Living related donor workup- CPG

36. LIVING RELATED DONOR WORKUP

36.1 Patient information

36.1.1 Short term risk
a. Surgical risk
Mortality rate of 0.03 – 0.05 %1,2,3
Morbidity (Table 36.1)2

Table 36.1: Summary of the incidence of early complications after donor nephrectomy
Complications Incidence
Atelectasis 15-30 %
Paraesthesia / nerve injury 6 %
Urinary tract infection 5 %
Pneumothorax 5 %
Wound infection 3 %
Blood transfusion 2 %
Pneumonia 1 %
Splenectomy 0.3 %
Pulmonary embolism 0.3 %

b. Psychological risk1
Minor feelings of depression are common in the immediate post operative period; more so if the graft fails

36.1.2 Long term risk to renal function is minimal4,5,6 (Level B)
There is no increase in proteinuria. There was a small increase in blood pressure but this increase was insufficient to result in increased prevalence of hypertension 4

36.1.3 Results of graft and recipient survival is dependent on the centre (refer to Renal Registry)

36.1.4 Assurance that donor may withdraw at any stage of pre transplant assessment

36.2 Selection criteria
36.2.1 Siblings / parents are the best donor1,3 (Level B)
In the absence of a relative, consideration can be given to emotionally related donor7 (Level B)

36.2.2 Age
Exclude those who are <> 65 years of age8,9,10,11,12 Biological age is more important than chronological age

36.2.3 ABO compatibility1,3,13 (Level A)

36.2.4 HLA A, B, DR phenotypes3 (Level A)
Priority should be given to the donor with 1 or 2 haplotype match

36.3 Contraindications to renal donation1,3,6,14
36.3.1 Absolute contraindications
a. Proteinuria / haematuria (refer to 36.4.4)
b. Impaired renal function (refer to 36.4.4)
c. Hypertension > 140/90 mmHg
d. Diabetes mellitus
e. Family history of type 2 diabetes mellitus with impaired glucose tolerance test
f. Transient gestational diabetes 15
g. Psychiatric illness e.g. psychotic disorders
h. Coagulopathy
i. Systemic illness with potential to develop renal disease
j. Drug abuse e.g. amphetamines, heroin and cocaine
k. Severe cardiac and pulmonary disease
l. Infectious disease eg. HIV
m. Pregnancy
n. Adult polycystic kidney disease (APKD).
For donors who are relatives of recipient with adult polycystic kidney disease use of US kidneys to rule out APKD is according to the following criteria 16 (Level B):
• Donor of less than 30 years of age, 2 cysts establish APKD. The cysts may be either unilateral of bilateral
• Between 30 to 59 years of age, at least 2 cysts must be present in each kidney
• Over the age of 60, 4 cysts must be present in each kidney

36.3.2 Relative contraindications
a. Obesity: BMI > 30 15,17,18
b. Living related donor <>10mIU/l)
• Renal donation from HCVAb positive donor to HCVAb positive, HCV RNA positive recipient is relatively safe19,20,21 provided the HCV genotype is similar (Level D). There is no difference in liver disease prevalence over a period of 10 years.21,22 Caution: Superinfection with a new genotype can occur unless HCV genotypes in donor-recipient are matched.22
f. Donors who are relatives of recipient with Alport’s syndrome 1
• Male relatives without haematuria can become a donor
• Female relatives without haematuria might be a carrier and she should consider that her child may inherit the disease and require future transplantation. Final decision should preferably be based on genotyping
• Recipient who gets a kidney from someone without Alport’s syndrome may develop anti glomerular basement membrane disease

36.4 Donor assessment
36.4.1 Motivation and psychosocial status assessment
The motive to donate to the potential recipient should be entirely altruistic. The potential donor should not be under duress, coerced or induced to donate. The potential donor should be seen individually and given sufficient time to decide. The rest of the family should also be seen to obtain collateral and feedback information. Other members of the transplant team including the dialysis staff should interact with the potential donor so that a continuous assessment of the motivation can be made and further doubts cleared.
In doubtful cases and in cases involving spousal donors, the potential donor should be independently assessed by another person outside the transplant team e.g. social worker, psychiatrist.

36.4.2 Cardiovascular assessment
ECG, CXR, fasting triglyceride and cholesterol
Referral for cardiology assessment is indicated for:
a. male donor who is more than 45 years old
b. female donor who is 50 years old or premature menopause.
c. donors who are 35 years or older with coronary risk factors e.g. smoking, family history of coronary heart disease, dyslipidaemia, obesity

36.4.3 Respiratory assessment
Potential donor with chronic smoking history and symptoms of chronic lung disease should be referred to a respiratory physician and anaesthetist for assessment.

36.4.4 Assessment of donor renal status
A full history and examination should be carried out with particular attention to the recipient’s primary renal disease and any history of familial renal disease.
Investigations include the following:
a. Renal profile
b. Fasting blood sugar (glucose tolerance test if indicated)
c. Serum calcium and phosphate, uric acid
d. Urine cystine, uric acid, calcium, phosphate (X3).
Abnormally high results should be assessed individually
e. 24 hour creatinine clearance (X3).
Exclude <> 300 mg /day8
g. Urine microscopy (X3)
h. Ultrasonography of the kidneys
i. KUB
j. IVP
k. DTPA renography. If GFR contradicts the 24 hour urine creatini-ne clearance, proceed to Cr EDTA scan
l. Selective renal angiography. Spiral CT angiogram23.24.25 (Level C) or Gadolinium-enhanced magnetic resonance angiography26 (Level C) could be an alternative

36.4.5 Assessment of potential risk of transmitting infection to the
recipient
a. Screening and treatment of
• Syphilis
• Tuberculosis
• Urinary tract infection
b. Screening of
• HIV
• HBV (including HBeAg in HBsAg positive cases)
• HCV antibody
• Toxoplasmosis
• Cytomegalovirus (See section on: Prevention of CMV disease post transplantation)

36.5 Laparoscopic donor nephrectomy
Laparoscopic donor nephrectomy can be performed with morbidity and mortality comparable to open donor nephrectomy in established centres27,28,29 (Level B)
36.5.1 First introduced in 1991
36.5.2 Benefits of laparoscopic versus open method are:
a. Shorter hospital stay
b. Less analgesic requirement
c. Earlier return to work
d. Less blood loss
e. Improved cosmetic results
f. No deaths reported
g. Can be performed on obese patients
h. Multiple renal vessels are not a contraindication

36.5.3 Disadvantages of laparoscopic method:
a. Longer operating time
b. Technically more demanding

36.5.4 Relative contraindication to laparoscopic method:
a. Prior open upper abdominal surgery
b. Right sided donor nephrectomy




References
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2. Richard DM, Stephen VL, Russell WS. The Living Organ Donor. Jeremy C (eds.). Organ and Tissue Donation for transplantation. Arnold Publication, 1997, 162-199
3. The EBPG Expert Group on Renal Transplantation. European Best Practice Guidelines for Renal Transplantation (Part 1). Nephrol Dial Transplant 2000; 15 (suppl 7)
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15. Morris RD et al. Obesity and hereditary in the etiology of non-insulin dependent diabetes mellitus in 32,662 adult white women. Am J Epidemiology 1989; 130: 112-121
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19. Ali MK et al. Donor hepatitis C virus status does not adversely affect short term outcomes in HCV + recipients in renal transplantation. Transplantation 1998; 66: 1694-1697
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28. Flowers JL et al. Comparison of open and laparoscopic live donor nephrectomy. Annals of Surgery 1997; 226 (4): 483-489
29. Ratner LE et al. Laparoscopic assisted live donor nephrectomy- a comparison with the open approach. Transplantation 1997; 63: 229-233