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Improving Living Kidney Donation with the New KDIGO Clinical Practice Guideline
Kidney Disease Improving Global Outcomes (KDIGO), the global non-profit organization that develops and implements evidence-based clinical practice guidelines in kidney disease, tackled a different subject in its recently published Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Unlike other KDIGO guidelines, which have focused on aspects of chronic kidney disease, acute kidney injury and kidney transplantation, this guideline set out to provide comprehensive recommendations for living donors: a unique group of people who in many instances are not patients but healthy individuals who are willing to undergo a procedure to have one of their kidneys removed on behalf of another individual.
Assessing living donor candidate suitability required a far more inclusive approach than traditional analysis of clinical variables and outcomes. A KDIGO guideline work group evaluated demographic, clinical and donation-related factors simultaneously, much like what happens in practice. And, because living kidney donors may be healthy, or certain clinical conditions may be unmasked in the process of the evaluation, ethical considerations were part of the donor evaluation process. The work group noted that potential donors should be willing to donate without undue pressure. While transplant programs have acknowledged autonomy, they should follow local laws and regulations and their policies have to be defensible with all candidates being evaluated using the same criteria. At the same time, the work group cited that efforts to increase public awareness of donation and transplant candidates should be assisted in identifying potential living donors.
Guideline recommendations in KDIGO use the GRADE structured approach to quality of evidence and strength of guideline recommendations. This structure takes into account the impact of the recommendations on patients, physicians and policy.
Not surprisingly, individuals with good kidney function (glomerular filtration rate [GFR] > 90 mL/min per 1.73M2; no albuminuria) and no other major contraindications would be good donor candidates per the guideline. Interestingly, kidney function could be measured initially by an estimated GFR (eGFR) and then confirmed using any one of a number of different tests, including a repeat eGFR. Individualized case decisions were recommended for potential donors with a GFR between 60-89 mL/min per 1.73M2 or an albumin excretion rate between 30–100 mg/d. Lower GFR or higher albumin excretion rate values disqualified the candidates. Similarly, case-by-case decisions could be made for individuals taking blood pressure medication but with no end-organ damage, individuals with pre-diabetes or type II diabetes mellitus, and individuals with small, simple cysts on their kidneys.
In addition to noting that gout and nephrolithiasis could be exacerbated by living donation and that other conditions, such as pregnancy and active malignancies, were contraindications to living donation, the work group acknowledged the importance of the donor psychosocial evaluation with suggested individuals to be involved in this part of the evaluation.
This work group went further than historical donor evaluations by recommending the surgical approach to the donor, which kidney should be removed and which kidneys might not be transplantable. In addition, the work group strongly endorsed a personalized plan of care for a living donor that includes regular assessment of blood pressure, body mass index, serum creatinine with eGFR, measurement of albuminuria and an understanding of lifestyle choices and use of appropriate health care resources to monitor for the potential evolution of chronic kidney disease.
Living donation is an amazing thing and doing it as safely as possible is essential. This clinical practice guideline advances practical knowledge that should help everyone who has a stake in a living donor transplant.