final donor.pptxvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvv

hfffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffff

1. Evaluation of the living kidney donor and risk of donor nephrectomy

2. 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

3. 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 .

4. 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.

5. THE EVALUATION PROCESS The core components of the evaluation process include: 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)

6. 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. February 2013, the Organ Procurement and Transplantation Network (OPTN)

7. 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. February 2013, the Organ Procurement and Transplantation Network (OPTN)

8. 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. February 2013, the Organ Procurement and Transplantation Network (OPTN)

9. 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.

10. 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. February 2013, the Organ Procurement and Transplantation Network (OPTN)

11. 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.

12. 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.

13. 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.

14. 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

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

16. 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.

17. EXCLUSIONARY CRITERIA

18. 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 .

19. 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.

20. 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.

21. 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

22. 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 .

23. 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

24. 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 Transplantation 2005;79: S53–S66

25. Urine Analysis for Blood 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)

26. Urine Analysis for Blood 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

27. 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.

28. PREDONATION BLOOD PRESSURE 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

29. PREDONATION BLOOD PRESSURE 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 .

30. 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.

31. History of nephrolithiasis Patients with nephrolithiasis should be screened for metabolic stone forming abnormalities. A Report of the Amsterdam Forum On the Care of the Live Kidney Donor: Data and Medical Guidelines Transplantation 2005;79: S53–S66

32. History of nephrolithiasis 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. A Report of the Amsterdam Forum On the Care of the Live Kidney Donor: Data and Medical Guidelines Transplantation 2005;79: S53–S66

33. History of nephrolithiasis 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: A Report of the Amsterdam Forum On the Care of the Live Kidney Donor: Data and Medical Guidelines Transplantation 2005;79: S53–S66

34. History of nephrolithiasis 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. A Report of the Amsterdam Forum On the Care of the Live Kidney Donor: Data and Medical Guidelines Transplantation 2005;79: S53–S66

35. History of nephrolithiasis 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. A Report of the Amsterdam Forum On the Care of the Live Kidney Donor: Data and Medical Guidelines Transplantation 2005;79: S53–S66

36. 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.

37. 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. A Report of the Amsterdam Forum On the Care of the Live Kidney Donor: Data and Medical Guidelines Transplantation 2005;79: S53–S66

38. 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. A Report of the Amsterdam Forum On the Care of the Live Kidney Donor: Data and Medical Guidelines Transplantation 2005;79: S53–S66

39. 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. A Report of the Amsterdam Forum On the Care of the Live Kidney Donor: Data and Medical Guidelines Transplantation 2005;79: S53–S66

40. 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. A Report of the Amsterdam Forum On the Care of the Live Kidney Donor: Data and Medical Guidelines Transplantation 2005;79: S53–S66

41. 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. A Report of the Amsterdam Forum On the Care of the Live Kidney Donor: Data and Medical Guidelines Transplantation 2005;79: S53–S66

42. 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. A Report of the Amsterdam Forum On the Care of the Live Kidney Donor: Data and Medical Guidelines Transplantation 2005;79: S53–S66

43. 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. A Report of the Amsterdam Forum On the Care of the Live Kidney Donor: Data and Medical Guidelines Transplantation 2005;79: S53–S66

44. 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. A Report of the Amsterdam Forum On the Care of the Live Kidney Donor: Data and Medical Guidelines Transplantation 2005;79: S53–S66

45. 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. A Report of the Amsterdam Forum On the Care of the Live Kidney Donor: Data and Medical Guidelines Transplantation 2005;79: S53–S66

46. 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 %. A Report of the Amsterdam Forum On the Care of the Live Kidney Donor: Data and Medical Guidelines Transplantation 2005;79: S53–S66

47. Smoking Cessation Smoking cessation at least 4 weeks prior to donation is advised, based on recommendations for patients undergoing elective surgical procedures. A Report of the Amsterdam Forum On the Care of the Live Kidney Donor: Data and Medical Guidelines Transplantation 2005;79: S53–S66

48. 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. A Report of the Amsterdam Forum On the Care of the Live Kidney Donor: Data and Medical Guidelines Transplantation 2005;79: S53–S66

49. 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.

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

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

52. 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.

53. RISK OF DONOR NEPHRECTOMY 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.

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

55. 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.

56. 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

57. 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. A Report of the Amsterdam Forum On the Care of the Live Kidney Donor: Data and Medical Guidelines Transplantation 2005;79: S53–S66

58. Maternal and fetal outcomes 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.

59. Maternal and fetal outcomes 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

60. Maternal and fetal outcomes 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.

61. THANK YOU