LD – Living Kidney Donor Selection Criteria
- Age Limit
- 18 years or older
- 65 years or older will be considered on an individual basis and will be correlated with the recipient's age and medical condition.
- Medical
- BP:
- Some patients with easily controlled hypertension who meet other defined criteria may represent a low risk group for development of kidney disease after donation and may be acceptable donors.
- Over 40 years old in whites or over 45 years old in African Americans as African Americans develop hypertension at an earlier age than whites.
- Patients with a reported blood pressure > 140/90 are usually not acceptable as donors
- Well controlled hypertension on a maximum of two medications
- GFR > 80 ml/min or normal kidney function for age
- Urinary albumin excretion < 30mg/day
- Weight:
- Patients with a BMI > 35 should be discouraged from donating, especially when other co-morbid conditions are present.
- BMI of 35 – 40 should be approved on an individual basis.
- Obese patients should be encouraged to lose weight prior to kidney donation.
- Obese patients should be informed of both acute and long term risks, especially when other co-morbid conditions exist
- Laboratory/Diagnostic:
- Normal laboratory findings that would exclude renal disease and diabetes.
- Dyslipidemia should be included along with other risk factors, but dyslipidemia alone does not exclude kidney donation.
- A GFR of < 80 ml/min generally precludes donation.
- A 24 hour urine protein > 200 mg / 24 hours is a contraindication to donation. Microalbuminuria determination of < 30 mg/day may be a more reliable marker of renal disease.
- Normal CXR and CTA of Kidneys
- Normal Cardiac test results (EKG and additional testing may be ordered based on the donor's cardiac history and/or the discretion of the evaluating nephrologist)
- Normal age appropriate testing, including PSA (based on donor prostate history), colon cancer screening (donors age 45 and older), mammogram (females age 45 and older).
- Hematuria:
- Patients with persistent microscopic hematuria should not be considered for donation unless urine cytology is reviewed and a complete urologic work up is performed if indicated based on cytology review.
- If urological malignancy and stone disease are excluded, a kidney biopsy may be indicated to rule out glomerular pathology such as IgA nephropathy.
- Diabetes:
- Individuals with a fasting blood glucose > 99 mg/dl on at least two occasions associated with an elevated Hemoglobin A1C >6% may be a contraindication to donation.
- Individuals with a diagnosis of diabetes mellitus type 2 (DM2) may be considered for donation if
the individualized assessment of donor demographics or comorbidities do not reveal evidence of
end organ damage or unacceptable lifetime risk of complications. Donors with DM2 should meet the
following criteria:
- Age 60 or older
- Hemoglobin A1C less than or equal to 6.5%
- Non-insulin dependent and be on one oral or injectable agent. If age 65 or older, can be on two non-insulin medications
- BMI equal to or less than 30
- Negative family history of diabetic kidney disease
- A history of gestational diabetes is a relative contraindication to donation.
- Diabetes type 1 is an absolute contraindication to donation.
- Polycystic Kidney Disease:
- If a family history of polycystic kidney disease exists, donors 18 – 24 years of age are excluded. Donors that are 25 years and older must have a negative Renal CTA.
- Stone Disease:
- History of kidney stones requires a stone risk analysis or metabolic evaluation
- Calcium oxalate stones (hypercalciuria) are not a contraindication to donation.
- Uric acid stones (hyperuricosuria) are a relative contraindication to donation (single episode, evaluate if more than 1 year by collecting 24 hour urine for uric acid stone risk analysis, calcium, citrate, and oxide).
- Struvite stones are an absolute contraindication to donation.
- An asymptomatic potential donor with a history of a single stone may be suitable for kidney
donation if:
- No significant metabolic disorder is present which would predispose the patient to recurrent problems including nephrocalcinosis
- No cystinuria, or hyperoxaluria are present
- No associated urinary tract infections are present
- No multiple stones or nephrocalcinosis are evident on CT
- An asymptomatic potential donor with a current single stone may be suitable if the donor meets the criteria shown previously for single stone formers and current stone is non-obstructing, or potentially removable during transplant.
- Stone formers who should not donate are those with nephrocalcinosis on x-ray or bilateral stone disease
- Pregnancy
- Pregnancy is a contraindication to donation. Donation may proceed three months after pregnancy.
- Malignancy:
- A prior history of malignancy usually excludes live kidney donation, but may be acceptable if the specific cancer is curable and potential transmission of cancer can be reasonably excluded.
- A prior history of the following malignancies usually excludes live kidney donation: melanoma, testicular cancer, renal cell carcinoma, choriocarcinoma, hematological malignancy, lung cancer, breast cancer, and monoclonal gammopathy (MGUS).
- A prior history of malignancy may only be acceptable for donation if prior treatment of the malignancy does not decrease renal reserve or place the donor at increased risk for ESRD.
- Prior treatment of malignancy does not increase the operative risk for nephrectomy
- Urinary Tract Infection:
- The donor urine should be sterile prior to donation; asymptomatic bacteriuria should be treated prior to donation.
- Pyuria and hematuria at the proposed time of donation is a contraindication to donation at that time
- Unexplained hematuria or pyuria requires appropriate evaluation
- Urinary tuberculosis or cancer is a contraindication to donation.
- Determination of Cardiovascular Risk:
- Unstable coronary syndromes, decompensated heart failure, significant arrhythmias and severe valvular disease are contraindications to donation.
- Mild angina, previous myocardial infarction, compensated or prior heart failure, diabetes mellitus are also contraindications to donation
- Older age, abnormal EKG, rhythm other than sinus, low cardiac functional capacity, history of stroke or uncontrolled hypertension warrant individual consideration.
- Assessment of Pulmonary Issues:
- Routine preoperative pulmonary function testing is not warranted for potential live kidney donors unless there is an associated risk factor such as chronic lung disease.
- Increased risk for post-operative complication is associated with an FEV1 < 70 % or FVC < 70 % of predicted, or a ratio of FEV1 / FVC < 65%.
- Determination of Vascular Risks:
- Deep vein thrombosis may be a contraindication to donation
- Peripheral artery disease or aortic artery disease may be contraindications to donation.
- Systemic Risks:
- Active systemic infection is a contraindication for donation (can resume evaluation once infection is controlled).
- Active systemic disorders (autoimmune diseases) may be contraindications for donation. Clinical remission must be present for an appropriate period based on disease.
- No other significant acute disease.
- Psychosocial
- An assessment of whether the decision to donate is free from inducement, coercion, and other undue pressure by exploring the reasons for donating and the nature of the relationship, if any, to the transplant recipient.
- Patient takes an active role in care and/or has a strong family support system.
- Appropriate motivation for donation.
- No active psychiatric concerns which would preclude adherence with medical care.
- Patient with psychological/psychosocial history may be referred to a psychologist/ psychiatrist per referral Guideline.
- Patient has decision making capabilities.
- No active smoking 4 weeks prior to donation.
- The living donor is evaluated for psychosocial issues, including mental health issues, that might complicate the living donor's recovery and could be identified as risks for poor psychosocial outcome.
- An assessment of risk criteria for acute HIV, HBV and HCV infection according to the U.S. Public Health Services (PHS) Guideline.
- The living donor is reviewed for history of smoking, alcohol, and drug use including past or present substance abuse disorder.
- The identification of factors that warrant educational or therapeutic intervention prior to the final donation decision.
- The determination that the living donor understands the short and long-term medical and psychosocial risks for both the living donor and recipient associated with living donation.
- An assessment of the living donor's ability to make an informed decision and the ability to cope with the major surgery and related stress. This includes evaluating whether the donor has a realistic plan for donation and recovery, with social, emotional and financial support available as recommended.
- The living donor is reviewed for occupation, employment status, health insurance status, living arrangements and social support.
- Financial
- Donor will undergo counseling by Social Worker to let them know the coverage for the evaluation, surgery and follow-up care. The donor will be informed the coverage exclusions and their financial responsibility.
- The determination that the living donor understands the potential financial implications of living donation.
- Independent Living Donor Advocate
- The advocate will meet with the potential donor privately and work to act as a resource to protect his/her rights and interests.
- The advocate will ensure that the potential donor makes informed decisions free of coercion through discussion.
- The advocate will serve as part of the multi-disciplinary team deciding donor candidacy.
- The well-being and welfare of the potential donor will be of primary importance to the donor advocate.
- BP: