Donors with mild-moderate HTN ( <140/90 mmHg &/or 135/85 mmHg with ABPM or home monitoring) on <3 anti-HTN drugs & no end organ damage are accepted. (C1)-Donors with HTN excluded if: (C1)
BP is not <140/90 mmHg on 1 or 2 drugs
End organ damage (retinopathy, LVH , proteinuria, previous CVD)
High risk of future CVD or lifetime incidence of ESRD
Donors encouraged to reduce risk of HTN & its complications pre-& pos-donation by lifestyle measures. (C1)
Donors with pre-or pos-donation HTN are managed according to BSH guidelines. (B1)
DIABETES MELLITUS
FBS (<6.1-6.9 mmol/l) A fasting glucose of >7.0 mmol/L is diabetes, between 6.1 and 6.9 mmol/L is an impaired fasting glucose (IFG).
IFG is an indication for a standard 2-hour oral glucose tolerance test (OGTT).
OGTT(A 2-hour glucose value of equal to or greater than 11.1 mmol/L indicates diabetes, A 2-hour value between 7.8 and 11.1 mmol/L indicates impaired glucose tolerance (IGT)
HbA1C (less than 6%)
Urine albumin excretion
Family history if present thaey are at high risk to develop DM.
unless end organ damage or CV risk factors or well managed, can be accepted for donation after good assessment. NEPHROLITHIASIS
Kidney stone is not a contraindication to donation if no significant metabolic abnormality. Long-term follow up needed. (C2)
HAEMATOLOGICAL DISEASE
diagnosing and treating anemia in the donor before donation is recommended. (A1)
FAMILIAL RENAL DISEASE
Family history of renal disease checked in all recipients, to help in the diagnosis for the recipient and show inheritance mode & identify at risk relatives. (A1)
Genetic testing is done for donor when recipient kidney disease is an inherited. (A1)
Clinical and laboratory genetics required in special setting(ie ADPKD). (B1)
DONOR MALIGNANCY
Exclude occult cancer before donation, particularly if age >50. (B1)
Active cancer is contraindication to donate; successfully treated low-grade disease may donate after careful evaluation and discussion. (B1)
Each case should be referred to specialists (ie hematologist , urologist…etc (B2)
How these guidelines are different from the guidelines you follow at your workplace?These guidelines are the same we use in our service, but no psychatric and social worker involved in our service which i think is important.
Last edited 2 years ago by Mohammad Alshaikh
Mahmoud Wadi
2 years ago
I. Guidelines for Living Donor Kidney Transplantation
Please summarise these guidelines in your own words
– The evaluation of potential living donors is resource intensive and a proportion of those who volunteer as donors will not be suitable to proceed for a variety of clinical and non-clinical reasons and help to maximise benefit, minimise risk and manage expectations for donors, recipients
and their families.
– The recipient’s suitability for transplantation ensured ahead of donor assessment.
– To avoid unnecessary delay, non-invasive assessment of the donor is done while recipient is undergoing additional assessment. (Not graded).
– Minimize any inconvenience & barriers in the donor assessment. (Not graded).
– Donor assessment must be focused, logical and appropriate.
– Unsuitable donors identified at an stage. (Not graded)
– Donors found unsuitable given support & follow-up.( Not graded).
– An agreed donor assessment protocol tailored to the needs of the individual & available resources.( Not graded)
– In pre-emptive transplantation, secure enough time for more than one donor to be assessed if needed .(B2)
– ABO Blood Grouping and Crossmatching Test
– ABO blood grouping is an important early screening test as it identifies if a (directed) donor is blood group compatible or incompatible with his/her intended recipient at an early stage.
– A compatible ABO blood group and human leucocyte antigen (HLA) transplant offers the best opportunity for success. (A1).
– Alternatively, in non-directed donation, it provides information that will be used to allocate the kidney to a suitable recipient.
– ABO blood group testing may be undertaken by the GP, nephrologist, specialist nurse, or at a transplant assessment clinic.
– Medical Assessment:
Past and present medical history
Haematuria/proteinuria/urinary tract infection-
-Difficulty in passing urine, including urgency, frequency, dysuria
-History of peripheral oedema
-Gout
Nephrolithiasis-
-Hypertension
-Diabetes mellitus, including family history
-Ischaemic heart disease/peripheral vascular disease/other atherosclerosis
Cardiovascular risk factors-
Thromboembolic disease-
-Sickle cell and other haemoglobinopathies
-Weight change
-Change in bowel habit
-Previous jaundice
-Previous or current malignancy
Systemic disease which may involve the kidney-
-Chronic infection such as tuberculosis
Family history of a renal condition that may affect the donor-
Smoking-
-Current or prior alcohol or drug dependence
Mental health history-
Obstetric history-
-Residence abroad
Previous medical assessment e.g. for life insurance-
Previous anaesthetic problem-
-History of back or neck pain and trauma
-Results of national screening programme tests e.g. cervical smear, mammography,
-colorectal screening. History with respect to Transmissible Infection Previous illnesses
Jaundice or hepatitis.-
Malaria.
Previous blood transfusion.-
Tuberculosis / atypical mycobacterium.-
Family history of tuberculosis-
-Family history of Creutzfeldt-Jakob disease, previous treatment with natural growth hormone, or undiagnosed degenerative neurological disorder.
-Specific geographical risk factors: e.g. fungi and parasites, tuberculosis, hepatitis, malaria, worms.
-Increased risk of HIV, HTLV1 and HTLV2, Hepatitis B and C infection.
Haemophiliac or sexual partner of haemophiliac-
-High risk sexual behaviour
-History of infectious hepatitis or syphilis
History of intravenous drug use-
-Tattoo or skin piercing within last 6 months
Sexual partner of an individual with positive serology-
Sexual partner of drug addict.
Points of Particular Importance when Undertaking Clinical Examination of a Potential Kidney Donor
-Potential Kidney Donor
Abdominal fat distribution-
Blood pressure-
-Body mass index
Dipstick urinalysis-
-Evidence of self-harm
Examination for abdominal masses or herniae-
Examination for scars or previous surgery-
-Examination for lymphadenopathy
-Examination / history of regular self-examination of the breasts.
-Examination / history of regular self-examination of the testes
Examination of the cardiovascular and respiratory systems-
Mental health- Routine Screening Investigations for the Potential Donor Urine
Dipstick for protein, blood and glucose (at least twice)-
Microscopy, culture and sensitivity (at least twice)-
Measurement of protein excretion rate (ACR or PCR)-
Blood
Haemoglobin and blood count-
-Coagulation screen (PT and APTT)
Thrombophilia screen (where indicated)–
Sickle cell trait (where indicated)-
-Haemoglobinopathy screen (where indicated)
G6PD deficiency (where indicated)-
Creatinine, urea and electrolytes
Isotopic or other reference test for measurement of GFR-
Liver function tests.
-Bone profile (calcium, phosphate, albumin and alkaline phosphatase Urate.
Fasting plasma glucose
Glucose tolerance test (if family history of diabetes or fasting plasma glucose >5.6 mmol/L)
-Fasting lipid screen (if indicated )
Thyroid function tests (if strong family history)-
Pregnancy test (if indicated)- Virology and infection screen
Hepatitis B and C
HIV
HTLV1 and 2 (if appropriate)
Cytomegalovirus
Epstein-Barr virus
Toxoplasma
Syphilis
Varicella zoster virus (where recipient seronegative)
HHV8 (where indicated)
Malaria (where indicated)
Trypanosoma cruzi (where indicated)
Schistosomiasis (where indicated-) Cardiorespiratory system
Chest X-ray
ECG
ECHO (where indicated
Cardiovascular stress test (as routine or where indicated) Assessment of Donor Renal Function The most commonly performed by an estimate
of glomerular filtration rate (eGFRcr) using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI). -Safe threshold level for kidney donation (the least GFR at which the patient can safely donate his kidney if there is no other contraindications) is ≥ 80 mL/min for donors ≥ 30 years and ≥ 90 mL/min/1.73 m2 for those <30 years old . -Split kidney function help to assess the function of each kidney for the purpose of donation of the lower functioning kidney , it can be best done using 99mTcDMSA scanning which is indicated if there is >10% variation in kidney size or abnormal renal anatomy detected by CT scan . Donor Age
· Old age alone is not an absolute contraindication to donation but the
medical work-up of older donors must be particularly rigorous to
ensure they are suitable. (A1)
· Both donor and recipient must be made aware that the older donor may
be at greater risk of peri-operative complications and that the function
and possibly the long-term survival of the graft may be compromised.
This is particularly evident with donors >60 years of age. (B1).
– Donors above 60 years of age need careful consideration with respect to the increased risk of peri-operative complications, existing comorbidities and residual function post-donation, and also the long-term transplant outcome in the recipient associated with reduced donor GFR and potential donor vasculopathy.
– Pre-donation cardio-respiratory function should be carefully assessed in older donors.
– DONOR OBESITY
– Healthy overweight (BMI 25-30 kg/m2) accepted as donors. (B1)
– Moderate obesity (BMI 30-35 kg/m2) carefully evaluated for CV, respiratory & kidney disease. (C2)
– Moderately obese donors counseled for higher perioperative risk. (B1)
– Moderately obese informed about the risk of kidney disease & to lose weight before & after donation. (B1)
-Donation discouraged in the very obese (BMI >35 kg/m2). (C1)
Hypertension in the donor
– Blood pressure must be checked on a minimum of 2 occasions. ABPM or home monitoring if BP is high, high normal or variable, or the donor is on antihypertension. (C2)
– BP<140/90 mmHg is accepted for donation. (C1)
– Donors must be aware of risk of donation-related HTN. Annual BP is a must, (C1)
– Donors with mild-moderate HTN ( <140/90 mmHg &/or 135/85 mmHg with ABPM or home monitoring) on <3 anti-HTN drugs & no end organ damage are accepted. (C1)
-Donors with HTN excluded if: (C1)
– BP is not <140/90 mmHg on 1 or 2 drugs
– End organ damage (retinopathy, LVH , proteinuria, previous CVD)
– High risk of future CVD or lifetime incidence of ESRD
– Donors encouraged to reduce risk of HTN & its complications pre-& pos-donation by lifestyle measures. (C1)
– Donors with pre-or pos-donation HTN are managed according to BSH guidelines. (B1) DIABETES MELLITUS
FBS(between 6.1-6.9 mmol/l) A fasting venous plasma glucose of >7.0 mmol/L indicates diabetes.
2- Fasting plasma glucose values of between 6.1 and 6.9 mmol/L indicate
impaired fasting glucose (IFG).
3- IFG is an indication for a standard 2-hour oral glucose tolerance test (OGTT).
4- OGTT(A 2-hour glucose value of equal to or greater than 11.1 mmol/L indicates diabetes .
5- A 2-hour value between 7.8 and 11.1 mmol/L indicates impaired glucose tolerance (IGT)
6- HbA1C (less than 6%)
7- Urine albumin excretion
8- Family history
9- BMI <30 (control wieght).
10- Smoking
11- If family history for DM with +GTT (high risk develop DM)
12- If no target organ damage & other CV risk factors are well managed, can be accepted for donation after good assessment of the lifetime risk of CV & progressive renal disease in the presence of a single kidney. (Not graded). CARDIOVASCULAR EVALUATION
– For donors at low cardiac risk, no evidence for routine use of stress testing. (C2)
– If H/O CVD, an exercise capacity of <4 METS or CVD risk factors, further pre-donation evaluation. (C2)
– Stress testing recommended in higher risk potential donors. (C2)
– Donors with higher CV & peri-operative risk evaluated by a MDT. (D2) proteinuria
All potential donors should have screening for proteinuria using urine ACR or PCR, and if abnormal the result may be confirmed using 24 hours urinary protein
If ACR >30 mg/mmol, PCR >50 mg/mmol, or protein excretion >500 mg/day the donor should be excluded form donation
If ACR 3-30mg/mmol, PCR 15-50 mg/mmol or 24-hour urine protein 150-500 mg/day, the donor should be informed that there may be a risk of increased albuminuria after donation
All potential donors should have screening for hematuria using urine analysis done in 2 separate occasions , if 2 positive test it is considered a case of positive non visible hematuria (PNVH). NVH
-Urine dipstick (on 2 or more occasions) done in all donors. (B1)
– PNVH is present if 2 or more dipstick tests are positive. (B1)
– If PNVH present, urine C/S & renal imaging to exclude infection, stone & cancer. (A1)
– Bladder pathology excluded by cystoscopy if age >40. (B1)
– Kidney biopsy if +ve dipstick & no cause is found. (B1)
Glomerular disease other than TBM disease is a contraindication for donation. (B1)
– If PANVH & FH of haematuria or X-linked Alport syndrome, biopsy (B1) & genetic consultation recommended. (B2) pyuria
Prospective donors found to have pyuria can only be considered for donation if it can be demonstrated that the pyuria is due to a reversible cause, such as an uncomplicated urinary tract infection. (C). INFECTION IN THE PROSPECTIVE DONORS
– Screening to identify risks for the donor & recipient (risks of transmission). (B1)
– Active HBV & HCV infection are contraindications to donation. (B1)
– HIV or HTLV infection is an absolute contraindication to donation. (B1)
– HBV, HCV & HIV infection rechecked within 1 month donation. (Not graded)
– Dietary advice to avoid HEV infection, & screening HEV viraemia by NAT within 1 month of donation. (Not graded)
– CMV tested for donor & recipient before transplantation. If donor +ve & recipient -ve, must be counselled about the risk of post-transplant CMV disease. (B1)
– EBV done for donor & recipient. If donor +ve & recipient -ve, must be counselled about the risk of developing PTLD. (B1)
-Travel history (acquired endemic infections) & appropriate microbiological tests if indicated. (Not graded) NEPHROLITHIASIS
– Kidney stone is not a contraindication to donation if no significant metabolic abnormality. Long-term follow up needed. (C2)
– Metabolic abnormalities detected discussed with a renal stone disease expert. (C2)
– Stone-bearing kidney is given for donation (the sound one left for the donor). (C2)
HAEMATOLOGICAL DISEASE
-Investigate & treat anemia in the donor before donation. (A1)
– A haemoglobinopathy screen in non-Northern European or indicated by FBC. (A1)
– If donor has haemoglobinopathies, donation considered with caution. (B1)
– For conditions not covered here, a hematologist consulted (Not graded)
FAMILIAL RENAL DISEASE
-Family history of renal disease checked in all recipients, to help in the diagnosis for the recipient and show inheritance mode & identify at risk relatives. (A1)
– Genetic and other appropriate testing are done for donor if the recipient kidney failure is an inherited disease. (A1)
– Clinical and laboratory genetics involved early to assess risk to family members & the use of appropriate genetic testing. (B1)
DONOR MALIGNANCY
– Exclude occult cancer before donation, particularly if age >50. (B1)
– Active cancer contraindicate donation; successfully treated low-grade disease may donate after careful evaluation & discussion. (B1)
– Incidental renal mass lesion referred to urology specialist. (A1)
– Imaging distinguish benign lesions (e.g. AML) or malignancy (e.g,RCC). Reviewed by a specialist uroradiologist. (C1)
– Bilateral AML and AML >4 cm preclude donation.
– Unilateral solitary AML <4 is not a contraindication.
– AML <1 cm may be accepted for donation.
– Kidneys with a single AML 1 to 4 cm can be donated depending on its position. (C1)
– Donors with an incidental small (<4 cm) appearing on imaging as a RCC must be seen & appropriately treated by a urologist. (D2)
SURGERY: TECHNICAL ASPECTS, DONOR RISK & PERI-OPERATIVE CARE
-Split function may be needed; the kidney with poorer function for donation(irrespective of vascular anatomy). (C2)
– Detailed imaging (CTA,MRA) of vascular anatomy of donor kidneys may be needed (B1)
= Structural abnormalities & multiple renal arteries are not absolute contraindications to donation. MDT evaluation. Is needed. (B2)
-Thrombo prophylaxis for all donors. Intraoperative mechanical compression, post-operative compression stockings, & LMW heparin. (A2)
– Donor surgery done or supervised by a surgeon with a good training in the technique. (C1)
– Pre-operative hydration improves CV stability during laparoscopic nephrectomy. (B2)
– Hartmann’s solution preferred to 0.9% Saline in Pre- & peri-operative fluid replacement. (B2)
– Laparoscopic nephrectomy is the preferred technique (quicker recovery, shorter hospital stay & less pain). Mini-incision surgery is preferable to standard open surgery. (B1)
– Clips not to be used to secure the renal artery during donor nephrectomy. (C2)
– “Enhanced recovery after surgery” (ERAS) programmes may benefit patients undergoing donor nephrectomy.(D2).
How these guidelines are different from the guidelines you follow at your workplace?
These guidelines served us in a lot of tips and advice
In our center, we do not do a split kidney function and HLA study.
In most cases, we do all the analyzes and laboratory tests regarding the preparation of the donor well, his psychological and moral preparation, and a full explanation of the details of the process before and after kidney donation and how to follow up in the clinic Kidney diseases and to assess his health condition after donation. with the kidneys.
Nahla Allam
2 years ago
Guidelines for Living Donor Kidney Transplantation
Please summarise these guidelines in your own words
How these guidelines are different from the guidelines you follow at your workplace?
Summary :
Kidney transplantation from a living donor, when available, is the treatment of choice for end stage kidney disease
Scope of the Guidelines:
include the ethical and medico-legal aspects of donor selection, medical and pre-operative donor evaluation, identification of high risk donors, the management of complications, and expected outcome.
DONOR EVALUATION:
The primary goal of the donor evaluation process is to ensure the suitability of the
donor and to minimise the risk of donation. This involves identifying contraindications to donation and potential clinical (physical and psychosocial) risks comprehensive evaluation for , potential donors must be assessed according to an evidence-based protocol includes multi-disciplinary team t and discussion. Investigations in a logical sequence to protected donor from unnecessary, particularly invasive, procedures.
the confidentiality of the donor achieved by ensuring that separate physicians and/or clinical teams assess the donor and recipient before donation and transplantation
ABO BLOOD GROUPING AND CROSSMATCH TESTING:
A compatible ABO blood group and human leucocyte antigen (HLA) transplant offers the best opportunity for success ABO blood grouping is an important early screening test as it identifies if a (directed) donor is blood group compatible or incompatible with his/her intended recipient at an early stage
MEDICAL ASSESSMENT:
History with respect to Transmissible Infection
Previous illnesses
Jaundice or hepatitis
Malaria
Previous blood transfusion
Tuberculosis / atypical mycobacterium
Family history of tuberculosis
Family history of Creutzfeldt-Jakob disease, previous treatment with natural growth
hormone, or undiagnosed degenerative neurological disorder
Specific geographical risk factors: e.g. fungi and parasites, tuberculosis, hepatitis,
malaria, worms
Increased risk of HIV, HTLV1 and HTLV2, Hepatitis B and C infection
Haemophiliac or sexual partner of haemophiliac
High risk sexual behaviour
History of infectious hepatitis or syphilis
History of intravenous drug use
Tattoo or skin piercing within last 6 months
Sexual partner of an individual with positive serology
Sexual partner of drug addict
Points of Particular Importance when Undertaking Clinical Examination of a Potential Kidney Donor
Abdominal fat distribution
Blood pressure
Body mass index
Dipstick urinalysis
Evidence of self-harm
Examination for abdominal masses or herniae
Examination for scars or previous surgery
Examination for lymphadenopathy
Examination / history of regular self-examination of the breasts
Examination / history of regular self-examination of the testes
Examination of he cardiovascular and respiratory systems
Mental health.
Routine Screening Investigations for the Potential Donor
Urine
Dipstick for protein, blood and glucose (at least twice)
Microscopy, culture and sensitivity (at least twice)
Measurement of protein excretion rate (ACR or PCR)
Blood
Haemoglobin and blood count
Coagulation screen (PT and APTT)
Thrombophilia screen (where indicated)
Sickle cell trait (where indicated)
Haemoglobinopathy screen (where indicated)
G6PD deficiency (where indicated)
Creatinine, urea and electrolytes
Isotopic or other reference test for measurement
Liver function tests
Bone profile (calcium, phosphate, albumin and alkaline phosphatase)
Urate
Fasting plasma glucose
Glucose tolerance test (if family history of diabetes or fasting plasma glucose
>5.6 mmol/L)
Fasting lipid screen (if indicated)
Thyroid function tests (if strong family history)
Pregnancy test (if indicated)
Virology and infection screen :
Hepatitis B and C
HIV
HTLV1 and 2 (if appropriate)
Cytomegalovirus
Epstein-Barr virus
Toxoplasma
Syphilis
Varicella
HHV8 (where indicated)
Malaria (where indicated)
Trypanosoma cruzi (where indicated)
Schistosomiasis (where indicated)
Cardiorespiratory system :
Chest X-ray
ECG
ECHO (where indicated)
Cardiovascular stress test (as routine or where indicated
ASSESSMENT OF RENAL FUNCTION:
Measurement of Renal Function
Ø Initial evaluation of donor candidates should be using estimated glomerular filtration rate (eGFR), expressed as mL/min/1.73m2 computed from a creatinine assay standardised to the International Reference Standard
DONOR AGE
Recommendations
Ø Old age alone is not an absolute contraindication to donation but the medical work-up of older donors must be particularly rigorous to ensure they are suitable
Ø Most programmes do not consider donors aged <18 years and >70 year groups
DONOR OBESITY:
Ø patients (BMI 25-30 kg/m2) proceed to kidney donation
HYPERTENSION IN THE DONOR:
blood pressure <140/90 mmHg is usually acceptable for donation. potential donors with hypertension are excluded from donation if:
Ø Blood pressure is not controlled to <140/90 mmHg on one or two antihypertensive drugs
Ø Evidence of end organ damage (retinopathy, left ventricular hypertrophy, proteinuria, previous cardiovascular disease)
Ø Unacceptable risk of future cardiovascular risk or lifetime incidence of ESRD
Management of Hypertension following Donor Nephrectomy
Hypertension will develop in at least 30% of patients following unilateral Nephrectomy
managed according to the standard guidelines of the British Hypertension Society
DIABETES MELLITUS
Recommendations
Ø All potential living kidney donors must have a fasting plasma glucose
level checked
Ø A fasting plasma glucose concentration between 6.1-6.9 mmol/L is indicative of an impaired fasting glucose impaired OGTT risks of developing diabetes after donation must be carefully considereddiabetic nephropathy in a kidney donor is not common during the follow-up periods reported in the published literature
CARDIOVASCULAR EVALUATION:
There is no evidence to support cardiac stress testing or invasive testing in potential
donors at low cardiac risk.and exclusion of individuals at higher risk.
PROTEINURIA:
A urine albumin/creatinine ratio (ACR) performed on a spot urine sample is the recommended screening test, although urine protein/creatinine ratio (PCR) ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day or protein excretion >500 mg/day represent absolute contraindications to donation
HAEMATURIA:
Non-visible haematuria is a common finding in the general population, may indicate either urological or renal parenchymal disease, and must be carefully evaluated in prospective living kidney donors donors with persistent asymptomatic non-visible haematuria (PANVH) and a family history of haematuria or X-linked Alport
syndrome, a renal biopsy , and referral to a clinical geneticist are recommended
PYURIA:
The cause of the pyuria must be established before a potential donor proceeds for further assessment
INFECTION IN THE PROSPECTIVE DONOR:
Screening for infection in the prospective donor is essential to identify potential risks for the donor from previous or current infection and to assess the risks of transmission of infection to the recipient.
NEPHROLITHIASIS:
In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as potential kidney donors. Full counselling of donor and recipient is required along with access to appropriate long-term donor follow up.
In appropriate donors with unilateral kidney stone(s) the stone-bearing kidney can be considered for donation (if vascular anatomy and split kidney function permit) in order to leave the donor with a stone-free kidney after donation
HAEMATOLOGICAL DISEASE
Donor anaemia needs to be investigated and treated before donation.
FAMILIAL RENAL DISEASE:
All potential transplant recipients must have a detailed family history recorded and confirmation where possible of the diagnosis in other family members with known kidney disease. This may aid diagnosis for the recipient, clarify any mode of inheritance and identify at risk relatives.
DONOR MALIGNANCY
Careful history taking, clinical examination and investigation of potential donors are essential to exclude occult malignancy before kidney donation, particularly in older (age >50 years) donors
SURGERY:
TECHNICAL ASPECTS, DONOR RISK AND PERI-OPERATIVE CARE:
Work-up for living kidney donation may include direct or indicative evaluation of split renal function with the kidney with poorer function selected for nephrectomy irrespective of vascular anatomy
HISTOCOMPATIBILITY TESTING FOR LIVING DONOR KIDNEY
TRANSPLANTATION:
Initial assessment of donor and recipient histocompatibility status must be undertaken at an early stage in living donor kidney transplant work-up to avoid unnecessary and invasive clinical investigation
EXPANDING THE DONOR POOL:
from living donors to be shared across the UK to maximise the number of transplant
opportunities and include:
Paired/pooled donation
Altruistic donor chains
DONOR FOLLOW-UP AND LONG-TERM OUTCOME:
Counselling and consent of potential living kidney donors must include acknowledgement that the baseline risk of ESRD is increased by donation
Annual review to include assessment of:
General health & lifestyle
Wound +/- complications
Medication
Renal profile
Full blood count
Dipstick urinalysis +/- mid-stream urine +/- albumin/creatinine ratio
Blood pressure; referral to GP for 24 hr ABPM / treatment if indicated
Weight & BMI
LIVING DONOR KIDNEY TRANSPLANTATION IN CHILDREN:
Ø Pre-emptive living related renal transplantation is the gold standard therapy for children with end-stage renal disease.
Ø The aim should be for children to receive a renal transplant from a blood group compatible well-matched donor, although ABO and/or HLA incompatible renal transplantation is feasible in children
Ø children who are ≥10 kg in weight are suitable to receive a kidney from an adult living donor
children with Stage 4 and 5 chronic kidney disease (CKD) should be assessed by a multi-disciplinary team, including a paediatric nephrologist, transplant surgeon, anaesthetist and urologist (where appropriate) prior to transplantation.
Donor Selection:
Any suitable adult may be considered as a potential donor,
How these guidelines are different from the guidelines you follow at your workplace: There are some different : We did not do split kidney function for donor Regarding screening against infection : We screen against : HIV,HBV.HCV,CMV,TB,RECENTLEY PCR FOR COVID 19.
Mohamed Mohamed
2 years ago
I. Guidelines for Living Donor Kidney Transplantation Please summarise these guidelines in your own words Legal:
Legislative acts regulate transplantation centers (& activities) (not graded). ——————————— ETHICS
Professionals must acknowledge moral & issues. (Not graded)
Donors benefit & safety is over the needs of the potential recipient. (Not graded)
Independent clinicians responsible for the donor & the recipient. (Not graded) ——————————— Supporting & informing the potential donor
Donor given relevant information about donation (benefits & risks). (B1)
Independent assessors of the donor & recipient.(Not graded)
Confidentiality discussed at the start (information of recipient & donor). Relevant clinical information shared across the team to optimize care (B1)
If the recipient is not willing to disclose information, the team must decide the way to provide donation risks & benefits without specific medical details. (Notgraded)
Separate teams for donor & recipient is best practice, but all co-ordinate the process without preaching the independence of either donor or recipient.
A donor advocate should assist donor to make autonomous decision. (B1)
Support for donor, recipient & family( specialist psychiatric/psychological services)(B1) ——————————— DONOR EVALUATION:
The recipient’s suitability for transplantation ensured ahead of donor assessment. To avoid unnecessary delay, non-invasive assessment of the donor is done while recipient is undergoing additional assessment. (Not graded)
Minimize any inconvenience & barriers in the donor assessment. (Not graded)
Donor assessment must be focused, logical & appropriate.Unsuitable donors identified at an stage. (Not graded)
Donors found unsuitable given support & follow-up.( Not graded)
An agreed donor assessment protocol tailored to the needs of the individual & available resources.( Not graded)
In pre-emptive transplantation, secure enough time for more than one donor to be assessed if needed .(B2) ——————————— ABO & XM Testing
ABO & HLA-c transplant offers the best chance for success. (A1)
Alternatives ( PKD & incompatible TX) discussed if ABO-i or HLA-i. (A1) ——————————— ASSESSMENT OF RENAL FUNCTION
eGFR for initial evaluation of the donor. (B1)
GFR then be assessed by mGFR(Cl of 51Cr-EDTA, 125iothalamate or Iohexol). (B1)
Split function (99mTcDMSA) if >10% variation in kidney size or strucural abnormality. (C1) ————————————- GFR Thresholds for Donation
mGFR should predict that post-donation GFR remains within the age & gender -specific normal range within the donor’s lifetime. (B1)
The risk ESRD post-donation is no higher than that of the general population. However, the donor must be informed there is a very small absolute increased lifetime risk of ESRD post-donation. (D2)
Approval of donor with below the advisory GFR level or who have other risk factors for the developing ESRD should be based on the individual predicted lifetime incidence of ESRD. (D2) ——————————— Monitoring of Kidney Donor
Lifelong annual assessment (creatinine, urine protein excretion & BP). (B1) ——————————— DONOR AGE
Old age is not a contraindication, but well assessed to ensure suitability. (A1)
Donor & recipient must be aware of the greater risk of peri-operative complications in older donors & that the function & survival of the graft may be lower (donors >60 years). (B1) ——————————— DONOR OBESITY
Healthy overweight (BMI 25-30 kg/m2) accepted as donors. (B1)
Moderate obesity (BMI 30-35 kg/m2) carefully evaluated for CV, respiratory & kidney disease. (C2)
Moderately obese donors counseled for higher perioperative risk. (B1)
Moderately obese informed about the risk of kidney disease & to lose weight before & after donation. (B1)
Donation discouraged in the very obese (BMI >35 kg/m2). (C1)
——————————— HYPERTENSION IN THE DONOR
BP must be checked on a minimum of 2 occasions. ABPM or home monitoring if BP is high, high normal or variable, or the donor is on ant-hypertension. (C2)
BP<140/90 mmHg is accepted for donation. (C1)
Donors must be aware of risk of donation-related HTN. Annual BP is a must, (C1)
Donors with mild-moderate HTN ( <140/90 mmHg &/or 135/85 mmHg with ABPM or home monitoring) on <3 anti-HTN drugs & no end organ damage are accepted. (C1)
Donors with HTN excluded if: (C1)
o BP is not <140/90 mmHg on 1 or 2 drugs
o End organ damage (retinopathy, LVH , protei-nuria, previous CVD)
o High risk of future CVD or lifetime incidence of ESRD
Donors encouraged to reduce risk of HTN & its complications pre-& pos-donation by lifestyle measures. (C1)
Donors with pre-or pos-donation HTN are managed according to BSH guidelines. (B1)
——————————— DIABETES MELLITUS
A FBG checked in all potential LKD. (B1)
If IFG (6.1-6.9 mmol/L), OGTT should be done. (B1)
OGTT done if high risk of type 1 DM (FH, H/O GD, ethnicity or obesity). (B1)
If IFG &/or IGT on OGTT, risks of diabetes after donation considered. (B1)
Diabetes risk calculator considered in discussion of potential kidney donation. (B2)
Diabetes as potential kidney donors: evaluate risks & benefits. If no target organ damage & other CV risk factors are well managed, can be accepted for donation after good assessment of the lifetime risk of CV & progressive renal disease in the presence of a single kidney. (Not graded)
——————————— CARDIOVASCULAR EVALUATION
For donors at low cardiac risk, no evidence for routine use of stress testing. (C2)
If H/O CVD, an exercise capacity of <4 METS or CVD risk factors, further pre-donation evaluation. (C2)
Stress testing recommended in higher risk potential donors. (C2)
Donors with higher CV & peri-operative risk evaluated by a MDT. (D2)
——————————— PROTEINURIA
Quantification of urine protein excretion should be done in living donors. (B1)
Spot urine ACR is the screening test (UPCR also accepted). (A1)
Donation contraindicated if ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/d or protein excretion >500 mg/day. (C2)
Moderate albuminuria (ACR 3-30 mg/mmol) & protei-nuria (PCR 15-50 mg/mmol or urine protein 150-500 mg/d) are relative contraindication to donation (b/c the risk of CKD & CV morbidity increase progressively in these cases). (C2)
———————————- NVH
Urine dipstick (on 2 or more occasions) done in all donors. (B1)
PNVH is present if 2 or more dipstick tests are positive. (B1)
If PNVH present, urine C/S & renal imaging to exclude infection, stone & cancer. (A1)
Bladder pathology excluded by cystoscopy if age >40. (B1)
Kidney biopsy if +ve dipstick & no cause is found. (B1)
Glomerular disease other than TBM disease is a contraindication for donation. (B1)
If PANVH & FH of haematuria or X-linked Alport syndrome, biopsy (B1) & genetic consultation recommended. (B2)
——————————– PYURIA
If reversible cause (e.g, uncomplicated UTI), not contraindication to donate. (C1)
———————————- INFECTION IN THE PROSPECTIVE DONORS
Screening to identify risks for the donor & recipient (risks of transmission). (B1)
Active HBV & HCV infection are contraindications to donation. (B1)
HIV or HTLV infection is an absolute contraindication to donation. (B1)
HBV, HCV & HIV infection rechecked within 1 month donation. (Not graded)
Dietary advice to avoid HEV infection, & screening HEV viraemia by NAT within 1 month of donation. (Not graded)
CMV tested for donor & recipient before transplantation. If donor +ve & recipient -ve, must be counselled about the risk of post-transplant CMV disease. (B1)
EBV done for donor & recipient. If donor +ve & recipient -ve, must be counselled about the risk of developing PTLD. (B1)
Travel history (acquired endemic infections) & appropriate microbiological tests if indicated. (Not graded)
——————————– NEPHROLITHIASIS
Kidney stone is not a contraindication to donation if no significant metabolic abnormality. Long-term follow up needed. (C2)
Metabolic abnormalities detected discussed with a renal stone disease expert. (C2)
Stone-bearing kidney is given for donation (the sound one left for the donor). (C2)
———————————- HAEMATOLOGICAL DISEASE
Investigate & treat anemia in the donor before donation. (A1)
A haemoglobinopathy screen in non-Northern European or indicated by FBC. (A1)
If donor has haemoglobinopathies, donation considered with caution. (B1)
For conditions not covered here, a haematologist consulted (Not graded)
——————————– FAMILIAL RENAL DISEASE
FH of renal disease checked in all recipients, to help in the diagnosis for the recipient & show inheritance mode & identify at risk relatives. (A1)
Genetic & other appropriate testing are done for donor if the recipient kidney failure is an inherited disease. (A1)
Clinical & laboratory genetics involved early to assess risk to family members & the use of appropriate genetic testing. (B1)
———————————- DONOR MALIGNANCY
Exclude occult cancer before donation, particularly if age >50. (B1)
Active cancer contraindicate donation; successfully treated low-grade disease may donate after careful evaluation & discussion. (B1)
Incidental renal mass lesion referred to urology specialist. (A1)
Imaging distinguish benign lesions (e.g. AML) or malignancy (e.g,RCC). Reviewed by a specialist uroradiologist. (C1)
Bilateral AML & AML >4 cm preclude donation.
Unilateral solitary AML <4 is not a contraindication.
AML <1 cm may be accepted for donation.
Kidneys with a single AML 1 to 4 cm can be donated depending on its position. (C1)
Donors with an incidental small (<4 cm) appearing on imaging as a RCC must be seen & appropriately treated by a urologist. (D2)
——————————– SURGERY: TECHNICAL ASPECTS, DONOR RISK & PERI-OPERATIVE CARE
Split function may be needed; the kidney with poorer function for donation(irrespective of vascular anatomy). (C2)
Detailed imaging (CTA,MRA) of vascular anatomy of donor kidneys may be needed (B1)
Structural abnormalities & multiple renal arteries are not absolute contraindications to donation. MDT evaluation. Is needed. (B2)
Thromboprophylaxis for all donors. Intraoperative mechanical compression,post-operative compression stockings, & LMW heparin. (A2)
Donor surgery done or supervised by a surgeon with a good training in the technique. (C1)
Pre-operative hydration improves CV stability during laparoscopic nephrectomy. (B2)
Hartmann’s solution preferred to 0.9% Saline in Pre- & peri-operative fluid replacement. (B2)
Laparoscopic nephrectomy is the preferred technique (quicker recovery, shorter hospital stay & less pain). Mini-incision surgery is preferable to standard open surgery. (B1)
Clips not to be used to secure the renal artery during donor nephrectomy. (C2)
“Enhanced recovery after surgery” (ERAS) programmes may benefit patients undergoing donor nephrectomy.(D2 ====================== How these guidelines are different from the guidelines you follow at your workplace?
These guidelines do not differ much from the guidelines used in our transplant center; however because of logistic issues, lack of enough resources, and non-availability of some tests (e.g, genetic testing), it is not uncommon for us to exclude many potential donors (who would be otherwise good donors ) from donation.
Sherif Yusuf
2 years ago
Summary
3 prerequisites should be met before transplantation: Consent taken from donor, no reward for donation and acceptance report from independent assessor of the donor and recipient
Donors are either directed to a specific recipient, non-directed, directed altruistic donation (the donor and recipient either know each other but no intimate relation between each other or the donor and recipient never met before) or go into paired donation
Mental health of potential altruistic donors should be assessed by experienced clinician
Safety of the donor is the first priority and should be taken in consideration regardless recipient benefit
Donor should be provided adequate information about the safety and the outcome of donation and should have time to decide
Confidentiality should be ensured
If the donor has contraindications (absolute or relative) or does not meet center specific criteria he/she should be offered a second opinion by other transplant center
Before assessment of the donor (if directed to a specific recipient), transplant recipient should be assessed first for the possibility of transplantation and if fit donors should be evaluate as early as possible in order to have time for more donors if they did not match.
Discussion between donor and recipient is started once GFR of the recipients is below 20 mL/min or if the recipient is expected to have a RRT within 1-1.5 years
Donor evaluation should take around 18 weeks, first 2 weeks (discussion), second 2 weeks (history, examination, investigations including HLA typing and ABO, cross matching), 1 month for time planning, 2 weeks for the feedback of the donor , 6 weeks for final preoperative discussion , 1 week before transplantation repeat final cross match and routine preoperative investigations, operation in week 18
If the donor is fit, he/she should be educated about the risk and risk factors that should be controlled to prevent ESRD, gestational HTN and preeclampsia (in young woman in child bearing period) and the patient should be offered an appropriate follow up plan after donation and if not fit they should be informed as soon as possible
ABO and HLA compatible transplantation provide the best results, if there is ABO or HLA incompatibility the patient should be offered one of the following choices either KPD or desensitization which should be done in experienced center
Albuminuria occur more commonly after donation and there is a slight increase in the risk of ESRD observed in donors. The risk of ESRD increase in current or former smoker, obese, diabetic, African- American and patients with albuminuria or renal impairment
The preferred option for assessment of kidney functions is estimated GFR using serum creatinine (CKD-EPI) this is a primary to exclude donors with evident CKD , this test should be confirmed by measuring creatinine clearance using 24 hours urine
Safe threshold level for kidney donation (the least GFR at which the patient can safely donate his kidney if there is no other contraindications) is ≥ 80 mL/min for donors ≥ 30 years and ≥ 90 mL/min/1.73 m2 for those <30 years old
Split kidney function help to assess the function of each kidney for the purpose of donation of the lower functioning kidney , it can be best done using 99mTcDMSA scanning which is indicated if there is >10% variation in kidney size or abnormal renal anatomy detected by CT
Old age > 60 years is not a contraindication to donation but he/she should be evaluated rigorously and donor and recipient should be informed with the increase in risk of perioperative complications
Obese with BMI 25-30 kg/m2 can proceed to donation safely, those with BMI 30-35 kg/m2 can proceed to donation if they accept the peri-operative and long term risk associated with obesity and are willing to lose weight, patients with BMI >35 kg/m2 should be excluded form donation
Risk factors for the development of HTN after kidney donation includes higher BP before donation, African American and Hispanic ethnity, obesity, Elderly, these patients should be educated about the risk of developing hypertension after donation
Evaluation of BP before kidney donation
Clinic BP which should be done in at least 2 separate visits, using calibrated BP device, proper sized cuff, by trained staff, after resting 5 min, and taking 3 readings at least 1 min apart
Home BP : Clinic BP reading should be confirmed with home BP evaluation
Ambulatory 24 hours BP monitoring is indicated if the clinic BP is ≥ 130/85, variable BP measurements or if the patient is on antihypertensive medications
Guidelines for safe donation (regarding BP)
Donors with clinic BP ≺ 140/90 mm Hg (≺135/85 mmHg if using ABPM or home monitoring) on no antihypertensive medications can proceed safely to kidney donation
Donors with clinic BP ≺ 140/90 mm Hg (≺135/85 mmHg if using ABPM or home monitoring) on 1 or 2 antihypertensive medications can proceed safely to kidney donation provided there is no evidence of end organ damage (LVH, albuminuria, retinopathy)
Donors with clinic BP ≥ 140/90 mm Hg on 2 antihypertensive medications an should be excluded from donation
Donors receiving more than 2 antihypertensive medications or having end organ damage should be excluded from donation
Treatment of hypertension post donation
Non pharmacological therapy including salt restriction, DASH diet, exercise, stress reduction, weight loss, reduce alcohol intake
Pharmacological treatment is given according to according to British Hypertension Society guidelines.
All donors should have fasting BG, OGTT (if there are risk factors such as obesity, positive family history of DM, history of gestational DM, African-American) and HBA1c may be also used to identify the donor as normal, impaired fasting, IGT or diabetic
Potential donors with impaired fasting or IGT can donate after education about the risk of developing DM while having single kidney and after addressing all cardiovascular risk factors (smoking, hyperlipidemia, hypertension)
Potential donors with DM can donate after education about the risk of DM while having single kidney and after addressing all cardiovascular risk factors provided that it is controlled and no target end-organ damage
High cardiovascular risk patients should be evaluated by noninvasive testing either stress echo or cardiac scintigraphy, or less commonly CT angiography and if positive, patient should be referred for cardiology evaluation and possible angiography
Low risk patients can proceed to transplantation after normal resting ECG, ECHO
All potential donors should have screening for proteinuria using urine ACR or PCR, and if abnormal the result may be confirmed using 24 hours urinary protein
If ACR >30 mg/mmol, PCR >50 mg/mmol, or protein excretion >500 mg/day the donor should be excluded form donation
If ACR 3-30mg/mmol, PCR 15-50 mg/mmol or 24-hour urine protein 150-500 mg/day, the donor should be informed that there may be a risk of increased albuminuria after donation
All potential donors should have screening for hematuria using urine analysis done in 2 separate occasions , if 2 positive test it is considered a case of positive non visible hematuria (PNVH).
PNVH should be evaluated by urine culture, imaging, if free, cystoscopy should be done (if donor is above 40 years) and if normal renal biopsy should be done and any form of glomerulonephritis found is a contraindication to transplantation except TBMD
Persistent sterile pyuria is a contraindication for donation, while transient pyuria due to UTI can donate
Donor should be screened for HBV, HCV, HIV and virology should be repeated after 1 month of donation. and Active HBV, HCV infection, presence of HIV or HTLV are considered contraindications to donation
The CMV status of donor should be determined before donation and if the donor is positive, recipient should be informed about the risk of CMV activation and the prophylaxis regimen with possible side effects
The EBV status of donor should be determined before donation and if the donor is positive and the recipient is negative, recipient should be informed about the risk of PTLD post transplantation
Patient with history of renal stones can donate provided it is not recurrent due to metabolic abnormality; in case of unilateral nephrolithiasis It is recommended to donate the kidney containing stone
In anemic patient, the cause of anemia should be known and treated before donation, in case of haemoglobinopathies the decision to donate is depending on the type and its long-term effect
All donors should have a detailed family history of renal disease, especially if the donor and recipient are genetically related
Active malignancy should be excluded before donation, donors with certain types of low grade malignancy can donate after successful treatment, screening for occult malignancy should be done in all donors >50 years
Renal mass should be diagnosed, and usually diagnosis is settled using US, CT with contrast or MRI
The presence of incidental bilateral or unilateral AML >4 cm are considered contraindication to donation, while unilateral AML 1-4 cm can be considered for donation with or without excision , patient with AML <1 cm can donate without excision
Patients with unilateral RCC <4 cm can donate their kidney after complete excision of the mass and reconstruction
Before donation vascular anatomy of the donor kidney should be evaluated using CTA or MRA , the decision to donate kidney with multiple renal arteries or with abnormal, anatomy is discussed in a case by case and is not considered absolute contraindication
Donor should receive adequate hydration (intra and post- operative) using normal saline together with thromboprophylaxis in the form of intraoperative mechanical compression (intra and post –operative) stocking and LMWH
Surgery is better to be done laparoscopically and if open surgery is indicated mini-incision surgery is recommended. Haem-o-lok clips are not recommended to be used for securing the renal artery
Use of enhanced recovery after surgery (ERAS) program is associated with better outcome
No recommendation to remove Rt or Lt kidney in a female in child bearing period for prevention of hydronephrosis
In pregnant female with unilateral kidney it is important to closely monitor BP, creatinine and fetous , and aspirin 75 mg can be given to prevent preeclampsia
The risk of recurrence of original kidney disease should be discussed with the recipient and donor
Primary FSGS (high rate of recurrence especially if recur before)
Atypical HUS and C3 glomerulopathy and DDD (avoid living related transplantation, eculizumab should be available if transplanting these cases)
Type 1 primary hype oxalosis (liver transplantation should be done)
AA amyloidosis (control of primary disease is mandatory before transplantation)
Other recurrent diseases such as DM1, DM2, SLE, vasculitis, IgA nephropathy, membranous nephropathy, and cystinosis although can recure but the condition is usually controlled
Anti-GBM (recurrence is rare)
The best therapy for ESRD in a child is pre-emptive matched living related renal transplantation is the gold standard, children ≥10 kg can receive an adult kidney.
How these guidelines are different from the guidelines you follow at your workplace?
We are dealing only with donors who are directed to a specific recipient
Any donor with any anatomical problem or mass in the kidney is excluded form donation
We do split kidney function to all donors
We do not do HLA /ABO incompatible transplantation
Enhanced recovery after surgery (ERAS) program is not used in our facility
Obese with BMI more than 30 are excluded form donation
That is a superb summary of the approach to living kidney donation. We have done a donor with a BMI of 32 after careful evaluation.
Mohammed Abdallah
2 years ago
These comprehensive guidelines are only for living kidney donor transplantation, adults and pediatrics. They include medical, surgical, immunological, identification of high risk donors with management, and legal and ethical issues. These guidelines based on recommendations and published studies (conference not included). Cut-off date was July 2017. Quality of evidence and strength recommendations as for KDIGO guidelines.
Types of living donation are directed donation (specified donation), paired or pool donation, non-directed altruistic donation and directed altruistic donation
Ethical principles for living kidney donors are altruism, autonomy, beneficence, dignity, non-maleficence, and reciprocity
A child < 18 years rarely candidate for donation (validity of consent and autonomy)
For valid consent, the donor should be informed about benefit and risk of donation including surgical risks. Independent assessment for donor and recipient is advise
Comprehensive assessment for the donor (MDT) includes history, physical examination and investigations. It is better to avoid invasive investigations until the appropriate step, parallel with the recipient
Donor evaluation should start early (when the recipient RRT expected to require RRT within 12-18 months) to allow for more donors if unsuitable (18 weeks for complete evaluation)
ABO and HLA compatibility is required and if there is any incompatibility, other options are available but not in all centers. This should discussed with donor and recipient
For the assessment of kidney function, estimate GFR with CKD-EPI equation and subsequently Cr-EDTA, 125iothalamate or Iohexol. Where there is >10% variation in kidney size or significant renal anatomical abnormality 99mTcDMSA is recommended. Donor should counsel about the small risk of ESRD and Lifelong follow-up postdonation is mandatory
There is no upper limit for accepting donors but older donors needs specific evaluation as per-operative risk is high and graft function may be affected
Guidelines also talk about obesity. Healthy overweight (BMI 25-30 kg/m2) may safely donate. BMI 30-35 kg/m2 should be counselled about the risk of kidney disease, advice to lose weight and carefully assess CVD and respiratory. No data for safety of very obese ((BMI >35 kg/m2)
All donors should be carefully assessed for HTN. Donation may be possible in controlled HTN with no target organ damage. Blood pressure may rise after donation and donors should be aware. Monitor blood pressure regularly after donation and encourage life style modifications to reduce risk of HTN and CVD
For diabetes, if fasting is impaired do OGTT. High risk of type 2 diabetes also candidate for OGTT. If test is impaird, risks of developing diabetes after donation must be carefully assessed. If no evidence of target organ damage and other CV risk (obesity, HTN, hyperlipidemia) are controlled, diabetics may be considered for donation
No need for stress testing or invasive testing in low risk CV disease. For high risk stress testing is recommended (CT calcium scoring may be used) and cardiologist should involve
Spot urine urine albumin/creatinine ratio is the preferred test for proteinuria (urine protein/creatinine ratio may be an alternative). ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day or protein excretion >500 mg/day represent absolute contraindications to donation
Persistent non-visible haematuria (PNVH) which is defined as persistent haematuria in at least two separate urine test, if present urine culture and renal imaging are required to exclude urological diseases (infection, nephrolithiasis and malignancy). Cystoscopy is indicated if no cause especially if >40 years. If no cause despite extensive investigations, kidney biobsy is recommended. Glomerular diseases preclude donation with the exception of TBM. Genetic study if family history of haematuria or x-linked Alport syndrome
Donor may be considered for donation only if pyuria is due to uncomplicated UTI
Screening of infection is paramount. HBV and HCV mostly contraindication of donation. HIV or HTLV absolutely preclude donation. Dietary advice to avoid HEV infection. Other important infections are CMV and EBV. Contact experts in infectious diseases if any concern of potential risk
Small kidney stones on imaging or limited history of stone in the absence of metabolic abnormalities not prevent donation. Unilateral stone may allow donation if and split kidney function and vascular anatomy permit
Anaemia should be identified and treated before donation. Screen for haemoglinpathies. Involve a haematolgist in uncertain cases
If recipient have a family history of kidney disease, detailed history is indicated to know the cause. If recipient kidney failure is due to an inherited diseases, genetic tests are recommended
Active malignancy is absolutely contraindicated. Exclude occult malignancy (>50years). Many low grade tumors allow donation after successful treatment. Refer incidental kidney mass for a urologis
t
To avoid risk of surgery, detailed vascular anatomy, kidney parenchyma andcollecting systems are important (CTA or MRA). Split kidney function in certain cases. Thrombotic prophylaxis and compression stockings are recommended. Donor should be hydrated for surgery. Fluid peri-operatively with lactated ringer (preferred to saline)
Do histocompatibility testing early to avoid unnecessary invasive investigations. If there is incompatibility (ABO/HLA), encourage patients to enter exchange scheme program
Postdonation follow-up for longtime with counseling of small risk of ESRD
The risk of recurrence of some diseases (high in FSGS and MCGN) should be discussed with donor and recipient with the possibility of graft loss
Pre-emptive living related renal transplantation is the preferred therapy in children. Children who are ≥10 kg are suitable to receive a kidney from an adult living donor
KAMAL ELGORASHI
2 years ago
This guideline established by British society of transplantation on 2018, it cover all aspects of transplantation, including both recipients and donors, it cover the following:
Objectives.
Legal framework.
Ethic’s.
Supporting information for potential kidney donors.
Donor evaluation.
Surgery.
Histocompatibility transplant testing.
Expanding donor pool.
Logistic consideration for living kidney donation.
Donor follow-up and long term outcome.
Recipient outcome post transplantation in adults.
Recurrent renal disease.
living donor transplantation in children.
All transplant in UK should be judged by , Human tissue Act 2004, and Human tissue (Scottland) Act 2006.
All transplant centers, for living organ donation , should be under govern of European union of donation directive.
All consent removal of kidney transplant should be under guide by requirement of Human tissue 2004, and mental capacity act 2005 in England and Wales, mental capacity Act in north Ireland 2016,. Ethics:
All health professionals in LDKT, they should have full moral issues, and good ethical experience.
Donor safety must be equally concerned, as recipient benefit.
Independency should be fully authorized between recipient team , and donor team. Supporting and informing the potential donor;
Living donor must be offered good environment for voluntary decision about donation.
Independency evaluation of donor and recipient, must be judged by primary legislation.
Confidentiality must be offered, to both , donor and recipient, shared information must be done with consent .
Separate clinicians team for donor and recipient is better, but health care professionals should work together without breaking confidentiality.
All aspect of support should be offered for donor ,recipient, and family . Donor evaluation;
Eligible recipient should prepared early before donor evaluation in directed donation.
Planed assessment od donor, to reduce inconvenience, and to avoid unnecessary barriers.
Good communication with donor by multidisciplinary team with coordination, and all lab results should be reflected to donor, accurately.
In order to accelerates the process of transplantation, donor assess should be start as early as possible to allow more time for other possible donors, and discussion for transplantation should be offered to potential recipient as early as GFR are 20 ml/min.
Surgery;
Nephrectomy to lower kidney GFR ( by split kidney function) should be done , irrespective to vascular anatomy .
Appropriate imaging to assess vascular tree , parenchyma, and collecting system should be offered to donor kidneys.
anatomical anomalies, and multiple vasculatures , are not more considered absolute contraindication to transplantation , and should be individualized.
LMWH is recommended as thromboprophylaxis offered by surgeon.
All transplantation surgery must be under consultant surgeon, with experience.
proper perioperative preparation and hydration is vital , including overnight infusion , intraoperative fluid blouses , and preferred fluid are ringer and normal saline.
Haemo-o-lock , not recommended for closure of renal artery..
Living donor should offer ERAS after surgery. Histocompatibility testing for living donation for transplantation;
Histocompatibility testing should always precede invasive investigation.
screening for recipient antibody panel, to optimize donor selection and graft survival.
Post transplantation antibody monitoring , must be undertaken to the BSHI/BTS, guidelines.
HLA types, and partner/offspring, of female recipient with previous pregnancy, should be determined, to avoid immunological risk fo repeat potential HLA mismatch in female with low level DSA.
Pre -transplant screen sample , collected for planned date of transplantation, must be tested for antibody screening and donor crossmatch, so transplantation should be delayed , unless +ve crossmatch is within accepted titer .
HLA matched donor is preferred whenever possible especially for younger recipient with possible future re=transplantation.
Recipient with ABO/HLA incompatible ,and /or poorly HLA mismatch, live donor should be enter UKLKSS .
Histocompatibility ab result should be interpretative , stating ,donor, recipient HLA mismatch, recipient sensitization status, crossmatch result and associated immunological risk for recipient and donor. Expanding donor pool;
UKLKSS, is to maximize number of transplant that may proceed.
opportunities for transplantation within UKLKSS is directed by;
UpToDate clinical assessment and bioincompatible screening .
if matched , crossmatch done and proceed to surgery.
relevant pool donors, matched to recipient should be discussed , and agreed by recipient.
The default, NDADs is to donate and directed within UKLKSS.
All AD if directed or not must have formal mental health assessment before transplantation.
all incompatible donors should directed to UKLKSS.
Donor should aware that; compatibility always associated with success, while incompatibility are not . Donor follow up and long term outcome;
Donor councelling about the risk of ESKD post donation , primarly associated with , age , sex, race, BMI, history of renal disease.
Provide high risk calculator to all donors.
follow up post nephrectomy must be inforemd for all female for risk and event with pregnancy include;
PIH
pre-eclmpsia , so asprin prophylaxis is mandated.
no evidence of association between hydronephrosis, and whether left or right nephrectomy .
Birth report, in registery of live donor event.
Recipient outcome after live donor transpalnt in adult;
Graft and recipient survival , after transplantationof living donor, should be within range of expected outcome.
If recipient is of high risk, transplantationshould be proced only if professional team involve, with expectation of recipient and graft functioning for 2 yrs.
Recipient with high risk of comorbidities, and poor outcome,due to immunological status, consider for transplantation when risk/benifit ratio is favourable. Recurrent renal disease:
Wide range of recurrent disease post transplantation,so the risk of recurrence , and consequences of graft function, and deterioration of renal function should be considered.
In atypical HUS, potential, denovo in a related donor need to be adressed clearly.
Recipient risk of SLE or systemic vasculitis, need adequate disease controll time. Living donor transplant in children;
Pre-emptive related transplant is the gold standard, transplant for children.
Aim for children is to receive transplant from ABO/HLA compatible, although incompatible ABO with HLA mismatch transplant is feasible in children.
effort to minimize HLA mismatch to reduce future sensitization.
CKD s4 s5 , child’s should be assessed by multidisciplinary team.
Children > 10 kg is suitable to receive kidney from adult donor.
Manal Malik
2 years ago
Summary of Guidelines for Living Donor Kidney TransplantationKidney transplantation from a living donor, is the treatment of choice to most patients with ESRD.
The guidelines relates only to living donor kidney transplantation and relevant to both adult and paediatrics settings
Recommendation of legal framework
ALL transplant performed from living donors must comply with the requirement of the primary legislation which regulate transplantation and organ donation across the united kingdom(not graded).
All transplant centres performing living organ donation must be licensed by the human tissue Authority in line with requirements of the European Union Organ Donation Directive which sets out the minimum requirements for quality and safety of organ for transplantation(not graded).
Consent for the removal of organs from living donors, for the purposes of transplantation, must comply with the requirements of the human Tissue Act 2004 and Mental capacity Act 2005 in England(not graded).
ETHICS Recommendations
· All health professional involved in living donor kidney transplantation must acknowledge the wide range of complex moral issues in this field(not grated).
· The potential living donor must take precedence over the needs of the optional transplantation recipient(not grated).
· Independence is recommended between the clinician for assessment and Human tissue authority (not grated).
· SUPPORTING AND INFORMING THE POTENTIAL DONOR:
· The living donor must be offered the best possible environment for making a voluntary and informed chance about donation(B1).
· To achieve the best outcome for donor ,recipient and transplant the confidentiality must be specified and discuss at the outset(B1).
· The recipient will discuss relevant information with the donor or allow it to be shared (not grated).
· For support for donor ,recipient and family is an integral part of the donation ,transplantation processes(B1).
· Donor evaluation recommendation :
· Direct donation (to known recipient ) the likely suitability of the protentional recipient for transplantation must be established before starting donor assessment(not grated).
· A policy must be in place to manage prospective donor who are found to be unsuitable to donate.
· The facilitate pre-emptive transplantation donor evaluation must start sufficient early to allow time for more than one donor to be assessed if required(B2).
· ABO BLOOD GROUPING AND CROSSMATCH TESTING
· Recommendation A compatible ABO blood group and human leucocytes antigen (HLA) transplant offers the best opportunity for success(A1).
· ABO OR HLA incompatibility is present, alternative option for transplantation must be discussed with the donor and recipient including paired /pooled donation and antibody incompatible transplantation and this later must be performed in a transplant centre with the relevant experience and appropriate support(A1).
· Recommendation of Assessment of renal function:
· Measurement of Renal function.
· Initial evaluation of donor should be using estimated glomerular filtration rate(B1).
· GFR must be assessed by a reference measured method such as clearance of cr-EDTA or performed according to guidelines by British Society of Nuclear Medicine (B1).
· Differential kidney function .determined by TcDMSA scanning is recommended.
· Threshold of e GFR for donations level is defined based on Age and gender .
· There is small increased life time risk of ESRD following denotation for which the potential donor must be consent (D2).
· The donor must be offered life long annual assessment of renal function including serum creatinine .urine protein execretion and blood pressure measurement(B1).
· Donor more than 60 years of age increase evident of peri-operative complication and affect graft survival and function.
Moderately obese patients (BMI 30 -35 ) must undergo careful preoperative evaluation to exclude CVS ,respiratory and kidney disease (C2).
Data on the safety of kidney donation in the very obese (BMI >35 )are limited and donation should be discouraged(C1).
Potential donors with mild -moderate hypertension that is controlled to <140/90mmhg (and or 135/85 mmhg with ABPM or home monitoring ) with one or two anti hypertension drugs and who have no evidence of end organ damage may be acceptable for donation(C1).
Consideration of patients’ with DM as potential kidney donors require very careful evaluation of the risks and beneficial (not grated).
CVS assessment for higher risk potential donors ,stress testing is recommended by which ever method is locally available or by CT calcium scoring (C2).
Discussion withhold or review by cardiologist ,anaesthetist and transplant MDT is recommended as part of the clinical assessment of donor with higher CVS and peri-operative risk (D2).
ACR>30 mg/mmol ,PCR >50 mg /mmol ,albumin excretion >300 mg/day or protein excretion >500mg/day represent absolutes contraindication to donations (D2).
Haematuria if no cause is found and the donor still wishes to donate ,then a kidney biopsy is recommended if haematuria is one plus or more on dipstick testing (B1).
Glomerular pathology precluded donations ,with the possible exception of thin basement disease(B1).
Donor with persisting asymptomatic non visible haematuria and a family history of haematuria or x-linked Alport syndrome ,a renal biopsy and referral to a clinical geneticist are recommended(B2).
Recommended donor to have pyuria can only donated if pyuria due to reversible cause (C1).
Active HBV and HCV infection in the donor are usually contraindication to Living donor kidney donation(B1).
HIV and HTLV infection is an absolute contraindication to living donation (B1).
The CMV status of donor and recipient must be determined before transplantation if CMV positive donor and CMV negative recipient ,the donor and recipient must be counselled about the risk of post -transplant CMV disease(B1).
EBV status of donor and recipient must be determined before transplantation(B1).
Previous history of kidney stone or imaging in the absence of metabolic abnormality ,still be considered as potential kidney donors (C2).Donor anemia needs to be investigated and treated before donation (A1).
Many inherited kidney disease are rare, so involvement of clinical and laboratory genetics services must be considered at an early stage to asset likely to risk family members and the appropriate use of molecular genetic testing (B1).
Active malignant disease is contraindication to living donation but donors with certain types of successfully treated low grade tumor may be considered after careful evaluation and discussion (B1).
Work up for living donor must include detail imaging confirming the vascular atomic of both donor kidneys and information about the renal parenchyma and collecting system either CTA or MRA can be used as current evidence indicate little difference in accuracy (B1).
Pre-and peri-operative IV fluid replacement with Hartman solution is preferable to 0.9% saline (B2).
Laparoscopic donor surgery is the preferred technique for living donor nephrectomy (B1).
Initial assessment of donor and recipient histocompatibility status must be undertaken at earlier stage in living donor kidney transplant workup (B2).
Screening of potential living donor kidney transplant recipient for clinical relevant antibodies is important for ensuring optimal donor selection and graft survival (A1).
Antibody screening is important when potential living donor transplant recipient undergo reduction or withdrawal of immunosuppression (B2).
Post-transplant antibody monitoring must be undertaken according to the BSH-BTS guide lines (B1).
Transplant and histocompatibility lab rotary must agree an evidence based protocol to define antibody screening and crossmatch results that constitute ahigh immunological risk to transplant(B2).
If crossmatch test collect ed sample 14 days of planned date for transplantation is positive ,transplant should not be performed unless antibody is show to be indication of acceptable immunological risk(A1).
HLA matching preformed when there is an option of selecting between living donors (B1).
The histocompatibility laboratory must issue an interpretation report stating the donor and recipient sensitization statement cross match result and define associated immunological risk for all living donor recipient pairs (A1).
All potential altruistic donors should be referred for mental health assessment.
Graft and patient survival after kidney transplantation should be within the national range of expected outcomes(A1).
Living related renal transplantation should be avoided in atypical HUS unless the cause of the disease in the recipient is known and this has been excluded in the donor .
In appropriately selected cases ,living donor kidney transplantation is a reasonable treatment option in primary hyperoxaluria .Both the donor and recipient should be counselled regarding the risks of recurrent disease.
2- in our center the age for recipient should be 60 or less to proceed for transplantation other wise follow same guidelines.
Hi Dr Manal Malik,
I would say that laparoscopic donor nephrectomy is the only option now, rather than stating that laparoscopic donor nephrectomy is the preferred option. Open surgery for donor operation is not an option. Of course, one should have no hesitation in converting to open operation for the sake of safety, though I have never needed to do that an open tray should be accessible at ultra-short notice. .
Ajay
Hussein Bagha baghahussein@yahoo.com
2 years ago
This is a comprehensive guideline discussing the the living donor organ program in the United Kingdom. It explains the regulatory legal frameworks and ethical frameworks pertaining to living donations in the UK to donor evaluation process including the histocompatibility testing and the surgical aspects to long-term donor follow up and briefly also talks about the pediatric transplantation
The Human Tissue Act (2004) sets out the licensing and legal framework for the storage and use of human organs and tissues from both living and deceased donors.
The Human Tissue Authority (HTA) was established as the regulatory body under the Human Tissue Act. The HTA is responsible for assessing all applications for organ donation from living people. All donors and recipients see an Independent Assessor (IA) who is trained and accredited by the HTA and acts on behalf of the HTA to ensure that the donor has given valid consent without duress or coercion and that reward is not a factor in the donation. If the HTA is satisfied on these matters, then approval for the living donation will be given.
Types of living donation permitted by the legislation include:
Directed donation
Paired pool donation
Non-directed altruistic donation
Directed altruistic donation
For a child to be allowed to donate, parental consent must be obtained and even after it is obtained, an advanced ruling from the court must be sought before proceeding.
In Scotland, living organ donation from children is not permitted.
The key ethical principles in living donation include:
Altruism
Autonomy
Beneficence
Dignity
Non-Maleficence
Reciprocity
The donor evaluation starts from counselling the potential donor and making sure that there is no coercion or duress or financial gain involved. The donor undergoes extensive work-up to make sure that the donor is safe during the surgery. The risks of developing ESKD and mortality during the surgery and post-donation albeit small should be very clearly discussed with the donor so that the donor has a clear picture of the risks. The histocompatibility testing should be carried out early in the process to prevent the donor from undergoing extensive radiological evaluations if not needed.
The donor must clearly be informed that during the evaluation process he/she might be diagnosed with certain conditions and pathways for referral must be in place to assist the donor in case certain conditions are discovered.
Donor confidentiality must be maintained at all times.
For pre-emptive kidney transplantation, the process must be faster to evaluate several donors if needed to try and ensure that the potential recipient gets transplanted before requiring hemodialysis
Donors who have diabetes or IFG are not allowed to donate. However, the guidelines give leeway to the centers to individualize the patients with IFG and no other comorbidities.
If a donor has mildly increased albuminuria or proteinuria they are disqualified from being donors.
Microscopic hematuria needs extensive evaluation including 2 cultures, cystoscopy and possibly even a kidney biopsy.
Patients with active malignancy are not allowed to donate. Patients who have had malignant melanoma, cancers of the breast, lung, colon (Dukes stages B or C) are barred from donation
Patients with non melanoma skin cancers and treated cancers with no risk of recurrence can be allowed to become donors but will require extensive work up and oncology evaluation before proceeding
Patients with renal masses will require referral to a specialist uro-radiologist to confirm if the masses are benign or malignant
For cardiac evaluation, a 12 lead ECG will suffice unless if the donor is high risk for CVD – then referral to a cardiologist is required.
Donors must have a pathway for follow-up post-donation. Most centers see the donor 4-6 weeks after the donation then annually.
Female donors must be counselled of the risk of pre-eclampsia post-donation and that they they should follow up closely with their gynecologist once they conceive
All transplant centers must do regular audits and Graft and patient survival after living donor kidney transplantation should be within the national range of expected outcomes. They should also do audits for secondary outcomes and compare them to other transplant centers
The guidelines also talk about recurrent renal disease. It is important to note that a number of renal diseases have a high rate of recurrence post transplantation. It is important to discuss both with the donor and the recipient about the risks of recurrence. FSGS and MCGN have the highest rate of recurrence approaching 50%. Therefore, the guidelines recommend that for these patients, living donation should be discouraged even if a donor is available and deceased donation is preferable. This is after counselling both the donor and the recipient.
For patients with SLE, the disease has to be quiescent before proceeding for transplantation.
For pediatric patients, pre-emptive kidney transplantation is the gold standard. Pediatric patients with CKD stage 4 should start being reviewed by the multidisciplinary team including a pediatric nephrologist, urologist, transplant surgeon and anesthetist. Pediatric patients who weigh more than 10 Kgs are eligible to receive a kidney from an adult living donor
Hi Dr Bagha,
I quote your reply here in italics: ‘The key ethical principles in living donation include:
Altruism
Autonomy
Beneficence
Dignity
Non-Maleficence
Reciprocity’
Which one of these is most important? This may sound rather a strange question, but there is a reason. There are times, especially in transplantation, when there is a conflict in decision-making when applying principles of ethics.
Dear Professor Sharma
From my view point the most important in living donation is Non-Maleficence
There are instances we will get a donor who is of sound mind, truly altruistic and wants to donate but because of medical contraindications will not be allowed to donate. And he/she will insist that he is willing to take the risk. As a physician we always have to make sure that we do no harm to the patient.
I had a 21 year old sister who wanted to donate a kidney to her brother. There was no contraindication for her. But we know that there can be possible medical problems she can face in the future: Development of elevated BPs, a higher risk of development of pre-eclampsia. There are also social implications as well due to the scar as we dont do do laparoscopic retrieval. After multiple sessions of counselling, she still insisted to donate and our ethics committee allowed her to become a donor
The Key Points to Discuss with a Potential Donor
General procedural, consent, and secrecy points:
. For a live donor to offer legal permission, he/she must be
general hazards (for all donors) and individual
risks.
. The information must be supplied concerning transplants
and GP
. Explain that testing may provide surprising results.
-The review process for potential donors should first and foremost focus on determining whether or not the
donor and reducing the potential risks associated with donation. Specifically, this entails determining
Donations shouldn’t be done if you have these conditions, plus these other possible clinical concerns (both physical and mental).
-In directed donations (to a known recipient), appropriateness before transplanting.
-Avoid unneeded delay. Non-invasive This step includes donor evaluation.
-To allow pre-emptive transplantation, donor assessment must commence
early enough so that more than one donor could be evaluated
if you need it.
-when the eGFR of the recipient is about 20 mL/min or when the
The recipient is likely to need kidney replacement therapy within 12 to 18 months.
months.
-The evaluation of a potential donor should be undertaken within an 18-week pathway.
-A compatible ABO blood group and human leucocyte antigen (HLA) transplant offers the best opportunity for success.
-When ABO or HLA are not compatible, there are other options for
Talks must take place with both the donor and the recipient,
including paired or pooled donations and antibodies that don’t work together
transplantation.
-A full past and present medical history must be taken.
– A psychosocial assessment is recommended for all donors with appropriate referral to a mental health professional as required.
-Estimates should be used to judge potential donors at first.
glomerular filtration rate (eGFR), which is written as mL/min/1.73m2
based on a creatinine test that was done according to the International
Standard of reference.
-GFR must be measured by a reference method.
(mGFR), such as 51Cr-EDTA, 125iothalamate, or Iohexol clearance
done according to rules set out by the British Society of
Nuclear Medicine.
-Differential kidney function, which can be found with a 99mTcDMSA scan, is
recommended when the size of the kidneys varies by more than 10% or
significant renal anatomical abnormality.
-The donor’s kidney function must be checked every year for the rest of his or her life. including serum creatinine, urine protein excretion estimation, and
blood pressure measurement.
-Old age by itself is not a reason to not donate, but older donors must go through a very thorough medical checkup to make sure they are fit.
– Otherwise healthy overweight patients (BMI 25-30 kg/m2 ) may safely proceed to kidney donation.
-We think that a blood pressure of less than 140/90 mmHg is usually good enough to donate.
-A fasting plasma glucose concentration between 6.1-6.9 mmol/L is indicative of an impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be undertaken.
-Urine protein excretion needs to be quantified in all potential living donors.
-All potential living donors must have reagent strip (dipstick) urinalysis performed on at least two separate occasions.
-Screening for infection in a potential donor is important to find out what risks the donor might face from a past or current infection and to figure out how likely it is that the infection will be passed on to the recipient.
-In the absence of a major metabolic problem, people who have had a few kidney stones in the past or who have small kidney stones on imaging may still be considered kidney donors. Both the donor and the recipient must get full counselling, and the donor must have access to long-term donor follow-up.
– Donor anaemia needs to be investigated and treated before donation.
-All people who might get a transplant must have a detailed family history written down and, if possible, have other family members with kidney disease confirm the diagnosis. This could help the person get a better diagnosis, figure out how the disease was passed down, and find relatives who are at risk.
-Before a kidney donation, a careful history, clinical exam, and investigation of the potential donor are needed to rule out occult malignancy. This is especially important for donors over the age of 50.
-Workup for a living kidney donation may include a direct or indirect evaluation of split renal function. The kidney with the worse function is chosen for nephrectomy, no matter how the blood vessels are set up.
I like your comprehensive reflective exercise on LRD criteria, dear Dr Weam.
Ajay
Nandita Sugumar
2 years ago
Introduction
These guidelines pertain to living kidney donor transplantation. This includes adult and pediatric settings. Scope of these guidelines extends to ethical and medico legal aspects of donor selection, medical and pre operative donor evaluation, identification of high risk donors, management of complications, and the corresponding outcomes that are expected.
The treating doctor in charge is responsible for obtaining consent for removing organs from living donors. This consent has to be valid and made with proper mental capacity. This also means that the donor understands the generic and specific risks of organ donation both in the short and long term.
HTA has to be satisfied that no reward has been given for the removal of the organ for transplant and that the donor is aware that the organ has been removed expressly for the purpose of transplantation.
The donor needs to know that his intention is priority in terms of the donated organ, that is, if the organ cannot be used for the intended recipient, then the donor can choose how and for whom the organ is going to be used.
Commercial dealings in terms of human organs for transplant is not allowed and is an offense.
People above 18 years of age can give consent for organ donation. This is so since children may not understand the full risks of donation, and in addition, donation is not generally in the best interests of the child donor.
Rare circumstances can allow donation from a child with parental consent. Court ruling is required in this case even with parental consent.
Court approval is needed for donation from adults without mental capacity in many regions. However, some areas like Scotland do not permit living donation from such adults.
The safety of the donor is more important than the needs of the intended recipient.
Different clinicians are to be responsible for the donor and the recipient.
Informed consent before donation is a special area that has to be taken seriously. Donor should be given an opportunity to give consent in a safe environment preferably in the absence of the recipient. This is done to prevent any external pressurization of the donor to give consent,
Donor evaluation is essential for approval or rejection of the donor. Any absolute contraindication means the donor will be rejected. If there is a relative contraindication then they may be able to donate based on transplant centre specific criteria.
It is especially important to note that donor age alone cannot be a factor for rejection of the donor. Instead, a more careful workup should be donor before selection.
When directed donation is considered, the potential recipient should be assessed first for transplant suitability before beginning the donor assessment. if recipients needed further evaluation it must be done immediately together with non-invasive evaluation of the donor.(Not graded)
Donor evaluation should be plan with flexibility regarding timing, coming for investigations and date of surgery. Avoid unnecessary obstacles to proceed for transplantation. (Not graded)
Donor assessment must be focus, logical ,and coherent. This must involve transplant coordinator who plays essential role in coordinating the assessment process. The results must be communicated effectively to the donors and those donors who are unsuitable must be known at the early stages of the assessments.(Not graded)
A policy or protocol must put in order to guide the managements, follow up and support for those donors who are unsuitable for transplantation.(Not graded)
The principle of donor evaluation depends on the centers, resources, and the personnel. An agreed donor assessment protocol must be available and tailored according to needs of the individual. (Not graded)
In cases of pre-emptive transplantation more than one donor may be needed and hence assessment of the potential donor must be as early as possible specifically if recipient eGFR is < 20 ml/min or expected to start RRT within 12 to 18 months. The evaluation of both recipient and donor will depend on speed of decline of renal function, disease specific consideration, and individual circumstances. (B2)
The donor must be evaluated within an 18 week pathway unless he/she is not available. Keep in mind some pauses due complicated recipient assessment.
The principle of this guideline similar to what we follow in our local practice. The only difference is that we are operating in a low resource setting and obviously the donor evaluation is tailored according that. We do have a transplant coordinator and she is responsible for coordinating most of the activities including the setting of multi-disciplinary meeting.
Thank you for your answer; I have noticed a lot of copying and pasting
Dear professor Ahmed, can we change in the graded recommendations, or just copy paste?
Transplant Legal framework in UK
The Human Tissue Act 2004 applies in England, Wales and Northern Ireland.
The Human Tissue (Scotland) Act 2006, applies in Scotland.
Types of Living Donation Permitted by the Legislation
1)Direct donation ( genetically related donation, Emotionally related donation )
2)Paired or pool donation. Donor-recipient pairs are involved in a linked exchange.
3)Non-directed altruistic donation. organ is donated by a healthy person to an unknown recipient.
4)Directed altruistic donation. Contact has been establish between donor and recipient. Both maybe either genetically related or not related.
All living organ donation must meet the following criteria
1) No rewards for donor.
2) Obtained consent for the purpose of transplantation.
3) Independent assessor for donor and recipient.
4)strict prohibition of commercial organ trafficking.
5)Children is defined as those below the age of 18 year old. In Scotland, living donation of solid organs from children is not permitted. In England and Wales, both parental consent and court approval must obtained before living organ donation from the children.
6) Living organ donation for mental incapable adults is not permitted in Scotland. In England, Wales and Northern Ireland, living organ donation from adult who lacks the capacity to consent requires court approval.
In Malaysia. The Ministry of Health regulating Living Donor Kidney Transplantation.
An individual willing to donate organ must be :
a. An adult legally able to give consent
b. Aware of all risks that can occur
c. Physically and mentally fit
d. Fully aware of the decision he/she is making
e. Able to fully evaluate and understand all information given to him/her
f. Not have received any coercion or any advice or opinions from sources other then the institution which is planning the transplantation.
g.Living unrelated donors must have access to all available information before signing the consent form. Enough time must be given for such consent. The doctor involved must ensure that the freedom to give consent is not hampered. The potential donor and the recipient or the recipient’s family should not be known each other to avoid any financial transaction.
h.Organ donation from unrelated donors is primarily not accepted unless in special circumstances. Such special circumstance may prevail when there is no suitable related living donor or a cadaveric donor for liver transplant. In such situations, application should be made for approval from the Unrelated Transplant Approval Committee (UTAC).
SUPPORTING AND INFORMING THE POTENTIAL DONOR
Recommendations
* The best environment must be provided for the live donor to decide to donate in a voluntary and informed manner. Primary legislation mandates that the donor and recipient be evaluated independently.
* The parameters of anonymity must be outlined and agreed at the outset in order to obtain the best results for donor, recipient, and transplant. The receiver should ideally talk to their donor about pertinent details or agree to them being provided.
* The best practice is to have separate clinical teams for the donor and recipient; but, in order to guarantee good communication and coordination of the transplant procedure without jeopardizing the independence of either donor or recipient, healthcare professionals must collaborate. The donation/transplantation process includes support for the potential donor, recipient, and family.
Confidentiality:
The relationship between the donor and recipient’s respective doctors should be private.
Informing the Potential Donor:
When requesting informed consent, registered doctors have a duty to act responsibly, according to the General Medical Council (GMC).
Informed Consent for Living Kidney Donation:
Summary of Key Points to be Discussed with a Potential Donor:
General points about process, consent and confidentiality:
1. Living donors must be adequately informed of both the general hazards (applied to all donors) and any unique, personal dangers in order to provide permission for donation that is legitimate (for them)
2. Prior to moving on to any stage of the pathway, informed consent must be obtained.
3. Information about what will be shared between the transplant team and the GP must be provided.
4. Information about what will not be disclosed to the prospective recipient, unless express consent is given to do so, must be provided.
5. It should be made clear that unexpected results from the tests could emerge, which may or may not be related to kidney donation. These findings might include:
A description of the recipient’s genetic relationship.
b. Anatomical or medical findings with ambiguous significance that may call for additional evaluation or referral to a different field of study.
6. It should be emphasized that the donor has the right to revoke consent at any time before the procedure.
Specific points about process and possible outcomes:
1. Risks of donation (generic and specific).
2. Nature of surgical procedure and length of stay in hospital.
3. Potential graft loss in the recipient.
4. Requirement for HTA assessment.
5. Reimbursement of expenses.
6. Requirement for annual review.
Understanding what is Involved:
The need for valid consent for kidney donation must be explained to the potential donor.
Information about Likely Outcomes for the Kidney:
Despite the fact that the nephrectomy’s surgical risks are unrelated to the recipient’s identification, the donor’s decision to contribute or not may be influenced by the possibility that the transplant would be successful. A crucial component of the consent procedure is disclosing information regarding the chances of success. The likelihood of a successful transplant must be realistically estimated for the potential living donor.
Independence of Decision:
The clinician in charge of obtaining consent must be certain that the potential donor has the capacity to make a competent and rational decision. Valid consent for surgery must be freely provided and informed.
The Responsibility of the Donor Surgeon:
Under the terms of his or her duty of care, the surgeon performing the living donor nephrectomy has a special obligation to make sure that the donor is fully aware of any possible dangers and the long-term repercussions of the procedure.
Donor Identity:
There is substantial discussion surrounding the importance of donor identity in the context of informed consent. During the living donor transplant work-up, details about a donor’s identity and genetic relationship with the potential receiver of their contribution may become known.
Patient Advocacy:
The UK regulatory framework reflects the long-held belief that the possible donor should be given the chance to meet separately with a party who is independent of the transplant team.
Independent Translators:
Within the UK, there is a wide range of cultures and ethnicities, and a sizable portion of donors do not speak English as their first language.
Psychological Issues:
Psychological issues are rare after donation, and most donors report higher self-esteem while their relationships with both donors and recipients improve.
Death and Transplant Failure:
For patients with higher baseline comorbidity, LDKT is becoming more widely regarded as the preferred course of treatment. The effective managing of expectations is a crucial component of the pre-transplant preparation for all parties involved because of the higher risk of post-operative co-morbidity, transplant failure, and death that is likely.
DONOR EVALUATION: SUMMARY
Recommendations
* Before beginning the donor assessment process in cases of directed donation (to a known recipient), it is necessary to determine the probable recipient’s likely suitability for transplantation. Avoid unnecessary delays if extra recipient assessment is necessary. This step allows for the non-invasive evaluation of the donor. Donor evaluation is designed to cause them as little inconvenience as possible and to remove any unnecessary obstacles to moving forward. Flexibility in scheduling appointments, attending investigations, and choosing a surgery date is beneficial.
* Donor evaluation needs to be organized in order to be clear, rational, and cogent. A designated co-ordinator should oversee the planning of the evaluation process to ensure good communication with the donor and participation of the larger multidisciplinary team. The results of the inquiry must be communicated to the potential donor accurately and effectively. At the earliest possible point in the assessment process, unsuitable donors must be found. When a potential donor is determined to be unfit to donate, a policy must be in place, and the proper follow-up and support must be made available. According on manpower and resource availability, donor evaluation centers will have different organizational characteristics, but all donors are subject to the same general guidelines. an agreed-upon donor evaluation
Summary of Key Points of Importance in the Medical +/- Family History of a Potential Kidney Donor
Haematuria/proteinuria/urinary tract infection
Difficulty in passing urine, including urgency, frequency, dysuria
History of peripheral oedema
Gout
Nephrolithiasis
Hypertension
Diabetes mellitus, including family history
Ischaemic heart disease/peripheral vascular disease/other atherosclerosis Cardiovascular risk factors
Thromboembolic disease
Sickle cell and other haemoglobinopathies
Weight change
Change in bowel habit
Previous jaundice
Previous or current malignancy
Systemic disease which may involve the kidney
Chronic infection such as tuberculosis
Family history of a renal condition that may affect the donor
Smoking
Current or prior alcohol or drug dependence
Mental health history
Obstetric history
Residence abroad
Previous medical assessment e.g. for life insurance
Previous anaesthetic problem
History of back or neck pain and trauma
Results of national screening programme tests e.g. cervical smear, mammography,
colorectal screening
History with respect to Transmissible Infection
Previous illnesses
Jaundice or hepatitis
Malaria
Previous blood transfusion Tuberculosis / atypical mycobacterium Family history of tuberculosis
Family history of Creutzfeldt-Jakob disease, previous treatment with natural growth hormone, or undiagnosed degenerative neurological disorder
Specific geographical risk factors: e.g. fungi and parasites, tuberculosis, hepatitis, malaria, worms
Increased risk of HIV, HTLV1 and HTLV2, Hepatitis B and C infection
Haemophiliac or sexual partner of haemophiliac High risk sexual behaviour
History of infectious hepatitis or syphilis
History of intravenous drug use
Tattoo or skin piercing within last 6 months
Sexual partner of an individual with positive serology Sexual partner of drug addict.
Points of Particular Importance when Undertaking Clinical Examination of a Potential Kidney Donor
Abdominal fat distribution
Blood pressure
Body mass index
Dipstick urinalysis
Evidence of self-harm
Examination for abdominal masses or herniae
Examination for scars or previous surgery
Examination for lymphadenopathy
Examination / history of regular self-examination of the breasts Examination / history of regular self-examination of the testes Examination of the cardiovascular and respiratory systems Mental health
Routine Screening Investigations for the Potential Donor
Urine
Dipstick for protein, blood and glucose (at least twice) Microscopy, culture and sensitivity (at least twice) Measurement of protein excretion rate (ACR or PCR)
Blood
Haemoglobin and blood count
Coagulation screen (PT and APTT) Thrombophilia screen (where indicated) Sickle cell trait (where indicated) Haemoglobinopathy screen (where indicated) G6PD deficiency (where indicated)
Creatinine, urea and electrolytes
Isotopic or other reference test for measurement of GFR
Liver function tests
Bone profile (calcium, phosphate, albumin and alkaline phosphatase)
Urate
Fasting plasma glucose
Glucose tolerance test (if family history of diabetes or fasting plasma glucose >5.6 mmol/L)
Fasting lipid screen (if indicated)
Thyroid function tests (if strong family history)
Pregnancy test (if indicated)
Virology and infection screen
Hepatitis B and C
HIV
HTLV1 and 2 (if appropriate)
Cytomegalovirus
Epstein-Barr virus
Toxoplasma
Syphilis
Varicella zoster virus (where recipient seronegative)
HHV8 (where indicated)
Malaria (where indicated) Trypanosoma cruzi (where indicated) Schistosomiasis (where indicated)
Cardiorespiratory system
Chest X-ray
ECG
ECHO (where indicated)
Cardiovascular stress test (as routine or where indicated)
ASSESSMENT OF RENAL FUNCTION
DONOR AGE
Recommendations:
* Although elderly age alone is not a strict no-no for donation, older donors must undergo more stringent medical screening to ensure they are suitable. It is important to inform both the donor and the recipient that the function and potentially even the long-term survival of the graft may be affected and that the older donor may be more susceptible to postoperative problems. This is especially clear with donors who are older than 60.
DONOR OBESITY
Recommendations:
HYPERTENSION IN THE DONOR Recommendations
* At least two different occasions must be used to measure blood pressure. If blood pressure is high, high normal, fluctuating, or the potential donor is receiving therapy for hypertension, ambulatory blood pressure monitoring or home monitoring are advised. We advise that blood pressure readings of less than 140/90 mmHg are typically suitable for donation. Especially if they are in a high-risk group, prospective donors need to be informed about the possibility of developing hypertension connected to donation. Annual donor monitoring includes taking blood pressure readings.
* Potential donors may be accepted for donation if they have mild to moderate hypertension that is under control at 140/90 mmHg (or 135/85 mmHg with ABPM or home monitoring) and show no signs of end organ damage. Acceptance will be determined by a general evaluation of cardiovascular risk and regional regulations. Potential donors with hypertension should be discouraged from giving if:
o Blood pressure is not controlled to <140/90 mmHg on one or two antihypertensive drugs
o Evidence of end organ damage (retinopathy, left ventricular hypertrophy, proteinuria, previous cardiovascular disease)
o Unacceptable risk of future cardiovascular risk or lifetime incidence of ESRD
* All living kidney donors must be urged to take lifestyle steps, such as quitting smoking, consuming less alcohol, exercising frequently, and, when necessary, losing weight, to reduce their risk of hypertension and its effects both before and after donation.
* It is advised that donors who are found to have hypertension during evaluation or who experience hypertension after donation be treated in accordance with British Hypertension Society recommendations.
DIABETES MELLITUS
Recommendations
* Fasting plasma glucose levels must be assessed for all possible living kidney donors. An oral glucose tolerance test (OGTT) should be performed when the fasting plasma glucose level is between 6.1-6.9 mmol/L, which indicates an impaired fasting glucose status. Prospective donors should additionally have an OGTT if they have a higher risk of type 2 diabetes due to family history, a history of gestational diabetes, ethnicity, or obesity.
* If OGTT results show a persistently impaired fasting glucose and/or impaired glucose tolerance, it is important to carefully weigh the risks of developing diabetes after donation. The usage of a diabetes risk calculator should be taken into account while having the conversation about future kidney donation. Diabetes patients must have their risks and benefits carefully weighed before being considered as kidney donors. After a thorough evaluation of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney, diabetics can be considered for kidney donation in the absence of evidence of target organ damage and after ensuring that other cardiovascular risk factors like obesity, hypertension, or hyperlipidaemia are optimally managed.
CARDIOVASCULAR EVALUATION Recommendations
* The routine use of stress testing to evaluate potential donors with low cardiac risk is not supported by any data. Before donating, potential kidney donors having a history of cardiovascular disease, an exercise capacity of less than 4 metabolic equivalents (METS), or with cardiovascular disease risk factors should be given more scrutiny. Stress testing by whichever method is locally accessible or by CT calcium scoring is advised for higher risk potential donors. As part of the clinical evaluation of donors with increased cardiovascular and peri-operative risk, discussion with and/or review by cardiologists, anesthesiologists, and the transplant MDT is advised.
PROTEINURIA
Recommendations
* The amount of protein excreted in the urine from all potential living donors must be measured.
* The recommended screening test is a urine albumin/creatinine ratio (ACR) carried out on a spot urine sample, while urine protein/creatinine ratio (PCR) is a suitable substitute.
* Absolute contraindications to donation include ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day, and protein excretion >500 mg/day.
* The impact of somewhat elevated proteinuria (PCR 15-50 mg/mmol or 24-hour urine protein 150-500 mg/day) and albuminuria (ACR 3-30 mg/mmol) has not been thoroughly examined in living kidney donors. However, these levels indicate a relative contraindication to donation because the risk of CKD and cardiovascular morbidity rises steadily with rising albuminuria or proteinuria.
NON-VISIBLE HAEMATURIA
Recommendations
* Reagent strip (dipstick) urinalysis must be conducted on all prospective living donors at least twice. Persistent non-visible haematuria is defined as having two or more positive tests, even if they are only trace positive (PNVH).
* Perform a urine culture and renal imaging if PNVH is present to rule out common urologic reasons include infection, nephrolithiasis, and urothelial cancer. Perform a cystoscopy on patients older than 40 to rule out bladder pathology if no reason is discovered. If the donor still wants to donate but there is no indication of a cause, a kidney biopsy is advised if the haematuria on the dipstick test is 1+ or higher.
Donation is prohibited by glomerular pathology, with the probable exception of thin basement membrane disease. A kidney biopsy and referral to a clinical geneticist are advised for donors who have persistent asymptomatic non-visible haematuria (PANVH) and a family history of the condition or the X-linked Alport syndrome.
PYURIA
Statement of Recommendation
* Prospective donors who are discovered to have pyuria will only be taken into consideration for donation if it can be shown that the pyuria is brought on by a treatable condition, such as a simple urinary tract infection.
INFECTION IN THE PROSPECTIVE DONOR Recommendations
* It is crucial to check for infections in potential donors in order to determine the risks of infection transmission to the recipient as well as any potential concerns for the donor from past or present infections. Donors with active viral replication may be considered in specific situations, but active HBV and HCV infection in the donor is typically a contraindication to living donor kidney donation. HIV infection or infection with the human T lymphotrophic virus (HTLV) is an absolute contraindication to living donation.
Within 30 days of donation, screening for HBV, HCV, and HIV infection must be repeated. All prospective donors should receive dietary recommendations for preventing HEV infection, and within 30 days of donation, nucleic acid testing should be done to check for HEV viraemia. Prior to transplantation, the CMV status of the donor and recipient must be established. The potential of post-transplant CMV illness must be discussed with the donor and recipient when the donor is CMV positive and the recipient is CMV negative. Prior to transplantation, the EBV status of the donor and recipient must be ascertained. The possibility of developing Post Transplant Lymphoproliferative Disease must be discussed with the donor and recipient when the donor is EBV positive and the recipient is EBV negative.
NEPHROLITHIASIS
Recommendations
* Potential donors with a limited history of prior kidney stones or minor renal stone(s) on imaging may still be regarded as potential kidney donors in the absence of a major metabolic problem. Both the donor and the receiver must receive complete counseling, and the donor must have access to the proper long-term donor follow-up.
* Potential donors should speak with a renal stone disease expert if metabolic problems were found during screening.
* If vascular anatomy and split kidney function allow, it may be possible to donate the stone-bearing kidney from suitable donors who have unilateral kidney stones such that they will receive a kidney free of stones following the donation.
These are the bts guidelines. It has started with ethical consideration regarding ensuring a a voluntary and informed choice about donation and independent assessment of the donor and recipient. Evaluation should be undertaken within an 18 week pathway, assuming there are no logistical issues such as donor unavailability. Having a compatible ABO blood group and human leucocyte antigen provides high chance of success. Otherwise, alternative options like paired/pooled donation and antibody incompatible transplantation should be discussed and performed in experienced center.
Renal function should be evaluated through estimated glomerular filtration rate followed by measured methods. 99mTcDMSA scanning should be considered when there is >10% variation in kidney size or significant renal anatomical abnormality. Pre-donation mGFR should be such that the predicted post-donation GFR remains within the gender and age-specific normal range.Donors need to be offered lifelong annual assessment of renal function. Age alone is not an absolute contraindication to donation but both donor and recipient must be aware that the older donor may be at greater risk of peri-operative complications and less graft survival. BMI 25-30 kg/m2can safely proceed to kidney donation but BMI 30-35 kg/m2need careful preoperative evaluation and counseling regarding weight reduction. BMI >35 kg/m2 should be discouraged. BP should be assessed on at least 2 separate occasions and use ambulatory / home monitoring if blood pressure is high, high normal or variable, or the potential donor is on treatment for hypertension. The target is <140/90 mmHg and all donors need to utilize all the measures needed to minimize the HTN risk.. Donors need to be warned about the risk of developing donation-related hypertension. Donors with controlled mild/moderate hypertension with one or two antihypertensive drugs and who have no evidence of end organ damage may be acceptable for donation after full assessment of cardiovascular risk. Otherwise they should be excluded.
fasting plasma glucose need to be checked and oral glucose tolerance test (OGTT) should be undertaken if FBG 6.1-6.9 mmol/L , presence of DM2 risk , family history, a history of gestational diabetes, ethnicity or obesity . if this is abnormal,then the risks of developing diabetes after donation must be carefully considered through use of a diabetes risk calculator.
Cardiac risk need to be assessed and reviewed with cardiologists and anaesthetists and further evaluation is needed in cases with a history of cardiovascular disease, an exercise capacity of <4 metabolic equivalents (or with risk factors for cardiovascular disease. Stress tests are applied to high risk potential donors.
Urine protein excretion quantification is recommended in all potential living donors through ACR or PCR initially. if ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day or protein excretion >500 mg/day ,this is an absolute contraindications to donation. Levels below this and above normal are a relative contraindication to donation.
All potential living donors must have reagent strip urinalysis performed on at least two separate occasions. In case of two or more positive tests, including trace positive, persistent non-visible haematuria, urine culture and renal imaging need to be done to exclude common urologic causes. If those are negative, perform cystoscopy in patients age >40 years.If no cause is found and the donor still wishes to donate, then a kidney biopsy is recommended if haematuria is 1+ or greater on dipstick testing. Glomerular pathology precludes donation, with the possible exception of thin basement membrane disease. For donors with persistent asymptomatic non-visible haematuria and a family history of haematuria or X-linked Alport syndrome, a renal biopsy and referral to a clinical geneticist are recommended.
Presence of pyuria if due to a reversible cause,is not a contraindication for donation. Infections need to be screened to identify potential risks for the donor from previous or current infection and to assess the risks of transmission of infection to the recipient and screening for HBV, HCV,HEV and HIV infection must be repeated within 30 days of donation. Active HBV and HCV infection in the donor are usually contraindications to living donor kidney donation; however, donors with evidence of active viral replication may be considered under some circumstances. HIV or human T lymphotrophic virus infection is an absolute contraindication to living donation. If the donor has CMV or EBV, and the recipient is CMV or EBV negative, the donor and recipient must be counselled about the risk of post-transplant CMV or EBV respectively. travel or abroad residence history need to be assessd to avoid risk of endemic infections.
Donors with PMH of stones may still be considered as potential kidney donors after full counselling and appropriate long-term donor follow up. If metabolic abnormalities were detected on screening, they should be discussed with a specialist in renal stone disease. In appropriate donors with unilateral kidney stone(s) the stone-bearing kidney can be considered for donation (if vascular anatomy and split kidney function permit) in order to leave the donor with a stone-free kidney after donation.
Donor anaemia needs to be investigated and treated before donation and if non Northern European heritage or if indicated, haemoglobinopathy screen must be carried out. Consultant haematologist advice is recommended.
detailed family history of kidney disease is mandatory and if the recipient has an inherited condition, appropriate tests are recommended in the potential donor.
Exclude donor malignancy through history, clinical examination and investigation.Active malignant disease is a contraindication to living donation but donors with certain types of successfully treated low-grade tumour may be considered after careful evaluation and discussion. Accidental renal mass lesion must be diagnosed, managed, referred to a Urology Specialist and appropriate images are recommended. An incidental, unilateral solitary AML <4 cm with typical characteristic CT criteria does not usually preclude donation. A kidney with an AML <1 cm may be considered for donation or left in situ in the donor’s remaining kidney. Kidneys containing a single AML between 1 and 4 cm can be considered for donation depending on its position, consideration of whether ex vivo excision of the AML is straightforward, or whether it can be left in situ in the recipient and followed with serial ultrasound imaging.
Surgery work-up for living kidney donation may include direct or indicative evaluation of split renal function with the kidney with poorer function selected for nephrectomy irrespective of vascular anatomy and it must include detailed imaging confirming the vascular anatomy of both donor kidneys and information about the renal parenchyma and collecting systems. Either CTA or MRA can be used as current evidence indicates little difference in accuracy. Multiple renal arteries or kidneys with anatomical anomalies are not absolute contraindications to donation. Decisions must be made on an individual basis as part of a multi-disciplinary team evaluation.
All living donors must receive adequate thromboprophylaxis and appropiate compression devices.
All living donor surgery must be performed or directly supervised by a Consultant surgeon with appropriate training in the technique. Laparoscopic donor surgery is the preferred technique and Mini-incision surgery is preferable to standard open surgery.hydration pre- and peri-operative intravenous fluid replacement with Hartmann’s solution is preferred to 0.9% Saline.
histocompatibility status assessment through an evidence-based protocol is recommended at an early stage of work-up with antibodies screening particularly for recipients with high potential of immunosuppression reduction or withdrawal. The histocompatibility laboratory must issue an interpretive report stating the donor and recipient HLA mismatch, recipient sensitisation status and crossmatch results, and define the associated immunological risk for all living donor-recipient pairs Post-transplant antibody monitoring must be undertaken according to the BSHI/BTS guidelines. When possible, the partners/offspring HLA types, for a female recipients who have had previous pregnancies should be determined. A 14 days pre-transplant serum sample collected must be tested in a sensitive antibody screening and donor crossmatch assay and transplantation should not usually be performed if the crossmatch test is positive, unless the antibody is shown to be indicative of acceptable immunological risk. Any changes in immunosuppression during the transplant work-up must be notified to the histocompatibility laboratory. HLA matching may be preferred when there is an option of selecting between living donors, particularly to reduce the possibility of subsequent sensitisation. For patients with an ABO/HLA incompatible and/or a poorly HLA matched living donor, consideration should be given to entry into the UK living kidney sharing scheme (UKLKSS) to identify a more suitable donor. To maximise transplant opportunities within the UKLKSS, donors and recipients must only be included in a matching run if:
1. Their clinical assessment and histocompatibility screening are complete and up to date.
2. If matched, they are available to attend for crossmatch testing and proceed to surgery within the designated timeframes.
3. Relevant complex donor considerations identified in the ‘prerun’ and donor HLA and age preferences have been discussed and agreed with the recipient.
4. They understand their roles and responsibilities with respect to other donors and recipient pairs in the schemes with whom they may be matched.
Donors need to be informed about the risk of donation and women must be informed of a greater risk of pregnancy-induced hypertension following kidney donation. Close monitoring of blood pressure, creatinine and foetal well-being is advisable in kidneys donors during pregnancy. Kidney donors may be offered Aspirin 75 mg daily for pre-eclampsia prophylaxis.
For recurrent diseases, the consequences for transplant function, and the time-course of any deterioration must all be considered. A discussion of the effects of immunosuppression and transplant failure on morbidity and mortality may also be appropriate, it is high in FSGS and MCGN.
Pre-emptive living related, from a blood group compatible well-matched donor, renal transplantation is the gold standard therapy for children with minimising HLA mismatches. they should be assessed by a multi-disciplinary team, and children who are ≥10 kg in weight are suitable to receive a kidney from an adult living donor.
Our local guidelines follows most of the recommendations except that we do not usually do invasive measures to donors.
This guideline is intended for the entire transplant community and aims to provide guidance on how to maintain the health and well-being of the living donor, including ethical and medico-legal principles regarding donor selection and preoperative medical evaluation. from the donor.
LEGAL FRAMEWORK:
All living donor transplants must comply with relevant UK legislation, highlighting the withdrawal consent that must comply with the requirements of the Human Tissue Act 2004 and the Mental Capacity Act 2005 and have evidence of non-commercial negotiation of human material.
Living donations can be:
– Targeted: known recipient, with pre-existing emotional or genetic relationship
– Paired: formation of donor-receiver pairs where a “linked exchange” is involved.
– Altruistic – Undirected: This is an unspecified donation to an unknown recipient.
– Altruistic – directed: this is a donation where the donor has the desire to donate and there is no relationship with the receiver prior to the decision to donate, but is built during the process.
ETHIC:
Ensuring the well-being and safety of the donor is a cornerstone, followed by independence between the medical teams responsible for the evaluation and preparation of the donor and recipient. Ethical principles such as: Autonomy, Beneficence, Dignity, Non-maleficence, Reciprocity and Confidentiality must be remembered throughout the process, both from the point of view of the donor and the recipient. And the Right to Information on specific points of the process and possible results is also a central commitment throughout the process.
DONOR EVALUATION:
Refers to clinical and psychosocial assessments that identify weaknesses that may contraindicate donation or identify clinical risks to the donor that need to be managed in the pre- and postoperative period. It is important to remember the possibility of requesting a second opinion throughout the process.
The following are important clinical conditions to be evaluated in potential donors:
A – Evaluation is the renal function and its risk of deterioration, with the establishment of the GRF limits that must be adopted and also the monitoring of the donor after the donation. Where aging with the natural loss of GFR and the development of comorbidities that may impair renal function are closely monitored. It is noteworthy that the incidence of end-stage renal disease is lower in this population than the incidence in the unselected general population.
B – Senility alone is not a contraindication for donation. It encompasses a higher risk of surgical complications and that long-term graft function and survival will be more compromised.
C – Obesity is a risk factor for surgical complications and is involved with a greater number of comorbidities (cardiovascular, respiratory and renal) that may harm the donor, with donation being contraindicated in very obese patients.
D – Hypertension: pre-donation management and warning about the possibility of development after donation.
E – Diabetes: just like hypertension, pre-donation management is carried out, with a thorough assessment of target organ damage and risk assessment using calculators.
F – Pre-donation cardiovascular assessment
G – Proteinuria: because it is a predictor of chronic kidney disease and cardiovascular mortality
H – Non-visible hematuria: after ruling out urological causes (lithiasis, infection and urothelial carcinoma), it is necessary to exclude bladder disease, so that we can assess glomerular disease. Persistent hematuria will prompt biopsy.
I – Pyuria: reversible disease must be evidenced – infectious condition – for approval of the donation.
J – Infections: the presence of active infections suspends the donation. Mandatory screening for Hepatitis (A, B and E), HIV, HTLV, CMV, EBV, fungal and parasitic infections, prion disease. Bacterial diseases deserve special attention due to the possibility of donation when good treatment is performed. Mycobacteria prevent transplantation.
L – Nephrolithiasis: patients with a limited history of previous renal lithiasic disease and small renal calculi, with no serious metabolic disease
M – Haematological disease: hemoglobinopathies need to be excluded.
N – Familial kidney disease: must be excluded both in the donor and in the recipient.
O – Donor malignancy: screening mainly for those living donors over 50 years old. It leads to suspension of the donation, except when there are low-grade tumors that have been successfully treated.
SURGERY: ethical and technical aspects, donor risks
Detailed imaging examination should be performed for vascular and anatomical evaluation (renal parenchyma and collecting systems), with no absolute contraindication if there is any problem. Thromboprophylaxis and preoperative hydration to improve cardiovascular stability are mandatory to reduce perioperative mortality, which is low.
The importance of multimodal strategies to improve recovery after nephrectomy should be valued (decreased preoperative fasting, epidural analgesia, preoperative psychology, preoperative fluid infusion)
HISTOCOMPATIBILITY TEST
Early stage to be performed to avoid unnecessary clinical investigation. The first action is the exclusion of clinically relevant antibodies to ensure optimal donor selection and graft survival. Adequacy between transplant units and histocompatibility laboratories is essential for following an established protocol.
Living kidney donation outcomes are always better than the deceased donation. Donors were well investigated before surgery and evaluated systematically. The transplant MDT should inform the donor with sufficient information regarding the risks and benefits. In the last years, there has been a trend to extend the donor pool. Minors younger than 18 years should rarely if ever accepted as donors. Donors should have the opportunity of independence of decision. The information needs to be comprehensive with honest. Donors need to be evaluated by a multidisciplinary team to determine the eligibility and risk of donation. Routine screening includes urine, blood test for CBC, biochemistry, and infectious agents evaluation in addition to systemic evaluation with special stress on cardiovascular evaluation. Each donor candidate should have at least basic ECO, CXr, ECHO and stress test (when indicated). Assessment of renal function includes eGFR and evaluation for proteinuria and hematuria. Differential eGFR with radio nuclear studies may be needed (combined EDTA and DMSA). Age itself is. Ot an absolute contraindicartion. Both recipient and donor should be aware of benefits vs risks. Blood pressure is important to evaluate. Donors are suggested to be excluded in case of evidence of end-organ damage and/or uncontrolled HT (target <140/90) with one or two medications. Concomitant risk factors like obesity and smoking should be minimized. DM is a well-known risk factor for CKD. Donors with DM should be evaluated for the lifetime risk of CKD before being considered for donation. Fasting blood glucose of more than 7 mmol/L of A1c>6.5 in addition to OGTT may be used. (QDiabetes®-2015 risk calculator: http://qdiabetes.org) maybe useful in evaluation. CVS evaluation is critical. Stress test is not usually routine but should be used in certain circumstances. CT calcium score is recommended for high-risk patients. Proteinurea is important. PCR or 24 hours quantitative measures may be used. ACR>30 mg/mmol or 300mg/day, and PCR>50 or 500mg/day are absolute contraindications for kidney donation. Non-visible hematuria should be evaluated, and cystoscopy is done when needed. Except for thin basement membranes, glomerular pathologies preclude donation. Active infection, active HBV, or HCV viral infections are contraindications. HIV and HTLV are also contraindications for donation. CMV positivity should be evaluated, and the risk of post-transplant CMV infection should be explained, especially in case the recipient is CMV-negative. This applies to EBV as well. In absence of metabolic reasons for kidney stones, donors may be accepted with the preference of donating kidneys with stones as long as split renal function allows. Some are incidental. Hematologic disease and evaluation of anaemias for hemoglobinopathies may need to be carefully considered.
Donor’s types and donor perceptive:
LRKT improved donation pool.
Welfare and safety of donor must be seeked.
Though compliance with both legal and medical act by transplantation center.
Donor give valid consent, without duress or coercion, and that reward is not a factor in the donation.
Understand potential risk of transplantation.
Donors can receive reimbursement of expenses, such as travel costs and loss of earnings result from donation of an organ.
. Types of Living Donation:
Directed donation, Paired or pool donation, Non-directed altruistic donation and directed altruistic donation.
Donor is not allowed for children below 18years and person without mental capacity (only by court).
Ethics:
Should be observed by all transplant team.
Independent assessment team is required for donors and recipient.
Psychiatric/psychological services must be available for donors/recipients requiring referral.
Confidentiality:
Should be maintained at outset and information shared decided at the start.
Donor advocacy and psychological services should be provided to donors.
Evaluation of donors:
Multi-disciplinary team and
Agreed, evidence-based protocol.
A logical sequence.
Option of a second opinion must always be available to donors and recipients if donor not found suitable.
Time of evaluation:
Variable, whenever recipient is ready for transplant.
Discussion with potential donors and recipients will usually be started when the recipient eGFR is approximately 20 mL/min or when the recipient is expected to require renal replacement therapy within 12-18 months.
Duration of evaluation:
Evaluation of a potential donor should be undertaken within an 18 WEEEKS
Evaluation should be planned.
An agreed donor assessment protocol must be in place.
A flow chart:
Early:
Early education & discussion with all potential transplant recipients +/- potential donors about optimal options for transplantation.
Establish recipient fit for transplantation & start appropriate pre-transplant assessment.
Weeks 0-2:
Donor identified, LD coordinator facilitates initial discussion with potential donor(s) +/- recipient & other family members as appropriate. Most appropriate should be identified, taking into account possible social, psychological and medical risk factors.
Weeks 2-4:
Primary contra-indications identified from donor(s) past and present medical history
ABO compatibility +/- HLA sensitization.
. Routine blood & urinalysis tests.
Weeks 4-8:
Donor evaluation is planned with the prospective donor, in a timely manner, to an agreed protocol & in accordance with the availability of local resources.
Weeks 8-10:
Results review by members of the MDT & feedback to the donor.
Weeks 11:
Suitable donor & recipient pair:
Referred for final preoperative discussion with Consultant Nephrologist and Transplant Surgeon.
Final cross match within the 7-10 days before transplantation and routine pre-op investigations,
Pre-admission visit.
Week 18:
OPERATION.
LD coordinator maintains contact with donor & facilitates life-long follow-up arrangements
If donor unsuitable, follow-up arranged.
In our centers less split test i used to assess donor kidney function.
Please summarize these guidelines in your own words
Requirements before transplantation:
1- Consent.
2- No reward or organ purchasing.
3- Independent assessor of donor and recipient.
Types of donors:
1- Directed to a specific recipient.
2- Non-directed.
3- Directed altruistic donation.
4- Paired donation.
The donors should be assessed for their mental health and physical safety for donation. They should be provided with information about the procedure, outcomes and complications.
Albuminuria occurs after donation with a slight increase in the risk of ESRD in donors. The risk of ESRD increase in current or former smoker, obese, diabetic, African- American and patients with albuminuria or renal impairment.
assessment of donor kidney functions is preferred by estimated GFR using serum creatinine (CKD-EPI) this is to exclude donors with CKD , this test should be confirmed by measuring creatinine clearance using 24 hours urine.
Safe threshold level for kidney donation is ≥ 80 mL/min for donors ≥ 30 years and ≥ 90 mL/min/1.73 m2 for those <30 years old.
Split kidney function helps assess the function of each kidney to donate the lower functioning kidney. it can be best done using 99mTcDMSA scanning.
Old age > 60 years is not a contraindication to donation. Donors should be evaluated and donor and recipient should be informed with the increase in risk of perioperative complications
Obese with BMI 25-30 kg/m2 can proceed to donation safely, those with BMI 30-35 kg/m2 can proceed to donation if they accept the peri-operative and long term risk associated with obesity and are willing to lose weight, patients with BMI >35 kg/m2 should be excluded form donation
Evaluation of BP before kidney donation
Guidelines for safe donation (regarding BP)
Donors with clinic BP ≺ 140/90 mm Hg (Home BP or AMBP ≺135/85 mmHg) on no antihypertensive medications: donate safely.
Donors with clinic BP ≺ 140/90 mm Hg (home BP or AMBP ≺135/85 mmHg) on 1 or 2 antihypertensive medications: can proceed safely to kidney donation if there is no evidence of end organ damage.
Donors with clinic BP ≥ 140/90 mm Hg on 2 antihypertensive medications: should be excluded from donation
Donors receiving more than 2 antihypertensive medications or having end organ damage should be excluded from donation.
Treatment of hypertension post donation as per British hypertension society guidelines.
All donors should be screened for proteinuria, if ACR > 30 mg/mmol or PCR> 50 mg/mmol and proteinuria> 500 mg/day –à excluded from donation.
All donors should be screened for hematuria in 2 separate occasions, if positive, they should be evaluated by urine culture, scanning and cystoscopy, renal biopsy can be done, if it reveals thin basement disease, the donor can proceed for the procedure.
Recipients are worked up for transplantation once GFR is below 20 ml/min/m2 and expected initiation of dialysis is within 1-1.5 years.
Donor evaluation: includes discussion, history, examination, investigations, planning, feedback of the donor, final pre-operative discussion, final cross match and routine peri-operative investigations.
Donors should be screened for infection as per protocol. Especially CMV status, EBV status.
Donors with renal stones can donate if not recurrent, if unilateral. They should donate the kidney with stones.
Vascular anatomy of the kidney should be assessed before donation using CTA or MRA.
If ABO and HLA incompatible-à kidney paired donation or desensitization should be done in expert center.
Cardiovascular assessment: non-invasive tests. If +ve coronary CT angiography, refer to cardiology for further evaluation and possible coronary angiography.
Risk of recurrence of original kidney disease should be discussed with both donor and recipient.
How these guidelines are different from the guidelines you follow at your workplace?
In my center, we deal with living related donation, all donors should have split renal function test by renal isotopic scan, kidneys with stone or masses are excluded from donation.
Ⅰ-comprehensive history and the physical exam:
1) The history of hypertension, diabetes, urinary tract infection (UTI), urinary symptoms, proteinuria or hematuria, nephrolithiasis, cardiovascular disease and its risk factors, thromboembolic events, gestational diabetes (GDM), low birth weight (if possible), birth weight of offspring(s), history of blood transfusion, and any significant medical conditions such as infectious diseases.
2) Female candidates with history of GDM in the past 10 years are excluded from
donation.
3) A history of alcohol abuse, smoking history, substance abuse, and NSAIDs usage should be taken.
4) Family history of diabetes, renal disease (Nephrolithiasis, ADPKD, IgA
nephropathy, SLE), and infectious diseases should be taken.
5) History of pregnancy or planning for pregnancy.
6) Body mass index should be calculated.
7) Blood pressure should be measured in office or by ABPM if indicated.
.
8) Signs of heart disease, lung disease, lymphadenopathy, hepatomegaly, and splenomegaly should be examined.
9) The vascular system (abdominal, femoral, carotid bruits) should be evaluated.
Ⅱ-Then laboratory investigations are necessary which include:
1) Blood group, Rh
2) Complete Blood Count (CBC), Differential
a) The potential donor with anemia must be evaluated for the etiology.
3) FBS
a) FBS ≥ 126 mgr/dl or post prandial glucose with oral GTT≥ 200 mg/dl or Hb A1c ≥ 6.5% preclude donation.
b) FBS between 100-126 mgr/dl with the history of diabetes in 1° relatives or obesity or gestational diabetes should be assessed by OGTT
4) BUN, Creatinine
a) Serum Creatinine level would be used to estimate GFR based on CKD-EPI
equation.
5) A comprehensive panel (Electrolytes, Lipid profile)
6) Uric acid
7) Liver function tests
8) PT, PTT, INR.
9) ESR, CRP
10) Urine analysis includes dipstick and microscopic evaluation and culture, protein excretion rate (ACR or PCR) must be done in all potential donors.
11) All the female prospective donors during the childbearing age should be tested for beta HCG.
12) Thrombophilia screen, the sickle cell trait, Hemoglobinopathy screen and G6PD (if indicated)
III. ASSESSMENT FOR LATENT AND ACTIVE INFECTIONS
1(VDRL or RPR
2) Wright’s test to detect brucellosis.
3) PPD with CXR
4) An antibody screening for HIV-1 and HIV-2.
5) HBsAg, HBsAb titer and HBcAb (IgM,IgG)
6) Anti-HCV Antibody (ELISA).
7) CMV antibodies (IgM, IgG).
8) EBV antibodies (IgM, IgG).
9) Anti-HSV Antibodies (IgM,IgG)
10) Anti HTLV1,2 antibodies.
11) Anti toxoplasma antibodies (IgM, IgG).
IV. HYPERTENSION
1) Donors should have at least 2 office blood pressure measurements less than 140/90 mm Hg.
V. OBESITY
1) Measurement of BMI is recommended.
VI. DIABETES MELLITUS
1) Donors with a positive history for diabetes or FBS equal or more than 126 mg/dL on at least two occasions or post prandial and OGTT ≥ 200 mg/dL or HbA1c ≥ 6.5% are excluded.
VI. CARDIOVASCULAR EVALUATION
1) All potential donors need an electrocardiogram and a CXR and echocardiography prior to surgery.
VII. PULMONARY EVALUATION
1) It is advised to quit smoking 4 weeks before the transplantation.
2) The pulmonary function test and pulmonary evaluation should be done in donors with a history of chronic lung disease or pulmonary symptoms.
VIII. MALIGANACY SCREENING
1) Age related malignancy screening should be done for prospective donors.
2) All the sexually active female donors should have a pap smear.
IX. RENAL FUNCTION
1) Estimating glomerular filtration (GFR) by CKD-EPI equation and measured GFR by EDTA are performed for donor evaluation. Safe GFRs for donation are according the following table (2, 24).
Summary
This guidance applies only to living donor kidney transplantation.
Type of donation:
1. Directed donation: (Genetically related donation &Emotionally related donation)
2. Paired or pool donation
3. Non-directed altruistic donation
4. Directed altruistic donation
Donor evaluation
The main target of donor evaluation is to confirm the convenience of the donor as well as minimization the risk of donation.
The confidentiality of the donor should be respected in addition to maintaining a strict separation of the mutual interests of the donor and recipient. In order to achieve this; two separate clinical teams assess the donor and recipient before donation.
A compatible ABO blood group and human leucocyte antigen (HLA) transplant offers the best opportunity for success
A full past and present medical history must be taken. A thorough clinical examination must be performed. A psychosocial assessment is recommended for all donors.
Crucial items concerning both the Medical and Family History of a candidate Potential Kidney Donor are:
Haematuria/proteinuria/urinary tract infection
Difficulty in passing urine, including urgency, frequency, dysuria
History of peripheral oedema
Gout
Nephrolithiasis
Hypertension
Diabetes mellitus, including family history
Ischemic heart disease/peripheral vascular disease/other atherosclerosis
Cardiovascular risk factors
Thromboembolic disease
Sickle cell and other haemoglobinopathies
Weight change
Change in bowel habit
Previous jaundice
Previous or current malignancy
Systemic disease which may involve the kidney
Chronic infection such as tuberculosis
Family history of a renal condition that may affect the donor
Smoking
Current or prior alcohol or drug dependence
Previous anaesthetic problem
History of back or neck pain and trauma
History with respect to Transmissible Infection
Previous illnesses: Jaundice or hepatitis, Malaria, Previous blood transfusion, Tuberculosis.
Increased risk of HIV, HTLV1 and HTLV2, Hepatitis B and C infection: Haemophiliac or sexual partner of haemophiliac, High risk sexual behaviour, History of infectious hepatitis or syphilis, History of intravenous drug use, Tattoo or skin piercing within last 6 months, Sexual partner of an individual with positive serology, Sexual partner of drug addict.
On Clinical Examination highlight the following:
Abdominal fat distribution
Blood pressure
Body mass index
Dipstick urinalysis
Evidence of self-harm
Examination for abdominal masses or herniae
Examination for scars or previous surgery
Examination for lymphadenopathy
Examination / history of regular self-examination of the breasts
Examination / history of regular self-examination of the testes
Examination of the cardiovascular and respiratory systems
Mental health
Routine Screening Investigations
Urine
Dipstick for protein, blood and glucose (at least twice)
Microscopy, culture and sensitivity (at least twice)
Measurement of protein excretion rate (ACR or PCR)
Blood
Haemoglobin and blood count
Coagulation screen (PT and APTT)
Thrombophilia screen
Creatinine, urea and electrolytes
Isotopic or other reference test for measurement of GFR
Liver function tests
Fasting plasma glucose
Virology and infection screen
Hepatitis B and C
HIV
Cytomegalovirus
Epstein-Barr virus
Toxoplasma
Cardiorespiratory system
Chest X-ray
ECG
ECHO
ASSESSMENT OF RENAL FUNCTION
Measurement of Renal Function: Initial evaluation by using estimated glomerular filtration rate (eGFR), in terms of mL/min/1.73m2 in a creatinine assay, followed by assessment by another reference measured method (mGFR) as clearance of 51Cr-EDTA, 125iothalamate or Iohexol.
Split renal function, evaluated by 99mTcDMSA scanning is recommended if there is >10% variation in kidney size or significant renal anatomical abnormality.
GFR Thresholds for Donation
Pre-donation mGFR ought to be within the gender and age-specific normal range. The potential donor must be consented for probability of increased lifetime risk of ESRD following donation.
Monitoring of Kidney Donor should be lifelong annual assessment of renal function at least serum creatinine, estimation of urine protein excretion and blood pressure measurement.
GFR in this normal population remains stable in both sexes until aged around 40 years and then declines each decade at a rate of 6.6 mL/min/1.73m2 for men and 7.7 mL/min/1.73m2 in women.
Increased lifetime risk ESRD in kidney donors is similar to the general population with exception of the presence of Hypertension, obesity and prediabetes.
A threshold GFR >80 mL/min/1.73m2 appears safe for donation in the 35 year and above age range. A threshold for donation of >90 mL/min/1.73m2 is set for those <30 years.
DONOR AGE
The older donor may be at greater risk of peri-operative complications and possibly the long-term survival of the graft may be affected which is apparent in cases with donors >60 years of age.
Pre-donation cardio-respiratory function should be carefully assessed in older donors. Most centres perform a stress echocardiogram and/or myocardial perfusion scan if indicated. Respiratory function tests are indicated in smokers and those with airway disease.
Screening of serum PSA is mandatory in males above 55 years.
Younger donors can develop later on diabetes, hypertension, obesity, immunologically mediated disease or other renal risk factors, and have more time for these risk factors to progress to CKD and finally ESRD.
DONOR OBESITY
Healthy overweight patients (BMI 25-30 kg/m2) can safely undergo kidney donation.
Moderately obese patients (BMI 30-35 kg/m2) necessitate careful preoperative assessment to exclude cardiovascular, respiratory and kidney disease as well as counselling about the increased risk of peri-operative complications. These donors must be advised to lose weight prior to donation and to maintain their ideal weight following donation. Obese donors have substantial increased risk of hypertension, hypercholesterolemia, insulin resistance and diabetes, heart disease, stroke, sleep apnoea and certain cancers. Obesity is considered a relative contra-indication to living kidney donation as there is a high increased risk for surgical complications.
Laparoscopic donor nephrectomy is an increasingly recommended safe procedure in the candidate healthy obese kidney donor and does not result in a high rate of major peri-operative complications.
HYPERTENSION IN THE DONOR
Blood pressure must be assessed on at least two separate occasions.
Ambulatory blood pressure monitoring or home monitoring is requested when blood pressure is high, high normal or variable, or the potential donor is on treatment for hypertension.
Blood pressure <140/90 mmHg is usually acceptable for donation.
Potential donors with mild-moderate hypertension that is controlled to <140/90 mmHg with one or two antihypertensive drugs and who have no evidence of end organ damage may be acceptable for donation.
DIABETES MELLITUS
Fasting plasma glucose concentration between 6.1-6.9 mmol/L is indicative of an impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be done.
CARDIOVASCULAR EVALUATION
Potential kidney donors with a history of cardiovascular disease, an exercise capacity of <4 metabolic equivalents (METS) or with risk factors for cardiovascular disease should undergo further evaluation prior to donation.
Cardiologists, anaesthetists and the transplant MDT is recommended as part of the clinical assessment of donors with higher cardiovascular and peri-operative risk.
CT coronary calcium scoring may be an alternative way of stratifying coronary risk.
PROTEINURIA
ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day or protein excretion >500 mg/day represent absolute contraindications for donation.
Orthostatic proteinuria should not be considered as a contraindication to donation.
NON-VISIBLE HAEMATURIA
All potential living donors must have reagent strip (dipstick) urinalysis performed on at least two separate occasions. Two or more positive tests, including trace positive, is considered as persistent non-visible haematuria (PNVH). If PNVH is present, perform urine culture and renal imaging to exclude common urologic causes including infection, nephrolithiasis and urothelial carcinoma. If no cause is found, perform cystoscopy in patients age >40 years to exclude bladder pathology.
The possible exception of Glomerular pathology is thin basement membrane disease. Renal biopsy may be needed.
INFECTION IN THE PROSPECTIVE DONOR
The presence of HIV or human T lymphotrophic virus (HTLV) infection is an absolute contraindication to living donation. Screening for HBV, HCV and HIV infection must be repeated within 30 days of donation. Active HBV and HCV infection in the donor are contraindications to living donor kidney donation.
The CMV status of donor and recipient must be determined before transplantation. When the donor is CMV positive and the recipient is CMV negative, the donor and recipient must be counselled about the risk of post-transplant CMV disease.
NEPHROLITHIASIS
In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as kidney donors.
In appropriate donors with unilateral kidney stone(s) the stone-bearing kidney can be considered for donation (if vascular anatomy and split kidney function permit) in order to leave the donor with a stone-free kidney post donation.
Follow Up these donors post donation by maintaining a high fluid intake for life (at least 2.5 litres of fluid per day) as well as regular follow-up imaging e.g. annual renal ultrasound and assessment of the metabolic profile should be considered.
ADPKD
A negative renal ultrasound beyond the age of 40 years excludes disease. Between the ages of 20-40 years, a negative ultrasound should be followed by a CT or MRI scan.
Our centre applies the British transplantation guidelines .
Please summarise these guidelines in your own words
Prerequisites:
There are three pre requisites before transplantation that include a proper consent from donor, it should be reward less, and acceptance report of donor and recipient should be assessed by an independent assessor.
Donors are either directed or non-directed. A directed altruistic donation could be the one in which A donor and recipient either know each other but have no blood relation between each other .A non-directed donation is the one in which the donor and recipient never met before or they go into go into paired donation
Mental health of potential altruistic donors should have a capacity to consent and that should be assessed by an experienced clinician.
Donor safety is the first priority and should be considered ,regardless of recipient benefit. He should be explained in detail about procedure , out come and safety
Donor Confidentiality should be ensured
If a donor does not meet centre specific criteria he/she should be offered a second opinion by other transplant centre.
Transplant recipient should be assessed first to be eligible for transplant and then donor should be evaluated as early as possible so that next donor can be screened in case of first donor failure.
Time of initiation of transplant workup
Once eGFR of the recipients is below 20 mL/min or if the recipient is expected to have a RRT within 1-1.5 years discussion between recipient and donor should be started.
Donor evaluation : it roughly takes around 18 weeks, discussion for first 2 weeks,, evaluation in next 2 weeks that includes history, examination, investigations including HLA typing and ABO, cross matching. 1 month for time planning, 2 weeks are given to donor for feedback , 6 weeks for final preoperative discussion. Last one week is just before transplantation 1 week before transplantation and a final repeat final cross match and routine preoperative investigations are done. Operation is done in 18th week.
Donor Education: every donor should be educated to minimize and control risks to prevent ESRD. Young child bearing age donors educated about gestational HTN and preeclampsia. An appropriate follow up plan after donation should be offered to all and if not fit they should be informed as soon as possible
To achieve best results ABO and HLA compatibility is a must. For ABO or HLA incompatibility the patient have options like KPD or desensitization which is done only in experienced centres.
Albuminuria –post operative is more common in donor and there is a slight increase in the risk of ESRD observed in donors. The risk of ESRD is more in current or former smoker, obese, diabetic, African- American and patients with albuminuria or renal impairment
It is always important to assess kidney functions pre operatively in donor by measuring estimated GFR using serum creatinine (CKD-EPI). This will help to exclude donors with evident CKD. Further confirmation is done by measuring creatinine clearance using 24 hours urine.
Safe threshold level for kidney donation is the least GFR at which the patient can safely donate his kidney if there is no other contraindications. This is ≥ 80 mL/min for donors ≥ 30 years and ≥ 90 mL/min/1.73 m2 for those <30 years old.
Donor with lower functioning kidney: Split Kidney Functions are done to assess the function of each kidney using 99mTcDMSA scanning which is indicated if there is >10% variation in kidney size or abnormal renal anatomy detected by CT.
If donor age > 60 years he/she should be evaluated rigorously and donor and recipient should be informed with the increase in risk of perioperative complications. But age above 60 is no contra indication.
Donors with BMI 25-30 kg/m2 can donate safely, those with BMI 30-35 kg/m2 can only donate if they accept the peri-operative and long term risk associated with obesity and are willing to lose weight, patients with BMI >35 kg/m2 should be excluded form donation.
HTN after kidney donation will develop if higher BP before donation, African American and Hispanic ethnicity and obesity, Elderly, these patients should be educated about the risk of developing hypertension after donation
Regarding Glycaemic control all donors should have fasting BG.If there are risk factors such as obesity, positive family history of DM, history of gestational DM, African-American OGTT is performed. HBA1c can identify the donor as normal, impaired fasting, IGT or diabetic.
Donors with impaired fasting or IGT need to be educated about the risk of developing DM while having single kidney and after addressing all cardiovascular risk factors (smoking, hyperlipidemia, hypertension) and if they understand the outcomes they should proceed for donation
Potential donors with DM can donate once fully educated about post donation outcome , provided cardiovascular system is controlled and no target end-organ damage is observed.
Potential donors with Low risk can proceed for kidney donation after normal resting ECG, ECHO
Potential donors with High Cardiovascular risk factors:This needs to be evaluated by non-invasive testing. This can be stress echo or cardiac scintigraphy. Sometimes if needed CT angiography and if positive, patient should be referred for cardiology evaluation and possible angiography
Proteinuria in donors:
Screening for prorienuria is done with urine ACR or PCR, and if abnormal , 24 hours urinary protein test is done to confirm proteinuria.
Hematuria in donor Urine:
Urine analysis is done in 2 separate occasionsin all potential donors to screen Hematuria , if both tests positive it is considered a case of positive non visible Hematuria (PNVH).
PNVH positive non visible Hematuria (PNVH).
This is further evaluated by urine culture and imaging. Cystoscopy should be done if donor is above 40 years and culture is negative. If Imaging is ,renal biopsy should be done. If any form of glomerulonephritis is found it becomes a contraindication to transplantation except TBMD.
Persistent sterile pyuria is a contraindication for donation, while transient pyuria due to UTI can donate.
Donor virology and serology
HBV, HCV, HIV and virology should be done pre operatively and then repeated after 1 month of donation. Active HBV, HCV infection, presence of HIV or HTLV are considered contraindications to donation
If the donor isCMV positive, recipient should be informed about the risk of CMV activation and the prophylaxis regimen should be explained with possible side effects.
If the donor is EBV positive and the recipient is negative, recipient should be informed about the risk of PTLD post transplantation
Renal stones: Nephrolithiasis if not recurrent due to metabolic abnormality does not stop one from donation. In case of unilateral nephrolithiasis It is recommended to donate the kidney containing stone.
Anaemic patient,anemia needs proper workup and cause identified and treated. In case of haemoglobinopathies the decision for donation is made on the type and its long-term effect.
Family History: Detailed family history of renal disease, especially if the donor and recipient are genetically related needs to be obtained.
Active malignancy :
It should be excluded before donation, certain low grade malignancy need to be treated successfully before kidney donation. All donors >50 years need to be screened for occult malignancy.
Renal mass should be diagnosed using US, CT with contrast or MRI
ANGIOMYOLIPOMA:
The presence of incidental bilateral or unilateral AML >4 cm are contraindication to donation,
Unilateral AML 1-4 cm can be considered for donation with or without excision
Patient with AML <1 cm can donate without excision
Renal cell carcinoma:
Unilateral RCC <4 cm can donate their kidney after complete excision of the mass and reconstruction.
Abnormal Renal Vasculature:
Before donation vascular anatomy of the donor kidney should be evaluated using CTA or MRA. Case of donor kidney with multiple renal arteries or with abnormal, anatomy is not considered absolute contraindication but such case need to be discussed individually.
Donor surgical management:
Intra and post- operative hydration of donor is mandatory using normal saline. Thromboprophylaxis in the form of intraoperative bothmechanical compression stocking and pharmacological with LMWH.
Laparoscopic kidney retrieval is the best choice and if open surgery is indicated mini-incision surgery is recommended. Haem-o-lok clips are not recommended to be used for securing the renal artery
Post operatively enhanced recoveryprotocols after surgery (ERAS) are associated with better outcome.
Cautions for pregnant ladies:
Rt or Lt kidney in a female in child bearing period can be donated without any added risk of hydronephrosis . In pregnant female with unilateral kidney it is important to closely monitor BP, creatinine and foetus , and aspirin 75 mg can be given to prevent preeclampsia
The risk of recurrence of original kidney disease should be discussed with the recipient and donor. These are the conditions associated with more chances of recurrence of original disease. Primary FSGS, Type 1 p Oxaluria etc
End stage renal disease in a child:
The the gold standardtherapy for ESRD in a child is pre-emptive matched living related renal transplantation. If a child weight is ≥10 kg he/she can receive an adult kidney.
How these guidelines are different from the guidelines you follow at your workplace?
Use HBA1c in assessment of glucose intolerance
BMI> 30- Exclude from donation
ERAS is used in our practice
No practice on HLAi/ABOi
We do split kidney function
Donor with anatomical abnormalities are excluded
LEGAL FRAMEWORK
DONOR EVALUATION: SUMMARY
Donor Age
DONOR OBESITY
HYPERTENSION IN THE DONOR
o Blood pressure is not controlled to <140/90 mmHg on one or two
antihypertensive drugs
o Evidence of end organ damage (retinopathy, left ventricular
hypertrophy, proteinuria, previous cardiovascular disease)
o Unacceptable risk of future cardiovascular risk or lifetime
incidence of ESRD
DIABETES MELLITUS
CARDIOVASCULAR EVALUATION
PROTEINURIA
NON-VISIBLE HAEMATURIA
INFECTION IN THE PROSPECTIVE DONOR
NEPHROLITHIASIS
FAMILIAL RENAL DISEASE
DONOR MALIGNANCY
Guidelines For Living Donor Kidney Transplantations
1. Introduction:
▪︎In these guidelines, the GRADE system has been used to rate the quality of
evidence and the strength of recommendations.
▪︎This approach is consistent with that adopted by KDIGO in its recent guidance relating to renal transplantation, and also with guidelines from the European Best Practice Committee, and from the Renal Association.
▪︎For each recommendation the quality of evidence has been graded as one of:
A (high)
B (moderate)
C (low)
D (very low)
▪︎For each recommendation, the strength of recommendation has been indicated as one of:
Level 1 (recommended)
Level 2 (suggested)
Not graded (where there is not enough evidence to allow formal grading)
▪︎These guidelines represent consensus opinion from experts in the field of transplantation in the United Kingdom. They represent a snapshot of the evidence available at the time of writing. It is recognised that recommendations are made even when the evidence is weak. It is felt that this is helpful to clinicians in daily practice and is similar to the approach adopted by KDIGO .
2. LEGAL FRAMEWORK
Recommendations
· All transplants performed from living donors must comply with the requirements of the primary legislation which regulate transplantation & organ donation across the United Kingdom. (Not graded)
· All transplant centres performing living organ donation must be licensed by the Human Tissue Authority in line with the requirements of the European Union Organ Donation Directive which sets out the minimum requirements for the Quality and Safety of Organs for
Transplantation. (Not graded)
· Consent for the removal of organs from living donors, for the purposes
of transplantation, must comply with the requirements of the Human
Tissue Act 2004, and the Mental Capacity Act 2005 in England and Wales, and the Mental Capacity Act 2016 in Northern Ireland. Consent
in Scotland must comply with the Human Tissue (Scotland) Act 2006
and the Adults with Incapacity (Scotland) Act 2000. (Not graded)
3. ETHICS
Recommendations
· All health professionals involved in living donor kidney transplantation
must acknowledge the wide range of complex moral issues in this field
and ensure that good ethical practice consistently underpins clinical practice. The BTS has an Ethics Committee to provide additional support and advice if required. (Not graded)
· Regardless of potential recipient benefit, the safety and welfare of the potential living donor must always take precedence over the needs of the potential transplant recipient. (Not graded)
· Independence is recommended between the clinicians responsible for
the assessment and preparation of the donor and the recipient, in
addition to the Independent Assessor for the Human Tissue Authority.
(Not graded)
4. SUPPORTING AND INFORMING THE POTENTIAL DONOR
Recommendations
· The living donor must be offered the best possible environment for making a voluntary and informed choice about donation. The
transplant team must provide generic information that is relevant to all donors as well as specific information that is material to the person intending to donate. This includes information about the assessment process and the benefits and risks of donation to the individual donor.
(B1)
· Independent assessment of the donor and recipient is required by primary legislation (Human Tissue Act 2004). (Not graded)
· To achieve the best outcome for donor, recipient and transplant, the boundaries of confidentiality must be specified and discussed at the outset. Relevant information about the recipient can only be shared
with the donor if the recipient has given consent and vice versa. Both
the recipient and donor must be informed that it is necessary and usual
for all relevant clinical information to be shared across the transplant
team in order to optimise the chance of a successful outcome for the transplant. (B1)
· Ideally, the recipient will discuss relevant information with their donor,
or allow it to be shared. If the recipient is not willing to disclose information, then the transplant team must decide whether it is
possible to communicate the risks and benefits of donating adequately, without needing to disclose specific medical details. (Not graded)
· Separate clinical teams for donor and recipient are considered best
practice but healthcare professionals must work together to ensure
effective communication and co-ordination of the transplant process without compromising the independence of either donor or recipient.
It is essential that an informed health professional who is not directly involved with the care of the recipient acts as the donor advocate in
addressing any outstanding questions, anxieties or difficult issues, and assists the donor in making a truly autonomous decision. (B1)
· Support for the prospective donor, recipient and family is an integral
part of the donation/transplantation process. Psychological needs must be identified at an early stage in the evaluation to ensure that
appropriate support and/or intervention is initiated. Access to specialist psychiatric/psychological services must be available for donors/recipients requiring referral. (B1)
5. DONOR EVALUATION:
5.2 Recommendations
· In cases of directed donation (to a known recipient) the likely suitability of the potential recipient for transplantation must be established before
starting donor assessment. If additional recipient assessment is required, unnecessary delay should be avoided. Non-invasive
assessment of the donor may be undertaken in this phase. (Not graded)
· As far as possible, donor assessment is planned to minimise inconvenience to him/her and to avoid unnecessary barriers to
proceeding. Flexibility in terms of timescales, planning consultations,
attending for investigations and date of surgery is helpful. (Not graded)
· Donor assessment must be planned to ensure that it is focused, logical & coherent. Good communication with the donor and involvement of
the wider multi-disciplinary team is essential and is achieved most effectively if a designated co-ordinator leads the organisation of the assessment process. The results of investigations must be relayed accurately and efficiently to the potential donor. Unsuitable donors
must be identified at the earliest possible stage of assessment. (Not graded)
· A policy must be in place to manage prospective donors who are found
to be unsuitable to donate and appropriate follow-up and support must
be made available. (Not graded)
· The organisational aspects for donor evaluation will vary between
centres, according to available resources and personnel, but the same
principles apply for all donors. An agreed donor assessment protocol
must be in place that is tailored to the needs of the individual. (Not graded)
· To facilitate pre-emptive transplantation, donor evaluation must start
sufficiently early to allow time for more than one donor to be assessed
if required. Information must be provided at an early stage and discussion with potential donors and recipients will usually be started when the recipient eGFR is approximately 20 mL/min or when the
recipient is expected to require renal replacement therapy within 12-18
months. Recipient and donor assessment can then be tailored according to the rate of decline of recipient renal function, disease
specific considerations and individual circumstances. (B2)
· The evaluation of a potential donor should be undertaken within an 18
week pathway, assuming there are no logistical issues such as donor
unavailability. There may, of course, be pauses if the recipient’s transplant assessment is complicated or if the recipient’s renal
function remains satisfactory.
5.3. ABO BLOOD GROUPING AND CROSSMATCH TESTING
Recommendations
· A compatible ABO blood group and human leucocyte antigen (HLA)
transplant offers the best opportunity for success. (A1)
· Where ABO or HLA incompatibility is present, alternative options for
transplantation must be discussed with the donor and recipient, including paired/pooled donation and antibody incompatible
transplantation. Antibody incompatibletransplantation must only be performed in a transplant centre with the relevant experience and
appropriate support. (A1)
5.5. ASSESSMENT OF RENAL FUNCTION
Recommendations
Measurement of Renal Function
· Initial evaluation of donor candidates should be using eGFR, expressed as mL/min/1.73m2 computed from a creatinine assay standardised to the International Reference Standard. (B1)
· GFR must subsequently be assessed by a reference measured method (mGFR) such as clearance of 51Cr-EDTA, 125iothalamate or Iohexol performed according to guidelines published by the British Society of Nuclear Medicine. (B1)
· Differential kidney function, determined by 99mTcDMSA scanning is
recommended where there is >10% variation in kidney size or significant renal anatomical abnormality. (C1
Advisory GFR Thresholds for Donation
· Pre-donation mGFR should be such that the predicted post-donation
GFR remains within the gender and age-specific normal range within the donor’s lifetime. (B1)
· The risk of end-stage renal disease (ESRD) after 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 consented. (D2)
· The decision to approve donor candidates whose renal function is below the advisory GFR threshold or who have additional risk factors for the development of ESRD should be individualised and based on
the predicted lifetime incidence of ESRD. (D2)
· The renal function requirements of the intended recipient, based upon the absolute GFR of the donor, are relevant to the decision to donate
(in a directed donation) and to the acceptance of a kidney offer from a
non-directed donor or within the UK Living Kidney Sharing Schemes.
(Not Graded)
Monitoring of Kidney Donor
· The donor must be offered lifelong annual assessment of renal function including serum creatinine, estimation of urine protein excretion and
blood pressure measurement. (B1)
5.6. DONOR AGE
Recommendations
· Old age alone is not an absolute contraindication to donation but the medical work-up of older donors must be particularly rigorous to ensure they are suitable. (A1)
· Both donor and recipient must be made aware that the older donor may be at greater risk of peri-operative complications and that the function and possibly the long-term survival of the graft may be compromised.
This is particularly evident with donors >60 years of age. (B1)
5.7. DONOR OBESITY
Recommendations
· Otherwise healthy overweight patients (BMI 25-30 kg/m2) may safely
proceed to kidney donation. (B1)
· Moderately obese patients (BMI 30-35 kg/m2) must undergo careful preoperative evaluation to exclude cardiovascular, respiratory and kidney
disease. (C2)
· Moderately obese patients (BMI 30-35 kg/m2) must be counselled about
the increased risk of peri-operative complications based on extrapolation of outcome data from very obese donors (BMI >35 kg/m2).
(B1)
· Moderately obese patients (BMI 30-35 kg/m2) must be counselled about the long-term risk of kidney disease and be advised to lose weight before donation and to maintain their ideal weight following donation.
(B1)
· Data on the safety of kidney donation in the very obese (BMI >35 kg/m2)
are limited and donation should be discouraged. (C
5.8. HYPERTENSION IN THE DONOR
Recommendations
· Blood pressure must be assessed on at least two separate occasions.
Ambulatory blood pressure monitoring or home monitoring is recommended if blood pressure is high, high normal or variable, or thepotential donor is on treatment for hypertension. (C2)
· We suggest that a blood pressure <140/90 mmHg is usually acceptable
for donation. (C1)
· Prospective donors must be warned about the risk of developing
donation-related hypertension, particularly if in a high-risk group.
Blood pressure measurement is part of annual donor monitoring. (C1)
· Potential donors with mild-moderate hypertension that is controlled to
<140/90 mmHg (and/or 135/85 mmHg with ABPM or home monitoring)
with one or two antihypertensive drugs and who have no evidence of
end organ damage may be acceptable for donation. Acceptance will be
based on an overall assessment of cardiovascular risk and local policy.
(C1)
· It is recommended that potential donors with hypertension are
excluded from donation if: (C1)
o Blood pressure is not controlled to <140/90 mmHg on one or two
antihypertensive drugs
o Evidence of end organ damage (retinopathy, left ventricularhypertrophy, proteinuria, previous cardiovascular disease)
o Unacceptable risk of future cardiovascular risk or lifetime
incidence of ESRD
· All living kidney donors must be encouraged to minimise the risk of
hypertension and its consequences before and after donation by
lifestyle measures including stopping smoking, reducing alcohol
intake, frequent exercise and, where appropriate, weight loss. (C1)
BTS/RA Living Donor Kidney Transplantation Guidelines 2018 91
· It is recommended that donors who are diagnosed with hypertension
during assessment or who develop hypertension following donation
are managed according to British Hypertension Society guidelines.
(B1)
5.9. DIABETES MELLITUS
Recommendations
· All potential living kidney donors must have a fasting plasma glucose
level checked. (B1)
· A fasting plasma glucose concentration between 6.1-6.9 mmol/L is
indicative of an impaired fasting glucose state and an oral glucose
tolerance test (OGTT) should be undertaken. (B1)
· Prospective donors with an increased risk of type 2 diabetes because
of family history, a history of gestational diabetes, ethnicity or obesity
should also undergo an OGTT. (B1)
· If OGTT reveals a persistent impaired fasting glucose and/or an
impaired glucose tolerance, then the risks of developing diabetes after
donation must be carefully considered. (B1)
· Consideration should be given to the use of a diabetes risk calculator
to inform the discussion of potential kidney donation. (B2)
· Consideration of patients with diabetes as potential kidney donors
requires very careful evaluation of the risks and benefits. In the
absence of evidence of target organ damage and having ensured that
other cardiovascular risk factors such as obesity, hypertension or
hyperlipidaemia are optimally managed, diabetics can be considered
for kidney donation after a thorough assessment of the lifetime risk of
cardiovascular and progressive renal disease in the presence of a
single kidney. (Not graded)
5.10. CARDIOVASCULAR EVALUATION
Recommendations
· There is no evidence to support the routine use of stress testing in the
assessment of the potential donor at low cardiac risk. (C2)
· Potential kidney donors with a history of cardiovascular disease, an
exercise capacity of <4 metabolic equivalents (METS) or with risk
factors for cardiovascular disease should undergo further evaluation
before donation. (C2)
· For higher risk potential donors, stress testing is recommended by
whichever method is locally available or by CT calcium scoring . (C2)
· Discussion with and/or review by cardiologists, anaesthetists and the
transplant MDT is recommended as part of the clinical assessment of
donors with higher cardiovascular and peri-operative risk. (D2)
5.11. PROTEINURIA
Recommendations
· Urine protein excretion needs to be quantified in all potential living
donors. (B1)
· A urine albumin/creatinine ratio (ACR) performed on a spot urine
sample is the recommended screening test, although urine
protein/creatinine ratio (PCR) is an acceptable alternative. (A1)
· ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day
or protein excretion >500 mg/day represent absolute contraindications
to donation. (C2)
· The significance of moderately increased albuminuria (ACR 3-30
mg/mmol) and proteinuria (PCR 15-50 mg/mmol or 24-hour urine
protein 150-500 mg/day) has not been fully evaluated in living kidney
donors. However, since the risk of CKD and cardiovascular morbidity
increase progressively with increasing albuminuria or proteinuria such levels are a relative contraindication to donation. (C2)
5.12. NON-VISIBLE HAEMATURIA
Recommendations
· All potential living donors must have reagent strip (dipstick) urinalysis
performed on at least two separate occasions. (B1)
· Two or more positive tests, including trace positive, is considered as
persistent non-visible haematuria (PNVH). (B1)
· If PNVH is present, perform urine culture and renal imaging to exclude
common urologic causes including infection, nephrolithiasis & urothelial carcinoma. (A1)
· If no cause is found, perform cystoscopy in patients age >40 years to
exclude bladder pathology. (B1)
· If no cause is found and the donor still wishes to donate, then a kidney
biopsy is recommended if haematuria is 1+ or greater on dipstick testing. (B1)
· Glomerular pathology precludes donation, with the possible exception of TMD. (B1)
· For donors with persistent asymptomatic non-visible haematuria
(PANVH) and a family history of haematuria or X-linked Alport syndrome, a renal biopsy (B1) and referral to a clinical geneticist are recommended. (B2)
5.13. PYURIA
Statement of Recommendation
· Prospective donors found to have pyuria can only be considered for donation if it can be demonstrated that the pyuria is due to a reversible cause, such as an uncomplicated urinary tract infection. (C1)
5.14. INFECTION IN THE PROSPECTIVE DONOR
Recommendations
· Screening for infection in the prospective donor is essential to identify
potential risks for the donor from previous or current infection and to
assess the risks of transmission of infection to the recipient. (B1)
· Active HBV and HCV infection in the donor are usually contraindications to living donor kidney donation; however, donors
with evidence of active viral replication may be considered under some
circumstances. (B1)
· The presence of HIV or human T lymphotrophic virus (HTLV) infection
is an absolutecontraindication to living donation. (B1)
· Screening for HBV, HCV and HIV infection must be repeated within 30
days of donation. (Not graded)
· All potential donors should be provided with dietary advice regarding
avoidance of HEV infection, and screening should be undertaken for
HEV viraemia by nucleic acid testing within 30 days of donation. (Not
graded)
· The CMV status of donor and recipient must be determined before
transplantation. When the donor is CMV positive and the recipient is
CMV negative, the donor and recipient must be counselled about the
risk of post-transplant CMV disease. (B1)
· The EBV status of donor and recipient must be determined before
transplantation. When the donor is EBV positive and the recipient is
EBV negative, the donor and recipient must be counselled about the
risk of developing Post Transplant Lymphoproliferative Disease. (B1)
· Potential donors must be screened by history for travel or residence
abroad to assess their potential risk for having acquired endemic
BTS/RA Living Donor Kidney Transplantation Guidelines 2018 126
infections and appropriate microbiological investigations instigated if
indicated. (Not graded)
5.15. NEPHROLITHIASIS
Recommendations
· In the absence of a significant metabolic abnormality, potential donors
with a limited history of previous kidney stones, or small renal stone(s)
on imaging, may still be considered as potential kidney donors. Full
counselling of donor and recipient is required along with access to
appropriate long-term donor follow up. (C2)
· Potential donors with metabolic abnormalities detected on screening
should be discussed with a specialist in renal stone disease. (C2)
· In appropriate donors with unilateral kidney stone(s) the stone-bearing
kidney can be considered for donation (if vascular anatomy and split
kidney function permit) in order to leave the donor with a stone-free
kidney after donation. (C2)
5.16. HAEMATOLOGICAL DISEASE
Recommendations
· Donor anaemia needs to be investigated and treated before donation.
(A1)
· A haemoglobinopathy screen must be carried out in patients with nonNorthern European heritage or if indicated by the full blood count. (A1)
· Careful consideration needs to be given to the use of potential donors
with haemoglobinopathies. (B1)
· Advice from a consultant haematologist is recommended for
haematological conditions not covered in this guideline. (Not graded
5.17. FAMILIAL RENAL DISEASE
Recommendations
· All potential transplant recipients must have a detailed family history
recorded and confirmation where possible of the diagnosis in other
family members with known kidney disease. This may aid diagnosis for
the recipient, clarify any mode of inheritance and identify at risk
relatives. (A1)
· When the cause of kidney failure in the recipient is due to an inherited
condition, appropriate tests – including genetic testing if available – are
recommended to exclude genetic disease in the potential donor. (A1)
· Many inherited kidney diseases are rare, so involvement of clinical and
laboratory genetics services must be considered at an early stage to
assess likely risks to family members and the appropriate use of
molecular genetic testing. (B1)
5.18. DONOR MALIGNANCY
Recommendations
· Careful history taking, clinical examination and investigation of
potential donors are essential to exclude occult malignancy before
kidney donation, particularly in older (age >50 years) donors. (B1)
· Active malignant disease is a contraindication to living donation but
donors with certain types of successfully treated low-grade tumour
may be considered after careful evaluation and discussion. (B1)
· Donors with an incidental renal mass lesion must have this diagnosed
and managed on its own merit (out with discussion of kidney donation)
with appropriate referral to a Urology Specialist in line with the ‘2-week
wait’ pathway. (A1)
· Contrast enhanced renal CT scan, ultrasound and / or MRI can usually
distinguish between benign lesions such as angiomyolipoma (AML) or
malignancy such as renal cell carcinoma (RCC). Review by a specialist
uroradiologist is recommended. (C1)
· Bilateral AML and AML >4 cm generally preclude living kidney donation
although occasionally unilateral large (>4 cm) AML can be used if ex
vivo excision of the AML appears to be straightforward.
· An incidental, unilateral solitary AML <4 cm with typical characteristic
CT criteria does not usually preclude donation.
· A kidney with an AML <1 cm may be considered for donation or left in
situ in the donor’s remaining kidney.
· Kidneys containing a single AML between 1 and 4 cm can be considered for donation depending on its position, consideration of
whether ex vivo excision of the AML is straightforward, or whether it
BTS/RA Living Donor Kidney Transplantation Guidelines 2018 160
can be left in situ in the recipient and followed with serial ultrasound
imaging. (C1)
· Donors with an incidental small (<4 cm) renal mass that appears on
imaging to be a RCC must be seen in a specialist Urology clinic and be
offered standard of care treatment options, including partial and radical
nephrectomy. Renal function permitting, if the person wishes to
consider radical nephrectomy, ex-vivo excision of the small renal mass
with subsequent donation of the reconstructed kidney can be
considered on an individual basis with specific caveats, full MDM
discussion and appropriate informed consent from the donor and recipient. (D2)
6. SURGERY: TECHNICAL ASPECTS, DONOR RISK AND
PERI-OPERATIVE CARE
Recommendations
· Work-up for living kidney donation may include direct or indicative
evaluation of split renal function with the kidney with poorer function
selected for nephrectomy irrespective of vascular anatomy (see
Chapter 5.5). (C2)
· Work-up for living kidney donation must include detailed imaging
confirming the vascular anatomy of both donor kidneys and
information about the renal parenchyma and collecting systems. Either
CTA or MRA can be used as current evidence indicates little difference
in accuracy. (B1)
· Multiple renal arteries or kidneys with anatomical anomalies are not
absolute contraindications to donation. Decisions must be made on an
individual basis as part of a multi-disciplinary team evaluation. (B2)
· All living donors must receive adequate thromboprophylaxis. Intraoperative mechanical compression and post-operative compression
stockings, along with low molecular weight heparin, are recommended.
(A2)
· All living donor surgery must be performed or directly supervised by a
Consultant surgeon with appropriate training in the technique. (C1)
· Pre-operative hydration with an overnight infusion and/or a fluid bolus
during surgery improves cardiovascular stability during laparoscopic
donor nephrectomy. (B2)
· Pre- and peri-operative intravenous fluid replacement with Hartmann’s
solution is preferred to 0.9% Saline. (B2)
· Laparoscopic donor surgery (fully laparoscopic or hand-assisted) is
the preferred technique for living donor nephrectomy, offering a
BTS/RA Living Donor Kidney Transplantation Guidelines 2018 172
quicker recovery, shorter hospital stay and less pain. Mini-incision
surgery is preferable to standard open surgery. (B1)
· Haem-o-lok clips are not to be used to secure the renal artery during
donor nephrectomy following a report of an adverse event involving
this technique.(C2)
· Patients undergoing living donor nephrectomy are likely to benefit
from the management approaches widely used in “enhanced recovery
after surgery” (ERAS) programmes. (D2)
7. HISTOCOMPATIBILITY TESTING FOR LIVING DONOR KIDNEY
TRANSPLANTATION
Recommendations
· Initial assessment of donor and recipient histocompatibility status
must be undertaken at an early stage in living donor kidney transplant
work-up to avoid unnecessary and invasive clinical investigation. (B2)
· Screening of potential living donor kidney transplant recipients for
clinically relevant antibodies is important for ensuring optimal donor
selection and graft survival. (A1)
· Antibody screening is especially important when potential living donor
transplant recipients undergo reduction or withdrawal of
immunosuppression. (B2)
· Post-transplant antibody monitoring must be undertaken according to
the BSHI/BTS guidelines. (B1)
· Transplant units and histocompatibility laboratories must agree an
evidence-based protocol to define antibody screening and crossmatch
results that constitute a high immunological risk to transplantation.
(B2)
· When possible, the HLA type(s) of partners/offspring of female
recipients who have had previous pregnancies should be determined
to aid immunological risk assessment for repeat paternal HLA
mismatches in women with low level DSA. (B1)
· A pre-transplant serum sample collected within 14 days of the planned
date for transplantation must be tested in a sensitive antibody
screening and donor crossmatch assay and transplantation should not
usually be performed if the crossmatch test is positive, unless the
antibody is shown to be indicative of acceptable immunological risk.
(A1)
BTS/RA Living Donor Kidney Transplantation Guidelines 2018 192
· Changes in immunosuppression during the transplant work-up must
be notified to the histocompatibility laboratory and additional antibody
screening and donor-recipient crossmatch tests must be undertaken
as indicated. (B1)
· HLA matching may be preferred when there is an option of selecting
between living donors, particularly to reduce the possibility of
subsequent sensitisation. This is important for younger recipients
where repeat transplantation may be required. However, it is
recognised that other donor factors will be taken into account. (B1)
· For patients with an ABO/HLA incompatible and/or a poorly HLA
matched living donor, consideration should be given to entry into the
UK living kidney sharing scheme (UKLKSS) to identify a more suitable
donor. (B2)
· The histocompatibility laboratory must issue an interpretive report
stating the donor and recipient HLA mismatch, recipient sensitisation
status and crossmatch results, and define the associated
immunological risk for all living donor-recipient pairs. (A1)
8. EXPANDING THE DONOR POOL
Recommendations
· Coherent organisational and clinical practices are essential between
transplant centres to optimise the UK Living Kidney Sharing Schemes
(UKLKSS) and to maximise the number of potential transplants that
proceed. (B1)
· To maximise transplant opportunities within the UKLKSS, donors and
recipients must only be included in a matching run if:
o Their clinical assessment and histocompatibility screening are
complete and up to date. (B1)
o If matched, they are available to attend for crossmatch testing
and proceed to surgery within the designated timeframes. (B1)
o Relevant complex donor considerations identified in the ‘prerun’ and donor HLA and age preferences have been discussed
and agreed with the recipient. (B1)
o They understand their roles and responsibilities with respect to
other donors and recipient pairs in the schemes with whom they
may be matched. (B1)
· The default for all non-directed altruistic kidney donors (NDADs) is to
donate into an altruistic donor chain (ADC) within the UKLKSS
provided that there is no higher priority patient on the national transplant list. (B1)
· All altruistic donors (non-directed and directed) must undergo formal mental health assessment with a mental health professional before donation. (C1)
· Living kidney donors who are antibody incompatible with their recipient must have all the options and risks explained to them,
including donation into the UKLKSS and antibody removal. (C1)
*This guidance relates only to living donor kidney transplantation and reflects a growing body of evidence, incorporating aspects of clinical practice that are relevant
to both adult and paediatric settings.
# Ethics Recommendations
* All health professionals involved in living donor kidney transplantation
must acknowledge the wide range of complex moral issues in this field
and ensure that good ethical practice consistently underpins clinical practice.
* Regardless of potential recipient benefit, the safety and welfare of the potential living donor must always take precedence over the needs of the potential transplant recipient.
* Independence is recommended between the clinicians responsible for
the assessment and preparation of the donor and the recipient, in addition to the Independent Assessor for the Human Tissue Authority.
*a living donor kidney transplant would almost always be the preferred option, with better transplant and patient survival than for deceased donation.
*Donating a kidney involves a detailed process of investigation, major surgery, and
a significant period of recovery.
The collective transplant MDT is responsible for informing the potential donor of the
risks associated with living kidney donation.
# SUPPORTING AND INFORMING THE POTENTIAL DONOR
*The living donor must be offered the best possible environment for making a voluntary and informed choice about donation.
* Independent assessment of the donor and recipient is required by primary legislation.
*To achieve the best outcome for donor, recipient and transplant, the boundaries of confidentiality must be specified and discussed at the outset. Relevant information about the recipient can only be shared with the donor if the recipient has given consent and vice versa.
* Ideally, the recipient will discuss relevant information with their donor, or allow it to be shared. If the recipient is not willing to disclose information, then the transplant team must decide whether it is possible to communicate the risks and benefits of donating adequately, without needing to disclose specific medical details.
*Separate clinical teams for donor and recipient are considered best practice but healthcare professionals must work together to ensure effective communication and co-ordination of the transplant process without compromising the independence of either donor or recipient.
*It is essential that an informed health professional who is not directly.
*Psychological problems are infrequent after donation and most donors experience
increased self-esteem, whilst donor and recipient relationships are enhanced.
# Death and Transplant Failure
*LDKT is increasingly considered the treatment of choice for recipients with higher
baseline comorbidity.
* An increased risk of post-operative co-morbidity, transplant failure and death is likely and the appropriate management of expectations is an essential part of the pre-transplant preparation for all parties concerned.
# DONOR EVALUATION
*The primary goal of the donor evaluation process is to ensure the suitability of the
donor and to minimise the risk of donation.
* In cases of directed donation the likely suitability of the potential recipient for transplantation must be established before starting donor assessment. If additional recipient assessment is required, unnecessary delay should be avoided. Non invasive assessment of the donor may be undertaken in this phase. (Not graded)
* As far as possible, donor assessment is planned to minimize inconvenience to him/her and to avoid unnecessary barriers to proceeding. Flexibility in terms of timescales, planning consultations, attending for investigations and date of surgery is helpful. (Not graded)
* Donor assessment must be planned to ensure that it is focused, logical and coherent. Good communication with the donor and involvement of
the wider multi-disciplinary team is essential and is achieved most
effectively if a designated co-ordinator leads the organisation of the
4l8assessment process. The results of investigations must be relayed
accurately and efficiently to the potential donor. Unsuitable donors
must be identified at the earliest possible stage of assessment. (Not graded)
* A policy must be in place to manage prospective donors who are found
to be unsuitable to donate and appropriate follow-up and support must
be made available. (Not graded)
*The organisational aspects for donor evaluation will vary between centres, according to available resources and personnel, but the same
principles apply for all donors. An agreed donor assessment protocol
must be in place that is tailored to the needs of the individual.
*To facilitate pre-emptive transplantation, donor evaluation must start sufficiently early to allow time for more than one donor to be assessed if required. Information must be provided at an early stage and discussion with potential donors and recipients will usually be started when the recipient eGFR is approximately 20 mL/min or when the recipient is expected to require renal replacement therapy within 12-18 months. Recipient and donor assessment can then be tailored according to the rate of decline of recipient renal function, disease specific considerations and individual circumstances. (B2)
*The evaluation of a potential donor should be undertaken within an 18 week pathway, assuming there ar/e no logistical issues such as donor unavailability.
#ABO BLOOD GROUPING AND CROSSMATCH TESTING
* A compatible ABO blood group and human leucocyte antigen (HLA) transplant offers the best opportunity for success. (A1)
* Where ABO or HLA incompatibility is present, alternative options for transplantation must be discussed with the donor and recipient, including paired/pooled donation and antibody incompatible transplantation. Antibody incompatible transplantation must only be performed in a transplant centre with the relevant experience and appropriate support.
# MEDICAL ASSESSMENT
*It is important to manage the expectations of the donor from the outset and to be clear about the difference between a healthy individual and a suitable donor.
*A full past and present medical history must be taken. A psychosocial assessment is recommended for all donors with appropriate referral to a mental health professional as requiredThe EPAT tool provides a structured approach to initial psychosocial assessment which can be performed by any member of the multi-disciplinary team and which can help to identify potential areas of concern.
*Donor assessment will usually be arranged by a specialist transplant/living donation
nurse, supported by a clinician.
#Summary of Key Points of Importance in the Medical +/- Family History of a
Potential Kidney Donor
Haematuria/proteinuria/urinary tract infection/ Difficulty in passing urine, including urgency, frequency, dysuria/ History of peripheral oedema/ Gout/ Nephrolithiasis
Hypertension/ Diabetes mellitus/ including family history Ischaemic heart disease/peripheral vascular disease/other atherosclerosis
Cardiovascular risk factors/ Thromboembolic disease/ Sickle cell and other haemoglobinopathies/ Weight change/ Change in bowel habit/ Previous jaundice
Previous or current malignancy/ Systemic disease which may involve the kidney
Chronic infection such as tuberculosis/ Family history of a renal condition that may affect the donor/ Smoking/ Current or prior alcohol or drug dependence/ Mental health history/ Obstetric history/ Residence abroad/ Previous medical assessment e.g. for life insurance/ Previous anaesthetic problem/ History of back or neck pain and trauma/ Results of national screening programme tests e.g. cervical smear, mammography,/ colorectal screening.
# Points of Particular Importance when Undertaking Clinical Examination of a
Potential Kidney Donor
Abdominal fat distribution/ Blood pressure/ Body mass index/Dipstick urinalysis
Evidence of self-harm/ Examination for abdominal masses or hernia/ Examination for scars or previous surgery/ Examination for lymphadenopathy/ Examination / history of regular self-examination of the breasts/ Examination / history of regular self/ examination of the testes/ Examination of the cardiovascular and respiratory systems
Mental health.
# Routine Screening Investigations for the Potential Donor
Haemoglobin and blood count/ Coagulation screen (PT and APTT)/ Thrombophilia screen (where indicated)/ Sickle cell trait (where indicated)/ Haemoglobinopathy screen (where indicated)/ G6PD deficiency (where indicated)/ Creatinine, urea and electrolytes/ Isotopic or other reference test for measurement of GFR/Liver function tests/ Bone profile (calcium, phosphate, albumin and alkaline phosphatase)/ Urate
Fasting plasma glucose/ Glucose tolerance test (if family history of diabetes or fasting plasma glucose/ >5.6 mmol/L)/ Fasting lipid screen (if indicated)/ Thyroid function tests (if strong family history)/ Pregnancy test (if indicated)/Hepatitis B and C
HIV/ HTLV1 and 2 (if appropriate)/ Cytomegalovirus/ Epstein-Barr virus/ Toxoplasma
Syphilis/ Varicella zoster virus (where recipient seronegative)/ HHV8 (where indicated)/ Malaria (where indicated)/ Trypanosoma cruzi (where indicated)/ Schistosomiasis (where indicated)/ Chest X-ray/ ECG/ ECHO (where indicated)/ Cardiovascular stress test (as routine or where indicated)
# ASSESSMENT OF RENAL FUNCTION
Measurement of Renal Function
* Initial evaluation of donor candidates should be using (eGFR), expressed as mL/min/1.73m2 computed from a creatinine assay standardised to the International
Reference Standard. (B1)
* GFR must subsequently be assessed by a reference measured method (mGFR) such as clearance of 51Cr-EDTA, 125iothalamate or Iohexol performed according to guidelines published by the British Society of Nuclear Medicine. (B1)
*Differential kidney function, determined by 99mTcDMSA scanning is recommended where there is >10% variation in kidney size or significant renal anatomical abnormality. (C1)
# Advisory GFR Thresholds for Donation
* Pre-donation mGFR should be such that the predicted post-donation GFR remains within the gender and age-specific normal range within the donors lifetime.
* The risk of end-stage renal disease (ESRD) after donation is no higher than that of the general population. However, there is a very small absolute increased lifetimerisk of ESRD following donation for which the potential donor must be consented. (D2)
* The decision to approve donor candidates whose renal function is below the advisory GFR threshold or who have additional risk factors for the development of ESRD should be individualised and based on the predicted lifetime incidence of ESRD. (D2)
* The renal function requirements of the intended recipient, based upon the absolute GFR of the donor, are relevant to the decision to donate (in a directed donation) and to the acceptance of a kidney offer from a non-directed donor or within the UK Living Kidney Sharing Schemes. (Not Graded)
# Monitoring of Kidney Donor
*The donor must be offered lifelong annual assessment of renal function including serum creatinine, estimation of urine protein excretion and blood pressure measurement. (B1)
# HYPERTENSION IN THE DONOR
* Blood pressure must be assessed on at least two separate occasions. Ambulatory blood pressure monitoring or home monitoring is recommended if blood pressure is high, high normal or variable, or the potential donor is on treatment for hypertension. (C2)
*We suggest that a blood pressure <140/90 mmHg is usually acceptable for donation. (C1)
* Prospective donors must be warned about the risk of developing donation-related hypertension, particularly if in a high-risk group. Blood pressure measurement is part of annual donor monitoring. (C1)
* Potential donors with mild-moderate hypertension that is controlled to <140/90 mmHg (and/or 135/85 mmHg with ABPM or home monitoring) with one or two antihypertensive drugs and who have no evidence of end organ damage may be acceptable for donation. Acceptance will be based on an overall assessment of cardiovascular risk and local policy.(C1)
*It is recommended that potential donors with hypertension are excluded from donation if: (C1)
o Blood pressure is not controlled to <140/90 mmHg on one or two antihypertensive drugs
o Evidence of end organ damage (retinopathy, left ventricular hypertrophy, proteinuria, previous cardiovascular disease)
o Unacceptable risk of future cardiovascular risk or lifetime incidence of ESRD
* All living kidney donors must be encouraged to minimise the risk of hypertension and its consequences before and after donation by lifestyle measures including stopping smoking, reducing alcohol intake, frequent exercise and, where appropriate, weight loss. (C1)
*It is recommended that donors who are diagnosed with hypertension during assessment or who develop hypertension following donation are managed according to British Hypertension Society guidelines. (B1)
# DIABETES MELLITUS
* All potential living kidney donors must have a fasting plasma glucose level checked. (B1)
* A fasting plasma glucose concentration between 6.1-6.9 mmol/L is indicative of an impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be undertaken. (B1)
* Prospective donors with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT. (B1)
*If OGTT reveals a persistent impaired fasting glucose and/or an impaired glucose tolerance, then the risks of developing diabetes after donation must be carefully considered. (B1)
* Consideration should be given to the use of a diabetes risk calculator to inform the discussion of potential kidney donation. (B2)
*Consideration of patients with diabetes as potential kidney donors requires very careful evaluation of the risks and benefits. In the absence of evidence of target organ damage and having ensured that other cardiovascular risk factors such as obesity, hypertension or hyperlipidaemia are optimally managed, diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney. (Not graded)
# CARDIOVASCULAR EVALUATION
* There is no evidence to support the routine use of stress testing in the assessment of the potential donor at low cardiac risk. (C2)
* Potential kidney donors with a history of cardiovascular disease, an exercise capacity of <4 metabolic equivalents (METS) or with risk factors for cardiovascular disease should undergo further evaluation before donation. (C2)
* For higher risk potential donors, stress testing is recommended by whichever method is locally available or by CT calcium scoring . (C2)
* Discussion with and/or review by cardiologists, anaesthetists and the transplant MDT is recommended as part of the clinical assessment of donors with higher cardiovascular and peri-operative risk. (D2)
# PROTEINURIA
* Urine protein excretion needs to be quantified in all potential living donors. (B1)
* A urine albumin/creatinine ratio (ACR) performed on a spot urine sample is the recommended screening test, although urine protein/creatinine ratio (PCR) is an acceptable alternative. (A1)
* ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day or protein excretion >500 mg/day represent absolute contraindications to donation. (C2)
*The significance of moderately increased albuminuria (ACR 3-30 mg/mmol) and proteinuria (PCR 15-50 mg/mmol or 24-hour urine protein 150-500 mg/day) has not been fully evaluated in living kidney donors. However, since the risk of CKD and cardiovascular morbidity increase progressively with increasing albuminuria or proteinuria such levels are a relative contraindication to donation. (C2)
# NON-VISIBLE HAEMATURIA
Recommendations
* All potential living donors must have reagent strip (dipstick) urinalysis performed on at least two separate occasions. (B1)
*Two or more positive tests, including trace positive, is considered as persistent non-visible haematuria (PNVH). (B1)
* If PNVH is present, perform urine culture and renal imaging to exclude common urologic causes including infection, nephrolithiasis and urothelial carcinoma. (A1)
*If no cause is found, perform cystoscopy in patients age >40 years to exclude bladder pathology. (B1)
* If no cause is found and the donor still wishes to donate, then a kidney biopsy is recommended if haematuria is 1+ or greater on dipstick testing. (B1)
* Glomerular pathology precludes donation, with the possible exception of thin basement membrane disease. (B1)
* For donors with persistent asymptomatic non-visible haematuria (PANVH) and a family history of haematuria or X-linked Alport syndrome, a renal biopsy (B1) and referral to a clinical geneticist are recommended. (B2)
# PYURIA
* Prospective donors found to have pyuria can only be considered for donation if it can be demonstrated that the pyuria is due to a reversible cause, such as an uncomplicated urinary tract infection. (C1)
# INFECTION IN THE PROSPECTIVE DONOR
* Screening for infection in the prospective donor is essential to identify potential risks for the donor from previous or current infection and to assess the risks of transmission of infection to the recipient. (B1)
* Active HBV and HCV infection in the donor are usually contraindications to living donor kidney donation; however, donors
with evidence of active viral replication may be considered under some circumstances. (B1)
* The presence of HIV or human T lymphotrophic virus (HTLV) infection is an absolute contraindication to living donation. (B1)
* Screening for HBV, HCV and HIV infection must be repeated within 30 days of donation. (Not graded)
* All potential donors should be provided with dietary advice regarding avoidance of HEV infection, and screening should be undertaken for HEV viraemia by nucleic acid testing within 30 days of donation. (Not graded)
* The CMV status of donor and recipient must be determined before transplantation. When the donor is CMV positive and the recipient is CMV negative, the donor and recipient must be counselled about the risk of post-transplant CMV disease. (B1)
* The EBV status of donor and recipient must be determined before transplantation. When the donor is EBV positive and the recipient is
EBV negative, the donor and recipient must be counselled about the risk of developing Post Transplant Lymphoproliferative Disease. (B1)
* Potential donors must be screened by history for travel or residence abroad to assess their potential risk for having acquired endemicinfections and appropriate microbiological investigations instigated if indicated. (Not graded)
# NEPHROLITHIASIS
* In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as potential kidney donors. Full counselling of donor and recipient is required along with access to appropriate long-term donor follow up. (C2)
* Potential donors with metabolic abnormalities detected on screening should be discussed with a specialist in renal stone disease. (C2)
* In appropriate donors with unilateral kidney stone(s) the stone-bearing kidney can be considered for donation (if vascular anatomy and split kidney function permit) in order to leave the donor with a stone-free kidney after donation. (C2)
# HAEMATOLOGICAL DISEASE
* Donor anaemia needs to be investigated and treated before donation. (A1)
* A haemoglobinopathy screen must be carried out in patients with non- Northern European heritage or if indicated by the full blood count. (A1)
*Careful consideration needs to be given to the use of potential donors with haemoglobinopathies. (B1)
* Advice from a consultant haematologist is recommended for haematological conditions not covered in this guideline. (Not graded)
# FAMILIAL RENAL DISEASE
* All potential transplant recipients must have a detailed family history recorded and confirmation where possible of the diagnosis in other family members with known kidney disease. This may aid diagnosis for the recipient, clarify any mode of inheritance and identify at risk relatives. (A1)
* When the cause of kidney failure in the recipient is due to an inherited condition, appropriate tests – including genetic testing if available – are recommended to exclude genetic disease in the potential donor. (A1)
* Many inherited kidney diseases are rare, so involvement of clinical and laboratory genetics services must be considered at an early stage to assess likely risks to family members and the appropriate use of molecular genetic testing. (B1)
# DONOR MALIGNANCY
* Careful history taking, clinical examination and investigation of potential donors are essential to exclude occult malignancy before kidney donation, particularly in older (age >50 years) donors. (B1)
* Active malignant disease is a contraindication to living donation but donors with certain types of successfully treated low-grade tumour may be considered after careful evaluation and discussion. (B1)
* Donors with an incidental renal mass lesion must have this diagnosed and managed on its own merit (out with discussion of kidney donation) with appropriate referral to a Urology Specialist in line with the 2-week wait pathway. (A1)
* Contrast enhanced renal CT scan, ultrasound and / or MRI can usually distinguish between benign lesions such as angiomyolipoma (AML) or malignancy such as renal cell carcinoma (RCC). Review by a specialist uroradiologist is recommended. (C1)
* Bilateral AML and AML >4 cm generally preclude living kidney donation although occasionally unilateral large (>4 cm) AML can be used if ex vivo excision of the AML appears to be straight forward.
* An incidental, unilateral solitary AML <4 cm with typical characteristic CT criteria does not usually preclude donation.
* A kidney with an AML <1 cm may be considered for donation or left in situ in the donors remaining kidney.
* Kidneys containing a single AML between 1 and 4 cm can be considered for donation depending on its position, consideration of whether ex vivo excision of the AML is straightforward, or whether it can be left in situ in the recipient and followed with serial ultrasound imaging. (C1)
* Donors with an incidental small (<4 cm) renal mass that appears on imaging to be a RCC must be seen in a specialist Urology clinic and be offered standard of care treatment options, including partial and radical nephrectomy. Renal function permitting, if the person wishes to consider radical nephrectomy, ex-vivo excision of the small renal mass with subsequent donation of the reconstructed kidney can be
considered on an individual basis with specific caveats, full MDM discussion and appropriate informed consent from the donor and recipient. (D2)
# SURGERY: TECHNICAL ASPECTS, DONOR RISK AND PERI-OPERATIVE CARE
* Work-up for living kidney donation may include direct or indicative evaluation of split renal function with the kidney with poorer function selected for nephrectomy irrespective of vascular anatomy(C2)
* Work-up for living kidney donation must include detailed imaging confirming the vascular anatomy of both donor kidneys and information about the renal parenchyma and collecting systems. Either CTA or MRA can be used as current evidence indicates little difference in accuracy. (B1)
* Multiple renal arteries or kidneys with anatomical anomalies are not absolute contraindications to donation. Decisions must be made on an individual basis as part of a multi-disciplinary team evaluation. (B2)
* All living donors must receive adequate thromboprophylaxis. Intraoperative mechanical compression and post-operative compression stockings, along with low molecular weight heparin, are recommended. (A2)
* All living donor surgery must be performed or directly supervised by a Consultant surgeon with appropriate training in the technique. (C1)
* Pre-operative hydration with an overnight infusion and/or a fluid bolus during surgery improves cardiovascular stability during laparoscopic donor nephrectomy. (B2)
* Pre- and peri-operative intravenous fluid replacement with Hartmanns solution is preferred to 0.9% Saline. (B2)
* Laparoscopic donor surgery (fully laparoscopic or hand-assisted) is the preferred technique for living donor nephrectomy, offering aquicker recovery, shorter hospital stay and less pain. Mini-incision surgery is preferable to standard open surgery. (B1)
* Haem-o-lok clips are not to be used to secure the renal artery during donor nephrectomy following a report of an adverse event involving this technique.(C2)
# HISTOCOMPATIBILITY TESTING FOR LIVING DONOR KIDNEY TRANSPLANTATION
* Initial assessment of donor and recipient histocompatibility status must be undertaken at an early stage in living donor kidney transplant work-up to avoid unnecessary and invasive clinical investigation. (B2)
* Screening of potential living donor kidney transplant recipients for clinically relevant antibodies is important for ensuring optimal donor selection and graft survival. (A1)
* Antibody screening is especially important when potential living donor transplant recipients undergo reduction or withdrawal of immunosuppression. (B2)
* Post-transplant antibody monitoring must be undertaken according to the BSHI/BTS guidelines. (B1)
* Transplant units and histocompatibility laboratories must agree an evidence-based protocol to define antibody screening and crossmatch results that constitute a high immunological risk to transplantation. (B2)
* When possible, the HLA type(s) of partners/offspring of female recipients who have had previous pregnancies should be determined to aid immunological risk assessment for repeat paternal HLA mismatches in women with low level DSA. (B1)
* A pre-transplant serum sample collected within 14 days of the planned date for transplantation must be tested in a sensitive antibody screening and donor crossmatch assay and transplantation should not usually be performed if the crossmatch test is positive, unless the antibody is shown to be indicative of acceptable immunological risk. (A1)
#Changes in immunosuppression during the transplant work-up must be notified to the histocompatibility laboratory and additional antibody
screening and donor-recipient crossmatch tests must be undertaken
as indicated. (B1)
*HLA matching may be preferred when there is an option of selecting between living donors, particularly to reduce the possibility of subsequent sensitisation. This is important for younger recipients where repeat transplantation may be required. However, it is recognised that other donor factors will be taken into account. (B1)
* For patients with an ABO/HLA incompatible and/or a poorly HLA matched living donor, consideration should be given to entry into the UK living kidney sharing scheme (UKLKSS) to identify a more suitable donor. (B2)
*The histocompatibility laboratory must issue an interpretive report stating the donor and recipient HLA mismatch, recipient sensitization status and crossmatch results, and define the associated immunological risk for all living donor-recipient pairs. (A1)
# Recommendations (Not graded)
* Antibody incompatible transplantation (AIT) should only be undertaken after prior consideration of entry of the donor-recipient pair into the UK Living Kidney Sharing Schemes (UKLKSS) (see Chapter 8).
* AIT should be considered as part of an ongoing structured programmers, and should not be performed on an occasional basis.
*To initiate a programme, a unit should be able to demonstrate a demand of at least five cases a year and appropriate support from clinical transplant, plasmapheresis and histocompatibility teams. An AIT programme requires funding for additional staff and consumables, and all programmes should receive Commissioner support.
* There is insufficient evidence to make precise recommendations for treatment protocols, but units should have a written protocol based on best published practice. This should include recommendations on prevention, diagnosis and treatment of antibody mediated rejection.
*Protocols that follow the above can be regarded as established treatment and do not require Ethics Committee approval as research procedures. However, the standard of consent should include detailed written information which describes the risks of the procedure. The transplant donor should receive equivalent information to the
recipient, so they are aware of the risks of the procedure to the recipient, whether it results in a transplant or not. Potential recipients and donors should be aware of their treatment choices, especially the option of exchange (pooled/paired) transplantation.
* Laboratories should be able to define antibodies to the standard defined in the BSHI/BTS document Guidelines for the Detection and
# Characterisation of Clinically Relevant Antibodies in Solid Organ Transplantation’. Sensitive and rapid techniques for the measurement of donor-specific HLA antibody levels must be available.
*If ABOi transplantation is to be performed, blood group antibody titres need to be measured, with differentiation between A1 and A2 subgroups of recipient blood group A (when appropriate) and discrimination between IgG- and IgM-specific ABO antibodies. In living donor transplantation, a 7 day per week service with same day turnaround time is required.
* AIT results in an improved quality of life when compared to dialysis. Additionally, many patients receiving antibody incompatible transplants may have no other chance of a transplant. Transplantation is cost effective over time with a saving of about £15,000 per annum compared to dialysis when averaged over a 10 year period
* Every patient undergoing AIT should be audited on a local and national basis, with the national audit through the AIT Registry.
*The UK AIT Registry will define the optimal dataset to be collected, and will be able to report AIT activity against benchmark outcome data from international reports and the national dataset of renal transplantation.
# EXPANDING THE DONOR POOL
* Coherent organisational and clinical practices are essential between transplant centres to optimise the UK Living Kidney Sharing Schemes (UKLKSS) and to maximise the number of potential transplants that proceed. (B1)
* To maximise transplant opportunities within the UKLKSS, donors and recipients must only be included in a matching run if:
o Their clinical assessment and histocompatibility screening are complete and up to date. (B1)
o If matched, they are available to attend for crossmatch testing and proceed to surgery within the designated timeframes. (B1)
o Relevant complex donor considerations identified in the prerun and donor HLA and age preferences have been discussed and agreed with the recipient. (B1)
o They understand their roles and responsibilities with respect to other donors and recipient pairs in the schemes with whom they may be matched. (B1)
* The default for all non-directed altruistic kidney donors (NDADs) is to donate into an altruistic donor chain (ADC) within the UKLKSS provided that there is no higher priority patient on the national transplant list. (B1)
* All altruistic donors (non-directed and directed) must undergo formal mental health assessment with a mental health professional before donation. (C1)
* Living kidney donors who are antibody incompatible with their recipient must have all the options and risks explained to them, including donation into the UKLKSS and antibody removal. (C1)
# Which potential donors should be referred?
* There is clear, emphatic consensus among mental health clinicians working in the field that ALL potential altruistic donors should be referred for mental health assessment.
# Who should undertake assessments?
* Mental health assessments of potential altruistic donors can be undertaken by any suitably qualified and sufficiently senior mental health clinician (whether psychiatrist, psychologist, social worker, counsellor or nurse specialist) who is sufficiently familiar with transplant procedures, risk and outcomes, ideally because they are
embedded within or affiliated to transplant services.
Centres with access to more than one type of clinician can direct
referrals accordingly (for example preferring that potential donors with a history of mental disorder treated by medication see a psychiatrist, rather than psychologist, initially). Some cases may require assessment by more than one professional.
# At what stage of work-up?
* Referral for mental health assessment of potential altruistic donors should be made after initial screening, clinical assessment, and provision of information by the transplant team, but before any investigations which carry risk. However, to avoid delay in the assessment process and in discussion with the donor, it may be
appropriate to perform mental health assessment in parallel with physical assessment.
# With what information to hand?
*Referral information should include, at a minimum, a clear description of any specific mental health concerns or a statement that there are none. Where concerns relate to past episodes of treatment, available details obtained from the GP should be forwarded to the referee. Mental health clinicians receiving referrals should be free to gather further information directly if they judge it relevant, either on referral or after interview. Potential donors should be advised by the referrer that this gathering and sharing of information will happen (just as it would if they had a cardiac history and were being referred for cardiology assessment), and should be asked to agree to it.
# What is the purpose of assessment?
*The multiple potential purposes of mental health assessment listed above should be acknowledged, together with their overlap with each other and with the IA role. Referral should, where possible, clarify the purpose(s) for which referral is made. Mental health clinicians should clarify the specific purpose(s) they have addressed in their assessment.
# How should it be undertaken?
* The nature of the assessment should be tailored to the referral question, the clinical circumstances, and the professional background of the assessor. Repeat interviews, third party interviews, standardized questionnaires and structured assessments may all be necessary, but the only element of assessment required in all cases is a clinical interview
# To whom should the assessment report be sent?
*As a minimum, the assessment report should go to the referring clinician in the transplant team, the GP, and any mental health services with which the potential donor is in (or may foreseeably require) follow up. Reports may also go directly to the patient, where this is consonant with practice in local mental health and renal services. The report should also be forwarded to the HTA-IA in due course. The patient should be informed about, and consent to, this dissemination of information.
# What are the follow-up requirements for those who go on to donate, and for those who are declined on mental health grounds?
*Assessing clinicians should identify routes to mental health follow-up for those who may need it in the short- or long-term after donation. For potential donors who are declined there should be direct liaison with relevant mental health services and the GP.
# LOGISTICAL CONSIDERATIONS
* Wherever possible, the aim is to ensure that the financial impact on the living donor is cost neutral by the reimbursement of legitimate expenses incurred as a direct result of the preparation for and/or act of donation. There are clear policies across the four UK countries to ensure that claims are settled in full and in a timely manner (B1)
* Donors who are non-UK residents present unique logistical challenges. To ensure that the process is clinically effective and to comply with Visa and Immigration requirements, there is an agreed entry visa application process and maximum duration of stay in the UK (six months) for the donor. Visa extensions will only be considered in exceptional or unforeseen circumstances. (B1)
#DONOR FOLLOW-UP AND LONG-TERM OUTCOME
* 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 risk of ESRD in living donors mandates lifelong follow-up after donor nephrectomy. For donors who are resident in the UK, this can be offered locally or at the transplant centre according to the wishes of the donor, but such arrangements must secure the collection of data for submission to the UK Living Donor Registry. (B1)
* Donors who are non UK residents and travel to the UK to donate (privately or to a NHS entitled recipient) are not entitled to NHS followup but must be given advice about appropriate follow-up before returning to their country of origin. (C1)
* Potential donors who are unable to proceed to donation must be appropriately followed up and referred for further investigation and management as required. (B1)
* Women must be informed of a greater risk of pregnancy-induced hypertension following kidney donation. (A1)
* Close monitoring of blood pressure, creatinine and foetal well-being is advisable in kidneys donors during pregnancy. (C1)
* Kidney donors may be offered Aspirin 75 mg daily for pre-eclampsia prophylaxis. (D2)
* There is no evidence to support the benefits of right or left nephrectomy to prevent pregnancy induced hydronephrosis. (Not graded)
*Births after kidney donation should be reported to the Living Donor Registry as a significant medical event at each annual review. (Not graded)
# RECIPIENT OUTCOME AFTER LIVING DONOR KIDNEY TRANSPLANTATION IN ADULTS
* Graft and patient survival after living donor kidney transplantation should be within the national range of expected outcomes. (A1)
* Transplant centres should regularly audit secondary outcomes and should reappraise practice if their results are not comparable with other units. (B1)
* Where a recipient is considered to be at high risk, transplantation should only proceed if, in the view of the team of professionals involved, there is an expectation that the patient is likely to survive with a functioning transplant for more than 2 years. (C2)
* Patients at higher risk of complications and a poor outcome, due to immunological status or co-morbidities, should be considered for transplantation when the clinical team regard the risk / benefit ratio to be favourable. Due process will include careful consideration of the likely outcome for that individual without transplantation. The potential donor must be fully appraised of the issues. A summary of these discussions (between the clinical team and the donor-recipient pair) should be documented in the clinical records and a copy should also be given to the donor and recipient. (C2)
#RECURRENT RENAL DISEASE
* A wide range of diseases that cause renal failure may recur in a transplanted kidney. This is important to consider when determining the optimal treatment strategy for a recipient and when counseling both donor and recipient on the relative risks and benefits of living donor transplantation. The risks of recurrence, the consequences for transplant function, and the time-course of any deterioration must all be considered. A discussion of the effects of immunosuppression and transplant failure on morbidity and mortality may also be appropriate. (B1)
* The risks of recurrent disease are high in FSGS and MCGN. In these diseases, the presence of specific adverse clinical features may indicate living donor transplantation should be avoided, even where a donor is available. This will require careful assessment and deliberation with all interested parties. (B2)
* In atypical HUS potential de novo disease in a related donor needs to be addressed directly. The risks of recurrent disease in the recipient need to be mitigated through regulated approval and consideration of the use of an inhibitor of complement activation, currently eculizumab. (A1)
* In patients with risks related to underlying activity such as SLE or systemic vasculitis, adequate disease control and an appropriate
period of quiescence are important to ensure optimal outcomes. (B1)
* Recommendations for individual diseases follow in the following text. Type 1 and type 2 diabetes are not contraindications to living donor transplantation, irrespective of whether they are the underlying cause of renal failure. Both the donor and recipient should be counseled regarding the increased risks associated with surgery.
Living donor kidney transplantation is a reasonable option in patients with primary FSGS. Both the donor and recipient need to be specifically counselled about the risk of recurrent disease, which may occur early and result in rapid graft loss. In those in whom a genetic aetiology has been established the risk of recurrent disease is low but not absent. A potential living related donor must also be investigated for evidence of the same genetic abnormality.
Transplantation in an individual with unequivocal evidence of graft loss secondary to recurrent disease constitutes a high risk of subsequent failure such that some centers consider this a contraindication to repeat transplantation. In this context, living donor transplantation should be considered only in special circumstances and after careful discussion between the multi professional team, the donor and the recipient. Equally it is incumbent upon that team to assess the circumstances of the original graft failure with absolute rigor. The risk of recurrence is low when the previous graft did not fail due to recurrent disease.
*The risk of recurrent disease does not contraindicate living donor transplantation in IgA nephropathy. Both the donor and recipient should be counselled regarding the risks of recurrent disease.
* This risk of recurrent disease does not contraindicate living donor transplantation in membranous nephropathy. Both the donor and recipient should be counselled regarding the risks of recurrent disease.
*Patients with amyloidosis should be discussed with the National Amyloidosis Centre before progressing to living donor transplantation.
Patients with AA amyloidosis should have effective disease control before surgery
*The overall risks associated with recurrent disease are small in SLE and living donor transplantation is safe in quiescent disease. Both the donor and recipient should be counselled regarding the risks of recurrent disease. (B2)
* The risks associated with recurrent disease are small and the outcomes of transplantation good, therefore AASV does not contraindicate living donor transplantation if the aforementioned criteria are met. Both the donor and recipient should be counseled regarding the risks of recurrent disease.
* The risks associated with recurrent disease are small and the outcomes of transplantation good, therefore Goodpasture’s disease does not contraindicate living donor transplantation if the aforementioned criteria are met. Both the donor and recipient should be counselled regarding the risks of recurrent disease.
* The overall risks associated with Alport syndrome are small and the outcomes of transplantation good, therefore Alport syndrome does not contraindicate living donor transplantation. Both the donor and recipient should be counselled regarding the risks of de novo anti-GBM disease. (B2)
* Type I and II MCGN do not contraindicate living donor transplantation. However, the risk of recurrent disease and subsequent graft loss is sufficiently high that transplantation should only be undertaken following careful discussion between the multi-professional team, the donor and the recipient. This is particularly the case if there is an identified abnormality of a soluble complement regulatory protein.
* Transplantation in an individual with unequivocal evidence of graft loss secondary to recurrent C3 glomerulopathy constitutes a high risk of subsequent failure such that some centres consider this a contraindication to repeat transplantation
* Among patients with genetic abnormalities in complement proteins or with an unknown cause of C3 glomerulopathy, a comparison with atypical HUS suggests that consideration should be given to avoiding living related donors in whom similar genetic mutations may predispose to the future development of C3 glomerulopathy afternephrectomy
* Living related renal transplantation should be avoided in atypical HUS unless the cause of the disease in the recipient is known and this has
been excluded in the donor. Even then related donors may be at a greater risk of aHUS and should be warned of this risk.
* In patients in whom the underlying cause has unequivocally been attributed to Shiga-toxin, the recurrence rate of HUS is low and living donor transplantation may be considered.
* In appropriately selected cases, living donor kidney transplantation is a reasonable treatment option in primary hyperoxaluria. Both the donor and recipient should be counselled regarding the risks of recurrent disease.
* Cystinosis is not a contra-indication to living donor transplantation. However, both donor and recipient should be counselled regarding the long-term extra-renal complications related to disease progression.
# LIVING DONOR KIDNEY TRANSPLANTATION IN CHILDREN
* Pre-emptive living related renal transplantation is the gold standard therapy for children with end-stage renal disease. (2C)
* The aim should be for children to receive a renal transplant from a blood group compatible well-matched donor, although ABO and/or HLA incompatible renal transplantation is feasible in children. (2C)
* Every effort should be made to minimise HLA mismatches (especially with common antigens) to reduce the risk of future sensitisation. (2D)
* All children with stage 4 and 5 chronic kidney disease should be assessed by a multi-disciplinary team, including a paediatric nephrologist, transplant surgeon, anaesthetist and urologist (where appropriate) prior to renal transplantation. (Not graded)
* In general, children who are ≥10 kg in weight are suitable to receive a kidney from an adult living donor. (2C)
Guidelines for Living Donor Kidney Transplantation
1- Please summarise these guidelines in your own words.
Donor considered unsuitable because they:
1. when there is absolute contraindication to donation.
2. Have a relative contraindication to donation.
3. Do not meet transplant centre-specific criteria for acceptance .
DONOR EVALUATION: SUMMARY
Recommendations
Ø For directdonation the likely suitability of the potential recipient for transplantation must be established before starting donor assessment.
Ø donor assessment is planned to minimize inconvenience to patient .
Ø Donor assessment must be planned to ensure that it is focused, logical and coherent and involvement of multi-disciplinary team is important . Unsuitable donors must be identified at the earliest possible stage of assessment.
Ø donor evaluation steps may vary between centers , but the principles apply for all donors are the same .
Ø pre-emptive transplantation, donor evaluation must start sufficiently early to allow time for more than one donor to be assessed if required. It is usually started when the recipient eGFR is approximately 20 mL/min or when the recipient is expected to require R R T within 12-18 months .
Ø The evaluation of a potential donor should be undertaken within an 18 week pathway, assuming there are no logistical issues such as donor unavailability.
Ø To promote planned, pre-emptive LD transplantation as the treatment ,To minimise time on dialysis .
ABO BLOOD GROUPING AND CROSSMATCH TESTING
Ø A compatible ABO and (HLA) transplant offers the best chance of success.
Ø If ABO or HLA incompatibility is present, the alternative is paired donation and antibody incompatible transplantation.
5.5 ASSESSMENT OF RENAL FUNCTION
Ø Initial evaluation of donor candidates should be using estimated(eGFR), expressed as mL/min/1.73m2 .
Ø GFR must subsequently be assessed by measured (mGFR) such as clearance of 51Cr-EDTA, 125iothalamate or Iohexol .
Ø Differential kidney function, estimated by 99mTcDMSA scanning is recommended in
o When there is >10% variation in kidney size or
o significant renal anatomical abnormality.
Ø Pre-donation mGFR should be such that the predicted post-donation GFR remains within the gender and age-specific normal range within the donor’s lifetime.
Ø The risk of (ESRD) after donation is not higher than that of the general population. But , there is a very small absolute increased lifetime risk of ESRD following .
Ø The donor must be offered lifelong annual assessment of renal function including serum creatinine, estimation of urine protein excretion and blood pressure measurement.
DONOR AGE
Ø Old age alone is not an absolute contraindication to donation .
Ø The donor and recipient must be made aware that
o Are at greater risk of peri-operative complications and that
o the function and survival of the graft may be compromised especially in those above 60 years .
Ø in Most centers do not consider donors aged <18 years and consider an age of 18-21 years as a relative contraindication to donation.
Summary
Most transplant programs are more flexible in older donors. Younger donors should be subjected to stringent exclusion criteria .
DONOR OBESITY
Ø overweight patients (BMI 25-30 kg/m2) may safely go to kidney donation.
Ø Moderately obese patients (BMI 30-35 kg/m2) should be assessed carefully preoperative
to exclude cardiovascular, respiratory and kidney disease.
– must be counselled aboutthe increased risk of peri-operative complications .
– must be counselled about the long-term risk of kidney disease
– advised to lose weight and to maintain their ideal weight following donation.
Ø kidney donation in the very obese (BMI >35 kg/m2) should be discouraged.
5.8 HYPERTENSION IN THE DONOR
Ø B p must be assessed on at least 2 separate occasions.
Ambulatory BP monitoring or home monitoring is recommended if
v blood pressure is high,
v high normal or variable,
v If donor is on treatment for hypertension.
Ø a blood pressure of <140/90 mmHg is usually acceptable for donation.
Ø Prospective donors should be warned about the risk of post donation hypertension.
Ø donors BP should be monitored annually.
Ø donors with mild-moderate HT that is controlled to <140/90 mmHg (and/or 135/85 mmHg with ABPM or home monitoring) with one or two antihypertensive drugs and who have no evidence of end organ damage may be acceptable for donation.
Ø donors with hypertension are excluded if:
v Blood pressure is not controlled to <140/90 mmHg on one or two antihypertensive drugs .
v Evidence of end organ damage (retinopathy, left ventricular hypertrophy, proteinuria, previous cardiovascular disease) .
v Unacceptable risk of future cardiovascular risk or lifetime incidence of ESRD .
Ø All living kidney donors must be encouraged to
v lifestyle measures including stopping smoking, reducing alcohol intake, frequent exercise and, weight loss.
Ø Hypertension will develop in at least 30% of patients following unilateral nephrectomy
DIABETES MELLITUS
Ø All donors must have a fasting plasma glucose level checked.
Ø A fasting plasma glucose concentration between 6.1-6.9 mmol/L (110-125mg/dl) is indicative of an impaired fasting glucose state and t (OGTT) should be undertaken.
Ø donors with an high risk of type 2 diabetes because of
o family history,
o a history of gestational diabetes,
o ethnicity or
o obesity
should also undergo an OGTT.
Ø diabetes as donors requires very careful evaluation
v In the absence of evidence of target organ damage
v other cardiovascular risk factors such as obesity, hypertension or hyperlipidaemia are optimally managed,
diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease .
CARDIOVASCULAR EVALUATION
Ø There is no need use of stress testing in the assessment of donor at low cardiac risk.
Ø Potential kidney donors with
v a history of cardiovascular disease,
v an exercise capacity of <4 metabolic equivalents (METS) or
v with risk factors for cardiovascular disease
should undergo further evaluation before donation.
Ø For higher risk potential donors, stress testing is recommended by Which ever method is locally available or by CT calcium scoring .
Ø The choice of stress test will be influenced by local service provision.
Ø CT coronary calcium scoring may be an alternative way of stratifying coronary risk.
PROTEINURIA
Ø Urine protein excretion should be assessed in all living donors.
Ø A urine albumin/creatinine ratio (ACR) is the recommended screening test, urine protein/creatinine ratio (PCR) is an alternative method .
Ø ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day or protein excretion >500 mg/day represent absolute contraindications to donation .
Ø The significance of moderately increased albuminuria (ACR 3-30 mg/mmol) and proteinuria (PCR 15-50 mg/mmol or 24-hour urine protein 150-500 mg/day) has not been fully evaluated in living kidney donors.
Ø since the risk of CKD and cardiovascular morbidity increase progressively with increasing albuminuria or proteinuria such levels are a relative contraindication to donation.
NON-VISIBLE HAEMATURIA
Ø All donors must have (dipstick) urinalysis performed on at least two occasions.
Ø Two or more positive tests, including trace positive, is considered as persistent non-visible haematuria (PNVH).
Ø If PNVH is present, we need to exclude
o infection,
o nephrolithiasis and
o urothelial carcinoma.
Ø If no cause is found, cystoscopy is indicated in patients >40 years to exclude bladder pathology. (B1)
Ø If cystoscopy is normal then a kidney biopsy is recommended if haematuria is 1+ or greater on dipstick testing.
Ø Glomerular pathology prevent donation, exception of thin basement membrane disease.
Ø With a family history of haematuria or X-linked Alport syndrome, a renal biopsy and referral to a clinical geneticist are recommended.
PYURIA
Ø donors found with pyuria can only be considered for donation if it is due to a reversible cause, such as an uncomplicated urinary tract infection.
INFECTION IN THE PROSPECTIVE DONOR
Ø Screening for infection in the donor is essential .
Ø Active HBV and HCV infection in the donor are usually contraindications .
Ø HIV or human T lymphotrophic virus (HTLV) infection is an absolute contraindication to living donation.
Ø Screening for HBV, HCV and HIV infection must be repeated within 3 days of donation.
Ø All donors should be provided with dietary advice regarding avoidance of HEV infection, and screening should be undertaken for HEV viraemia by nucleic acid testing within 30 days of donation.
Ø The CMV status of donor and recipient must be determined before transplantation.
Ø The EBV status of donor and recipient must be tested before transplantation.
NEPHROLITHIASIS
Ø In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging , may still be considered as potential kidney donors.
Ø Potential donors with metabolic abnormalities detected on screening should be discussed with a specialist in renal stone disease.
Ø In appropriate donors with unilateral kidney stone(s) the stone-bearing kidney can be considered for donation .
HAEMATOLOGICAL DISEASE
Ø Donor anaemia needs to be investigated and treated before donation.
Ø A haemoglobinopathy screen must be carried out if indicated by the full blood count.
Ø Careful consideration needs to be given to the use of potential donors with haemoglobinopathies .
FAMILIAL RENAL DISEASE
Ø All potential transplant recipients must have a detailed family history recorded .
Ø When the cause of kidney failure in the recipient is due to an inherited condition, appropriate tests are recommended to exclude genetic disease .
DONOR MALIGNANCY
Ø history taking, clinical examination and investigation of donors are essential to exclude occult malignancy , in older (age >50 years) .
Ø Active malignant disease is a contraindication to donation .
Ø Contrast enhanced renal CT scan, ultrasound and / or MRI can usually distinguish between benign or malignant lesion .
Ø Bilateral AML and AML >4 cm generally preclude living kidney donation .
Ø An incidental, unilateral solitary AML <4 cm with typical characteristic CT criteria does not usually preclude donation.
Ø A kidney with an AML <1 cm may be considered for donation or left in situ in the donor’s remaining kidney.
Ø Kidneys containing a single AML between 1 and 4 cm can be considered for donation.
Ø Donors with an incidental small (<4 cm) renal mass suggesting a RCC must be offer partial and radical nephrectomy.
Ø Renal function permitting ,the reconstructed kidney can be Considered for donation .
Q2 How these guidelines are different from the guidelines you follow at your workplace?
Actually I did not compare with others , therefore I donot know .
Summary:
Donor evaluation:
In cases of directed donation the likely suitability of the potential recipient for transplantation must be established before starting donor assessment.
As far as possible, donor assessment is planned to minimize inconvenience to him/her and to avoid unnecessary barriers to the proceeding.
Donor assessment must be planned to ensure that it is focused, logical and coherent.
ABO BLOOD GROUPING AND CROSSMATCH TESTING
Compatible ABO blood group and HLA transplant offer the best opportunity for success.
Where ABO or HLA incompatibility is present, alternative options for transplantation must be discussed with the donor and recipient, including paired/pooled donation and antibody incompatible transplantation. Antibody incompatible transplantation must only be performed in a transplant center with the relevant experience and appropriate support.
ASSESSMENT OF RENAL FUNCTION
Measurement of Renal Function:
Initial evaluation of donor candidates should be using estimated glomerular filtration rate (eGFR), expressed as mL/min/1.73m2 computed from a creatinine assay standardised to the International Reference Standard.
GFR must subsequently be assessed by a reference measured method (mGFR) such as clearance of 51Cr-EDTA, 125 iothalamates or Iohexol performed according to guidelines published by the British Society of Nuclear Medicine.
Differential kidney function, determined by 99mTcDMSA scanning is recommended where there is >10% variation in kidney size or a significant renal anatomical abnormality.
DONOR AGE
Old age alone is not an absolute contraindication to donation but the medical work-up of older donors must be particularly rigorous to ensure they are suitable.
Both donor and recipient must be made aware that the older donor may be at greater risk of peri operative complications and that the function and possibly the long-term survival of the graft may be compromised. This is particularly evident with donors >60 years of age.
DONOR OBESITY
Otherwise healthy overweight patients (BMI 25-30 kg/m2 ) may safely proceed to kidney donation.
Moderately obese patients (BMI 30-35 kg/m2 ) must undergo a careful preoperative evaluation to exclude cardiovascular, respiratory and kidney disease.
Moderately obese patients (BMI 30-35 kg/m2 ) must be counselled about the increased risk of peri-operative complications based on extrapolation of outcome data from very obese donors (BMI >35 kg/m2 ).
Moderately obese patients (BMI 30-35 kg/m2 ) must be counselled about the long-term risk of kidney disease and be advised to lose weight before donation and to maintain their ideal weight following donation.
Data on the safety of kidney donation in the very obese (BMI >35 kg/m2 ) are limited, and the donation should be discouraged.
HYPERTENSION IN THE DONOR
Blood pressure must be assessed on at least two separate occasions. Ambulatory blood pressure monitoring or home monitoring is recommended if blood pressure is high, high normal or variable, or the potential donor is on treatment for hypertension.
We suggest that a blood pressure <140/90 mmHg is usually acceptable for donation.
Prospective donors must be warned about the risk of developing donation-related hypertension, particularly if in a high-risk group. Blood pressure measurement is part of annual donor monitoring.
Potential donors with mild-moderate hypertension that is controlled to <140/90 mmHg (and/or 135/85 mmHg with ABPM or home monitoring) with one or two antihypertensive drugs and who have no evidence of end-organ damage may be acceptable for donation. Acceptance will be based on an overall cardiovascular risk assessment and local policy.
DIABETES MELLITUS
All potential living kidney donors must have a fasting plasma glucose level checked.
A fasting plasma glucose concentration between 6.1-6.9 mmol/L indicates an impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be undertaken.
Prospective donors with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT. (B1) If OGTT reveals persistent impaired fasting glucose and/or impaired glucose tolerance, the risk of developing diabetes after donation must be carefully considered.
Consideration should be given to using a diabetes risk calculator to inform the discussion of potential kidney donation.
Consideration of patients with diabetes as potential kidney donors requires carefully evaluating the risks and benefits.
CARDIOVASCULAR EVALUATION
There is no evidence to support the routine use of stress testing in assessing the potential donor at low cardiac risk.
Potential kidney donors with a history of cardiovascular disease, an exercise capacity of <4 metabolic equivalents (METS) or risk factors for cardiovascular disease should undergo further evaluation before donation.
For higher-risk potential donors, stress testing is recommended by whichever method is locally available or by CT calcium scoring.
Discussion with and/or review by cardiologists, anaesthetists and the transplant MDT is recommended as part of the clinical assessment of donors with higher cardiovascular and peri-operative risk.
PROTEINURIA
Urine protein excretion needs to be quantified in all potential living donors.
A urine albumin/creatinine ratio (ACR) performed on a spot urine sample is the recommended screening test, although urine protein/creatinine ratio (PCR) is an acceptable alternative.
ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day or protein excretion >500 mg/day represent absolute contraindications to donation.
The significance of moderately increased albuminuria (ACR 3-30 mg/mmol) and proteinuria (PCR 15-50 mg/mmol or 24-hour urine protein 150-500 mg/day) has not been fully evaluated in living kidney donors. However, since the risk of CKD and cardiovascular morbidity increase progressively with increasing albuminuria or proteinuria, such levels are a relative contraindication to donation.
NON-VISIBLE HAEMATURIA
All potential living donors must have reagent strip (dipstick) urinalysis performed on at least two separate occasions.
Two or more positive tests, including trace positive, is considered as persistent non-visible haematuria (PNVH).
This guidance relates to living donor kidney transplantation and includes the ethical and medico-legal aspects of donor selection, medical and pre-operative donor evaluation,Identification of high risk donors, the management of complications, and expected Outcome. The guidance also includes antibody incompatible transplantation, recurrent disease and Transplantation in the context of other co-morbidities.
LEGAL FRAMEWORK:
All transplants performed from living donors must comply with the Human Tissue Act 2004 and Human Tissue (Scotland) Act 2006). Transplant centres performing living organ donation must be licensed by the Human Tissue Authority according with the requirements of the European Union Organ Donation Directive. Consent for the removal of organs from living donors, must comply with the requirements of the Human Tissue Act 2004, and the Mental Capacity Act 2005 in England and Wales, and the Mental Capacity Act 2016 in Northern Ireland. Consent in Scotland must comply with the Human Tissue (Scotland) Act 2006 and the Adults with Incapacity (Scotland) Act 2000.
ETHICS: complex moral issues in this field and good ethical practice in living donor kidney transplantation should be owned by all health professional involved. Safety and welfare of the potential living donor should always take priority. Altruism, Autonomy, Beneficence, Dignity, Non-maleficence and Reciprocity are the Ethical Principles of Living Donor Transplantation.
SUPPORTING AND INFORMING THE POTENTIAL DONOR: The living donor should receive the best possible environment for making a voluntary and informed choice about donation. Donor and recipient require an Independent assessment (primary legislation Human Tissue Act 2004). Confidentiality must be specified and discussed at the beginning. Relevant information about the recipient can only be shared with the donor if the recipient has given consent and vice versa.
Psychological needs must be identified to ensure that appropriate support and/or intervention is initiated. An informed health professional not directly
involved with the care of the recipient acts as the donor advocate in
addressing any outstanding questions, and assists the donor in making an autonomous decision
ABO BLOOD GROUPING AND CROSSMATCH TESTING:
Compatible ABO blood group and HLA transplant offers the best opportunity the best outcome. Alternative options for transplantation must be discussed with the donor and recipient, If ABO or HLA incompatibility is present. Alternative options for transplantation include paired/pooled donation and antibody incompatible
transplantation. Antibody incompatible transplantation should be
performed in a centres with relevant experience.
DONOR EVALUATION
The process of donor evaluation is to ensure the suitability of the donor and to minimise the risk of donation. Potential donors must be assessed following evidence-based protocol. Donor evaluation will start only when the suitability of the potential recipient for transplantation has been established.
For pre-emptive transplantation in order to maximize and avoid unnecessary delay where the probability of recipient contraindications is low, it may be appropriate to start the donor work-up in parallel to the recipient assessment.
Routine Screening Investigations for the Potential Donor
Urine
Dipstick for protein, blood and glucose, Microscopy, culture and sensitivity,
Measurement of urine ACR or PCR
Blood
Haemoglobin and blood count, Coagulation screen (PT and APTT), Thrombophilia screen,
Sickle cell trait, Haemoglobinopathy screen, G6PD deficiency, Creatinine, urea and electrolytes, Isotopic or other reference test for measurement of GFR, LFT’s, Bone profile
Urate, Fasting plasma glucose, Glucose tolerance test (if family history of diabetes or fasting plasma glucose >5.6 mmol/L), Fasting lipid screen (if indicated), Thyroid function tests (if strong family history), Pregnancy test (if indicated)
Virology and infection screen (see section 5.14)
Hepatitis B and C, HIV, HTLV1 and 2 (if appropriate),CMV, EBV, Toxoplasma, Syphilis
Varicella zoster virus (where recipient seronegative), HHV8 (where indicated), Malaria (where indicated), Trypanosoma cruzi (where indicated), Schistosomiasis (where indicated)
Cardiorespiratory system
Chest X-ray, ECG, ECHO
Cardiovascular stress test (Where indicated)
Renal Function evaluation:
Initial assessment of renal function in living kidney donors is by measurement of serum creatinine which is usually performed by an estimate GFR using the CKD- Epidemiology Collaboration. Measurement of GFR using a clearance of inulin, 51Cr-EDTA, 125I-iothalamate or iohexol offer a more detailed assessment of potential donor function. These measurement are used to inform potential donors of the long-term risks of donation and potential recipients of the anticipated level of kidney function being transplanted. The mean age at donation of the cohorts has been around 45 years and the lower threshold for donation a GFR >80 mL/min/1.73m2. If the patient age is equal or more than 35 year old eGFR should be greater than 80 ml/min. If patient age is less than 30 year old eGFR should be greater than 90 ml/min.
In the general population a decreased GFR is associated with an increased risk of Adverse outcomes, ESRD, cardiovascular disease and death.
In the presence of >10% variation in kidney size or anatomical abnormality of the kidneys Split kidney function need to be evaluated.
Old age is not a contraindication to donation. However, donor and recipient need be aware that the older donor (particularly evident with donors >60 years of age) are at higher risk of peri-operative complications. Moreover the function and the long-term survival of the graft may be compromised.
Patients with BMI 30-35 kg/m2need a preoperative assessment to exclude cardiovascular, respiratory and kidney disease. Moreover they shsould be informed
Of the increased risk of peri-operative complications and the long-term risk of kidney disease. Moderately obese patients should be advised to lose weight before donation and to maintain their ideal weight following donation
Blood pressure <140/90 mmHg is usually acceptable for donation. A patient with BP < 140/90 mmHg (and or 135/85 mmHg with ABPM or Home monitoring) controlled with one or two antihypertensive drugs and no evidence of end organ damage may be considered for donation. Potential donor should be excluded if Blood pressure is not controlled ( <140/90 mmHg) while on one or two antihypertensive drugs and if there is evidence of end organ damage. Patient with high risk of future cardiovascular risk or lifetime incidence of ESRD should be excluded from donation.
Fasting plasma glucose (FPG) must be checked in all potential living donors. A FPG concentration between 6.1-6.9 mmol/L indicate an impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be performed. Donors with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT. The risks of developing diabetes after donation should be considered if OGTT reveals a persistent IFG or an IGT
Patients with diabetes may be considered as potential kidney donors if target organ damage has been excluded and other cardiovascular risk factors are optimally managed.
Potential donors should undergo cardiac evaluation before donation if they have history of cardiovascular disease, risk factors for cardiovascular disease and an exercise capacity of <4 metabolic equivalents. Stress testing or CT calcium scoring should be doen For higher risk potential donors. Donors with higher cardiovascular and peri-operative risk should be discussed in the transplant MDT and reviewed by cardiologists and anaesthetists.
Proteinuria is a contraindication for transplant (ACR > 30 mg/mmol and PCR > 50 mg/mmol). Albumin excretion >300 mg/day or protein excretion >500 mg/day represent absolute contraindications to donation.
Urinalysis should be performed on at least two separate occasions to exclude non visible haematuria. Two or more positive tests (including trace positive), is considered as persistent non-visible haematuria (PNVH). If PNVH is present, potential donor should have a urine culture and renal imaging to exclude common urologic causes such as infection, nephrolithiasis and urothelial carcinoma and if no cause is found, in patients age above 40 years, a cystoscopy should be done to exclude bladder pathology. If donor still wishes to donate and no cause is found then a kidney biopsy is recommended (haematuria of 1+ or greater on dipstick testing. Glomerular pathology is a contraindication for donation with the exception of thin basement membrane disease.
Donors found to have pyuria can be considered for donation if the pyuria is due to a reversible cause (uncomplicated urinary tract infection)
Potential donor should be screened for infection in order to identify potential risks for the donor from previous or current infection and to assess the risks of transmission of infection to the recipient. Active HBV and HCV infection in the donor are usually contraindications to living donor kidney donation. Screening for HBV, HCV and HIV infection must be repeated within 30 days of donation. Active HBV and HCV infection in the donor are usually contraindications to living donor kidney donation. The CMV status of donor and recipient need to be determined before transplantation. If the donor is CMV positive and the recipient is CMV negative, the donor and recipient should be informed about the risk of posttransplant CMV disease. If the donor is EBV positive and the recipient is EBV negative, the donor and recipient must be informed about the risk of developing Post Transplant Lymphoproliferative Disease.
Donors with no significant metabolic abnormalities or with a little history of previous kidney stones, or small renal stone on imaging, may still be considered for donation. Potential donors with metabolic abnormalities should be discussed with a specialist in renal stone disease.
Potential donor with anaemia needs to be investigated and treated before donation.
Perspective donors with haemoglobinopathies should receive a careful consideration (Haematology evaluation)
In case of congenital conditions genetic testing and family historyry should be done.
In age >50 years malignancy should be excluded. Active cancer is a contraindication to organ donation. If donors have some treated low-grade tumors or unilateral renal mass less than 4 cm (if AML, without excision; and if RCC, with excision and renal reconstruction).can be considered eligible for donation.
In regard to technical aspects of the surgery the necessary assessments include: Direct or indirect evaluation of split renal function, vascular anatomy, renal parenchyma and collecting system imaging using CTA or MRA needs to be arranged. Pre- and post-operative adequate hydration is crucial. All patients should receive thromboprophylaxis. It is preferable to provide donors with laparoscopics nephrectomy. Enhanced recovery after surgery programs and long term follow up post donation should be offered. In case of pregnancy post donation close monitoring of BP, creatinine, foetal evaluation and pre-eclampsia prophylaxis (aspirin 75 mg) are needed.
Patients should receive counselling about the risks of recurrence of the disease.
It is highly recommended in children with ESRD to carry out pre-emptive transplant with a compatible blood group and minimal HLA mismatches. Adult living donor kidney can be received by all who weigh more than 10kg.
We use the same criteria
· Kidney transplantation from a living donor is recommended for most ESKD patients, particularly complex recipients.
· About 1 in 3 kidney transplants performed in the UK are from living donors
· For each recommendation of the guideline the quality of evidence has been graded as one of:
A (high) B (moderate) C (low) D (very low)
· For each recommendation, the strength has been indicated as one of:
Level 1 (we recommend) Level 2 (we suggest) Not graded (where there is not enough evidence to allow formal grading)
The Human Tissue Authority (HTA)
· is responsible for assessing all applications for organ donation from living people
· ensure that the donor has given valid consent, and gives approval for the living donation
The European Union Organ Donation Directive (EUODD)
· It is the first pan-European regulatory framework governing the donation and transplantation of organs from the living and deceased and responsible about follow-up of living donors across the EU
· The HTA is the Competent Authority for the UK under the EUODD
Consent for the Removal of Organs from Living Donors
· treating clinician is responsible to get the consent for the removal of organs from living donors
· The clinician responsible for the living donor is required to confirm to the HTA that the donor understands all risks of donation
Types of Living Donation Permitted by the Legislation
1. Directed donation
(i) Genetically related donation: blood relative
(ii) Emotionally related donation: for example, spouse, partner, or close friend;
2.Paired or pool donation:
· The donors are not genetically related or known to their respective recipients.
· ‘Paired donations’ involve two pairs in an exchange
· ‘pooled donations’ include a series of paired donations, each of which is linked to another in the same series
3.Non-directed altruistic donation: an organ is donated by a healthy person to an unknown recipient
4.Directed altruistic donation:
(i) Genetic relationship and no established emotional relationship
(ii) No pre-existing relationship between donor and recipient before the need for a transplant
Requirements for Transplants Involving a Living Donor
· To give approval HTA want to be sure that
1. No reward has been, or will be, given;
2. Consent to removal for the purpose of transplantation has been given
3. An Independent Assessor (IA) has performed separate interviews with the donor and the recipient
and offer a report of their assessment to the HTA.
· In cases of directed genetically or emotionally related donation, the HTA needs a conformation about the relationship
· higher regulatory risk needs at least 3 members of HTA, this may include:
1. Paired and pooled donation
2. Non-directed altruistic living donation
3. Directed altruistic donation cases where the donor is non-resident in the UK
4. Certain directed donation cases where the donor has an economic
5. dependence on the recipient
6. If the organ donor is a child
7. If the organ donor is an adult who lacks capacity
Exceptional Circumstances
Children
· a person under 18 years old
· The use of a living organ from a child can only proceed with Court approval followed by approval from an HTA panel
Adults without Mental Capacity
· Donation requires court approval, then approval from HTA panel
· In Scotland, living donation from adults without mental capacity is not permitted under the Human Tissue
ETHICS: Recommendations
· All health professionals involved in living donor kidney transplantation should have good knowledge about ethical issues related to this field
· The priority is for donor safety over recipient benefit.
· Independence is recommended between the clinicians responsible for the assessment and preparation of the donor and the recipient
SUPPORTING AND INFORMING THE POTENTIAL DONOR
· The living donor must be offered the best possible environment for making a voluntary and informed choice about donation. The transplant team must provide generic information that is relevant to all donors as well as specific information that is material to the person intending to donate. This includes information about the assessment process and the benefits and risks of donation to the individual donor. (B1)
· Independent assessment of the donor and recipient is required by primary legislation (Human Tissue Act 2004). (Not graded)
· To achieve the best outcome for donor, recipient and transplant, the boundaries of confidentiality must be specified and discussed at the outset. Relevant information about the recipient can only be shared with the donor if the recipient has given consent and vice versa. Both the recipient and donor must be informed that it is necessary and usual for all relevant clinical information to be shared across the transplant team in order to optimise the chance of a successful outcome for the transplant. (B1)
· Ideally, the recipient will discuss relevant information with their donor, or allow it to be shared. If the recipient is not willing to disclose information, then the transplant team must decide whether it is possible to communicate the risks and benefits of donating adequately, without needing to disclose specific medical details. (Not graded)
· Separate clinical teams for donor and recipient are considered best practice but healthcare professionals must work together to ensure effective communication and co-ordination of the transplant process without compromising the independence of either donor or recipient. It is essential that an informed health professional who is not directly involved with the care of the recipient acts as the donor advocate in addressing any outstanding questions, anxieties or difficult issues, and assists the donor in making a truly autonomous decision. (B1)
· Support for the prospective donor, recipient and family is an integral part of the donation/transplantation process. Psychological needs must be identified at an early stage in the evaluation to ensure that appropriate support and/or intervention is initiated. Access to specialist psychiatric/psychological services must be available for donors/recipients requiring referral. (B1)
A Summary of Key Points to be Discussed with a Potential Donor
General points about process, consent and confidentiality:
1. For a living donor to give valid consent for donation, he/she must be properly
informed about the generic risks (for all donors) and any specific, individual
risks (for them) (see section 4.3.5 and Chapter 2).
2. Informed consent must be sought before progressing to each stage of the
pathway.
3. Information must be given about what will be shared amongst the transplant
team and the GP.
4. Information must be given about what will not be shared with the potential
recipient, unless explicit consent is given to do so.
5. It should be explained that the tests might throw up unexpected findings that
may or may not be relevant to donating a kidney. These findings might
include:
a. Information about the genetic relationship with the recipient.
b. Medical or anatomical findings of uncertain significance that might
require further assessment or referral to another specialty.
6. It should be emphasised that the donor can withdraw from the process at
any time up until the time of surgery.
Specific points about process and possible outcomes:
1. Risks of donation (generic and specific).
2. Nature of surgical procedure and length of stay in hospital.
3. Potential graft loss in the recipient.
4. Requirement for HTA assessment.
5. Reimbursement of expenses.
6. Requirement for annual review.
DONOR EVALUATION
· In cases of directed donation (to a known recipient) the likely suitability of the potential recipient for transplantation must be established before starting donor assessment. If additional recipient assessment is required, unnecessary delay should be avoided. Non-invasive assessment of the donor may be undertaken in this phase. (Not graded)
· As far as possible, donor assessment is planned to minimize inconvenience to him/her and to avoid unnecessary barriers to proceeding. Flexibility in terms of timescales, planning consultations, attending for investigations and date of surgery is helpful. (Not graded)
· Donor assessment must be planned to ensure that it is focused, logical and coherent. Good communication with the donor and involvement of the wider multi-disciplinary team is essential and is achieved most effectively if a designated coordinator leads the organization of the assessment process. The results of investigations must be relayed accurately and efficiently to the potential donor. Unsuitable donors must be identified at the earliest possible stage of assessment. (Not graded)
· A policy must be in place to manage prospective donors who are found to be unsuitable to donate and appropriate follow-up and support must be made available. (Not graded)
· The organizational aspects for donor evaluation will vary between centers, according to available resources and personnel, but the same principles apply for all donors. An agreed donor assessment protocol must be in place that is tailored to the needs of the individual
· To facilitate pre-emptive transplantation, donor evaluation must start sufficiently early to allow time for more than one donor to be assessed if required. Information must be provided at an early stage and discussion with potential donors and recipients will usually be started when the recipient eGFR is approximately 20 mL/min or when the recipient is expected to require renal replacement therapy within 12-18 months. Recipient and donor assessment can then be tailored according to the rate of decline of recipient renal function, disease specific considerations and individual circumstances. (B2)
· The evaluation of a potential donor should be undertaken within an 18-week pathway, assuming there are no logistical issues such as donor unavailability. There may, of course, be pauses if the recipient’s transplant assessment is complicated or if the recipient’s renal function remains satisfactory
ABO BLOOD GROUPING AND CROSSMATCH TESTING
· A compatible ABO blood group and human leucocyte antigen (HLA) transplant offers the best opportunity for success. (A1)
· Where ABO or HLA incompatibility is present, alternative options for transplantation must be discussed with the donor and recipient, including paired/pooled donation and antibody incompatible transplantation.
· Antibody incompatible transplantation must only be performed in a transplant centre with the relevant experience and appropriate support. (A1)
Summary of Key Points of Importance in the Medical +/- Family History of a Potential Kidney Donor
Haematuria/proteinuria/urinary tract infection
Difficulty in passing urine, including urgency, frequency, dysuria
History of peripheral oedema
Gout
Nephrolithiasis
Hypertension
Diabetes mellitus, including family history
Ischaemic heart disease/peripheral vascular disease/other atherosclerosis
Cardiovascular risk factors
Thromboembolic disease
Sickle cell and other haemoglobinopathies
Weight change
Change in bowel habit
Previous jaundice
Previous or current malignancy
Systemic disease which may involve the kidney
Chronic infection such as tuberculosis
Family history of a renal condition that may affect the donor
Smoking
Current or prior alcohol or drug dependence
Mental health history
Obstetric history
Residence abroad
Previous medical assessment e.g. for life insurance
Previous anaesthetic problem
History of back or neck pain and trauma
Results of national screening programme tests e.g. cervical smear, mammography,
colorectal screening
History with respect to Transmissible Infection
Previous illnesses
Jaundice or hepatitis
Malaria
Previous blood transfusion
Tuberculosis / atypical mycobacterium
Family history of tuberculosis
Family history of Creutzfeldt-Jakob disease, previous treatment with natural growth
hormone, or undiagnosed degenerative neurological disorder
Specific geographical risk factors: e.g. fungi and parasites, tuberculosis, hepatitis,
malaria, worms
Increased risk of HIV, HTLV1 and HTLV2, Hepatitis B and C infection
Haemophiliac or sexual partner of haemophiliac
High risk sexual behaviour
History of infectious hepatitis or syphilis
History of intravenous drug use
Tattoo or skin piercing within last 6 months
Sexual partner of an individual with positive serology
Sexual partner of drug addict
Points of Particular Importance when Undertaking Clinical Examination of a Potential Kidney Donor
Abdominal fat distribution
Blood pressure
Body mass index
Dipstick urinalysis
Evidence of self-harm
Examination for abdominal masses or herniae
Examination for scars or previous surgery
Examination for lymphadenopathy
Examination / history of regular self-examination of the breasts
Examination / history of regular self-examination of the testes
Examination of the cardiovascular and respiratory systems
Mental health
Routine Screening Investigations for the Potential Donor
Urine
Dipstick for protein, blood and glucose (at least twice)
Microscopy, culture and sensitivity (at least twice)
Measurement of protein excretion rate (ACR or PCR)
Blood
Haemoglobin and blood count
Coagulation screen (PT and APTT)
Thrombophilia screen (where indicated)
Sickle cell trait (where indicated)
Haemoglobinopathy screen (where indicated)
G6PD deficiency (where indicated)
Creatinine, urea and electrolytes
Isotopic or other reference test for measurement of GFR
Liver function tests
Bone profile (calcium, phosphate, albumin and alkaline phosphatase)
Urate
Fasting plasma glucose
Glucose tolerance test (if family history of diabetes or fasting plasma glucose
>5.6 mmol/L)
Fasting lipid screen (if indicated)
Thyroid function tests (if strong family history)
Pregnancy test (if indicated)
Virology and infection screen
Hepatitis B and C
HIV
HTLV1 and 2 (if appropriate)
Cytomegalovirus
Epstein-Barr virus
Toxoplasma
Syphilis
Varicella zoster virus (where recipient seronegative)
-HHV8, Malaria, Trypanosoma cruzi, Schistosomiasis (where indicated)
Cardiorespiratory system
Chest X-ray
ECG
ECHO (where indicated)
Cardiovascular stress test (as routine or where indicated)
ASSESSMENT OF RENAL FUNCTION
Measurement of Renal Function
· Initial evaluation of donor candidates should be using estimated glomerular filtration rate (eGFR), expressed as mL/min/1.73m2 computed from a creatinine assay standardised to the International Reference Standard. (B1)
· GFR must subsequently be assessed by a reference measured method (mGFR) such as clearance of 51Cr-EDTA, 125iothalamate or Iohexol performed according to guidelines published by the British Society of Nuclear Medicine. (B1)
· Differential kidney function, determined by 99mTcDMSA scanning is recommended where there is >10% variation in kidney size or significant renal anatomical abnormality. (C1)
Advisory GFR Thresholds for Donation
· Pre-donation mGFR should be such that the predicted post-donation GFR remains within the gender and age-specific normal range within the donor’s lifetime.
· The risk of end-stage renal disease (ESRD) after 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 consented. (D2)
· The decision to approve donor candidates whose renal function is below the advisory GFR threshold or who have additional risk factors for the development of ESRD should be individualised and based on the predicted lifetime incidence of ESRD. (D2)
· The renal function requirements of the intended recipient, based upon the absolute GFR of the donor, are relevant to the decision to donate (in a directed donation) and to the acceptance of a kidney offer from a non-directed donor or within the UK Living Kidney Sharing Schemes. (Not Graded)
Monitoring of Kidney Donor
· The donor must be offered lifelong annual assessment of renal function including serum creatinine, estimation of urine protein excretion and blood pressure measurement. (B1)
Divided Renal Function
· measured by combining 51Cr-EDTA and 99mTc-DMSA
· indicated if there is a size disparity between the two kidneys (>10%) in a potential donor, if renal function is close to the acceptable threshold for donation, or when there is anatomical abnormality or complexity.
· the kidney with lower function is usually donated.
· Some centres choose to perform split function testing routinely on all donors
What is a Safe Threshold Level of Kidney Function to Donate?
The mean age at donation of the cohorts has been around 45 years and the lower threshold for donation a GFR >80 mL/min/1.73m2
Normal Kidney Function & Change in Kidney Function with Aging
· renal function corrected for BSA is significantly higher for men than women after age 40 years.
· GFR remains stable in both sexes until aged around 40 years and then declines each decade at a rate of 6.6 mL/min/1.73m2 for men and 7.7 mL/min/1.73m2 in women
Early changes to Renal Function Following Living Kidney Donation
· By three months, remnant kidney clearance increases to a mean GFR of around 65-75% of pre-donation renal function.
· the average decrement in GFR after donation was 26 mL/min/1.73m2
Long-Term Loss of GFR in Kidney Donors
The recommended age-related GFR thresholds for donation ensure that predicted renal function will remain within the lower limit of normal GFR with aging.
Is Donation Associated with an Increased Risk of End-Stage Renal Disease, Cardiovascular Disease or Death?
· 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
· The absolute risk for young donors over a lifetime, particularly with additional risk factors for ESRD is likely to be more significant
Individualization in Discussion of the Risks of ESRD
factors associated with an increased lifetime risk ESRD:
· Measured GFR just below the guideline threshold
· Ethnic groups at higher risk (African Caribbean or South Asian origin (by inference))
· Hypertension, obesity and/or (pre) diabetes
Advisory Threshold Measured GFR Considered Safe for Donation
· A threshold GFR >80 mL/min/1.73m2 appears safe for donation in the 35 year and above age range
· A threshold for donation of >90 mL/min/1.73m2 has been set for those <30 years
DONOR AGE
· Old age alone is not an absolute contraindication to donation but the medical work-up of older donors must be particularly rigorous to ensure they are suitable. (A1)
· Both donor and recipient must be made aware that the older donor may be at greater risk of peri-operative complications and that the function and possibly the long-term survival of the graft may be compromised. This is particularly evident with donors >60 years of age. (B1)
The Young Donor
· Most programmes do not consider donors aged <18 years and
· age of 18-21 years considered a relative contraindication to donation
· Younger donors, may still develop diabetes, hypertension, obesity, immunologically mediated disease or other renal risk factors, and have more time for these risk factors to progress to CKD and ultimately ESRD
The Older Donor
· In the last five years there has been a significant increase in the number of living donations in the UK from the 60-69 and >70 year groups
· Donors above 60 years of age have:
– increased risk of peri-operative complications,
-existing comorbidities and residual function post-donation,
-long-term transplant outcome in the recipient associated with reduced donor GFR and potential donor vasculopathy
Donor Complication Rates Related to Age
· peri-operative outcomes such as operative time, blood loss and length of stay are shown in some recent studies to be no different from younger donors in carefully selected donors above 60 years.
· Pre-donation cardio-respiratory function should be carefully assessed in older donors
Graft Outcome from Older Donors
· Renal function declines progressively with age and kidneys from older living donors have reduced function
· the use of older kidney donors appears to be an equivalent or beneficial alternative to awaiting deceased donor kidneys
Long Term Risk for Older Donors
· Older donors with potential risk factors for kidney disease, are less likely than younger donors to have enough time for such risk factors to lead to progressive kidney diseas
DONOR OBESITY
· Otherwise healthy overweight patients (BMI 25-30 kg/m2 ) may safely proceed to kidney donation. (B1)
· Moderately obese patients (BMI 30-35 kg/m2 ) must undergo careful pre[1]operative evaluation to exclude cardiovascular, respiratory and kidney disease. (C2)
· Moderately obese patients (BMI 30-35 kg/m2 ) must be counselled about the increased risk of peri-operative complications based on extrapolation of outcome data from very obese donors (BMI >35 kg/m2 ). (B1)
· Moderately obese patients (BMI 30-35 kg/m2 ) must be counselled about the long-term risk of kidney disease and be advised to lose weight before donation and to maintain their ideal weight following donation. (B1)
· Data on the safety of kidney donation in the very obese (BMI >35 kg/m2 ) are limited and donation should be discouraged. (C1)
HYPERTENSION IN THE DONOR
· Blood pressure must be assessed on at least two separate occasions. Ambulatory blood pressure monitoring or home monitoring is recommended if blood pressure is high, high normal or variable, or the potential donor is on treatment for hypertension. (C2)
· We suggest that a blood pressure <140/90 mmHg is usually acceptable for donation. (C1)
· Prospective donors must be warned about the risk of developing donation-related hypertension, particularly if in a high-risk group. Blood pressure measurement is part of annual donor monitoring. (C1)
· Potential donors with mild-moderate hypertension that is controlled to <140/90 mmHg (and/or 135/85 mmHg with ABPM or home monitoring) with one or two antihypertensive drugs and who have no evidence of end organ damage may be acceptable for donation. Acceptance will be based on an overall assessment of cardiovascular risk and local policy. (C1)
· It is recommended that potential donors with hypertension are excluded from donation if: (C1)
o Blood pressure is not controlled to <140/90 mmHg on one or two antihypertensive drugs
o Evidence of end organ damage (retinopathy, left ventricular hypertrophy, proteinuria, previous
cardiovascular disease)
o Unacceptable risk of future cardiovascular risk or lifetime incidence of ESRD
· All living kidney donors must be encouraged to minimise the risk of hypertension and its consequences before and after donation by lifestyle measures including stopping smoking, reducing alcohol intake, frequent exercise and, where appropriate, weight loss. (C1)
· It is recommended that donors who are diagnosed with hypertension during assessment or who develop hypertension following donation are managed according to British Hypertension Society guidelines. (B1)
DIABETES MELLITUS
· All potential living kidney donors must have a fasting plasma glucose level checked. (B1)
· A fasting plasma glucose concentration between 6.1-6.9 mmol/L is indicative of an impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be undertaken. (B1)
· Prospective donors with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT. (B1)
· If OGTT reveals a persistent impaired fasting glucose and/or an impaired glucose tolerance, then the risks of developing diabetes after donation must be carefully considered. (B1)
· Consideration should be given to the use of a diabetes risk calculator to inform the discussion of potential kidney donation. (B2)
· Consideration of patients with diabetes as potential kidney donors requires very careful evaluation of the risks and benefits. In the absence of evidence of target organ damage and having ensured that other cardiovascular risk factors such as obesity, hypertension or hyperlipidaemia are optimally managed, diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney. (Not graded)
HbA1c
· HbA1c >6.5% is sufficient to diagnose diabetes if confirmed by repeat testing
· An HbA1c <6.5% may be used to predict the future likelihood of developing diabetes
· HbA1c result of 6.0-6.5% indicates a 5-year incidence risk of diabetes of 25-50%, 20 times higher than that associated with a HbA1c of 5%
· OGTT should be strongly considered when the HbA1c is in the range 6.0-6.5
Risk of Type 1 Diabetes
· Type 1 diabetes presents predominantly in childhood and early adulthood and 50% of cases have presented by the age of 20 years
· The incidence of type 1 diabetes in adults is less than 1 in 10,000
· First degree relatives of an individual with type 1 diabetes have a 15-fold increased risk of developing the disease
· As a working definition, type 1 diabetes is characterised by onset below the age of 30 years and a requirement for insulin treatment from the time of diagnosis
Risk of Type 2 Diabetes
· Individuals who have a family history (first degree relative) of type 2 diabetes are at higher risk of developing the disease
· The combination of a positive family history and obesity (BMI >30 kg/m2 ) places an individual at very high risk of diabetes in later life
· A history of gestational diabetes is an independent risk factor for later diabetes.
Risk Calculators
· use data for a particular individual to give an estimated risk for that individual for the development of diabetes over the subsequent 10 years
· Such calculators may usefully be used in the assessment of kidney donors and discussion of the results may be part of the assessment process
Impaired Fasting Glucose and Kidney Donation
· Those with IFG appeared to do well, when compared with donors with a normal fasting glucose. Urine albumin excretion and MDRD eGFR were similar in both groups
Risk of Diabetes Causing ESRD in Living Kidney Donors
· There is a sharp increase in the incidence of type 2 diabetes after the age of 50 and the median age at diagnosis is around 60 years
· Less than 1% of Europeans with type 2 diabetes develop ESRD but the incidence is higher in other ethnic groups
CARDIOVASCULAR EVALUATION
· There is no evidence to support the routine use of stress testing in the assessment of the potential donor at low cardiac risk. (C2)
· Potential kidney donors with a history of cardiovascular disease, an exercise capacity of <4 metabolic equivalents (METS) or with risk factors for cardiovascular disease should undergo further evaluation before donation. (C2)
· For higher risk potential donors, stress testing is recommended by whichever method is locally available or by CT calcium scoring. (C2)
· Discussion with and/or review by cardiologists, anaesthetists and the transplant MDT is recommended as part of the clinical assessment of donors with higher cardiovascular and peri-operative risk. (D2)
PROTEINURIA
· Urine protein excretion needs to be quantified in all potential living donors. (B1)
· A urine albumin/creatinine ratio (ACR) performed on a spot urine sample is the recommended screening test, although urine protein/creatinine ratio (PCR) is an acceptable alternative. (A1)
· ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day or protein excretion >500 mg/day represent absolute contraindications to donation. (C2)
· The significance of moderately increased albuminuria (ACR 3-30 mg/mmol) and proteinuria (PCR 15-50 mg/mmol or 24-hour urine protein 150-500 mg/day) has not been fully evaluated in living kidney donors. However, since the risk of CKD and cardiovascular morbidity increase progressively with increasing albuminuria or proteinuria such levels are a relative contraindication to donation. (C2)
NON-VISIBLE HAEMATURIA
· All potential living donors must have reagent strip (dipstick) urinalysis performed on at least two separate occasions. (B1)
· Two or more positive tests, including trace positive, is considered as persistent non-visible haematuria (PNVH). (B1)
· If PNVH is present, perform urine culture and renal imaging to exclude common urologic causes including infection, nephrolithiasis and urothelial carcinoma. (A1)
· If no cause is found, perform cystoscopy in patients age >40 years to exclude bladder pathology. (B1)
· If no cause is found and the donor still wishes to donate, then a kidney biopsy is recommended if haematuria is 1+ or greater on dipstick testing. (B1)
· Glomerular pathology precludes donation, with the possible exception of thin basement membrane disease. (B1)
· For donors with persistent asymptomatic non-visible haematuria (PANVH) and a family history of haematuria or X-linked Alport syndrome, a renal biopsy (B1) and referral to a clinical geneticist are recommended. (B2)
PYURIA
· Prospective donors found to have pyuria can only be considered for donation if it can be demonstrated that the pyuria is due to a reversible cause, such as an uncomplicated urinary tract infection. (C1)
INFECTION IN THE PROSPECTIVE DONOR
· Screening for infection in the prospective donor is essential to identify potential risks for the donor from previous or current infection and to assess the risks of transmission of infection to the recipient. (B1)
· Active HBV and HCV infection in the donor are usually contraindications to living donor kidney donation; however, donors with evidence of active viral replication may be considered under some circumstances. (B1)
· The presence of HIV or human T lymphotrophic virus (HTLV) infection is an absolute contraindication to living donation. (B1)
· Screening for HBV, HCV and HIV infection must be repeated within 30 days of donation. (Not graded)
· All potential donors should be provided with dietary advice regarding avoidance of HEV infection, and screening should be undertaken for HEV viraemia by nucleic acid testing within 30 days of donation. (Not graded)
· The CMV status of donor and recipient must be determined before transplantation. When the donor is CMV positive and the recipient is CMV negative, the donor and recipient must be counselled about the risk of post-transplant CMV disease. (B1)
· The EBV status of donor and recipient must be determined before transplantation. When the donor is EBV positive and the recipient is EBV negative, the donor and recipient must be counselled about the risk of developing Post Transplant Lymphoproliferative Disease. (B1)
· Potential donors must be screened by history for travel or residence abroad to assess their potential risk for having acquired endemic infections and appropriate microbiological investigations instigated if indicated. (Not graded)
NEPHROLITHIASIS
· In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as potential kidney donors. Full counselling of donor and recipient is required along with access to appropriate long-term donor follow up. (C2)
· Potential donors with metabolic abnormalities detected on screening should be discussed with a specialist in renal stone disease. (C2)
· In appropriate donors with unilateral kidney stone(s) the stone-bearing kidney can be considered for donation (if vascular anatomy and split kidney function permit) in order to leave the donor with a stone-free kidney after donation. (C2)
Incidence, Natural History and Management of Renal Stones
· 5% of potential kidney donors have asymptomatic small kidney stones detected by non-contrast CT scan
· 75% of renal stones are composed mainly of calcium oxalate, and a metabolic abnormality (e.g. hypercalciuria, hyperoxaluria, or hypocitraturia) may be detected in over 50%
· 25% of stones are composed of uric acid, pure calcium phosphate, cysteine or struvite (magnesium ammonium phosphate stones)
· Uric acid stones are often associated with a history of gout, ileostomy, diarrhoea or with the metabolic syndrome (acidic urine)
· people with Cystine stones should not donate a kidney
· people with Infection stones (with an anatomical abnormality) should not donate a kidney unless the anatomical abnormality is easily correctable
· asymptomatic stone formers may lack the co-morbidities found in symptomatic stone formers
· Patients with large or staghorn stones should not be considered as donors
Assessment of Potential Donors
· a non-contrast CT KUB is advisable to determine the number, size and location of suspected stones
· A DMSA scan is useful if renal scarring is suspected and will give an estimate of split renal function
· before donation 24-hour urine collections for calcium, oxalate, citrate and urate, and early morning pH assessment should be done for a potential donors with a history of stone disease
Proceeding to Donation
· If a significant and uncorrectable metabolic abnormality is identified then kidney donation is contra-indicated
· donation may be considered in potential donors with minor or correctable metabolic abnormalities e.g., isolated hypocitraturia, isolated hypercalciuria, isolated hyperuricosuria
· In potential donors who have a history of previous stones but no metabolic abnormality, proceeding with donation should be considered providing the number, size and frequency of previous stones has been low
· If donation proceeds, it is preferable to remove the kidney containing the suspected calculus.
· People with bilateral kidney stones should in general not be considered as kidney donors
Follow Up
· Donor with a stone bearing kidney should be counselled about symptoms of renal colic and anuria
· Donors should drink a high fluid intake for life (at least 2.5 litres of fluid per day) and to continue any specific drug for stones
HAEMATOLOGICAL DISEASE
· Donor anaemia needs to be investigated and treated before donation. (A1)
· A haemoglobinopathy screen must be carried out in patients with non-Northern European heritage or if indicated by the full blood count. (A1)
· Careful consideration needs to be given to the use of potential donors with haemoglobinopathies. (B1)
· Advice from a consultant hematologist is recommended for hematological conditions not covered in this guideline. (Not graded)
Anaemia
· WHO classification Hb <130 g/L for men and <120 g/L for women
Sickle cell disease and sickle cell trait
· Sickle cell disease is an absolute contraindication to living kidney donation, due to higher risk of progressive CKD and general anaesthetic.
· in potential donors with sickle call trait (SCT):
1. There is a high incidence of urine concentrating abnormalities
2. visible and non-visible haematuria are well described
3. could be associated with a higher risk of progression to end stage renal disease, a higher incidence of CKD and albuminuria, and a more rapid deterioration in renal function
4. the peri-operative risks may be higher including complications such as venous thromboembolism
5. Individuals with SCT are also at increased risk of renal medullary carcinoma.
· SCT should not be an absolute contraindication to kidney donation
Thalassaemia. Categories:
1. transfusion dependent thalassaemia (TDT)
2. non-transfusion dependent thalassaemia (NTDT) (including haemoglobin H disease)
3. thalassaemia trait (thalassaemia carriers).
– Only patients with thalassaemia trait can be considered for living kidney donation
– There have been a few reports of minor tubular dysfunction in some patients with thalassaemia trait
Red cell membrane disorders
· These include hereditary spherocytosis and hereditary eliptocytosis, inherited haemolytic anaemias of variable severity
· organ donation is acceptable in mild forms
White Cell Disorders
· Monoclonal gammopathy of uncertain significance (MGUS)
MGUS per se does not cause end organ disease and individuals with this condition could with caution be considered as living kidney donors
· Myelodysplasia
– The presence of MDS should be considered a strong contraindication to donation.
Clotting Disorders
· Patients with a history of VTE have a relative contraindication to donation
FAMILIAL RENAL DISEASE
· All potential transplant recipients must have a detailed family history recorded and confirmation where possible of the diagnosis in other family members with known kidney disease. This may aid diagnosis for the recipient, clarify any mode of inheritance and identify at risk relatives. (A1)
· When the cause of kidney failure in the recipient is due to an inherited condition, appropriate tests – including genetic testing if available – are recommended to exclude genetic disease in the potential donor. (A1)
· Many inherited kidney diseases are rare, so involvement of clinical and laboratory genetics services must be considered at an early stage to assess likely risks to family members and the appropriate use of molecular genetic testing. (B1)
Conditions in which renal dysfunction may be inherited and transplantation indicated for renal replacement therapy include the following:
· Autosomal dominant: ADPKD; Renal cysts and diabetes; Von Hippel Lindau disease; Familial haemolytic uraemic syndrome; Familial FSGS; Tuberose sclerosis complex; UMOD associated nephropathy (autosomal dominant tubulointerstitial disease); Nail patella syndrome
· Autosomal recessive: ARPKD; Alport syndrome; Familial nephrotic syndrome, renal ciliopathies including nephronophthisis
· X-linked: Alport syndrome; Fabry disease; Dent disease
· Polygenic: VUR; FSGS, IgA nephropathy
– In the majority of these conditions, the presence of disease in the potential donor precludes transplantation.
ADPKD
· The most common inherited renal disease, affects 1:1000-1:2000 individuals and is responsible for ~10% of UK patients receiving renal replacement therapy
· The diagnosis is based on the following recently revised ultrasound criteria:
1. Three or more unilateral or bilateral cysts in individuals aged 15-39 years
2. At least two cysts in each kidney for individuals aged 40 to 59 years
3. At least four cysts in each kidney for individuals aged >60 years
· A negative renal ultrasound beyond the age of 40 years excludes disease
· Between the ages of 20-40 years, a negative ultrasound should be followed by a CT or MRI scan
· Criteria for the diagnosis or exclusion of disease using CT or MRI have recently been published with a total of >10 cysts being sufficient for diagnosis and
· genetic testing for ADPKD is more accurate to exclude disease in donors
Reflux Nephropathy
· family studies show a high sibling recurrence risk and significant risk of inheritance
· affects around 1-2% of infants and is one of the most common reasons for transplantation in young adults
· A careful search for evidence of reflux or its consequences should be undertaken in relatives being considered as donors
· A history of childhood enuresis or urinary tract infection is common in affected individuals.
· Nuclear medicine scanning can detect renal scars and this may indicates reflux in potential donors
DONOR MALIGNANCY:
Recommendations
· Careful history taking, clinical examination and investigation of potential donors are essential to exclude occult malignancy before kidney donation, particularly in older (age >50 years) donors. (B1)
· Active malignant disease is a contraindication to living donation but donors with certain types of successfully treated low-grade tumour may be considered after careful evaluation and discussion. (B1)
· Donors with an incidental renal mass lesion must have this diagnosed and managed on its own merit (out with discussion of kidney donation) with appropriate referral to a Urology Specialist in line with the ‘2-week wait’ pathway. (A1)
· Contrast enhanced renal CT scan, ultrasound and / or MRI can usually distinguish between benign lesions such as angiomyolipoma (AML) or malignancy such as renal cell carcinoma (RCC). Review by a specialist uroradiologist is recommended. (C1)
· Bilateral AML and AML >4 cm generally preclude living kidney donation although occasionally unilateral large (>4 cm) AML can be used if ex vivo excision of the AML appears to be straightforward.
· An incidental, unilateral solitary AML <4 cm with typical characteristic CT criteria does not usually preclude donation.
· A kidney with an AML <1 cm may be considered for donation or left in situ in the donor’s remaining kidney.
· Kidneys containing a single AML between 1 and 4 cm can be considered for donation depending on its position, consideration of whether ex vivo excision of the AML is straightforward, or whether it can be left in situ in the recipient and followed with serial ultrasound imaging. (C1)
· Donors with an incidental small (<4 cm) renal mass that appears on imaging to be a RCC must be seen in a specialist Urology clinic and be offered standard of care treatment options, including partial and radical nephrectomy. Renal function permitting, if the person wishes to consider radical nephrectomy, ex-vivo excision of the small renal mass with subsequent donation of the reconstructed kidney can be considered on an individual basis with specific caveats, full MDM discussion and appropriate informed consent from the donor and recipient. (D2)
Two types of donor-derived malignancies are possible:
· inadvertent transfer of tumour tissue (donor transmitted)
· de-novo malignancy arising after transplantation in donor-derived tissue (donor derived)
Previous Cancer and Fitness for Living Donation
Strong or absolute contraindication:
· Malignant melanoma · Testicular cancer · Renal cell carcinoma >3 cm · Choriocarcinoma · Haematological malignancy · Lung cancer · Breast cancer · Sarcoma
Possible donation
Treated cancer with high probability of cure after 5-10 years e.g.
· Colon cancer (Dukes’ A >5 years ago) · non-melanoma skin cancer · Carcinoma-in-situ of the cervix or vulva · Localised low grade prostate cancer with curative treatment, minimum cancer-free period of 5 years · Renal cell carcinoma
SURGERY: TECHNICAL ASPECTS, DONOR RISK AND PERI-OPERATIVE CARE
Recommendations
· Work-up for living kidney donation may include direct or indicative evaluation of split renal function with the kidney with poorer function selected for nephrectomy irrespective of vascular anatomy (C2)
· Work-up for living kidney donation must include detailed imaging confirming the vascular anatomy of both donor kidneys and information about the renal parenchyma and collecting systems. Either CTA or MRA can be used as current evidence indicates little difference in accuracy. (B1)
· Multiple renal arteries or kidneys with anatomical anomalies are not absolute contraindications to donation. Decisions must be made on an individual basis as part of a multi-disciplinary team evaluation. (B2)
· All living donors must receive adequate thromboprophylaxis. Intra-operative mechanical compression and post-operative compression stockings, along with low molecular weight heparin, are recommended. (A2)
· All living donor surgery must be performed or directly supervised by a Consultant surgeon with appropriate training in the technique. (C1)
· Pre-operative hydration with an overnight infusion and/or a fluid bolus during surgery improves cardiovascular stability during laparoscopic donor nephrectomy. (B2)
· Pre- and peri-operative intravenous fluid replacement with Hartmann’s solution is preferred to 0.9% Saline. (B2)
· Laparoscopic donor surgery (fully laparoscopic or hand-assisted) is the preferred technique for living donor nephrectomy, offering a quicker recovery, shorter hospital stays and less pain. Mini-incision surgery is preferable to standard open surgery. (B1)
· Haem-o-lok clips are not to be used to secure the renal artery during donor nephrectomy following a report of an adverse event involving this technique. (C2)
· Patients undergoing living donor nephrectomy are likely to benefit from the management approaches widely used in “enhanced recovery after surgery” (ERAS) programmes. (D2)
Peri-operative Fasting and Insulin Resistance
· Guidelines surrounding peri-operative fasting in non-emergency surgical cases recommend fasting for six hours for solids (including milk in tea or coffee) and two hours for clear liquids
· Reversing the ‘fasting’ state of the patient by administration of an oral carbohydrate drink pre-operatively can increase insulin sensitivity by 50%, a state which continues into the post-operative period
· pre-operative carbohydrate loading in patients undergoing donor nephrectomy is considered( Nutricia 4 x 200 mL cartons between 9 pm and midnight before the operation with a further 2 x 200 mL 2 hours pre-operatively)
HISTOCOMPATIBILITY TESTING FOR LIVING DONOR KIDNEY TRANSPLANTATION
Recommendations
· Initial assessment of donor and recipient histocompatibility status must be undertaken at an early stage in living donor kidney transplant work-up to avoid unnecessary and invasive clinical investigation. (B2)
· Screening of potential living donor kidney transplant recipients for clinically relevant antibodies is important for ensuring optimal donor selection and graft survival. (A1)
· Antibody screening is especially important when potential living donor transplant recipients undergo reduction or withdrawal of immunosuppression. (B2)
· Post-transplant antibody monitoring must be undertaken according to the BSHI/BTS guidelines. (B1)
· Transplant units and histocompatibility laboratories must agree an evidence-based protocol to define antibody screening and crossmatch results that constitute a high immunological risk to transplantation. (B2)
· When possible, the HLA type(s) of partners/offspring of female recipients who have had previous pregnancies should be determined to aid immunological risk assessment for repeat paternal HLA mismatches in women with low level DSA. (B1)
· A pre-transplant serum sample collected within 14 days of the planned date for transplantation must be tested in a sensitive antibody screening and donor crossmatch assay and transplantation should not usually be performed if the crossmatch test is positive, unless the antibody is shown to be indicative of acceptable immunological risk. (A1)
· Changes in immunosuppression during the transplant work-up must be notified to the histocompatibility laboratory and additional antibody screening and donor-recipient crossmatch tests must be undertaken as indicated. (B1)
· HLA matching may be preferred when there is an option of selecting between living donors, particularly to reduce the possibility of subsequent sensitisation. This is important for younger recipients where repeat transplantation may be required. However, it is recognised that other donor factors will be taken into account. (B1)
· For patients with an ABO/HLA incompatible and/or a poorly HLA matched living donor, consideration should be given to entry into the UK living kidney sharing scheme (UKLKSS) to identify a more suitable donor. (B2)
· The histocompatibility laboratory must issue an interpretive report stating the donor and recipient HLA mismatch, recipient sensitisation status and crossmatch results, and define the associated immunological risk for all living donor-recipient pairs. (A1)
Assessment of Donor-Recipient HLA Mismatch Status
· The level of donor and recipient HLA compatibility is usually expressed as an HLA-A, -B and -DR mismatch grade determined from the number of donor HLA specificities at each locus that are absent in the recipient
· A donor and recipient with no HLA-A, -B, -DR incompatibilities is denoted ‘0.0.0’, whereas a fully mismatched combination is denoted ‘2.2.2’
Identification and Characterisation of Alloantibodies
Pre-transplant antibody screening
· Immunological sensitisation can be due to: transfusion of blood products, pregnancy, and previous transplantation.
· HLA-specific alloantibodies can also arise naturally through cross[1]reactivity with pathogens, when they are termed idiopathic antibodies.
· low-level donor HLA-specific antibodies in patients previously exposed to that same HLA specificity through previous transplantation or, in female patients, pregnancy( could have risk for response refractory to baseline induction immunosuppression)
· Recipient serum samples must be obtained for HLA-specific antibody screening at least every three months, and additional samples collected at 14 and 28 days after transfusion of any blood products
· For patients with a failing/failed transplant, consideration should be given to the potential benefits of immunosuppression reduction/withdrawal and the risks of developing de novo HLA-specific allosensitisation that could severely restrict future options for transplantation
· In cases where HLA-DP-specific antibodies are detected in recipient serum, donor-recipient HLA-DP status and potential HLA-DP-specific antibody incompatibility should be determined
Post-transplant antibody screening. can provide:
· prognostic information for the diagnosis of antibody-mediated rejection
· guide post-transplant rejection treatment,
· antibody reduction therapy
· choice of maintenance immunosuppressive therapy
Pre-transplant Donor-Recipient Crossmatch Test
· performed to confirm the presence or absence of donor HLA-specific alloantibodies
· If donor HLA-specific antibodies are present in recipient serum, the crossmatch test can provide information about antibody levels and the associated immunological risk
· Pre-formed donor HLA-specific antibodies present in recipient serum can cause hyperacute and acute rejection
· Living donor crossmatch testing is usually carried out at the time of first referral.
· The final crossmatch must always be undertaken using a serum sample obtained within 14 days of the planned operation date
· It is recommended that allosensitised recipients with pre-formed HLA class I- and/or class II-specific alloantibodies and recipients awaiting repeat transplantation should undergo donor T lymphocyte (for HLA class I sensitised patients) or T and B lymphocyte (for HLA class II sensitised patients) flow cytometric crossmatching as a minimum
· A positive donor lymphocyte crossmatch test performed using DTT treated sera by CDC carries a high immunological risk of hyperacute and acute humoral rejection and constitutes a veto to transplantation, unless an effective HLAi strategy is used to minimise the risk of graft failure
· Patients with a previous failed or failing kidney transplant that remains in situ often reduce or withdraw immunosuppressive drugs. This is frequently associated with the development of de novo HLA-specific antibodies to the allograft which cause a previously unexpected positive crossmatch and which then preclude future transplantation from an HLA- mismatched living donor
· A reduction or stopping of immunosuppression within one month of the planned operation date is contraindicated and may delay or preclude transplantation
Selection of Suitable D
All health professionals involved in LDKT must ensure that good ethical practice consistently followed in clinical practice.
Safety and welfare of the potential living donor must always take precedence over the needs of the potential transplant recipient.
Key Ethical Principles in LDKT are
· Altruism,
· Autonomy,
· Beneficence,
· Dignity,
· Non-maleficence
· Reciprocity.
Potential living donor should be informed about all the possible risks to give valid consent
and can withdraw from the transplant process at any time.
Information about processes involved and possible outcomes must be clarified:
· Risks of donation (generic and specific). Nature of surgical procedure and length of stay in hospital. Potential graft loss in the recipient. Requirement for HTA assessment. Reimbursement of expenses. Requirement for annual review.
· full psychological or psychiatric assessment has been importanrt part of donor workup to ensure firstly volunteer willing for donation and is essential to identify pre-existing or potential mental health issues that might arise later.
DONOR EVALUATION
The primary is to ensure the suitability of the donor and to minimise the risk of donation. This involves identifying contraindications to donation and potential physical and psychosocial risks.
The evaluation should be comprehensive, potential donors must be assessed according to evidence-based protocol which includes multi-disciplinary input and discussion.
Detailed history and clinical examination followed by relevant laboratory and radiological investigating should be done
Initiate assessment with ABO compatibility +/- HLA sensitisation, primary contra-indications identified from donor(s) past and present medical history, routine blood & urinalysis tests.
Routine Screening Investigations for the Potential Donor
Urine: Dipstick for protein, blood, and glucose (minimum twice), Microscopy, culture and sensitivity (minimum twice), Measurement of protein excretion rate (ACR or PCR)
Blood:
· Full blood count
· Coagulation screen
· Thrombophilia screen (if indicated)
· Sickle cell trait (if indicated)
· Haemoglobinopathy screen (if indicated)
· G6PD deficiency (if indicated)
· Renal profile and electrolytes
· measurement of GFR
· Liver function tests
· Bone profile (calcium, phosphate, albumin, and alkaline phosphatase)
· Uric acid
· Fasting plasma glucose
· Glucose tolerance test (family history of diabetes or fasting blood sugar >5.6 mmol/L)
· Fasting lipid screen
· Thyroid function tests (if strong family history)
· Pregnancy test for female at fertility age
Virology and infection screen:
Hepatitis B and C, HIV. HTLV1 and 2 (if appropriate)
· Cytomegalovirus
· Epstein-Barr virus
· Toxoplasma, Syphilis
· Varicella zoster virus (if recipient seronegative), HHV8 (if indicated)
· Malaria (if indicated), Trypanosoma cruzi (if indicated), Schistosomiasis (if indicated)
Cardiorespiratory system:
· Chest X-ray
· ECG
· ECHO
· Cardiovascular stress test
Assessment of Renal Function:
· Initial evaluation of donor candidates should be using estimated glomerular filtration rate (eGFR), expressed as mL/min/1.73m2 using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation
· Pre-donation mGFR should be such that the predicted post-donation GFR remains within the gender and age-specific normal range within the donor’s lifetime. A threshold GFR >80 mL/min/1.73m2 appears safe for donation more than 35 years old.
Donor Age:
· Old age is not an absolute contraindication to donation but the rigorous medical work-up of older donors must be done.
· Donors aged <18 years is contraindicated while in most centres an age of18-21 years consider as a relative contraindication to donation.
· Older donors are more likely than younger donors to be excluded from donating based on problems discovered during the medical evaluation. However, each case should be considered on individual basis.
Donor Obesity:
Healthy BMI 25-30 kg/m2 may safely undergoes kidney donation. Obesity grade 1 must be counselled about the increased risk of peri-operative complications and advise to lose weight, Data on the safety of kidney donation in BMI >35 kg/m2 are limited and donation should be discouraged
Hypertension in the Donor:
It is recommended potential donors with hypertension are excluded from donation if:
· Blood pressure is not controlled to <140/90 mmHg on one or two antihypertensive
· Evidence of end organ damage (retinopathy, LVH, proteinuria, previous cardiovascular disease)
· Unacceptable risk of future cardiovascular risk
Diabetes Mellitus:
· FBS must done and concentration between 6.1-6.9 mmol/L is indicative of an impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be done
· Donor with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT, Diabetes may also be diagnosed based upon HbA1c criteria, a result 6.5% being sufficient to diagnose diabetes and confirmatory test should be done.
Cardiovascular Evaluation:
· There is no evidence to support the routine use of stress testing in the assessment of the potential donor at low cardiac risk
· For higher risk potential donors, stress testing is recommended by whichever method is locally available or by CT calcium scoring .
Proteinuria:
Urine protein excretion needs to be quantified in all potential living donors. ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day or protein excretion >500 mg/day represent absolute contraindications to donation.
Non-Visible Haematuria
· Two or more positive tests, including trace positive, is considered as persistent non-visible haematuria
· If PNVH is present, perform urine culture and renal imaging to exclude common urologic causes including infection, nephrolithiasis and urothelial carcinoma. If no cause is found, perform cystoscopy in patients age >40 years to exclude bladder pathology. Glomerular pathology precludes donation, except for thin basement membrane disease
Pyuria:
pyuria can only be considered for donation if it can be demonstrated that the pyuria is due to a reversible cause, such as an uncomplicated urinary tract infection
Infection in the Prospective Donor:
· Active HBV and HCV infection in the donor are usually contraindications to living donor kidney donation; however, donors with evidence of active viral replication may be considered under some circumstances. While The presence of HIV or human T lymphotropic virus (HTLV) infection is an absolute contraindication to living donation.
· The CMV status of donor and recipient must be determined before transplantation. When the donor is CMV positive and the recipient is CMV negative, the donor and recipient must be counselled about the risk of post-transplant CMV disease
Nephrolithiasis:
In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone on imaging, may still be considered as potential kidney donors.
Haematological Disease: Careful consideration needs to be given to the use of potential donors with haemoglobinopathies.
Donor Malignancy: Careful history taking, clinical examination and investigation of potential donors are essential to exclude occult malignancy before kidney donation, particularly in older (age >50 years) donors. Active malignant disease is a contraindication to living donation.
Work-up for living kidney donation must include detailed imaging confirming the vascular anatomy of both donor kidneys and information about the renal parenchyma and collecting systems. Either CTA or MRA can be used as current evidence indicates little difference in accuracy. Multiple renal arteries or kidneys with anatomical anomalies are not absolute contraindications to donation.
Summary:
Legal framework:
Recommendations:
All transplants performed from living donors must comply with the requirements of the primary legislation. (Not graded)
All transplant centres performing living organ donation must be licensed by the Human Tissue Authority (Not graded)
Consent for the removal of organs from living donors must comply with the requirements of the Human Tissue Act 2004 (Not graded)
Ethics:
Recommendations:
All health professionals involved in living donor kidney transplantation must acknowledge the wide range of complex moral issues in this field and ensure that good ethical practice consistently underpins clinical practice. (Not graded)
Regardless of potential recipient benefit, the safety and welfare of the potential living donor must always take precedence over the needs of the potential transplant recipient. (Not graded)
Independence is recommended between the clinicians responsible for the assessment and preparation of the donor and the recipient, in addition to the Independent Assessor for the Human Tissue Authority. (Not graded)
Donor evaluation:
Recommendations:
In cases of directed donation the likely suitability of the potential recipient for transplantation must be established before starting donor assessment. (Not graded)
As far as possible, donor assessment is planned to minimise inconvenience to him/her and to avoid unnecessary barriers to the proceeding. (Not graded)
Donor assessment must be planned to ensure that it is focused, logical and coherent. (Not graded)
A policy must be in place to manage prospective donors who are found to be unsuitable to donate and appropriate follow-up and support must be made available. (Not graded) The organisational aspects for donor evaluation will vary between centres, according to available resources and personnel, but the same principles apply to all donors. An agreed donor assessment protocol must be in place that is tailored to the needs of the individual. (Not graded)
To facilitate pre-emptive transplantation, donor evaluation must start sufficiently early to allow time for more than one donor to be assessed if required. . (B2)
The evaluation of a potential donor should be undertaken within an 18-week pathway, assuming there are no logistical issues such as donor unavailability.
ABO BLOOD GROUPING AND CROSSMATCH TESTING
Recommendations:
A compatible ABO blood group and HLA transplant offer the best opportunity for success. (A1).
Where ABO or HLA incompatibility is present, alternative options for transplantation must be discussed with the donor and recipient, including paired/pooled donation and antibody incompatible transplantation. Antibody incompatible transplantation must only be performed in a transplant centre with the relevant experience and appropriate support.
ASSESSMENT OF RENAL FUNCTION
Recommendations
Measurement of Renal Function:
Initial evaluation of donor candidates should be using estimated glomerular filtration rate (eGFR), expressed as mL/min/1.73m2 computed from a creatinine assay standardised to the International Reference Standard. (B1)
GFR must subsequently be assessed by a reference measured method (mGFR) such as clearance of 51Cr-EDTA, 125 iothalamates or Iohexol performed according to guidelines published by the British Society of Nuclear Medicine. (B1)
Differential kidney function, determined by 99mTcDMSA scanning is recommended where there is >10% variation in kidney size or a significant renal anatomical abnormality. (C1)
Monitoring of Kidney Donor:
The donor must be offered a lifelong annual assessment of renal function including serum creatinine, estimation of urine protein excretion and blood pressure measurement. (B1)
DONOR AGE
Recommendations
Old age alone is not an absolute contraindication to donation but the medical work-up of older donors must be particularly rigorous to ensure they are suitable. (A1)
Both donor and recipient must be made aware that the older donor may be at greater risk of peri-operative complications and that the function and possibly the long-term survival of the graft may be compromised. This is particularly evident with donors >60 years of age. (B1)
DONOR OBESITY
Recommendations:
Otherwise healthy overweight patients (BMI 25-30 kg/m2 ) may safely proceed to kidney donation. (B1)
Moderately obese patients (BMI 30-35 kg/m2 ) must undergo a careful preoperative evaluation to exclude cardiovascular, respiratory and kidney disease. (C2)
Moderately obese patients (BMI 30-35 kg/m2 ) must be counselled about the increased risk of peri-operative complications based on extrapolation of outcome data from very obese donors (BMI >35 kg/m2 ). (B1)
Moderately obese patients (BMI 30-35 kg/m2 ) must be counselled about the long-term risk of kidney disease and be advised to lose weight before donation and to maintain their ideal weight following donation. (B1)
Data on the safety of kidney donation in the very obese (BMI >35 kg/m2 ) are limited, and the donation should be discouraged. (C1)
HYPERTENSION IN THE DONOR
Recommendations:
Blood pressure must be assessed on at least two separate occasions. Ambulatory blood pressure monitoring or home monitoring is recommended if blood pressure is high, high normal or variable, or the potential donor is on treatment for hypertension. (C2)
We suggest that a blood pressure <140/90 mmHg is usually acceptable for donation. (C1)
Prospective donors must be warned about the risk of developing donation-related hypertension, particularly if in a high-risk group. Blood pressure measurement is part of annual donor monitoring. (C1)
Potential donors with mild-moderate hypertension that is controlled to <140/90 mmHg (and/or 135/85 mmHg with ABPM or home monitoring) with one or two antihypertensive drugs and who have no evidence of end-organ damage may be acceptable for donation. Acceptance will be based on an overall cardiovascular risk assessment and local policy. (C1)
It is recommended that potential donors with hypertension are excluded from donation if: (C1) o Blood pressure is not controlled to
DIABETES MELLITUS
Recommendation:
All potential living kidney donors must have a fasting plasma glucose level checked. (B1)
A fasting plasma glucose concentration between 6.1-6.9 mmol/L indicates an impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be undertaken. (B1)
Prospective donors with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT. (B1) If OGTT reveals persistent impaired fasting glucose and/or impaired glucose tolerance, the risk of developing diabetes after donation must be carefully considered. (B1)
Consideration should be given to using a diabetes risk calculator to inform the discussion of potential kidney donation. (B2)
Consideration of patients with diabetes as potential kidney donors requires carefully evaluating the risks and benefits. (Not graded)
CARDIOVASCULAR EVALUATION
Recommendations
There is no evidence to support the routine use of stress testing in assessing the potential donor at low cardiac risk. (C2)
Potential kidney donors with a history of cardiovascular disease, an exercise capacity of <4 metabolic equivalents (METS) or risk factors for cardiovascular disease should undergo further evaluation before donation. (C2)
For higher-risk potential donors, stress testing is recommended by whichever method is locally available or by CT calcium scoring. (C2)
Discussion with and/or review by cardiologists, anaesthetists and the transplant MDT is recommended as part of the clinical assessment of donors with higher cardiovascular and peri-operative risk. (D2)
PROTEINURIA
Recommendations:
Urine protein excretion needs to be quantified in all potential living donors. (B1)
A urine albumin/creatinine ratio (ACR) performed on a spot urine sample is the recommended screening test, although urine protein/creatinine ratio (PCR) is an acceptable alternative. (A1)
ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day or protein excretion >500 mg/day represent absolute contraindications to donation. (C2)
The significance of moderately increased albuminuria (ACR 3-30 mg/mmol) and proteinuria (PCR 15-50 mg/mmol or 24-hour urine protein 150-500 mg/day) has not been fully evaluated in living kidney donors. However, since the risk of CKD and cardiovascular morbidity increase progressively with increasing albuminuria or proteinuria, such levels are a relative contraindication to donation. (C2)
NON-VISIBLE HAEMATURIA
Recommendations:
All potential living donors must have reagent strip (dipstick) urinalysis performed on at least two separate occasions. (B1)
Two or more positive tests, including trace positive, is considered as persistent non-visible haematuria (PNVH). (B1)
If PNVH is present, perform urine culture and renal imaging to exclude common urologic causes including infection, nephrolithiasis and urothelial carcinoma. (A1)
If no cause is found, perform cystoscopy in patients age >40 years to exclude bladder pathology. (B1)
If no cause is found and the donor still wishes to donate, then a kidney biopsy is recommended if haematuria is 1+ or greater on dipstick testing. (B1)
Glomerular pathology precludes donation, with the possible exception of thin basement membrane disease. (B1)
For donors with persistent asymptomatic non-visible haematuria (PANVH) and a family history of haematuria or X-linked Alport syndrome, a renal biopsy (B1) and referral to a clinical geneticist are recommended. (B2)
PYURIA
Recommendation
Prospective donors found to have pyuria can only be considered for donation if it can be demonstrated that the pyuria is due to a reversible cause, such as an uncomplicated urinary tract infection. (C1)
INFECTION IN THE PROSPECTIVE DONOR
Recommendations
Screening for infection in the prospective donor is essential to identify
potential risks for the donor from previous or current infection and to
assess the risks of transmission of infection to the recipient. (B1)
Active HBV and HCV infection in the donor are usually
contraindications to living donor kidney donation; however, donors
with evidence of active viral replication may be considered under some
circumstances. (B1)
The presence of HIV or human T lymphotropic virus (HTLV) infection
is an absolute contraindication to living donation. (B1)
Screening for HBV, HCV and HIV infection must be repeated within 30
days of donation. (Not graded)
All potential donors should be provided with dietary advice regarding
avoidance of HEV infection, and screening should be undertaken for
HEV viraemia by nucleic acid testing within 30 days of donation. (Not
graded)
The CMV status of the donor and recipient must be determined before
transplantation. When the donor is CMV positive and the recipient is
CMV negative, the donor and recipient must be counselled about the
risk of post-transplant CMV disease. (B1)
The EBV status of donor and recipient must be determined before
transplantation. When the donor is EBV positive and the recipient is
EBV negative, the donor and recipient must be counselled about the
risk of developing Post Transplant Lymphoproliferative Disease. (B1)
Potential donors must be screened by history for travel or residence
abroad to assess their potential risk of acquiring endemic infections and appropriate microbiological investigations instigated if indicated. (Not graded)
NEPHROLITHIASIS
Recommendations:
In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as potential kidney donors. Full counselling of donor and recipient is required along with access to appropriate long-term donor follow-up. (C2)
Potential donors with metabolic abnormalities detected on screening should be discussed with a specialist in renal stone disease. (C2)
Inappropriate donors with a unilateral kidney stone(s) the stone-bearing kidney can be considered for donation (if vascular anatomy and split kidney function permit) to leave the donor with a stone-free kidney after donation. (C2)
HAEMATOLOGICAL DISEASE
Recommendations
Donor anaemia needs to be investigated and treated before donation. (A1)
A haemoglobinopathy screen must be carried out in patients with non Northern European heritage or if indicated by the full blood count. (A1)
Careful consideration needs to be given to the use of potential donors with haemoglobinopathies. (B1)
Advice from a consultant haematologist is recommended for haematological conditions not covered in this guideline. (Not graded)
FAMILIAL RENAL DISEASE
Recommendations
All potential transplant recipients must have a detailed family history recorded and confirmation where possible of the diagnosis in other family members with known kidney disease. This may aid diagnosis for the recipient, clarify any mode of inheritance and identify at-risk relatives. (A1)
When the cause of kidney failure in the recipient is due to an inherited condition, appropriate tests – including genetic testing if available – are recommended to exclude genetic disease in the potential donor. (A1)
Many inherited kidney diseases are rare, so involvement of clinical and laboratory genetics services must be considered early to assess likely risks to family members and the appropriate use of molecular genetic testing. (B1)
HISTOCOMPATIBILITY TESTING FOR LIVING DONOR KIDNEY TRANSPLANTATION Recommendations
Initial assessment of donor and recipient histocompatibility status must be undertaken early. (B2)
Screening of potential living donor kidney transplant recipients for clinically relevant antibodies is important for ensuring optimal donor selection and graft survival. (A1) Antibody screening is especially important when potential living donor transplant recipients undergo reduced or withdrawn immunosuppression. (B2)
Post-transplant antibody monitoring must be undertaken according to the BSHI/BTS guidelines. (B1)
Transplant units and histocompatibility laboratories must agree an evidence-based protocol to define antibody screening and crossmatch results that constitute a high immunological risk to transplantation. (B2)
When possible, the HLA type(s) of partners/offspring of female recipients who have had previous pregnancies should be determined to aid immunological risk assessment for repeat paternal HLA mismatches in women with low level DSA. (B1)
A pre-transplant serum sample collected within 14 days of the planned date for transplantation must be tested in a sensitive antibody screening and donor crossmatch assay and transplantation should not usually be performed if the crossmatch test is positive unless the antibody is shown to be indicative of acceptable immunological risk. (A1)
Changes in immunosuppression during the transplant work-up must be notified to the histocompatibility laboratory and additional antibody screening and donor-recipient crossmatch tests must be undertaken as indicated. (B1)
HLA matching may be preferred when there is an option of selecting between living donors, particularly to reduce the possibility of subsequent sensitisation. This is important for younger recipients where repeat transplantation may be required. However, it is recognised that other donor factors will be taken into account. (B1)
For patients with an ABO/HLA incompatible and/or a poorly HLA matched living donor, consideration should be given to entry into the UK living kidney sharing scheme to identify a more suitable donor. (B2)
The histocompatibility laboratory must issue an interpretive report stating the donor and recipient HLA mismatch, recipient sensitisation status and crossmatch results, and define the associated immunological risk for all living donor-recipient pairs. (A1)
At my workplace, we usually follow KDIGO guidelines.
▪︎LEGAL FRAMEWORK
• All transplants from living donors must follow requirements of the primary legislation.•
•Written Consent must comply with the requirements of the corresponding authority organs.
▪︎ETHICS Recommendations
• All health professionals must acknowledge the wide range of complex moral issues in this field and ensure that good ethical practice.
• the safety of the potential living donor must always take precedence over the needs of the potential transplant recipient.
• Independence is recommended between the clinicians responsible for the assessment and preparation of the donor and the recipient, in addition to the Independent Assessor for the Human Tissue Authority.
▪︎SUPPORTING AND INFORMING THE POTENTIAL DONOR
• The living donor must be free and at comfort environment for making a voluntary and informed choiceato donate .
• Independent assessment of the donor and recipient is required by primary legislation
• boundaries of confidentiality must be specified and discussed at the outset.
•Separate clinical teams for donor and recipient are considered best practice but healthcare professionals must work together to ensure effective communication and co-ordination of the transplantation process .
• Support for the prospective donor, recipient and family is an integral part of the donation/transplantation process. Psychological needs must be identified at an early stage in the evaluation to ensure that appropriate support and/or intervention is initiated.
▪︎ BLOOD GROUPING AND CROSSMATCH TESTING
• A compatible ABO blood group and human leucocyte antigen (HLA) transplant offers the best opportunity for success. (A1)
• if ABO or HLA incompatibility is present, alternative options for transplantation must be discussed with the donor and recipient, as paired/pooled donation and antibody incompatible transplantation.
▪︎Evaluation OF Kidney FUNCTION
Measurement of RenalFunction Initial evaluation of donor candidates should be using estimated glomerular filtration rate (eGFR), expressed as mL/min/1.73m2 computed from a creatinine assay.
• GFR must subsequently be assessed by a reference measured method (mGFR) such as clearance of 51Cr-EDTA, 125iothalamate or Iohexol.
•Differential kidney function, determined by 99mTcDMSA scanning is recommended where there is >10% variation in kidney size or significant renal anatomical abnormality. (C1)
• Pre-donation mGFR should be such that the predicted post-donation GFR remains within the gender and age-specific normal range within the donor’s lifetime.
• The risk of end-stage renal disease (ESRD) after 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 consented. (D2)
• The decision to approve donor candidates whose renal function is below recommended GFR threshold or who have additional risk factors for the development of ESRD should be individualised and based on the predicted lifetime incidence of ESRD. (D2).
▪︎DONOR AGE
• Old age alone is not an absolute contraindication to donation but the more medical work-up . (A1)
• Both donor and recipient must be made aware that the older donor may be at greater risk of peri-operative complications and that the function and possibly the long-term survival of the graft may be compromised especially in donors >60 years of age. (B1).
▪︎DONOR OBESITY
• healthy overweight patients (BMI 25-30 kg/m2 ) may safely proceed to kidney donation. (B1) •
•Moderately obese patients (BMI 30-35 kg/m2 ) must undergo careful preoperative evaluation to exclude cardiovascular, respiratory and kidney disease. (C2) .
• Moderately obese patients (BMI 30-35 kg/m2 ) must be counselled about the increased risk of peri-operative complications based on extrapolation of outcome data from very obese donors (BMI >35 kg/m2 ). (B1)
• Moderately obese patients (BMI 30-35 kg/m2 ) must be counselled about the long-term risk of kidney disease and be advised to lose weight before donation and to maintain their ideal weight following donation. (B1)
• Data on the safety of kidney donation in the very obese (BMI >35 kg/m2 ) are limited and donation should be discouraged. (C1)
▪︎HYPERTENSION IN THE DONOR
• Blood pressure must be assessed on at least two separate occasions.
Ambulatory blood pressure monitoring or home monitoring is recommended if blood pressure is high, high normal or variable, or the potential donor is on treatment for hypertension. (C2)
• that a blood pressure <140/90 mmHg is usually acceptable for donation. (C1)•
•donors must know about the risk of developing donation-related hypertension, particularly if in a high-risk group. Blood pressure measurement is part of annual donor monitoring.
• Potential donors with mild-moderate hypertension that is controlled to <140/90 mmHg with one or two antihypertensive drugs and who have no evidence of end organ damage may be acceptable for donationC1).
• potential donors are excluded from donation if: (C1)o Blood pressure is not controlled to <140/90 mmHg on one or two antihypertensive drug or if there us evidence of end organ damage (retinopathy, left ventricular hypertrophy, proteinuria, previous cardiovascular disease).
• All living kidney donors must be encouraged to avoid risk factors by lifestyle measures including stopping smoking, reducing alcohol intake, frequent exercise and, weight loss. (C1).
▪︎DIABETES MELLITUS
• All potential living kidney donors must have a fasting plasma glucose level checked. (B1) .
if there is impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be undertaken. (B1)
• Prospective donors with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT. (B1) •
If OGTT reveals a persistent impaired fasting glucose and/or an impaired glucose tolerance, then the risks of developing diabetes after donation must be carefully considered. (B1) •
• patients with diabetes as potential kidney donors requires careful evaluation of the risks and benefits. In the absence of evidence of target organ damage diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney. (Not graded)
▪︎CARDIOVASCULAR EVALUATION
• kidney donors with a history of cardiovascular disease, an exercise capacity of <4 metabolic equivalents (METS) or with risk factors for cardiovascular disease should undergo further evaluation before donation. (C2)•
•For higher risk potential donors, stress testing is recommended by methods available or by CT calcium scoring . (C2)•
•Discussion with and/or review by cardiologists, anaesthetists and the transplant MDT is recommended as part of the clinical assessment of donors with higher cardiovascular and peri-operative risk. (D2)
▪︎NON-VISIBLE HAEMATURIA
• All potential living donors must have dipstick urinalysis performed on at least two separate occasions. (B1) •
Two or more positive tests, including trace positive, is considered as persistent non-visible haematuria (PNVH). (B1)
•If PNVH is present, perform urine culture and renal imaging to exclude common urologic causes including infection, nephrolithiasis and urothelial carcinoma. (A1•
•If no cause is found, perform cystoscopy in patients age >40 years to exclude bladder pathology. (B1)
• If no cause is found and the donor still wishes to donate, then a kidney biopsy is recommended if haematuria is 1+ or greater on dipstick testing. (B1)
• Glomerular pathology precludes donation, with the possible exception of thin basement membrane disease. (B1)•
▪︎PYURIA
• donors found to have pyuria can only be considered for donation if pyuria is due to a reversible cause, such as an uncomplicated urinary tract infection. (C1)
▪︎INFECTION IN THE PROSPECTIVE DONOR
• Screening for infection in the donor is essential to identify potential risks for the donor from previous or current infection and to assess the risks of transmission of infection to the recipient.
• Active HBV and HCV infection in the donor are usually contraindications to living donor kidney donation; however, donors with evidence of active viral replication may be considered under some circumstances. (B1) •
•The presence of HIV or human T lymphotrophic virus (HTLV) infection is an absolute contraindication to living donation. (B1) •
•The CMV status of donor and recipient must be determined before transplantation. When the donor is CMV positive and the recipient is CMV negative, the donor and recipient must be counselled about the risk of post-transplant CMV disease. (B1)
• The EBV status of donor and recipient must be determined before transplantation. When the donor is EBV positive and the recipient is EBV negative, the donor and recipient must be counselled about the risk of developing Post Transplant Lymphoproliferative Disease. (B1) •
▪︎NEPHROLITHIASIS
• In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as potential kidney donors.
• donors with metabolic abnormalities detected on screening should be discussed with a specialist in renal stone disease. (C2)
• In appropriate donors with unilateral kidney stone(s) the stone-bearing kidney can be considered for donation (if vascular anatomy and split kidney function permit) in order to leave the donor with a stone-free kidney after donation. (C2)
▪︎HAEMATOLOGICAL DISEASE
• Donor anaemia needs to be investigated and treated before donation. (A1)
• Careful consideration needs to be given to the use of donors with haemoglobinopathies. (B1)
▪︎FAMILIAL RENAL DISEASE
• All transplant recipients must have a detailed family history recorded if possible of the diagnosis in other family members with known kidney disease. This may aid diagnosis for the recipient, clarify any mode of inheritance and identify at risk relatives. (A1) •
When the cause of kidney failure in the recipient is due to an inherited condition, tests and genetic testing are recommended to exclude genetic disease in the donor. (A1)
▪︎DONOR MALIGNANCY
• Careful history taking, clinical examination and investigation of donors are essential to exclude occult malignancy before kidney donation, particularly in older (age >50 years) donors. (B1)
• Active malignant disease is a contraindication to living donation .
• Donors with an incidental renal mass lesion must be diagnosed and managed
• Contrast enhanced renal CT scan, ultrasound and / or MRI can usually distinguish between benign lesions such as angiomyolipoma (AML) or malignancy such as renal cell carcinoma (RCC).
• Bilateral AML and AML >4 cm generally preclude living kidney donation although occasionally unilateral.
• An incidental, unilateral solitary AML <4 cm with typical characteristic CT criteria does not usually preclude donation.
• A kidney with an AML <1 cm may be considered for donation or left in situ in the donor’s remaining kidney.
• Kidneys containing a single AML between 1 and 4 cm can be considered for donation depending on its position, consideration of whether ex vivo excision of the AML is straightforward, or whether it can be left in situ in the recipient and followed with serial ultrasound imaging. (C1)
• Donors with an incidental small (<4 cm) renal mass that appears on imaging to be a RCC must be seen in a specialist Urology clinic and be offered standard of care treatment options, including partial and radical nephrectomy. Renal function permitting, if the person wishes to consider radical nephrectomy, ex-vivo excision of the small renal mass with subsequent donation of the reconstructed kidney can be considered on an individual basis.
▪︎SURGERY: TECHNICAL ASPECTS, DONOR RISK AND PERI-OPERATIVE CARE
• Work-up for living kidney donation may include direct or indicative evaluation of split renal function with the kidney with poorer function selected for donation .
• Work-up for living kidney donation must include detailed imaging confirming the vascular anatomy of both donor kidneys and information about the renal parenchyma and collecting systems.
• Multiple renal arteries or kidneys with anatomical anomalies are not absolute contraindications to donation.
•All living donors must receive adequate thromboprophylaxis. Intraoperative mechanical compression and post-operative compression stockings, along with low molecular weight heparin, are recommended.
• • Pre- and peri-operative hydration and intravenous fluid replacement with Hartmann’s solution is preferred to 0.9% Saline. (B2) •
•Laparoscopic donor surgery (fully laparoscopic or hand-assisted) is the preferred technique
• Patients undergoing living donor nephrectomy are likely to benefit from the management approaches widely used in “enhanced recovery after surgery” (ERAS) programmes. (D2)
▪︎HISTOCOMPATIBILITY TESTING FOR LIVING DONOR KIDNEY TRANSPLANTATION
• Initial assessment of donor and recipient histocompatibility status must be undertaken at an early stage in living donor kidney transplant work-up to avoid unnecessary and invasive clinical investigation. (B2)
• Screening of recipients for clinically relevant antibodies is important for ensuring optimal donor selection and graft survival. (A1)
• Antibody screening is especially important when recipients undergo reduction or withdrawal of immunosuppression. (B2)
• Post-transplant antibody monitoring must be undertaken according to the BSHI/BTS guidelines. (B1)
• When possible, the HLA type(s) of partners/offspring of female recipients who have had previous pregnancies should be determined to aid immunological risk assessment for repeat paternal HLA mismatches in women with low level DSA. (B1)
• A pre-transplant serum sample collected within 14 days of the planned date for transplantation must be tested in a sensitive antibody screening and donor crossmatch assay .
Transplantation should not usually be performed if the crossmatch test is positive, unless the antibody is shown to be indicative of acceptable immunological risk. (A1)
• HLA matching may be preferred when there is an option of selecting between living donors, particularly to reduce the possibility of subsequent sensitisation.
• The histocompatibility laboratory must issue an interpretive report stating the donor and recipient HLA mismatch, recipient sensitisation status and crossmatch results, and define the associated immunological risk for all living donor-recipient pairs. (A1)
▪︎DONOR FOLLOW-UP AND LONG-TERM OUTCOME
• Counselling and consent of potential living kidney donors must include acknowledgement that the baseline risk of ESRD is increased by donation .
• 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
• Risk calculators predicting lifetime ESRD risk may help inform the consent process.
• The risk of ESRD in living donors mandates lifelong follow-up after donor nephrectomy.
• Potential donors who are unable to proceed to donation must be appropriately followed up and referred for further investigation and management as required. (B1)
• Women must be informed of a greater risk of pregnancy-induced hypertension following kidney donation. (A1)
• Close monitoring of blood pressure, creatinine and foetal well-being is advisable in kidneys donors during pregnancy. (C1)
• Kidney donors may be offered Aspirin 75 mg daily for pre-eclampsia prophylaxis. (D2) .
▪︎RECIPIENT OUTCOME AFTER LIVING DONOR KIDNEY TRANSPLANTATION IN ADULTS
• Graft and patient survival after living donor kidney transplantation should be within the national range of expected outcomes. (A1)
• Where a recipient is considered to be at high risk, transplantation should only proceed if, in the view of the team of professionals involved, there is an expectation that the patient is likely to survive with a functioning transplant for more than 2 years. (C2) •
▪︎RECURRENT RENAL DISEASE
The risks of recurrence, the consequences for transplant function, and the time-course of any deterioration must all be considered.
A discussion of the effects of immunosuppression and transplant failure on morbidity and mortality may also be appropriate. (B1)
• The risks of recurrent disease are high in FSGS and MCGN.
In these diseases, the presence of specific adverse clinical features may indicate living donor transplantation should be avoided.
• In atypical HUS potential de novo disease in a related donor needs to be addressed directly. The risks of recurrent disease in the recipient need to be mitigated through regulated approval and consideration of the use of an inhibitor of complement activation, currently eculizumab. (A1)
• In patients with risks related to underlying activity such as SLE or systemic vasculitis, adequate disease control and an appropriate period of quiescence are important to ensure optimal outcomes. (B1)
▪︎LIVING DONOR KIDNEY TRANSPLANTATION IN CHILDREN
• Pre-emptive living related renal transplantation is the gold standard therapy for children with end-stage renal disease.
• The aim should be for children to receive a renal transplant from a blood group compatible well-matched donor, although ABO and/or HLA incompatible renal transplantation is feasible in children.
• Every effort should be made to minimise HLA mismatches (especially with common antigens) to reduce the risk of future sensitisation.
• All children with stage 4 and 5 chronic kidney disease should be assessed by a multi-disciplinary team, including a paediatric nephrologist, transplant surgeon, anaesthetist and urologist prior to renal transplantation.
• In general, children who are ≥10 kg in weight are suitable to receive a kidney from an adult living donor.
LEGAL FRAMEWORK
Recommendations
· All transplants performed from living donors must comply with the requirements of the primary legislation (Human Tissue Act 2004 and Human Tissue (Scotland) Act 2006), which regulate transplantation and organ donation across the United Kingdom. (Not graded)
· All transplant centres performing living organ donation must be licensed by the Human Tissue Authority in line with the requirements of the European Union Organ Donation Directive which sets out the minimum requirements for the Quality and Safety of Organs for Transplantation. (Not graded)
· Consent for the removal of organs from living donors, for the purposes of transplantation, must comply with the requirements of the Human Tissue Act 2004, and the Mental Capacity Act 2005 in England and Wales, and the Mental Capacity Act 2016 in Northern Ireland. Consent in Scotland must comply with the Human Tissue (Scotland) Act 2006 and the Adults with Incapacity (Scotland) Act 2000. (Not graded)
ETHICS
Recommendations
· All health professionals involved in living donor kidney transplantation must acknowledge the wide range of complex moral issues in this field and ensure that good ethical practice consistently underpins clinical practice. The BTS has an Ethics Committee to provide additional support and advice if required. (Not graded)
· Regardless of potential recipient benefit, the safety and welfare of the potential living donor must always take precedence over the needs of the potential transplant recipient. (Not graded)
· Independence is recommended between the clinicians responsible for the assessment and preparation of the donor and the recipient, in addition to the Independent Assessor for the Human Tissue Authority. (Not graded)
SUPPORTING AND INFORMING THE POTENTIAL DONOR
Recommendations
· The living donor must be offered the best possible environment for making a voluntary and informed choice about donation. The transplant team must provide generic information that is relevant to all donors as well as specific information that is material to the person intending to donate. This includes information about the assessment process and the benefits and risks of donation to the individual donor. (B1)
· Independent assessment of the donor and recipient is required by primary legislation (Human Tissue Act 2004). (Not graded)
· To achieve the best outcome for donor, recipient and transplant, the boundaries of confidentiality must be specified and discussed at the outset. Relevant information about the recipient can only be shared with the donor if the recipient has given consent and vice versa. Both the recipient and donor must be informed that it is necessary and usual for all relevant clinical information to be shared across the transplant team in order to optimise the chance of a successful outcome for the transplant. (B1)
· Ideally, the recipient will discuss relevant information with their donor, or allow it to be shared. If the recipient is not willing to disclose information, then the transplant team must decide whether it is possible to communicate the risks and benefits of donating adequately, without needing to disclose specific medical details. (Not graded)
· Separate clinical teams for donor and recipient are considered best practice but healthcare professionals must work together to ensure effective communication and co-ordination of the transplant process without compromising the independence of either donor or recipient. It is essential that an informed health professional who is not directly BTS/RA Living Donor Kidney Transplantation Guidelines 2018 33 involved with the care of the recipient acts as the donor advocate in addressing any outstanding questions, anxieties or difficult issues, and assists the donor in making a truly autonomous decision. (B1)
· Support for the prospective donor, recipient and family is an integral part of the donation/transplantation process. Psychological needs must be identified at an early stage in the evaluation to ensure that appropriate support and/or intervention is initiated. Access to specialist psychiatric/psychological services must be available for donors/recipients requiring referral. (B1)
DONOR EVALUATION
Donor and/or recipient may be considered unsuitable because they:
1. Have an absolute contraindication to donation/transplantation according to UK Guidelines (i.e. general comorbidity or kidney specific issue)
2. Have a relative contraindication to donation/transplantation according to UK Guidelines
3. Do not meet transplant centre-specific criteria for acceptance of referral (e.g. age; comorbidity; complex anatomy; body mass index; immunological risk)
If donor and/or recipient unsuitable, decision discussed:
1. At transplant multi-disciplinary meeting (in collaboration with the transplant centre if referral originates in referring nephrology unit, according to type of contraindication +/- donor/recipient preferences)
2. With donor and/or recipient and second opinion offered: · Routinely if categories 2 or 3 apply · Exceptionally if category 1 applies (depending upon type of contraindication +/- donor/recipient preferences
Recommendations
· In cases of directed donation (to a known recipient) the likely suitability of the potential recipient for transplantation must be established before starting donor assessment. If additional recipient assessment is required, unnecessary delay should be avoided. Non-invasive assessment of the donor may be undertaken in this phase. (Not graded)
· As far as possible, donor assessment is planned to minimise inconvenience to him/her and to avoid unnecessary barriers to proceeding. Flexibility in terms of timescales, planning consultations, attending for investigations and date of surgery is helpful. (Not graded)
· Donor assessment must be planned to ensure that it is focused, logical and coherent. Good communication with the donor and involvement of the wider multi-disciplinary team is essential and is achieved most effectively if a designated co-ordinator leads the organisation of the assessment process. The results of investigations must be relayed accurately and efficiently to the potential donor. Unsuitable donors must be identified at the earliest possible stage of assessment. (Not graded)
· A policy must be in place to manage prospective donors who are found to be unsuitable to donate and appropriate follow-up and support must be made available. (Not graded)
· The organisational aspects for donor evaluation will vary between centres, according to available resources and personnel, but the same principles apply for all donors. An agreed donor assessment protocol must be in place that is tailored to the needs of the individual. Table 5.2.1 shows a suggested best practice model with an audit standard for donor evaluation. (Not graded) BTS/RA Living Donor Kidney Transplantation Guidelines 2018 53
· To facilitate pre-emptive transplantation, donor evaluation must start sufficiently early to allow time for more than one donor to be assessed if required. Information must be provided at an early stage and discussion with potential donors and recipients will usually be started when the recipient eGFR is approximately 20 mL/min or when the recipient is expected to require renal replacement therapy within 12-18 months. Recipient and donor assessment can then be tailored according to the rate of decline of recipient renal function, disease specific considerations and individual circumstances. (B2)
· The evaluation of a potential donor should be undertaken within an 18 week pathway, assuming there are no logistical issues such as donor unavailability. There may, of course, be pauses if the recipient’s transplant assessment is complicated or if the recipient’s renal function remains satisfactory.
ABO BLOOD GROUPING AND CROSSMATCH TESTING
Recommendations
· A compatible ABO blood group and human leucocyte antigen (HLA) transplant offers the best opportunity for success. (A1)
· Where ABO or HLA incompatibility is present, alternative options for transplantation must be discussed with the donor and recipient, including paired/pooled donation and antibody incompatible transplantation. Antibody incompatible transplantation must only be performed in a transplant centre with the relevant experience and appropriate support. (A1)
Points of Particular Importance when Undertaking Clinical Examination of a Potential Kidney Donor
– Abdominal fat distribution
– Blood pressure
– Body mass index
– Dipstick urinalysis
– Evidence of self-harm
– Examination for abdominal masses or herniae
– Examination for scars or previous surgery
– Examination for lymphadenopathy
– Examination / history of regular self-examination of the breasts
– Examination / history of regular self-examination of the testes
– Examination of the cardiovascular and respiratory systems
– Mental health
Routine Screening Investigations for the Potential Donor
Urine
Dipstick for protein, blood and glucose (at least twice)
Microscopy, culture and sensitivity (at least twice)
Measurement of protein excretion rate (ACR or PCR)
Blood
Haemoglobin and blood count
Coagulation screen (PT and APTT)
Thrombophilia screen (where indicated)
Sickle cell trait (where indicated)
Haemoglobinopathy screen (where indicated)
G6PD deficiency (where indicated)
Creatinine, urea and electrolytes
Isotopic or other reference test for measurement of GFR
Liver function tests
Bone profile (calcium, phosphate, albumin and alkaline phosphatase)
Urate
Fasting plasma glucose
Glucose tolerance test (if family history of diabetes or fasting plasma glucose
>5.6 mmol/L)
Fasting lipid screen (if indicated)
Thyroid function tests (if strong family history)
Pregnancy test (if indicated)
Virology and infection screen (see section 5.14)
Hepatitis B and C
HIV
HTLV1 and 2 (if appropriate)
Cytomegalovirus
Epstein-Barr virus
Toxoplasma
Syphilis
Varicella zoster virus (where recipient seronegative)
BTS/RA Living Donor Kidney Transplantation Guidelines 2018 65
HHV8 (where indicated)
Malaria (where indicated)
Trypanosoma cruzi (where indicated)
Schistosomiasis (where indicated)
Cardiorespiratory system (see section 5.10)
Chest X-ray
ECG
ECHO (where indicated)
Cardiovascular stress test (as routine or where indicated
ASSESSMENT OF RENAL FUNCTION
Recommendations
Measurement of Renal Function · Initial evaluation of donor candidates should be using estimated glomerular filtration rate (eGFR), expressed as mL/min/1.73m2 computed from a creatinine assay standardised to the International Reference Standard. (B1)
· GFR must subsequently be assessed by a reference measured method (mGFR) such as clearance of 51Cr-EDTA, 125iothalamate or Iohexol performed according to guidelines published by the British Society of Nuclear Medicine. (B1)
· Differential kidney function, determined by 99mTcDMSA scanning is recommended where there is >10% variation in kidney size or significant renal anatomical abnormality. (C1) Advisory GFR Thresholds for Donation
· Pre-donation mGFR should be such that the predicted post-donation GFR remains within the gender and age-specific normal range within the donor’s lifetime. Recommended threshold levels are defined in Table 5.5.2. (B1)
· The risk of end-stage renal disease (ESRD) after 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 consented. (D2)
· The decision to approve donor candidates whose renal function is below the advisory GFR threshold or who have additional risk factors for the development of ESRD should be individualised and based on the predicted lifetime incidence of ESRD. (D2) BTS/RA Living Donor Kidney Transplantation Guidelines 2018 67
· The renal function requirements of the intended recipient, based upon the absolute GFR of the donor, are relevant to the decision to donate (in a directed donation) and to the acceptance of a kidney offer from a non-directed donor or within the UK Living Kidney Sharing Schemes. (Not Graded) Monitoring of Kidney Donor
· The donor must be offered lifelong annual assessment of renal function including serum creatinine, estimation of urine protein excretion and blood pressure measurement. (B1)
DONOR AGE
Recommendations
– Old age alone is not an absolute contraindication to donation but the
medical work-up of older donors must be particularly rigorous to
ensure they are suitable. (A1)
– Both donor and recipient must be made aware that the older donor may
be at greater risk of peri-operative complications and that the function
and possibly the long-term survival of the graft may be compromised.
This is particularly evident with donors >60 years of age. (B1)
DONOR OBESITY
Recommendations
– Otherwise healthy overweight patients (BMI 25-30 kg/m2) may safely
proceed to kidney donation. (B1)
– Moderately obese patients (BMI 30-35 kg/m2) must undergo careful pre[1]operative evaluation to exclude cardiovascular, respiratory and kidney
disease. (C2)
– Moderately obese patients (BMI 30-35 kg/m2) must be counselled about
the increased risk of peri-operative complications based on
extrapolation of outcome data from very obese donors (BMI >35 kg/m2). (B1)
– Moderately obese patients (BMI 30-35 kg/m2) must be counselled about the long-term risk of kidney disease and be advised to lose weight before donation and to maintain their ideal weight following donation. (B1)
– Data on the safety of kidney donation in the very obese (BMI >35 kg/m2) are limited and donation should be discouraged. (C1)
–HYPERTENSION IN THE DONOR
Recommendations
– Blood pressure must be assessed on at least two separate occasions.
– Ambulatory blood pressure monitoring or home monitoring is recommended if blood pressure is high, high normal or variable, or the potential donor is on treatment for hypertension. (C2)
– We suggest that a blood pressure <140/90 mmHg is usually acceptable for donation. (C1)
– Prospective donors must be warned about the risk of developing donation-related hypertension, particularly if in a high-risk group.
– Blood pressure measurement is part of annual donor monitoring. (C1)
– Potential donors with mild-moderate hypertension that is controlled to <140/90 mmHg (and/or 135/85 mmHg with ABPM or home monitoring) with one or two antihypertensive drugs and who have no evidence of end organ damage may be acceptable for donation. Acceptance will be based on an overall assessment of cardiovascular risk and local policy. (C1)
– It is recommended that potential donors with hypertension are excluded from donation if: (C1) Blood pressure is not controlled to <140/90 mmHg on one or two antihypertensive drugs , Evidence of end organ damage (retinopathy, left ventricular hypertrophy, proteinuria, previous cardiovascular disease)
– Unacceptable risk of future cardiovascular risk or lifetime incidence of ESRD
– All living kidney donors must be encouraged to minimise the risk of hypertension and its consequences before and after donation by lifestyle measures including stopping smoking, reducing alcohol intake, frequent exercise and, where appropriate, weight loss. (C1) BTS/RA Living Donor Kidney Transplantation Guidelines 2018 91
– It is recommended that donors who are diagnosed with hypertension during assessment or who develop hypertension following donation are managed according to British Hypertension Society guidelines.(B1)
DIABETES MELLITUS
– Recommendations
– · All potential living kidney donors must have a fasting plasma glucose level checked. (B1)
– · A fasting plasma glucose concentration between 6.1-6.9 mmol/L is indicative of an impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be undertaken. (B1)
– · Prospective donors with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT. (B1)
– · If OGTT reveals a persistent impaired fasting glucose and/or an impaired glucose tolerance, then the risks of developing diabetes after donation must be carefully considered. (B1)
– · Consideration should be given to the use of a diabetes risk calculator to inform the discussion of potential kidney donation. (B2)
– · Consideration of patients with diabetes as potential kidney donors requires very careful evaluation of the risks and benefits. In the absence of evidence of target organ damage and having ensured that other cardiovascular risk factors such as obesity, hypertension or hyperlipidaemia are optimally managed, diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney. (Not graded)
CARDIOVASCULAR EVALUATION
Recommendations
– There is no evidence to support the routine use of stress testing in the
– assessment of the potential donor at low cardiac risk. (C2)
– Potential kidney donors with a history of cardiovascular disease, an exercise capacity of <4 metabolic equivalents (METS) or with risk factors for cardiovascular disease should undergo further evaluation before donation. (C2)
– For higher risk potential donors, stress testing is recommended by whichever method is locally available or by CT calcium scoring . (C2)
– Discussion with and/or review by cardiologists, anaesthetists and the transplant MDT is recommended as part of the clinical assessment of donors with higher cardiovascular and peri-operative risk. (D2)
PROTEINURIA
Recommendations
· Urine protein excretion needs to be quantified in all potential living donors. (B1)
· A urine albumin/creatinine ratio (ACR) performed on a spot urine sample is the recommended screening test, although urine protein/creatinine ratio (PCR) is an acceptable alternative. (A1)
· ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day or protein excretion >500 mg/day represent absolute contraindications to donation. (C2)
· The significance of moderately increased albuminuria (ACR 3-30 mg/mmol) and proteinuria (PCR 15-50 mg/mmol or 24-hour urine protein 150-500 mg/day) has not been fully evaluated in living kidney donors. However, since the risk of CKD and cardiovascular morbidity increase progressively with increasing albuminuria or proteinuria such levels are a relative contraindication to donation. (C2)
NON-VISIBLE HAEMATURIA
Recommendations
· All potential living donors must have reagent strip (dipstick) urinalysis performed on at least two separate occasions. (B1)
· Two or more positive tests, including trace positive, is considered as persistent non-visible haematuria (PNVH). (B1)
· If PNVH is present, perform urine culture and renal imaging to exclude common urologic causes including infection, nephrolithiasis and urothelial carcinoma. (A1)
· If no cause is found, perform cystoscopy in patients age >40 years to exclude bladder pathology. (B1)
· If no cause is found and the donor still wishes to donate, then a kidney biopsy is recommended if haematuria is 1+ or greater on dipstick testing. (B1)
· Glomerular pathology precludes donation, with the possible exception of thin basement membrane disease. (B1)
· For donors with persistent asymptomatic non-visible haematuria (PANVH) and a family history of haematuria or X-linked Alport syndrome, a renal biopsy (B1) and referral to a clinical geneticist are recommended. (B2)
PYURIA
Recommendation
· Prospective donors found to have pyuria can only be considered for donation if it can be demonstrated that the pyuria is due to a reversible cause, such as an uncomplicated urinary tract infection. (C1)
INFECTION IN THE PROSPECTIVE DONOR
Recommendations
· Screening for infection in the prospective donor is essential to identify potential risks for the donor from previous or current infection and to assess the risks of transmission of infection to the recipient. (B1)
· Active HBV and HCV infection in the donor are usually contraindications to living donor kidney donation; however, donors with evidence of active viral replication may be considered under some circumstances. (B1)
· The presence of HIV or human T lymphotrophic virus (HTLV) infection is an absolute contraindication to living donation. (B1)
· Screening for HBV, HCV and HIV infection must be repeated within 30 days of donation. (Not graded)
· All potential donors should be provided with dietary advice regarding avoidance of HEV infection, and screening should be undertaken for HEV viraemia by nucleic acid testing within 30 days of donation. (Not graded)
· The CMV status of donor and recipient must be determined before transplantation. When the donor is CMV positive and the recipient is CMV negative, the donor and recipient must be counselled about the risk of post-transplant CMV disease. (B1)
· The EBV status of donor and recipient must be determined before transplantation. When the donor is EBV positive and the recipient is EBV negative, the donor and recipient must be counselled about the risk of developing Post Transplant Lymphoproliferative Disease. (B1)
· Potential donors must be screened by history for travel or residence abroad to assess their potential risk for having acquired endemic BTS/RA Living Donor Kidney Transplantation Guidelines 2018 126 infections and appropriate microbiological investigations instigated if indicated. (Not graded)
Serological Testing of Donor
Routine tests for all donors
HbsAg and HBcAb HCV IgG HIV 1/2 Ab / HIV Ag combination assay (minimum 4th generation assay) HTLV 1/2 Ab Treponema pallidum Ab CMV IgG EBV IgG Toxoplasma gondii IgG
Consider in selected cases
*Coccidiomycosis antibody *Malaria blood film *Schistosomiasis antibody, urine microscopy *Trypanosoma cruzi antibody *Strongyloides stercoralis antibody *West Nile Virus antibody/RNA
NEPHROLITHIASIS
Recommendations
· In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as potential kidney donors. Full counselling of donor and recipient is required along with access to appropriate long-term donor follow up. (C2)
· Potential donors with metabolic abnormalities detected on screening should be discussed with a specialist in renal stone disease. (C2)
· In appropriate donors with unilateral kidney stone(s) the stone-bearing kidney can be considered for donation (if vascular anatomy and split kidney function permit) in order to leave the donor with a stone-free kidney after donation. (C2)
HAEMATOLOGICAL DISEASE
Recommendations
· Donor anaemia needs to be investigated and treated before donation. (A1)
· A haemoglobinopathy screen must be carried out in patients with non Northern European heritage or if indicated by the full blood count. (A1)
· Careful consideration needs to be given to the use of potential donors with haemoglobinopathies. (B1)
· Advice from a consultant haematologist is recommended for haematological conditions not covered in this guideline. (Not graded)
FAMILIAL RENAL DISEASE
Recommendations
· All potential transplant recipients must have a detailed family history recorded and confirmation where possible of the diagnosis in other family members with known kidney disease. This may aid diagnosis for the recipient, clarify any mode of inheritance and identify at risk relatives. (A1)
· When the cause of kidney failure in the recipient is due to an inherited condition, appropriate tests – including genetic testing if available – are recommended to exclude genetic disease in the potential donor. (A1)
· Many inherited kidney diseases are rare, so involvement of clinical and laboratory genetics services must be considered at an early stage to assess likely risks to family members and the appropriate use of molecular genetic testing. (B1)
DONOR MALIGNANCY
Recommendations
· Careful history taking, clinical examination and investigation of potential donors are essential to exclude occult malignancy before kidney donation, particularly in older (age >50 years) donors. (B1) · Active malignant disease is a contraindication to living donation but donors with certain types of successfully treated low-grade tumour may be considered after careful evaluation and discussion. (B1)
· Donors with an incidental renal mass lesion must have this diagnosed and managed on its own merit (out with discussion of kidney donation) with appropriate referral to a Urology Specialist in line with the ‘2-week wait’ pathway. (A1)
· Contrast enhanced renal CT scan, ultrasound and / or MRI can usually distinguish between benign lesions such as angiomyolipoma (AML) or malignancy such as renal cell carcinoma (RCC). Review by a specialist uroradiologist is recommended. (C1)
· Bilateral AML and AML >4 cm generally preclude living kidney donation although occasionally unilateral large (>4 cm) AML can be used if ex vivo excision of the AML appears to be straightforward
. · An incidental, unilateral solitary AML <4 cm with typical characteristic CT criteria does not usually preclude donation.
– A kidney with an AML <1 cm may be considered for donation or left in
situ in the donor’s remaining kidney.
– Kidneys containing a single AML between 1 and 4 cm can be considered for donation depending on its position, consideration of whether ex vivo excision of the AML is straightforward, or whether it can be left in situ in the recipient and followed with serial ultrasound imaging. (C1)
– Donors with an incidental small (<4 cm) renal mass that appears on imaging to be a RCC must be seen in a specialist Urology clinic and be offered standard of care treatment options, including partial and radical nephrectomy. Renal function permitting, if the person wishes to consider radical nephrectomy, ex-vivo excision of the small renal mass with subsequent donation of the reconstructed kidney can be considered on an individual basis with specific caveats, full MDM discussion and appropriate informed consent from the donor and recipient. (D2) :
– Cancers with Strong or absolute contraindication :
· Malignant melanoma
· Testicular cancer
· Renal cell carcinoma >3 cm
· Choriocarcinoma
· Haematological malignancy
· Lung cancer
· Breast cancer
· Sarcoma
– Cancers with Possible donation : Treated cancer with high probability of cure after 5-10 years (favourable classification and staging)
· Colon cancer (Dukes’ A >5 years ago)
· Non-melanoma skin cancer
· Carcinoma-in-situ of the cervix or vulva
· Localised low grade prostate cancer with curative treatment, minimum cancer-free period of 5 years
· Renal cell carcinoma
SURGERY: TECHNICAL ASPECTS, DONOR RISK AND PERI-OPERATIVE CARE
Recommendations
· Work-up for living kidney donation may include direct or indicative evaluation of split renal function with the kidney with poorer function selected for nephrectomy irrespective of vascular anatomy (C2)
· Work-up for living kidney donation must include detailed imaging confirming the vascular anatomy of both donor kidneys and information about the renal parenchyma and collecting systems. Either CTA or MRA can be used as current evidence indicates little difference in accuracy. (B1)
· Multiple renal arteries or kidneys with anatomical anomalies are not absolute contraindications to donation. Decisions must be made on an individual basis as part of a multi-disciplinary team evaluation. (B2)
· All living donors must receive adequate thromboprophylaxis. Intraoperative mechanical compression and post-operative compression stockings, along with low molecular weight heparin, are recommended. (A2)
· All living donor surgery must be performed or directly supervised by a Consultant surgeon with appropriate training in the technique. (C1)
· Pre-operative hydration with an overnight infusion and/or a fluid bolus during surgery improves cardiovascular stability during laparoscopic donor nephrectomy. (B2)
· Pre- and peri-operative intravenous fluid replacement with Hartmann’s solution is preferred to 0.9% Saline. (B2)
· Laparoscopic donor surgery (fully laparoscopic or hand-assisted) is the preferred technique for living donor nephrectomy, offering a BTS/RA Living Donor Kidney Transplantation Guidelines 2018 172 quicker recovery, shorter hospital stay and less pain. Mini-incision surgery is preferable to standard open surgery. (B1)
· Haem-o-lok clips are not to be used to secure the renal artery during donor nephrectomy following a report of an adverse event involving this technique.(C2)
· Patients undergoing living donor nephrectomy are likely to benefit from the management approaches widely used in “enhanced recovery after surgery” (ERAS) programmes. (D2)
HISTOCOMPATIBILITY TESTING FOR LIVING DONOR KIDNEY TRANSPLANTATION Recommendations
· Initial assessment of donor and recipient histocompatibility status must be undertaken at an early stage in living donor kidney transplant work-up to avoid unnecessary and invasive clinical investigation. (B2)
· Screening of potential living donor kidney transplant recipients for clinically relevant antibodies is important for ensuring optimal donor selection and graft survival. (A1)
· Antibody screening is especially important when potential living donor transplant recipients undergo reduction or withdrawal of immunosuppression. (B2)
· Post-transplant antibody monitoring must be undertaken according to the BSHI/BTS guidelines. (B1)
· Transplant units and histocompatibility laboratories must agree an evidence-based protocol to define antibody screening and crossmatch results that constitute a high immunological risk to transplantation. (B2)
· When possible, the HLA type(s) of partners/offspring of female recipients who have had previous pregnancies should be determined to aid immunological risk assessment for repeat paternal HLA mismatches in women with low level DSA. (B1)
· A pre-transplant serum sample collected within 14 days of the planned date for transplantation must be tested in a sensitive antibody screening and donor crossmatch assay and transplantation should not usually be performed if the crossmatch test is positive, unless the antibody is shown to be indicative of acceptable immunological risk. (A1)
· Changes in immunosuppression during the transplant work-up must be notified to the histocompatibility laboratory and additional antibody screening and donor-recipient crossmatch tests must be undertaken as indicated. (B1)
· HLA matching may be preferred when there is an option of selecting between living donors, particularly to reduce the possibility of subsequent sensitisation. This is important for younger recipients where repeat transplantation may be required. However, it is recognised that other donor factors will be taken into account. (B1)
· For patients with an ABO/HLA incompatible and/or a poorly HLA matched living donor, consideration should be given to entry into the UK living kidney sharing scheme (UKLKSS) to identify a more suitable donor. (B2)
· The histocompatibility laboratory must issue an interpretive report stating the donor and recipient HLA mismatch, recipient sensitisation status and crossmatch results, and define the associated immunological risk for all living donor-recipient pairs. (A1)
EXPANDING THE DONOR POOL Recommendations
· Coherent organisational and clinical practices are essential between transplant centres to optimise the UK Living Kidney Sharing Schemes (UKLKSS) and to maximise the number of potential transplants that proceed. (B1)
· To maximise transplant opportunities within the UKLKSS, donors and recipients must only be included in a matching run if: o Their clinical assessment and histocompatibility screening are complete and up to date. (B1) o If matched, they are available to attend for crossmatch testing and proceed to surgery within the designated timeframes. (B1) o Relevant complex donor considerations identified in the ‘prerun’ and donor HLA and age preferences have been discussed and agreed with the recipient. (B1) o They understand their roles and responsibilities with respect to other donors and recipient pairs in the schemes with whom they may be matched. (B1)
· The default for all non-directed altruistic kidney donors (NDADs) is to donate into an altruistic donor chain (ADC) within the UKLKSS provided that there is no higher priority patient on the national transplant list. (B1)
· All altruistic donors (non-directed and directed) must undergo formal mental health assessment with a mental health professional before donation. (C1)
· Living kidney donors who are antibody incompatible with their recipient must have all the options and risks explained to them, including donation into the UKLKSS and antibody removal. (C1)
· As a minimum, donors must be made aware that a compatible transplant has the best chance of success and direct antibody incompatible transplant is associated with higher short- and long-term risk, if that is what is proposed. (C1)
I. Guidelines for Living Donor Kidney Transplantation
Introduction:
The guidelines are indeed fascinating. It includes various sections and firstly it started with an introduction that speaks about kidney transplants from living donors. Many patients have the problem of developing kidney failure, and the best treatment is a renal transplant. It is the most popular choice and most available one. Therefore, in the UK they have expanded the kidney door pool. Since the presence of UKLKSS, there have been changes to the guidelines to ensure that there is an expansion of the potential donor pool. With all the improvements of the guidelines, the donor remains at risk and must be vigilant before reducing renal function.
The scope of the guidelines relates only to living donor kidney transplantation. It also reflects the evidence and incorporates aspects of clinical practice that are relevant to the groups to transplant. Its deals with the ethical and medico-legal aspects of donor selections. It also deals with the other part of transplantation like the complications, outcomes, etc.
The process of writing and methodology of the UK guidelines for living donor kidney transplantation was commissioned by the British Transplantation Society and the Renal Association. The guidelines went through different scrutinize to ensure all aspects were covered in detail and at the end of March 2018 was the final document posted.
The editorial committee was formed by different experts in the field of transplantation. There were also contributing authors. The guideline used the GRADE system to grade and ensure the quality of the guidelines was up to date and errorless.
The guidelines were made of a legal framework, and it deals with the human tissue act of 2004, the human tissue authority (HTA), the European Union organ donation directive, and consent for the removal of organs from living donors.
The types of living donation permitted by the legislation that was established in September 2012 help to specify the types of relationships that allows transplant between living donors and recipients. It involves:
1) Directed donation entails a specific donation where a healthy person donates an organ or part of one.
2) Paired or pool donation that involves donor-recipient pairs are involved in a linked exchange.
3) Non-directed altruistic donation is an unspecific donation where a healthy person donates to an unknown person
4) Directed altruistic donation the donor provides an organ donation to a recipient that has been introduced too.
The requirements for transplants involving a living donor require that every living donation must be approved by the HTA before the donation can proceed.
There are laws for the prohibition of commercial dealings in human materials based on the ACT 2004 that prevents individuals from commercial dealings. Also, the ACT 2004 allows donors to receive reimbursement for all the expenses they went through.
Based on the guidelines, there are exceptional circumstances where organ donation must be careful and may not be accepted unless proven otherwise. They are:
1) In children especially under 18 years of age.
2) Adults without mental capacity
The human tissue Act 2006 in Scotland stipulates that organs must not be removed unless the required conditions have been met by the constitution.
The other important aspect of this guideline is the concept of Ethics. Since the living donor transplantation started, many ethical issues have been questioned and as such, it was considered in this guideline. They are:
1) The key ethical principles in living donor transplantation deal with:
a) Altruism where an organ is given without remuneration
b) Autonomy is the personal right to donate
c) Beneficence is the promotion to ensure the well-being of all
d) Dignity deals with a special status where dignity and monetary terms are not compatible.
e) Non-maleficence is not harming anyone
f) Reciprocity has to do with giving benefits to others who have helped
2) The recipient’s perspective. The LDKT risk and benefits are being protected. Living donors’ kidneys are of better organ quality and the expectancy or survival of the graft is excellent when compared with other forms.
3) The donor perspective. Donating a kidney involves risks and complications that can lead the patient to death. In this regard, donor rights are being protected to ensure there is no ill-treatment and ensure all benefits are granted.
4) The transplant team perspective. The team that is the MDT ensures that the donor’s right is protected and once the team has identified any issues, the donation can be canceled.
5) Expanding the living donor pool. As the program develops and grows, the legal framework ensures all the ethical criteria be followed.
6) The child or young person as a living donor. Protecting the right of minors are important and must not be overseen.
7) The British transplant society (BTS) ethics committee.
Supporting and informing the potential donor:
1) Confidentiality: this is important since it protects the right of the donor and recipient.
2) Informing the potential donor. The GMC ensures doctors are registered for proper consent and coverage
3) Informed consent for living kidney donation.
4) Understanding what is involved. The process of donation must be explained in detail to the donor.
5) Information about likely outcomes for the kidney. All possible complications must be explained to the donor so that a clear decision can be made.
6) Independence of decision. The donor must decide on their own.
7) The responsibility of the donor surgeon. The surgeon must explain to the donor all the possible complications of the procedure.
8) Donor identity.
9) Primary advocacy. The donor must be given an opportunity to meet an independent party to hear their advice.
10) Independent translator. Individuals must be given a translator to better understand what they are dealing with and there are no discrepancies.
11) Psychology issues.
12) Death and transplant failure. Patients must know all the possible complications and the worse is death.
Donor Evaluation
The goal of donor evaluation is to ensure that the donor is comfortable and there is minimal risk. The donors must be assessed based on protocol and include MDT input. The assessment will vary based on the clinical circumstances of the patient.
The donor evaluation includes:
1) initiating a second opinion for a living donor or recipient of a living donor kidney transplant.
2) Donor evaluation: summary and organizational chart with questionnaires
3) ABO blood grouping and crossmatch testing.
4) Medical assessment that involves:
a) a summary of the key points of importance in the medical and family history potential kidney donor.
b) A history with respect to transmissible infection
c) Points of particular importance when undertaking a clinical examination of a potential kidney donor
d) Routine screen investigation for the potential donor
5) Assessment of renal function that includes:
a) Initial assessment of donor renal function
b) Divided renal function and what is a safe threshold level of kidney function to donate.
c) Normal kidney function and change in the kidney function with aging
d) Early changes to renal function following living kidney donation
e) Long-term loss of GFR in kidney donors
f) Is donation associated with an increased risk of end-stage renal disease, cardiovascular disease, or death
g) Individualisation in a discussion of the risks of ESRD. The risk factors can be measured as GFR, ethnic groups and HTN, obesity, and DM
h) Advisory threshold measured GFR considered safe for donation
6) Donor age:
a) Includes the young donor: less than 18 years old not considered donor and 18-21 relative contraindication.
b) The older donor: above 60 years old should be carefully considered
c) Donor complication rates related to age.
d) Graft outcomes from older donors
e) Long-term risk for older donors
7) Donor obesity: BMI 25-30 kg/m2 can be donated safely, BMI 30-35 KG/M2 must be carefully evaluated, and BMI 35 or more should be discouraged.
8) Hypertension in the donor, BP LESS THAN 140/90 IS USUALLY ACCEPTABLE
9) DM: patient fasting plasma glucose level must be checked and glucose of 6.1-6.9 mmol/l is impaired. An oral glucose tolerance test must be measured.
10) Cardiovascular evaluation must be considered before transplant and the test can be EKG, CT CORONARY CALCIUM, ETC.
11) Proteinuria both ACR and PCR can be done
12) Nonvisible haematuria and must be investigated for glomerulopathies
13) Pyuria must be investigated, and it is defined as having more than 10 white cells/mm2
14) Infection in the prospective donor and screening for infections must be investigated like HBV, HCV, ETC
15) NEPHROLITHIASIS must be investigated.
Once the donor has met all the criteria, the patient must start to be processed and follow-ups.
It must be noted that hematological diseases must be investigated like anemia, hemoglobinopathies, etc.
Donor malignancy is also of interest and if suspected must be investigated.
The surgical techniques must be explained to the donor, the risk, and possible complications.
Other investigations needed are the group and crossmatch with HLA.
As the transplant program develops and continues growing the transplant pool must be extended and carefully addressed.
Summary; the guideline is about the preparation of donors for donation and ensuring all the necessary protocols be followed to avoid litigations.
At my workplace currently, I don’t have any program for transplantation.
Key General ethics and principles:
All health professionals involved in living donor kidney transplantation must ensure that good ethical practice consistently underpins clinical practice.
Safety and welfare of the potential living donor must always take precedence over the needs of the potential transplant recipient.
Key Ethical Principles in Living Donor Transplantation are: Altruism, Autonomy, Beneficence, Dignity, Non-maleficence and Reciprocity.
Potential living donor should be informed about all the possible risks in order to give valid consent for donation, and to feel free If they wish to withdraw from the transplant process at any time.
Specific points about process and possible outcomes must be clarify:
Risks of donation (generic and specific). Nature of surgical procedure and length of stay in hospital. Potential graft loss in the recipient. Requirement for HTA assessment. Reimbursement of expenses. Requirement for annual review.
full psychological or psychiatric assessment is important part of donor workup to ensure firstly volunteer willing for donation and is essential to identify pre-existing or potential mental health issues that might arise later on.
DONOR EVALUATION
The primary goal of the donor evaluation process is to ensure the suitability of the donor and to minimise the risk of donation. This involves identifying contraindications to donation and potential clinical (physical and psychosocial) risks.
The evaluation is comprehensive, potential donors must be assessed according to an agreed, evidence-based protocol which includes multi-disciplinary input and discussion.
Detailed history and clinical examination followed by relevant laboratory and radiological investigating .
Initiate assessment with ABO compatibility +/- HLA sensitisation , Primary contra-indications identified from donor(s) past and present medical history, Routine blood & urinalysis tests.
Routine Screening Investigations for the Potential Donor
Urine: Dipstick for protein, blood and glucose (at least twice), Microscopy, culture and sensitivity (at least twice), Measurement of protein excretion rate (ACR or PCR)
Blood
Haemoglobin and blood count
Coagulation screen (PT and APTT)
Thrombophilia screen (where indicated)
Sickle cell trait (where indicated)
Haemoglobinopathy screen (where indicated)
G6PD deficiency (where indicated)
Creatinine, urea and electrolytes
Isotopic or other reference test for measurement of GFR
Liver function tests
Bone profile (calcium, phosphate, albumin and alkaline phosphatase)
Urate
Fasting plasma glucose
Glucose tolerance test (if family history of diabetes or fasting plasma glucose >5.6 mmol/L)
Fasting lipid screen (if indicated)
Thyroid function tests (if strong family history)
Pregnancy test (if indicated)
Virology and infection screen :
Hepatitis B and C, HIV. HTLV1 and 2 (if appropriate)
Cytomegalovirus
Epstein-Barr virus
Toxoplasma, Syphilis
Varicella zoster virus (where recipient seronegative),HHV8 (where indicated)
Malaria (where indicated),Trypanosoma cruzi (where indicated),Schistosomiasis (where indicated)
Cardiorespiratory system :
Chest X-ray
ECG
ECHO (where indicated)
Cardiovascular stress test (as routine or where indicated)
Assessment of Renal Function :
Initial evaluation of donor candidates should be using estimated glomerular filtration rate (eGFR), expressed as mL/min/1.73m2 using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and employing a creatinine assay
Pre-donation mGFR should be such that the predicted post-donation GFR remains within the gender and age-specific normal range within the donor’s lifetime. A threshold GFR >80 mL/min/1.73m2 appears safe for donation in the 35 year and
above age range.
Donor Age :
Old age alone is not an absolute contraindication to donation but the medical work-up of older donors must be particularly rigorous to ensure they are suitable. donors aged <18 years is contraindicated while in most centres an age of18-21 years consider as a relative contraindication to donation.
Older donors are more likely than younger donors to be excluded from donating on the basis of problems discovered during the medical evaluation. However, each case should be considered on individual basis .
Donor Obesity:
Otherwise healthy overweight patients (BMI 25-30 kg/m2) may safely proceed to kidney donation. (BMI 30-35 kg/m2) must be counselled about the increased risk of peri-operative complications and advise to lose weight, Data on the safety of kidney donation in the very obese (BMI >35 kg/m2) are limited and donation should be discouraged
Hypertension in the Donor:
It is recommended potential donors with hypertension are excluded from donation if:
o Blood pressure is not controlled to <140/90 mmHg on one or two antihypertensive
o Evidence of end organ damage (retinopathy, left ventricular hypertrophy, proteinuria, previous cardiovascular disease)
o Unacceptable risk of future cardiovascular risk or lifetime incidence of ESRD
Diabetes Mellitus:
a fasting plasma glucose must be level checked, concentration between 6.1-6.9 mmol/L isindicative of an impaired fasting glucose state and an oral glucose
tolerance test (OGTT) should be undertaken.
Prospective donors with an increased risk of type 2 diabetes because
of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT, Diabetes may also be diagnosed based upon HbA1c criteria, a result >48 mmol/mol (6.5%) being sufficient to diagnose diabetes if confirmed by repeat testing.
Cardiovascular Evaluation:
There is no evidence to support the routine use of stress testing in the
assessment of the potential donor at low cardiac risk
For higher risk potential donors, stress testing is recommended by
whichever method is locally available or by CT calcium scoring .
Proteinuria:
Urine protein excretion needs to be quantified in all potential living
donors. ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day
or protein excretion >500 mg/day represent absolute contraindications to donation.
Non-Visible Haematuria
Two or more positive tests, including trace positive, is considered as
persistent non-visible haematuria, If PNVH is present, perform urine culture and renal imaging to exclude common urologic causes including infection, nephrolithiasis and
urothelial carcinoma. If no cause is found, perform cystoscopy in patients age >40 years to exclude bladder pathology. Glomerular pathology precludes donation, with the possible exception of thin basement membrane disease
Pyuria:
Prospective donors found to have pyuria can only be considered for
donation if it can be demonstrated that the pyuria is due to a reversible
cause, such as an uncomplicated urinary tract infection
Infection in the Prospective Donor :
Active HBV and HCV infection in the donor are usually
contraindications to living donor kidney donation; however, donors
with evidence of active viral replication may be considered under some
circumstances. While The presence of HIV or human T lymphotrophic virus (HTLV) infection is an absolute contraindication to living donation.
The CMV status of donor and recipient must be determined before
transplantation. When the donor is CMV positive and the recipient is
CMV negative, the donor and recipient must be counselled about the
risk of post-transplant CMV disease
Nephrolithiasis:
In the absence of a significant metabolic abnormality, potential donors
with a limited history of previous kidney stones, or small renal stone
on imaging, may still be considered as potential kidney donors.
Haematological Disease: Careful consideration needs to be given to the use of potential donors with haemoglobinopathies.
Donor Malignancy: Careful history taking, clinical examination and investigation of
potential donors are essential to exclude occult malignancy before
kidney donation, particularly in older (age >50 years) donors. Active malignant disease is a contraindication to living donation.
Work-up for living kidney donation must include detailed imaging
confirming the vascular anatomy of both donor kidneys and
information about the renal parenchyma and collecting systems. Either
CTA or MRA can be used as current evidence indicates little difference
in accuracy. Multiple renal arteries or kidneys with anatomical anomalies are not
absolute contraindications to donation.
No major differences in the guidelines and our local protocol * some tests are not availabe
Donor’s types and donor perceptive:
LRKT improved donation pool.
Welfare and safety of donor must be seeked.
Though compliance with both legal and medical act by transplantation center.
Donor give valid consent, without duress or coercion, and that reward is not a factor in
the donation.
Understand potential risk of transplantation.
Donors can receive reimbursement of expenses, such as travel costs and loss of
earnings result from donation of an organ.
Types of Living Donation:
Directed donation, Paired or pool donation, Non-directed altruistic donation and
directed altruistic donation.
Donor is not allowed for children below 18years and person without mental capacity
(only by court).
Ethics:
Should be observed by all transplant team.
Independent assessment team is required for donors and recipient
.
Psychiatric/psychological services must be available for donors/recipients requiring
referral.
Confidentiality:
Should be maintained at outset and information shared decided at the start.
Donor advocacy and psychological services should be provided to donors.
Evaluation of donors:
Multi-disciplinary team and
Agreed, evidence-based protocol.
A logical sequence.
Option of a second opinion must always be available to donors and recipients if donor
not found suitable.
Time of evaluation:
Variable, whenever recipient is ready for transplant.
Discussion with potential donors and recipients will usually be started when the recipient
eGFR is approximately 20 mL/min or when the recipient is expected to require renal
replacement therapy within 12-18 months.
Duration of evaluation:
Evaluation of a potential donor should be undertaken within an 18 WEEEKS
Evaluation should be planned.
An agreed donor assessment protocol must be in place.
A flow chart:
Early:
Early education & discussion with all potential transplant recipients and potential donors
about optimal options for transplantation.
Establish recipient fit for transplantation & start appropriate pre-transplant assessment.
Weeks 0-2:
Donor identified, LD coordinator facilitates initial discussion with potential donor,
recipient & other family members as appropriate. Most appropriate should be identified,
taking into account possible social, psychological and medical risk factors.
Weeks 2-4:
Primary contra-indications identified from donor, past and present medical history
ABO compatibility +/- HLA sensitization.
. Routine blood & urinalysis tests.
Weeks 4-8:
Donor evaluation is planned with the prospective donor, in a timely manner, to an agreed
protocol & in accordance with the availability of local resources.
Weeks 8-10:
Results review by members of the MDT & feedback to the donor.
Weeks 11:
Suitable donor & recipient pair:
Referred for final preoperative discussion with Consultant Nephrologist and Transplant
Surgeon.
Final cross match within the 7-10 days before transplantation and routine pre-op
investigations.
Pre-admission visit.
Week 18:
OPERATION.
LD coordinator maintains contact with donor & facilitates life-long follow-up
arrangements
If donor unsuitable, follow-up arranged.
The guidelines involve adult kidney transplantation with respect to legal and ethical framework, supporting and informing the potential donor, the donor evaluation, blood group and histocompatibility testing, the surgical aspects including donor risk and peri-operative care, measures to increase the donor pool, donor follow-up and long-term outcomes, recipient outcomes and recurrent renal diseases, in addition to paediatric transplantation.
Legal framework: All renal transplantation should be as per the Human Tissue Act 2004. The consent for organ donation from the donor should be obtained after explaining the generic and specific material risks of donation. The donor could be either direct (genetically or emotionally related to the recipient); paired or pool donor; or directed or non-directed altruistic donor. There should be no reward (or commercial dealing) for donation and an independent assessor should assess both the donor and recipient. The donor can receive reimbursement of expenses and loss of earnings attributable to donation.
Ethical considerations: The safety and welfare of the donor is the priority.
Donor support and information: The donor should be provided generic and specific information material with respect to donation. Confidentiality must be maintained. A donor advocate, not directly involved with care of recipient can assist the donor in taking a truly autonomous decision. Access to psychological support should be present. A full psychological assessment of the donor should be performed if there is a concern regarding the mental health of the donor.
Donor evaluation: It should be done to identify potential contraindications and risks, by following an agreed, evidence-based protocol. It should be started after ensuring suitability of the recipient for transplantation, although it can be started early if the chances of finding recipient unsuitability are low. Option of second opinion must be given to both the donor and the recipient. In case of a pre-emptive transplant, donor evaluation should start early, when eGFR is approximately 20 ml/min, or when the recipient is expected to need renal replacement therapy in next 12-18 months. Donor evaluation should take place within 18 weeks (2 weeks for discussion, 2 weeks for history, examination and routine investigations including ABO and HLA compatibility, 4 weeks for detailed donor evaluation, 2 weeks for review by MDT members, 6-7 week for final pre-operative discussions, 1 week for pre-transplant cross-match and other investigations, and transplant in the 18th week).
ABO and HLA compatibility testing: Blood group and HLA compatible transplants have best results. Screening for donor specific antibodies is important for optimal donor selection and graft survival. Post-transplant antibody monitoring must be done in the recipient as per protocol. In presence of incompatibility, options like ABO incompatible transplant, kidney paired donation and desensitization should be discussed and offered only in an experienced centre.
Detailed donor evaluation:
Donor renal function should be estimated initially using serum creatinine and then measured using 51Cr-EDTA, 125Iothalamte or Iohexol. It should be more than the threshold levels recommended (>80 ml/min in aged 35 or more and >90 ml/min for age <30 years). If the renal function is below threshold level, decision should be taken on individual basis after assessing lifetime risk of ESRD in the specific donor. Split kidney function to be assessed only in presence of >10% variation in kidney size or anatomical abnormality of the kidneys.
Donors should be offered long-term annual assessment in form of serum creatinine, proteinuria, and blood pressure measurement.
Donor with age >60 years can also donate after detailed assessment and making both the donor and recipient aware of the risks and complications involved as well as the graft outcomes in such cases.
Donor with BMI >35 should be discouraged. Donors with BMI 30-35 must be taken up after detailed evaluation and counselling regarding risks involved.
Donors should be warned about risks of developing hypertension post-donation, especially in high-risk groups like African-Americans, Hispanics obese and presence of hypertension. Those with BP <140/90 (or <135/85 with ABPM or home monitoring), on 1-2 antihypertensives and no target organ damage (LVH, albuminuria, retinopathy etc) and without unacceptable future cardiovascular/ ESRD risk can be taken up for donation. The donors should be encouraged to follow a healthy lifestyle to minimized risk of hypertension. Hypertension should be treated using both non-pharmacological and pharmacological methods.
Donors should be checked for fasting blood glucose levels. If FBS is between 6.1-6.9 mmol/L, or there is history of gestational diabetes, family history of type 2 diabetes, obesity or African-American ethnicity, then the donor should under OGTT. Donors with IFG of IGT can donate after counselling and explaining the risks of developing diabetes after donating, and taking care of risk factors like obesity, dyslipidemia and hypertension.
Those with diabetes, and without any target organ damage, can be taken up as a donor after thorough assessment of lifetime risks of CV disease and ESRD, and management of risk factors.
Cardiovascular assessment for low-risk donors includes ECG and ECHO. Detailed evaluation is required in patients with history of cardiovascular disease and risks of CV disease. High risk donors should be evaluated by stress testing or CT calcium scoring and need multidisciplinary team evaluation.
Proteinuria assessment includes urinary albumin creatinine ratio (ACR) or protein creatinine ratio (PCR). ACR > 30 mg/mmol and PCR>50mg/mmol are contraindications for renal donation.
Urinary dipstick testing should be done twice to detect non-visible hematuria, and if present twice, then urine culture and imaging should be performed to exclude infection, nephrolithiasis, and urothelial carcinoma. Cystoscopy should be performed in age >40 years to rule out bladder pathology. A kidney bippsy should be performed before donation if no cause is found. Glomerular pathology prohibit donation, except presence of thin basement disease.
Presence of pyuria is a contraindication, unless it is due to a reversible cause like uncomplicated UTI.
Screening for HBV, HCV, HIV, CMV and EBV should be done and HIV, HBV and HCV testing should be repeated 1-month post-donation. Risks of CMV infection and PTLD in recipient should be explained in case of donor positive, recipient negative pairs of CMV and EBV.
Donor with small renal stone, or past history of renal stone, in absence of any metabolic abnormality can donate after counselling and offer of long-term follow-up post-donation. In unilateral stone, kidney with stone should be transplanted.
Donor with anemia should be evaluated for cause and treated. A hematologist should be involved decision-making in presence of hemoglobinopathies.
Detailed family history and genetic testing, in case of inherited conditions, should be undertaken.
Detailed evaluation (history, clinical examination, and investigation) to exclude malignancy, especially in age >50 years should be done. Active malignancy is a contraindication. Donors with certain treated low-grade tumors can be taken up. Donors with unilateral renal mass less than 4 cm, can be taken as donor (if AML, without excision; and if RCC, with excision and renal reconstruction).
Technical aspects of the surgery: Direct or indirect evaluation of split renal function, detailed vascular anatomy, renal parenchyma and collecting system imaging using CTA or MRA. Pre- and post-operative adequate hydration is essential. Adequate thromboprophylaxis should be provided. Laparoscopic donor nephrectomy is preferred and donors may benefit with ‘enhanced recovery after surgery’ programmes. Donors should be offered long-term follow-up post-donation. Pregnancy post-donation requires close monitoring of BP, creatinine, and fetal evaluation and pre-eclampsia prophylaxis (aspirin 75 mg).
Risks of basic disease recurrence post-transplant should be assessed and the patient should be counselled regarding the same.
In children with ESRD, pre-emptive transplant with a blood group compatible and minimal HLA mismatches is best. Those weighing more than 10 Kg can receive an adult living donor kidney.
Ours is a living related donor kidney transplant program. We do not take up donors with diabetes (excluded on the basis of FBS, PPBS, HbA1c and OGTT). Split kidney function is performed in all donors. ABO incompatible transplants and kidney paired donation transplants are performed in our unit. Donors with multiple vessels and anatomical variations like dual ureters are taken up. Donors with BMI>30 are excluded. Enhanced recovery after surgery protocol is not followed in our unit. We do not perform HLA incompatible and pediatric transplants.
● Direct transplantation
First assesst patient suitability to transplantation
● Flexibility in terms of timescales, planning consultations, attending for investigations and date of surgery
● Ensure that donor is focused , logical and coherent
● Involve MDT in assessment donor
● In pre-emptive transplantation assessment of donor and recipient must start when eGFR 20 ml/min or the expected period to RRT is 12 – 18 weeks
● Where ABO or HLA incompatibity is pesent other options had to discuss as paired/pooled donation or antibody incopatible transplantation
● important points in medical and family history of donor
UTIs , hematuria , proteinuria , dysuria , urgency , frequency , gout , nephrotithiasis , hypertention , DM , IHD , PVD , smoking , malignancy , jaundice , bowel habit , weight change , thromboembolic disease , TB , systemic disease alcohol or drug dependenceobstetric history , residence abroad , previous medical and anaesthetic assessment
● History of transmissible infection : Hepatitis , malaria , TB , blood transfusion ,
● Increased risk of HIV , HTLV1 , HTLV2 , HBV , HCV
haemophiliac or high risk sexual behaviour and history of syphilis or intravenous drug use , tattoo sexual partner with positive serology and drug addict
● Points of Particular Importance when Undertaking Clinical Examination of Donor
Abdominal fat distribution , Bp , BMI , Dipstick urinalysis , Evidence of self-harm, abdominal masses or herniae , scars or previous surgery , lymphadenopathy , examination of the breasts , testes , and cardiovascular and respiratory systems , Mental health
● Routine Screening Investigations for the Potential Donor
Urine
** Dipstick for protein, blood and glucose , Microscopy, culture and sensitivity (at least twice)
** (ACR or PCR)
Blood
** CBC , (PT and APTT)
** Thrombophilia screen , Sickle cell trait , Haemoglobinopathy screen , G6PD deficiency (where indicated)
** Creatinine, urea and electrolytes
** measurement of GFR
** LFT
** Bone profile (Ca, P, ALB , ALP)
** Urate
** FBG
** GTT
** Fasting lipid screen , pregnancy test (if indicated)
** Thyroid function tests (if strong family history)
** Virology and infection screen ( Hepatitis B and C , HIV , HTLV1 and 2 , CMV , EBV , Toxoplasma , Syphilis , VZV
** HHV8 , Malaria , Trypanosoma cruzi , Schistosomiasis (where indicated)
** Cardiorespiratory system ( Chest X-ray , ECG , ECHO (where indicated) Cardiovascular stress test (as routine or where indicated)
● ASSESSMENT OF RENAL FUNCTION
** Initial test is (eGFR), expressed as mL/min/1.73m2
** subsequently be assessed by (mGFR) such as clearance of 51Cr-EDTA, 125iothalamate or Iohexol
** Differential kidney function, determined by 99mTcDMSA scanning is recommended where there is >10% variation in kidney size or significant renal anatomical abnormality
● Advisory GFR Thresholds for Donation
Pre-donation mGFR should be such that the predicted post-donation
● GFR remains within the gender and age-specific normal range within the donor’s lifetime.
● Risk of (ESRD) after donation is no higher than that of the general population. But is a very small absolute increased lifetime risk of ESRD following donation
● Monitoring of Kidney Donor
lifelong annual assessment of renal function including serum creatinine, estimation of urine protein excretion and blood pressure measurement.
● Donation Associated with an Increased Risk of End-Stage Renal Disease, Cardiovascular Disease and Death
● Old age alone is not an absolute contraindication to donation but may be at greater risk of peri-operative complications
particularly evident with donors >60 years of age.
● Younger potential with borderline risk factors should be subjected to stringent exclusion criteria
● Healthy overweight patients (BMI 25-30 kg/m2) may safely proceed to kidney donation. But Moderately obese patients (BMI 30-35 kg/m2) must undergo careful preoperative evaluation to exclude cardiovascular, respiratory and kidney disease and counselled about the increased risk of perioperative complications and the long-term risk of kidney disease and be advised to lose weight before and after donation
● very obese (BMI >35 kg/m2 )donors should be excluded
● Blood pressure must be assessed on at least two separate occasions.
● Ambulatory blood pressure monitoring or home monitoring is recommended if blood pressure is high, high normal or variable, or the potential donor is on treatment for hypertension.
● We suggest that a blood pressure <140/90 mmHg is usually acceptable for donation.
● Prospective donors must be warned about the risk of developing donation-related hypertension 30 % particularly if in a high-risk group.
● Blood pressure measurement is part of annual donor monitoring.
● Potential donors with mild-moderate hypertension that is controlled to <140/90 mmHg (and/or 135/85 mmHg with ABPM or home monitoring) with one or two antihypertensive drugs and who have no evidence of end organ damage may be acceptable for donation based on an overall assessment of cardiovascular risk and local policy.
● It is recommended that potential donors with hypertension are excluded from donation if:
o Blood pressure is not controlled to <140/90 mmHg on one or two
antihypertensive drugs
o Evidence of end organ damage (retinopathy, left ventricular hypertrophy, proteinuria, previous cardiovascular disease)
o Unacceptable risk of future cardiovascular risk or lifetime incidence of ESRD
● All living kidney donors must be encouraged to minimise the risk of hypertension and its consequences before and after donation by lifestyle measures including stopping smoking, reducing alcohol intake, frequent exercise and, where appropriate, weight loss.
● It is recommended that donors who are diagnosed with hypertension during assessment or who develop hypertension following donation are managed according to British Hypertension Society guidelines.
● All potential living kidney donors must have a fasting plasma glucose level checked
● A fasting plasma glucose concentration between 6.1-6.9 mmol/L is indicative of an impaired fasting glucose state
● (OGTT) should be done in donors with ** ** family history of type 2 diabetes
** a history of gestational diabetes
** ethnicity
** obesity
● If OGTT reveals a persistent impaired fasting glucose and/or an impaired glucose tolerance, then the risks of developing diabetes after donation must be carefully considered.
● Consideration should be given to the use of a diabetes risk calculator to inform the discussion of potential kidney donation
● Consideration of patients with diabetes as potential kidney donors requires very careful evaluation of the risks and benefits. ● In the absence of evidence of target organ damage and having ensured that other cardiovascular risk factors such as obesity, hypertension or hyperlipidaemia are optimally managed, diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney.
● Stress or invasive test is unnecessary in donor at low cardiac risk.
● Donors with
** a history of cardiovascular disease,
** an exercise capacity of <4 metabolic equivalents (METS)
** risk factors for cardiovascular disease should undergo further evaluation by method is locally available or by CT calcium scoring
● Discussion with and/or review by cardiologists, anaesthetists and the transplant MDT is recommended as part of the clinical assessment of donors with higher cardiovascular and peri-operative risk.
● Urine protein excretion needs to be quantified in all potential living donors.
●A urine albumin/creatinine ratio (ACR) performed on a spot urine sample is the recommended screening test although urine protein/creatinine ratio (PCR) is an acceptable alternative.
● ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day or protein excretion >500 mg/day represent absolute contraindications to donation.
● The significance of moderately increased albuminuria (ACR 3-30 mg/mmol) and proteinuria (PCR 15-50 mg/mmol or 24-hour urine protein 150-500 mg/day) has not been fully evaluated in living kidney donors.
● since the risk of CKD and cardiovascular morbidity increase progressively with increasing albuminuria or proteinuria such levels are a relative contraindication to donation.
● All potential living donors must have reagent strip (dipstick) urinalysis performed on at least two separate occasions.
● Two or more positive tests, including trace positive,not related to fever, menstruation or exercise. is considered as persistent non-visible haematuria (PNVH)
● If PNVH is present, perform urine culture and renal imaging to exclude common urologic causes including infection, nephrolithiasis and urothelial carcinoma.
● If no cause is found, perform cystoscopy in patients age >40 years to exclude bladder pathology.
● If no cause is found and the donor still wishes to donate, then a kidney biopsy is recommended if haematuria is 1+ or greater on dipstick testing.
● Glomerular pathology precludes donation, with the possible exception of thin basement membrane disease
● For donors with persistent asymptomatic non-visible haematuria (PANVH) and a family history of haematuria or X-linked Alport syndrome, a renal biopsy and referral to a clinical geneticist are recommended.
● Prospective donors found to have pyuria can only be considered for donation if it can be demonstrated that the pyuria is due to a reversible cause, such as an uncomplicated urinary tract infection
● Active HBV and HCV infection in the donor are usually contraindications to living donor kidney donation; donors with evidence of active viral replication may be considered undersome circumstances
● Screening for HBV, HCV and HIV infection must be repeated within 30 days of donation
● The presence of HIV or human T lymphotrophic virus (HTLV) infection is an absolute contraindication to living donation
● All potential donors should be provided with dietary advice regarding avoidance of HEV infection, and screening should be undertaken for HEV viraemia by nucleic acid testing within 30 days of donation.
● The CMV status of donor and recipient must be determined before transplantation. When the donor is CMV positive and the recipient is CMV negative, the donor and recipient must be counselled about the risk of post-transplant CMV disease
● The EBV status of donor and recipient must be determined before transplantation. When the donor is EBV positive and the recipient is EBV negative, the donor and recipient must be counselled about the risk of developing Post Transplant Lymphoproliferative Disease
● Potential donors must be screened by history for travel or residence abroad to assess their potential risk for having acquired endemic infections and appropriate microbiological investigations instigated if indicated.
● In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as potential kidney donors. Full counselling of donor and recipient is required along with access to appropriate long-term donor follow up
● Potential donors with metabolic abnormalities detected on screening should be discussed with a specialist in renal stone disease
● In appropriate donors with unilateral kidney stone(s) the stone-bearing kidney can be considered for donation (if vascular anatomy and split kidney function permit) in order to leave the donor with a stone-free kidney after donation
● Donor anaemia needs to be investigated and treated before donation.
● A haemoglobinopathy screen must be carried out in patients with nonNorthern European heritage or if indicated by the full blood count
● Careful consideration needs to be given to the use of potential donors with haemoglobinopathies
● All potential transplant recipients must have a detailed family history recorded and confirmation where possible of the diagnosis in other family members with known kidney disease. This may aid diagnosis for the recipient, clarify any mode of inheritance and identify at risk relatives
● When the cause of kidney failure in the recipient is due to an inherited condition, appropriate tests – including genetic testing if available – are recommended to exclude genetic disease in the potential donor
● Many inherited kidney diseases are rare, so involvement of clinical and laboratory genetics services must be considered at an early stage to assess likely risks to family members and the appropriate use of molecular genetic testing
● Careful history taking, clinical examination and investigation of potential donors are essential to exclude occult malignancy before kidney donation, particularly in older (age >50 years) donors
● Active malignant disease is a contraindication to living donation but donors with certain types of successfully treated low-grade tumour may be considered after careful evaluation and discussion
● Donors with an incidental renal mass lesion must have this diagnosed and managed on its own merit (out with discussion of kidney donation) with appropriate referral to a Urology Specialist in line with the ‘2-week wait’ pathway
● Contrast enhanced renal CT scan, ultrasound and / or MRI can usually distinguish between benign lesions such as angiomyolipoma (AML) or malignancy such as renal cell carcinoma (RCC). Review by a specialist uroradiologist is recommended
● Bilateral AML and AML >4 cm generally preclude living kidney donation although occasionally unilateral large (>4 cm) AML can be used if exvivo excision of the AML appears to be straightforward.
● An incidental, unilateral solitary AML <4 cm with typical characteristic CT criteria does not usually preclude donation.
● A kidney with an AML <1 cm may be considered for donation or left in situ in the donor’s remaining kidney
● Kidneys containing a single AML between 1 and 4 cm can be considered for donation depending on its position, consideration of whether ex vivo excision of the AML is straightforward, or whether it
can be left in situ in the recipient and followed with serial ultrasound imaging
● Donors with an incidental small (<4 cm) renal mass that appears on imaging to be a RCC must be seen in a specialist Urology clinic and be offered standard of care treatment options, including partial and radical nephrectomy. Renal function permitting, if the person wishes to consider radical nephrectomy, ex-vivo excision of the small renal mass with subsequent donation of the reconstructed kidney can be considered on an individual basis with specific caveats, full MDM discussion and appropriate informed consent from the donor and recipient
● Work-up for living kidney donation may include direct or indicative evaluation of split renal function with the kidney with poorer function selected for nephrectomy irrespective of vascular anatomy
● Work-up for living kidney donation must include detailed imaging confirming the vascular anatomy of both donor kidneys and information about the renal parenchyma and collecting systems. Either CTA or MRA can be used as current evidence indicates little difference in accuracy
● Multiple renal arteries or kidneys with anatomical anomalies are not absolute contraindications to donation. Decisions must be made on an individual basis as part of a multi-disciplinary team evaluation
● All living donors must receive adequate thromboprophylaxis. Intraoperative mechanical compression and post operative compression stockings, along with low molecular weight heparin, are recommended
● All living donor surgery must be performed or directly supervised by a Consultant surgeon with appropriate training in the technique
● Pre-operative hydration with an overnight infusion and/or a fluid bolus during surgery improves cardiovascular stability during laparoscopic donor nephrectomy
● Pre- and peri-operative intravenous fluid replacement with Hartmann’s solution is preferred to 0.9% Saline.
● Laparoscopic donor surgery (fully laparoscopic or hand-assisted) is the preferred technique for living donor nephrectomy, offering a quicker recovery, shorter hospital stay and less pain.
● Mini-incision surgery is preferable to standard open surgery
● Haem-o-lok clips are not to be used to secure the renal artery during donor nephrectomy following a report of an adverse event involving this technique
● Patients undergoing living donor nephrectomy are likely to benefit from the management approaches widely used in “enhanced recovery after surgery” (ERAS) programmes.
● Initial assessment of donor and recipient histocompatibility status must be undertaken at an early stage in living donor kidney transplant work-up to avoid unnecessary and invasive clinical investigation
● Screening of potential living donor kidney transplant recipients for clinically relevant antibodies is important for ensuring optimal donor selection and graft survival
● Antibody screening is especially important when potential living donor transplant recipients undergo reduction or withdrawal of immunosuppression.
● Post-transplant antibody monitoring must be undertaken according to the BSHI/BTS guidelines
● Transplant units and histocompatibility laboratories must agree an evidence-based protocol to define antibody screening and crossmatch results that constitute a high immunological risk to transplantation.
● When possible, the HLA type(s) of partners/offspring of female recipients who have had previous pregnancies should be determined to aid immunological risk assessment for repeat paternal HLA mismatches in women with low level DSA.
● A pre-transplant serum sample collected within 14 days of the planned date for transplantation must be tested in a sensitive antibody screening and donor crossmatch assay and transplantation should not غusually be performed if the crossmatch test is positive, unless the antibody is shown to be indicative of acceptable immunological risk.
● Changes in immunosuppression during the transplant work-up must be notified to the histocompatibility laboratory and additional antibody screening and donor-recipient crossmatch tests must be undertaken as indicated
● HLA matching may be preferred when there is an option of selecting between living donors, particularly to reduce the possibility of subsequent sensitisation. This is important for younger recipients where repeat transplantation may be required. However, it is recognised that other donor factors will be taken into account.
● For patients with an ABO/HLA incompatible and/or a poorly HLA matched living donor, consideration should be given to entry into the UK living kidney sharing scheme (UKLKSS) to identify a more suitable donor.
● The histocompatibility laboratory must issue an interpretive report stating the donor and recipient HLA mismatch, recipient sensitisation status and crossmatch results, and define the associated immunological risk for all living donor-recipient pairs
● Antibody incompatible transplantation (AIT) should only be undertaken after prior consideration of entry of the donor-recipient
● AIT should be considered as part of an ongoing structured programme, and should not be performed on an occasional basis
● To initiate a programme, a unit should be able to demonstrate a demand of at least five cases a year and appropriate support from clinical transplant, plasmapheresis and histocompatibility teams. An
AIT programme requires funding for additional staff and consumables, and all programmes should receive Commissioner support.
● There is insufficient evidence to make precise recommendations for treatment protocols, but units should have a written protocol based on best published practice. This should include recommendations on prevention, diagnosis and treatment of antibody mediated rejection.
● Protocols that follow the above can be regarded as established treatment and do not require Ethics Committee approval as research procedures. However, the standard of consent should include detailed written information which describes the risks of the procedure. The transplant donor should receive equivalent information to the recipient, so they are aware of the risks of the procedure to the recipient, whether it results in a transplant or not. Potential recipients and donors should be aware of their treatment choices, especially the option of exchange (pooled/paired) transplantation.
● Laboratories should be able to define antibodies to the standard defined in the BSHI/BTS document ‘Guidelines for the Detection and Characterisation of Clinically Relevant Antibodies in Solid Organ Transplantation’. Sensitive and rapid techniques for the measurement of donor-specific HLA antibody levels must be available.
● If ABOi transplantation is to be performed, blood group antibody titres need to be measured, with differentiation between A1 and A2 subgroups of recipient blood group A (when appropriate) and discrimination between IgG- and IgM-specific ABO antibodies. In living donor transplantation, a 7 day per week service with same day turn-around time is required.
● AIT results in an improved quality of life when compared to dialysis.
Additionally, many patients receiving antibody incompatibletransplants may have no other chance of a transplant. Transplantation is cost effective over time with a saving of about £15,000 per annum compared to dialysis when averaged over a 10 year period
● Every patient undergoing AIT should be audited on a local and national basis, with the national audit through the AIT Registry.
● All altruistic donors (non-directed and directed) must undergo formal mental health assessment with a mental health professional before donation
● Donors and recipients must only be included in a matching run if:
o Their clinical assessment and histocompatibility screening are complete and up to date. (B1)
o If matched, they are available to attend for crossmatch testing and proceed to surgery within the designated timeframes.
o Relevant complex donor considerations identified in the ‘pre-run’ and donor HLA and age preferences have been discussed and agreed with the recipient.
o They understand their roles and responsibilities with respect to other donors and recipient pairs in the schemes with whom they may be matched.
● Living kidney donors who are antibody incompatible with their recipient must have all the options and risks explained to them, including donation into the UKLKSS and antibody removal.
● As a minimum, donors must be made aware that a compatible transplant has the best chance of success and direct antibody incompatible transplant is associated with higher short- and long-term risk, if that is what is proposed
● The UKLKSS enables kidneys donated from living donors to be shared across the UK to maximise the number of transplant opportunities and include:
* Paired/pooled donation
* Altruistic donor chains
● Specific Considerations in Directed and Non-directed Altruistic Donation
◇ Psychosocial assessment
◇ Age
◇ Donor motivation
◇ Social support
◇ Anonymity
◇ Donor expectations
◇ Donors with terminal illnesses
◇ Logistical considerations
● Options for antibody incompatible living donor pairs
☆ Deceased donor transplantation
☆ Entry of the pair into the UKLKSS
☆ Direct antibody incompatible transplantation
☆ Acceptance of a lower risk antibody incompatible transplant
● There is clear, emphatic consensus among mental health clinicians working in the field that ALL potential altruistic donors should be referred for mental health assessment.
● 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
● Women must be informed of a greater risk of pregnancy-induced hypertension following kidney donation.Close monitoring of blood pressure, creatinine and foetal well-being is advisable in kidneys donors during pregnancy
● Kidney donors may be offered Aspirin 75 mg daily for preeclampsia prophylaxis
● There is no evidence to support the benefits of right or left nephrectomy to prevent pregnancy induced hydronephrosis
● Births after kidney donation should be reported to the Living Donor Registry as ‘a significant medical event’ at each annual review
● Patients at higher risk of complications and a poor outcome, due to immunological status or co-morbidities, should be considered for transplantation when the clinical team regard the risk / benefit ratio to be favourable. Due process will include careful consideration of the likely outcome for that individual without transplantation. The potential donor must be fully appraised of the issues
● The risks of recurrent disease are high in FSGS and MCGN. In these diseases, the presence of specific adverse clinical features may indicate living donor transplantation should be avoided, even where a donor is available. This will require careful assessment and deliberation with all interested parties
● In atypical HUS potential de novo disease in a related donor needs to be addressed directly. The risks of recurrent disease in the recipient need to be mitigated through regulated approval and consideration of the use of an inhibitor of complement activation, currently eculizumab.
● In patients with risks related to underlying activity such as SLE or systemic vasculitis, adequate disease control and an appropriate period of quiescence are important to ensure optimal outcomes
● Type 1 and type 2 diabetes are not contraindications to living donor transplantation, irrespective of whether they are the underlying cause of renal failure.
● The risk of recurrent disease does not contraindicate living donor transplantation in IgA nephropathy and membranous nephropaty
● Patients with amyloidosis should be discussed with the National Amyloidosis Centre before progressing to living donor transplantation. Patients with AA amyloidosis should have effective disease control before surgery.
● The overall risks associated with recurrent disease are small in SLE and living donor transplantation is safe in quiescent disease.
● The risks associated with recurrent disease are small and the outcomes of transplantation good, therefore AASV does not contraindicate living donor transplantation if the aforementioned criteria are met.
● The risks associated with recurrent disease are small and the outcomes of transplantation good, therefore Goodpasture’s disease does not contraindicate living donor transplantation if the aforementioned criteria are met
● The overall risks associated with Alport syndrome are small and the outcomes of transplantation good, therefore Alport syndrome does not contraindicate living donor transplantation.
● Type I and II MCGN do not contraindicate living donor transplantation. However, the risk of recurrent disease and subsequent graft loss is sufficiently high that transplantation should only be undertaken following careful discussion between the multi-professional team, the donor and the recipient. This is particularly the case if there is an identified abnormality of a soluble complement regulatory protein.
● Transplantation in an individual with unequivocal evidence of graft loss secondary to recurrent C3 glomerulopathy constitutes a high risk of subsequent failure such that some centres consider this a contraindication to repeat transplantation
● Among patients with genetic abnormalities in complement proteins or with an unknown cause of C3 glomerulopathy, a comparison with atypical HUS suggests that consideration should be given to avoiding living related donors in whom similar genetic mutations may predispose to the future development of C3 glomerulopathy after nephrectomy
● Living related renal transplantation should be avoided in atypical HUS unless the cause of the disease in the recipient is known and this has been excluded in the donor. Even then related donors may be at a greater risk of aHUS and should be warned of this risk.
● In patients in whom the underlying cause has unequivocally been attributed to Shiga-toxin, the recurrence rate of HUS is low and living donor transplantation may be considered.
● In appropriately selected cases, living donor kidney transplantation is a reasonable treatment option in primary hyperoxaluria
● Cystinosis is not a contra-indication to living donor transplantation. However, both donor and recipient should be counselled regarding the long-term extra-renal complications related to disease progression
● Pre-emptive living related renal transplantation is the gold standard therapy for children with end-stage renal disease
● The aim should be for children to receive a renal transplant from a blood group compatible well-matched donor, although ABO and/or HLA incompatible renal transplantation is feasible in children.
● In general, children who are ≥10 kg in weight are suitable to receive a kidney from an adult living donor
LEGAL FRAMEWORK
Recommendations
• All transplants performed from living donors must comply with the requirements of the primary legislation.
• All transplant centres performing living organ donation must be licensed by the Human Tissue Authority in line with the requirements of the European Union Organ Donation Directive.
• Consent for the removal of organs from living donors, for the purposes of transplantation, must comply with the requirements of the corresponding authority organs.
ETHICS
Recommendations
• All health professionals involved in living donor kidney transplantation must acknowledge the wide range of complex moral issues in this field and ensure that good ethical practice consistently underpins clinical practice.
• Regardless of potential recipient benefit, the safety and welfare of the potential living donor must always take precedence over the needs of the potential transplant recipient. (Not graded)
• Independence is recommended between the clinicians responsible for the assessment and preparation of the donor and the recipient, in addition to the Independent Assessor for the Human Tissue Authority. (Not graded)
SUPPORTING AND INFORMING THE POTENTIAL DONOR
Recommendations
• The living donor must be offered the best possible environment for making a voluntary and informed choice about donation. The transplant team must provide generic information that is relevant to all donors as well as specific information that is material to the person intending to donate.
• Independent assessment of the donor and recipient is required by primary legislation .
• To achieve the best outcome for donor, recipient and transplant, the boundaries of confidentiality must be specified and discussed at the outset.
• Ideally, the recipient will discuss relevant information with their donor, or allow it to be shared. If the recipient is not willing to disclose information, then the transplant team must decide whether it is possible to communicate the risks and benefits of donating adequately, without needing to disclose specific medical details. (Not graded)
• Separate clinical teams for donor and recipient are considered best practice but healthcare professionals must work together to ensure effective communication and co-ordination of the transplant process without compromising the independence of either donor or recipient.
• Support for the prospective donor, recipient and family is an integral part of the donation/transplantation process. Psychological needs must be identified at an early stage in the evaluation to ensure that appropriate support and/or intervention is initiated.
ABO BLOOD GROUPING AND CROSSMATCH TESTING
Recommendations
• A compatible ABO blood group and human leucocyte antigen (HLA) transplant offers the best opportunity for success. (A1)
• Where ABO or HLA incompatibility is present, alternative options for transplantation must be discussed with the donor and recipient, including paired/pooled donation and antibody incompatible transplantation.
ASSESSMENT OF RENAL FUNCTION
Recommendations
Measurement of Renal Function
• Initial evaluation of donor candidates should be using estimated glomerular filtration rate (eGFR), expressed as mL/min/1.73m2 computed from a creatinine assay.
• GFR must subsequently be assessed by a reference measured method (mGFR) such as clearance of 51Cr-EDTA, 125iothalamate or Iohexol performed according to guidelines published by the British Society of Nuclear Medicine.
• Differential kidney function, determined by 99mTcDMSA scanning is recommended where there is >10% variation in kidney size or significant renal anatomical abnormality. (C1) Advisory GFR Thresholds for Donation
• Pre-donation mGFR should be such that the predicted post-donation GFR remains within the gender and age-specific normal range within the donor’s lifetime. Recommended threshold levels are defined in Table 5.5.2. (B1)
• The risk of end-stage renal disease (ESRD) after 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 consented. (D2)
• The decision to approve donor candidates whose renal function is below the advisory GFR threshold or who have additional risk factors for the development of ESRD should be individualised and based on the predicted lifetime incidence of ESRD. (D2)
DONOR AGE
Recommendations
• Old age alone is not an absolute contraindication to donation but the medical work-up of older donors must be particularly rigorous to ensure they are suitable. (A1)
• Both donor and recipient must be made aware that the older donor may be at greater risk of peri-operative complications and that the function and possibly the long-term survival of the graft may be compromised. This is particularly evident with donors >60 years of age. (B1)
DONOR OBESITY
Recommendations
• Otherwise healthy overweight patients (BMI 25-30 kg/m2 ) may safely proceed to kidney donation. (B1)
• Moderately obese patients (BMI 30-35 kg/m2 ) must undergo careful preoperative evaluation to exclude cardiovascular, respiratory and kidney disease. (C2)
• Moderately obese patients (BMI 30-35 kg/m2 ) must be counselled about the increased risk of peri-operative complications based on extrapolation of outcome data from very obese donors (BMI >35 kg/m2 ). (B1)
• Moderately obese patients (BMI 30-35 kg/m2 ) must be counselled about the long-term risk of kidney disease and be advised to lose weight before donation and to maintain their ideal weight following donation. (B1)
• Data on the safety of kidney donation in the very obese (BMI >35 kg/m2 ) are limited and donation should be discouraged. (C1)
HYPERTENSION IN THE DONOR
Recommendations
• Blood pressure must be assessed on at least two separate occasions. Ambulatory blood pressure monitoring or home monitoring is recommended if blood pressure is high, high normal or variable, or the potential donor is on treatment for hypertension. (C2)
• We suggest that a blood pressure <140/90 mmHg is usually acceptable for donation. (C1)
• Prospective donors must be warned about the risk of developing donation-related hypertension, particularly if in a high-risk group. Blood pressure measurement is part of annual donor monitoring. (C1)
• Potential donors with mild-moderate hypertension that is controlled to <140/90 mmHg with one or two antihypertensive drugs and who have no evidence of end organ damage may be acceptable for donationC1).
• It is recommended that potential donors with hypertension are excluded from donation if: (C1)
o Blood pressure is not controlled to <140/90 mmHg on one or two antihypertensive drugs
o Evidence of end organ damage (retinopathy, left ventricular hypertrophy, proteinuria, previous cardiovascular disease)
o Unacceptable risk of future cardiovascular risk or lifetime incidence of ESRD.
• All living kidney donors must be encouraged to minimise the risk of hypertension and its consequences before and after donation by lifestyle measures including stopping smoking, reducing alcohol intake, frequent exercise and, where appropriate, weight loss. (C1)
• It is recommended that donors who are diagnosed with hypertension during assessment or who develop hypertension following donation are managed according to British Hypertension Society guidelines. (B1)
DIABETES MELLITUS
Recommendations
• All potential living kidney donors must have a fasting plasma glucose level checked. (B1)
• A fasting plasma glucose concentration between 6.1-6.9 mmol/L is indicative of an impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be undertaken. (B1)
• Prospective donors with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT. (B1)
• If OGTT reveals a persistent impaired fasting glucose and/or an impaired glucose tolerance, then the risks of developing diabetes after donation must be carefully considered. (B1)
• Consideration should be given to the use of a diabetes risk calculator to inform the discussion of potential kidney donation. (B2)
• Consideration of patients with diabetes as potential kidney donors requires very careful evaluation of the risks and benefits. In the absence of evidence of target organ damage and having ensured that other cardiovascular risk factors such as obesity, hypertension or hyperlipidaemia are optimally managed, diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney. (Not graded)
CARDIOVASCULAR EVALUATION
Recommendations
• There is no evidence to support the routine use of stress testing in the assessment of the potential donor at low cardiac risk. (C2)
• Potential kidney donors with a history of cardiovascular disease, an exercise capacity of <4 metabolic equivalents (METS) or with risk factors for cardiovascular disease should undergo further evaluation before donation. (C2)
• For higher risk potential donors, stress testing is recommended by whichever method is locally available or by CT calcium scoring . (C2)
• Discussion with and/or review by cardiologists, anaesthetists and the transplant MDT is recommended as part of the clinical assessment of donors with higher cardiovascular and peri-operative risk. (D2)
NON-VISIBLE HAEMATURIA
Recommendations
• All potential living donors must have reagent strip (dipstick) urinalysis performed on at least two separate occasions. (B1)
• Two or more positive tests, including trace positive, is considered as persistent non-visible haematuria (PNVH). (B1)
• If PNVH is present, perform urine culture and renal imaging to exclude common urologic causes including infection, nephrolithiasis and urothelial carcinoma. (A1)
• If no cause is found, perform cystoscopy in patients age >40 years to exclude bladder pathology. (B1)
• If no cause is found and the donor still wishes to donate, then a kidney biopsy is recommended if haematuria is 1+ or greater on dipstick testing. (B1)
• Glomerular pathology precludes donation, with the possible exception of thin basement membrane disease. (B1)
• For donors with persistent asymptomatic non-visible haematuria (PANVH) and a family history of haematuria or X-linked Alport syndrome, a renal biopsy (B1) and referral to a clinical geneticist are recommended. (B2)
PYURIA Statement of Recommendation
• Prospective donors found to have pyuria can only be considered for donation if it can be demonstrated that the pyuria is due to a reversible cause, such as an uncomplicated urinary tract infection. (C1)
INFECTION IN THE PROSPECTIVE DONOR
Recommendations
• Screening for infection in the prospective donor is essential to identify potential risks for the donor from previous or current infection and to assess the risks of transmission of infection to the recipient. (B1)
• Active HBV and HCV infection in the donor are usually contraindications to living donor kidney donation; however, donors with evidence of active viral replication may be considered under some circumstances. (B1)
• The presence of HIV or human T lymphotrophic virus (HTLV) infection is an absolute contraindication to living donation. (B1)
• Screening for HBV, HCV and HIV infection must be repeated within 30 days of donation. (Not graded)
• All potential donors should be provided with dietary advice regarding avoidance of HEV infection, and screening should be undertaken for HEV viraemia by nucleic acid testing within 30 days of donation. (Not graded)
• The CMV status of donor and recipient must be determined before transplantation. When the donor is CMV positive and the recipient is CMV negative, the donor and recipient must be counselled about the risk of post-transplant CMV disease. (B1)
• The EBV status of donor and recipient must be determined before transplantation. When the donor is EBV positive and the recipient is EBV negative, the donor and recipient must be counselled about the risk of developing Post Transplant Lymphoproliferative Disease. (B1)
• Potential donors must be screened by history for travel or residence abroad to assess their potential risk for having acquired endemic infections and appropriate microbiological investigations instigated if indicated. (Not graded)
NEPHROLITHIASIS
Recommendations
• In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as potential kidney donors. Full counselling of donor and recipient is required along with access to appropriate long-term donor follow up. (C2)
• Potential donors with metabolic abnormalities detected on screening should be discussed with a specialist in renal stone disease. (C2)
• In appropriate donors with unilateral kidney stone(s) the stone-bearing kidney can be considered for donation (if vascular anatomy and split kidney function permit) in order to leave the donor with a stone-free kidney after donation. (C2)
HAEMATOLOGICAL DISEASE
Recommendations
• Donor anaemia needs to be investigated and treated before donation. (A1)
• A haemoglobinopathy screen must be carried out in patients with nonNorthern European heritage or if indicated by the full blood count. (A1)
• Careful consideration needs to be given to the use of potential donors with haemoglobinopathies. (B1)
• Advice from a consultant haematologist is recommended for haematological conditions not covered in this guideline. (Not graded)
FAMILIAL RENAL DISEASE
Recommendations
• All potential transplant recipients must have a detailed family history recorded and confirmation where possible of the diagnosis in other family members with known kidney disease. This may aid diagnosis for the recipient, clarify any mode of inheritance and identify at risk relatives. (A1)
• When the cause of kidney failure in the recipient is due to an inherited condition, appropriate tests – including genetic testing if available – are recommended to exclude genetic disease in the potential donor. (A1)
• Many inherited kidney diseases are rare, so involvement of clinical and laboratory genetics services must be considered at an early stage to assess likely risks to family members and the appropriate use of molecular genetic testing. (B1)
DONOR MALIGNANCY
Recommendations
• Careful history taking, clinical examination and investigation of potential donors are essential to exclude occult malignancy before kidney donation, particularly in older (age >50 years) donors. (B1)
• Active malignant disease is a contraindication to living donation but donors with certain types of successfully treated low-grade tumour may be considered after careful evaluation and discussion. (B1)
• Donors with an incidental renal mass lesion must have this diagnosed and managed on its own merit (out with discussion of kidney donation) with appropriate referral to a Urology Specialist in line with the ‘2-week wait’ pathway. (A1)
• Contrast enhanced renal CT scan, ultrasound and / or MRI can usually distinguish between benign lesions such as angiomyolipoma (AML) or malignancy such as renal cell carcinoma (RCC). Review by a specialist uroradiologist is recommended. (C1)
• Bilateral AML and AML >4 cm generally preclude living kidney donation although occasionally unilateral large (>4 cm) AML can be used if ex vivo excision of the AML appears to be straightforward.
• An incidental, unilateral solitary AML <4 cm with typical characteristic CT criteria does not usually preclude donation.
• A kidney with an AML <1 cm may be considered for donation or left in situ in the donor’s remaining kidney.
• Kidneys containing a single AML between 1 and 4 cm can be considered for donation depending on its position, consideration of whether ex vivo excision of the AML is straightforward, or whether it can be left in situ in the recipient and followed with serial ultrasound imaging. (C1)
• Donors with an incidental small (<4 cm) renal mass that appears on imaging to be a RCC must be seen in a specialist Urology clinic and be offered standard of care treatment options, including partial and radical nephrectomy. Renal function permitting, if the person wishes to consider radical nephrectomy, ex-vivo excision of the small renal mass with subsequent donation of the reconstructed kidney can be considered on an individual basis with specific caveats, full MDM discussion and appropriate informed consent from the donor and recipient. (D2)
SURGERY: TECHNICAL ASPECTS, DONOR RISK AND PERI-OPERATIVE CARE
Recommendations
• Work-up for living kidney donation may include direct or indicative evaluation of split renal function with the kidney with poorer function selected for nephrectomy irrespective of vascular anatomy (see Chapter 5.5). (C2)
• Work-up for living kidney donation must include detailed imaging confirming the vascular anatomy of both donor kidneys and information about the renal parenchyma and collecting systems. Either CTA or MRA can be used as current evidence indicates little difference in accuracy. (B1)
• Multiple renal arteries or kidneys with anatomical anomalies are not absolute contraindications to donation. Decisions must be made on an individual basis as part of a multi-disciplinary team evaluation. (B2)
• All living donors must receive adequate thromboprophylaxis. Intraoperative mechanical compression and post-operative compression stockings, along with low molecular weight heparin, are recommended. (A2)
All living donor surgery must be performed or directly supervised by a Consultant surgeon with appropriate training in the technique. (C1)
• Pre-operative hydration with an overnight infusion and/or a fluid bolus during surgery improves cardiovascular stability during laparoscopic donor nephrectomy. (B2)
• Pre- and peri-operative intravenous fluid replacement with Hartmann’s solution is preferred to 0.9% Saline. (B2)
• Laparoscopic donor surgery (fully laparoscopic or hand-assisted) is the preferred technique for living donor nephrectomy, offering a quicker recovery, shorter hospital stay and less pain. Mini-incision surgery is preferable to standard open surgery. (B1)
• Haem-o-lok clips are not to be used to secure the renal artery during donor nephrectomy following a report of an adverse event involving this technique.(C2)
• Patients undergoing living donor nephrectomy are likely to benefit from the management approaches widely used in “enhanced recovery after surgery” (ERAS) programmes. (D2)
HISTOCOMPATIBILITY TESTING FOR LIVING DONOR KIDNEY TRANSPLANTATION Recommendations
• Initial assessment of donor and recipient histocompatibility status must be undertaken at an early stage in living donor kidney transplant work-up to avoid unnecessary and invasive clinical investigation. (B2)
• Screening of potential living donor kidney transplant recipients for clinically relevant antibodies is important for ensuring optimal donor selection and graft survival. (A1)
• Antibody screening is especially important when potential living donor transplant recipients undergo reduction or withdrawal of immunosuppression. (B2)
• Post-transplant antibody monitoring must be undertaken according to the BSHI/BTS guidelines. (B1)
• Transplant units and histocompatibility laboratories must agree an evidence-based protocol to define antibody screening and crossmatch results that constitute a high immunological risk to transplantation. (B2)
• When possible, the HLA type(s) of partners/offspring of female recipients who have had previous pregnancies should be determined to aid immunological risk assessment for repeat paternal HLA mismatches in women with low level DSA. (B1)
• A pre-transplant serum sample collected within 14 days of the planned date for transplantation must be tested in a sensitive antibody screening and donor crossmatch assay and transplantation should not usually be performed if the crossmatch test is positive, unless the antibody is shown to be indicative of acceptable immunological risk. (A1)
• Changes in immunosuppression during the transplant work-up must be notified to the histocompatibility laboratory and additional antibody screening and donor-recipient crossmatch tests must be undertaken as indicated. (B1)
• HLA matching may be preferred when there is an option of selecting between living donors, particularly to reduce the possibility of subsequent sensitisation. This is important for younger recipients where repeat transplantation may be required. However, it is recognised that other donor factors will be taken into account. (B1)
• For patients with an ABO/HLA incompatible and/or a poorly HLA matched living donor, consideration should be given to entry into the UK living kidney sharing scheme (UKLKSS) to identify a more suitable donor. (B2)
• The histocompatibility laboratory must issue an interpretive report stating the donor and recipient HLA mismatch, recipient sensitisation status and crossmatch results, and define the associated immunological risk for all living donor-recipient pairs. (A1)
EXPANDING THE DONOR POOL
Recommendations
• Coherent organisational and clinical practices are essential between transplant centres to optimise the UK Living Kidney Sharing Schemes (UKLKSS) and to maximise the number of potential transplants that proceed. (B1)
• To maximise transplant opportunities within the UKLKSS, donors and recipients must only be included in a matching run if:
o Their clinical assessment and histocompatibility screening are complete and up to date. (B1)
o If matched, they are available to attend for crossmatch testing and proceed to surgery within the designated timeframes. (B1)
o Relevant complex donor considerations identified in the ‘prerun’ and donor HLA and age preferences have been discussed and agreed with the recipient. (B1)
o They understand their roles and responsibilities with respect to other donors and recipient pairs in the schemes with whom they may be matched. (B1)
• The default for all non-directed altruistic kidney donors (NDADs) is to donate into an altruistic donor chain (ADC) within the UKLKSS provided that there is no higher priority patient on the national transplant list. (B1)
• All altruistic donors (non-directed and directed) must undergo formal mental health assessment with a mental health professional before donation. (C1)
• Living kidney donors who are antibody incompatible with their recipient must have all the options and risks explained to them, including donation into the UKLKSS and antibody removal. (C1)
• As a minimum, donors must be made aware that a compatible transplant has the best chance of success and direct antibody incompatible transplant is associated with higher short- and long-term risk, if that is what is proposed. (C1)
LOGISTICAL CONSIDERATIONS
Recommendations
• Wherever possible, the aim is to ensure that the financial impact on the living donor is cost neutral by the reimbursement of legitimate expenses incurred as a direct result of the preparation for and/or act of donation. There are clear policies across the four UK countries to ensure that claims are settled in full and in a timely manner (B1)
• Donors who are non-UK residents present unique logistical challenges. To ensure that the process is clinically effective and to comply with Visa and Immigration requirements, there is an agreed entry visa application process and maximum duration of stay in the UK (six months) for the donor. Visa extensions will only be considered in exceptional or unforeseen circumstances. (B1)
DONOR FOLLOW-UP AND LONG-TERM OUTCOME
Recommendations
• Counselling and consent of potential living kidney donors must include acknowledgement that the baseline risk of ESRD is increased by donation (see also section 5.5). (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 (see also sections 5.6- 5.9). (A1)
• Risk calculators predicting lifetime ESRD risk may help inform the consent process. (C2)
• The risk of ESRD in living donors mandates lifelong follow-up after donor nephrectomy. For donors who are resident in the UK, this can be offered locally or at the transplant centre according to the wishes of the donor, but such arrangements must secure the collection of data for submission to the UK Living Donor Registry. (B1)
• Donors who are non UK residents and travel to the UK to donate (privately or to a NHS entitled recipient) are not entitled to NHS followup but must be given advice about appropriate follow-up before returning to their country of origin. (C1)
• Potential donors who are unable to proceed to donation must be appropriately followed up and referred for further investigation and management as required. (B1)
• Women must be informed of a greater risk of pregnancy-induced hypertension following kidney donation. (A1)
• Close monitoring of blood pressure, creatinine and foetal well-being is advisable in kidneys donors during pregnancy. (C1)
• Kidney donors may be offered Aspirin 75 mg daily for pre-eclampsia prophylaxis. (D2)
• There is no evidence to support the benefits of right or left nephrectomy to prevent pregnancy induced hydronephrosis. (Not graded)
• Births after kidney donation should be reported to the Living Donor Registry as ‘a significant medical event’ at each annual review. (Not graded)
RECIPIENT OUTCOME AFTER LIVING DONOR KIDNEY TRANSPLANTATION IN ADULTS Recommendations
• Graft and patient survival after living donor kidney transplantation should be within the national range of expected outcomes. (A1)
• Transplant centres should regularly audit secondary outcomes and should reappraise practice if their results are not comparable with other units. (B1)
• Where a recipient is considered to be at high risk, transplantation should only proceed if, in the view of the team of professionals involved, there is an expectation that the patient is likely to survive with a functioning transplant for more than 2 years. (C2)
• Patients at higher risk of complications and a poor outcome, due to immunological status or co-morbidities, should be considered for transplantation when the clinical team regard the risk / benefit ratio to be favourable. Due process will include careful consideration of the likely outcome for that individual without transplantation. The potential donor must be fully appraised of the issues. A summary of these discussions (between the clinical team and the donor-recipient pair) should be documented in the clinical records and a copy should also be given to the donor and recipient. (C2)
RECURRENT RENAL DISEASE
Summary of Recommendations
• A wide range of diseases that cause renal failure may recur in a transplanted kidney. This is important to consider when determining the optimal treatment strategy for a recipient and when counselling both donor and recipient on the relative risks and benefits of living donor transplantation. The risks of recurrence, the consequences for transplant function, and the time-course of any deterioration must all be considered. A discussion of the effects of immunosuppression and transplant failure on morbidity and mortality may also be appropriate. (B1)
• The risks of recurrent disease are high in FSGS and MCGN. In these diseases, the presence of specific adverse clinical features may indicate living donor transplantation should be avoided, even where a donor is available. This will require careful assessment and deliberation with all interested parties. (B2)
• In atypical HUS potential de novo disease in a related donor needs to be addressed directly. The risks of recurrent disease in the recipient need to be mitigated through regulated approval and consideration of the use of an inhibitor of complement activation, currently eculizumab. (A1)
• In patients with risks related to underlying activity such as SLE or systemic vasculitis, adequate disease control and an appropriate period of quiescence are important to ensure optimal outcomes. (B1)
• Recommendations for individual diseases follow in the following text.
LIVING DONOR KIDNEY TRANSPLANTATION IN CHILDREN
Recommendations
• Pre-emptive living related renal transplantation is the gold standard therapy for children with end-stage renal disease. (2C)
• The aim should be for children to receive a renal transplant from a blood group compatible well-matched donor, although ABO and/or HLA incompatible renal transplantation is feasible in children. (2C)
• Every effort should be made to minimise HLA mismatches (especially with common antigens) to reduce the risk of future sensitisation. (2D)
• All children with stage 4 and 5 chronic kidney disease should be assessed by a multi-disciplinary team, including a paediatric nephrologist, transplant surgeon, anaesthetist and urologist (where appropriate) prior to renal transplantation. (Not graded)
• In general, children who are ≥10 kg in weight are suitable to receive a kidney from an adult living donor. (2C)
This guideline was established by British society of transplantation on 2018, it includes
2-legal framework
-All transplants in the UK should be judged by (tissue evaluation organizations which include (The human tissue Act 2004 and the Human Tissue (Scotland) Act 2006).
-All consent removal of kidney transplants should be under guide by (tissue and mental evaluation) requirement of Human tissue 2004, and mental capacity act 2005 in England and Wales, and mental capacity Act in north Ireland 2016.
The Human Tissue Authority (HTA) is responsible for assessing all applications for organ donation from living people.
-All donors and recipients see an Independent Assessor (IA) who is trained and accredited by the HTA and acts on behalf of the HTA to ensure that the donor has given valid consent without duress or coercion and that reward is not a factor in the donation. If the HTA is satisfied with these matters, then approval for the living donation will be given.
Types of living donation permitted by the legislation include:
The key ethical principles in living donation include:
3-Ethics:
All health professionals in LDKT should have full moral issues and good ethical experience.
Donor safety must be equally concerned, as recipient benefit.
Independence should be fully authorized between the recipient team and the donor team.
4-Supporting and informing the potential donor;
-Living donors must be offered a good environment for a voluntary decision about donation.
–Independence evaluation of donor and recipient, must be judged by primary legislation.
–Confidentiality must be offered, to both, donor and recipient, and shared information must be done with consent.
–Separate clinician’s team for donor and recipient is better, but health care professionals should work together without breaking confidentiality.
–All aspects of support should be offered to donors, recipients, and families.
5-Donor evaluation;
–recipient evaluation should be done before donor evaluation and the Plan for assessment of the donor should be done before counseling him, to reduce inconvenience, and avoid unnecessary barriers.
-all lab results should be reflected by the donor, accurately by a multidisciplinary team.
-for preemptive kidney transplantation recipient evaluation should be offered as early as GFR are 20 ml/min and acceleration of the process of transplantation is needed, donor assets should be started as early as possible to allow more time for discussion for transplantation Surgery.
– after a split evaluation of kidney functions by split kidney function, Nephrectomy is done to the lower kidney in GFR irrespective of vascular anatomy.
–If a donor’s labs showed mild increased albuminuria or proteinuria, they are disqualified from being donors.
-If a donor’s labs showed microscopic hematuria needs extensive evaluation including 2 cultures, cystoscopy, and possibly even a kidney biopsy.
-potential donors with active malignancy are not allowed to donate. Patients who have had malignant melanoma, and cancers of the breast, lung, and colon (Dukes stages B or C) are barred from the donation.
-potential donors with non-melanoma skin cancers and treated cancers with no risk of recurrence can be allowed to become donors but will require extensive workup and oncology evaluation before proceeding.
-Patients with renal masses will require referral to a specialist uro-radiologist to confirm if the masses are benign or malignant
–donor cardiac evaluation, a 12 lead ECG will suffice unless if the donor is at high risk for CVD – then referral to a cardiologist is required.
–Appropriate imaging to assess vascular tree, parenchyma, and collecting system should be offered to the donor’s kidneys. if there are anatomical anomalies, multiple vasculatures should be evaluated by a transplant surgeon and are not an absolute contraindication to transplantation.
–LMWH is recommended as thromboprophylaxis is offered by surgeons.
–All transplantation surgery must be done under a consultant surgeon
6-Histocompatibility testing for living donation for transplantation;
-for donor evaluation, blood group and Histocompatibility testing should be done before any invasive investigation after screening for the recipient blood group and antibody panel, to optimize donor selection and graft survival.
–Post transplantation antibody monitoring, must be undertaken to the BSHI/BTS, guidelines.
-for female recipients with previous pregnancies, HLA typing for partner and offspring should be determined to avoid more immunological risks.
–Pre-transplant screen samples must be tested for antibody screening and donor crossmatch, so transplantation should be delayed unless positive crossmatch is within the accepted titer.
-HLA matched donor is preferred especially for the younger recipients with the possible future need for re-transplantation to avoid sensitization.
-Recipient with ABO/HLA incompatible, and /or poorly HLA mismatch, the live donor should enter paired kidney donation program.
-The histocompatibility result report should be stating (donor, recipient HLA mismatch, recipient sensitization status, crossmatch result, and associated immunological risk for recipient and donor).
7-Expanding donor pool by UKLKSS;
The UK Living Kidney Sharing Scheme is to maximize the number of transplantations.
-The default, non-directed altruistic donors are to donate and be directed within UKLKSS.
-All altruistic donors if directed or not must have a formal mental health assessment before transplantation.
-all incompatible donors should be directed to UKLKSS.
-Donors should aware that; compatibility is always associated with success, while incompatibility is not.
8-Donor follow-up and long-term outcome;
-the risk of ESKD post donation is related to multiple risk factors including age, sex, race, BMI, and history of renal disease so, follow-up post nephrectomy must be informed to all donors, especially females for increased risks and events with pregnancy including hypertension and pre-eclampsia,
9-Recipient outcome after live donor transplant in adult;
-Graft and recipient survival, after transplantation of living donor, should be within range of expected outcome for high-risk patients’ expectation of recipient and graft functioning should be at least for 2 yrs.
–All transplant centers must do regular audits and Graft and patient survival after living donor kidney transplantation should be within the national range of expected outcomes. They should also do audits for secondary outcomes and compare them to other transplant centers.
10-Recurrent renal disease:
there is a wide range of recurrent diseases of Glomerular disease post-transplantation, so the risk of recurrence and graft survival should be discussed with both donor and recipient.
-for diseases with a high recurrence rate like atypical HUS, living donors are not preferred and the diseased donor is preferred
-Recipient risk of SLE or systemic vasculitis, needs adequate disease control time.
11-Living donor transplant in children;
-Pre-emptive related transplant is the gold standard transplant for children.
-children with CKD stage IV and V should be assessed by a multidisciplinary team.
-Children > 10 kg is suitable to receive a kidney from an adult donor.
-All transplants done from living donors must fulfil the requirements of the primary legislation with all it’s aspects
-The different legalised living donation types include directed either genetically or emotionally related ,paired, Non-directed altruistic donation, directed altruistic donation.
– HTA must approve the living donations for organ transplantation before processing.
– Health care givers involved in living donor kidney transplantation must recognize the wide range of complex moral issues and make sure that good ethical practice is provided also ethical committe can be available for support.
-Multidisciplinary team must explain to the possible donor about all aspects and risks on the short and long term perspective ,ensuring to fulfil the wrights and needs of the recipient and the donor.
-The donor surgeon is responsible of ensuring that the donor understands all the process and approves with his own unpressurised will to proceed and give written and verbal consent.
-Potential donors must be evaluated according to an agreed, evidence-based protocol involving a multi-disciplinary
input including psychological assessment and discussion covering all aspects for the donor’s benefit.
-Second opinion can be taken for the appropriateness of the donor and enough work up time frame for the donor need to be available.
-directed donor /recipient pair evaluation includes early education and discussion with both parties then identification of suitable recipient ,then potential donor within 2 weeks .
Primary contraindications for donors are detected through history and investigations and screening questionnaire then ABO and HLA compitability can be tested from week 2-4
Week 4-8 ,the suitable donor is enrolled in gold standard investigation and further evaluation by MDT .
Week 8-10 results are reviewed and feedback given to donor
Week 11 if donor is not fit ,follow up and further needed ttt need to be provided
If fit for transplant both donor and recipient discuss with MDT team for legalisation of the process and signing the consents.
7-10 days before the surgery day another final crossmatch and preoperative further investigations can be carried out
Week 18 the operation can be done
Followed by postoperative follow up and LD coordinator has to facilitate long term arrangements for long term care provided by the facility to the donor.
-ABO or HLA are incompatible other options as paired/pooled donation and antibody incompatible transplantation has to be discussed with the donor and the recipient.
-Some specifically important pointes need to be clarified in donor’s history regarding hematuria ,proteinuria , UTI , frequency ,urgency, oedema ,DM ,HTN ,cardiac history, malignancy history , smoking as well as exposure to certain infections as TB , malaria , hepatitis B, C ,HIV and drug abuse history others
– for the clinical exam ,some points need to be highlightended along with general detailed exam as mental status ,BP,BMI ,abdominal fat , scars, Lymph node exam,breast or testicular exam, chest and cvs exam.
-Investigations involve routine tests including urine analysis and albumin /creatinine ratio blood count, coagulation profile ,thrombophilia screen ,sickle cell screen, kidney function tests , isotope or other investigation for measuring GFR,liver function, urate , blood glucose measuring tests, thyroid function, lipid profile and pregnancy tests and virology and infection screening as well as cardiorespiratory evaluation by chest xray ,ECG and echo.
– Initial assessment of renal function by eGFR computed from a creatinine assay standardised to the International Reference Standard.
-Then GFR need further evaluation by a measured reference method as clearance of 51Cr-EDTA, 125iothalamate or Iohexol.
– Differential kidney function using 99mTcDMSA scanning is
adviced when there is >10% variation in kidney size or
renal anatomical anomaly.
– Pre-donation m GFR need to be considered in order that predicted post-donation GFR remains within the gender and age-specific normal range
-ESRD post donation risk is similar to general population but slight higher risk can occur for which donor have not be consented.
-The acceptance of donors with GFR below the recommended threshold or with comorbides need to be individualised
-Early postdonation compensatory increase of renal function of the remaining kidney occurs and nearly post 3 momths the eGFR increases 65-70% of the predonation level.Some studies mentioned decrease of GFR post donation by average of 26 mL/min/1.73m2
-On long term bases the rate of decline of GFR post donation is not higher than that for matched general population.
– ESRD incidence for living kidney donors is similar to or lower than that in the unselected general population inspite of reduction in GFR opposing other studies which published that donors compared with healthy matched controls had an increased risk of ESRD postdonation and absolute risk is higher for younger donors specially with black ethnicity.
– The cardiovascular and life expectancy risk for donors compared to matched controls is debatable .
– Long term study revaled a minor increase in risk of ESRD for donors with mGFR >80 mL/min/1.73m2 with mean age at donation was 40-50 years.
– A threshold for donation of >90 mL/min/1.73m2 was set for those <30 years, and candidates >45 years the threshold renal function is predicated on post-donation GFR as (75% of pre-donation function) staying above the lower limit of the age and gender-specific normal range.
-Old age is not n absolute contraindication for donation if medically fit meanwhile they will be more liable to perioperative complications and the graft long term outcome can be compromised.
-Candidates < 18 y must not be considered for donation and those 18-21 y are relative contraindication as most of them can develop comorbidities and OPTN data showed that most donors of this age group experienced ESRD 15 y postdonation.
-Donors with BMI 25-30 can proceed to donation ,those with BMI 30-35 need further cardiovascular, respiratory evaluation ,as well as explanation of the high risk of perioperative complications and long term outcomes ,therefore they will need to loose weight .Donors with BMI>35 are declined .Obese candidates are more liable to perioperative complications and post nephrectomy more prone to develop proteinuria and ESRD .
-Donors with high normal ,high or variable BP and on antihypertensive therapy need ABPM or multiple home BP monitoring. BP <140/90 can be acceptable for donation, candidates with moderate HTN controlled on antihypertensives can be accepted according to overall cardiovascular assessment, while those with uncontrolled hypertension ,evidence of end organ damage and high risk of future cardiovascular complications are declined.
-Donors with impaired fasting glucose state , family history of type 2 DM, a history of gestational diabetes, ethnicity or obesity need to undergo an oral glucose tolerance test (OGTT) because if there is impaired glucose tolerance test ,the risk of developing DM postdonation will be high, consideration of risk and benefit will be needed before accepting diabetic candidate as a potential donor
-Risk calculators use data for a donor to give an estimated risk for the development of diabetes over the subsequent 10 years
-potential kidney donors with high cardiovascular risk factor or with exercise capacity <4 METS can be evaluated by stress test or CT Ca scoring along with MDT assessment.
-Potential donors screened by ACR if >30mg/mmol ,they shall be declined due to increased risk of CKD and cardiovascular morbidity.
-Potential donors need to have dipstick urine testing at least twice if PNVPH was detected further urinary cultures and imaging will be needed if non conclusive , cystoscopy will be needed for those>40 y old if non conclusive with hematuria +1 , renal biopsy can be done ,meanwhile thin basement membrane can donate but it has to be distinguished from Alport syndrome which is contraindicated to donate .
-Possible donors with pyuria will not be considered except after proving that pyuria is due to reversible cause as uncomplicated UTI.
-Screening of the potential donor for infection is essential as candidates with active hepatitis B,C ,HIV ,HTLV is contraindication also CMV and EBV status need to be known and both parties counselled specially if positive donors are donating to negative recipients .
-Donors without significant metabolic anomalies with limited renal stone history can be included after counselling and further assessment, if a suitable candidate with unilateral renal stone, the kidney with the stone can be donated if the split renal function and vascular anatomy allows donation.
-Donors with anemia has to be investigated and treated ,also cases with hemoglobinopathies needs further assessment and hematological evaluation.
-Recipients with inherited disease need to have genetic testing which will also aid in excluding relatives at risk to the same genetic disease to be excluded.
-Screening for occult malignancy in donors>50 Y is essential as active malignancy is a contraindication for donation, meanwhile some treated low grade tumours can be accepted after precise evaluation.
-potential donors can need evaluation of split renal function selecting the kidney with less function as well as imaging for vascular anatomy and renal parenchyma, thromboprophylaxis is needed ,adequate hydration is applied , laparoscopic nephrectomy is preferred, ERAS program application is beneficial
-Initial evaluation of HLA compatibility is done early to avoid unnecessary tests besides antibody screening followed by post transplant monitoring to decide for the immunosuppression regimen guided by certain protocol ,if 2 parties are incompatible they can be enrolled into the UK living kidney sharing scheme to identify a more compatible candidate. An interpretative detailed report need to be issued by histocompatibility lab.
-AIT can be performed after entry of the couple to the UKLKSS including a specific experienced program including plasma pharesis, if ABOi transplantation will be done specific protocol need to be followed.
-To enhance transplant opportunities within the UKLKSS, for Paired/pooled donation and altruistic donor chains donors and recipients must be involved according to specific considerations.
-Altruistic kidney donors need to be psychologically and mentally assessed in addition to other routine tests .
– Living Donor Expenses need to be reimbursed
– The risk of ESRD in living donors necessitates lifelong follow-up .
– The risks of recurrent disease are high post transplantation as in FSGS and MCGN so living donor better to be avoided after MDT evaluation.
– children with body weight ≥10 kg are suitable to receive a
kidney from an adult living donor after evaluation of MDT.
Kidney transplantation from a living donor, when available, is the treatment of choice or most patients with ESRD.
This guidance relates only to living donor kidney transplantation and reflects a growing body of evidence.
ETHICS
All health professionals involved in LDT must be familiar with the general principles of ethical practice; altruism, autonomy, Beneficence, Dignity, Non-maleficence, and Reciprocity
DONOR EVALUATION
-During evaluation of potential donor contraindication and unsuitability of donors must be identified at the earliest possible stage of assessment.
-It may be appropriate to start the donor work-up in parallel to the recipient assessment to maximize the chance of pre-emptive transplantation and avoid unnecessary delay.
ABO BLOOD GROUPING AND CROSSMATCH TESTING
– A compatible ABO blood group and HLA transplant offers the best opportunity for success. (A1)
– Where ABO or HLA incompatibility is present, alternative options for transplantation must be discussed with the donor and recipient,. (A1)
MEDICAL ASSESSMENT
-A full past and present medical history must be taken to identify any risk of latent or current infection in the donor that could be transmitted to the recipient by a kidney allograft
-A thorough clinical examination must be performed, taking particular account of the cardiovascular and respiratory systems.
-A psychosocial assessment is recommended for all donors with appropriate referral to a mental health professional as required.
– Routine Screening Investigations for the Potential Donor:
Urine (at least twice): Dipstick Microscopy, culture and sensitivity and ACR or PCR.
Blood:
CBC, Coagulation screen (PT and APTT)
Thrombophilia screen (where indicated)
Sickle cell trait (where indicated)
Haemoglobinopathy screen (where indicated)
G6PD deficiency (where indicated)
Creatinine, urea and electrolytes
Isotopic or other reference test for measurement of GFR
Liver function tests
Bone profile (calcium, phosphate, albumin and alkaline phosphatase)
Urate
Fasting plasma glucose
Glucose tolerance test (if family history of diabetes or fasting plasma glucose
>5.6 mmol/L)
Fasting lipid screen (if indicated)
Thyroid function tests (if strong family history)
Pregnancy test (if indicated)
Virology and infection screen:
Hepatitis B and C
HIV
HTLV1 and 2 (if appropriate)
Cytomegalovirus
Epstein-Barr virus
Toxoplasma
Syphilis
Varicella zoster virus (where recipient seronegative)
HHV8 (where indicated)
Malaria (where indicated)
Trypanosoma cruzi (where indicated)
Schistosomiasis (where indicated)
Cardiorespiratory system
Chest X-ray
ECG
ECHO (where indicated)
Cardiovascular stress test (as routine or where indicated)
ASSESSMENT OF RENAL FUNCTION
– eGFR (CKD-EPI) expressed as mL/min/1.73m2 computed from a creatinine assay standardized to the International Reference Standard. (B1)
– GFR must subsequently be assessed by a reference measured method (mGFR) Cr-EDTA, iothalamate or Iohexol (B1)
– Differential kidney function, determined by 99mTcDMSA scanning is recommended where there is >10% variation in kidney size or significant renal anatomical abnormality. (C1)
– GFR Thresholds for donation defined based on the gender and age-specific normal range within the donor’s lifetime (B1)
– Donor whose renal function is below the GFR threshold or who have additional risk factors for ESRD should be individualized. (D2)
– The donor must be offered lifelong annual assessment of renal function including serum creatinine, estimation of UPC and BP measurement. (B1)
– The risk of ESRD after 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 consented. (D2)
– The risk of death and cardiovascular events was lower and the risk of death-censor cardiovascular events was the same in the donors as compared with the healthy matched population.
DONOR AGE
– Old age alone is not an absolute contraindication to donation, they need careful consideration.(A1)
– The older donor may be at greater risk of perioperative complications and that the function and possibly the long-term survival of the graft may be compromised. This is particularly evident with donors >60 years of age. (B1)
– Most programs do not consider donors aged <18 year.
DONOR OBESITY
– Otherwise healthy with (BMI 25-30 kg/m2) may safely proceed to donation. (B1)
– Moderately obese donors (BMI 30-35 kg/m2): Need to exclude CVD, respiratory and kidney disease. (C2), counselled about the increased risk of perioperative complications (B1). Counselled about the long-term risk of kidney disease and be advised to lose weight before donation and to maintain their ideal weight following donation. (B1)
– Limited data on the safety of kidney donation in the very obese (BMI >35 kg/m2) and should be discouraged. (C1)
HYPERTENSION IN THE DONOR
– BP must be assessed on at least two separate occasions.
– ABPM or home monitoring is recommended if BP is high, high normal or variable, or the potential donor is on treatment for hypertension. (C2)
– BP <140/90 mmHg is usually acceptable for donation. (C1)
– Donors must be warned about the risk of developing donation-related hypertension, particularly if in a high-risk group.
– BP measurement is part of annual donor monitoring. (C1)
– Donors with HTN controlled on medications (1 or 2) , no evidence of EOD may be acceptable for donation. Acceptance will be based on an overall assessment of cardiovascular risk and local policy. (C1)
– All LKD must be encouraged to adapt lifestyle measures including stopping smoking, reducing alcohol intake, frequent exercise and, where appropriate, weight loss, to decrease the risk of hypertension.
– Donors who are diagnosed with HTN pre- or post-donation are managed according to BHS (B1)
DIABETES MELLITUS
– FBG in all donors (B1), if indicate an impaired fasting glucose state and an OGTT should be undertaken. (B1)
– Donors with an increased risk of T2DM because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT. (B1)
– If OGTT reveals a persistent impaired fasting glucose and/or an impaired glucose tolerance, then the risks of developing diabetes after donation must be carefully considered. (B1)
– Use of a diabetes risk calculator to inform the discussion of potential kidney donation. (B2)
– Diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney. (Not graded)
CARDIOVASCULAR EVALUATION
– Routine use of stress testing in the assessment of donors at low cardiac risk, is not indicated (C2)
– Donors with a history of CVD, an exercise capacity of <4 metabolic equivalents (METS) or with risk factors for CVD should undergo further evaluation before donation. (C2)
– Higher risk donors, stress testing is recommended or by CT calcium scoring . (C2)
– MDT discussion is recommended as part of the clinical assessment of donors with higher cardiovascular and peri-operative risk. (D2)
PROTEINURIA
– Urine protein excretion needs to be quantified in all living donors. (B1)
– Urine ACR is the recommended screening test, although urine PCR is an acceptable alternative. (A1)
– ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day protein excretion >500 mg/day represent absolute contraindications to donation. (C2)
– The significance of moderately increased albuminuria and proteinuria has not been fully evaluated in living kidney donors. However, since the risk of CKD and cardiovascular morbidity increase progressively with increasing albuminuria or proteinuria such levels are a relative contraindication to donation. (C2)
NON-VISIBLE HAEMATURIA
– All living donors must have (dipstick) urinalysis on at least two separate occasions. (B1)
– 2 or more positive tests (including trace), is considered as persistent non-visible haematuria (PNVH). (B1)
– If PNVH is present, urine culture and renal imaging to exclude common urologic causes (A1)
– If no cause is found, perform cystoscopy in patients age >40 years to exclude bladder pathology. (B1)
– If no cause is found and the donor still wishes to donate, then a kidney biopsy is recommended if haematuria is 1+ or greater on dipstick testing. (B1)
– Glomerular pathology precludes donation, with the possible exception of thin basement membrane disease. (B1)
– For donors with persistent asymptomatic (PANVH) and a family history of haematuria or X-linked Alport syndrome, a renal biopsy (B1) and referral to a clinical geneticist are recommended. (B2)
PYURIA
–Donors with pyuria can only be considered for donation if it is due to a reversible cause, such as an uncomplicated urinary tract infection.
INFECTION IN THE PROSPECTIVE DONOR
– Screening to identify potential risks of donor infection and transmission to the recipient. (B1)
– Active HBV and HCV infection in the donor are usually contraindications to living kidney donation; however, donors with evidence of active viral replication may be considered under some circumstances. (B1)
– HIV or HTLV infection is an absolute contraindication to living donation. (B1)
– Screening for HBV, HCV and HIV infection must be repeated within 30 days of donation. (Not graded)
– All donors should be provided with dietary advice regarding avoidance of HEV infection, and screening by nucleic acid testing within 30 days of donation. (Not graded)
– The CMV status of donor and recipient must be determined before transplantation. When the donor is CMV positive and the recipient is CMV negative, the donor and recipient must be counselled about the risk of post-transplant CMV disease. (B1)
– The EBV status of donor and recipient must be determined before transplantation. When the donor is EBV positive and the recipient is EBV negative, the donor and recipient must be counselled about the risk of developing PTLD. (B1)
-Potential donors must be screened by history for travel or residence abroad to assess their potential risk for having acquired endemic infections and appropriate microbiological investigations instigated if indicated. (Not graded)
NEPHROLITHIASIS
– In the absence of a significant metabolic abnormality, donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as potential kidney donors. Full counselling of donor and recipient is required along with access to appropriate long-term donor follow up. (C2)
– Donors with metabolic abnormalities detected on screening should be discussed with a specialist in renal stone disease. (C2)
– In appropriate donors with unilateral kidney stone(s) the stone-bearing kidney can be considered for donation (if vascular anatomy and split kidney function permit) in order to leave the donor with a stone-free kidney after donation. (C2)
HAEMATOLOGICAL DISEASE
– Donor anemia needs to be investigated and treated before donation. (A1)
– A haemoglobinopathy screen must be carried out in patients with non-Northern European heritage or if indicated by the full blood count. (A1)
– Careful consideration needs to be given to the use of donors with haemoglobinopathies. (B1)
– Advice from a hematologist is recommended for hematological conditions not covered in this guideline. (Not graded)
FAMILIAL RENAL DISEASE
– All transplant recipients must have a detailed family history recorded and confirmation where possible of the diagnosis in other family members with known kidney disease. This may aid diagnosis for the recipient, clarify any mode of inheritance and identify at risk relatives. (A1)
– When the cause of ERSD in the recipient is due to an inherited condition, appropriate tests – including genetic testing if available – are recommended to exclude genetic disease in the potential donor. (A1)
– Many inherited kidney diseases are rare, so involvement of clinical and laboratory genetics services must be considered at an early stage to assess likely risks to family members and the appropriate use of molecular genetic testing. (B1)
DONOR MALIGNANCY
– Careful H&E and investigation of donors are essential to exclude occult malignancy, particularly in older (age >50 years) donors. (B1)
– Active malignant disease is a contraindication to LD but donors with certain types of successfully treated low-grade tumour may be considered (B1)
– Donors with an incidental renal mass lesion to be evaluated by Urologist (A1)
– Contrast enhanced renal CT scan, ultrasound and / or MRI can usually distinguish between benign lesions such as AML) or malignancy as RCC. Review by a specialist uroradiologist is recommended. (C1)
– Bilateral AML and AML >4 cm generally preclude living kidney donation
– AML <1 cm may be considered for donation or left in situ in the donor’s remaining kidney.
– Single AML (1-4 cm) can be considered for donation depending on its position, consideration of excision of the AML is straightforward, or whether it can be left in situ in the recipient and followed with serial ultrasound imaging. (C1)
– Donors with an incidental small (<4 cm) renal mass that appears on imaging to be RCC must be seen in a specialist Urology clinic and be offered standard of care treatment (D2)
SURGERY: TECHNICAL ASPECTS, DONOR RISK ANDPERI-OPERATIVE CARE
– Evaluation of split renal function with the kidney with poorer function selected for nephrectomy irrespective of vascular anatomy (C2)
-Detailed imaging (CTA or MRA) confirming the vascular anatomy of both donor kidneys and information about the renal parenchyma and collecting system. (B1)
– Multiple renal arteries or kidneys with anatomical anomalies are not absolute contraindications to donation. (B2)
– All living donors must receive adequate thromboprophylaxis A2)
– Pre-operative hydration with an overnight infusion and/or a fluid bolus during surgery improves cardiovascular stability during laparoscopic donor nephrectomy. (B2)
– Laparoscopic donor surgery (fully laparoscopic or hand-assisted) is the preferred technique for living donor nephrectomy.(C2)
– “enhanced recovery after surgery” (ERAS) programs for all patient undergoing the surgery. (D2)
HISTOCOMPATIBILITY TESTING FOR LIVING DONOR KIDNEY TRANSPLANTATION
– Initial assessment of HLA status must be undertaken at an early stage in living donor kidney transplant work-up to avoid unnecessary and invasive clinical investigation. (B2)
– Screening of recipients for clinically relevant antibodies is important for ensuring optimal donor selection and graft survival. (A1)
– Antibody screening is especially important when recipients undergo reduction or withdrawal of immunosuppression. (B2)
– Post-transplant antibody monitoring must be undertaken according to the BSHI/BTS guidelines. (B1)
– Transplant units and histocompatibility laboratories must agree an evidence-based protocol to define antibody screening and crossmatch results that constitute a high immunological risk to transplantation. (B2)
– When possible, the HLA type(s) of partners/offspring of female recipients who have had previous pregnancies should be determined to aid immunological risk assessment for repeat paternal HLA mismatches in women with low level DSA. (B1)
– A pre-transplant serum sample collected within 14 days of the planned date for transplantation must be tested in a sensitive antibody screening and donor crossmatch assay and transplantation should not usually be performed if the crossmatch test is positive, unless the antibody is shown to be indicative of acceptable immunological risk. (A1)
– Changes in immunosuppression during the transplant work-up must be notified to the histocompatibility laboratory and additional antibody screening and donor-recipient crossmatch tests must be undertaken as indicated. (B1)
– HLA matching may be preferred to reduce the possibility of subsequent sensitization. However, it is recognized that other donor factors will be taken into account. (B1)
– For patients with an ABO/HLA incompatible and/or a poorly HLA matched living donor, consideration should be given to entry into the UKLKSS to identify a more suitable donor. (B2)
– The histocompatibility laboratory must issue an interpretive report stating the donor and recipient HLA mismatch, recipient sensitization status and crossmatch results, and define the associated immunological risk for all living donor-recipient pairs. (A1)
RECURRENT RENAL DISEASE
– This is important to consider the risks of recurrence, the consequences for transplant function, and the time-course of any deterioration must all be considered. A discussion of the effects of immunosuppression and transplant failure on morbidity and mortality may also be appropriate. (B1)
LIVING DONOR KIDNEY TRANSPLANTATION IN CHILDREN
– Pre-emptive living related renal transplantation is the gold standard therapy for children with ESRD. (2C)
– In general, children who are ≥10 kg in weight are suitable to receive a kidney from an adult living donor. (2C)
– The aim should be transplant from a blood group compatible well-matched donor, although ABO and/or HLA incompatible renal transplantation is feasible in children. (2C)
– Effort should be made to minimize HLA mismatches (especially with common antigens) to reduce the risk of future sensitization. (2D)
– All children with ERSD should be assessed by a MDT prior to renal transplantation. (Not graded)
BTS guideline has comprehensive recommendations which contain these headlined:
1- donor evaluation
2- surgery technique
3- histocompatibility test
4 expanding to donor pool
5- Logistical considerations
6- Donor Follow up
7- recipient outcome
8- recurrent renal disease
9- living donor kidney transplant in children
I will try to highlight some important recommendations from each topic
Old age now it’s not contraindication for donation but we should be careful especially about period operative complications
Also, graft survival from old donor( > 59 y ) is lower notably after 5 years
On the other hand most program refuse donor younger than 18 years because of risk of (CVD- DM……) development
Obesity is one of risk factors for both donor and recipient
Donation with BMI > 35 should be discouraged
They’d rather donor with BMI (20-30)
Donor with BMI (30- 35) needs per- transplant consultation to rule out risk factor ( CVD- BP- respiratory functions)
BTS guideline explains in details the (definition – methods of BP measurement) and identifies acceptable criteria;
BTS guideline recommends lifestyle changes: (smoking cessation- weight reduction- exercise…)
Diabetic nephropathy development after donation is not common ( comparing to general population- and need long time follow up)
All donors must have a fasting plasma glucose test , if positive , OGTT should be performed or if family history of DM , a history of gestational diabetes, ethnicity or obesity is positive
In the absence of evidence of target organ damage and having ensured that other cardiovascular risk factors such as obesity, hypertension or hyperlipidaemia are optimally managed, diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney.
Cardiac evaluation
All patient should perform echocardiogram to screen cardiomyopathy or past ischemia
Stress test not recommended routinely in low risk donor
But in the presence of risk factors CT calcium scanning or other available test
Multidisciplinary teamwork is preferred
Proteinuria more than 500 mg per day is an absolute contraindication for renal transplantation
Proteinuria 150- 500 mg a day is a relative contraindication
All living donors must perform (dipstick) urinalysis on at least two separate occasions to rule out non visible hematuria , if positive, in donor older than 40years, perform cystoscopy to exclude bladder pathology.
Kidney biopsy is recommended to exclude glomerular disease which may preclude donation, with the exception of thin basement membrane
If x linked Alport syndrome is suspected genetic test should be done
Active HBV- HCV and HIV infection in the donor are usually contraindications
CMV/EBV status of donor and recipient must be determined before transplantation. When the donor is CMV/EBV positive and the recipient is CMV/EBV negative, the donor and recipient must be counselled about the risk of post-transplant CMV/EBV disease
Metabolic cause for lithiasis consider a specialist
Kidney bearing stones maybe considered for donation
Anemia should be interpreted and treated with hematologist
Active malignant is contraindication for donor recipient
ECHO- CT OR MRI have well valuation for AML OR RCC
Donor with AML OR RCC should consult urologists
Bilateral and usually > 4 cm unilateral AML preclude donation
Donor with AML < 1 cm unilateral AML can undergo procedure
UKLKSS is exit for patients with an ABO/HLA incompatible and/or a poorly HLA matched living donor
To initiate a programme of AIT, a unit should be able to demonstrate a demand of at least five cases a year and appropriate support from clinical transplant, plasmapheresis and histocompatibility teams
Sensitive and rapid techniques for the measurement of DSA levels must be available
If ABOi transplantation is to be performed, blood group antibody titres need to be measured, with differentiation between A1 and A2 subgroups of recipient blood group A (when appropriate) and discrimination between IgG- and IgM-specific ABO antibodies.
SURGERY: TECHNICAL ASPECTS, DONOR RISK AND PERI-OPERATIVE CARE
All living donor surgery must be performed by a Consultant surgeon with appropriate training in the technique
Haem-o-lok clips are not to be used to secure the renal artery during donor nephrectomy
LIVING DONOR KIDNEY TRANSPLANTATION IN CHILDREN
• Pre-emptive
• living related donor
• blood group compatible well-matched donor,
• minimise HLA mismatches to reduce the risk of future sensitisation.
• multi-disciplinary team, prior to renal transplantation
• children who are ≥10 kg in weight are suitable to receive a kidney from an adult living donor.
BTS guideline discusses recurrent disease with some considerations
IgA nephropathy
membranous nephropathy
ANCA vasculitis
Goodpasture
SLE
cystinosis
Primary hyperoxaluria (selected cases)
Not contraindication for LD RTX
We should avoid living related donor in Atypical HUS
Primary FSGS AND Type I and II MCGN do not contraindicate living donor transplantation.
But graft loss secondary to recurrent C3 glomerulopathy is a contraindication to repeat transplantation
Alport Syndrome
not contraindicate LD transplantation. But should be careful about the risks of de novo anti-GBM disease
For amyloidosis we should control disease before transplant
Ethical consideration ;
Donating a kidney involves a detailed process of investigation, major surgery, and a significant period of recovery. Whilst there are documented overall benefits for the individual donor and wider society, living donor surgery entails risk, which includes
a small risk of death
Donor medical assessment ;
1-History and examination
2-Basic laboratory investigation , in addition to screening for viral infection and common transmitted disease .
Assessment of donor renal function ;
1-Estimate the GFR using the CKD-EPI equation .
2-Split renal function, measured by combining 51Cr-EDTA and 99mTc-DMSA, can be helpful when there is anatomical abnormality or complexity.
3-Age and Gender-Specific GFR based is recommended for Safe Threshold Level of Kidney Function to Donate .
Donor age ;
1-Old age is not absolutely contraindication to donate .
2- Donors aged <18 are not allowed to donate in most o the transplant program and an age of 18-21 years considered as a relative contraindication to donation.
Obesity ;
BMI 25-30 kg/m2) may safely proceed to kidney donation.
BMI 30-35 kg/m2) must be counseled about the long-term risk of kidney disease and be advised to lose weight before donation and to maintain their ideal weight following donation.
The very obese (BMI >35 kg/m2) are limited and donation should be discouraged.
HYPERTENSION IN THE DONOR;
1- a blood pressure of <140/90 mmHg is usually acceptable for donation.
2-mild-moderate hypertension that is controlled to <140/90 mmHg (and/or 135/85 mmHg with ABPM or home monitoring) with one or two antihypertensive drugs and who have no evidence of end organ damage may be acceptable for donation.
DIABETES MELLITUS;
1-All potential living kidney donors must have a fasting plasma glucose level checked.
2-an OGTT should be performed to potential donor with IGF and those with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity .
ARDIOVASCULAR EVALUATION;
1. No evidence to support the routine use of stress testing in the assessment of the potential donor at low cardiac risk.
2. For higher risk potential donors, stress testing is recommended by whichever method is locally available or by CT calcium scoring.
3. MDT is recommended.
PROTEINUR;
1- ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day or protein excretion >500 mg/day represent absolute contraindications to donation.
NON-VISIBLE HAEMATUR;
1-If PNVH is present, perform urine culture and renal imaging to exclude common urologic causes including infection, nephrolithiasis and urothelial carcinoma.
2-If no cause is found, perform cystoscopy in patients age >40 years to exclude bladder pathology.
3- If no cause is found and the donor still wishes to donate, then a kidney biopsy is recommended if haematuria is 1+ or greater on dipstick testing.
PYURI;
pyuria can only be considered for donation if it can be demonstrated that the pyuria is due to a reversible cause, such as an uncomplicated urinary tract infection
INFECTION IN THE PROSPECTIVE DONOR;
1-Active HBV and HCV infection in the donor are usually contraindications to living donor kidney donation; however, donors with evidence of active viral replication may be considered under some circumstances.
2- The presence of HIV or human T lymphotrophic virus (HTLV) infection is an absolute contraindication to living donation.
3- When the donor is CMV positive and the recipient is CMV negative, the donor and recipient must be counselled about the risk of post-transplant CMV disease.
4- When the donor is EBV positive and the recipient is EBV negative, the donor and recipient must be counselled about the risk of developing Post Transplant Lymphoproliferative Disease.
NEPHROLITHIAS ;
1-In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as potential kidney donors.
HAEMATOLOGICAL DISEA;
1- Donor anaemia needs to be investigated and treated before donation.
2- A haemoglobinopathy screen must be carried out in patients with non- Northern European heritage or if indicated by the full blood count.
DONOR MALIGNANCY;
1-It is essential to exclude occult malignancy before kidney donation, particularly in older (age >50 years) donors.
2- Active malignant disease is a contraindication to living donation but donors with certain types of successfully treated low-grade tumour may be considered after careful evaluation and discussion.
3- Donors with an incidental renal mass lesion must have this diagnosed and managed on its own merit (out with discussion of kidney donation) with appropriate referral to a Urology Specialist in line with the ‘2-week wait’ pathway.
3- Contrast enhanced renal CT scan, ultrasound and / or MRI can usually distinguish between benign lesions such as angiomyolipoma (AML) or malignancy such as renal cell carcinoma (RCC). Review by a specialist uroradiologist is recommended.
4- Bilateral AML and AML >4 cm generally preclude living kidney donation .
5- A kidney with an AML <1 cm may be considered for donation or left in situ in the donor’s remaining kidney.
6-Kidneys containing a single AML between 1 and 4 cm can be considered for donation depending on its position, consideration of whether ex vivo excision of the AML is straightforward, or whether it
How these guidelines are different from the guidelines you follow at your workplace?
These guidelines do not differ from the guidelines used in our transplant center.
Tropical diseases (schisosomiasis and urinary tract tuberculosis )is apart of work up
SUMMARY
Introduction:
Kidney transplantation, particularly from a living donor does not only shorten the waiting time of patients with ESRD but offers better graft and patient survival. Disease donor is not readily available and for those that might even want a preemptive kidney transplant, this may be very difficult to achieve with disease donor and hence the UK living kidney sharing scheme (UKLKSS) has been of a tremendous help in allocating quality and better matched kidney to different recipient. In UK, living donor poor has been on the rise in the last 20 years as 1 in every 3-kidney transplant done in UK now a living donor
Legal Framework
Types of Living Donation Permitted by Legislation
Ethics
As the pool and the number of those involved in living kidney donor is growing, every health worker must be up to date on the complex ethical issues that arise in the course of this process. The need for them to be very professional and independent is expected of them, the following guidelines must be carefully followed to avoid been caught up in the complexity of organ donation,
Donor Evaluation:
The evaluation of a donor is part of the critical steps to achieve successful kidney transplantation. The aim is ensured suitability and reduce the possible risk that may come with donation and each of the sages of the test must be discussed well with donor and an agreement reached before proceeding on those investigations. It is also important to do test in stages to prevent unnecessary exposure to some test that may not be needed if there is lack of suitability in the preliminary tests. The donor GP should be contacted for possible past medical history that may be of help. Furthermore, both the donor and recipient should be free to seek for a second opinion on tests conducted on them.
Routine Screening Test for the Donor.
a) HLA mismatch status
b) identification of alloantibodies
c) donor-recipient antibody
Donor above the age of 60 years has been increasing now in UK and they must counsel on the need to do more detailed work up and possibility of perioperative complication. Also, the outcome of the graft function after the surgery must be explained to the recipient because of the physiologically expected decline in kidney function as one gets older. Furthermore, donors with peculiar situation like hypertension, obesity, impaired glycemic control or DM, proteinuria, hematuria must be subjected to more intense investigation, proper counselling, and risk assessment before surgery.
Surgery and Perioperative Care:
Living kidney donation is a major surgery that involves multidisciplinary team that must be lead and done by surgeon. Patient needs to be put through all the stages of the surgery with possible complications and how to manage if it arises. There should be a written documented protocol on pre-operative, perioperative and post-transplant care which must be regularly updated based on current evidence. Inform consent about the surgery, site on the body to be marked and the whether right or left kidney will be harvested for the surgery should well spelt out. DVT prophylaxis should be used since is a major surgery and an antibiotic cover with analgesic for pain control.
Donor Follow up and long-Term Outcome
The main pillar of a continue positive outcome in kidney donor surgery is to maintain safety and long term follow up of patient. Studies in USA and Sweden have reported a reduction in the occurrence of ESRD and cardiovascular disease among donor compared to the genral population. Also, some other studies have demonstrated a lower rate of ESRD among younger donors compared to old donors. However, every transplant centre should have their respective standard of operation on follow up of patient for early detection of any untoward complications like recurrent of native disease
The above is different from my centre in term of the more extensive investigations that are not readily available in the developing am practicing especially the genetic studies and some radiological studies like split renal function
it is too long, sir. how can I summarize 295 pages.
Guidelines for Living Donor Kidney Transplantation
Summary
Key ethical principals in living donor transplantation:
· Altruism.
· Autonomy.
· Beneficence.
· Dignity.
· Non-maleficence.
· Reciprocity.
Key Points to be Discussed with a Potential Donor
1. Valid consent for donation.
2. There should be confidentiality(Both the donor and recipient have a right to a confidential relationship with their respective clinicians).
3. The donor should be informed about process and possible outcomes:
a) Risks of donation (generic and specific).
b) Nature of surgical procedure and length of stay in hospital.
c) Potential graft loss in the recipient.
d) Requirement for Human Tissue Authority (HTA) assessment.
e) Reimbursement of expenses.
f) Requirement for annual review.
Donor Evaluation
1. Identify contraindications to donation and potential clinical (physical and psychosocial) risks.The donor should be assessed medically and psychologically.
2. ABO blood grouping and crossmatch testing.
Summary of Key Points of Importance in the Medical +/- Family History of a Potential Kidney Donor:
· Haematuria/proteinuria/urinary tract infection.
· Difficulty in passing urine, including urgency, frequency, dysuria.
· History of peripheral oedema.
· Gout.
· Nephrolithiasis.
· Hypertension.
· Diabetes mellitus, including family history.
· Ischaemic heart disease/peripheral vascular disease/other atherosclerosis.
· Cardiovascular risk factors.
· Thromboembolic disease.
· Sickle cell and other haemoglobinopathies.
· Weight change.
· Change in bowel habit.
· Previous jaundice.
· Previous or current malignancy.
· Systemic disease which may involve the kidney.
· Chronic infection such as tuberculosis.
· Family history of a renal condition that may affect the donor.
· Smoking.
· Current or prior alcohol or drug dependence.
· Mental health history.
· Obstetric history.
· Residence abroad.
· Previous medical assessment e.g. for life insurance.
· Previous anaesthetic problem.
· History of back or neck pain and trauma.
· Results of national screening programme tests e.g. cervical smear, mammography, colorectal screening
History with respect to Transmissible Infection
1. Previous illnesses
2. Jaundice or hepatitis
3. Malaria.
4. Previous blood transfusion.
5. Tuberculosis / atypical mycobacterium Family history of tuberculosis
6. Family history of Creutzfeldt-Jakob disease, previous treatment with natural growth hormone, or undiagnosed degenerative neurological disorder
7. Specific geographical risk factors: e.g. fungi and parasites, tuberculosis, hepatitis, malaria, worms
8. Increased risk of HIV, HTLV1 and HTLV2, Hepatitis B and C infection:
i) Haemophiliac or sexual partner of haemophiliac.
ii) High risk sexual behaviour.
iii) History of infectious hepatitis or syphilis.
iv)History of intravenous drug use
v) Tattoo or skin piercing within last 6 months.
vi)Sexual partner of an individual with positive serology.
vii) Sexual partner of drug addict.
The important Points in the Clinical Examination of a Potential Kidney Donor
Abdominal fat distribution
Blood pressure
Body mass index
Dipstick urinalysis
Evidence of self-harm
Examination for abdominal masses or herniae
Examination for scars or previous surgery
Examination for lymphadenopathy
Examination / history of regular self-examination of the breasts Examination / history of regular self-examination of the testes Examination of the cardiovascular and respiratory systems Mental health
Routine Screening Investigations for the Potential Donor
1. Urine
· Dipstick for protein, blood and glucose (at least twice)
· Microscopy, culture and sensitivity (at least twice)
· Measurement of protein excretion rate (ACR or PCR)
2. Blood : CBC, Coagulation screen (PT and APTT), Thrombophilia screen (where indicated), Sickle cell trait (where indicated), Haemoglobinopathy screen (where indicated), G6PD deficiency (where indicated)
3. KFT, Bone profile and LFT.
4. Isotopic or other reference test for measurement of GFR
5. Fasting plasma glucose and Glucose tolerance test (if family history of diabetes or fasting plasma glucose >5.6 mmol/L), Fasting lipid screen (if indicated), Thyroid function tests (if strong family history), Pregnancy test (if indicated)
6. Virology and infection screen;Hepatitis B and C, HIV, HTLV1 and 2 (if appropriate), Cytomegalovirus, Epstein-Barr virus, T oxoplasma, Syphilis, Varicella zoster virus (where recipient seronegative), HHV8 (where indicated), Malaria (where indicated), Trypanosoma cruzi (where indicated), Schistosomiasis (where indicated).
7. Cardiorespiratory system: Chest X-ray, ECG, ECHO (where indicated), Cardiovascular stress test (as routine or where indicated).
The selection criteria for donation, GFR >80 mL/min/1.73m2. Recently the current practice relies on the age and gender-specific GFRs that are considered safe to donate.
Advisory Threshold GFR Levels Considered Acceptable for Living Kidney Donation
DONOR AGE
· The younger donor Age > 18 y.
· Donors above 60 years of age need careful consideration with respect to the increased risk of peri-operative complications, existing comorbidities and residual function post-donation, and also the long-term transplant outcome in the recipient associated with reduced donor GFR and potential donor vasculopathy.
DONOR OBESITY
1. BMI 25-30 kg/m2: healthy overweight patient may safely proceed to kidney donation.
2. BMI 30-35 kg/m2: Moderately obese patients
a) must undergo careful pre-operative evaluation to exclude cardiovascular, respiratory and kidney disease.
b) must be counselled about the increased risk of peri-operative complications based on extrapolation of outcome data from very obese donors (BMI >35 kg/m2).
c) must be counselled about the long-term risk of kidney disease and be advised to lose weight before donation and to maintain their ideal weight following donation.
3. BMI >35 kg/m2 : Data on the safety of kidney donation in the very obese are limited and donation should be discouraged.
HYPERTENSION IN THE DONOR
1. Blood pressure must be assessed on at least two separate occasions.
2. Ambulatory blood pressure monitoring or home monitoring is recommended if blood pressure is high, high normal or variable, or the potential donor is on treatment for hypertension.
3. Blood pressure <140/90 mmHg is usually acceptable for donation.
4. Potential donors with hypertension are excluded from donation if:
a) Blood pressure is not controlled to <140/90 mmHg on one or two antihypertensive drugs.
b) Evidence of end organ damage.
c) Unacceptable risk of future cardiovascular risk or lifetime incidence of ESRD.
DIABETES MELLITUS
1. All potential living kidney donors must have a fasting plasma glucose level checked. FPG between 6.1-6.9 mmol/L is indicative of an impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be undertaken.
2. Prospective donors with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT.
3. Diabetics can be considered for kidney donation after a thorough assessment:
a) No end organ damage.
b) Optimally managed cardiovascular risk factors(HTN, obesity and hyperlipidemia).
CARDIOVASCULAR EVALUATION
1. No evidence to support the routine use of stress testing in the assessment of the potential donor at low cardiac risk.
2. For higher risk potential donors, stress testing is recommended by whichever method is locally available or by CT calcium scoring.
3. MDT is recommended.
PROTEINURIA
1. Urine protein excretion needs to be quantified in all potential living donors.
2. A urine albumin/creatinine ratio (ACR) performed on a spot urine sample is the recommended screening test, although urine protein/creatinine ratio (PCR) is an acceptable alternative.
3. ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day or protein excretion >500 mg/day represent absolute contraindications to donation.
4. Moderate proteinuria(ACR 3- 30 mg/mmol, PCR 15-50 mg/mmol, 24 h UrPr 150-500 mg) is a relative contraindication to donation.
NON-VISIBLE HAEMATURIA
1. All potential living donors must have reagent strip (dipstick) urinalysis performed on at least two separate occasions.
2. Two or more positive tests, including trace positive, is considered as persistent non-visible haematuria (PNVH).
3. If PNVH is present, perform urine culture and renal imaging to exclude common urologic causes including infection, nephrolithiasis and urothelial carcinoma.
4. If no cause is found, perform cystoscopy in patients age >40 years to exclude bladder pathology.
5. If no cause is found and the donor still wishes to donate, then a kidney biopsy is recommended if haematuria is 1+ or greater on dipstick testing.
6. Glomerular pathology precludes donation, with the possible exception of thin basement membrane disease.
7. For donors with persistent asymptomatic non-visible haematuria (PANVH) and a family history of haematuria or X-linked Alport syndrome, a renal biopsy and referral to a clinical geneticist are recommended.
PYURIA
· Prospective donors with pyuria can only be considered for donation if it can be demonstrated that the pyuria is due to a reversible cause, such as an uncomplicated urinary tract infection.
INFECTION IN THE PROSPECTIVE DONOR
1. Screening for HBV, HCV and HIV infection must be repeated within 30 days of donation.
2. Contraindication to LDKT: Active HBV and HCV infection(donors with evidence of active viral replication may be considered under some circumstances), HIV or human T lymphotrophic virus (HTLV) infection.
3. The CMV and EBV status must be determined before transplantation.
NEPHROLITHIASIS
1. The potential donor with limited history of previous stone or small stone in the absence of metabolic abnormality, can be considered for donation.
2. In unilateral small kidney stone, stone-bearing kidney can be considered for donation if vascular anatomy and split kidney function permit.
HAEMATOLOGICAL DISEASE
1. Donor anaemia needs to be investigated and treated before donation.
2. A haemoglobinopathy screen must be carried out if indicated by the full blood count. Careful consideration needs to be given to the use of potential donors with haemoglobinopathies.
i) SCD and transfusion dependent thalassaemia (TDT) are an absolute contraindication to LDKT.
ii) Compound heterozygote with Hb S (e.g; Hb SC, Hb ES, etc): Such patients behave like patients with sickle cell disease and therefore should not be accepted as living kidney donors.
iii) non-transfusion dependent thalassaemia (NTDT) can be considered for living kidneydonation.
iv) LKD is acceptable in mild form of red cell membrane disorder (spherocytosis, elliptocytosis and inherited hemolytic anemia).
v) MGUS per se with caution can be considered as living kidney donors.
vi) MDS should be considered a strong contraindication to donation.
vii) VTE and clotting disorder represent a relative contraindication to donation.
FAMILIAL RENAL DISEASE
1. When the cause of ESRD is an inherited condition, genetic testing if available are recommended.
2. Genetic testing may aid the prediction of the likelihood of disease recurrence in the transplanted kidney(e.g. aHUS and SRNS).
3. Alport syndrome(AR); carriers with no renal abnormality by age 45 might be considered as donors in a similar manner to X-linked Alport syndrome.
DONOR MALIGNANCY
1. Active malignant disease is a contraindication to living donation.
2. Bilateral AML and AML >4 cm generally preclude living kidney donation.
SURGERY: TECHNICAL ASPECTS, DONOR RISK AND PERI-OPERATIVE CARE
1. Work-up for living kidney donation must include detailed imaging confirming the vascular anatomy of both donor kidneys and information about the renal parenchyma and collecting systems. Either CTA or MRA can be used as current evidence indicates little difference in accuracy.
2. Multiple renal arteries or kidneys with anatomical anomalies are not absolute contraindications to donation.
3. Pre- and peri-operative intravenous fluid replacement with Hartmann’s solution is preferred to 0.9% Saline.
4. Laparoscopic donor surgery (fully laparoscopic or hand-assisted) is the preferred technique for living donor nephrectomy.
HISTOCOMPATIBILITY TESTING FOR LIVING DONOR KIDNEY TRANSPLANTATION
1. The initial assessment of donor and recipient histocompatibility status must be undertaken at an early stage in living donor kidney transplant work-up to avoid unnecessary and invasive clinical investigation.
2. Antibody screening is especially important when potential living donor transplant recipients undergo reduction or withdrawal of immunosuppression.
How these guidelines are different from the guidelines you follow at your workplace?
In our practice we do not routinely screen for :
· HTLV 1/2 Ab
· Treponema pallidum Ab
· EBV IgG
· Toxoplasma gondii IgG
The split kidney function is not considered in the workup of KT as potential donor with questionable kidney size or function will be excluded from donation list. The split kidney function can be performed in the general nephrology practice to help diagnosing and treating patients in regards to possible surgical intervention.
This is comprehensive guidance for kidney donation.This include full assessment for the donor for medical, surgical and immunological .
Also it include Quality of evidence and reads recommendation as for KDIGO guidelines.
We need to conduct full donor assessment in MDT along with full investigation better to avoid the invasive procedure until final step-in parallel with the recipient.
Donor assessment should start early better preemptive when the recipient expected to begin RRT. Most center go for ABO and HLA compatibility .
Kidney function assessment by eGFR and mGFR equation ,the consent should include possibility of small risk ESRD in the future .
Young donor <18 years can be in rare and exceptional situation ,as no valid consent and autonomy.
Older donor is accepted provided they are fully assessed for pre operative risk .
Obesity: BMI 25to 30kg/m2 can donate .
BMI 30 to 35 kg/m2counselled about the risk of kidney disease ,CVD,respectively.
HTN; possible donation case of no end organ damage and on 1 or 2 anti HTN but he will need regular BP post donation as there is risk of 7% of HTN post donation.Lifestyle modification to reduce the risk of CVD post donation.
Diabetes: if high fasting of high risk for diabetes need to do OGTT. he can proceed with donation provided he is not obese,HTN,or hyperlipedeamic.
CVS;LOW RISK NO NEED for stress test while high risk need stress testing and Cardiology assessment .
Spot urine albumin/creatinine ration:
ACR>30mg/mmol or PCR>50mg/mmol absolute contraindication for donation.
Persistent hematuria in two occasion urine samples will need for further urological assessment including cystoscopy if he is above 40 years .if no clear cause ,the kidney biopsy is recommended.
Kidney ston: unilateral and uncomplicated in the absence of metabolic abnormality not prevent donation. Split eGFR May be need it
Anemia: should be investigated thoroughly .
Genetice and family history of kidney disease need. full assessment before donation
Active malignancy is absolute contraindication.
The donor should have detailed peri and post operative periods ,and he needs to be under regular longterm follow up
Please summarise these guidelines in your own words:
===============================================
The evaluation of potential living donors is systemic and multi resources approach for the sake of their general health and safety, and for better out come for the recipient.
ABO Blood Grouping and Crossmatching Test
ABO blood grouping is the first to be done to identify people can donate to specific recipient, and to proceed for evaluation of donor and recipient as well.
After getting the compatible ABO group, Human leucocyte antigen (HLA) transplant offers the best opportunity for success.
In cadaveric and paired exchange donation, these tests can afford better allocation of the kidney to the specific donors.
Medical Assessment:
Points of Particular Importance when Undertaking Clinical Examination of a Potential Kidney Donor
Blood pressure, Pulses.
Hight and weight , BMI.
Head and neck exam including lymphnode exam.
Cardio-respiratory exam.
Abdominal exam
Musculoskeletal exam.
Examination / history of regular self-examination of the breasts.
Mental health evaluation and assessment.
Routine Screening Investigations for the Potential Donor
Urine:
Dipstick for protein, blood and glucose, Microscopy, culture and sensitivity (twice at least)
Evaluation for protein excretion (protein and albumin/creatinine ratio spot urine or by 24 hours urine protein excretion), If ACR >30 mg/mmol, PCR >50 mg/mmol, or protein excretion >500 mg/day the donor should be excluded form donation.
If ACR 3-30mg/mmol, PCR 15-50 mg/mmol or 24-hour urine protein 150-500 mg/day, the donor should be informed that there may be a risk of increased albuminuria after donation.
Evaluation of hematuria:(should be repeated twice) by urine dipstick (B1), if present, urine C/S & renal imaging to exclude infection, stone and cancer. (A1)
Bladder pathology should be excluded by cystoscopy if age >40. (B1)
Kidney biopsy considered if +ve dipstick and no cause is found. (B1)
Glomerular disease other than TBM disease is a contraindication for donation. (B1)
FH of haematuria or X-linked Alport syndrome, biopsy (B1) & genetic consultation recommended. (B2).
24-hr urine for creatinine clearance.
Blood:
CBC , coagulation profile( PT,APTT,INR), in some cases after taking the history can do work up for thrombophilia, blood film .. etc
Kidney function test and serum electrolytes:
Creatinine serum, eGFR, and creatinine clearance, Na, K, Ca, Po4, uric acid and magnesium.
Liver function test:
ALT,AST, Alkaline phosphatase, albumin…etc
Fasting glucose and lipid profile and HbA1C
Thyroid function test, and pregnancy test if needed.
Virology and infection screen
Hepatitis B and C, HIV, Cytomegalovirus, Epstein-Barr virus, Toxoplasma, Syphilis
Varicella zoster virus (if recipient seronegative)…etc
Cardiorespiratory system
Chest X-ray
ECG
ECHO (where indicated
Cardiovascular stress test (if indicated)
Assessment of Donor Renal Function
The safe eGFR at which the patient can donate his kidney is ≥ 80 mL/min/1.73m2 for donors ≥ 30 years and ≥ 90 mL/min/1.73 m2 for those <30 years old.
Donor Age
Old age alone is not an absolute contraindication to donation, but they usually need a thorough medical evaluation to ensure they are suitable. (A1)
Both donor and recipient must be aware that older donor may be at greater risk of peri-operative complications and the graft survival may be less, particularly evident with donors >60 years of age. (B1).
DONOR OBESITY
Hypertension in the donor
Blood pressure must be checked on a minimum of 2 occasions, ABPM or home monitoring if any high reading BP or the donor is on antihypertension. (C2)
BP<140/90 mmHg is accepted for donation. (C1)
Donors must be aware of risk of donation-related HTN. Annual BP measurment is a must, (C1)
Donors with mild-moderate HTN ( <140/90 mmHg &/or 135/85 mmHg with ABPM or home monitoring) on <3 anti-HTN drugs & no end organ damage are accepted. (C1)-Donors with HTN excluded if: (C1)
DIABETES MELLITUS
FBS (<6.1-6.9 mmol/l) A fasting glucose of >7.0 mmol/L is diabetes, between 6.1 and 6.9 mmol/L is an impaired fasting glucose (IFG).
IFG is an indication for a standard 2-hour oral glucose tolerance test (OGTT).
OGTT(A 2-hour glucose value of equal to or greater than 11.1 mmol/L indicates diabetes, A 2-hour value between 7.8 and 11.1 mmol/L indicates impaired glucose tolerance (IGT)
HbA1C (less than 6%)
Urine albumin excretion
Family history if present thaey are at high risk to develop DM.
unless end organ damage or CV risk factors or well managed, can be accepted for donation after good assessment.
NEPHROLITHIASIS
Kidney stone is not a contraindication to donation if no significant metabolic abnormality. Long-term follow up needed. (C2)
HAEMATOLOGICAL DISEASE
diagnosing and treating anemia in the donor before donation is recommended. (A1)
FAMILIAL RENAL DISEASE
Family history of renal disease checked in all recipients, to help in the diagnosis for the recipient and show inheritance mode & identify at risk relatives. (A1)
Genetic testing is done for donor when recipient kidney disease is an inherited. (A1)
Clinical and laboratory genetics required in special setting(ie ADPKD). (B1)
DONOR MALIGNANCY
Exclude occult cancer before donation, particularly if age >50. (B1)
Active cancer is contraindication to donate; successfully treated low-grade disease may donate after careful evaluation and discussion. (B1)
Each case should be referred to specialists (ie hematologist , urologist…etc (B2)
How these guidelines are different from the guidelines you follow at your workplace?These guidelines are the same we use in our service, but no psychatric and social worker involved in our service which i think is important.
I. Guidelines for Living Donor Kidney Transplantation
– The evaluation of potential living donors is resource intensive and a proportion of those who volunteer as donors will not be suitable to proceed for a variety of clinical and non-clinical reasons and help to maximise benefit, minimise risk and manage expectations for donors, recipients
and their families.
– The recipient’s suitability for transplantation ensured ahead of donor assessment.
– To avoid unnecessary delay, non-invasive assessment of the donor is done while recipient is undergoing additional assessment. (Not graded).
– Minimize any inconvenience & barriers in the donor assessment. (Not graded).
– Donor assessment must be focused, logical and appropriate.
– Unsuitable donors identified at an stage. (Not graded)
– Donors found unsuitable given support & follow-up.( Not graded).
– An agreed donor assessment protocol tailored to the needs of the individual & available resources.( Not graded)
– In pre-emptive transplantation, secure enough time for more than one donor to be assessed if needed .(B2)
– ABO Blood Grouping and Crossmatching Test
– ABO blood grouping is an important early screening test as it identifies if a (directed) donor is blood group compatible or incompatible with his/her intended recipient at an early stage.
– A compatible ABO blood group and human leucocyte antigen (HLA) transplant offers the best opportunity for success. (A1).
– Alternatively, in non-directed donation, it provides information that will be used to allocate the kidney to a suitable recipient.
– ABO blood group testing may be undertaken by the GP, nephrologist, specialist nurse, or at a transplant assessment clinic.
– Medical Assessment:
-History of peripheral oedema
-Gout
Nephrolithiasis-
-Hypertension
-Diabetes mellitus, including family history
-Ischaemic heart disease/peripheral vascular disease/other atherosclerosis
Cardiovascular risk factors-
Thromboembolic disease-
-Sickle cell and other haemoglobinopathies
-Weight change
-Change in bowel habit
-Previous jaundice
-Previous or current malignancy
Systemic disease which may involve the kidney-
-Chronic infection such as tuberculosis
Family history of a renal condition that may affect the donor-
Smoking-
-Current or prior alcohol or drug dependence
Mental health history-
Obstetric history-
-Residence abroad
Previous medical assessment e.g. for life insurance-
Previous anaesthetic problem-
-History of back or neck pain and trauma
-Results of national screening programme tests e.g. cervical smear, mammography,
-colorectal screening.
History with respect to Transmissible Infection
Previous illnesses
Jaundice or hepatitis.-
Malaria.
Previous blood transfusion.-
Tuberculosis / atypical mycobacterium.-
Family history of tuberculosis-
-Family history of Creutzfeldt-Jakob disease, previous treatment with natural growth hormone, or undiagnosed degenerative neurological disorder.
-Specific geographical risk factors: e.g. fungi and parasites, tuberculosis, hepatitis, malaria, worms.
-Increased risk of HIV, HTLV1 and HTLV2, Hepatitis B and C infection.
Haemophiliac or sexual partner of haemophiliac-
-High risk sexual behaviour
-History of infectious hepatitis or syphilis
History of intravenous drug use-
-Tattoo or skin piercing within last 6 months
Sexual partner of an individual with positive serology-
Sexual partner of drug addict.
Points of Particular Importance when Undertaking Clinical Examination of a Potential Kidney Donor
-Potential Kidney Donor
Abdominal fat distribution-
Blood pressure-
-Body mass index
Dipstick urinalysis-
-Evidence of self-harm
Examination for abdominal masses or herniae-
Examination for scars or previous surgery-
-Examination for lymphadenopathy
-Examination / history of regular self-examination of the breasts.
-Examination / history of regular self-examination of the testes
Examination of the cardiovascular and respiratory systems-
Mental health-
Routine Screening Investigations for the Potential Donor
Urine
Blood
-Coagulation screen (PT and APTT)
-Haemoglobinopathy screen (where indicated)
Creatinine, urea and electrolytes
-Bone profile (calcium, phosphate, albumin and alkaline phosphatase Urate.
Fasting plasma glucose
Glucose tolerance test (if family history of diabetes or fasting plasma glucose >5.6 mmol/L)
-Fasting lipid screen (if indicated )
Thyroid function tests (if strong family history)-
Pregnancy test (if indicated)-
Virology and infection screen
Hepatitis B and C
HIV
HTLV1 and 2 (if appropriate)
Cytomegalovirus
Epstein-Barr virus
Toxoplasma
Syphilis
Varicella zoster virus (where recipient seronegative)
HHV8 (where indicated)
Malaria (where indicated)
Trypanosoma cruzi (where indicated)
Schistosomiasis (where indicated-)
Cardiorespiratory system
Chest X-ray
ECG
ECHO (where indicated
Cardiovascular stress test (as routine or where indicated)
Assessment of Donor Renal Function
The most commonly performed by an estimate
of glomerular filtration rate (eGFRcr) using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI).
-Safe threshold level for kidney donation (the least GFR at which the patient can safely donate his kidney if there is no other contraindications) is ≥ 80 mL/min for donors ≥ 30 years and ≥ 90 mL/min/1.73 m2 for those <30 years old .
-Split kidney function help to assess the function of each kidney for the purpose of donation of the lower functioning kidney , it can be best done using 99mTcDMSA scanning which is indicated if there is >10% variation in kidney size or abnormal renal anatomy detected by CT scan .
Donor Age
· Old age alone is not an absolute contraindication to donation but the
medical work-up of older donors must be particularly rigorous to
ensure they are suitable. (A1)
· Both donor and recipient must be made aware that the older donor may
be at greater risk of peri-operative complications and that the function
and possibly the long-term survival of the graft may be compromised.
This is particularly evident with donors >60 years of age. (B1).
– Donors above 60 years of age need careful consideration with respect to the increased risk of peri-operative complications, existing comorbidities and residual function post-donation, and also the long-term transplant outcome in the recipient associated with reduced donor GFR and potential donor vasculopathy.
– Pre-donation cardio-respiratory function should be carefully assessed in older donors.
– DONOR OBESITY
– Healthy overweight (BMI 25-30 kg/m2) accepted as donors. (B1)
– Moderate obesity (BMI 30-35 kg/m2) carefully evaluated for CV, respiratory & kidney disease. (C2)
– Moderately obese donors counseled for higher perioperative risk. (B1)
– Moderately obese informed about the risk of kidney disease & to lose weight before & after donation. (B1)
-Donation discouraged in the very obese (BMI >35 kg/m2). (C1)
Hypertension in the donor
– Blood pressure must be checked on a minimum of 2 occasions. ABPM or home monitoring if BP is high, high normal or variable, or the donor is on antihypertension. (C2)
– BP<140/90 mmHg is accepted for donation. (C1)
– Donors must be aware of risk of donation-related HTN. Annual BP is a must, (C1)
– Donors with mild-moderate HTN ( <140/90 mmHg &/or 135/85 mmHg with ABPM or home monitoring) on <3 anti-HTN drugs & no end organ damage are accepted. (C1)
-Donors with HTN excluded if: (C1)
– BP is not <140/90 mmHg on 1 or 2 drugs
– End organ damage (retinopathy, LVH , proteinuria, previous CVD)
– High risk of future CVD or lifetime incidence of ESRD
– Donors encouraged to reduce risk of HTN & its complications pre-& pos-donation by lifestyle measures. (C1)
– Donors with pre-or pos-donation HTN are managed according to BSH guidelines. (B1)
DIABETES MELLITUS
FBS(between 6.1-6.9 mmol/l) A fasting venous plasma glucose of >7.0 mmol/L indicates diabetes.
2- Fasting plasma glucose values of between 6.1 and 6.9 mmol/L indicate
impaired fasting glucose (IFG).
3- IFG is an indication for a standard 2-hour oral glucose tolerance test (OGTT).
4- OGTT(A 2-hour glucose value of equal to or greater than 11.1 mmol/L indicates diabetes .
5- A 2-hour value between 7.8 and 11.1 mmol/L indicates impaired glucose tolerance (IGT)
6- HbA1C (less than 6%)
7- Urine albumin excretion
8- Family history
9- BMI <30 (control wieght).
10- Smoking
11- If family history for DM with +GTT (high risk develop DM)
12- If no target organ damage & other CV risk factors are well managed, can be accepted for donation after good assessment of the lifetime risk of CV & progressive renal disease in the presence of a single kidney. (Not graded).
CARDIOVASCULAR EVALUATION
– For donors at low cardiac risk, no evidence for routine use of stress testing. (C2)
– If H/O CVD, an exercise capacity of <4 METS or CVD risk factors, further pre-donation evaluation. (C2)
– Stress testing recommended in higher risk potential donors. (C2)
– Donors with higher CV & peri-operative risk evaluated by a MDT. (D2)
proteinuria
All potential donors should have screening for proteinuria using urine ACR or PCR, and if abnormal the result may be confirmed using 24 hours urinary protein
All potential donors should have screening for hematuria using urine analysis done in 2 separate occasions , if 2 positive test it is considered a case of positive non visible hematuria (PNVH).
NVH
-Urine dipstick (on 2 or more occasions) done in all donors. (B1)
– PNVH is present if 2 or more dipstick tests are positive. (B1)
– If PNVH present, urine C/S & renal imaging to exclude infection, stone & cancer. (A1)
– Bladder pathology excluded by cystoscopy if age >40. (B1)
– Kidney biopsy if +ve dipstick & no cause is found. (B1)
Glomerular disease other than TBM disease is a contraindication for donation. (B1)
– If PANVH & FH of haematuria or X-linked Alport syndrome, biopsy (B1) & genetic consultation recommended. (B2)
pyuria
Prospective donors found to have pyuria can only be considered for donation if it can be demonstrated that the pyuria is due to a reversible cause, such as an uncomplicated urinary tract infection. (C).
INFECTION IN THE PROSPECTIVE DONORS
– Screening to identify risks for the donor & recipient (risks of transmission). (B1)
– Active HBV & HCV infection are contraindications to donation. (B1)
– HIV or HTLV infection is an absolute contraindication to donation. (B1)
– HBV, HCV & HIV infection rechecked within 1 month donation. (Not graded)
– Dietary advice to avoid HEV infection, & screening HEV viraemia by NAT within 1 month of donation. (Not graded)
– CMV tested for donor & recipient before transplantation. If donor +ve & recipient -ve, must be counselled about the risk of post-transplant CMV disease. (B1)
– EBV done for donor & recipient. If donor +ve & recipient -ve, must be counselled about the risk of developing PTLD. (B1)
-Travel history (acquired endemic infections) & appropriate microbiological tests if indicated. (Not graded)
NEPHROLITHIASIS
– Kidney stone is not a contraindication to donation if no significant metabolic abnormality. Long-term follow up needed. (C2)
– Metabolic abnormalities detected discussed with a renal stone disease expert. (C2)
– Stone-bearing kidney is given for donation (the sound one left for the donor). (C2)
HAEMATOLOGICAL DISEASE
-Investigate & treat anemia in the donor before donation. (A1)
– A haemoglobinopathy screen in non-Northern European or indicated by FBC. (A1)
– If donor has haemoglobinopathies, donation considered with caution. (B1)
– For conditions not covered here, a hematologist consulted (Not graded)
FAMILIAL RENAL DISEASE
-Family history of renal disease checked in all recipients, to help in the diagnosis for the recipient and show inheritance mode & identify at risk relatives. (A1)
– Genetic and other appropriate testing are done for donor if the recipient kidney failure is an inherited disease. (A1)
– Clinical and laboratory genetics involved early to assess risk to family members & the use of appropriate genetic testing. (B1)
DONOR MALIGNANCY
– Exclude occult cancer before donation, particularly if age >50. (B1)
– Active cancer contraindicate donation; successfully treated low-grade disease may donate after careful evaluation & discussion. (B1)
– Incidental renal mass lesion referred to urology specialist. (A1)
– Imaging distinguish benign lesions (e.g. AML) or malignancy (e.g,RCC). Reviewed by a specialist uroradiologist. (C1)
– Bilateral AML and AML >4 cm preclude donation.
– Unilateral solitary AML <4 is not a contraindication.
– AML <1 cm may be accepted for donation.
– Kidneys with a single AML 1 to 4 cm can be donated depending on its position. (C1)
– Donors with an incidental small (<4 cm) appearing on imaging as a RCC must be seen & appropriately treated by a urologist. (D2)
SURGERY: TECHNICAL ASPECTS, DONOR RISK & PERI-OPERATIVE CARE
-Split function may be needed; the kidney with poorer function for donation(irrespective of vascular anatomy). (C2)
– Detailed imaging (CTA,MRA) of vascular anatomy of donor kidneys may be needed (B1)
= Structural abnormalities & multiple renal arteries are not absolute contraindications to donation. MDT evaluation. Is needed. (B2)
-Thrombo prophylaxis for all donors. Intraoperative mechanical compression, post-operative compression stockings, & LMW heparin. (A2)
– Donor surgery done or supervised by a surgeon with a good training in the technique. (C1)
– Pre-operative hydration improves CV stability during laparoscopic nephrectomy. (B2)
– Hartmann’s solution preferred to 0.9% Saline in Pre- & peri-operative fluid replacement. (B2)
– Laparoscopic nephrectomy is the preferred technique (quicker recovery, shorter hospital stay & less pain). Mini-incision surgery is preferable to standard open surgery. (B1)
– Clips not to be used to secure the renal artery during donor nephrectomy. (C2)
– “Enhanced recovery after surgery” (ERAS) programmes may benefit patients undergoing donor nephrectomy.(D2).
These guidelines served us in a lot of tips and advice
Guidelines for Living Donor Kidney Transplantation
Summary :
Kidney transplantation from a living donor, when available, is the treatment of choice for end stage kidney disease
Scope of the Guidelines:
include the ethical and medico-legal aspects of donor selection, medical and pre-operative donor evaluation, identification of high risk donors, the management of complications, and expected outcome.
DONOR EVALUATION:
The primary goal of the donor evaluation process is to ensure the suitability of the
donor and to minimise the risk of donation. This involves identifying contraindications to donation and potential clinical (physical and psychosocial) risks comprehensive evaluation for , potential donors must be assessed according to an evidence-based protocol includes multi-disciplinary team t and discussion. Investigations in a logical sequence to protected donor from unnecessary, particularly invasive, procedures.
the confidentiality of the donor achieved by ensuring that separate physicians and/or clinical teams assess the donor and recipient before donation and transplantation
ABO BLOOD GROUPING AND CROSSMATCH TESTING:
A compatible ABO blood group and human leucocyte antigen (HLA) transplant offers the best opportunity for success ABO blood grouping is an important early screening test as it identifies if a (directed) donor is blood group compatible or incompatible with his/her intended recipient at an early stage
MEDICAL ASSESSMENT:
History with respect to Transmissible Infection
Previous illnesses
Jaundice or hepatitis
Malaria
Previous blood transfusion
Tuberculosis / atypical mycobacterium
Family history of tuberculosis
Family history of Creutzfeldt-Jakob disease, previous treatment with natural growth
hormone, or undiagnosed degenerative neurological disorder
Specific geographical risk factors: e.g. fungi and parasites, tuberculosis, hepatitis,
malaria, worms
Increased risk of HIV, HTLV1 and HTLV2, Hepatitis B and C infection
Haemophiliac or sexual partner of haemophiliac
High risk sexual behaviour
History of infectious hepatitis or syphilis
History of intravenous drug use
Tattoo or skin piercing within last 6 months
Sexual partner of an individual with positive serology
Sexual partner of drug addict
Points of Particular Importance when Undertaking Clinical Examination of a Potential Kidney Donor
Abdominal fat distribution
Blood pressure
Body mass index
Dipstick urinalysis
Evidence of self-harm
Examination for abdominal masses or herniae
Examination for scars or previous surgery
Examination for lymphadenopathy
Examination / history of regular self-examination of the breasts
Examination / history of regular self-examination of the testes
Examination of he cardiovascular and respiratory systems
Mental health.
Routine Screening Investigations for the Potential Donor
Urine
Dipstick for protein, blood and glucose (at least twice)
Microscopy, culture and sensitivity (at least twice)
Measurement of protein excretion rate (ACR or PCR)
Blood
Haemoglobin and blood count
Coagulation screen (PT and APTT)
Thrombophilia screen (where indicated)
Sickle cell trait (where indicated)
Haemoglobinopathy screen (where indicated)
G6PD deficiency (where indicated)
Creatinine, urea and electrolytes
Isotopic or other reference test for measurement
Liver function tests
Bone profile (calcium, phosphate, albumin and alkaline phosphatase)
Urate
Fasting plasma glucose
Glucose tolerance test (if family history of diabetes or fasting plasma glucose
>5.6 mmol/L)
Fasting lipid screen (if indicated)
Thyroid function tests (if strong family history)
Pregnancy test (if indicated)
Virology and infection screen :
Hepatitis B and C
HIV
HTLV1 and 2 (if appropriate)
Cytomegalovirus
Epstein-Barr virus
Toxoplasma
Syphilis
Varicella
HHV8 (where indicated)
Malaria (where indicated)
Trypanosoma cruzi (where indicated)
Schistosomiasis (where indicated)
Cardiorespiratory system :
Chest X-ray
ECG
ECHO (where indicated)
Cardiovascular stress test (as routine or where indicated
ASSESSMENT OF RENAL FUNCTION:
Measurement of Renal Function
Ø Initial evaluation of donor candidates should be using estimated glomerular filtration rate (eGFR), expressed as mL/min/1.73m2 computed from a creatinine assay standardised to the International Reference Standard
DONOR AGE
Recommendations
Ø Old age alone is not an absolute contraindication to donation but the medical work-up of older donors must be particularly rigorous to ensure they are suitable
Ø Most programmes do not consider donors aged <18 years and >70 year groups
DONOR OBESITY:
Ø patients (BMI 25-30 kg/m2) proceed to kidney donation
HYPERTENSION IN THE DONOR:
blood pressure <140/90 mmHg is usually acceptable for donation. potential donors with hypertension are excluded from donation if:
Ø Blood pressure is not controlled to <140/90 mmHg on one or two antihypertensive drugs
Ø Evidence of end organ damage (retinopathy, left ventricular hypertrophy, proteinuria, previous cardiovascular disease)
Ø Unacceptable risk of future cardiovascular risk or lifetime incidence of ESRD
Management of Hypertension following Donor Nephrectomy
Hypertension will develop in at least 30% of patients following unilateral Nephrectomy
managed according to the standard guidelines of the British Hypertension Society
DIABETES MELLITUS
Recommendations
Ø All potential living kidney donors must have a fasting plasma glucose
level checked
Ø A fasting plasma glucose concentration between 6.1-6.9 mmol/L is indicative of an impaired fasting glucose impaired OGTT risks of developing diabetes after donation must be carefully considered diabetic nephropathy in a kidney donor is not common during the follow-up periods reported in the published literature
CARDIOVASCULAR EVALUATION:
There is no evidence to support cardiac stress testing or invasive testing in potential
donors at low cardiac risk.and exclusion of individuals at higher risk.
PROTEINURIA:
A urine albumin/creatinine ratio (ACR) performed on a spot urine sample is the recommended screening test, although urine protein/creatinine ratio (PCR) ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day or protein excretion >500 mg/day represent absolute contraindications to donation
HAEMATURIA:
Non-visible haematuria is a common finding in the general population, may indicate either urological or renal parenchymal disease, and must be carefully evaluated in prospective living kidney donors donors with persistent asymptomatic non-visible haematuria (PANVH) and a family history of haematuria or X-linked Alport
syndrome, a renal biopsy , and referral to a clinical geneticist are recommended
PYURIA:
The cause of the pyuria must be established before a potential donor proceeds for further assessment
INFECTION IN THE PROSPECTIVE DONOR:
Screening for infection in the prospective donor is essential to identify potential risks for the donor from previous or current infection and to assess the risks of transmission of infection to the recipient.
NEPHROLITHIASIS:
In the absence of a significant metabolic abnormality, potential donors with a limited history of previous kidney stones, or small renal stone(s) on imaging, may still be considered as potential kidney donors. Full counselling of donor and recipient is required along with access to appropriate long-term donor follow up.
In appropriate donors with unilateral kidney stone(s) the stone-bearing kidney can be considered for donation (if vascular anatomy and split kidney function permit) in order to leave the donor with a stone-free kidney after donation
HAEMATOLOGICAL DISEASE
Donor anaemia needs to be investigated and treated before donation.
FAMILIAL RENAL DISEASE:
All potential transplant recipients must have a detailed family history recorded and confirmation where possible of the diagnosis in other family members with known kidney disease. This may aid diagnosis for the recipient, clarify any mode of inheritance and identify at risk relatives.
DONOR MALIGNANCY
Careful history taking, clinical examination and investigation of potential donors are essential to exclude occult malignancy before kidney donation, particularly in older (age >50 years) donors
SURGERY:
TECHNICAL ASPECTS, DONOR RISK AND PERI-OPERATIVE CARE:
Work-up for living kidney donation may include direct or indicative evaluation of split renal function with the kidney with poorer function selected for nephrectomy irrespective of vascular anatomy
HISTOCOMPATIBILITY TESTING FOR LIVING DONOR KIDNEY
TRANSPLANTATION:
Initial assessment of donor and recipient histocompatibility status must be undertaken at an early stage in living donor kidney transplant work-up to avoid unnecessary and invasive clinical investigation
EXPANDING THE DONOR POOL:
from living donors to be shared across the UK to maximise the number of transplant
opportunities and include:
Paired/pooled donation
Altruistic donor chains
DONOR FOLLOW-UP AND LONG-TERM OUTCOME:
Counselling and consent of potential living kidney donors must include acknowledgement that the baseline risk of ESRD is increased by donation
Annual review to include assessment of:
General health & lifestyle
Wound +/- complications
Medication
Renal profile
Full blood count
Dipstick urinalysis +/- mid-stream urine +/- albumin/creatinine ratio
Blood pressure; referral to GP for 24 hr ABPM / treatment if indicated
Weight & BMI
LIVING DONOR KIDNEY TRANSPLANTATION IN CHILDREN:
Ø Pre-emptive living related renal transplantation is the gold standard therapy for children with end-stage renal disease.
Ø The aim should be for children to receive a renal transplant from a blood group compatible well-matched donor, although ABO and/or HLA incompatible renal transplantation is feasible in children
Ø children who are ≥10 kg in weight are suitable to receive a kidney from an adult living donor
children with Stage 4 and 5 chronic kidney disease (CKD) should be assessed by a multi-disciplinary team, including a paediatric nephrologist, transplant surgeon, anaesthetist and urologist (where appropriate) prior to transplantation.
Donor Selection:
Any suitable adult may be considered as a potential donor,
How these guidelines are different from the guidelines you follow at your workplace:
There are some different :
We did not do split kidney function for donor
Regarding screening against infection :
We screen against :
HIV,HBV.HCV,CMV,TB,RECENTLEY PCR FOR COVID 19.
I. Guidelines for Living Donor Kidney Transplantation
Please summarise these guidelines in your own words
Legal:
Legislative acts regulate transplantation centers (& activities) (not graded).
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ETHICS
Professionals must acknowledge moral & issues. (Not graded)
Donors benefit & safety is over the needs of the potential recipient. (Not graded)
Independent clinicians responsible for the donor & the recipient. (Not graded)
———————————
Supporting & informing the potential donor
Donor given relevant information about donation (benefits & risks). (B1)
Independent assessors of the donor & recipient.(Not graded)
Confidentiality discussed at the start (information of recipient & donor). Relevant clinical information shared across the team to optimize care (B1)
If the recipient is not willing to disclose information, the team must decide the way to provide donation risks & benefits without specific medical details. (Not graded)
Separate teams for donor & recipient is best practice, but all co-ordinate the process without preaching the independence of either donor or recipient.
A donor advocate should assist donor to make autonomous decision. (B1)
Support for donor, recipient & family( specialist psychiatric/psychological services)(B1)
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DONOR EVALUATION:
The recipient’s suitability for transplantation ensured ahead of donor assessment. To avoid unnecessary delay, non-invasive assessment of the donor is done while recipient is undergoing additional assessment. (Not graded)
Minimize any inconvenience & barriers in the donor assessment. (Not graded)
Donor assessment must be focused, logical & appropriate.Unsuitable donors identified at an stage. (Not graded)
Donors found unsuitable given support & follow-up.( Not graded)
An agreed donor assessment protocol tailored to the needs of the individual & available resources.( Not graded)
In pre-emptive transplantation, secure enough time for more than one donor to be assessed if needed .(B2)
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ABO & XM Testing
ABO & HLA-c transplant offers the best chance for success. (A1)
Alternatives ( PKD & incompatible TX) discussed if ABO-i or HLA-i. (A1)
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ASSESSMENT OF RENAL FUNCTION
eGFR for initial evaluation of the donor. (B1)
GFR then be assessed by mGFR(Cl of 51Cr-EDTA, 125iothalamate or Iohexol). (B1)
Split function (99mTcDMSA) if >10% variation in kidney size or strucural abnormality. (C1)
————————————-
GFR Thresholds for Donation
mGFR should predict that post-donation GFR remains within the age & gender -specific normal range within the donor’s lifetime. (B1)
The risk ESRD post-donation is no higher than that of the general population. However, the donor must be informed there is a very small absolute increased lifetime risk of ESRD post-donation. (D2)
Approval of donor with below the advisory GFR level or who have other risk factors for the developing ESRD should be based on the individual predicted lifetime incidence of ESRD. (D2)
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Monitoring of Kidney Donor
Lifelong annual assessment (creatinine, urine protein excretion & BP). (B1)
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DONOR AGE
Old age is not a contraindication, but well assessed to ensure suitability. (A1)
Donor & recipient must be aware of the greater risk of peri-operative complications in older donors & that the function & survival of the graft may be lower (donors >60 years). (B1)
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DONOR OBESITY
Healthy overweight (BMI 25-30 kg/m2) accepted as donors. (B1)
Moderate obesity (BMI 30-35 kg/m2) carefully evaluated for CV, respiratory & kidney disease. (C2)
Moderately obese donors counseled for higher perioperative risk. (B1)
Moderately obese informed about the risk of kidney disease & to lose weight before & after donation. (B1)
Donation discouraged in the very obese (BMI >35 kg/m2). (C1)
———————————
HYPERTENSION IN THE DONOR
BP must be checked on a minimum of 2 occasions. ABPM or home monitoring if BP is high, high normal or variable, or the donor is on ant-hypertension. (C2)
BP<140/90 mmHg is accepted for donation. (C1)
Donors must be aware of risk of donation-related HTN. Annual BP is a must, (C1)
Donors with mild-moderate HTN ( <140/90 mmHg &/or 135/85 mmHg with ABPM or home monitoring) on <3 anti-HTN drugs & no end organ damage are accepted. (C1)
Donors with HTN excluded if: (C1)
o BP is not <140/90 mmHg on 1 or 2 drugs
o End organ damage (retinopathy, LVH , protei-nuria, previous CVD)
o High risk of future CVD or lifetime incidence of ESRD
Donors encouraged to reduce risk of HTN & its complications pre-& pos-donation by lifestyle measures. (C1)
Donors with pre-or pos-donation HTN are managed according to BSH guidelines. (B1)
———————————
DIABETES MELLITUS
A FBG checked in all potential LKD. (B1)
If IFG (6.1-6.9 mmol/L), OGTT should be done. (B1)
OGTT done if high risk of type 1 DM (FH, H/O GD, ethnicity or obesity). (B1)
If IFG &/or IGT on OGTT, risks of diabetes after donation considered. (B1)
Diabetes risk calculator considered in discussion of potential kidney donation. (B2)
Diabetes as potential kidney donors: evaluate risks & benefits. If no target organ damage & other CV risk factors are well managed, can be accepted for donation after good assessment of the lifetime risk of CV & progressive renal disease in the presence of a single kidney. (Not graded)
———————————
CARDIOVASCULAR EVALUATION
For donors at low cardiac risk, no evidence for routine use of stress testing. (C2)
If H/O CVD, an exercise capacity of <4 METS or CVD risk factors, further pre-donation evaluation. (C2)
Stress testing recommended in higher risk potential donors. (C2)
Donors with higher CV & peri-operative risk evaluated by a MDT. (D2)
———————————
PROTEINURIA
Quantification of urine protein excretion should be done in living donors. (B1)
Spot urine ACR is the screening test (UPCR also accepted). (A1)
Donation contraindicated if ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/d or protein excretion >500 mg/day. (C2)
Moderate albuminuria (ACR 3-30 mg/mmol) & protei-nuria (PCR 15-50 mg/mmol or urine protein 150-500 mg/d) are relative contraindication to donation (b/c the risk of CKD & CV morbidity increase progressively in these cases). (C2)
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NVH
Urine dipstick (on 2 or more occasions) done in all donors. (B1)
PNVH is present if 2 or more dipstick tests are positive. (B1)
If PNVH present, urine C/S & renal imaging to exclude infection, stone & cancer. (A1)
Bladder pathology excluded by cystoscopy if age >40. (B1)
Kidney biopsy if +ve dipstick & no cause is found. (B1)
Glomerular disease other than TBM disease is a contraindication for donation. (B1)
If PANVH & FH of haematuria or X-linked Alport syndrome, biopsy (B1) & genetic consultation recommended. (B2)
——————————–
PYURIA
If reversible cause (e.g, uncomplicated UTI), not contraindication to donate. (C1)
———————————-
INFECTION IN THE PROSPECTIVE DONORS
Screening to identify risks for the donor & recipient (risks of transmission). (B1)
Active HBV & HCV infection are contraindications to donation. (B1)
HIV or HTLV infection is an absolute contraindication to donation. (B1)
HBV, HCV & HIV infection rechecked within 1 month donation. (Not graded)
Dietary advice to avoid HEV infection, & screening HEV viraemia by NAT within 1 month of donation. (Not graded)
CMV tested for donor & recipient before transplantation. If donor +ve & recipient -ve, must be counselled about the risk of post-transplant CMV disease. (B1)
EBV done for donor & recipient. If donor +ve & recipient -ve, must be counselled about the risk of developing PTLD. (B1)
Travel history (acquired endemic infections) & appropriate microbiological tests if indicated. (Not graded)
——————————–
NEPHROLITHIASIS
Kidney stone is not a contraindication to donation if no significant metabolic abnormality. Long-term follow up needed. (C2)
Metabolic abnormalities detected discussed with a renal stone disease expert. (C2)
Stone-bearing kidney is given for donation (the sound one left for the donor). (C2)
———————————-
HAEMATOLOGICAL DISEASE
Investigate & treat anemia in the donor before donation. (A1)
A haemoglobinopathy screen in non-Northern European or indicated by FBC. (A1)
If donor has haemoglobinopathies, donation considered with caution. (B1)
For conditions not covered here, a haematologist consulted (Not graded)
——————————–
FAMILIAL RENAL DISEASE
FH of renal disease checked in all recipients, to help in the diagnosis for the recipient & show inheritance mode & identify at risk relatives. (A1)
Genetic & other appropriate testing are done for donor if the recipient kidney failure is an inherited disease. (A1)
Clinical & laboratory genetics involved early to assess risk to family members & the use of appropriate genetic testing. (B1)
———————————-
DONOR MALIGNANCY
Exclude occult cancer before donation, particularly if age >50. (B1)
Active cancer contraindicate donation; successfully treated low-grade disease may donate after careful evaluation & discussion. (B1)
Incidental renal mass lesion referred to urology specialist. (A1)
Imaging distinguish benign lesions (e.g. AML) or malignancy (e.g,RCC). Reviewed by a specialist uroradiologist. (C1)
Bilateral AML & AML >4 cm preclude donation.
Unilateral solitary AML <4 is not a contraindication.
AML <1 cm may be accepted for donation.
Kidneys with a single AML 1 to 4 cm can be donated depending on its position. (C1)
Donors with an incidental small (<4 cm) appearing on imaging as a RCC must be seen & appropriately treated by a urologist. (D2)
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SURGERY: TECHNICAL ASPECTS, DONOR RISK & PERI-OPERATIVE CARE
Split function may be needed; the kidney with poorer function for donation(irrespective of vascular anatomy). (C2)
Detailed imaging (CTA,MRA) of vascular anatomy of donor kidneys may be needed (B1)
Structural abnormalities & multiple renal arteries are not absolute contraindications to donation. MDT evaluation. Is needed. (B2)
Thromboprophylaxis for all donors. Intraoperative mechanical compression,post-operative compression stockings, & LMW heparin. (A2)
Donor surgery done or supervised by a surgeon with a good training in the technique. (C1)
Pre-operative hydration improves CV stability during laparoscopic nephrectomy. (B2)
Hartmann’s solution preferred to 0.9% Saline in Pre- & peri-operative fluid replacement. (B2)
Laparoscopic nephrectomy is the preferred technique (quicker recovery, shorter hospital stay & less pain). Mini-incision surgery is preferable to standard open surgery. (B1)
Clips not to be used to secure the renal artery during donor nephrectomy. (C2)
“Enhanced recovery after surgery” (ERAS) programmes may benefit patients undergoing donor nephrectomy.(D2
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How these guidelines are different from the guidelines you follow at your workplace?
These guidelines do not differ much from the guidelines used in our transplant center; however because of logistic issues, lack of enough resources, and non-availability of some tests (e.g, genetic testing), it is not uncommon for us to exclude many potential donors (who would be otherwise good donors ) from donation.
Summary
3 prerequisites should be met before transplantation: Consent taken from donor, no reward for donation and acceptance report from independent assessor of the donor and recipient
Donors are either directed to a specific recipient, non-directed, directed altruistic donation (the donor and recipient either know each other but no intimate relation between each other or the donor and recipient never met before) or go into paired donation
Mental health of potential altruistic donors should be assessed by experienced clinician
Safety of the donor is the first priority and should be taken in consideration regardless recipient benefit
Donor should be provided adequate information about the safety and the outcome of donation and should have time to decide
Confidentiality should be ensured
If the donor has contraindications (absolute or relative) or does not meet center specific criteria he/she should be offered a second opinion by other transplant center
Before assessment of the donor (if directed to a specific recipient), transplant recipient should be assessed first for the possibility of transplantation and if fit donors should be evaluate as early as possible in order to have time for more donors if they did not match.
Discussion between donor and recipient is started once GFR of the recipients is below 20 mL/min or if the recipient is expected to have a RRT within 1-1.5 years
Donor evaluation should take around 18 weeks, first 2 weeks (discussion), second 2 weeks (history, examination, investigations including HLA typing and ABO, cross matching), 1 month for time planning, 2 weeks for the feedback of the donor , 6 weeks for final preoperative discussion , 1 week before transplantation repeat final cross match and routine preoperative investigations, operation in week 18
If the donor is fit, he/she should be educated about the risk and risk factors that should be controlled to prevent ESRD, gestational HTN and preeclampsia (in young woman in child bearing period) and the patient should be offered an appropriate follow up plan after donation and if not fit they should be informed as soon as possible
ABO and HLA compatible transplantation provide the best results, if there is ABO or HLA incompatibility the patient should be offered one of the following choices either KPD or desensitization which should be done in experienced center
Albuminuria occur more commonly after donation and there is a slight increase in the risk of ESRD observed in donors. The risk of ESRD increase in current or former smoker, obese, diabetic, African- American and patients with albuminuria or renal impairment
The preferred option for assessment of kidney functions is estimated GFR using serum creatinine (CKD-EPI) this is a primary to exclude donors with evident CKD , this test should be confirmed by measuring creatinine clearance using 24 hours urine
Safe threshold level for kidney donation (the least GFR at which the patient can safely donate his kidney if there is no other contraindications) is ≥ 80 mL/min for donors ≥ 30 years and ≥ 90 mL/min/1.73 m2 for those <30 years old
Split kidney function help to assess the function of each kidney for the purpose of donation of the lower functioning kidney , it can be best done using 99mTcDMSA scanning which is indicated if there is >10% variation in kidney size or abnormal renal anatomy detected by CT
Old age > 60 years is not a contraindication to donation but he/she should be evaluated rigorously and donor and recipient should be informed with the increase in risk of perioperative complications
Obese with BMI 25-30 kg/m2 can proceed to donation safely, those with BMI 30-35 kg/m2 can proceed to donation if they accept the peri-operative and long term risk associated with obesity and are willing to lose weight, patients with BMI >35 kg/m2 should be excluded form donation
Risk factors for the development of HTN after kidney donation includes higher BP before donation, African American and Hispanic ethnity, obesity, Elderly, these patients should be educated about the risk of developing hypertension after donation
Evaluation of BP before kidney donation
Guidelines for safe donation (regarding BP)
Treatment of hypertension post donation
All donors should have fasting BG, OGTT (if there are risk factors such as obesity, positive family history of DM, history of gestational DM, African-American) and HBA1c may be also used to identify the donor as normal, impaired fasting, IGT or diabetic
Potential donors with impaired fasting or IGT can donate after education about the risk of developing DM while having single kidney and after addressing all cardiovascular risk factors (smoking, hyperlipidemia, hypertension)
Potential donors with DM can donate after education about the risk of DM while having single kidney and after addressing all cardiovascular risk factors provided that it is controlled and no target end-organ damage
High cardiovascular risk patients should be evaluated by noninvasive testing either stress echo or cardiac scintigraphy, or less commonly CT angiography and if positive, patient should be referred for cardiology evaluation and possible angiography
Low risk patients can proceed to transplantation after normal resting ECG, ECHO
All potential donors should have screening for proteinuria using urine ACR or PCR, and if abnormal the result may be confirmed using 24 hours urinary protein
All potential donors should have screening for hematuria using urine analysis done in 2 separate occasions , if 2 positive test it is considered a case of positive non visible hematuria (PNVH).
PNVH should be evaluated by urine culture, imaging, if free, cystoscopy should be done (if donor is above 40 years) and if normal renal biopsy should be done and any form of glomerulonephritis found is a contraindication to transplantation except TBMD
Persistent sterile pyuria is a contraindication for donation, while transient pyuria due to UTI can donate
Donor should be screened for HBV, HCV, HIV and virology should be repeated after 1 month of donation. and Active HBV, HCV infection, presence of HIV or HTLV are considered contraindications to donation
The CMV status of donor should be determined before donation and if the donor is positive, recipient should be informed about the risk of CMV activation and the prophylaxis regimen with possible side effects
The EBV status of donor should be determined before donation and if the donor is positive and the recipient is negative, recipient should be informed about the risk of PTLD post transplantation
Patient with history of renal stones can donate provided it is not recurrent due to metabolic abnormality; in case of unilateral nephrolithiasis It is recommended to donate the kidney containing stone
In anemic patient, the cause of anemia should be known and treated before donation, in case of haemoglobinopathies the decision to donate is depending on the type and its long-term effect
All donors should have a detailed family history of renal disease, especially if the donor and recipient are genetically related
Active malignancy should be excluded before donation, donors with certain types of low grade malignancy can donate after successful treatment, screening for occult malignancy should be done in all donors >50 years
Renal mass should be diagnosed, and usually diagnosis is settled using US, CT with contrast or MRI
The presence of incidental bilateral or unilateral AML >4 cm are considered contraindication to donation, while unilateral AML 1-4 cm can be considered for donation with or without excision , patient with AML <1 cm can donate without excision
Patients with unilateral RCC <4 cm can donate their kidney after complete excision of the mass and reconstruction
Before donation vascular anatomy of the donor kidney should be evaluated using CTA or MRA , the decision to donate kidney with multiple renal arteries or with abnormal, anatomy is discussed in a case by case and is not considered absolute contraindication
Donor should receive adequate hydration (intra and post- operative) using normal saline together with thromboprophylaxis in the form of intraoperative mechanical compression (intra and post –operative) stocking and LMWH
Surgery is better to be done laparoscopically and if open surgery is indicated mini-incision surgery is recommended. Haem-o-lok clips are not recommended to be used for securing the renal artery
Use of enhanced recovery after surgery (ERAS) program is associated with better outcome
No recommendation to remove Rt or Lt kidney in a female in child bearing period for prevention of hydronephrosis
In pregnant female with unilateral kidney it is important to closely monitor BP, creatinine and fetous , and aspirin 75 mg can be given to prevent preeclampsia
The risk of recurrence of original kidney disease should be discussed with the recipient and donor
The best therapy for ESRD in a child is pre-emptive matched living related renal transplantation is the gold standard, children ≥10 kg can receive an adult kidney.
How these guidelines are different from the guidelines you follow at your workplace?
That is a superb summary of the approach to living kidney donation. We have done a donor with a BMI of 32 after careful evaluation.
These comprehensive guidelines are only for living kidney donor transplantation, adults and pediatrics. They include medical, surgical, immunological, identification of high risk donors with management, and legal and ethical issues. These guidelines based on recommendations and published studies (conference not included). Cut-off date was July 2017. Quality of evidence and strength recommendations as for KDIGO guidelines.
Types of living donation are directed donation (specified donation), paired or pool donation, non-directed altruistic donation and directed altruistic donation
Ethical principles for living kidney donors are altruism, autonomy, beneficence, dignity, non-maleficence, and reciprocity
A child < 18 years rarely candidate for donation (validity of consent and autonomy)
For valid consent, the donor should be informed about benefit and risk of donation including surgical risks. Independent assessment for donor and recipient is advise
Comprehensive assessment for the donor (MDT) includes history, physical examination and investigations. It is better to avoid invasive investigations until the appropriate step, parallel with the recipient
Donor evaluation should start early (when the recipient RRT expected to require RRT within 12-18 months) to allow for more donors if unsuitable (18 weeks for complete evaluation)
ABO and HLA compatibility is required and if there is any incompatibility, other options are available but not in all centers. This should discussed with donor and recipient
For the assessment of kidney function, estimate GFR with CKD-EPI equation and subsequently Cr-EDTA, 125iothalamate or Iohexol. Where there is >10% variation in kidney size or significant renal anatomical abnormality 99mTcDMSA is recommended. Donor should counsel about the small risk of ESRD and Lifelong follow-up postdonation is mandatory
There is no upper limit for accepting donors but older donors needs specific evaluation as per-operative risk is high and graft function may be affected
Guidelines also talk about obesity. Healthy overweight (BMI 25-30 kg/m2) may safely donate. BMI 30-35 kg/m2 should be counselled about the risk of kidney disease, advice to lose weight and carefully assess CVD and respiratory. No data for safety of very obese ((BMI >35 kg/m2)
All donors should be carefully assessed for HTN. Donation may be possible in controlled HTN with no target organ damage. Blood pressure may rise after donation and donors should be aware. Monitor blood pressure regularly after donation and encourage life style modifications to reduce risk of HTN and CVD
For diabetes, if fasting is impaired do OGTT. High risk of type 2 diabetes also candidate for OGTT. If test is impaird, risks of developing diabetes after donation must be carefully assessed. If no evidence of target organ damage and other CV risk (obesity, HTN, hyperlipidemia) are controlled, diabetics may be considered for donation
No need for stress testing or invasive testing in low risk CV disease. For high risk stress testing is recommended (CT calcium scoring may be used) and cardiologist should involve
Spot urine urine albumin/creatinine ratio is the preferred test for proteinuria (urine protein/creatinine ratio may be an alternative). ACR >30 mg/mmol, PCR >50 mg/mmol, albumin excretion >300 mg/day or protein excretion >500 mg/day represent absolute contraindications to donation
Persistent non-visible haematuria (PNVH) which is defined as persistent haematuria in at least two separate urine test, if present urine culture and renal imaging are required to exclude urological diseases (infection, nephrolithiasis and malignancy). Cystoscopy is indicated if no cause especially if >40 years. If no cause despite extensive investigations, kidney biobsy is recommended. Glomerular diseases preclude donation with the exception of TBM. Genetic study if family history of haematuria or x-linked Alport syndrome
Donor may be considered for donation only if pyuria is due to uncomplicated UTI
Screening of infection is paramount. HBV and HCV mostly contraindication of donation. HIV or HTLV absolutely preclude donation. Dietary advice to avoid HEV infection. Other important infections are CMV and EBV. Contact experts in infectious diseases if any concern of potential risk
Small kidney stones on imaging or limited history of stone in the absence of metabolic abnormalities not prevent donation. Unilateral stone may allow donation if and split kidney function and vascular anatomy permit
Anaemia should be identified and treated before donation. Screen for haemoglinpathies. Involve a haematolgist in uncertain cases
If recipient have a family history of kidney disease, detailed history is indicated to know the cause. If recipient kidney failure is due to an inherited diseases, genetic tests are recommended
Active malignancy is absolutely contraindicated. Exclude occult malignancy (>50years). Many low grade tumors allow donation after successful treatment. Refer incidental kidney mass for a urologis
t
To avoid risk of surgery, detailed vascular anatomy, kidney parenchyma andcollecting systems are important (CTA or MRA). Split kidney function in certain cases. Thrombotic prophylaxis and compression stockings are recommended. Donor should be hydrated for surgery. Fluid peri-operatively with lactated ringer (preferred to saline)
Do histocompatibility testing early to avoid unnecessary invasive investigations. If there is incompatibility (ABO/HLA), encourage patients to enter exchange scheme program
Postdonation follow-up for longtime with counseling of small risk of ESRD
The risk of recurrence of some diseases (high in FSGS and MCGN) should be discussed with donor and recipient with the possibility of graft loss
Pre-emptive living related renal transplantation is the preferred therapy in children. Children who are ≥10 kg are suitable to receive a kidney from an adult living donor
This guideline established by British society of transplantation on 2018, it cover all aspects of transplantation, including both recipients and donors, it cover the following:
All transplant in UK should be judged by , Human tissue Act 2004, and Human tissue (Scottland) Act 2006.
All transplant centers, for living organ donation , should be under govern of European union of donation directive.
All consent removal of kidney transplant should be under guide by requirement of Human tissue 2004, and mental capacity act 2005 in England and Wales, mental capacity Act in north Ireland 2016,.
Ethics:
All health professionals in LDKT, they should have full moral issues, and good ethical experience.
Donor safety must be equally concerned, as recipient benefit.
Independency should be fully authorized between recipient team , and donor team.
Supporting and informing the potential donor;
Living donor must be offered good environment for voluntary decision about donation.
Independency evaluation of donor and recipient, must be judged by primary legislation.
Confidentiality must be offered, to both , donor and recipient, shared information must be done with consent .
Separate clinicians team for donor and recipient is better, but health care professionals should work together without breaking confidentiality.
All aspect of support should be offered for donor ,recipient, and family .
Donor evaluation;
Eligible recipient should prepared early before donor evaluation in directed donation.
Planed assessment od donor, to reduce inconvenience, and to avoid unnecessary barriers.
Good communication with donor by multidisciplinary team with coordination, and all lab results should be reflected to donor, accurately.
In order to accelerates the process of transplantation, donor assess should be start as early as possible to allow more time for other possible donors, and discussion for transplantation should be offered to potential recipient as early as GFR are 20 ml/min.
Surgery;
Nephrectomy to lower kidney GFR ( by split kidney function) should be done , irrespective to vascular anatomy .
Appropriate imaging to assess vascular tree , parenchyma, and collecting system should be offered to donor kidneys.
anatomical anomalies, and multiple vasculatures , are not more considered absolute contraindication to transplantation , and should be individualized.
LMWH is recommended as thromboprophylaxis offered by surgeon.
All transplantation surgery must be under consultant surgeon, with experience.
proper perioperative preparation and hydration is vital , including overnight infusion , intraoperative fluid blouses , and preferred fluid are ringer and normal saline.
Haemo-o-lock , not recommended for closure of renal artery..
Living donor should offer ERAS after surgery.
Histocompatibility testing for living donation for transplantation;
Histocompatibility testing should always precede invasive investigation.
screening for recipient antibody panel, to optimize donor selection and graft survival.
Post transplantation antibody monitoring , must be undertaken to the BSHI/BTS, guidelines.
HLA types, and partner/offspring, of female recipient with previous pregnancy, should be determined, to avoid immunological risk fo repeat potential HLA mismatch in female with low level DSA.
Pre -transplant screen sample , collected for planned date of transplantation, must be tested for antibody screening and donor crossmatch, so transplantation should be delayed , unless +ve crossmatch is within accepted titer .
HLA matched donor is preferred whenever possible especially for younger recipient with possible future re=transplantation.
Recipient with ABO/HLA incompatible ,and /or poorly HLA mismatch, live donor should be enter UKLKSS .
Histocompatibility ab result should be interpretative , stating ,donor, recipient HLA mismatch, recipient sensitization status, crossmatch result and associated immunological risk for recipient and donor.
Expanding donor pool;
UKLKSS, is to maximize number of transplant that may proceed.
opportunities for transplantation within UKLKSS is directed by;
The default, NDADs is to donate and directed within UKLKSS.
All AD if directed or not must have formal mental health assessment before transplantation.
all incompatible donors should directed to UKLKSS.
Donor should aware that; compatibility always associated with success, while incompatibility are not .
Donor follow up and long term outcome;
Donor councelling about the risk of ESKD post donation , primarly associated with , age , sex, race, BMI, history of renal disease.
Provide high risk calculator to all donors.
follow up post nephrectomy must be inforemd for all female for risk and event with pregnancy include;
Recipient outcome after live donor transpalnt in adult;
Graft and recipient survival , after transplantationof living donor, should be within range of expected outcome.
If recipient is of high risk, transplantationshould be proced only if professional team involve, with expectation of recipient and graft functioning for 2 yrs.
Recipient with high risk of comorbidities, and poor outcome,due to immunological status, consider for transplantation when risk/benifit ratio is favourable.
Recurrent renal disease:
Wide range of recurrent disease post transplantation,so the risk of recurrence , and consequences of graft function, and deterioration of renal function should be considered.
In atypical HUS, potential, denovo in a related donor need to be adressed clearly.
Recipient risk of SLE or systemic vasculitis, need adequate disease controll time.
Living donor transplant in children;
Pre-emptive related transplant is the gold standard, transplant for children.
Aim for children is to receive transplant from ABO/HLA compatible, although incompatible ABO with HLA mismatch transplant is feasible in children.
effort to minimize HLA mismatch to reduce future sensitization.
CKD s4 s5 , child’s should be assessed by multidisciplinary team.
Children > 10 kg is suitable to receive kidney from adult donor.
Summary of Guidelines for Living Donor Kidney TransplantationKidney transplantation from a living donor, is the treatment of choice to most patients with ESRD.
The guidelines relates only to living donor kidney transplantation and relevant to both adult and paediatrics settings
Recommendation of legal framework
ALL transplant performed from living donors must comply with the requirement of the primary legislation which regulate transplantation and organ donation across the united kingdom(not graded).
All transplant centres performing living organ donation must be licensed by the human tissue Authority in line with requirements of the European Union Organ Donation Directive which sets out the minimum requirements for quality and safety of organ for transplantation(not graded).
Consent for the removal of organs from living donors, for the purposes of transplantation, must comply with the requirements of the human Tissue Act 2004 and Mental capacity Act 2005 in England(not graded).
ETHICS Recommendations
· All health professional involved in living donor kidney transplantation must acknowledge the wide range of complex moral issues in this field(not grated).
· The potential living donor must take precedence over the needs of the optional transplantation recipient(not grated).
· Independence is recommended between the clinician for assessment and Human tissue authority (not grated).
· SUPPORTING AND INFORMING THE POTENTIAL DONOR:
· The living donor must be offered the best possible environment for making a voluntary and informed chance about donation(B1).
· To achieve the best outcome for donor ,recipient and transplant the confidentiality must be specified and discuss at the outset(B1).
· The recipient will discuss relevant information with the donor or allow it to be shared (not grated).
· For support for donor ,recipient and family is an integral part of the donation ,transplantation processes(B1).
· Donor evaluation recommendation :
· Direct donation (to known recipient ) the likely suitability of the protentional recipient for transplantation must be established before starting donor assessment(not grated).
· A policy must be in place to manage prospective donor who are found to be unsuitable to donate.
· The facilitate pre-emptive transplantation donor evaluation must start sufficient early to allow time for more than one donor to be assessed if required(B2).
· ABO BLOOD GROUPING AND CROSSMATCH TESTING
· Recommendation A compatible ABO blood group and human leucocytes antigen (HLA) transplant offers the best opportunity for success(A1).
· ABO OR HLA incompatibility is present, alternative option for transplantation must be discussed with the donor and recipient including paired /pooled donation and antibody incompatible transplantation and this later must be performed in a transplant centre with the relevant experience and appropriate support(A1).
· Recommendation of Assessment of renal function:
· Measurement of Renal function.
· Initial evaluation of donor should be using estimated glomerular filtration rate(B1).
· GFR must be assessed by a reference measured method such as clearance of cr-EDTA or performed according to guidelines by British Society of Nuclear Medicine (B1).
· Differential kidney function .determined by TcDMSA scanning is recommended.
· Threshold of e GFR for donations level is defined based on Age and gender .
· There is small increased life time risk of ESRD following denotation for which the potential donor must be consent (D2).
· The donor must be offered life long annual assessment of renal function including serum creatinine .urine protein execretion and blood pressure measurement(B1).
· Donor more than 60 years of age increase evident of peri-operative complication and affect graft survival and function.
Moderately obese patients (BMI 30 -35 ) must undergo careful preoperative evaluation to exclude CVS ,respiratory and kidney disease (C2).
Data on the safety of kidney donation in the very obese (BMI >35 )are limited and donation should be discouraged(C1).
Potential donors with mild -moderate hypertension that is controlled to <140/90mmhg (and or 135/85 mmhg with ABPM or home monitoring ) with one or two anti hypertension drugs and who have no evidence of end organ damage may be acceptable for donation(C1).
Consideration of patients’ with DM as potential kidney donors require very careful evaluation of the risks and beneficial (not grated).
CVS assessment for higher risk potential donors ,stress testing is recommended by which ever method is locally available or by CT calcium scoring (C2).
Discussion withhold or review by cardiologist ,anaesthetist and transplant MDT is recommended as part of the clinical assessment of donor with higher CVS and peri-operative risk (D2).
ACR>30 mg/mmol ,PCR >50 mg /mmol ,albumin excretion >300 mg/day or protein excretion >500mg/day represent absolutes contraindication to donations (D2).
Haematuria if no cause is found and the donor still wishes to donate ,then a kidney biopsy is recommended if haematuria is one plus or more on dipstick testing (B1).
Glomerular pathology precluded donations ,with the possible exception of thin basement disease(B1).
Donor with persisting asymptomatic non visible haematuria and a family history of haematuria or x-linked Alport syndrome ,a renal biopsy and referral to a clinical geneticist are recommended(B2).
Recommended donor to have pyuria can only donated if pyuria due to reversible cause (C1).
Active HBV and HCV infection in the donor are usually contraindication to Living donor kidney donation(B1).
HIV and HTLV infection is an absolute contraindication to living donation (B1).
The CMV status of donor and recipient must be determined before transplantation if CMV positive donor and CMV negative recipient ,the donor and recipient must be counselled about the risk of post -transplant CMV disease(B1).
EBV status of donor and recipient must be determined before transplantation(B1).
Previous history of kidney stone or imaging in the absence of metabolic abnormality ,still be considered as potential kidney donors (C2).Donor anemia needs to be investigated and treated before donation (A1).
Many inherited kidney disease are rare, so involvement of clinical and laboratory genetics services must be considered at an early stage to asset likely to risk family members and the appropriate use of molecular genetic testing (B1).
Active malignant disease is contraindication to living donation but donors with certain types of successfully treated low grade tumor may be considered after careful evaluation and discussion (B1).
Work up for living donor must include detail imaging confirming the vascular atomic of both donor kidneys and information about the renal parenchyma and collecting system either CTA or MRA can be used as current evidence indicate little difference in accuracy (B1).
Pre-and peri-operative IV fluid replacement with Hartman solution is preferable to 0.9% saline (B2).
Laparoscopic donor surgery is the preferred technique for living donor nephrectomy (B1).
Initial assessment of donor and recipient histocompatibility status must be undertaken at earlier stage in living donor kidney transplant workup (B2).
Screening of potential living donor kidney transplant recipient for clinical relevant antibodies is important for ensuring optimal donor selection and graft survival (A1).
Antibody screening is important when potential living donor transplant recipient undergo reduction or withdrawal of immunosuppression (B2).
Post-transplant antibody monitoring must be undertaken according to the BSH-BTS guide lines (B1).
Transplant and histocompatibility lab rotary must agree an evidence based protocol to define antibody screening and crossmatch results that constitute ahigh immunological risk to transplant(B2).
If crossmatch test collect ed sample 14 days of planned date for transplantation is positive ,transplant should not be performed unless antibody is show to be indication of acceptable immunological risk(A1).
HLA matching preformed when there is an option of selecting between living donors (B1).
The histocompatibility laboratory must issue an interpretation report stating the donor and recipient sensitization statement cross match result and define associated immunological risk for all living donor recipient pairs (A1).
All potential altruistic donors should be referred for mental health assessment.
Graft and patient survival after kidney transplantation should be within the national range of expected outcomes(A1).
Living related renal transplantation should be avoided in atypical HUS unless the cause of the disease in the recipient is known and this has been excluded in the donor .
In appropriately selected cases ,living donor kidney transplantation is a reasonable treatment option in primary hyperoxaluria .Both the donor and recipient should be counselled regarding the risks of recurrent disease.
2- in our center the age for recipient should be 60 or less to proceed for transplantation other wise follow same guidelines.
Hi Dr Manal Malik,
I would say that laparoscopic donor nephrectomy is the only option now, rather than stating that laparoscopic donor nephrectomy is the preferred option. Open surgery for donor operation is not an option. Of course, one should have no hesitation in converting to open operation for the sake of safety, though I have never needed to do that an open tray should be accessible at ultra-short notice. .
Ajay
This is a comprehensive guideline discussing the the living donor organ program in the United Kingdom. It explains the regulatory legal frameworks and ethical frameworks pertaining to living donations in the UK to donor evaluation process including the histocompatibility testing and the surgical aspects to long-term donor follow up and briefly also talks about the pediatric transplantation
The Human Tissue Act (2004) sets out the licensing and legal framework for the storage and use of human organs and tissues from both living and deceased donors.
The Human Tissue Authority (HTA) was established as the regulatory body under the Human Tissue Act. The HTA is responsible for assessing all applications for organ donation from living people. All donors and recipients see an Independent Assessor (IA) who is trained and accredited by the HTA and acts on behalf of the HTA to ensure that the donor has given valid consent without duress or coercion and that reward is not a factor in the donation. If the HTA is satisfied on these matters, then approval for the living donation will be given.
Types of living donation permitted by the legislation include:
For a child to be allowed to donate, parental consent must be obtained and even after it is obtained, an advanced ruling from the court must be sought before proceeding.
In Scotland, living organ donation from children is not permitted.
The key ethical principles in living donation include:
The donor evaluation starts from counselling the potential donor and making sure that there is no coercion or duress or financial gain involved. The donor undergoes extensive work-up to make sure that the donor is safe during the surgery. The risks of developing ESKD and mortality during the surgery and post-donation albeit small should be very clearly discussed with the donor so that the donor has a clear picture of the risks. The histocompatibility testing should be carried out early in the process to prevent the donor from undergoing extensive radiological evaluations if not needed.
The donor must clearly be informed that during the evaluation process he/she might be diagnosed with certain conditions and pathways for referral must be in place to assist the donor in case certain conditions are discovered.
Donor confidentiality must be maintained at all times.
For pre-emptive kidney transplantation, the process must be faster to evaluate several donors if needed to try and ensure that the potential recipient gets transplanted before requiring hemodialysis
Donors who have diabetes or IFG are not allowed to donate. However, the guidelines give leeway to the centers to individualize the patients with IFG and no other comorbidities.
If a donor has mildly increased albuminuria or proteinuria they are disqualified from being donors.
Microscopic hematuria needs extensive evaluation including 2 cultures, cystoscopy and possibly even a kidney biopsy.
Patients with active malignancy are not allowed to donate. Patients who have had malignant melanoma, cancers of the breast, lung, colon (Dukes stages B or C) are barred from donation
Patients with non melanoma skin cancers and treated cancers with no risk of recurrence can be allowed to become donors but will require extensive work up and oncology evaluation before proceeding
Patients with renal masses will require referral to a specialist uro-radiologist to confirm if the masses are benign or malignant
For cardiac evaluation, a 12 lead ECG will suffice unless if the donor is high risk for CVD – then referral to a cardiologist is required.
Donors must have a pathway for follow-up post-donation. Most centers see the donor 4-6 weeks after the donation then annually.
Female donors must be counselled of the risk of pre-eclampsia post-donation and that they they should follow up closely with their gynecologist once they conceive
All transplant centers must do regular audits and Graft and patient survival after living donor kidney transplantation should be within the national range of expected outcomes. They should also do audits for secondary outcomes and compare them to other transplant centers
The guidelines also talk about recurrent renal disease. It is important to note that a number of renal diseases have a high rate of recurrence post transplantation. It is important to discuss both with the donor and the recipient about the risks of recurrence. FSGS and MCGN have the highest rate of recurrence approaching 50%. Therefore, the guidelines recommend that for these patients, living donation should be discouraged even if a donor is available and deceased donation is preferable. This is after counselling both the donor and the recipient.
For patients with SLE, the disease has to be quiescent before proceeding for transplantation.
For pediatric patients, pre-emptive kidney transplantation is the gold standard. Pediatric patients with CKD stage 4 should start being reviewed by the multidisciplinary team including a pediatric nephrologist, urologist, transplant surgeon and anesthetist. Pediatric patients who weigh more than 10 Kgs are eligible to receive a kidney from an adult living donor
Hi Dr Bagha,
I quote your reply here in italics:
‘The key ethical principles in living donation include:
Which one of these is most important? This may sound rather a strange question, but there is a reason. There are times, especially in transplantation, when there is a conflict in decision-making when applying principles of ethics.
Dear Professor Sharma
From my view point the most important in living donation is Non-Maleficence
There are instances we will get a donor who is of sound mind, truly altruistic and wants to donate but because of medical contraindications will not be allowed to donate. And he/she will insist that he is willing to take the risk. As a physician we always have to make sure that we do no harm to the patient.
I had a 21 year old sister who wanted to donate a kidney to her brother. There was no contraindication for her. But we know that there can be possible medical problems she can face in the future: Development of elevated BPs, a higher risk of development of pre-eclampsia. There are also social implications as well due to the scar as we dont do do laparoscopic retrieval. After multiple sessions of counselling, she still insisted to donate and our ethics committee allowed her to become a donor
You are a master, dear Dr Bagha. Your example is worthwhile to allude to, and your reasoning is crystal clear.
Ajay
Thank you Professor Sharma
The Key Points to Discuss with a Potential Donor
General procedural, consent, and secrecy points:
. For a live donor to offer legal permission, he/she must be
general hazards (for all donors) and individual
risks.
. The information must be supplied concerning transplants
and GP
. Explain that testing may provide surprising results.
-The review process for potential donors should first and foremost focus on determining whether or not the
donor and reducing the potential risks associated with donation. Specifically, this entails determining
Donations shouldn’t be done if you have these conditions, plus these other possible clinical concerns (both physical and mental).
-In directed donations (to a known recipient), appropriateness before transplanting.
-Avoid unneeded delay. Non-invasive This step includes donor evaluation.
-To allow pre-emptive transplantation, donor assessment must commence
early enough so that more than one donor could be evaluated
if you need it.
-when the eGFR of the recipient is about 20 mL/min or when the
The recipient is likely to need kidney replacement therapy within 12 to 18 months.
months.
-The evaluation of a potential donor should be undertaken within an 18-week pathway.
-A compatible ABO blood group and human leucocyte antigen (HLA) transplant offers the best opportunity for success.
-When ABO or HLA are not compatible, there are other options for
Talks must take place with both the donor and the recipient,
including paired or pooled donations and antibodies that don’t work together
transplantation.
-A full past and present medical history must be taken.
– A psychosocial assessment is recommended for all donors with appropriate referral to a mental health professional as required.
-Estimates should be used to judge potential donors at first.
glomerular filtration rate (eGFR), which is written as mL/min/1.73m2
based on a creatinine test that was done according to the International
Standard of reference.
-GFR must be measured by a reference method.
(mGFR), such as 51Cr-EDTA, 125iothalamate, or Iohexol clearance
done according to rules set out by the British Society of
Nuclear Medicine.
-Differential kidney function, which can be found with a 99mTcDMSA scan, is
recommended when the size of the kidneys varies by more than 10% or
significant renal anatomical abnormality.
-The donor’s kidney function must be checked every year for the rest of his or her life. including serum creatinine, urine protein excretion estimation, and
blood pressure measurement.
-Old age by itself is not a reason to not donate, but older donors must go through a very thorough medical checkup to make sure they are fit.
– Otherwise healthy overweight patients (BMI 25-30 kg/m2 ) may safely proceed to kidney donation.
-We think that a blood pressure of less than 140/90 mmHg is usually good enough to donate.
-A fasting plasma glucose concentration between 6.1-6.9 mmol/L is indicative of an impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be undertaken.
-Urine protein excretion needs to be quantified in all potential living donors.
-All potential living donors must have reagent strip (dipstick) urinalysis performed on at least two separate occasions.
-Screening for infection in a potential donor is important to find out what risks the donor might face from a past or current infection and to figure out how likely it is that the infection will be passed on to the recipient.
-In the absence of a major metabolic problem, people who have had a few kidney stones in the past or who have small kidney stones on imaging may still be considered kidney donors. Both the donor and the recipient must get full counselling, and the donor must have access to long-term donor follow-up.
– Donor anaemia needs to be investigated and treated before donation.
-All people who might get a transplant must have a detailed family history written down and, if possible, have other family members with kidney disease confirm the diagnosis. This could help the person get a better diagnosis, figure out how the disease was passed down, and find relatives who are at risk.
-Before a kidney donation, a careful history, clinical exam, and investigation of the potential donor are needed to rule out occult malignancy. This is especially important for donors over the age of 50.
-Workup for a living kidney donation may include a direct or indirect evaluation of split renal function. The kidney with the worse function is chosen for nephrectomy, no matter how the blood vessels are set up.
I like your comprehensive reflective exercise on LRD criteria, dear Dr Weam.
Ajay
Introduction
These guidelines pertain to living kidney donor transplantation. This includes adult and pediatric settings. Scope of these guidelines extends to ethical and medico legal aspects of donor selection, medical and pre operative donor evaluation, identification of high risk donors, management of complications, and the corresponding outcomes that are expected.
Thank you, BUT this is not enough
Thank you, any more summary?
Yes prof