What are the criteria for determining donor and recipient suitability for transplantation?

Criteria for Determining Donor and Recipient Suitability for Transplantation

Successful transplantation requires rigorous evaluation of both donors and recipients to ensure optimal outcomes, with specific criteria determining suitability for each organ type and transplant scenario.

General Donor Suitability Criteria

Medical Evaluation

• ABO compatibility is mandatory for preliminary evaluation of potential living donors, with blood group typing performed twice before donation to prevent incompatible transplantation 1
• HLA typing and cross-matching against potential recipients are required, with biologically related donors generally preferred over unrelated donors 2
• Absolute contraindications for living kidney donation include known diabetes mellitus, fasting plasma glucose ≥126 mg/dL on multiple occasions, or plasma glucose ≥200 mg/dL after oral glucose challenge 2
• Relative contraindications include impaired fasting glucose (110-125 mg/dL) and impaired glucose tolerance (2-hour plasma glucose 140-199 mg/dL) 2
• Cardiac evaluation is indicated for donors with risk factors including age (≥45 years in men, ≥55 years in women), smoking history, family history of premature coronary artery disease, dyslipidemia, hypertension, or abnormal ECG 2

Age Considerations

• Advanced donor age should not be an absolute contraindication for liver donation, as studies show acceptable outcomes with careful selection 3
• For living kidney donors, age-related decline in renal function must be considered, with elderly donors requiring particularly careful monitoring 2

Special Populations

• Women with childbearing potential should avoid pregnancy from approval for donation until recovery after nephrectomy, with pregnancy testing required immediately before donation 2
• Women with prior hypertensive disorders of pregnancy should be informed about long-term risks and may be acceptable donors if post-donation risks are deemed acceptable 2
• Nursing mothers require special consideration for anesthesia and analgesia planning if donating within a year after childbirth 2

Recipient Suitability Criteria

Medical Evaluation

• Cardiac transplant recipients with moderate hypokinesia (shortening fraction 10-25%), non-critical coronary disease, or history of carbon monoxide inhalation with carboxyhemoglobin <20% may still be suitable candidates 2
• For hematopoietic cell transplantation, recipient factors affecting outcomes include cytomegalovirus serostatus, performance score, disease type, and disease status 2
• Immunosuppressive medication considerations are essential, with tacrolimus and cyclosporine requiring careful monitoring to prevent nephrotoxicity 4, 5

Allocation Principles

• Utility principle dictates that organs should go to patients with the best predicted post-transplant outcomes 2
• Justice principle ensures that patients with similar predicted outcomes have equal chances of receiving organs 2
• Transplant benefit principle considers the difference between post-transplant life expectancy and waitlist/alternative treatment life expectancy 2

Matching Considerations

HLA Matching

• For unrelated hematopoietic cell donors, high-resolution matching for HLA-A, -B, -C, and -DRB1 maximizes post-transplantation survival 2
• The number of HLA mismatches directly correlates with mortality risk, with each mismatch having greater impact in recipients with "low-risk" disease 2

ABO Compatibility

• ABO blood group compatibility is the primary consideration for donor eligibility to prevent hyperacute rejection 1
• ABO-incompatible transplantation carries increased risks and should be considered experimental, with kidney paired donation programs as alternatives 1

Psychosocial Evaluation

• In-person psychosocial evaluation by professionals experienced in donor concerns is essential for living donors 2
• Voluntariness assessment requires at least part of the evaluation to be conducted without the intended recipient or family members present 2
• Potential donors should be informed about typical quality of life outcomes after donation 2
• Psychological outcomes including benefits (increased self-esteem) and risks (resentment or depression after unsuccessful transplantation) must be discussed 2

Common Pitfalls and Considerations

• Relying solely on ABO compatibility without proper crossmatching can lead to transplant failure 1
• Donor availability is a significant challenge, with nearly 50% of registered unrelated donors unavailable when identified as potential matches 2
• Immunosuppressive medication monitoring is critical, as cyclosporine and tacrolimus can cause nephrotoxicity that may be difficult to distinguish from rejection 4, 5
• For living donors with medical conditions that would disqualify unrelated donors, transplant centers should carefully weigh risks and benefits, as criteria are typically less strict for related donors 6

Special Transplant Scenarios

• HIV-positive organ transplantation under the HIV Organ Policy Equity (HOPE) Act requires specialized infectious disease evaluation of donors 7
• Extended criteria donors (age >65, organ dysfunction, steatosis >40%, etc.) may be suitable for recipients with less severe disease, particularly for liver transplantation 2
• Machine perfusion techniques can help evaluate or recondition organs from extended criteria donors 2