Living donor kidney transplantation is regarded as “the best treatment” for kidney
failure, providing superior patient survival, quality of life and cost savings compared
to dialysis and deceased donor transplantation. Each year, nearly 30,000 people worldwide
donate a kidney to help a loved one, a friend or even a stranger. Although living
kidney donation is considered to be safe in healthy, low risk persons, evaluation
procedures and acceptance criteria for donor candidates vary widely across transplant
centers. A major driver of such variation has been uncertainty in the impact of baseline
demographic and health traits on long-term health after donation.
To date, clinical practice guidelines and regional policies recommended consideration
of one risk factor at a time in the assessment of living donor candidates – for example,
separate candidacy criteria are offered for blood pressure, obesity and smoking that
regard each of these factors in isolation. The evidence supporting past recommendations
is also limited by frequent foundation in data from general populations (whose baseline
health status differs from healthy donors), often using surrogate endpoints. Ultimately,
poor understanding of comprehensive risk has led to inconsistent donor selection practices.
This month, the KDIGO international work group published a new “Clinical Practice
Guideline on the Evaluation and Care of Living Kidney Donors.” Developed by a work
group of international practitioners and co-chaired by Krista Lentine, M.D., Ph.D.,
professor of internal medicine at Saint Louis University and medical director of living
donation at the SSM Health Transplant Center at Saint Louis University Hosptial, and
Amit Garg, M.D., Ph.D., professor of medicine at Western University in Ontario, Canada,
the guideline advances a new framework for donor candidate evaluation grounded in
the simultaneous consideration of the combined impact of each candidate’s profile
of demographic (i.e., age, sex and race) and health characteristics (e.g., kidney
function, blood pressure, body mass index, smoking status) on their risk of serious
adverse outcomes after donation.
With the collaboration of the Chronic Kidney Disease Prognosis Consortium, original
data analyses were undertaken to produce a “proof-in-concept” risk-prediction model
for kidney failure in healthy persons tailored for the individual’s demographic and
health profile. This model was published separately in the New England Journal of Medicine and is now available as an online risk projection tool (www.transplantmodels.com/esrdrisk).
“We believe this new framework changes the paradigm for quantitative risk assessment
in the donor candidate evaluation and supports defensible shared decision-making,”
“Improving the safety and transparency of donor selection is critical for advancing
living donation and transplantation within a defensible system of practice,” said
The guideline offers recommendations across the continuum of donation-related care
including the psychosocial evaluation, approaches to the donation surgery, ethical
and policy considerations, and post-donation follow-up. Importantly, the work group
identified ongoing knowledge gaps and provides recommendations for future research.
“We see this work as starting point, and advocate strongly for continued efforts to
improve the precision, tailoring and generalizability of prediction of all risks relevant
to donors,” Garg notes.
“The altruistic, life-saving act of donation warrants ongoing pursuit of the highest
standards of evidence to ensure that potential risks are identified and considered
in selection and informed consent, and that care is optimized to minimize risks,”
KDIGO past-chair and work group member Bertram Kasiske, M.D., said “By grounding more
consistent, transparent selection processes, this new framework will advance the ability
of transplant programs to support donor candidates in autonomous donation decisions,
within a program’s upper bound of acceptable risk.”
Andrew S. Levey, M.D., work group member and professor of medicine at Tufts University
said “We must not forget the need to embrace a long-term relationship with the donor,
because some risks are uncertain or evolving.”
The KDIGO Outcomes (KDIGO) “Clinical Practice Guideline on the Evaluation and Care
of Living Kidney Donors” was published July 31, 2017, in the journal Transplantation.
The Work Group includes: Krista L. Lentine, M.D., Ph.D.*, Bertram L. Kasiske, M.D.,
Andrew S. Levey, M.D., Patricia L. Adams, M.D., Josefina Alberú, M.D., Mohamed A.
Bakr, M.D., Lorenzo Gallon, M.D., Catherine A. Garvey, RN,Sandeep Guleria, MBBS, Philip
Kam-Tao Li, M.D., Dorry L. Segev, M.D., Ph.D., Sandra J. Taler, M.D.,Kazunari Tanabe,
M.D., Ph.D.,Linda Wright, MHSc, MSW, Martin G. Zeier, M.D., Michael Cheung, M.A.,and
Amit X. Garg, M.D., Ph.D.* (*Guideline Co-chairs)
Established in 1836, Saint Louis University School of Medicine has the distinction
of awarding the first medical degree west of the Mississippi River. The school educates
physicians and biomedical scientists, conducts medical research, and provides health
care on a local, national and international level. Research at the school seeks new
cures and treatments in five key areas: cancer, liver disease, heart/lung disease,
aging and brain disease, and infectious diseases.