Kidney transplant donor evaluation

1. PRE TRANSPLANT DONOR
EVALUATION
Dr Nayyar Saleem FRCP (Glasg), FCPS (Nephrology)
Clinical Fellowship in Nephrology & Transplant (Canada)
Consultant Nephrologist
Multan Institute of Kidney Diseases

2. Objectives
■ Understanding the general principles of donor
assessment and approval
■ Know the main criteria for donor selection relevant to
prevent CKD
■ Decisions regarding living donors are often arbitrary but
should favor long term safety of donor’s health

3.  Education, counseling and consenting
 Psychologicalevaluation
 Medical screening process
 Identification of transmissibleinfections
 Evaluation of renal function and anatomy
Donor evaluation process

4. Education, counseling and consenting
 Complications
 Blood grouping and HLA
 Medical evaluation steps
 Stress of the right to withdraw at any time
 Follow up
 Informed consent
Erratum in: Am J Transplant. 2015 May;15(5):1447

5.  Psychiatrist,psychologist or socialworker for :
 Psychological evaluation and identification of active mental
health problems
 Socialassessmentincluding high risk behavior
 Assessmentof consentingability
 Assessment for any financial gains
Psychological evaluation

6.  History and physicalexamination
 Laboratory testing
 Identification of transmissibleinfection
 Evaluating renal anatomy andfunction
Medical screeningprocess

7.  Absolute
• <18year-old
• Active substanceabuse
• Impaired ability to make a
decision
• Uncontrolled Hypertension
• DM
• Morbid obesity >35
• Proteinuria >300mg/24hr
• CrCL<80ml/min/m2
• Renal stones
• Chronic Infections
• Cancer
• Cardiovasculardisease
Contraindications for donation
 Relative
• Age >65
• ControlledHypertension
• Impaired glucosetolerance
• Obesity >30
• Microscopic hematuria
• Single renal stone

8. Routine Tests for Donors
■ CBC, PT, INR
■ Creatinine , Electrolytes, Calcium
Phosphate, LFTs
■ Lipis profile, Blood glucose,
HBA1C,
■ 24 hour creatinine clearane,
protein and albumin
■ HBsAg, HBsAb, HBcAB
■ Anti HCV Ab
■ Anti HIV
■ HTLV
■ Syphilis
■ Urine Culture
■ EBV, CMV

9. Routine Tests for Donors
■ Imaging
■ Abdominal U/S
■ CT Angiogram
■ DTPA Scan for total and
differential GFR
■ CXR
■ ECG, Echocardiography and
Cardiac consultation in
appropriate patients
■ Tissue Typing and cross match
■ Psychosocial Assessment

10. Optional Studies
■ GTT for family history of DM, Gestational
diabetes
■ Stress Echocardiogram for >40 years old
■ Age appropriate cancer screening (Pap smear,
Mammogram)

11. Special Situations

12. Ethical Issues
Transplantation Reviews 28 (2014) 134–139
Donation by a woman in an extra-marital relationship with a married man
Case of the older recipient and young spousal donor
Young unmarried daughter donating to her 60 year old father
Married to a woman recently just to get her kidney

13. HCV
Nat. Rev. Nephrol. 11, 172–182 (March 2015); published online 3 February 2015;

14. Safety of using HCV ab +ve non-
viremic kidney donors to HCV-ve
recipients
■ Data confirm that HCV Ab +ve, PCR –ve to HCV negative
recipients is safe
■ HCV Ab reactive organs should not be denied for
Transplantation in general.
■ However extended virological testing should be
considered and comprehensive informed consent needs
to be obtained from recipient.

15. Cancer

16. Anasymptomatic potential donor with history of a single stone
may be suitable for kidney donationif:
 No hypercalciuria, hyperuricemia or metabolic acidosis.
 No cystinuria or hyperoxaluria.
 No urinary tract infection.
 No multiple stones or nephrocalcinosis are evident on CT
scan
Live Donor:
UrinaryStones

17. Controversial Issues
■ Treated/Untreated Hypertension
■ Acceptable GFR Limit
– UNOS 80m/min/1.73m2
– Japanese 70ml/min/1.73m2
– UHN 90ml/min/1.73m2
■ Features of Metabolic Syndrome
■ Isolated microscopic Hematuria

18. Case 1
■ 50 year old man from outskirts of Bahawalpur wishes
to donate to his brother who has ESRD due to
unknown etiology (Small kidneys)
– HD for 2 years two times per week with all symptoms of
inadequate dialysis
– Quality of life for both is impaired by
– Difficulty Traveling
– Severely restricted diet
– Feels unwell post HD due to large volume ultrafiltration

19. Donor Profile
■ 30 year history of smoking 15 cigarettes/day
■ 24 hr urine CrCL 70 and 75ml/min/1.73m
■ DTPA blood GFR 80ml/min/1.73

20. Donor’s Response
■ Donor argues against being turned down
■ In any case , I am willing to risk CKD and even ESRD for
my brother’s life and quality of life of our whole family.

21. KDIGO
■ Donor candidacy is evaluated in light of long-term risk, in which
GFR is one of many factors
■ Two GFR thresholds are used for decision-making: a high
threshold (≥90 ml/min per 1.73 m2) to accept and a low
threshold (<60 ml/min per 1.73 m2) to decline, with 60–89
ml/min per 1.73 m2 as an intermediate range in which the
decision to accept or decline is made on the basis of factors in
addition to GFR

22. Donor GFR and Risk of CKD
What is evidence?
■ Evidence is imperfect
■ Few long term studies >10-15 years Follow up (30-40%
Lost to Follow up)
■ Data suggest slightly increased risk of ESRD and
increased mortality in Kidney donors as compared to
matched healthy non donor population

23. Norwegian study
Kidney international, 2014-07, Vol.86 (1), p.162-167
N=1901, Control=3268
HR for Death=1.48
HR for ESRD=11.48

24. GFR Post Donation
■ What happens to GFR in Donors
– How many have low GFR (<60ml/min/1.73m2)
■ If some donors reached stage 3 CKD:
– Is increased CV risk shown in general population equivalent
to healthy kidney donor
– Does low GFR itself lead to increased vascular disease or is it
the pathologic processes that cause low GFR?

25. Predictors of GFR <60ml/min
■ Pre-donation GFR
■ Older
■ Higher BP
■ Higher BMI

26. Case 1: Summary and opinion
■ Modern data suggests GFR falls to 65% of baseline in
donors
■ Pre-Donation GFR of 80ml/min predicts post donation
GFR of 52 ml/min
■ There is concern that GFR<60 in donors may increase
risk of ESRD and death

27. Case 2:Metabolic Syndrome in young
Female
■ 30 old female wants to donate to her father (Diabetic
Nephropathy)
■ Strong Family history of DM
■ No previous illness, no meds
■ Non smoker, non drinker, no drugs
■ Never exercises

28. Physical Exam
■ Obese BMI 34
■ BP initially 145/80
– 130/80 after 5 minutes of quiet resting

29. Labs and Imaging
■ Normal routine except
■ ALT 49
■ FBG 90, 2 hr BG 101
■ Urate 6.5
■ LDL 157, TC 256, HDL 50, TG 345
■ GFR 120ml/min, no proteinuria
■ Normal imaging except for fatty liver on US

30. Case 2: Summary
■ Obese
■ Fatty liver, slight elevation of ALT
■ Strong family history of DM
■ Labile hypertension
■ High urate and lipids

31. Assessment
■ None of the abnormalities alone necessitates
rejection
■ If no change in lifestyle, odds extremely high,
she will have early onset DM2
– 20-30% chance of CKD

32. How Should we Decide?
■ Donor’s health is our first priority
■ Turn down on basis of risk for DM
OR
■ Give patient chance to demonstrate ability to
change lifestyle over 6-12 month s and provide
long term follow up.

33. Case 3
45 year old woman with microscopic hematuria
■ Wishes to donate to her husband with chronic GN
■ Told about 10 years ago she had small amount of blood
in urine
■ PMH, Physical exam, routine labs all normal
■ Urine: Moderate bloodx3, normal protein, 10-15
RBC/HPF with some dysmorphic cells
■ Normal cystoscopy

34. Assessment
■ Isolated Microscopic hematuria
■ Probably renal in origin
■ Possibilities are:
– IgA nephropathy
– Thin basement membrane disease
– No diagnosis

36. Persistent Glomerular Hematuria in
Living kidney donors confers risk of
progressive kidney disease in donors
■ Risk of Persistent Proteinuria OR
– Dipstick+Proteinuria 14
– Glomerular Hematuria 12.3
– Hypertension 3.74
■ Risk of Decline in GFR
– Glomerular Hematuria 1.69
■ Study indicates that donors with persistent
glomerular hematuria should be excluded
American Journal of Transplantation 2010; 10: 1597–
1604

37. Role of kidney biopsy
■ Mandatory in some centers with isolated microscopic
hematuria
■ Reject IgA Nephropathy
■ Accept normal and minor abnormalities
■ What About Thin basement membrane disease?

38. Research on Donor outcomes
■ Short term surrogate outcomes are likely inadequate
– BP, Albuminuria, GFR
■ Important long term outcomes could take decades to complete
and large number of donors
– Incidence of ESKD, CV disease
– Amit Garg , Canadian study
■ Paradigm shifting but use caution until we better do

39. Thank you