Living Kidney Donation : Best Practices in Evaluation, Care and Follow-up

This book provides a complete guide to the evaluation, care, and follow-up of living kidney donors. Living donor kidney transplantation is established as the best treatment option for kidney failure. However, despite the tremendous benefits of living donation to recipients and society, the outcomes and optimal care of donors themselves have received relatively less attention. Fortunately, things are changing – including recent landmark developments in living donor risk assessment, policy and guidance. This volume offers authoritative, evidence-based guidance on the full range of clinical scenarios encountered in the evaluation and care of living kidney donors. The approach to key elements of risk assessment, ethical considerations and informed consent is accompanied by recommendations for patient-centered care before, during, and after donation. Advocacy initiatives and policies to remove disincentives to donation and advance a defensible system of practice are also discussed. General and transplant nephrologists, as well as related allied health professionals, can look to this book as a comprehensive resource addressing contemporary clinical topics in the practice of living kidney donation. Patients’ Foreword Preface Contents Contributors 1: Rationale and Landscape of Living Kidney Donation in Contemporary Practice Rationale for Living Donor Kidney Transplantation: The Organ Shortage Chronic Kidney Disease and Kidney Failure Kidney Transplantation vs. Chronic Dialysis Living vs. Deceased Donor Kidney Transplantation Landscape of Living Kidney Donation Geographic Variation and Trends in Living Donor Kidney Transplantation Temporal Trends in Living Kidney Donors Recipient Disparities in Access to Living Donor Kidney Transplantation Primum Non Nocere: First, Do No Harm Risks to the Living Kidney Donor Follow-Up Care of Living Kidney Donors Advances in the Field of Living Kidney Donation Surgical Approaches for Donor Nephrectomy Kidney Paired Donation Conclusion References 2: Informed Consent and Framework of Living Donor Care Background and History of Living Donation Living Donor Evaluation and Care Overview for Donors The Role of an Independent Living Donor Advocate Ethical Framework for Living Kidney Donation Non-maleficence Beneficence Respect for Persons or Autonomy General Requirements for Informed Consent Decisional Capacity Disclosure Specific Disclosure Requirements for Living Donors Living Donor Rights and Care Processes Recipient Care, Rights, and Processes Donation Risks Methods of Disclosure The Dilemma of the “Recommendation” and Shared Decision-Making Comprehension Voluntariness Protections Against Undue Influence or “Undue Pressure” Protections Against Coercion Absence of “Valuable Consideration” Agreement Presence of an Affirmative Decision Special Considerations in Informed Consent Dilemmas About Disclosure of Misattributed Paternity Dilemmas About Testing for Genetic Risk Factors Vulnerable Populations: Incarcerated Donors Other Vulnerable Populations Nondirected Donors and Directed Donors with Limited Relationship Potential Donors Solicited via Social Media or Public Pleas Donors in “Advanced Donation” Donors with “Increased Risk Status” per the US Public Health Service Criteria Future Research Disclosure Comprehension Voluntariness Standardization Value, Use of, and Satisfaction with Informed Consent Priority Setting and Donor Engagement Develop and Evaluate Interventions Case Scenario #1: Undue Pressure Case Evaluation Recommendations Case Scenario #2: Internally Felt Pressure Case Evaluation Recommendations Case Scenario #3: Coercion Case Evaluation Recommendations Case Scenario #4: An Incarcerated Donor Candidate Case Evaluation Recommendations Case Scenario #5: An Incarcerated Donor Candidate Case Evaluation Recommendations Case Scenario #6: Clinical Care for Donor Candidates Who Meet US Public Health Service “Increased Risk” Criteria Case Evaluation Recommendations References 3: Evaluation of Glomerular Filtration Rate, Albuminuria and Hematuria in Living Donor Candidates Introduction Glomerular Filtration Rate Pathophysiology and Measurement Risk of Kidney Failure Related to Decreased GFR Box 3.1: 2017 KDIGO Living Donor Guideline Recommendations related to Predonation GFR Albuminuria Pathophysiology and Measurement Risk of Kidney Failure Related to Elevated Albuminuria Box 3.2: 2017 KDIGO Living Donor Guideline Recommendations Related to Predonation Albuminuria Hematuria Pathophysiology and Measurement Risk of Kidney Failure Related to Hematuria Box 3.3: 2017 KDIGO Living Donor Guideline Recommendations Related to Predonation Hematuria References 4: Evaluation of Renal Anatomy, Structure and Nephrolithiasis in Living Donor Candidates Introduction Kidney Structure and Anatomy Development of the Kidney Arterial Anatomy Renal Artery Stenosis Renal Vein Anatomy Left Kidney Retro-aortic Veins Renal Nutcracker Vein Ureteral Anatomy Horseshoe Kidney Renal Structure Kidney Size and Volume Factors Associated with Kidney Function Pre- and Postdonation Effects of Donor Kidney Size: “Nephron Dose” Histology of Implant Biopsies and Relevance to Donor Health Nephrolithiasis and Kidney Donation Epidemiology and History of Stone Disease in Donor Candidates Donor Candidates with Clinical Stone Disease Stone Disease After Kidney Donation Conclusion References 5: Evaluation of Hypertension in Living Donor Candidates Introduction Evaluation Blood Pressure Assessment Prior to Donation Office Blood Pressure Assessment Ambulatory Blood Pressure Monitoring (ABPM) Review of Medications Selection of Donor Candidates Based on Blood Pressure Readings Special Considerations Donor Candidates with Hypertension Additional Considerations Impact of Donor Nephrectomy on Blood Pressure, Risk for Cardiovascular Events, and Kidney Survival Impact of Donor Nephrectomy on Future Pregnancies Blood Pressure Care for Donors After Donation Need for Additional Studies Case Discussions Case 1 Case 2 Case 3 Case 4 References 6: Evaluation of Metabolic and Cardiovascular Risks in Living Donor Candidates Introduction Evaluation for Metabolic and Cardiovascular Risk Factors Special Considerations in Medically Complex Donors Obesity Measurement Outcomes Data Current Recommendations for Selection Glucose Intolerance Measurement Outcomes Data Current Recommendations for Selection Dyslipidemia and Metabolic Syndrome Measurement Outcomes Data Current Recommendations for Selection Hypertension Measurement Outcomes Data Current Recommendations for Selection Tobacco Use Measurement Outcomes Data Current Recommendations for Selection Cardiovascular Risk Measurement Outcomes Data Current Recommendations for Selection Apolipoprotein L1 Gene Measurement Outcomes Data Current Recommendations for Selection Conclusion References 7: Infection and Cancer Screening in Living Donor Candidates Evaluation and Management of the Living Donor Candidate to Prevent Infection Transmission Identifying Risk Factors Routine Infectious Screening Cytomegalovirus Epstein-Barr Virus (EBV) Syphilis Human Immunodeficiency Virus, Hepatitis B Virus, and Hepatitis C Virus Seasonal and Geographic Infections Endemic Fungal Infections Histoplasmosis Histoplasma capsulatum can be found worldwide, but is most common in North and Central America, specifically in the Ohio and Mississippi River valleys in the United States [35]. It is typically acquired from inhaling airborne Coccidioidomycosis Coccidioides immitis is found in the San Joaquin Valley in California, and Coccidioides posadasii is found in desert soil in the southwestern part of the United States (including Southwestern Arizona and West Texas), Northern Endemic Parasitic Infections Strongyloides Strongyloides stercoralis is an intestinal nematode that is endemic in tropical and subtropical countries, but can also be found in the Appalachia and southeastern United States [38]. Initial Strongyloides infection occurs when t Chagas Disease Trypanosoma cruzi, the protozoan parasite responsible for Chagas disease, is estimated to be present in 6–7 million people worldwide, most of whom live in Central America [44]. Based on most recent estimates, approximately 300,000 Endemic Bacterial Infections Tuberculosis Mycobacterium tuberculosis is one of the most common bacterial causes of donor-derived infections in solid organ transplantation [48]. Although only 4% of posttransplant tuberculosis (TB) is thought to be donor derived, an estim Endemic Viral Infections West Nile Virus West Nile virus (WNV) is a flavivirus that primarily infects birds and mosquitoes. Although transmission to humans is primarily through bites from infected Culex mosquitoes, transmission has been reported to occur via blood trans Zika Virus Zika virus (ZKV) is a flavivirus transmitted by Aedes aegypti. First recognized in Brazil in 2014, the CDC now lists many countries in Asia, Africa, Central and South America, the Pacific Islands, and the Caribbean as areas where Zika Evaluation and Management of the Living Donor Candidate to Prevent Cancer Transmission Cancer Screening in Living Donor Candidates Risk of Cancer Transmission Donor Candidates with a History of Cancer Living Donation in the Setting of Known Cancer Outcomes after Donor Cancer Transmission Conclusion References 8: Evaluation of Genetic Kidney Disease in Living Donor Candidates Introduction ESKD and the Role of Kidney Transplantation Scope of Risks to Living Kidney Donors Risk of Kidney Disease after Living Donation Diagnostic Tools to Estimate Risk of CKD and ESKD in Living Donor Candidates Genetic Mechanisms of CKD Assigning Pathogenicity to Identified Genetic Variants Methods of Genetic Testing Gene-Focused Testing by PCR Broad-Based or Comprehensive Screening by Next-Generation Sequencing Copy Number Variant Analysis Screening Living Donor Candidates for Individual Diseases Autosomal Dominant Polycystic Kidney Disease Autosomal Dominant Tubulointerstitial Disease Alport Nephropathy Genetic FSGS (Including Diffuse Mesangial Sclerosis and Steroid-Resistant Nephrotic Syndrome) Atypical HUS Fabry Disease Uncharacterized Renal Disease in Transplant Candidates Renal Disease Risk Variants: APOL1 Renal Risk Variants and Sickle Cell Trait Identification of the APOL1 Gene Distribution of the APOL1 Risk Variants Association Between APOL1 Renal Risk Variants, ESKD, and CKD APOL1 and the Second Hit Hypothesis Sickle Cell Trait Role of Sickle Cell Trait in Living Donation and Living Donor Kidney Transplantation Role of APOL1 in Living Donation and Living Donor Kidney Transplantation Interaction Between Sickle Cell and APOL1 Recommendation for Testing Living Donor Candidates for APOL1 and the Sickle Cell Trait Role of a Renal Genetics Clinic Summary References 9: Perioperative Evaluation and Management of Living Donor Candidates Overview of Preoperative Evaluation of the Living Kidney Donor and Frequency of Complications History and Physical Exam Preoperative Laboratory and Imaging Tests Preoperative Evaluation for Risk Stratification and to Minimize Complications Cardiac Bleeding Venous Thromboembolism (VTE) Pulmonary Intraoperative Donor Nephrectomy Considerations Intravascular Volume Expansion Avoidance of Vasopressors Tolerance of Mild Hypercapnia Postoperative Management of the Living Kidney Donor Enhanced Recovery Protocols References 10: Compatibility, Kidney Paired Donation, and Incompatible Living Donor Transplants Compatibility ABO Incompatibility HLA Incompatibility Assessment of HLA Incompatibility and Crossmatch Techniques Kidney Paired Donation Assessment of Quality of a Donor Kidney Scope of KPD Desensitization for Incompatible Living Donor Transplants Combining KPD and Desensitization Conclusion References 11: Psychosocial Evaluation, Care and Quality of Life in Living Kidney Donation Introduction The Content of the Psychosocial Evaluation The Psychosocial Evaluation Process and Predonation Care The Screening of Prospective Donors The Psychosocial Evaluation Interview Role and Qualifications of the Evaluator Communication with the Living Donor Transplantation Team About Psychosocial Evaluation Findings Referral for Additional Assessments or for Psychosocial Treatments or Interventions Communication with the Prospective Donor After Team Decisions Are Made About Donor Candidacy Postdonation Psychosocial Care and HRQOL Outcomes Psychosocial Care Psychosocial and HRQOL Outcomes Qualitative Research Quantitative Research Conclusion References 12: Risk Assessment Tools and Innovations in Living Kidney Donation Introduction Perioperative Risks Long-Term Risks Unknown Risks Known Benefits Summary References 13: Living Donor Nephrectomy: Approaches, Innovations, and Outcomes Surgical Considerations Living Donor Eligibility Technical Factors Approaches Open Retroperitoneal Donor Nephrectomy Laparoscopic Transperitoneal Donor Nephrectomy Modifications of Laparoscopic Nephrectomy Hand-Assisted Laparoscopy Robotic-Assisted Laparoscopy Retroperitoneoscopic Donor Nephrectomy Single-Port Surgery and Transvaginal Extraction Donor Outcomes Conclusions References 14: Follow-Up Care after Living Kidney Donation Introduction Elements of Living Donor Follow-up Medical Psychosocial and Socioeconomic Follow-Up Processes United States: Policy and Practice International Models of Donor Follow-Up Challenges To Living Donor Follow-Up Additional Considerations Ongoing Efforts and Strategies Living Donor Collective Novel Technological Strategies for Patient Reporting Transplant Center-Based Initiatives OPTN/UNOS “Toolbox” Recommendations Conclusions References 15: Ethical and Policy Considerations in Living Kidney Donor Evaluation and Care The Ethics of Living Donor Transplantation: Values and Principles Why Living Donation and LDKT Are Ethically Challenging Informed Consent Balancing Anticipated Benefits and Potential Harms Considerations of Fairness Other Ethical Values Bearing on LDKT Current Ethical Challenges in Living Donor Kidney Transplantation Participation of Compatible Pairs in Kidney Paired Donation Genetic Testing: The Case of APOL1 Public Solicitation of Living Donors Conclusion References 16: Living Donor Transplant Program Growth, Innovation and Sustainability Barriers to Increased Rates of Living Donation Institutional Culture to Promote Living Donor Transplantation Interventions to Reduce the Financial Burden of Living Donation Interventions to Increase Living Donor Transplantation among Racial and Ethnic Minorities Role of Technology in Advancing Living Donation Social Media as a Tool to Increase Living Donation Institutional Strategies and Resources Needed to Increase Living Donation Leadership and Staffing Programmatic Support Electronic Living Donor Candidate Screening Education of Transplant and Donor Candidates A Timely Evaluation Process for all Donor Candidates Ensuring Living Donor Follow-Up Robust Quality Assurance and Performance Improvement Processes Living Donor Satisfaction Partnerships with Community Providers to Increase Living Donor Transplantation Partnering with Chronic Kidney Disease (CKD) Management Clinics Conclusions References Index