This document provides guidelines for evaluating potential renal transplant recipients and living kidney donors. For recipients, a thorough history, clinical exam, lab tests, imaging and biopsies are recommended to assess suitability and detect contraindications. Original kidney disease must be evaluated for risk of recurrence. For donors, standard criteria include age over 21, no infections, diseases, or malignancies. Donors require medical, lab and imaging exams as well as informed consent regarding risks. High risk donors like those with obesity, hypertension or hematuria may require further testing or be deemed unsuitable to donate.

1. How to prepare a couple for renal
transplantation?
Ayman Refaie, MD
Chief Transplantation & dialysis Unit
Urology & Nephrology Center
Mansoura University

2. Successful Transplantation
GOAL
Good Preparation
=

3. A- Recipient Evaluation: Guidelines

4. A- Recipient Evaluation: Guidelines

5. 1- History
2- Clinical
3- Laboratory
4- Radiology
5- Endoscopy
6- Histopathology
A- Recipient Evaluation

6. • Active infection (TB, acute hepatitis, HIV ,)
• Malignancy
• Severe psychiatric & mental disorders
• Non compliance
Contraindications of kidney transplantation

7. Recipient Evaluation: Malignancy

8. • Original kidney disease
• Medical illness
• Family history (renal failure)
• Dialysis (Type, duration, adequacy…..)
• Drugs
Recipient Evaluation: History

9. • General examination
• Chest & heart
• Liver
• ECG
Recipient Evaluation: Clinical

10. • History:
Nephrotic syndrome, stones, hypertension, DM,
family history
• Clinical
• Investigations
Recipient Evaluation:
Original kidney disease

11. Impact of recurrent glomerular diseases
on death-censored graft survival
Unknown, 5%
Fibrosis/atrophy
30%
Recurrent GN
16%
Medical
16%
Acute Rejection
11%
Tx Glomerulopathy
16%
De Novo GN
7%
(Ziad El-Zoghby, Cosio AJT 9:527-535, 2009)

12. Recipient Evaluation: Original kidney disease

13. Recurrent Renal Disease
• Primary FSGS
• IgA Nephropathy
• Mesangiocapillary Glomerulonephritis
• Membranous Nephropathy
• Diabetic Nephropathy
• Primary Hyperoxaluria
• Amyloidosis
• SLE
• ANCA Associated Systemic Vasculitis
• Goodpasture’s Disease
• Alport Syndrome
• HUS
• Cystinosis
Recipient Evaluation: Original kidney disease

14. Recipient Evaluation: Original kidney disease
Mansoura Experience

17. • Urine analysis, culture, ZN&PCR (TB)
• Full chemistry: Liver function
• Complete blood count (CBC)
• Viral profile: HCV, HBV, CMV, HIV, EBV
Recipient Evaluation: Laboratory

18. • UTP
• Abdominal US
• Micturating cysto-urethrogram (MCUG)
• Chest x-ray / Echocardiography
Recipient Evaluation: Radiology

19. Recipient Evaluation: Abd U/S

20. Recipient Evaluation: Plain x-ray
Chest x-ray
UTP
MCUG

21. • Gastroduodenoscopy
• Cystoscopy
Recipient Evaluation: Endoscopy

22. • Renal
• Liver
• Rectal
Recipient Evaluation: Histopathology

23. • Infection
• Stones / Obstruction
• V-U reflux ( nephrouretrectomy )
• Polycystic kidneys
• Uncontrolled hypertension
Indications of native nephrectomy

24. V-U reflux (Treatment options)
Mansoura Experience

25. V-U reflux (Treatment options)
Mansoura Experience
Conclusion:
Injection with PDS for reflux accompanying CRF is an appealing treatment and
results in an acceptable success rate and very low morbidity.

26. B- Donor Evaluation

27. Standard donor criteria (SDC): Guidelines

28. Standard donor criteria (SDC): Guidelines

29. Standard donor criteria (SDC): Guidelines

30. Standard donor criteria (SDC): Guidelines

31. Standard donor criteria (SDC): Guidelines

32. Standard donor criteria (SDC): Guidelines

33. Standard donor criteria (SDC): Guidelines

34. 34
Kidney transplant physicians and surgeons met in Amsterdam, The
Netherlands, from April 1–4, 2004 for the International Forum on the Care of
the Live Kidney Donor.
Forum participants included over 100 experts and leaders in transplantation
representing more than 40 countries from around the world.

35. • Should be free from any disease
Potential kidney donor

36. Exclusion Criteria
 Age younger than 21 (18 years, abroad)
 Hypertension
 Diabetes
 History of thrombosis or embolism
 Psychiatric contraindications
 Obesity: body mass index > 35
 Coronary artery disease, reduced cardiac function, symptomatic valvular, peripheral
vascular disease
 Chronic lung disease
 Recent malignancy
 Infections: HIV, HCV, HBV
Potential kidney donor

37. Informed Consent for Living Kidney
Donation
 Should be explained to the potential donor (both verbal and written)
 Information about living kidney donation should be provided.
 The risks of short and long-term complications must be fully explained
Potential kidney donor

38. According to the report of the Amsterdam Forum on the care of live kidney
donors:
*A prior history of the following malignancies excludes living related kidney
donation:
Melanoma, testicular cancer, renal cell carcinoma, choriocarcinoma, hematologic
malignancy, bronchial cancer, breast cancer, and monoclonal gammopathy.
*A prior history of malignancy may only be acceptable for donation if:
Prior treatment of the malignancy does not decrease renal reserve or place the donor at
increased risk for end-stage renal disease.
The specific cancer is curable and the potential transmission of the cancer can reasonably
be excluded, for example:
- colon cancer (Dukes A, more than 5 years ago),
- nonmelanoma skin cancer.
- carcinoma in situ of the cervix.
Donors with history of malignancy

39. Elderly donors
.
• Most of the studies confirmed the safety and applicability of using
older donors provided that they are cautiously selected and
extensively examined.
• Using specific immunosuppressive protocols for this special donor
subgroup to decrease the incidence of interstitial fibrosis and tubular
atrophy, especially with CNI-based protocols

40. 40

41. • General examination: BMI, BP
• Chest & heart
• Liver
• ECG
• Echocardiogram and/or exercise stress test:(>50
years old)
• Pulmonary function tests for smokers
Donor Evaluation: Clinical

42. Obese donors
• Patients with a BMI > 40 should be discouraged from donating,
especially when other comorbid conditions are present.
• BMI of 35 – 40 should be approved by donor surgeon.
• Obese patients should be encouraged to lose weight prior to kidney
donation.
• Obese patients should be informed of both acute and long term
risks, especially when other co-morbid conditions exist.
42

43. • Obese donors, the risk of greater intra operative complications,
more hypertension, diabetes and proteinuria is anticipated.
• Obesity has been found to be a common and strong risk factor for
CKD, focal glomerulosclerosis , and end stage renal disease.
• Biopsies of obese patients commonly show glomerular changes
such as glomerulomegaly and increased mesangial matrix.
Obese donors

44. • Ambulatory blood pressure monitoring has been
proposed as a more sensitive method than office
blood pressure measurements in identifying
hypertension in living donors
Blood pressure assessment in potential kidney donors
Clinic BP hypertension defined as 140/90
Ambulatory BP hypertension defined as mean 24-h 130/80.

45. Out of 63 individuals with hypertension by clinic BP, 62% had white-coat
hypertension by ambulatory BP and were therefore eligible to donate.
Out of 115 individuals who were normotensive by clinic BP, 17% had masked
hypertension by ambulatory BP and were excluded from donation.

46. Hypertensive donors
Short-term results of donation from well controlled, mild
hypertensive donors with a reasonable graft outcome, but more
detailed studies are needed for more reassurance on the long-term
outcome.
Some with easily controlled hypertension who meet other defined
criteria (age >50 years, GFR >80 ml/min, and urinary albumin
excretion <30 mg/day) may represent a low-risk group for
development of kidney disease after donation and may be
acceptable as kidney donors.

47. Diabetes Mellitus
• Potential donors with several risk factors for diabetes,
such as parental history, impaired fasting glucose, and
elevated BMI, most likely should not donate.
• A history of gestational diabetes is a contraindication.

49. Microscopic haematuria
Persistent microscopic haematuria mostly indicates underlying occult
renal disease, and a renal biopsy is indicated in that situation for clear
decision making regarding acceptance, as recommended by the
Amsterdam Forum group.
• Donors with dysmorphic persistent haematuria should be excluded.

50. Recipient Evaluation: Laboratory
Mansoura Experience

51. Thirty potential living related kidney donors with asymptomatic microscopic
hematuria of nonsurgical causes were included in this study
They were subjected to kidney biopsies which were examined by light
microscopy, direct and indirect immunofluorescent microscopy, and electron
microscopy

52. Hereditary nephritis (with or without sensorineural deafness) was found to be the
most common cause of asymptomatic microscopic hematuria (25/30)
Isolated C3 deposits disease (3/30)
IgA nephropathy (1/30)
IgM nephropathy (1/30)

53. Conclusion: The relatives of uremic patients with asymptomatic microscopic hematuria
should not be considered for kidney donation even if they are strongly motivated.

54. • Urine analysis X3, ± phase contrast (RBCs)
• Urine culture and ZN & PCR (TB)
• Creatinine clearance
• Full chemical & hematological profile
• Viral profile: HBV, HCV, HIV, CMV, EBV
Donor Evaluation: Laboratory

55. • ABO group
• Tissue typing
Matching

56. • Cross match
• PRA: Class I, II
• HLA:
– Class I A B
– Class II DR
Tissue Typing
(Histocompatability testing)

57. 1, 8, 10
3,14, 17
2, 7, 11
10, 16, 8
2, 7, 11
3, 14, 17
3, 14, 17
10, 16, 8
1, 8, 10
2, 7, 11
1, 8, 10
2, 7, 11
1, 8, 10
10, 16, 8
SISTERBROTHERSISTERSISTERBROTHER
FATHER MOTHER
HLA is inherited as a “set” of the three HLA groups, A, B, DR.
This set is known as a “haplotye”

58. Tissue Typing
(Histocompatability testing)

59. Tissue Typing
(Histocompatability testing)

60. • UTP, Non contrast spiral CT
• Abdominal US
• Chest X-ray
• Urinary system (IVP MRU CTU)
• Vascular system ( Angiography, MRA, CTA)
• Renogram
Donor Evaluation: Radiology

61. Donor Evaluation: Plain x-ray
Chest x-ray UTP

62. Donors with stones
As stated by the Amsterdam forum, asymptomatic
small stones (<1.5 cm) can be accepted after careful
selection and exclusion of any metabolic abnormalities.
The stone can be treated conservatively, during surgery
or with lithotripsy.

63. Donor Evaluation: Abd U/S

64. Donors with grade I echogenicity: 34 (32.7 + 8.45) years
Donors normal echogenicity: 10 matched controls
ALL: GFR , measured, isotopic scintigraphy and estimation of renal reserve.

65. Donors with grade I echogenicity: 34 (32.7 + 8.45, 23–48) years, 17 biopsied
Donors normal echogenicity: 10 matched controls
ALL: GFR , measured, isotopic scintigraphy and estimation of renal reserve.

66. Donors with grade I echogenicity: 34 (32.7 + 8.45, 23–48) years, 17 biopsied
Donors normal echogenicity: 10 matched controls, 8 biopsied
ALL: GFR , measured, isotopic scintigraphy and estimation of renal reserve.

67. 67

68. Segmental patch of sclerosis, periodic acid-Schiff X200 Mild segmental mesangial thickening, PASX400

69. Mild focal tubular atrophy, PASX200 Mild focal interstitial fibrosis, Masson trichrome X200

70. Conclusion:
Grade 1 echogenicity might be a sign of unrecognized kidney disease.
Renal biopsy is mandatory when such related donors are the only available ones.
Abnormal histopathology contraindicates donation.

71. Donor: urography
MRU
CTU

72. Donor : Angiography
MRA
CTA

73. Donor Evaluation: Radiology
Mansoura Experience

74. Donor Evaluation: Radiology
Mansoura Experience

75. Donor Evaluation: Radiology
Mansoura Experience

76. .
Donor Evaluation: Radiology
Mansoura Experience

77. • Multiple arteries did not affect clinical outcomes of open donor nephrectomy.
• For laparoscopic donor nephrectomy , multiple arteries were associated
with longer operative times and increased blood loss. Neither multiple
arteries nor vascular reconstructions influenced recipient creatinine
clearance or ureteral complication rate.
However, accessory arteries to the lower pole were associated with an
increased rate of ureteral complications.
Kok et al Transplantation. 2008 Jun 27;85(12):1760-5
Multiple renal arteries

78. Wednesday, February 3, 2016 GCP Aurangabad. 78

79. Donor Evaluation: Renogram

80. Donor Evaluation: Renogram

81. • Is it an easy task?
• Potential living donors should undergo a rigorous screening
• Procedure to ensure the best functional outcome for recipients
• No or minimal morbidity for donors.

82. 82
Dilemma in selection of living donors

83. Donor Evaluation
Mansoura Experience

84. Donor Evaluation
Mansoura Experience

85. Donor Evaluation
Mansoura Experience

86. Donor Evaluation
Mansoura Experience

87. Donor Evaluation
Mansoura Experience

88. Conclusions:
Although kidneys from living donors provide the best functional
outcome, 50% of potential candidates must be excluded.
Donor Evaluation
Mansoura Experience

89. TRANSPLANT PREPARATION SHEET
Name : Sex: Age: Y Wt: Kg
Number: Blood group : Social status: Offsprings:
1- EVALUATION : Nephrology Urology Special ECG
II- IMMUNOLOGY : *CXM:-ve *HLA: % *DR: % *MLC: : 1
III- LABORATORY : Urine: Analysis Culture Z.N. & PCR for T.B.
RFT LFT Bl. Sugar Hematology Sputum (Z.N.PCR)
Viral profile: HBV HCV CMV HIV
IV- RADIOLOGY : U.S. UTP C.X.R. MCUG Others
V- ENDOSCOPY : FOGD Bladder Rectum
VI- BIOPSY : Renal Liver Rectum Others
VII- DIALYSIS DURATION :
VIII- ORIGINAL KIDNEY DISEASE :
IX: UOP : c.c /day
NAME : Sex: Age: Y Wt: Kg Consanguinity:
Number: Blood group : Social status: Offsprings:
I- EVALUATION : Nephrology Urology Special ECG
II- LABORATORY : Urine: Analysis Culture Z.N. & PCR for T.B.
RFT LFT Bl. Sugar Hematology
Viral profile: HBV HCV CMV HIV
III- RADIOLOGY : C.X.R. U.S. UTP M.R.U
LT: LT: LT: ml/min
RT RT : RT: ml/min
* Patient : Renal allotransplantation.
* Donor : Nephrectomy
M.R.A. RenogramFlush
RECIPIENT
DONOR
‫المنصورة‬ ‫جامعة‬
‫ولية‬‫الب‬ ‫مسالك‬ ‫ال‬‫و‬ ‫الكلى‬ ‫اض‬‫ر‬ ‫أم‬ ‫كز‬‫ر‬ ‫م‬
MANSOURA UNIVERSITY
UROLOGY & NEPHROLOGY CENTER
MANSOURA EGYPT

90. TRANSPLANT PREPARATION SHEET
Name : Sex: Age: Y Wt: Kg
Number: Blood group : Social status: Offsprings:
1- EVALUATION : Nephrology Urology Special ECG
II- IMMUNOLOGY : *CXM:-ve *HLA: % *DR: % *MLC: : 1
III- LABORATORY : Urine: Analysis Culture Z.N. & PCR for T.B.
RFT LFT Bl. Sugar Hematology Sputum (Z.N.PCR)
Viral profile: HBV HCV CMV HIV
IV- RADIOLOGY : U.S. UTP C.X.R. MCUG Others
V- ENDOSCOPY : FOGD Bladder Rectum
VI- BIOPSY : Renal Liver Rectum Others
VII- DIALYSIS DURATION :
VIII- ORIGINAL KIDNEY DISEASE :
IX: UOP : c.c /day
RECIPIENT
‫المنصورة‬ ‫جامعة‬
‫البولية‬ ‫مسالك‬‫ال‬‫و‬ ‫الكلى‬ ‫اض‬‫ر‬ ‫أم‬ ‫ركز‬‫م‬
MANSOURA UNIVERSITY
UROLOGY & NEPHROLOGY CENTER
MANSOURA EGYPT
Transplantation Preparation Sheet Recipient
Name Sex: Age: y Wt: kg Ht cm
TX NO Blood group: social state: offspring:
I-Evaluation: Nephrology Urology special ECG
------------------------------------------------------------------------------------------------------
VII-Dialysis duration
------------------------------------------------------------------------------------------------------
VIII-Original kidney disease:
-------------------------------------------------------------------------------------------------------
IX-UOP: ML/day
II-Immunology: CXM HLA % DR % PRA : I
II
------------------------------------------------------------------------------------------------------
III-Laboratory: Urine analysis culture ZN&PCR for TB
RFT LFT BL.sugar Hematology sputum(zn>PCR)
Viral profile HBV HCV CMV HIV
---------------------------------------------------------------------------------------------------------
IV-Radiology: US UTP CXR MCUG others
-------------------------------------------------------------------------------------------------------
V-Endoscopies: FOGD Bladder Rectum
VI-Biopsy: Renal Liver Rectum Others
============================================================

91. VI- BIOPSY : Renal Liver Rectum Others
VII- DIALYSIS DURATION :
VIII- ORIGINAL KIDNEY DISEASE :
IX: UOP : c.c /day
NAME : Sex: Age: Y Wt: Kg Consanguinity:
Number: Blood group : Social status: Offsprings:
I- EVALUATION : Nephrology Urology Special ECG
II- LABORATORY : Urine: Analysis Culture Z.N. & PCR for T.B.
RFT LFT Bl. Sugar Hematology
Viral profile: HBV HCV CMV HIV
III- RADIOLOGY : C.X.R. U.S. UTP M.R.U
LT: LT: LT: ml/min
RT RT : RT: ml/min
* Patient : Renal allotransplantation.
* Donor : Nephrectomy
M.R.A. RenogramFlush
DONORTRANSPLANT PREPARATION SHEET
Name : Sex: Age: Y Wt: Kg
Number: Blood group : Social status: Offsprings:
1- EVALUATION : Nephrology Urology Special ECG
II- IMMUNOLOGY : *CXM:-ve *HLA: % *DR: % *MLC: : 1
III- LABORATORY : Urine: Analysis Culture Z.N. & PCR for T.B.
RFT LFT Bl. Sugar Hematology Sputum (Z.N.PCR)
Viral profile: HBV HCV CMV HIV
IV- RADIOLOGY : U.S. UTP C.X.R. MCUG Others
V- ENDOSCOPY : FOGD Bladder Rectum
VI- BIOPSY : Renal Liver Rectum Others
VII- DIALYSIS DURATION :
VIII- ORIGINAL KIDNEY DISEASE :
IX: UOP : c.c /day
RECIPIENT
‫المنصورة‬ ‫جامعة‬
‫البولية‬ ‫مسالك‬‫ال‬‫و‬ ‫الكلى‬ ‫اض‬‫ر‬ ‫أم‬ ‫ركز‬‫م‬
MANSOURA UNIVERSITY
UROLOGY & NEPHROLOGY CENTER
MANSOURA EGYPT
Rt / LT
Rt / LT

92. The living kidney donor:
giving life, avoiding harm

93. • Over the last decade.
• Mansoura Post donation Clinic.
• Recipient (hand in hand) with his/her related donor
• Evaluation:
Clinical: BP, BMI
Lab: urinalysis, S. Cr, Cr Clearance, etc…..
U/s for the remaining kidney
• Medications: provided when needed.
94

94. 95

95. 96

96. 97

97. 98

98. 99

99. 100

100. Successful Transplantation
GOAL
Good Preparation
=

103. Thank You