SLU Professor Develops New Guidelines for Living Kidney Donors

08/17/2017

In a paper published in Transplantation, experts share new guidelines and a risk projection tool to offer better advice about comprehensive risk assessment and care for living kidney donors. The new recommendations evaluate factors like demographics, blood pressure and smoking as a whole, rather than in isolation. The guidelines are the culmination of many years’ work by medical specialists on the Kidney Disease: Improving Global Outcomes (KDIGO) international work group.

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 Hospital, 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,” said Lentine.

“Improving the safety and transparency of donor selection is critical for advancing living donation and transplantation within a defensible system of practice,” said Garg.

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,” said Lentine. 

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)

http://journals.lww.com/transplantjournal/toc/2017/08001

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.