Transmission of Amyloidosis from Kidney Donors to Recipients
Amyloidosis can be transmitted from a kidney donor to a recipient, particularly in cases of systemic amyloidosis, which is why donors with systemic amyloidosis should be excluded from donation. 1
Types of Amyloidosis and Transmission Risk
- Amyloidosis is classified into different types based on the precursor protein that forms amyloid fibrils, with AL (light chain) and ATTR (transthyretin) being the most common systemic forms 2
- In systemic AL amyloidosis, the kidney is one of the most common sites of amyloid deposition, affecting approximately 70% of patients, typically presenting with nephrotic syndrome and progressive kidney dysfunction 2
- The primary concern with systemic amyloidosis is the risk of recurrence in transplanted organs, which is not applicable in cases of truly localized disease 2
Guidelines on Donor Selection and Amyloidosis
- The 2020 KDOQI guidelines state that donors with active malignancy should be excluded from donation, with amyloidosis generally considered in this category due to transmission risk 1
- The 2024 EASL guidelines specifically mention that domino liver transplantation from donors with familial amyloidotic polyneuropathy can be considered in selected recipients, acknowledging that amyloidosis can be transmitted 1
- After domino liver transplantation for familial amyloidotic polyneuropathy, close monitoring for early detection of de novo TTR-neuropathy and cardiomyopathy is recommended, confirming the transmission risk 1
Localized vs. Systemic Amyloidosis in Donors
- For living kidney donors with any history of amyloidosis, comprehensive evaluation should include confirmation that the amyloidosis is truly localized through thorough clinical assessment 2
- Localized forms of amyloidosis (such as isolated nasopharyngeal amyloidosis) may be acceptable for donation after thorough evaluation to confirm the disease is truly localized 2
- Screening for proteinuria and assessment of kidney function using cystatin C-based GFR measurements is recommended for potential donors with any history of amyloidosis 2
Outcomes of Kidney Transplantation in Recipients with Amyloidosis
- While not directly addressing transmission from donors with amyloidosis, studies show that patients with amyloidosis can undergo kidney transplantation safely with outcomes similar to those patients who receive transplantations for other reasons 3
- Five- and 10-year actuarial graft survival rates for amyloidosis patients receiving transplants were found to be comparable to control groups (79.35% versus 84.04% at 5 years) 4
- Recurrence of amyloidosis in transplanted kidneys has been documented, though rare (4.3% in one study after 10 years) 4
Risk Assessment and Decision-Making
- When considering donation from a donor with a known history of cancer or amyloidosis, the risk of disease transmission versus the risk of death on the waiting list should be weighed carefully 1
- An individual value-based decision and shared decision-making for transplantation should be made if the risk of death on the waiting list outweighs the risk of disease transmission 1
- The recipient must provide informed consent when accepting an organ with potential transmission risk 1
Monitoring and Management
- Post-transplant monitoring should include periodic assessment for proteinuria and kidney function in recipients of kidneys from donors with any history of amyloidosis 2
- The risk of transmission of donor-derived infections or diseases cannot be reduced to zero, and the shortage of suitable organ donors must be balanced against these risks 1
- It is essential to implement control mechanisms to ensure rapid recognition of potential disease transmission and prompt communication to treating physicians 1
In conclusion, while localized forms of amyloidosis in donors may be acceptable for transplantation after thorough evaluation, systemic amyloidosis presents a significant transmission risk and generally contraindicates donation.