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Renal and cardiac assessment of living kidney donor candidates

Nature Reviews Nephrology volume 13, pages 420–428 (2017)Cite this article

Subjects

Key Points

  • The medical assessment of living kidney donor candidates can include additional investigations beyond the minimal recommended requirements to select candidates at lowest risk of renal and cardiac complications following donation

  • Measured glomerular filtration rate by isotopic methods provides a more accurate assessment of renal function than calculations of estimated glomerular filtration rate (eGFR), but might not be necessary for a large proportion of donor candidates who have acceptable eGFR values

  • Persistent isolated microscopic haematuria should be investigated to exclude urologic and glomerular diseases and might reveal abnormalities that would preclude donation

  • Donor candidates who are at low risk of perioperative cardiac events following nephrectomy do not need to undergo additional cardiac assessment

Abstract

Living kidney donation provides the best therapeutic outcomes for eligible patients with end-stage renal disease. To ensure suitability for living kidney donation, donor candidates undergo a thorough medical, surgical, and psychosocial evaluation by a multidisciplinary transplant assessment team. Numerous guidelines are available to assist clinicians in the process of donor evaluation and selection. These guidelines outline the minimum recommended requirements for donor screening and additional tests that are indicated when abnormalities arise; however, evidence suggests that some of these additional tests might not be required in certain donor candidates. Measured glomerular filtration rate (GFR) using isotopic methods is more accurate than estimated GFR for the assessment of renal function; however, a new clinical tool might enable the identification of donor candidates for whom nuclear medicine renal scans are not needed. Persistent isolated microscopic haematuria caused by urologic or glomerular diseases can preclude donation and such abnormalities can often be identified by kidney biopsy. Cystoscopy might not be useful for young patients, however, owing to the rarity of urological cancers in this population. Currently, no evidence exists to support the notion that donor candidates at low-risk of cardiac events should undergo additional preoperative cardiovascular evaluation before donation. Reducing and/or eliminating the need for additional testing has the potential to enhance efficiency in the donor evaluation process, improve patient satisfaction, and increase access to living donor kidney transplantation.

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Figure 1: Recommendations for the renal and cardiac assessment of living kidney donor candidates.

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Acknowledgements

N.N.L. is supported by the Kidney Research Scientist Core Education and National Training Program (KRESCENT) New Investigator award. K.L.L. is supported by a grant from the NIH/National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), “Long-Term Health Outcomes After Live Kidney Donation in African Americans” (R01-DK096008). A.X.G. received an investigator-initiated grant from Astellas to support a Canadian Institutes of Health Research study in living kidney donors, and his institution has received unrestricted research funding from Pfizer. He is supported by the Dr Adam Linton Chair in Kidney Health Analytics.

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Authors and Affiliations

  1. Department of Medicine, Division of Nephrology, 11–113 Clinical Sciences Building, 11350–83 Avenue NW, University of Alberta, Edmonton, T6G 2G3, Alberta, Canada

    Ngan N. Lam

  2. Center for Abdominal Transplantation, Saint Louis University School of Medicine, 1402 South Grand Boulevard, St Louis, 63104, Missouri, USA

    Krista L. Lentine

  3. Department of Medicine, Division of Nephrology, Western University, 800 Commissioners Road East, London, N6A 4G5, Ontario, Canada

    Amit X. Garg

  4. Department of Epidemiology and Biostatistics, Western University, 1151 Richmond Street, London, N6A 3K7, Ontario, Canada

    Amit X. Garg

  5. Institute for Clinical Evaluative Sciences (ICES), 2075 Bayview Avenue, Toronto, M4N 3M5, ON, Canada

    Amit X. Garg

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N.N.L. researched the data for the article. All authors contributed substantially to discussion of the article's content, writing, and review or editing the manuscript before submission.

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Correspondence to Ngan N. Lam.

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Competing interests

A.X.G. has received funding from Astellas, and his institution has received unrestricted research funding from Pfizer. The other authors declare no competing interests.

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Revised Cardiac Risk Index

(RCRI). The RCRI includes the following risk factors to assess the risk of perioperative cardiac death, non-fatal myocardial infarction, and non-fatal cardiac arrest: history of ischaemic heart disease, congestive heart failure, cerebrovascular disease, diabetes mellitus requiring insulin, chronic kidney disease (serum creatinine >177 μmol/l (>2 mg/dl)), and high-risk surgery (supra-inguinal vascular, intra-peritoneal, or intra-thoracic surgery).

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Lam, N., Lentine, K. & Garg, A. Renal and cardiac assessment of living kidney donor candidates. Nat Rev Nephrol 13, 420–428 (2017). https://doi.org/10.1038/nrneph.2017.43

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