What is the evaluation process for a healthy individual donating a kidney?

Evaluation Process for Living Kidney Donation in Healthy Individuals

A healthy individual seeking to donate a kidney must undergo a comprehensive, multidisciplinary evaluation that prioritizes donor safety through verification of voluntary consent, assessment of medical and psychosocial suitability, and establishment of acceptable short- and long-term risk thresholds before proceeding with donation. 1

Core Principles of Donor Evaluation

The evaluation framework rests on six fundamental goals that must be addressed systematically 1:

• Voluntary consent verification - The donor candidate's willingness must be confirmed without evidence of undue pressure or coercion 1
• Individualized risk-benefit assessment - Both short-term surgical risks and long-term health consequences must be quantified for each candidate 1
• Program policy adherence - Acceptance or exclusion decisions must follow established transplant center protocols that comply with UNOS and CMS requirements 1
• Comprehensive education and counseling - Candidates require detailed information about risks, risk minimization strategies, and mandatory postdonation follow-up 1
• Postdonation care planning - An explicit plan for ongoing monitoring and management must be established before donation 1
• Support for excluded candidates - Those deemed unsuitable require explanation, referrals, and appropriate care planning 1

Evaluation Structure and Timeline

Phase I: Initial Screening

The evaluation begins with preliminary assessment to identify obvious contraindications before proceeding with invasive testing 1, 2:

• Blood type compatibility must be verified twice to prevent incompatible transplantation 3
• Basic health screening includes blood pressure (<140/90 mmHg on at least two measurements), fasting glucose, and baseline kidney function 4, 3
• Preliminary psychosocial assessment screens for coercion, financial incentives, substance dependence, or psychiatric instability that would preclude further evaluation 1

If clear contraindications emerge during Phase I, the evaluation should be discontinued with appropriate explanation and referrals provided to the candidate 1.

Phase II: Comprehensive On-Site Evaluation

Once initial screening is cleared, detailed medical and psychosocial assessment proceeds 1, 3:

Medical Assessment Components

Kidney function evaluation requires 3:

• 24-hour urine collection for creatinine clearance (preferred method over estimated GFR) 3
• GFR must be ≥90 mL/min/1.73 m² for donation approval 4
• Urinalysis to detect proteinuria, hematuria, or pyuria 3
• Urine albumin excretion <30 mg/day (>100 mg/day is absolute contraindication) 4

Anatomical imaging includes 3:

• CT angiography or MRI/MRA to evaluate renal parenchyma, vascular anatomy, and collecting system 3
• CT is preferred for detecting calcifications and defining renal vein anatomy 3

Cardiovascular assessment must include 4, 3:

• Cardiac stress testing for men ≥45 years or women ≥55 years, or those with smoking history, family history of premature coronary disease, dyslipidemia, hypertension, or abnormal ECG 4, 3
• Blood pressure control verification (<140/90 mmHg office or <135/85 mmHg ambulatory) 3

Metabolic and infectious disease screening encompasses 3:

• Fasting plasma glucose (diabetes is absolute contraindication) 4, 3
• Lipid panel 3
• HIV, hepatitis B and C, syphilis (RPR), and tuberculosis (PPD) testing 3

Age-appropriate cancer screening based on standard guidelines 3:

• Colorectal (age 50+), breast (age 40+), cervical (age 18+), prostate (age 50+, or 45+ for African Americans or family history) 3

Genetic/familial disease screening when indicated 3:

• ADPKD screening for donors related to recipients with genetic kidney diseases 3
• Evaluation for thin basement membrane disease, SLE (ANA, complement levels), and familial glomerulonephritis 3

Psychosocial Evaluation Requirements

This mandatory assessment must be conducted by independent evaluators not involved in recipient care 1:

• Initial interview conducted alone with the donor candidate, followed by a second session including significant others 1
• Two-session structure: First session by clinical social worker or nurse specialist covering all components; second session by psychologist or psychiatrist for in-depth evaluation of concerns 1
• Assessment domains include motivation, understanding of risks, capacity for informed consent, evidence of coercion, financial incentives, substance use history, psychiatric history, and social support 1, 3
• Mandatory cooling-off period of at least 2 weeks after Phase II evaluation to ensure adequate consideration 1

Decision-Making Framework

The donor candidate, intended recipient, and transplant program must all agree before proceeding 1. Critical decision-making principles include:

• Risk threshold comparison - Programs must establish numeric thresholds for acceptable short- and long-term postdonation risks (expressed as absolute, not relative risks) 1
• Uniform criteria application - All candidates must be evaluated using identical standards regardless of directed versus non-directed donation 1
• Conflict of interest minimization - At least one key team member not involved in recipient care must participate in donor evaluation and acceptance decisions 1
• Privacy protection - All evaluation details and decision considerations must remain confidential 1

Absolute Contraindications

Donation must not proceed if any of the following are present 4:

• Diabetes mellitus or abnormal glucose tolerance 4
• Uncontrolled hypertension or evidence of hypertensive organ damage 4
• GFR <60 mL/min/1.73 m² 4
• Significant proteinuria (albumin excretion >100 mg/day) 4
• Active substance dependence 1
• Evidence of coercion or undue pressure 1

Postdonation Follow-Up Requirements

Annual monitoring is mandatory for all living donors and includes 1, 3:

• Blood pressure measurement (target <130/80 mmHg) 1, 3
• BMI measurement 1
• Serum creatinine with GFR estimation 1
• Albuminuria measurement 1
• Lifestyle counseling (exercise, diet, tobacco abstinence) 1
• Psychosocial well-being assessment 1
• Avoidance of nephrotoxic medications 3

Donors who develop CKD postdonation require management according to standard CKD guidelines 1.

Critical Pitfalls to Avoid

Do not proceed with invasive testing if clear contraindications are identified during initial screening - this protects candidates from unnecessary procedures and costs 1.

Do not allow recipient care team members to conduct donor evaluation - this creates unacceptable conflicts of interest that may compromise donor safety 1.

Do not rush the evaluation process - the mandatory cooling-off period and comprehensive assessment timeline exist to ensure truly informed, voluntary consent 1.

Do not neglect occupational considerations - certain professions (e.g., commercial airline pilots) may face unique risks including temporary or permanent loss of certification, even when medical criteria are met 4.