Improving Live Donor Kidney Transplant Guidelines: More Evidence Required

Abstract

The availability of clinical guidelines on living donor kidney transplantation has undoubtedly aided clinical decision-making in this area and hopefully helped to minimize adverse outcomes and unintended harm to living donors. Several countries, including the United Kingdom, the United States, Canada, Australia, and countries in continental Europe, have published guidelines that cover the screening and follow-up of living kidney donors. In addition, in 2005, the Transplantation Society produced an international consensus report from the Amsterdam Forum that includes medical guidelines for living donation. The intention of guidelines is to synthesize available evidence into recommendations for best practice. Where evidence is poor or lacking, it is replaced by aspiration or opinion, either of an individual or, more often, a group of clinicians with experience in the area in question. How do the various guidelines compare? In this issue of Transplantation, Tong et al. (1) report a carefully undertaken and comprehensive comparison of the scope, quality, and consistency of the published guidelines on the screening of potential living donors and donor follow-up. They evaluated nine published guidelines, including those from the Amsterdam Forum, using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument (2). This appraisal instrument examines the quality of the guidelines, both in terms of the evidence used and the way it is reported, and provides a benchmark for producing high-quality guidelines. The quality of guidelines assessed was variable. Reassuringly, many of the recommendations made in the different published guidelines were consistent. However, in several areas, the guidelines differed in their recommendations, particularly with respect to the medical contraindications to donation. For example, the acceptable thresholds stated for hypertension, obesity, glucose metabolism, and cardiovascular disease were not consistent across the different guidelines, although some of these differences may reflect the different populations for which they were written. Tong et al. also make the important observation that although the published guidelines are consistent in emphasizing the importance of assessing the potential donors' psychological state, they failed to provide adequate guidance on how and with what tools psychological state should be assessed. Many of the recommendations made in the guidelines examined were based on limited evidence, and this reflects the relative lack of good long-term data on which to base such guidance. Given the lack of available high-quality evidence in many areas, it is not perhaps surprising that there should sometimes be a lack of consensus. This should serve, however, as a very timely reminder of the need to improve the evidence base for evaluating potential living donors. This requires much better long-term follow-up data than is currently available, and this need is particularly pressing in view of the trend toward accepting living donors which may in previous years have been declined on the basis of comorbid conditions. Living kidney donation is a major undertaking for donor and recipient. The donor agrees to undergo surgery in the belief that the risks are defined and are minimized. They have a right to understand fully the short- and long-term risks of donation that they are exposing themselves to, especially where comorbidity makes them less than ideal donors. There are many barriers to achieving long-term follow-up, in addition to the cost and workload involved. The donor may live some distance from the transplant unit, and may be ambivalent about participating in long-term follow-up, or may not wish to be reminded about their surgery and that there may be long-term sequelae. Similarly, long-term studies are not appealing to research funding bodies or researchers because the results by definition will be a long time coming and as such are not useful for career progression. Nevertheless, it is important that more effort is made by the medical community to follow-up, and when necessary give appropriate support to, living donors. Perhaps the most important message from the study of Tong et al. is that there is a need for more effort to be made in gathering long-term data on living donors. Their call for mandatory submission of registry data, along with improved long-term monitoring by healthcare providers, and appropriate education and support to maintain a healthy lifestyle should be supported. Tong et al. conclude that there is an urgent need to ensure that guidelines for living donation are consistent, evidence-based, and comprehensive to promote best outcome. Most transplant clinicians would agree, but the key to this is a better evidence base than is currently available. A major focus on improving the evidence base in living donor assessment and long-term outcome is required without delay. Other clinical practice guidelines should adopt the same rigorous approach recommended for living kidney donor guidelines if they are to be accurate, useful, and appropriate.