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Evaluation of the living kidney donor
and risk of donor nephrectomy

Objectives
• Understanding the general principles of donor
assessment and approval
• Know the main criteria for donor selection relevant to
prevent CKD
• Decisions regarding living donors are often arbitrary
but should favor long term safety of donor’s health

RATIONALE FOR LIVE KIDNEY DONATION
 Patients who receive living donor grafts have superior long-
term survival, as well as shorter waiting times.
 Allows elective planning with optimization of the recipient’s
health status.
 Pre-emptive transplantation- improved graft survival .

RATIONALE FOR LIVE KIDNEY DONATION
 Early graft function is significantly better for kidneys from
living versus deceased donors.
Deceased Living
Primary non-function 2.7% 1.4%
Delayed graft function 23.5% 3.4%
Survival rates at 10 years 42.7% 59.6%
OPTN/SRTR 2010 annual data report. Rockville, MD: Department of Health and Human Services, Health Resources
and Services Administration, Healthcare Systems Bureau; 2011.

THE EVALUATION PROCESS
 The core components of the evaluation process include:
(1) Education, counseling, and consent of the donor.
(2) Psychosocial evaluation.
(3) Medical evaluation.
(4) Review of all results at a multidisciplinary meeting.
February 2013, the Organ Procurement and Transplantation Network (OPTN)

Education, Counseling, and Consent of the
Potential Donor
 Consent should first be given to undergo the evaluation
process.
 Potential donors should be carefully educated about all
aspects of the evaluation and must understand that they are
free to withdraw from the process at any time.
 Supportive of the donor and defend the confidentiality of
donor findings and donor decisions.

Psychosocial Evaluation
 Should be carried out by a trained psychiatrist, psychologist, or
social worker with a particular interest and expertise in
transplantation.
(1) Psychological assessment with identification of active
mental health problems.
(2) A social assessment including high-risk behaviors.
(3) Assessment of the ability of the donor to consent
ensuring that the donor’s decision is free of
inducement or coercion.

Medical Screening Process
 History and physical examination with specific focus on renal
disease and family history of renal disease.
 Laboratory testing to evaluate renal function and determine
immunological compatibility.
 Identification of transmissible infectious disease.
 Evaluation of renal anatomy.
 Completion of an age-appropriate health screening including
cancer screening.

History and Physical Examination
 Concentrate on symptoms and signs of renal disease, as well
as personal and familial risk factors.
 Comorbidities, including hypertension, diabetes,
cardiovascular or cerebrovascular disease, should be sought.
 Blood pressure – three separate measurements. Additional
24-hour blood pressure monitoring study as indicated.

Laboratory Testing
 Donor ABO typing.
 Complete blood count with platelet count and differential count.
 Fasting serum glucose and measurement of transaminases.
 Fasting lipid profile.
 Donor glomerular filtration rate (GFR) should be estimated from
serum creatinine (eGFRcr) for initial assessment, following
recommendations from the KDIGO 2012 CKD guideline.

Laboratory Testing
 Measurement of urinary protein excretion.
 Coagulation studies to include the prothrombin time, and
partial thromboplastin time.
 Urinalysis and urine culture (if clinically indicated).
 Chest X-ray.
 Electrocardiograph.

Laboratory Testing
 Patients with a history of kidney stones or nephrolithiasis (>3
mm) identified on imaging must have a 24-hour urine stone
panel including calcium, oxalate, uric acid, citric acid,
creatinine, and sodium.
 Tissue Crossmatch.
 Human leukocyte antigen (HLA) typing of the donor.

Identify Transmissible Infectious Disease
 Cytomegalovirus (CMV) antibody.
 Epstein-Barr virus (EBV) antibody.
 HIV antibody (anti-HIV) testing or HIV antigen/antibody (Ag/Ab)
combination test as close as possible, but within 28 days prior to
organ recovery.

Identify Transmissible Infectious Disease
• Donor candidates should complete a urinalysis and
testing for HIV, HBV, HCV, cytomegalovirus (CMV),
Epstein Barr virus (EBV), and Treponema pallidum
(syphilis).
• In general, donor infection risk factor and microbiological
assessments should be performed or updated as close in
time to donation as possible. For HIV, HBV and HCV,
screening should be current within 28 days of donation

Evaluation of Renal Anatomy
 Abdominal imaging using computed tomography angiography
or magnetic resonance angiography.

Age-Appropriate Health Screening, Including
Cancer Screening
 Prostate-specific antigen (Male >= 50).
 Gynecologic examination with Papanicolaou smear.
 Colonoscopy (Adults >= 50).
 Mammogram ( Female >= 40).
 Echocardiography and cardiac stress testing as indicated.

Glucose Intolerance
• Donor candidates should be asked about prior diagnosis of
diabetes mellitus, gestational diabetes, and family history of
diabetes.
• Glycaemia should be assessed by fasting blood glucose and/or
glycated hemoglobin (HbA1c) before donation.
• 2-hour glucose tolerance or HbA1c testing should be performed
in donor candidates with elevated fasting blood glucose, history
of gestational diabetes, or family history of diabetes in a first-
degree relative, and results should be used to classify diabetes or
prediabetes status using established criteria for the general
population.

Glucose Intolerance
• Donor candidates with type 1 diabetes mellitus should not
donate.
• The decision to approve donor candidates with prediabetes or
type 2 diabetes should be individualized based on
demographic and health profile in relation to the transplant
program’s acceptable risk threshold.
• Donor candidates with prediabetes or type 2 diabetes should
be counseled that their condition may progress over time and
may lead to end-organ complications.

Renal function
• GFR of 90 mL/min per 1.73 m2 or greater should be
considered an acceptable level of kidney function for
donation.
• The decision to approve donor candidates with GFR 60 to 89
mL/min per 1.73 m2 should be individualized based on
demographic and health profile in relation to the transplant
program’s acceptable risk threshold.

Renal function
• Donor candidates with GFR less than 60 mL/min per 1.73 m2
should not donate.
• When asymmetry in GFR, parenchymal abnormalities,
vascular abnormalities, or urological abnormalities are present
but do not preclude donation, the more severely affected
kidney should be used for donation

Urine Analysis for Protein
• Donor proteinuria should be measured as albuminuria, not
total urine protein.
• Initial evaluation of donor albuminuria (screening) should be
performed using urine albumin-to-creatinine ratio (ACR) in a
random (untimed) urine specimen.
Donor albuminuria should be confirmed using:
• Albumin excretion rate (AER, mg/day [mg/d]) in a timed urine
specimen
• Repeat ACR if AER cannot be obtained Selection .

Urine Analysis for Protein
• Urine AER less than 30 mg/d should be considered an
acceptable level for donation.
• The decision to approve donor candidates with AER 30 to
100 mg/d should be individualized based on demographic
and health profile in relation to the transplant program’s
acceptable risk threshold.
• Donor candidates with urine AER greater than 100 mg/d
should not donate

Urine Analysis for Blood
 Patients with persistent microscopic hematuria should not be
considered for kidney donation unless urine cytology and a
complete urologic work up are performed.
 If urological malignancy and stone disease are excluded, a
kidney biopsy may be indicated to rule out glomerular
pathology, such as IgA nephropathy.
A Report of the Amsterdam Forum On the Care of the Live Kidney Donor: Data and Medical Guidelines

• Donor candidates should be assessed for microscopic hematuria.
• Donor candidates with persistent microscopic hematuria should
undergo testing to identify possible causes, which may include:
• Urinalysis and urine culture to assess for infection
• Cystoscopy and imaging to assess for urinary tract malignancy
• 24-hour urine stone panel to assess for nephrolithiasis and/or
microlithiasis
• Kidney biopsy to assess for glomerular disease (eg, thin
basement membrane nephropathy, IgA nephropathy, Alport
syndrome)

• Donor candidates with hematuria from a
reversible cause that resolves (eg, a treated
infection) may be acceptable for donation.
• Donor candidates with IgA nephropathy
should not donate

PREDONATION BLOOD PRESSURE
• Blood pressure should be measured before donation on at least
2 occasions by clinical staff trained in accurate measurement
technique, using equipment calibrated for accuracy.
• When the presence or absence of hypertension in a donor
candidate is indeterminate based on history and clinic
measurements (eg, blood pressure is high normal or variable),
blood pressure should be further evaluated using ambulatory
blood pressure monitoring (ABPM) or repeated using
standardized blood pressure measurements.

• Normal blood pressure, as defined by guidelines for the general
population in the country or region where donation is planned, is
acceptable for donation.
• Donor candidates with hypertension that can be controlled to
systolic blood pressure less than 140 mm Hg and diastolic blood
pressure less than 90 mm Hg using 1 or 2 antihypertensive agents,
who do not have evidence of target organ damage, may be
acceptable for donation.
• The decision to approve donor candidates with hypertension
should be individualized based on demographic and health profile
in relation to the transplant program’s acceptable risk threshold

• Donor candidates should be counseled on lifestyle
interventions to address modifiable risk factors for
hypertension and cardiovascular disease, including healthy
diet, smoking abstinence, achievement of healthy body weight,
and regular exercise according to guidelines for the general
population. These measures should be initiated before
donation and maintained lifelong.
• We suggest that donor candidates should be informed that
blood pressure may rise with aging, and that donation may
accelerate a rise in blood pressure and need for
antihypertensive treatment over expectations with normal
aging.

Obesity
• Body mass index (BMI) should be computed based on weight
and height measured before donation, and classified based on
World Health Organization (WHO) criteria for the general
population or race-specific categories.
• The decision to approve donor candidates with obesity and
BMI >30 kg/m2 should be individualized based on
demographic and health profile.
• Donor candidates who have had bariatric surgery should be
assessed for risk of nephrolithiasis.

History of nephrolithiasis
 Patients with nephrolithiasis should be screened for metabolic
stone forming abnormalities.

 An asymptomatic potential donor with history of a single
stone may be suitable for kidney donation if:
 No hypercalcuria, hyperuricemia, or metabolic acidosis.
 No cystinuria or hyperoxaluria.
 No urinary tract infection.
 Multiple stones or nephrocalcinosis are not evident on
computed tomography (CT) scan.
 Current stone is <1.5 cm in size or potentially removable
during transplant.

 Stone formers who should not donate are those with:
 Nephrocalcinosis on X ray or bilateral stone disease
 Stone types that have high recurrence rates and are
difficult to prevent, such as:

 Cystine stones that have a high rate of recurrence and a need
for urologic procedures in the donor.
 Struvite stones or infection stones that are difficult to
eradicate and thus not feasible to transplant them into an
immunosuppressed patient.

 Associated with inherited or other systemic disorders, such as
primary or enteric hyperoxaluria, distal renal tubular acidosis
because of the probability of a high rate of recurrence and the
risk of renal insufficiency.
 Stones in the setting of inflammatory bowel disease with an
increased risk of stones particularly after bowel resection, also
increased risk of renal insufficiency.

Donor Malignancy
• Donor candidates should undergo cancer screening consistent
with clinical practice guidelines for the country or region
where the donor candidate resides. Transplant programs
should ensure that screening is current according to guideline
criteria at the time of donation.
• In general, donor candidates with active malignancy should be
excluded from donation. In some cases of active malignancy
with low transmission risk, a clear management plan and
minimal risk to the donor, donation may be considered.

Infectious Diseases
 HIV infection- An ELISA result positive for HIV-1 or HIV-2
should be confirmed by Western blot analysis. A positive test
result excludes the donor.
 Hepatitis B- Positivity for hepatitis B surface antigen generally
excludes the donor.

Infectious Diseases
 Hepatitis C- HCV-positive donors should be excluded if the
recipient is HCV negative.
 HCV-positive donors wishing to donate to HCV-positive
recipients should undergo quantitative PCR testing.
 If the PCR finding is positive, the donor should be excluded.

Infectious Diseases
 If the PCR finding is negative, the donor may still donate, since
the kidney is not a known reservoir for HCV.
 Genotyping of HCV-positive donors and recipients should be
done.
 Previously treated HCV-positive donors, especially those with
favorable genotypes, can be considered as donors.

Infectious Diseases
 CMV/EBV infection-
 Donors with positive result on immunoglobulin M and PCR
testing for CMV cannot donate until their PCR test result is
negative.
 It is preferable, if feasible, for a donor who is positive for both
CMV and EBV to donate to a child who is positive, since
posttransplantation lymphoproliferative disease is a major issue
in seronegative children who receive organs from seropositive
adults.

Infectious Diseases
 TB- Active TB is a contraindication to donation. Donors with a
history of TB may be considered, especially if they were
treated and undergo extensive evaluation for genitourinary
TB.

Infectious Diseases
 Syphilis- Should be screened with RPR or VDRL.
 Positive test results should be confirmed by the fluorescent
treponemal antibody absorption test.
 Donors with a positive result on the latter test should be
treated before donation.

Urinary tract infections
 The donor urine should be sterile prior to donation; asymptomatic
bacteria should be treated per donation.
 Pyuria and hematuria at the proposed time of donation is a
contraindication to donation.
 Unexplained hematuria or pyuria necessitates evaluation for
adenovirus, tuberculosis, and cancer.
 Urinary tuberculosis or cancer are contraindications to donation.
Transplantation 2005;79: S53–S66

Determination of cardiovascular risk
 The clinical predictors of an increased perioperative cardiovascular
risk (for non-cardiac surgery) by the American College of
Cardiology/American Hospital Association standards fall into 3
categories:
 major,
 intermediate,
 minor.

Determination of cardiovascular risk
 All major predictors: unstable coronary syndromes, decompensated heart
failure, significant arrhythmias and severe valvular disease are
contraindications to live kidney donation.
 Most of the intermediate predictors: mild angina, previous myocardial
infarction, compensated or prior heart failure, diabetes mellitus are also
contraindications to donation.
 Minor predictors: older age, abnormal ECG, rhythm other than sinus, low
cardiac functional capacity, history of stroke or uncontrolled hypertension
warrant individual consideration.

Assessment of pulmonary issues
 A careful history and physical examination are the most important parts
of assessing risk.
 Routine preoperative PFT is not warranted for potential live kidney
donors unless there is an associated risk factor such as chronic lung
disease.
 Increased risk of post operative pulmonary complication is associated
with an FEV1 <70 % or FVC <70 % of predicted, or a ratio of FEV1/FVC
<65 %.

Smoking Cessation
 Smoking cessation at least 4 weeks prior to donation is
advised, based on recommendations for patients undergoing
elective surgical procedures.

Alcohol Abstinence
 Cessation of alcohol abuse defined by DSM-3: 60g alcohol/day
sustained 6 months should be avoided for a minimum of 4
weeks to decrease the known risk of post- operative
morbidity.

EXCLUSIONARY CRITERIA
 Absolute contraindications
 Chronic active viral infection (HIV, Hepatitis B and C).
 Active malignancy.
 History of malignancy, arising from lung, breast, renal or
urologic, gastrointestinal, or hematologic organs and
melanoma.

 Absolute contraindications
 Diabetes mellitus
 Nephrocalcinosis, bilateral kidney stones, or recurrent
nephrolithiasis
 Poorly controlled psychosis
 Active substance abuse
 Pregnancy.

 Some relative contraindications
 Active peptic ulcer disease
 History of nephrolithiasis
 Morbid obesity, most commonly defined as body mass
index >35.

RISK OF DONOR NEPHRECTOMY
 IMMEDIATE RISK
 Atelectasis
 Pneumothorax
 Pneumonia
 Urinary tract infection
 Wound complication
 Deep vein thrombosis with or without pulmonary embolism
 Death, 3.1 per 10,000 donors.*
*Segev DL, Muzaale AD, Caffo BS, et al. Perioperative mortality and long-term survival following live kidney donation.
JAMA 2010; 303:959.

 LONG-TERM RISK
 Overall long-term survival after donor nephrectomy is the same
as similar matched individuals who did not undergo surgery.
 Although 50% of the functioning renal mass is removed,
compensatory hypertrophy returns the GFR to 70% of baseline
at 10- 14 days and 75-85% of baseline at long-term follow-up.

 LONG-TERM RISK
 Change in Glomerular Filtration Rate with Age in Kidney Donors.
 Prevalence of Hypertension.
 Potential Acceleration of Kidney Disease in One Kidney.

QUALITY OF LIFE AFTER KIDNEY DONATION
 In general, living donors report a similar, or better, quality of
life compared with the general population.
 Factors associated with decreased quality of life- poor donor
or recipient physical outcome, a negative personal donor-
recipient relationship, and financial hardship.

 About 60% of the donors rated their physical health higher
than the average for their age and gender peers in the U.S.
general population.
 62% of the donors rated their mental health higher than did
their age and gender peers.
 Because individuals with serious physical or mental health
problems are either discouraged from donating or disqualified
once evaluated.
QUALITY OF LIFE AFTER KIDNEY DONATION

Maternal and fetal outcomes
 To delay pregnancy until at least 2 months after nephrectomy
to assess renal compensation prior to conception with
evaluation including blood pressure, GFR, and assessment for
microalbuminuria.

 106 pregnancies post donation Vs 620 pregnancies prior to
donation, and a random sample 21,511 pregnancies.
 Compared with pregnancy before donation, pregnancy after
donation was associated with a significantly increased risk of
preeclampsia (5.7 Vs 2.6%) and a non significant increase in
stillbirth (2.8 Vs 1.1%).
Reisaeter AV, Røislien J, Henriksen T, et al. Pregnancy and birth after kidney donation: the Norwegian experience. Am J
Transplant 2009; 9:820.

 However, there were no differences in adverse pregnancy
outcomes between kidney donors and the general population.
 There is an increased risk for fetal loss, gestational diabetes,
gestational hypertension, and preeclampsia with pregnancy
after kidney donation, compared to pregnancy prior to kidney
donation. **
**Ibrahim HN, Akkina SK, Leister E, et al. Pregnancy outcomes after kidney donation. Am J Transplant 2009; 9:825. **
2102 kidney donors

 The generally good outcomes should NOT exclude donors
who have not completed child-bearing.
 However, we must be aware of the increased risks with
pregnancy after kidney donation.

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