What is involved in a comprehensive kidney transplant donor workup?

Comprehensive Kidney Transplant Donor Workup

A comprehensive kidney transplant donor workup requires a thorough medical, psychosocial, and laboratory evaluation to ensure donor safety and minimize risks to both donor and recipient, including mandatory ABO compatibility testing, HLA typing, cross-matching, and assessment of kidney function through GFR measurement. 1

Initial Screening and Compatibility Testing

Preliminary Mandatory Testing

• ABO blood type compatibility
• HLA typing
• Cross-matching against potential recipient 1
• Initial screening questions about medical history and motivation for donation 1

Selection Criteria When Multiple Donors Available

• Degree of HLA matching
• Donor age
• Biologically related donors generally preferred over unrelated donors 1

Medical Evaluation Components

Kidney Function Assessment

• GFR measurement (expressed as mL/min/1.73 m²) rather than serum creatinine alone 1
• Initial assessment using estimated GFR from serum creatinine (eGFRcr)
• Confirmation with measured GFR when necessary

Cardiovascular Risk Assessment

• Indications for cardiac stress testing:
  • Age ≥45 years in men or ≥55 years in women
  • History of smoking
  • Family history of premature coronary artery disease
  • History of dyslipidemia
  • History of hypertension
  • Abnormal ECG (left ventricular hypertrophy, left bundle branch block, ST-T abnormalities) 1

Diabetes/Glucose Metabolism Screening

• Fasting plasma glucose
• Oral glucose tolerance test when indicated

Absolute Contraindications

• Known diabetes mellitus
• Fasting plasma glucose ≥126 mg/dL on 2+ occasions
• Plasma glucose ≥200 mg/dL 2 hours after oral glucose challenge on 2+ occasions 1

Relative Contraindications

• Impaired fasting glucose (110-125 mg/dL)
• Impaired glucose tolerance (2-hour glucose 140-199 mg/dL) 1

Infectious Disease Screening

• Serologic screening for viral infections
• Nucleic acid testing for hepatitis B, hepatitis C, and HIV
• Additional testing for endemic exposures when indicated 2

Cancer Screening

• Age-appropriate cancer screening
• Evaluation of any pre-existing malignancies 3

Pregnancy Considerations

• Pregnancy testing for women of childbearing potential
• Counseling about avoiding pregnancy from approval to post-donation recovery
• Discussion of potential effects on future pregnancies 1

Psychosocial Evaluation

Two-Phase Approach for Unrelated Donors

1. Phase I: Initial Screening

   • General screening questions about medical history
   • Connection with transplant candidate
   • Reasons for and expectations about donation
   • Knowledge of risks involved 1

2. Phase II: On-Site Evaluation

   • Detailed psychosocial evaluation (mandatory for unrelated donors)
   • Conducted early in the medical evaluation process
   • Initial interview conducted alone, with additional interview including significant other
   • Evaluation by independent donor team separate from recipient's team
   • "Cooling off" period of at least 2 weeks 1

Key Components of Psychosocial Assessment

• Verification of voluntary donation without undue pressure
• Assessment of motivation and expectations
• Evaluation of psychological stability
• Assessment of social support system
• Understanding of risks and benefits
• Financial considerations 1

Post-Evaluation Decision Making

Framework for Decision-Making

• Donor candidate, recipient, and transplant program must all agree with decision
• Transplant program policies must be defensible based on current understanding of risks and benefits
• Risks should be expressed as absolute rather than relative risks 1

Risk Communication

• Individualized quantitative estimates of short-term and long-term risks
• Recognition of associated uncertainty
• Information presented in an easily understood manner 1

Common Pitfalls to Avoid

1. Failing to ensure true voluntariness - Always conduct at least part of the psychosocial evaluation in the absence of the recipient, family members, or others who might influence the donation decision 1

2. Inadequate assessment of long-term risks - Recent evidence shows increased risk of kidney failure in donors, contrary to previous beliefs of negligible risk 1

3. Overlooking pregnancy-related risks - Women with prior hypertensive disorders of pregnancy require careful evaluation of long-term risks 1

4. Insufficient "cooling off" period - Ensure donors have adequate time (at least 2 weeks) to consider their decision 1

5. Neglecting post-donation care planning - A comprehensive plan for donation care and follow-up should be formulated to minimize risks 1

By following this comprehensive approach to donor evaluation, transplant centers can maximize safety for donors while ensuring optimal outcomes for recipients.