61 Live kidney donor information
Description
This article is from the Organ Transplant FAQ, by mike_holloway@hotmail.com (Michael Holloway) with numerous contributions by others.
61 Live kidney donor information
The following is a summary of "Donating a kidney to a family member- How
primary care physicians can help prepare potential donors"
Authors: Michael L. O'Dell, MD
Kristi J. O'Dell, ACSW
Thomas T. Crouch, MD
VOL 89/NO 3/February 15, 1991/Postgraduate Medicine . Kidney
Donation
Summarized by Katherine Eberle, eberle@gdls.com for the
TRNSPLNT FAQ Jan 1994.
Preview
When a relative needs a kidney to survive, family members often
impulsively offer to donate one without stopping to consider the
physical, emotional, and financial ramifications, which can be
considerable. The family's primary care physician can be very
helpful in guiding and educating potential donors and, by arranging
for screening to be done in the community, can ease the financial
strain. The authors discuss the things a potential kidney donor
should consider.
The desirability of transplantation is increasing and the supply of
cadaveric kidneys falls far short of the demand. So searching for a
possible living related donor is becoming more and more common.
Much of the preliminary testing required to identify a donor can be
easily performed in the potential donor's community, under the
direction of the primary care physician in communication with the
transplant team. Additionally, the donor's care is aided when the
evaluating physician serves as an advocate.
Evaluation for Immunologic Match
Usually, the first test performed is determination of ABO blood type
compatibility. Many physicians follow ABO compatibility testing
with HLA typing.
Tests required by most centers and a description of results that may
prohibit transplantation:
TESTS Potential Disqualifying
Factor
History and Physical Age under 18 or over 55 yr
Examination Obesity
Hypertension
Systemic disorder with
potential to impair health
Psychiatric disorder
Deep vein thrombosis
Family history of polycystic
kidney disease,
diabetes in both parents,
hereditary nephritis,
systemic lupus erythematosus
Laboratory Studies
Blood typing Poor match with recipient
Complete blood cell count Anemia or blood dyscrasia
Automated biochemical Abnormalities indicating
analysis significant disease state
Screening for diabetes Evidence of diabetes
Serologic tests for syphilis Evidence of current
infection
Hepatitis B surface antigen, Evidence of current
antibodies, core antigen infection
Human immunodeficiency virus Evidence of current
testing infection
24-hr urine collection for
Creatinine Diminished clearance
Protein Significant proteinuria
Calcium Hypercalciuria
Oxalate Hyperoxaluria
Urate Hyperuricemia
Urine osmolality after Inability to concentrate to
overnight thirst >700 mOsm/L
Urinalysis Unexplained hematuria and/or
other abnormality
(eg, proteinuria)
Urine culture Evidence of urinary tract
infection
Pregnancy test (where Positive for pregnancy
applicable)
HLA typing Poor immunologic match with
recipient
Radiographic Studies
Chest x-ray film Evidence of significant
disease
Intravenous urography Anatomic abnormality
Renal arteriography Anatomic abnormality
Other Studies
other significant
abnormality
Tuberculin and Candida skin Evidence of active
tests tuberculosis or anergy
Multiple gated acquisition Evidence of ischemic heart
stress test (in men over age disease
45 yr and women over 50 yr)
Pulmonary function testing Significant abnormality in
(in smokers) lung function
If the potential recipient is a reasonable match, renal angiography
is performed to determine which of the donor's kidneys is the more
accessible and the better anatomic match and to screen for
abnormalities that might preclude uninephrectomy. In general, the
left kidney, with its longer renal vein, is selected.
Potential donors should also be screened for psychosocial risk
factors. An evaluation of the stability of the individual and the
family and the financial impact of donation should be undertaken.
This is often performed by social workers. An important
consideration is psychosocial evaluation is whether the potential
donor is being coerced into the donation. Purchase of a kidney is
illegal in the United States. Occasionally, evaluators discover
potential donors who are unwilling to donate and yet are being
significantly pressured to do so by family members. Such persons
should be skillfully assisted in resisting such coercion, perhaps by
honestly describing them as "not an appropriate match."
Potential Disqualifying Psychosocial Factors in Kidney
Donor:
Evidence of significant coercion to donate
Evidence that donation would cause extreme financial
hardship
Evidence that spouse is strongly opposed to donation
Evidence of significant psychiatric disturbance
Often, family members spontaneously decide to donate a kidney before
they have had an opportunity to consult medical personnel. They
make their decision on moral rather than technical grounds, often
describing it as "the right thing to do" or their "calling."
Effects on the Donor
PHYSICAL EFFECTS - The actual risks to the donor from uninephrectomy
may be divided into short- and long-term. Short-term risks are those
typically seen with this major surgical procedure (ie, pulmonary
embolus, severe infection or sepsis, renal failure, hepatitis,
myocardial infarction, splenic laceration, pneumothorax). Estimates
of the mortality rate are generally less than 0.1% and of
significant complications less than 5%. Less than 1% of donors have
any permanent disability. Long term risks are controversial and
largely unknown. In one third of all donors, nonprogressive
proteinuria develops. This finding has led to a recommendation that
donors restrict their protein intake after uninephrectomy. In
addition, donors experience a slight rise in the serum creatinine
level, which is also nonprogressive.
PSYCHOSOCIAL EFFECTS - These risks to potential and actual donors
may also be short- or long-term. Potential donors who choose not to
donate may experience guilt about their decision or be ostracized by
the family, although detailed studies of potential donors who choose
not to donate are few.
About one fourth of those who choose to donate experience moderate
to severe financial difficulties. Even though the cost of the
evaluation and procedure is borne by the federal End Stage Renal
Disease Program, unreimbursed financial losses resulting from job
absence and travel can be significant. Most authorities cite a
return to work 4 weeks after uncomplicated uninephrectomy. Some
centers use donor- specific blood transfusions as a means of
enhancing graft survival. This requires blood donation from the
potential donor several days before the actual procedure, which may
extend the time away from home and work.
Troubled marriages may fail when the added stress of a kidney
donation is introduced. According to one study, one third of the
couples whose marriage failed cited the kidney donation as a major
factor in the failure.
Although much attention may be lavished on the donor in the
perioperative period, it may be short-lived and tends to quickly
refocus on the recipient. The recipient may, paradoxically,
criticize the donor's decision or become distant or angry toward the
donor.
However, the increase in self-esteem gained from the altruistic
action of donating a kidney may counterbalance such losses.
Donation of a kidney has provided many donors with a sense of deep
satisfaction.
In view of the potential risks to donors, some centers refuse to
perform transplantation from a living related donor. With effective
immunosuppressive therapy, cadaveric transplantation is quite
successful, and these centers argue that the benefit to the
recipient is not greatly enhanced by transplantation from a living
related donor. However, cadaveric organs are scarce. In contrast,
proponents of transplantation from a living related donor argue that
thwarting legitimate altruistic behavior by denying the procedure is
paternalistic, particularly since enhanced graft survival is noted
in such recipients compared with recipients of a cadaveric
transplant.
Conclusion
Although the use of living related donors will remain controversial,
everyone involved should be struck by the courage of those willing
to donate a kidney to a relative. For physicians providing care to
these families, an exceptional opportunity for guidance exists.
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