Medical Risks in Living Kidney Donors: Absence of Proof Is Not Proof of Absence

Demographic and Clinical Characteristics of Kidney Donors at First Check: A Single-Center Experience

OBJECTIVES

Kidney transplant is the best treatment for patients with end-stage kidney disease. In many regions of the world, including the Middle East, most kidney transplants are from living donors. In contrast to recipients, data for living donors remain scarce. Here, we describe living donor baseline characteristics at first hospital check at a single center in Baghdad, Iraq.

MATERIALS AND METHODS

We collected and analyzed demographic, laboratory, imaging, and histocompatibility data from donor records at the Nephrology and Renal Transplantation Center, Medical City-Baghdad, Baghdad, Iraq, from July 2022 to September 2022.

RESULTS

We included 124 kidney donors (56.4% male) who donated their kidneys 1 to 3 years previous to our study, with a mean age of 34.84 ± 10.04 years and mean body mass index (weight in kilograms divided by height in meters squared) of 27.11 ± 2.12. Most donors donated their kidneys to a firstdegree relative (69.2%); blood group O was the most prevalent (47.5%). More than half of the donors were unemployed. Histocompatibility testing showed that 40% of the donors had >3 human leukocyte antigen mismatches with their recipients, and 30% of the recipients were high-risk sensitized patients with a calculated panel reactive antibody >50%. Regarding the virus status, 68.5% of the donors tested positive for cytomegalovirus immunoglobulin G, 8% of the transplants were high-risk cytomegalovirus status, and 43.5% tested positive for Epstein-Barr virus immunoglobulin G. Renal imaging showed that 75.8% of donors had a single artery and 24.1% had a double artery (26.6% double left, 40% double right, and 33.3% both).

CONCLUSIONS

For living transplant procedures at a single center in Iraq, most were from related donors. Most donors are unemployed, which mandates future health and social support. High immunological and viral risks must not be ignored in a single center with living related donors.

Use of Continuous Glucose Monitors by People Without Diabetes: An Idea Whose Time Has Come?

BACKGROUND

Continuous glucose monitor (CGM) systems were originally intended only for people with diabetes. Recently, there has been interest in monitoring glucose concentrations in a variety of other situations. As data accumulate to support the use of CGM systems in additional states unrelated to diabetes, the use of CGM systems is likely to increase accordingly.

METHODS

PubMed and Google Scholar were searched for articles about the use of CGM in individuals without diabetes. Relevant articles that included sufficient details were queried to identify what cohorts of individuals were adopting CGM use and to define trends of use.

RESULTS

Four clinical user cases were identified: (1) metabolic diseases related to diabetes with a primary dysregulation of the insulin-glucose axis, (2) metabolic diseases without a primary pathophysiologic derangement of the insulin-glucose axis, (3) health and wellness, and (4) elite athletics. Seven trends in the use of CGM systems in people without diabetes were idenfitied which pertained to both FDA-cleared medical grade products as well as anticipated future products, which may be regulated differently based on intended populations and indications for use.

CONCLUSIONS

Wearing a CGM has been used not only for diabetes, but with a goal of improving glucose patterns to avoid diabetes, improving mental or physical performance, and promoting motivate healthy behavioral changes. We expect that clinicians will become increasingly aware of (1) glycemic patterns from CGM tracings that predict an increased risk of diabetes, (2) specific metabolic glucotypes from CGM tracings that predict an increased risk of diabetes, and (3) new genetic and genomic biomarkers in the future.

An Unexpected Catastrophe-Renal Artery Thrombosis in a Living Donor: A Case Report

BACKGROUND

Renal artery thrombosis is a devastating complication if not detected early. Cardioembolic disease or surgical and technical complications are frequent causes of renal artery thrombosis. There are some reports of renal artery thrombosis in a renal allograft, but to our knowledge, this is the first case of renal artery thrombosis reported in a kidney donor.

The Living Kidney Donor Safety Study: Protocol of a Prospective Cohort Study

Background

Living kidney donation is considered generally safe in healthy individuals; however, there is a need to better understand the long-term effects of donation on blood pressure and kidney function.

Objectives

To determine the risk of hypertension in healthy, normotensive adults who donate a kidney compared with healthy, normotensive non-donors with similar indicators of baseline health. We will also compare the 2 groups on the rate of decline in kidney function, the risk of albuminuria, and changes in health-related quality of life.

Design Participants and Setting

Prospective cohort study of 1042 living kidney donors recruited before surgery from 17 transplant centers (12 in Canada and 5 in Australia) between 2004 and 2014. Non-donor participants (n = 396) included relatives or friends of the donor, or donor candidates who were ineligible to donate due to blood group or cross-match incompatibility. Follow-up will continue until 2021, and the main analysis will be performed in 2022. The anticipated median (25th, 75th percentile, maximum) follow-up time after donation is 7 years (6, 8, 15).

Measurements

Donors and non-donors completed the same schedule of measurements at baseline and follow-up (non-donors were assigned a simulated nephrectomy date). Annual measurements were obtained for blood pressure, estimated glomerular filtration rate (eGFR), albuminuria, patient-reported health-related quality of life, and general health.

Outcomes

Incident hypertension (a systolic/diastolic blood pressure ≥ 140/90 mm Hg or receipt of anti-hypertensive medication) will be adjudicated by a physician blinded to the participant's donation status. We will assess the rate of change in eGFR starting from 12 months after the nephrectomy date and the proportion who develop an albumin-to-creatinine ratio ≥3 mg/mmol (≥30 mg/g) in follow-up. Health-related quality of life will be assessed using the 36-item RAND health survey and the Beck Anxiety and Depression inventories.

Limitations

Donation-attributable hypertension may not manifest until decades after donation.

Conclusion

This prospective cohort study will estimate the attributable risk of hypertension and other health outcomes after living kidney donation.

Managing the Costs of Routine Follow-up Care After Living Kidney Donation: a Review and Survey of Contemporary Experience, Practices, and Challenges

Purpose of Review

While living organ donor follow-up is mandated for 2 years in the USA, formal guidance on recovering associated costs of follow-up care is lacking. In this review, we discuss current billing practices of transplant programs for living kidney donor follow-up, and propose future directions for managing follow-up costs and supporting cost neutrality in donor care.

Recent Findings

Living donors may incur costs and financial risks in the donation process, including travel, lost time from work, and dependent care. In addition, adherence to the Organ Procurement and Transplantation Network (OPTN) mandate for US transplant programs to submit 6-, 12-, and 24-month postdonation follow-up data to the national registry may incur out-of-pocket medical costs for donors. Notably, the Centers for Medicare and Medicaid Services (CMS) has explicitly disallowed transplant programs to bill routine, mandated follow-up costs to the organ acquisition cost center or to the recipient’s Medicare insurance. We conducted a survey of transplant staff in the USA (distributed October 22, 2020–March 15, 2021), which identified that the mechanisms for recovering or covering the costs of mandated routine postdonation follow-up at responding programs commonly include billing recipients’ private insurance (40%), while 41% bill recipients’ Medicare insurance. Many programs reported utilizing institutional allowancing (up to 50%), and some programs billed the organ acquisition cost center (25%). A small percentage (11%) reported billing donors or donors’ insurance.

Summary

To maintain a high level of adherence to living donor follow-up without financially burdening donors, up-to-date resources are needed on handling routine donor follow-up costs in ways that are policy-compliant and effective for donors and programs. Development of a government-supported national living donor follow-up registry like the Living Donor Collective may provide solutions for aspects of postdonation follow-up, but requires transplant program commitment to register donors and donor candidates as well as donor engagement with follow-up outreach contacts after donation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40472-022-00379-w.

Effects of body fat components on early renal functions of individuals following kidney donation

Objective:

Obesity stands as a risk factor for the chronic kidney disease. The objective of this study was to investigate the relationship between early renal function following kidney donation and the measurements of body fat components.

Methods:

In total, 86 donors followed up for at least 6 months postoperatively were included. Height and weight measurements and results of laboratory analysis of all donors were recorded retrospectively. Visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), hepatic fat (HF), pancreatic fat (PF) and splenic fat (SF) measurements were performed, and pancreatic splenic fat fraction difference (P−S) and pancreatic splenic fat fraction ratio (P/S) were calculated by a radiologist using the records of preoperative computed tomography scans of donors.

Results:

The estimated glomerular filtration rate (eGFR), serum creatinine and spot urinary microalbumin/creatinine ratio values of the donors at the sixth month postoperatively were statistically different from those of the preoperative values ( p < 0.001). In addition, the individuals were divided into two categories based on the postoperative eGFR: ⩾ 60 mL/min/1.73 m2 and < 60 mL/min/1.73 m2. Age, low-density lipoprotein (LDL) level and VAT/SAT ratio were lower in group eGFR: ⩾ 60 ( p < 0.001, p = 0.03, p = 0.007, respectively). Age and VAT/SAT ratio were the parameters found to be affecting the eGFR significantly, and VAT/SAT ratio (0.729, 95% CI: 0.602–0.856, p = 0.007) had higher predictive value in receiver operating characteristic curve (ROC).

Conclusion:

Preoperative measurements of body fat components may provide significant information to predict postoperative renal functions of kidney donor candidates.

Level of evidence:

Not applicable.

Living kidney donation in a developing country

Background

Living kidney donation has been advocated as a means to ameliorate the chronic shortage of organs for transplantation. Significant rates of comorbidity and familial risk for kidney disease may limit this approach in the local context; there is currently limited data describing living donation in Africa.

Methods

We assessed reasons for non-donation and outcomes following donation in a cohort of 1208 ethnically diverse potential living donors evaluated over a 32-year period at a single transplant centre in South Africa.

Results

Medical contraindications were the commonest reason for donor exclusion. Black donors were more frequently excluded (52.1% vs. 39.3%; p<0.001), particularly for medical contraindications (44% vs. 35%; p<0.001); 298 donors proceeded to donor nephrectomy (24.7%). Although no donor required kidney replacement therapy, an estimated glomerular filtration rate below 60 ml/min/1.73 m2 was recorded in 27% of donors at a median follow-up of 3.7 years, new onset albuminuria >300 mg/day was observed in 4%, and 12.8% developed new-onset hypertension. Black ethnicity was not associated with an increased risk of adverse post-donation outcomes.

Conclusion

This study highlights the difficulties of pursuing live donation in a population with significant medical comorbidity, but provides reassurance of the safety of the procedure in carefully selected donors in the developing world.

Paired kidney donation: are we going beyond reasonable limits in living-donor transplantation?

The growing demand for transplant kidneys requires strategies to increase organ supply and avoid long waiting periods on the list. The increase in the number of transplants from living donors involves the growth in the use of unrelated donors and paired kidney donation. Most of these transplants are performed in the USA, where they already represent, respectively, 34% and 16% of total transplants from living donors. In Latin America, and especially in Brazil, there is no collective enthusiasm for these modalities, either at the request of transplanters or that of the community, with the region's priority being to increase transplants from deceased donors, which growth can be up to three-fold. Concerning transplants from matched donors, the possible conflicting results between donors can generate public challenges and they risk compromise the concepts of equal opportunities for transplant candidates, with the possibility of generating resistance to organ donation, especially in regions with socioeconomic limitations and disparities in access to qualified health care and education. This donation model involves challenging ethical and logistical issues, which are subject to questionings, starting with an act of exchange between two pairs until reaching embarrassing proposals, which can compromise the altruistic character of organ donation, and thus not be universally incorporated.

Prevalence, Mechanisms, Treatment, and Complications of Hypertension Postliving Kidney Donation

Living kidney donors represent a unique population of patients. Potential donors are selected based on the belief that their preoperative fitness is likely to mitigate the risks of long- and short-term harm following uninephrectomy. Studies performed on postdonation outcomes have largely focused on mortality and the risk of end-stage renal failure, but have also investigated secondary outcomes such as cardiovascular morbidity and hypertension. It has been postulated that hypertension is a possible outcome of living kidney donation. A variety of studies have been conducted to investigate the prevalence, epidemiology, mechanisms, treatment strategies, and long-term ramifications of hypertension postdonation. These studies are heterogeneous in their population, design, methodology, and outcome measures and have presented contradicting outcomes. Additionally, the absence of a well-matched control group has made it challenging to interpret and generalise the reported findings. As such, it is not possible to definitively conclude that hypertension occurs at a higher rate among donors than the general population. This article will review the evidence of postdonation hypertension prevalence, mechanisms, treatment, and complications.

Improving HLA matching in living donor kidney transplantation using kidney paired exchange program

BACKGROUND

The inclusion of compatible pairs within kidney paired exchange programs has been described as a way to enhance these programs. Improved immunological matching for the recipient in compatible pair has been described to be a possible benefit.

METHODS

The main purpose of our study was to determine if the introduction of compatible pairs in the Portuguese kidney paired exchange program would result in a better match for these patients, but also to assess if this strategy would increase the number of incompatible pairs with a possible match. We included 17 compatible pairs in kidney paired exchange pool of 35 pairs and performed an in-silico simulation determining HLA eplet mismatch load between the co-registered and matched pairs using HLA MatchMaker, version 3.0.

RESULTS

Our study showed that the inclusion of fully HLA-A, -B, -DR mismatched compatible pairs within the national Portuguese KEP increased matched rate within ICP (0.71%) and improved HLA eplet matching within compatible pairs. 16 of 17 (94.12%) of the CP obtained one or more transplants possibilities and 13 (81.25%) would have been transplanted with significantly lower HLA class I and class II total and antibody-verified eplet mismatch load (83.9 ± 16.9 vs. 59.8 ± 12.2, P = .002 and 30.1 ± 5.5 vs. 21.2 ± 3.0, P = .003, respectively).

CONCLUSIONS

This strategy is a viable alternative for compatible pairs seeking a better matched kidney and Portuguese KEP program should allow them this possibility.

Serum Klotho in Living Kidney Donors and Kidney Transplant Recipients: A Meta-Analysis

α-Klotho is a known anti-aging protein that exerts diverse physiological effects, including phosphate homeostasis. Klotho expression occurs predominantly in the kidney and is significantly decreased in patients with chronic kidney disease. However, changes in serum klotho levels and impacts of klotho on outcomes among kidney transplant (KTx) recipients and kidney donors remain unclear. A literature search was conducted using MEDLINE, EMBASE, and Cochrane Database from inception through October 2019 to identify studies evaluating serum klotho levels and impacts of klotho on outcomes among KTx recipients and kidney donors. Study results were pooled and analyzed utilizing a random-effects model. Ten cohort studies with a total of 431 KTx recipients and 5 cohort studies with a total of 108 living kidney donors and were identified. After KTx, recipients had a significant increase in serum klotho levels (at 4 to 13 months post-KTx) with a mean difference (MD) of 243.11 pg/mL (three studies; 95% CI 67.41 to 418.81 pg/mL). Although KTx recipients had a lower serum klotho level with a MD of = -234.50 pg/mL (five studies; 95% CI -444.84 to -24.16 pg/mL) compared to healthy unmatched volunteers, one study demonstrated comparable klotho levels between KTx recipients and eGFR-matched controls. Among kidney donors, there was a significant decrease in serum klotho levels post-nephrectomy (day 3 to day 5) with a mean difference (MD) of -232.24 pg/mL (three studies; 95% CI -299.41 to -165.07 pg/mL). At one year following kidney donation, serum klotho levels remained lower than baseline before nephrectomy with a MD of = -110.80 pg/mL (two studies; 95% CI 166.35 to 55.24 pg/mL). Compared to healthy volunteers, living kidney donors had lower serum klotho levels with a MD of = -92.41 pg/mL (two studies; 95% CI -180.53 to -4.29 pg/mL). There is a significant reduction in serum klotho levels after living kidney donation and an increase in serum klotho levels after KTx. Future prospective studies are needed to assess the impact of changes in klotho on clinical outcomes in KTx recipients and living kidney donors.

Risks of Living Kidney Donation: Current State of Knowledge on Outcomes Important to Donors

In the past decade, there have been increasing efforts to better define and quantify the short- and long-term risks of living kidney donation. Recent studies have expanded upon the previous literature by focusing on outcomes that are important to potential and previous donors, applying unique databases and/or registries to follow large cohorts of donors for longer periods of time, and comparing outcomes with healthy nondonor controls to estimate attributable risks of donation. Leading outcomes important to living kidney donors include kidney health, surgical risks, and psychosocial effects of donation. Recent data support that living donors may experience a small increased risk of severe CKD and ESKD compared with healthy nondonors. For most donors, the 15-year risk of kidney failure is <1%, but for certain populations, such as young, black men, this risk may be higher. New risk prediction tools that combine the effects of demographic and health factors, and innovations in genetic risk markers are improving kidney risk stratification. Minor perioperative complications occur in 10%-20% of donor nephrectomy cases, but major complications occur in <3%, and the risk of perioperative death is <0.03%. Generally, living kidney donors have similar or improved psychosocial outcomes, such as quality of life, after donation compared with before donation and compared with nondonors. Although the donation process should be financially neutral, living kidney donors may experience out-of-pocket expenses and lost wages that may or may not be completely covered through regional or national reimbursement programs, and may face difficulties arranging subsequent life and health insurance. Living kidney donors should be fully informed of the perioperative and long-term risks before making their decision to donate. Follow-up care allows for preventative care measures to mitigate risk and ongoing surveillance and reporting of donor outcomes to inform prior and future living kidney donors.

Risk of subsequent health disorders among living kidney donors

Few studies have investigated the risk of physiological sequelae in living kidney donors (KDs). We conducted a population-based cohort study using the National Health Insurance Research Database of Taiwan, which covers more than 99% of citizens.We comprehensively investigated the risk of medical disorders after kidney donation in living KDs using a maximum follow-up of 13 years. From January 1997 to December 2010, 1081 living KDs and 1082 age- and sex-matched non-KDs were eligible. Primary outcomes comprised end-stage renal disease, chronic kidney disease, stroke, cancer, acute myocardial infarction, acute renal failure (ARF), and diabetes.The adjusted hazard ratios (HRs) for developing ARF, diabetes, hyperlipidemia, hypertension, cancer, end-stage renal disease, acute myocardial infarction, and stroke were similar between the KD and non-KD cohorts (P > .05). Although differences in the adjusted HRs of ARF were nonsignificant, the cumulative incidence rate of ARF 13 years after donation was 7.48 per 1000 person-years in the KD cohort compared with 3.46 in the matched non-KD cohort. The incidence rate ratio for ARF between donors and nondonors significantly increased to 2.16 (95% confidence interval, 1.61-2.71).Living KDs experienced no significant health disorders following kidney donation but should be alert to the higher incidence rate of ARF.

Predictive Factors of Renal Adaptation After Nephrectomy in Kidney Donors

BACKGROUND

Despite compensatory hyperfiltration in remaining nephrons following donor nephrectomy, some donors show impaired renal adaptation and low estimated glomerular filtration rate (eGFR). We investigated the factors predicting early renal adaptation after nephrectomy and identified kidney donors at risk of inadequate renal adaptation.

METHODS

A total of 265 living kidney donors from 2010 to 2013 were retrospectively analyzed. Renal function was serially followed for 6 months after the operation. Regression analyses were performed to identify the independent predictors of low eGFR (eGFR <60 mL/min/1.73 m²) and impaired renal adaptation (%Modification of Diet in Renal Disease [MDRD] <66% of baseline eGFR).

RESULTS

A total of 148 donors belonged to the low eGFR group, and changes in eGFR (ΔeGFR) at postoperative (PO) 1 day and 1 month were identified as independent predictors of low eGFR. Impaired renal adaptation was related to age, ΔeGFR PO 2-3 days, and ΔeGFR PO 1 month. Early renal adaptation was associated with age, male gender, and residual kidney computerized tomography angiography (CTA) volume. The best sensitivity and specificity were obtained with a cutoff value of ΔeGFR 31 at PO 1 day and 1 month for predicting low eGFR and with a value of ΔeGFR 27 at PO 2-3 days and 1 month for predicting impaired renal adaptation.

CONCLUSIONS

Our study showed that the degree of early renal adaptation determines subsequent renal function in kidney donors. Closer monitoring and management may be required in old or male donors with small residual CTA kidney volume as well as donors with persistent ΔeGFR >27 within 1 month of nephrectomy.

Death of recipients after kidney living donation triples donors' risk of dropping out from follow-up: a retrospective study

Although kidney transplantation from the donation of a living donor is a safe treatment for end-stage renal disease, inferences about safety of living kidney donors might be biased by an informative censoring caused by the noninclusion of a substantial percentage of donors lost to follow-up. With the aim of assessing the presence of a potential informative censoring in living kidney donation outcomes of Catalan donors for a period of 12 years, 573 donors followed and lost to follow-up were compared. Losses of follow-up over time were also assessed by univariate and multivariate survival analysis, along with Cox regression. Younger and older ages, and the death of their recipient differentiated those donors who were lost to follow-up over time. The risk of dropping out from follow-up was more than twofold for the youngest and oldest donors, and almost threefold for those donors whose recipient died. Results of studies on postdonation outcomes of Catalan living kidney donors might have overlooked older and younger cases, and, remarkably, a percentage of donors whose recipient died. If these donors showed a higher incidence of psychological problems, conclusions about living donors' safety might be compromised thus emphasizing the necessity of sustained surveillance of donors and prompt identification of these cases.

Risk Factors Associated with Decreased Renal Function after Hand-Assisted Laparoscopic Donor Nephrectomy: A Multivariate Analysis of a Single Surgeon Experience

Background: Hand-assisted laparoscopic donor nephrectomy is a minimally invasive procedure for living kidney donation. The surgeon operative volume is associated with postoperative morbidity and mortality. We evaluated the risk factors associated with decreased renal function after hand-assisted laparoscopic donor nephrectomy performed by a single experienced surgeon. Methods: We included living renal donors who underwent hand-assisted laparoscopic donor nephrectomy by a single experienced surgeon between 2006 and 2013. Decreased renal function was defined as an estimated glomerular filtration rate (eGFR) of < 60 mL/min/1.73 m² on postoperative day 4. The donors were categorized into groups with postoperative eGFR < 60 mL/min/1.73 m² or ≥ 60 mL/min/1.73 m². Univariate and multivariate logistic regression analyses were performed to evaluate the risk factors associated with decreased renal function after hand-assisted laparoscopic donor nephrectomy. The hospital stay duration, intensive care unit admission rate, and eGFR at postoperative year 1 were evaluated. Results: Of 643 patients, 166 (25.8%) exhibited a postoperative eGFR of < 60 mL/min/1.73 m². Multivariate logistic regression analysis demonstrated that the risk factors for decreased renal function were age [odds ratio (95% confidence interval), 1.062 (1.035-1.089), P < 0.001], male sex [odds ratio (95% confidence interval), 3.436 (2.123-5.561), P < 0.001], body mass index (BMI) [odds ratio (95% confidence interval), 1.093 (1.016-1.177), P = 0.018], and preoperative eGFR [odds ratio (95% confidence interval), 0.902 (0.881-0.924), P < 0.001]. There were no significant differences in postoperative hospital stay duration and intensive care unit admission rate between the two groups. In addition, 383 of 643 donors were analyzed at postoperative year 1. Sixty donors consisting of 14 (5.0%) from the group of 279 donors in eGFR ≥ 60 mL/min/1.73 m², and 46 (44.2%) from the group of 104 donors in eGFR < 60 mL/min/1.73 m² had eGFR < 60 mL/min/1.73 m² at postoperative year 1 (P < 0.001). Conclusions: Increased age, male sex, higher BMI, and decreased preoperative eGFR were risk factors for decreased renal function after hand-assisted laparoscopic donor nephrectomy by a single experienced surgeon. These results provide important evidence for the safe perioperative management of living renal donors.

Understanding and Communicating Medical Risks for Living Kidney Donors: A Matter of Perspective

Communicating the current knowledge of medical outcomes after live kidney donation necessary to support donor candidates in well informed decision-making requires grounding in perspectives of comparison. Baseline risk (without donating), risk attributable to donation, and absolute risk (after donating) need to be considered. Severe perioperative complications and death are rare, but vary by demographic, clinical, and procedure factors. Innovative capture of "healthy" controls designed to simulate donor selection processes has identified higher risk of ESRD attributable to donation in two studies; importantly, however, the absolute 15-year ESRD incidence in donors remains very low (0.3%). In the first decade after donation, the risk of all-cause mortality and cardiovascular events is no higher than in healthy nondonors. Pregnancies in donors may incur attributable risk of gestational hypertension or preeclampsia (11% versus 5% incidence in one study). A modest rise in uric acid levels beginning early after donation, and a small (1.4%) increase in the 8-year incidence of gout, have also been reported in comparisons to healthy nondonors. As in the general population, postdonation outcomes vary by race, sex, and age. Efforts to improve the counseling and selection of living donors should focus on developing tools for tailored risk prediction according to donor characteristics, and ideally, compared with similar healthy nondonors.

Is an 87-Year-Old Grandfather Too Marginal for Being a Kidney Donor? The View of Anesthesiologists

Living kidney donation has been accepted increasingly as a result of growth in the number of end-stage renal disease patients awaiting organ. In this aspect using grafts from marginal donors such as with advanced age is increasing in worldwide practice and also in Turkey. Therefore, anesthetic management of donors is particularly important. We herein report the anesthetic management of an 87-year-old grandfather donating his kidney to her granddaughter and review the current anesthetic strategies in a geriatric patient.

Male Gender and Body Mass Index Are Associated With Hypertension and Reduced Kidney Function 5 or More Years After Living Kidney Donation

BACKGROUND

The objective of this study was to evaluate renal function and to explore the relationship between some risk factors in kidney donors 12.37 ± 7.60 years after donation.

PATIENTS AND METHODS

In a cross-sectional study conducted in a transplant unit, 77 nephrectomized subjects were assessed ≥5 years after donation to evaluate their renal function and the presence or absence of hypertension, dyslipidemia, and microalbuminuria.

RESULTS

Twenty donors had an estimated glomerular filtration rate of <60 mL/min/1.73 m(2). Nine donors showed urinary albumin excretion of >20 μg/min (11.68%). Subjects with an EGFR of <60 mL/min were predominantly male and hypertensive and showed higher body mass index (BMI), higher uric acid, higher total cholesterol/high-density lipoprotein cholesterol (TC/HDL-C), and logarithm of triglycerides/HDL-C (log TG/HDL-C) ratios than donors with an EGFR of >60 mL/min. Hypertensive donors were older and had higher BMI, higher UA serum values, higher TC/HDL-C and log TG/HDL-C ratios and microalbuminuria than nonhypertensive donors (P < .005). A multivariate analysis was conducted and, after final adjustment, a filtration rate of <60 mL/min was 3.05 times higher in men than women, increased 10% for each 1-unit increase in BMI and was positively associated with log (TG/HDL-C). The frequency of hypertension increased by 10% for each 1-unit increase in BMI and was positively associated with microalbuminuria.

CONCLUSION

In this sample of kidney donors from a single transplant unit, ≥5 years after donation, male sex and high BMI were positively associated with the presence of kidney failure.

Investigating kidney donation as a risk factor for hypertension and microalbuminuria: findings from the Swiss prospective follow-up of living kidney donors

OBJECTIVES

To assess the role of nephrectomy as a risk factor for the development of hypertension and microalbuminuria.

DESIGN

Prospective, long-term follow-up study.

SETTING

Swiss Organ Living-Donor Health Registry.

PARTICIPANTS

All living kidney donors in Switzerland between 1993 and 2009.

INTERVENTIONS

Data on health status and renal function before 1 year and biennially after donation were collected.

PRIMARY AND SECONDARY OUTCOME MEASURES

Comparison of 1-year and 5-year occurrences of hypertension among normotensive donors with 1-year and 5-year estimates from the Framingham hypertension risk score. Multivariate random intercept models were used to investigate changes of albumin excretion after donation, correcting for repeated measurements and cofactors such as age, male gender and body mass index.

RESULTS

A total of 1214 donors contributed 3918 data entries with a completed biennial follow-up rate of 74% during a 10-year period. Mean (SD) follow-up of donors was 31.6 months (34.4). Median age at donation was 50.5 years (IQR 42.2-58.8); 806 donors (66.4%) were women. Donation increased the risk of hypertension after 1 year by 3.64 (95% CI 3.52 to 3.76; p<0.001). Those participants remaining normotensive 1 year after donation return to a risk similar to that of the healthy Framingham population. Microalbuminuria before donation was dependent on donor age but not on the presence of hypertension. After nephrectomy, hypertension became the main driver for changes in albumin excretion (OR 1.19; 95% CI 0.13 to 2.25; p=0.03) and donor age had no effect.

CONCLUSIONS

Nephrectomy propagates hypertension and increases susceptibility for the development of hypertension-induced microalbuminuria.

BARTERING FOR A COMPATIBLE KIDNEY USING YOUR INCOMPATIBLE, LIVE KIDNEY DONOR: LEGAL AND ETHICAL ISSUES RELATED TO KIDNEY CHAINS

Kidney chains are a recent and novel method of increasing the number of available kidneys for transplantation and have the potential to save thousands of lives. However, because they are novel, kidney chains do not fit neatly within existing legal and ethicalframeworks, raising potential barriers to their full implementation. Kidney chains are an extension of paired kidney donation, which began in the United States in 2000. Paired kidney donations allow kidney patients with willing, but incompatible, donors to swap donors to increase the number of donor/recipient pairs and consequently, the number of transplants. More recently, transplant centers have been using non-simultaneous, extended, altruistic donor ("NEAD") kidney chains--which consist of a sequence of donations by incompatible donors--to further expand the number of donations. This Article fully explains paired kidney donation and kidney chains and focuses on whether NEAD chains are more coercive than traditional kidney donation to a family member or close friend and whether NEAD chains violate the National Organ Transplant Act's prohibition on the transfer of organs for valuable consideration.

Race, Relationship and Renal Diagnoses After Living Kidney Donation

BACKGROUND

In response to recent studies, a better understanding of the risks of renal complications among African American and biologically related living kidney donors is needed.

METHODS

We examined a database linking U.S. registry identifiers for living kidney donors (1987-2007) to billing claims from a private health insurer (2000-2007 claims) to identify renal condition diagnoses categorized by International Classification of Diseases 9th Revision coding. Cox regression with left and right censoring was used to estimate cumulative incidence of diagnoses after donation and associations (adjusted hazards ratios, aHR) with donor traits.

RESULTS

Among 4650 living donors, 13.1% were African American and 76.3% were white; 76.1% were first-degree relatives of their recipient. By 7 years post-donation, after adjustment for age and sex, greater proportions of African American compared with white donors had renal condition diagnoses: chronic kidney disease (12.6% vs 5.6%; aHR, 2.32; 95% confidence interval [95% CI], 1.48-3.62), proteinuria (5.7% vs 2.6%; aHR, 2.27; 95% CI, 1.32-3.89), nephrotic syndrome (1.3% vs 0.1%; aHR, 15.7; 95% CI, 2.97-83.0), and any renal condition (14.9% vs 9.0%; aHR, 1.72; 95% CI, 1.23-2.41). Although first-degree biological relationship to the recipient was not associated with renal risk, associations of African American race persisted for these conditions and included unspecified renal failure and reported disorders of kidney dysfunction after adjustment for biological donor-recipient relationship.

CONCLUSIONS

African Americans more commonly develop renal conditions after living kidney donation, independent of donor-recipient relationship. Continued research is needed to improve risk stratification for renal outcomes among African American living donors.

Long term prospective assessment of living kidney donors: single center experience

Virtually, all studies reporting the outcomes of living kidney donation beyond the first year from donation were retrospective. In this prospective study, the outcome of 81 consecutive living kidney donors was thoroughly evaluated. Clinical, laboratory, and radiological assessments were carried out at predonation (basal), 3, 6, 12, and 24 months after donation. The mean age at time of donation was 37.8 ± 9.8 years and the majority was females (75.3%). The mean BMI increased significantly after donation (P < 0.04). The mean serum creatinine levels (mg/dl) were 0.75 ± 0.14, 1.01 ± 0.22, 0.99 ± 0.21, 0.98 ± 0.20, and 0.94 ± 0.20 (P < 0.0001). Likewise, the mean levels of measured creatinine clearance (mL/min) were 148.8 ± 35.7, 94.7 ± 26.6, 95.5 ± 24.6, 96.7 ± 20.2, and 101.6 ± 26.2 (P < 0.0001). The mean 24 hours urinary protein excretion (gm/dL) were 0.09 ± 0.03, 0.19 ± 0.18, 0.16 ± 0.09, 0.18 ± 0.25, and 0.17 ± 0.12 (P < 0.0001). There were significant increases in the means of the longitudinal and transverse diameters of the remaining kidney over time (P < 0.001). Out of 42 female donors, eleven female donors have got successful postdonation pregnancies. There were no reported surgical complications, either intra- or postoperative. Long-term follow-up is necessary for all living kidney donors through local institutional and world registries. This trial is registered with ClinicalTrials.gov NCT00813579.

Nutrition assessment and counseling of the medically complex live kidney donor

Kidney transplantation is the preferred option for patients with end-stage renal disease facing the need for dialysis because it provides maximum survival benefit. The number of people seeking kidney transplantation greatly exceeds available deceased donor organs. Organs from live donors provide a survival advantage over organs from deceased donors while also broadening the pool of available organs. The purpose of this review is to discuss the clinical guidelines that pertain to live kidney organ donation and to describe the nutrition evaluation and care of live kidney donors. The process for living kidney donation is dictated by policies centered on protecting the donor. In a perfect world, the living donor would present with a flawless medical examination and a benign family health history. The obesity epidemic has emerged as a major health concern. Live donor programs are faced with evaluating increasing numbers of obese candidates. These "medically complex donors" may present with obesity and its associated comorbid conditions, including hypertension, impaired glycemic control, and kidney stone disease. The dietitian's role in the live donor program is not well defined. Participation in the living donor selection meeting, where details of the evaluation are summarized, provides a platform for risk stratification and identification of donors who are at increased lifetime risk for poor personal health outcomes. Guiding the donor toward maintenance of a healthy weight through diet and lifestyle choices is a legitimate goal to minimize future health risks.

The decline in living kidney donation in the United States: random variation or cause for concern?

The annual number of living kidney donors in the United States peaked at 6647 in 2004. The preceding decade saw a 120% increase in living kidney donation. However, since 2004, living kidney donation has declined in all but 1 year, resulting in a 13% decline in the annual number of living kidney donors from 2004 to 2011. The proportional decline in living kidney donation has been more pronounced among men, blacks, younger adults, siblings, and parents. In this article, we explore several possible explanations for the decline in living kidney donation, including an increase in medical unsuitability, an aging transplant patient population, financial disincentives, public policies, and shifting practice patterns, among others. We conclude that the decline in living donation is not merely reflective of random variation but one that warrants action by the transplant centers, the broader transplant community, and the state and national governments.

Protocol of a cluster randomized trial of an educational intervention to increase knowledge of living donor kidney transplant among potential transplant candidates

Background

The best treatment option for end-stage renal disease is usually a transplant, preferably a live donor kidney transplant (LDKT). The most effective ways to educate kidney transplant candidates about the risks, benefits, and process of LDKT remain unknown.

Methods/design

We report the protocol of the Enhancing Living Donor Kidney Transplant Education (ELITE) Study, a cluster randomized trial of an educational intervention to be implemented during initial transplant evaluation at a large, suburban U.S. transplant center. Five hundred potential transplant candidates are cluster randomized (by date of visit) to receive either: (1) standard-of-care (“usual”) transplant education, or (2) intensive education that is based upon the Explore Transplant series of educational materials. Intensive transplant education includes viewing an educational video about LDKT, receiving print education, and meeting with a transplant educator. The primary outcome consists of knowledge of the benefits, risks, and process of LDKT, assessed one week after the transplant evaluation. As a secondary outcome, knowledge and understanding of LDKT are assessed 3 months after the evaluation. Additional secondary outcomes, assessed one week and 3 months after the evaluation, include readiness, self-efficacy, and decisional balance regarding transplant and LDKT, with differences assessed by race. Although the unit of randomization is the date of the transplant evaluation visit, the unit of analysis will be the individual potential transplant candidate.

Discussion

The ELITE Study will help to determine how education in a transplant center can best be designed to help Black and non-Black patients learn about the option of LDKT.

Trial registration

Clinicaltrials.gov number NCT01261910

Public awareness and attitudes to living organ donation: systematic review and integrative synthesis

BACKGROUND

The deceased-donor organ shortage has driven widespread adoption of living-donor transplantation. Yet, public views on living donation are not well understood. This study aims to synthesize studies on public awareness and attitudes toward living organ donation.

METHODS

Electronic databases and reference lists were searched to September 2012. Summary estimates from survey data were obtained by random effects meta-analysis. Qualitative descriptive synthesis of each study was performed.

RESULTS

Forty-seven studies involving 34,610 respondents were included. The proportion of respondents aware of living organ donation was 76.7% (4 studies, n=3248; 95% confidence interval, 46.2%-97.0%; I=99.7%). The majority were in favor of living directed donation (85.5% (11 studies, n=15,836; 95% confidence interval, 81.6%-89.6%; I=98%), with recipient and community benefit as the rationale provided. However, barriers included fear of surgical and health risks, lack of knowledge, respect for cultural norms, financial loss, distrust in hospitals, and avoiding recipient indebtedness. The public voiced concern about possible risks or an obligatory pressure exerted on the donor. Many supported reimbursement for out-of-pocket expenses, paid leave, wait-listing priority, health insurance, and donor acknowledgment. There was strong opposition to financial incentives, which they believed risked exploitation and inequity and diminished voluntary altruistic donation.

CONCLUSIONS

The public is generally supportive of living donation and articulated important equity and ethical considerations for protecting the health and safety of living donors. This supports increased public engagement and strengthening of a shared view among professionals and the public in living donation practice and policy.

Living kidney donor assessment: challenges, uncertainties and controversies among transplant nephrologists and surgeons

The assessment of living kidney donors presents unique ethical challenges and complex psychosocial implications. This study aimed to ascertain the perspectives of transplant nephrologists and surgeons on living kidney donor assessment. Semi-structured, face-to-face interviews were conducted with 110 transplant nephrologists and surgeons from 43 transplant units in 12 countries from Europe, Australasia and North America. The challenge of defining acceptable risk to the donor was central to five themes identified: burden of responsibility (personal accountability, policing morality, democratic decision making, meeting legal obligations, optimizing outcomes and innovation, relinquished control); medical protectiveness (prognostic uncertainty, skepticism of donor risk perception, avoidance of undue coercion, concerns for dubious motivations and coercion, safeguard donor well-being, ethical information disclosure); respecting donor autonomy (facilitate informed-decision making, concede to donor risk acceptance, benefit of the doubt, donor mandate to maintain health, acceptable altruism); driving ideologies (preserving equity, championing living donation, cognizance of anti-paternalism) and contextual pressures (evolving donor demographic, resource limitations). Living kidney donor assessment involves complex interactions between safeguarding the donors' welfare and respecting their autonomy. In our opinion, authoritative and well-described transplant unit, hospital and public policy positions that make explicit the considerations that are often implicit may reduce the uncertainty within which living donors are assessed today.

Kidney function in living donors undergoing nephrectomy by sevoflurane or desflurane anesthesia

PURPOSE

Although there is no clinical evidence of nephrotoxicity with the volatile anesthetics currently used in general anesthesia, a better agent should be needed in terms of preserving postoperative renal function in living kidney donors who have only single remaining kidney. The purpose of the current retrospective, single-center study was to evaluate and compare renal function of living kidney donors after nephrectomy under either sevoflurane or desflurane anesthesia.

MATERIALS AND METHODS

From January 2006 through December 2011, a total of 228 donors undergoing video assisted minilaparotomy surgery nephrectomy for kidney donation were retrospectively enrolled in the current study. The donors were categorized into a sevoflurane group or desflurane group based on the type of volatile anesthetic used. We collected laboratory data from the patients preoperatively, immediately after the operation, on the first postoperative day and on the third postoperative day. We also compared renal function of the kidney donors after donor nephrectomy by comparing creatinine level and estimated glomerular filtration rate (eGFR).

RESULTS

The decrease in renal function after surgery in both groups was the most prominent on the first postoperative day. There were no significant differences between the two groups in postoperative changes of creatinine or eGFR.

CONCLUSION

Sevoflurane and desflurane can be used safely as volatile anesthetics in donors undergoing nephrectomy.

Health care follow-up by live kidney donors more than three yr post-nephrectomy

BACKGROUND

Live kidney donors are advised to follow up regularly with healthcare providers to monitor kidney function and to diagnose and treat relevant comorbidities. We sought to determine the frequency and correlates of follow-up care among live kidney donors.

METHODS

We sent a mailed questionnaire to 606 live kidney donors from a single center who were at least three yr post-nephrectomy.

RESULTS

We received usable responses from 276 (45.5%), at a median of 6.2 yr post-donation. Compared with non-responders, responding donors were more likely to be older (p < 0.001), female (p = 0.002), white (p < 0.001), and married to the recipient (p < 0.001). In the prior year, 87.7% of respondents reported seeing a physician or other healthcare professional, and 79.0% had seen a "general doctor" such as their primary care provider. In univariable analyses of live kidney donors who responded to our survey, lack of medical follow-up in the past year was associated with younger age, current lack of health insurance, and infrequent contact with the transplant recipient.

CONCLUSIONS

Most responding live kidney donors had seen a healthcare provider within the past year. To improve donors' follow-up, transplant centers can consider targeting donors who are younger or lack health insurance.

Long-term consequences of uninephrectomy in male and female rats

We investigated the effects of uninephrectomy (UNX) in 6-week-old male and female rats on blood pressure (BP), renal sodium handling, salt sensitivity, oxidative stress, and renal injury over 18 months postsurgery, studying control sham-operated and UNX-operated rats at 6, 12, and 18 months postsurgery, evaluating their renal sodium handling, BP, urinary isoprostanes, N-acetyl-β-D-glucosaminidase, and proteinuria before and after a 2-week high-salt intake period. At 18 months, plasma variables were measured and kidney samples were taken for the analysis of renal morphology and tissue variables. BP was increased at 6 months in male UNX rats versus controls and at 12 and 18 months in both male and female UNX rats and was increased in male versus female UNX groups at 18 months. UNX did not affect water and sodium excretion under basal conditions and after the different test in male and female rats at different ages. However, the renal function curve was shifted to the right in both male and female UNX rats. High-salt intake increased BP in both UNX groups at 6, 12, and 18 months and in the female control group at 18 months, and it increased proteinuria, N-acetyl-β-D-glucosaminidase, and isoprostanes in both UNX groups throughout the study. Renal lesions at 18 months were more severe in male versus female UNX rats. In summary, long-term UNX increased the BP, creatinine, proteinuria, pathological signs of renal injury, and salt sensitivity. Earlier BP elevation was observed and morphological lesions were more severe in male than in female UNX rats.

Risks and outcomes of living donation

Living donors supply approximately 40% of renal allografts in the United States. Based on current data, perioperative mortality after donor nephrectomy is approximately 3 per 10,000 cases, and major and minor perioperative complications affect approximately 3% to 6% and 22% of donors, respectively. Donor nephrectomy does not appear to increase long-term mortality compared with controls, nor does it appear to increase ESRD risk among white donors. Within the donor population, the likelihood of postdonation chronic renal failure and medical comorbidities such as hypertension and diabetes appears to be relatively higher among some donor subgroups, such as African Americans and obese donors, but the impact of uninephrectomy on the lifetime risks of adverse events expected without nephrectomy in these subgroups has not yet been defined. As national follow-up of living donors in the United States is limited in scope, duration, and completeness, additional methods for quantifying risk among diverse living donors are needed. In addition to improved national collection of follow-up data, possible sources of information on donor outcomes may include focused studies with carefully defined control groups, and database integration projects that link national donor registration records to other data sources. Given the growth and evolving characteristics of the living donor population, as well as changes in surgical techniques, tracking of short- and long-term risks after living kidney donation is vital to support truly informed consent and to maintain public trust in living donation. The transplant community must persist in their efforts to accurately assess risk across demographically diverse living kidney donors.

Living donation: the global perspective

Of 195 independent countries in the world, 83 have transplant programs. Some countries (areas) have emphasized living donation; others, decreased donation. As a consequence, rates of living donation vary widely between geographic areas and often between countries within the same geographic area. The major ethical issue in living donation is the risk to the donor. Internationally, numerous guidelines have been developed outlining acceptable donor evaluation and criteria for approval. An ongoing issue is that there remains considerable variation between countries (and programs within a country) in evaluation and in acceptance criteria. A major problem for most countries is the shortage of organs. As a consequence, illegal or quasi-legal unregulated markets have developed in some areas. These markets have not provided protection for either donor or recipient. The transplant community has taken a unified stand against these underground unregulated markets.

The living kidney donor evaluation: focus on renal issues

Living kidney donor evaluations and follow-up have previously been addressed mostly by transplant physicians and surgeons. However, this area is significantly informed by basic principles of renal physiology and is of increasing clinical interest to general nephrologists. The general nephrology community is increasingly involved in evaluating the suitability of potential donors and in following them after donation when questions are raised about low GFR, hypertension, and other renal concerns. This article focuses on some of the most central and common issues that arise in evaluating potential donors and attempts to provide guidance on the basis of our review of the living donor literature, extrapolations from the general nephrology literature, and our own clinical experience.

Screening and follow-up of living kidney donors: a systematic review of clinical practice guidelines

To minimize the health risks faced by living kidney donors, multiple clinical practice guidelines have been developed on the assessment and care of potential donors. This study aims to compare the quality, scope, and consistency of these guidelines. We searched for guidelines on living kidney donation in electronic databases, guideline registries, and relevant Web sites to February 21, 2011. Methodological quality was assessed using the Appraisal of Guidelines for Research and Education (AGREE) instrument. Textual synthesis was used to compare guideline recommendations. Ten guidelines, published from 1996 to 2010, were identified. Although generally comprehensive, scope varied considerably and mostly appeared to lack methodological rigor. Many recommendations were consistent, but important differences were evident, particularly for thresholds for comorbidities which precluded donation; obesity/overweight (body mass index, 30-35 kg/m), diabetes/prediabetes (fasting blood glucose level, 6.1-7.0 mmol/L and oral glucose tolerance test, 7.8-11.1 mmol/L), hypertension (130/85 to 140/90 mm Hg), cardiovascular disease, malignancy, and nephrolithiasis. The importance of informed voluntary consent, genuine motivation, support, and psychological health were recognized but difficult to implement as specific tools for conducting psychosocial assessments were not recommended. Multiple major guidelines for living kidney donation have been published recently, resulting in unnecessary duplicative efforts. Most do not meet standard processes for development, and important recommendations about thresholds for exclusion based on comorbidities are contradictory. There is an urgent need for international collaboration and coordination to ensure, where possible, that guidelines for living donation are consistent, evidence based, and comprehensive to promote best outcomes for a precious resource.

Vitamin A metabolism is changed in donors after living-kidney transplantation: an observational study

Background

The kidneys are essential for the metabolism of vitamin A (retinol) and its transport proteins retinol-binding protein 4 (RBP4) and transthyretin. Little is known about changes in serum concentration after living donor kidney transplantation (LDKT) as a consequence of unilateral nephrectomy; although an association of these parameters with the risk of cardiovascular diseases and insulin resistance has been suggested. Therefore we analyzed the concentration of retinol, RBP4, apoRBP4 and transthyretin in serum of 20 living-kidney donors and respective recipients at baseline as well as 6 weeks and 6 months after LDKT.

Results

As a consequence of LDKT, the kidney function of recipients was improved while the kidney function of donors was moderately reduced within 6 weeks after LDKT. With regard to vitamin A metabolism, the recipients revealed higher levels of retinol, RBP4, transthyretin and apoRBP4 before LDKT in comparison to donors. After LDKT, the levels of all four parameters decreased in serum of the recipients, while retinol, RBP4 as well as apoRBP4 serum levels of donors increased and remained increased during the follow-up period of 6 months.

Conclusion

LDKT is generally regarded as beneficial for allograft recipients and not particularly detrimental for the donors. However, it could be demonstrated in this study that a moderate reduction of kidney function by unilateral nephrectomy, resulted in an imbalance of components of vitamin A metabolism with a significant increase of retinol and RBP4 and apoRBP4 concentration in serum of donors.

When good intentions are not enough: obtaining follow-up data in living kidney donors

The Organ Procurement Transplant Network/United Network for Organ Sharing (OPTN/UNOS) has increased the amount of data collected before and after donation and increased the duration of donor follow-up to 2 years, yet there is evidence that reporting is incomplete. We examined the frequency of missing data in the OPTN/UNOS donor follow-up registry and found that reporting rates were low, particularly for donors who may have limited access to health care. We argue that a national donor follow-up registry is essential to ensure transparency in ascertaining long-term health outcomes among all living donors and in providing assessments of quality assurance within transplant programs. We have suggested approaches to strengthen the donor follow-up registry system. These include setting clear and high standards for follow-up reporting, a system of incentives and penalties that would motivate transplant centers to comply with these standards and would encourage donors to follow-up and lifelong follow-up reporting by primary care providers. We argue that the US government must provide funding to support a donor follow-up registry that can allow for meaningful and valid conclusions, in recognition of donors' public service and to maintain trust in the system of living organ donation.

Lack of health insurance in living kidney donors

Living donors are recommended to receive lifelong routine health maintenance after donation. There has been little examination of health insurance status among living donors, despite the fact that lack of health insurance is likely to impede donors' ability to obtain long-term healthcare post-donation. We performed a retrospective chart review for all living kidney donors at our institution between 2004 and 2008 to determine insurance status, demographic, socioeconomic, and basic health characteristics. Twenty-three percent of donors were uninsured at the time of donation. Odds of being uninsured were significantly lower in donors who were older than 40 yr of age or who had at least a college education, and significantly higher in donors who were non-white, non-English-speaking, or non-US citizens. Odds of being uninsured did not differ according to whether donors were obese, hypertensive, or smokers. On multivariate analysis, only non-white race, non-US citizenship, and education level less than a college degree were associated with lack of insurance. Lack of health insurance is more prevalent in living kidney donors than in the general US population. Its disproportionate impact on minorities, non-citizens, and the less well educated is greater than that in the general population.

Long-term effects of kidney donation on renal function and blood pressure in African Americans

BACKGROUND AND OBJECTIVES

African Americans (AAs) have four times higher prevalence of ESRD than Caucasians. Therefore, long-term effects of kidney donation are of considerable importance in this patient population.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

GFR was measured by (125)I-iothalamate clearance, 24-hour urine albumin excretion, and 24-hour BP monitoring in 33 AAs and 11 CAs who donated kidneys for transplantation 5 to 23 years previously.

RESULTS

Mean GFRs were 76 ± 13 and 78 ± 11 ml/min per 1.73 m(2) for AA and CA donors, respectively. Nine percent of the AA donors and none of the CA donors had GFRs below 60 ml/min per 1.73 m(2). AA donors had a tendency for lower prevalence of microalbuminuria compared with CA donors (18.1% versus 36.3%) and a tendency for higher prevalence of macroalbuminuria compared with CAs (12.1% versus 0.0%). Twenty-four percent of the AAs, and 45% of the CAs were hypertensive with mean daytime BP ≥135/85 mmHg. Only 6% of AAs had a decrease in mean nocturnal systolic BP of 10% or more as compared with daytime readings. Older age at time of donation was associated (P = 0.046) with lower GFR values compared with younger ages.

CONCLUSION

Carefully selected AA kidney donors have well preserved renal function and a low prevalence of hypertension many years after kidney donation. Abnormal albumin excretion and loss of physiologic decrease in nocturnal BP is more prevalent in AA donors than the general AA population. Older age at donation may predict lower GFR after donation.