A new set of practice guidelines aims to help transplant professionals provide better evaluation and care for living kidney donors.
The Kidney Disease: Improving Global Outcomes (KDIGO) organization released the guidelines in August, although a draft was distributed for public comments as early as October 2013. The guidelines were developed by a group of international physicians in transplantation and dialysis care and in consultation with The Transplantation Society..
Guideline has 19 sections
The literature review for the main practice guideline on caring for kidney donors focused on the incidence of short-term (perinephrectomy) and long-term health outcomes for living kidney donors compared with healthy nondonors, looking at the occurrence of medical conditions like obesity and hypertension before and after donation.
Key recommendations in the guidelines include:
- Provide the donor candidate with individualized estimates of short- and long-term risks.
- Evaluate medical risks with respect to predetermined program acceptance thresholds.
- Obtain consent from the donor candidate for evaluation.
- Obtain consent from the donor candidate for donation. Specifically, “The transplant program has a responsibility to establish that the donor candidate has the capacity to give informed consent, is adequately informed of the likely risks and benefits of donation and the alternative treatment options available to the potential recipient understands this information, and is acting voluntarily,” the guidelines note. “Transplant programs need a process to ensure that the requirements of informed consent are met.
At least a portion of the informed consent process should be performed in the absence of the potential recipient, family members, and other persons who could influence the donation decision to minimize risks of a conflict of interest or external pressures, the authors wrote.
Other recommendations include:
- Determine ABO blood type and human leukocyte antigen compatibility
- Inform incompatible donors about exchange programs and incompatible live donor transplantation options
- Conduct a preoperative assessment as per local guidelines to minimize risk
- Estimate glomerular filtration rate (GFR) using serum creatinine-based estimating equations
- Assess albuminuria using albumin-to-creatinine ratio in an untimed urine specimen.
- Confirm albuminuria with albumin excretion rate (AER) in a timed urine specimen or by repeating albumin-to-creatinine ratio if AER cannot be obtained.
- Perform testing to identify cause of microscopic hematuria that is not reversible. “The presence of hematuria is not normal and should always be evaluated when found in a donor candidate,” the guidelines state.
- Assess history and renal imaging for kidney stones and gout
- Measure blood pressure before donation on at least two occasions.
- Assess risk factors for kidney and cardiovascular disease, including:
- Body mass index (BMI)
- History of diabetes mellitus, gestational diabetes, and family history of diabetes
- Fasting blood glucose and/or glycated hemoglobin (HbA1c)
- Fasting lipid profile including total cholesterol, low-density lipoprotein cholesterol and high-density lipoprotein cholesterol, and triglycerides
- Present and past use of tobacco products
“Metabolic and lifestyle risk factors for kidney and cardiovascular disease should be identified prior to donation and addressed by counseling to promote long-term health…The decision to approve donor candidates with obesity and BMI greater than 30 kg/m2 should be individualized based on demographic and health profile in relation to the transplant program’s acceptance threshold,” the guidelines offer.
Obtain screening tests for the following infections before donation:
- Human immunodeficiency virus
- Hepatitis B virus
- Hepatitis C virus
- Epstein-Barr virus
- Treponema pallidum (syphilis)
- Urinary tract infection
- Other potential infections based on geography and environmental exposures
“Evaluation of donor candidates should include assessment of the individual’s history of past infections and infectious disease risk factors (e.g., risk of local endemic infections or travel to endemic areas), awareness of current patterns of geographically endemic infections, and focused microbiological screening,” the guideline authors wrote.
Perform cancer screening as per local guidelines, and assess family history of kidney disease
Confirm a negative quantitative human chorionic gonadotropin (β-hCG) pregnancy test immediately before donation in women with childbearing potential. “Female donor candidates should be asked about prior hypertensive disorders of pregnancy (e.g., gestational hypertension, preeclampsia, or eclampsia).
Perform face-to-face psychosocial evaluation, education and planning session with 1 or more trained, experienced health professionals. “The psychosocial evaluation helps determine if a donor candidate is psychologically fit for donation, addresses donor candidate concerns, and ensures potential psychosocial risks and benefits of kidney donation are disclosed and understood. The psychosocial evaluation can also be used to develop a plan to support the donor candidate in having a positive psychosocial experience throughout the evaluation and donation processes, and long-term after donation.”
• Select optimal surgical approach by an experienced surgeon.
• Follow local laws and regulations on living donation, and explain these rules to donor candidates.
• Respect donor autonomy during all phases of evaluation and donation, including:
Perform annual post donation, follow-up care that includes:
• Blood pressure measurement
• BMI measurement
• Serum creatinine measurement with GFR estimation
• Albuminuria measurement
• Review and promotion of healthy lifestyle practices including exercise, diet, and smoking abstinence
• Review and support of psychosocial health and well-being.