Potential Living Kidney Donors Research Articles

Analyse der mehrphasigen 64-Zeilen-Multidetektor-Computertomographie zur präoperativen angiographischen Evaluation potenzieller Lebendnierenspender

Anatomical imaging and the ascertainment of any anomalies in the renal vessels and the ureters are essential in the planning of a kidney donation. The aim of the present study was to assess the value of 64-row multidetector CT in noninvasive examination of the renal vessels and ureters of potential living kidney donors. The evaluation embraced 63 living renal donors (LNS) who underwent preoperative CT examination from December 2004 to January 2007. The examinations were all carried out using a Somatom Sensation -Cardiac 64 (Siemens Medical Solutions, Germany). As well as CT angiography (CTA), a venous phase of the abdomen and a late phase after 15 min using low-dose technique were performed for CT urography (CTU). The radiological findings were compared with the surgical results, or with the angiograms in 2 cases. Sensitivity, specificity and both negative and positive predictive value were calculated. In the 63 (31 female, 32 male) donors CTA had a sensitivity of 100% in examination of the main and accessory renal arteries and of 98.3% when the venous and ureteric anatomy were assessed. The sensitivity of low-dose CTU was also 100%. The findings recorded in this study indicate that noninvasive preoperative planning with 64-row multidetector CTA and CTU is a reliable "one-stop shopping" method of examination for potential living kidney donors.

Evaluating Living Kidney Donors: Relationship Types, Psychosocial Criteria, and Consent Processes at US Transplant Programs

We conducted a survey of 132 US kidney transplant programs to examine how they evaluate and select potential living kidney donors, focusing on donor-recipient relationships, psychosocial criteria, and consent processes. There is heterogeneity in donor-recipient relationships that are considered acceptable, although most programs (70%) will not consider publicly solicited donors. Most programs (75%) require a psychosocial evaluation for all potential living donors. Most programs agree that knowledge of financial reward (90%), active substance abuse (86%), and active mental health problems (76%) are absolute contraindications to donation. However, there is greater variability in how other psychosocial issues are considered in the selection process. Consent processes are highly variable across programs: donor and recipient consent for the donor evaluation is presumed in 57% and 76% of programs, respectively. The use of 13 different informed consent elements varied from 65% (alternative donation procedures) to 86% (description of evaluation, surgery and recuperative period) of programs. Forty-three percent use a 'cooling off' period. Findings demonstrate high variability in current practice regarding acceptable donor-recipient relationships, psychosocial criteria, and consent processes. Whether greater consensus should be reached on these donor evaluation practices, especially in the context of more expansive use of living donor kidney transplantation, is discussed.

Routine Use of Ambulatory Blood Pressure Monitoring in Potential Living Kidney Donors

Most transplant centers exclude prospective living kidney donors with hypertension from donation. Centers routinely identify hypertension using BP measured in the clinic, but it is not clear that clinic BP accurately detects the presence or absence of hypertension in potential donors. We therefore conducted a prospective study to determine the impact of routine ambulatory BP monitoring on diagnosis of hypertension in potential donors and the value of other baseline characteristics in predicting ambulatory BP results. We compared classification of hypertension status by clinic BP and by ambulatory BP monitoring in 178 potential living kidney donors. Of 63 individuals with hypertension by clinic BP, 62% had white-coat hypertension by ambulatory BP and were therefore eligible to donate. Of 115 individuals who were normotensive by clinic BP, 17% had masked hypertension by ambulatory BP and were excluded from donation. Individuals with masked hypertension were older, were more likely to be male, and had a somewhat higher clinic BP than individuals with sustained normotension. Individuals with white-coat hypertension had a somewhat lower clinic diastolic BP than individuals with sustained hypertension. Routine ambulatory BP monitoring may identify a large number of individuals with white-coat hypertension and a smaller but significant number of individuals with masked hypertension, ensuring adequate protection of potential donors and accurate assessment of donor risk. Differences in baseline characteristics are small and are not clinically useful in distinguishing individuals with masked hypertension from individuals with sustained normotension or individuals with white-coat hypertension from individuals with sustained hypertension, demonstrating the importance of ambulatory BP monitoring in this population.

Extrarenal CT angiography findings in potential living kidney donors: costs and consequences

Extrarenal CT angiography findings in potential living kidney donors: costs and consequences

Transplant professionals vary in the long-term medical risks they communicate to potential living kidney donors: an international survey

Discussing long-term medical risks with potential living donors is a vital aspect of informed consent. We considered whether there are global practice variations in the information communicated to potential living kidney donors. Transplant professionals participated in a survey to determine which long-term risks are communicated to potential living kidney donors. Self-administered questionnaires were distributed in person and by electronic mail. We surveyed 203 practitioners from 119 cities in 35 different countries. Sixty-three percent of participants were nephrologists, and 27% were surgeons. Risks of hypertension, proteinuria or kidney failure requiring dialysis were frequently discussed (usually over 80% of practitioners discussed each medical condition). However, many practitioners do not believe these risks are increased after donation, with surgeons being less convinced of long-term sequelae compared with nephrologists (P < 0.01). About 30% of practitioners discuss long-term risks of premature cardiovascular disease or death with potential donors. Transplant professionals vary in the long-term risks they communicate to potential donors. Improving consensus will enhance decision-making, and emphasize best practices which maintain good, long-term donor health.

Extrarenal CT angiography findings in potential living kidney donors: costs and consequences

Extrarenal CT angiography findings in potential living kidney donors: costs and consequences

Typologie des potentiels donneurs vivants de rein en Côte-d'Ivoire : une enquête prélude à un projet de greffe de rein en Afrique noire francophone

The source of living kidney donors in the general population remains underused. The present study aims at assessing the prevalence and the characteristics of potential living kidney donors in Ivory Coast in a view of a project of kidney transplantation in French Black Africa. A survey was undertaken in Abidjan from 30 june to 7 july 2006. Nine hundred (and) sixty-two subjects living in the capital and aged between 19 and 64 years old were randomly chosen using data from the 1998 population census. Subjects were asked their age, gender, nationality, marital status, information on kidney graft and renal failure, and their willingness to donate kidney to a relative or friend for transplantation purpose. Seventy per cent of the population study appeared favourable to kidney donation. Potentials living kidney donors have displayed following characteristics: age inferior to 26 years old [OR = 2.08, P < 0.02, 95%CI: 1.10–3.92]; ivorians national [OR = 2.72, P < 0.002, 95% CI 1.42–5.21]; having heard of kidney transplantation (OR = 1.89, P < 0.047, 95% CI 1–3.54]); the death of a relative or friend from renal failure [OR = 1.82, P < 0.002, 95 % CI 1.25 2.67]. Being married adversely affect kidney donation [OR = 0.52, P < 0.0002, 95% CI 0.34–0.79]. Potentials living kidney donors are in great number in Ivory Coast, who had specific characteristics.

Improving on-line information for potential living kidney donors

Individuals who consider becoming living kidney donors often search the internet for reliable information before contacting the transplant center. The quality of such information requires due consideration. Using the search engines Google and Yahoo and the WebMD information portal, two reviewers independently abstracted data on the classification, readability, and general quality of websites. The coverage and accuracy of each site's discussion of the risks, benefits, and process of living donation was also assessed against a checklist of recommended information. Eighty-six unique websites on living kidney donation were found. Most were created by transplant programs and transplant organizations. Although the content of most sites was accurate, almost all (98%) were written above the recommended patient reading level (i.e., fifth grade). On average, each site covered 38% of the recommended information on living donation (range 8-76%). Educational topics of potential long-term medical risks, psychological risks, and expected benefits to the donor were often missing. The most visited websites were often not ranked among the best sites to provide information. By better understanding the nature of on-line information, transplant professionals can direct their patients to the best available websites. Local educational efforts, including the effective use of internet resources, will ensure living donation and complete understanding of the risks by potential donors and recipients.

Decentralized glomerular filtration rate (GFR) estimates in healthy kidney donors show poor correlation and demonstrate the need for improvement in quality and standardization of GFR measurements in Sweden

Objective. Glomerular filtration rate (GFR) is generally accepted as the best overall index of renal function. Thus, all potential live kidney donors are tested to ensure that they have a normal GFR before they are eligible for kidney transplantation. The choice of GFR test is very much dependent on local traditions and may include iohexol, 51Cr‐EDTA, inulin, or creatinine clearance based on urine collection, and creatinine clearance calculated from the Cockcroft‐Gault or Modification of Diet in Renal Disease (MDRD) equation as well as cystatin C. The aim of this study was to compare the results of GFR measurements performed in all actual live kidney donors who have undergone live donor nephrectomy at the University Hospital in Uppsala, Sweden, between the years 2000 and 2004. Material and methods. The patients were selected from all parts of Sweden and the measurements were performed at their local hospital. Results. We found large discrepancies between repeated iohexol measurements in these presumably healthy individuals. There was also a poor correlation between iohexol clearance and calculated creatinine clearance using the Cockcroft‐Gault (R2 = 0.046) or MDRD formula (R2 = 0.045). Conclusions.The study shows that the standardization and quality of GFR measurements in Sweden have to be improved.

Economic and ethical impact of extrarenal findings on potential living kidney donor assessment with computed tomography angiography

To determine the prevalence and spectrum of extrarenal findings in a screening population of potential living kidney donors undergoing renal Computed tomography angiography (CTA) and evaluate their impact on subsequent patient management and imaging costs. Two radiologists retrospectively reviewed 175 consecutive renal CTA's performed for assessment of potential living kidney donors. Extrarenal radiological findings were recorded and classified according to high, medium, or low importance based on clinical relevance and the need for further investigations and/or treatment. The cost of additional imaging examinations was calculated using 2002 Canadian (British Columbia) reimbursements. There were 73 extrarenal findings in 71/175 (40.6%) of the potential kidney donors in the study population. Findings were categorized as of high clinical importance in 18 (10.3%) cases, including lung lesions, bowel tumors, and liver tumors and as medium importance in 31 (17.7%). Twenty-two (12.6%) individuals had findings categorized as low importance, probably of no clinical significance and requiring no follow-up. Further potential evaluation of the 49 patients (28%) with highly and moderately significant extrarenal findings may require an additional $6137 (mean $35.1 per each case of all the screened patients). Transplantation of a kidney from a living donor is an excellent alternative to cadaveric allografts. Potential living kidney donors are a highly selected population of healthy individuals, screened for significant past or current medical conditions before undergoing CTA. Despite this screening, potentially significant extrarenal findings (classified as high or medium importance) were revealed in 28% of patients. These patients may require further investigations and/or treatment. The referring physician and patient should be aware of such potentially high probability, which may require further nontransplant related evaluation and treatment. This has medical, legal, economic, and ethical implications.

Gender Disparities in the Live Kidney Donor Evaluation Process

Females are live kidney donors more often than males. We examined the pool of potential donors to determine at what point in the donor evaluation process this gender disparity develops. We selected patients who underwent blood typing as potential live kidney donors for recipients being evaluated for transplantation at our center between January 2000 and January 2004. We reviewed patient records to determine when in the evaluation process elimination occurred: ABO incompatible, positive cross-match, no medical workup, medical workup incomplete, medical contraindication, social contraindication, recipient too sick or dead, approved but did not donate, or donated. A total of 506 potential donors (55% female, 45% male) were evaluated. Males and females were equally likely to get through each step of the evaluation and be approved for donation. Overall, females were significantly more likely to donate than males. However, when approved donors are divided into those who were evaluated during the open nephrectomy (ON) era versus the laparoscopic nephrectomy (LN) era, the gender disparity among donors was present only in the ON era. In the ON era, there were 54 donors, 37 females and 17 males (P=0.004), whereas in the LN era, there were 61 donors, 32 females and 29 males (P=NS). Among potential donors approved for donation, females have been significantly more likely to donate than males. The introduction of LN at our center was associated with a decrease in the gender difference in kidney donation.

Optimizing Living Donor Kidney Graft Function by Donor-Recipient Pair Selection

With the rising prevalence of living donor kidney transplantations (LDKT), we increasingly encounter transplant candidates who present with multiple potential living donors. For a given candidate, it can be unclear which donor offers the best opportunity for optimal posttransplant graft function. This study was undertaken to determine the relative contributions of individual donor demographic factors on graft function following LDKT. All LDKT donor-recipient pairs between January 1, 1999 and December 31, 2002 entered into the Scientific Registry of Transplant Recipients (SRTR) were reviewed. Suboptimal one year graft function was defined as a serum creatinine (Cr) greater than 1.5 mg/dL. Of 20,528 adult LDKTs performed, 8,603 donor-recipient pairs had complete donor, recipient, and one year graft function data. Over one third (36%) of all LDKTs had suboptimal one year graft function. Logistic regression identified simple recipient and donor characteristics associated with suboptimal one year graft function. Four recipient factors (age, gender, race, and size), three donor factors (age, gender, and size) and recipient-donor relatedness were used to derive an equation that predicts the risk of suboptimal one year graft function posed by each potential living donor for a given transplant candidate. In the setting of multiple potential living kidney donors, this quantitative tool may facilitate the choice of the optimal donor.

Lean body mass‐adjusted Cockcroft and Gault formula improves the estimation of glomerular filtration rate in subjects with normal‐range serum creatinine

Assessment of glomerular filtration rate (GFR) in individuals with normal-range serum creatinine is important in certain clinical situations, such as in potential living kidney donors. Accurate measurements of GFR invariably involve using an invasive method (e.g. inulin clearances), but is inconvenient. The aim of the present study was to determine whether serum creatinine-based prediction formulae adjusted for lean body mass (LBM) could improve the accuracy of GFR estimation in these subjects. Glomerular filtration rate was determined by the clearance of technetium-99m-labelled diethylenetriamine penta-acetic acid ((99m)Tc DTPA) from plasma in 56 subjects with normal serum creatinine. For each subject, GFR was estimated using prediction formulae +/- LBM adjustment and compared with measured GFR. Formulae analysed include Cockcroft-Gault, Levey, Gates, Mawer, Hull, Toto, Jellife and Bjornsson. All formulae +/- LBM adjustment underestimated measured GFR, with poor precision, poor agreement and correlation (r (2) <or= 0.25). Between 69% and 95% of the estimated GFR determined by the formulae correctly classified those with a normal measured GFR. LBM-adjusted formulae significantly improved the accuracy of GFR estimation compared with unadjusted formulae. The lean body mass-adjusted Cockcroft-Gault formula was the closest to measured GFR but is not accurate enough to replace radionuclide GFR measurement. Prediction formulae should be adjusted for LBM to improve GFR estimation.

Direction of the Organ Procurement and Transplantation Network and United Network for Organ Sharing Regarding the Oversight of Live Donor Transplantation and Solicitation for Organs

The Organ Procurement and Transplantation Network (OPTN) operated by United Network for Organ Sharing (UNOS) has taken recent steps to address public solicitation for organ donors and its oversight of live donor transplantation. This report provides the direction of the OPTN regarding deceased donor solicitation. The OPTN has authority under federal law to equitably allocate deceased donor organs within a single national network based upon medical criteria, not upon one's social or economic ability to utilize resources not available to all on the waiting list. The OPTN makes a distinction between solicitations for a live donor organ versus solicitations for directed donation of deceased organs. As to live donor solicitation, the OPTN cannot regulate or restrict ways relationships are developed in our society, nor does it seek to do so. OPTN members have a responsibility of helping protect potential recipients from hazards that can arise from public appeals for live donor organs. Oversight and support of the OPTN for live donor transplantation is now detailed by improving the reporting of live donor follow-up, by providing a mechanism for facilitating anonymous live kidney donation, and by providing information for potential live kidney donors via the UNOS Transplant Living website.

Living Donor Kidney Transplantation

Living Donor Kidney Transplantation Gaston, RS, Wadström, J (eds). London: Taylor & Francis, 2005. Hardcover, 196 pages. Living Donor Kidney Transplantation is a new book published by Taylor & Francis. The editors, R. S. Gaston and J. Wadström, have compiled a remarkable source of up-to-date information on living donor kidney transplantation from well-known experts in the field. There are 15 chapters that deal with various aspects of living donor kidney transplantation with an emphasis on practical medical and ethical issues, in many cases supported by careful metaanalysis of published evidence. The first chapter gives a brief history of living donor kidney transplantation and its vital role in the development of transplantation surgery as a whole. It addresses the paradigm shifts that first resulted in a decline in living donation activity during the cyclosporine era and the major resurgence seen in the last decade. The second chapter nicely brings together the landmark findings drawn from huge databases that prove not only the long-suspected survival advantage of MHC-matched living-related over cadaveric kidney transplantation or chronic dialysis, but more importantly demonstrate a substantial survival benefit of MHC-mismatched living-unrelated as compared to cadaveric transplantation. Chapter 3 focuses on the theoretical advantages of living donor transplantation with respect to tolerance induction protocols. The availability of donor cells and tissues well in advance of the procedure could obviously be exploited for the implementation of protocols that ask for donor-specific blood transfusions or adjunctive bone marrow transplantation before solid organ grafting. This chapter provides an adequate introduction to the field and enables readers with a special interest in the field of induction of donor-specific tolerance to locate the more specialist literature. The following two chapters give a detailed description of evaluation proceedings and selection criteria of potential living kidney donors as well as statistical data on the risk of kidney donation in healthy donors as compared to donors with isolated medical abnormalities (i.e., arterial hypertension). In Chapter 6, J. Wadström describes the multitude of surgical techniques to living kidney donation that are in use today, such as open intra- or extraperitoneal, laparoscopic intra- or extraperitoneal, and the various modifications and combinations of these. The focus here lies on comparing statistical risks of the different surgical techniques in an attempt to find the “best” approach. Chapters 7 and 8 provide a detailed account of the medical and psychological long term risks for the kidney donor including an exhaustive review of the respective literature. Overcoming ABO incompatibility between donor and recipient is an interesting field in itself, but in living donor kidney transplantation there are special implications. Many potential donors for living-related or living-unrelated transplantation are rejected solely on grounds of ABO incompatibility with the recipient despite evolving data in support of ABO-incompatible kidney transplantation. The considerations necessary for implementation of ABO incompatible kidney transplantation, including blood group antibody-depleting protocols are discussed in detail in Chapter 9. Chapter 10 then focuses on another antibody-mediated hurdle to kidney transplantation, preformed allo-antibodies. Here, the Johns Hopkins group describes their plasmapheresis/intervenous immunoglobulin (IVIg)-based protocol to deplete donor-specific antibodies from the serum of sensitized recipients of living-donor kidney transplantation. These protocols are only feasible in living donor transplantation since the depletion has to be started weeks before surgery. It seems likely that the anticipated advantages of a timely transplant, avoiding long periods of time on hemodialysis, may well outweigh any potential disadvantages of antibody-depleting protocols, such as morbidity caused by frequent plasmapheresis, IVIg administration, or anti-CD20 Ab treatment. Two further chapters discuss new ways to increase the donor organ pool, namely paired-exchange and nondirected living donation by altruistic individuals. Although controversial to some degree in the public perception and not in line with legislation in some European countries, these approaches make donor organs available that could otherwise not be transplanted. The authors also make a strong point in carefully explaining the respective ethical standards and precautions required to ensure sound ethical practice. The final three chapters of this very relevant book discuss further the various ethical issues connected with living donor kidney transplantation. The editors have to be credited for including these difficult issues in such detail. In particular, Chapter 15, providing evidence in favor or against paying living donors from two contributors with very different standpoints, is a stimulating read. Taken together, this new book is a very worthy addition to bookshelves, not only of specialists in the field, but also individuals or institutions with a more general interest in the medical and ethical developments of living organ donation. Gregor Warnecke, M.D.

EXPANDING THE DONOR POOL - WE NEED MORE LIVING DONORS

This paper describes some of the issues currently influencing thoughts and practice in expanding the use of living kidney donors. One of the challenges facing kidney transplantation is the increasing number of patients with Established Renal Failure (ERF) waiting for a kidney, and the ethical concerns raised as a result of meeting these challenges by the use of living donors. Nephrology professionals play an important role in the education of patients and potential living kidney donors and should be familiar with current issues related to this field.

Novel MRI technique for assessing potential live kidney donors

Novel MRI technique for assessing potential live kidney donors

Attitudes, Psychology, and Risk Taking of Potential Live Kidney Donors: Strangers, Relatives, and the General Public

It is unclear whether potential living kidney donors and the general public differ in attitudes and psychological characteristics. We performed a case-control study to explore differences in these groups using a standardized questionnaire (analyzed using conditional logistic regression). Strangers (N = 42) were more willing than controls (N = 126) to incur risks: 64% strangers versus 35% controls accepting >50% medical complications (MC) risk; 90% strangers versus 61% controls accepting >8 days hospitalization; 71% strangers versus 43% controls accepting >3 months unpaid; 55% strangers versus 16% controls accepting 100% kidney failure (KF) risk; 70% strangers versus 34% controls accepting < or =10% likelihood of successful transplant (all p < 0.01). Relatives (N = 251) were also more willing than controls (N = 251) to incur risks. Strangers were most willing to incur MC, KF and transplant failure. Groups did not differ in attitudes, depression or anxiety. Potential stranger and related donors are willing to undergo greater risks with donation than the general public, but do not differ in other attitudes, depression or anxiety. This should help reassure transplant centers and the public that both forms of live donation do not necessarily involve increased ethical risks of donor coercion or irrational thought processes. Still, careful attention to communication of all risks of donation is warranted.

Magnetic resonance imaging as a sole method for the morphological and functional evaluation of live kidney donors

To evaluate gadolinium-enhanced dynamic magnetic resonance imaging (MRI) as the sole method for the anatomical and functional assessment of potential live-kidney donors. The study included 50 consecutive kidney donors; in addition to routine donor evaluation, the kidney was imaged with Gd-enhanced dynamic MRI, which was also used for selectively determining the glomerular filtration rate (GFR) of each kidney. All donors had a m99Tc-mercaptoacetyltriglycine (MAG3) renal scan as the reference standard to measure GFR. The anatomical results of MRI were compared with the findings at donor nephrectomy, and the GFR estimated from MRI compared with that from MAG3 scintigraphy. MR angiography had 100% sensitivity, 94% specificity and 96% overall accuracy for detecting the number of renal arteries, and 100% sensitivity, 98% specificity and 98% overall accuracy for the number of renal veins. There was a close correlation (r = 0.54, P < 0.01) between the GFR of each kidney estimated by MRI or MAG3. For the right and left kidneys the mean isotope clearance was not significantly different from that of mean MRI clearance. MR urography allowed visualization of the urinary tract and the detection of any abnormality. Gd-enhanced dynamic MRI can provide accurate information about the anatomy of the urinary tract and vasculature of the kidney, and can be used to accurately estimate the selective GFR of each kidney. Therefore, we recommend MRI as a single imaging diagnostic method for assessing potential live kidney donors.

Patterns of Volunteerism, Testing, and Exclusion Among Potential Living Kidney Donors

We found that in kidney transplantation, more females donate. We analyzed transplant recipients for patterns of potential donor exclusion and found that equal proportions of male and female po tential donors existed among first-degree biological relatives. More male recipients were married and therefore had more spousal potential donors. Among friends and non-first-degree relatives, significantly fewer males offered to donate to females. Equal proportions of female and male potential donors were excluded from donating for medical comorbidities, blood type incompatibility, recipient refusal, and potential donor reluctance. We concluded that female transplant candidates had fewer potential donors among spouses and opposite sex volunteers from friends and non-first-degree relatives.