The most living donor procedures performed in the world

Living Donor Kidney Transplants: The Difficult Decisions

Though the process of evaluating prospective donors and recipients is standardized through what we call donor protocols, there are exceptions to consider in many cases. The decision to proceed with a living donation is often difficult, but there are ways to consider the pros and cons so it can be a well reasoned and fully informed choice.

At The Transplant Center discussing these difficult situations normally involves the prospective donor, the recipient, the primary care physician and the respective families. Often the discussions are held separately. When risk to the donor or recipient is increased, or the long-term outcome is compromised, either the donor or recipient may not wish to proceed. The wishes of every donor and every recipient are essential to consider.

Decisions Involving All Donors for a Given Recipient

Should a Recipient With a Short Life Expectancy Have a Living Donor Transplant?

We have no formal policy, but in general, the worse the long-term forecast, the more forcefully we tend to discourage a living donor transplant. The benefit to the recipient may be too small to warrant the risk to the donor. The donor must fully understand the situation and be given adequate time for reflection and review.

When there are Many Potential Donors, Which One Should Donate?

When multiple siblings are interested and have no obvious disqualifying medical conditions, our practice is to perform tissue typing on all of them. We are testing for a human leukocyte antigen (HLA)-identical sibling. If we find one with an exact match we recommend continuing with that person’s evaluation. Transplants of HLA-identical sibling kidneys produce superior results.

If there are no HLA-identical siblings, we believe the overriding influence on the decision should rest in the answer to social issues, such as, who can take time off work? Or, who does not have young children to care for?

If there are no siblings being considered, and all things are equal regarding social issues, age is often considered. Of two qualified potential donors age 33 and 56, the younger one may have a slightly lower surgical risk and the implanted kidney may survive longer. On the other hand, if the kidney functions 20 years and then fails, the older person would then be 76 and likely an unacceptable donor candidate, whereas the younger one would be 53 and could still donate. There are other scenarios that provide no clear-cut answers and should be discussed with potential donors and their families.

Should a Recipient With a Chance of Recurrent Disease Have a Living Donor Transplant?

A number of diseases are known to recur in the transplanted kidney. For most of those diseases (Diabetic nephropathy, Idiopathic nephritic syndrome, Immunoglobulin A nephropathy (Henoch-Schönlein purpura), Lupus nephritis, Membranoproliferative glomerulonephritis type 1, Wegener’s granulomatosis, Vasculitis) the risk of rapid graft failure is low and need not rule out a living donor transplant.

For diseases of higher risk of recurrence we often recommend a deceased-donor transplant, but again, there are circumstances where we have supporting data and outcome experiences that make it possible to consider a living donor. Our goal is to avoid the potential for a graft failure for as long as possible, so it is important for the donor to understand the prospects of recurrent disease and the possibility that the success rate may not be as high.

Should a Noncompliant Recipient Have a Living Donor Transplant?

Our policy for recipients with a history of non-cooperation with the medical regimen is to insist on a period of no less than six months of absolute compliance. We ask the referring physicians and, if applicable, the dialysis unit to keep us informed of the potential recipient’s behavior. If the noncompliant behavior continues, particularly if it includes failure to comply with life-sustaining medications (or therapies), we will not do a transplant.

We discuss the potential recipient’s previous behavior pattern with all prospective living donors (often in the recipient’s presence). We point out that noncompliance is a major risk for graft loss and that previous behavior is a risk for post-transplant noncompliance. We ask donors to discuss these issues frankly with the recipient. We also recommend they not consider donating until they are comfortable that the recipient will comply with the post-transplant regimen.

Should a Living-Related Donor With a Family History of Kidney Disease Be Accepted?

Many kidney diseases run in families. For some, but not all, we have much information about inheritance patterns and can predict the chance of disease developing in the donor. In addition to sharing this information, we also discuss the chance of kidney disease developing in the donor’s children. A potential donor may decide not to donate to a sibling if there is a chance that his or her child may someday need a kidney transplant.

Should Someone with Hypertension Accept a Kidney from His or Her Child?

More research is needed before definitive advice can be offered on this question. Because hypertension usually develops later in life, it is unknown whether a child, who is at increased risk, might accelerate development of hypertension. Another question is, if hypertension does develop, will having one kidney accelerate the course to end stage renal disease (ESRD)? And, if hypertension is diagnosed and treated early in a donor after donation, can ESRD be prevented?

These are complicated discussions and the decision needs to be the donor’s. We strongly recommend annual screening for hypertension.

Should an Individual With Diabetes Accept a Graft From His or Her Child?

Because there is a strong hereditary tendency for type 2 diabetes, younger children of a recipient with type 2 diabetes carry a higher risk of developing the disease than when the donor is older. The possible risks do need to be discussed, but it is likely that the risk does diminish with the age of the donor.

Decisions on Whether to Use a Specific Donor

When there is only one prospective living donor for a given recipient—from borderline donor kidney function to obesity, questions arise about increased risk for the donor and recipient. Each of these must be discussed, and there is often no right answer in many situations.

Details of this report were published in Living Donor Kidney Transplants: The Difficult Decisions, Ramcharan, Kasiske and Matas, Transplantation Reviews, Vol. 17, No. 1, pp 3-10, Jan. 2003.