ASN Communities Weekly Rewind
Scherly Leon, MD
Introduction and Background
While living kidney donation provides great potential benefits to kidney disease patients donor evaluation practices, policies and thresholds vary considerably, and importantly, long waiting lists have stimulated non-directed altruistic donation and paired exchange programs, which present their own unique legal and ethical challenges, controversies and complex psychosocial implications. Although living kidney donation offers the recipient better outcomes than deceased kidney donation, live donors face the risks of surgical complications, long-term health and psychological harms and even death.
A person with history of coronary artery disease, coronary artery bypass grafting (CABG) and no other comorbidities is being evaluated as potential kidney donor. Stress test (TMT) and stress echocardiography are currently normal. Can such a person be considered for kidney donation? If not, are there any guidelines and what other factors should be considered?
Online discussion focused on two points:
Living Kidney Donor Assessment: Individualized decision making
As physicians we look to guidelines, but any assessment requires an individualized approach that captures all aspects of a prospective donor’s medical and family history.
Although most donors experience good outcomes and have good quality of life after donation, kidney donation is associated with short and longer-term risks. The Organ Procurement and Transplantation Network (OPTN), in February 2013, implemented policy requirements for all living kidney donor recovery hospitals in the United States to promote consistency in the informed consent, medical and psychosocial evaluation, and follow-up of living donors. In 2014, these requirements were incorporated within global policies for living organ donors. These policies define the minimum requirements for the evaluation and selection of living kidney donors in the US and are available here: https://optn.transplant.hrsa.gov/media/1200/optn_policies.pdf.
Based on the absolute exclusions for living kidney donors list from OPTN, the patient in question would not qualify to donate a kidney.
Living Kidney Donor Assessment: Challenges and Considerations
One challenge mentioned was discussion of risk/benefits when obtaining informed consent. Since “the benefits are few and not easily quantified (self-gratification of making an altruistic decision; psychological wellbeing, etc.) and “the risk are numerous, quantifiable and meaningful (death, postoperative morbidity, hypertension. proteinuria, CKD, ESRD).” It advised that physicians not have both donor and recipient as patients. Also, in settings where the donor and recipient have direct personal or genetic relationship, focus on benefits to recipient rather than risk to donor should be avoided.
When assessing a potential living donor candidate, we need an individualized approach. Since there is never any benefit to a live kidney donor, other than psychological, we have to be as certain as possible that risks both short term and long term are as minimal as possible.
Read the whole discussion here