RENAL TRANSPLANTATION 0039-6109/98 $8.00 + .

OO
THE EVALUATION OF
PROSPECTIVE RENAL
TRANSPLANT RECIPIENTS AND
LIVING DONORS
Bertram L. Kasiske, MD
GENERAL APPROACH TO TRANSPLANT RECIPIENTS
AND DONORS
For many patients, renal transplantation is the treatment of choice
for end-stage renal disease (ESRD). As soon as it is evident that a patient
will need therapy for ESRD, renal transplantation should be considered.
Transplantation should be considered sooner, rather than later, because
some patients may be able to undergo pre-emptive transplantation and
avoid dialysis altogether. The evaluation of transplant candidates should
be directed to ensuring that the risk of surgery and immunosuppression
is acceptable to both patient and. physician. The evaluation should also
attempt to determine the likelihood that the graft will function well
enough and long enough to improve the quality of life of the recipient.
The shortage of organs for transplantation in the United States is
growing. The median waiting time for a cadaveric kidney is more than
2 years. Therefore, increasing emphasis is being placed on using living
donors for renal transplantation. In addition, kidneys from living-related
donors tend to function longer than kidneys from cadaveric donors. The
primary goal in the evaluation of a potential living donor is to ensure
the donors safety. Both the short- and long-term risks of donation need
to be carefully assessed. In addition, the living donor evaluation should
From the Division of Nephrology, Department of Medicine, University of Minnesota,
College of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
SURGICAL CLINICS OF NORTH AMERICA
VOLUME 78 * NUMBER 1 . FEBRUARY 1998 27
28 KASISKE
consider whether the kidney to be transplanted will provide suitable
long-term function for the recipient.
THE EVALUATION OF POTENTIAL RENAL
TRANSPLANT RECIPIENTS
The Initial Evaluation
The recipient evaluation should be cost-effective. Often, a brief
history and physical examination can determine that a patient is not a
suitable candidate for transplantation before other, more expensive tests
are carried out. Age and poor overall health may be reason enough not
to proceed with additional evaluation (Table 1). Transplantation has
no absolute age contraindication, but the risks of both surgery and
immunosuppression increase with age. Age should be judged in the
context of the patients overall health. The concept of physiologic age,
although difficult to define, underscores the importance of considering
both age and overall health status together.
Diabetes is now the most common cause of ESRD in the United
States, and the incidence of ESRD from diabetes continues to grow at a
faster rate than that due to other cause^.'^Diabetes frequently influences
the evaluation process from the outset. Compared with most other
causes of ESRD, patients with diabetes experience increased morbidity
and mortality. Thus, special consideration should be given to patients
with diabetes to ensure that the risk of transplantation is minimized and
their quality of life is enhanced as much as possible. With regard to risk,
special consideration should be given to the cardiovascular evaluation
because cardiovascular disease complications are particularly common
among diabetics and may greatly increase the risk of transplant surgery.
In addition, some diabetic patients may be candidates for simultaneous
kidney-pancreas transplantation.
Screening for Cancer
Except for locally invasive basal cell or fully excised squamous cell
carcinomas, patients with an active malignancy should not receive a
Table 1. POTENTIAL CONTRAINDICATIONS FOR RENAL TRANSPLANT RECIPIENTS
Advanced age and poor health
Malignancy
Infection
Liver disease
Previous allograft lost to recurrent focal segmental glomerulosclerosis
Inoperable coronary artery disease
Substance abuse
Medical nonadherence
PROSPECTIVE RENAL TRANSPLANT RECIPIENTS AND LIVING DONORS 29
renal transplant. The pretransplant evaluation should screen for malig-
nancies and should include a thorough physical examination, chest
radiography, and stool Hemoccult testing. Flexible sigmoidoscopy
should be considered for older individuals to rule out colorectal carci-
noma, Women with a family history of breast carcinoma should undergo
mammography, and all women over 40 should have had a recent mam-
mogram. Women should also have a pelvic examination and Pap test.
Management of transplant candidates with a history of malignancy
but no evidence of active tumor is particularly difficult. Although immu-
nosuppression increases the risk of tumor recurrence in this setting, it is
difficult to precisely determine that risk. For many patients, the risk may
not be great enough to justify foregoing transplantation. Data from post-
transplant tumor registries give some insight into the risk of recurrence,
and that risk varies for different tumor types but generally declines over
time. The overall risk of recurrence for a patient who has been free
from all evidence of malignancy for 2 years is about 47% after renal
transplantation, and the risk after 5 years is approximately 13%. How-
ever, different tumors behave differently, and guidelines address how
different tumors should be approached'
Screening for Infections
The presence of an active, potentially life-threatening infection is a
contraindication to transplantation, and patients should be carefully
screened for infections as part of the pretransplant evaluation. All pa-
tients should be screened for human immunodeficiency virus (HIV),
and transplantation should probably be avoided in those who are HIV
p~si ti ve.~ Chest radiography and a purified protein derivative (PPD)
skin test should be used to screen for tuberculosis, especially in patients
from high-risk populations. Patients who are PPD positive and have not
already been adequately treated should probably receive prophylactic
therapy prior to transplantation. Patients on peritoneal dialysis should
not be transplanted if they have had peritonitis within the previous 3 to
4 weeks. Cytomegalovirus (CMV) infection is common after transplanta-
tion. However, the best predictor of post-transplant CMV infection is an
increased CMV antibody titer in the donor, especially if the recipient has
a low titer. Screening for CMV antibodies in donor and recipient should
not influence the decision to transplant but can be used to guide prophy-
lactic therapy after tran~plantation.~
Liver Disease
All transplant candidates should be screened for the presence of
viral hepatitis. It is generally accepted that patients who are hepatitis B
surface antigen (HBsAg) positive are at increased risk of dying after
transplantation. Nevertheless, HBsAg is not a contraindication to trans-
30 KASISKE
plantation per se. However, patients who are HBsAg positive and have
serologic evidence of viral replication should probably not receive a
transplant. Patients without evidence of active hepatitis B viral replica-
tion, but with elevated enzymes, should be considered for biopsy. Even
if enzymes are normal, a biopsy should be considered because liver
enzymes are a poor marker of disease activity in ESRD patients. Patients
with hepatitis B and moderate to severe chronic active hepatitis on
biopsy are probably at high risk for disease progression after transplanta-
tion. Such patients may best remain on dialysis. Patients without liver
disease who are HBsAg negative should be vaccinated for hepatitis B.
The risk conferred by hepatitis C virus (HCV) is less well defined.
Indeed, whether hepatitis C increases the risk of renal transplantation
continues to be controversial. 'Nevertheless, patients who are HCV anti-
body positive should be considered for liver biopsy if enzymes are
elevated. Patients with evidence of viral replication and patients with
chronic active hepatitis on biopsy are probably at increased risk for liver
disease progression after transplantation. Such patients should be clearly
informed of this risk, and careful consideration should be given to the
advisability of transplantation.
Recurrent Renal Disease Risk
The possibility that the underlying renal disease will cause the
allograft to fail is usually not great enough to preclude transplantation.
An exception may be the occasional patient with idiopathic focal seg-
mental glomerulosclerosis (FSGS) who has already lost at least one
allograft to disease recurrence. For such a patient, the risk of losing a
second or third allograft to recurrent FSGS may be quite The
rate of graft loss due to recurrence of most other forms of glomerulone-
phritis is too low to justify denying transplantation. Similarly, diabetes
regularly recurs in the allograft, but the rate of progression is generally
slow, and diabetes is still a relatively uncommon cause of graft failure.
Primary oxalosis was once considered to be a contraindication to trans-
plantation because recurrence in the allograft was rapid. Currently, pa-
tients can be successfully treated with orthophosphate and pyridoxine,
and pre-emptive renal transplantation with possible liver transplantation
should be considered.
Cardiovascular Disease
The morbidity and mortality from ischemic heart disease (IHD) are
high in both the early and late post-transplant periods. Therefore, pa-
tients should be carefully screened for IHD as part of the pretransplant
evaluation. Patients with symptomatic IHD should probably undergo
coronary angiography prior to transplantation. Asymptomatic patients
who are at increased risk for IHD should be considered for a noninvasive
PROSPECTIVE RENAL TRANSPLANT RECIPIENTS AND LIVING DONORS 31
cardiac stress test, and those with a positive stress test should undergo
angiography. High-risk individuals include patients with a prior history
of IHD, diabetics over the age of 40 to 45, and individuals with multiple
risk factors, such as smoking, hypertension, hypercholesterolemia, and
a positive family history of premature IHD.4 Patients who have critical
coronary artery lesions on angiography should undergo revasculariza-
tion prior to transplantation. Unfortunately, the rate of reocclusion after
revascularization is high among patients with ESRD. Risk factor inter-
vention should be aggressively pursued for all patients with IHD or
increased risk for IHD. Many may be candidates for aspirin prophylaxis
after transplantation.
The risk for strokes after renal transplantation is also increased.
Patients with a history of cerebral vascular disease should be carefully
evaluated prior to transplantation and should be free of symptoms for
at least 6 months prior to transplantation. For asymptomatic patients
with a carotid bruit, carotid ultrasonography should be considered.
However, in the general population, controlled clinical trials have shown
that the success of prophylactic carotid endarterectomy is center-depen-
dent. The decision to treat asymptomatic patients with prophylactic
carotid endarterectomy should probably be individualized. Certainly,
prophylactic aspirin and risk-factor intervention should be considered
in patients with atherosclerotic cerebral vascular disease.
Psychosocial Evaluation
Nonadherence to immunosuppression is a major cause of renal
allograft failure. An attempt should be made prior to transplantation to
identify individuals who are likely to be nonadherent. However, it is
often difficult to reliably predict who will fail to adhere to therapy, and
care should be taken to avoid unjustifiably denying transplantation to
patients who may have changed their behavior. Most believe that pa-
tients with a history of substance abuse should undergo treatment and
demonstrate a period of abstinence before transplantation.'O Finally, can-
didates with major cognitive or psychiatric disorders are usually discov-
ered during the early phases of the evaluation, and they can be referred
to appropriate specialists.
Urologic Evaluation
Patients with chronic urinary infection and/or incomplete bladder
emptying can usually be identified during the history and physical
examination. Therefore, a voiding cystourethrogram is probably not
necessary for all patients. For patients with a urinary diversion, every
attempt should be made to establish bladder drainage before trans-
plantation. If necessary, intermittent self-catheterization can be used
following transplantation. Consideration should also be given to ne-
32 KASISKE
phrectomy prior to transplantation. Selected patients with ureteral reflux
and chronic infection, polycystic kidneys that are too large or have
infected cysts, severe nephrotic syndrome, nephrolithiasis with infection,
renal carcinoma, or hypertension that is difficult to control may be
candidates for unilateral or bilateral nephrectomy. A laparoscopic ap-
proach can sometimes be used to reduce the morbidity and cost of
nephrectomy.
Gastrointestinal Evaluation
Cholecystectomy should be considered for patients who have had
recent cholecystitis. Otherwise, routine screening for asymptomatic cho-
lelithiasis may not be necessary. Patients with symptomatic diverticulitis
should be considered for partial colectomy. However, screening for
asymptomatic disease may not be cost-effective. Similarly, pretransplant
radiographic or endoscopic evaluation for peptic ulcer disease can prob-
ably be restricted to patients with signs and symptoms of peptic ulcer
disease.
Blood and Tissue Typing
The three major immunologic barriers to transplantation should be
assessed as part of the pretransplant evaluation: (1) ABO blood group
compatibility, (2) A, B, and DR major histocompatibility complexes
(MHC), and (3) the presence of preformed antibodies. In general, trans-
plants should not be performed across incompatible ABO blood groups.
Although some consider the degree of MHC matching to be an optional
consideration for living donor and cadaveric transplantation, the United
Network for Organ Sharing (UNOS) mandates the sharing of zero-
antigen mismatched kidneys and awards points (as part of its cadaveric
organ allocation system) in inverse proportion to the degree of MHC
mismatching. As a final screen, the recipients serum is tested against
donor tissue for the presence of preformed antibodies that can cause
hyperacute rejection. The presence of preformed antibodies is generally
considered to be a contraindication to transplantation with that donor.
EVALUATION OF POTENTIAL LIVING DONORS
The Donor Initial Evaluation
The primary goal of the living donor evaluation is to ensure the
safety and well-being of the donor (Table 2). Both the potential donor
and his or her physician must ultimately agree that the risk of donation
is acceptable. An initial evaluation should attempt to quickly and effi-
ciently identify individuals who cannot donate because they are immu-
PROSPECTIVE RENAL TRANSPLANT RECIPIENTS AND LIVING DONORS 33
Table 2. POTENTIAL CONTRAINDICATIONS FOR LIVING KIDNEY DONORS
ABO incompatibility Diabetes
Positive crossmatch
Age less than 18 or over 65 years
Malignancy Nephrolithiasis
Infection
Hypertension (>140/90 mm Hg)
Proteinuria (>150 mg/24 h)
Renal disease or reduced renal function
Increased medical risk for surgery
Inability to give informed consent
nologically incompatible. This saves time, money, and unnecessary anxi-
ety expended by family members who are ultimately found to be
immunologically incompatible. Blood typing is relatively inexpensive,
and if the blood type is not compatible with that of the recipient, the
evaluation of that potential donor need not proceed further. Some cen-
ters also perform an initial crossmatch to eliminate the need for addi-
tional, expensive work-up if the crossmatch is positive. A preliminary
medical evaluation can then be carried out if the blood type is compati-
ble and the preliminary crossmatch is negative. This preliminary exami-
nation can then be followed by a more detailed evaluation that usually
culminates in a renal angiogram.
Ideally, the donor evaluation should be carried out by individuals
who are not members of the transplant team. This eliminates any possi-
ble conflict of interest among transplant team members, who must
balance their wishes to offer transplantation to the recipient with their
obligation to protect the donor. Unfortunately, cost and other logistical
barriers may not permit completely separate teams to evaluate potential
donors and recipients. However, every donor can and should have a
personal physician who is not a member of the transplant team. The
donors physician can be an effective advocate who can help the patient
make an informed decision on donation.
Choosing of the Best Living Donor
The best donor is usually a blood relative. If more than one blood
relative wishes to donate, the choice should be based on both medical
and nonmedical criteria. In addition to choosing the best MHC match,
donor age, geographic location, occupational risk, and parental responsi-
bilities may play a role in the decision. The best MHC match is an
identical twin. The next best match is an MHC-identical (two-haplotype)
sibling, followed by a one-haplotype matched sibling or parent. It is
essential that the donation be truly voluntary and that the potential
donor be given every opportunity to choose not to donate. Health care
workers should protect individuals who decide not to donate by offering
to tell the family that the donor is not suitable.
If a suitable blood relative is not found, consideration can be given
to using an emotionally related donor.8 The survival of kidneys donated
34 KASISKE
from spouses exceeds that from cadaveric donors.14 A relative by mar-
riage or adoption or even a very close personal friend may be a suitable
donor. However, great care should be taken to ensure that the donation
is truly voluntary.
The Economic Risk of Donation
In the United States, Medicare covers all expenses related to organ
donation. Nevertheless, potential donors should understand that there
may still be some financial risk. Expenses that may not be covered by
Medicare include time off from work (vacation or sick leave) and travel
to and from the transplant center. The cost of health insurance should
not increase as a result of donation; however, there is always a remote
possibility that a medical condition will be discovered during the evalua-
tion, such as proteinuria, that could jeopardize future insurability.
Psychological Assessment
A psychological evaluation of the donor should be carried out by a
trained psychologist, psychiatrist, and/or social worker. This evaluation
should ensure that the potential donor is informed about the psychologi-
cal risks of donation, including the depression that may occur if the
outcome is not favorable. The evaluation should also attempt to uncover
any psychological pressures influencing the voluntary nature of the
potential donor's decision to donate. Finally, during this phase of the
evaluation, provision should be made for psychological support for the
donor after transplantation.
Surgical Risk of Donation
Mortality associated with nephrectomy is estimated to be 0.03% to
0.05%.3, Major postoperative complications have been estimated to
occur in approximately 4% of cases. These include incidental splenec-
tomy, deep vein thrombosis, pulmonary embolus, intra-abdominal ab-
scess, wound hematoma or infection, pneumonia, and atelectasis. Malnu-
trition, cardiovascular disease, poorly controlled blood pressure, and
diabetes each increase the risk of postoperative complications. Thus,
evidence for any of these conditions should generally preclude organ
donation.
Long-Term Risk of Donation
The long-term risk of donating a kidney appears to be very small if
the donor does not have underlying renal disease. Weconducted a meta-
PROSPECTIVE RENAL TRANSPLANT RECIPIENTS AND LIVING DONORS 35
analysis of epidemiologic studies that examined the long-term effects of
reduced renal mass.6 There were 48 studies in which 3124 patients with
reduced renal mass were compared with 1703 two-kidney controls.
Organ donors made up 61% of the patients with reduced renal mass.
No progressive decline in renal function occurred during the follow-up
period. Proteinuria was more common after a 50% reduction in renal
mass, but there were no progressive increases in protein excretion over
time. A small increment in systolic blood pressure was noted in patients
with reduced renal mass, but this increase was insufficient to result in
an increased prevalence of hypertension. Thus, from these results, the
long-term risk of donating a kidney appears to be very small. However,
the exact risk of donating is unknown, and a registry of living donors is
needed that would allow the accurate collection of these data.
It is at least theoretically possible that donating a kidney could
accelerate diabetic nephropathy, so the donor should be screened for
diabetes. However, the theoretical risk of accelerating diabetic nephropa-
thy should be weighed against the risk of false-positive screening tests
for diabetes. A fasting plasma glucose level, a glucose tolerance test, and
a glycosylated hemoglobin are all reasonable tests to screen for diabetes.
About 4% to 10% of normal individuals may have a false-positive
glucose tolerance test.
Autosomal recessive polycystic kidney disease is uncommon and
should be evident in any patient old enough to donate a kidney. Autoso-
ma1 dominant polycystic kidney disease (ADPKD) is much more com-
mon. Specific criteria based on age and the number of cysts present have
been developed to aid in the diagnosis of ADPKD (Table 3)." The
specificity of ultrasound diagnosis using these criteria is nearly 100% by
age 30, so that ultrasonography should be sufficient if the potential
donor is over 30. If the potential donor is 25 to 30 years old, CT should
be obtained to enhance the diagnostic sensitivity. If the potential donor
is less than 25, testing for the ADPKD 1 and ADPKD 2 genes should be
considered.
Hereditary nephritis, or Alport's syndrome, is generally familial,
although up to 15% of cases may occur in the absence of a family history.
When family history of hereditary nephritis is documented, it is usually
inherited in an X-linked pattern. Males with the gene usually develop
hematuria by age 5, long before they would be considered candidates for
Table 3. CRITERIA FOR DIAGNOSING AUTOSOMAL DOMINANT POLYCYSTIC
KIDNEY DISEASE
Age (years) Criteria
Less than 30
30-59
At least 60
At least two renal cysts (unilateral or bilateral)
At least two cysts in each kidney
At least four cysts in each kidney
Data from Ravine D, Gibson RN, Walker RG, et al: Evaluation of ultrasonographic diagnostic criteria
for autosomal dominant polycystic kidney disease 1. Lancet 343B24-827, 1994.
36 KASISKE
donation. Asymptomatic males do not carry the gene, and heterozygous
females with hematuria rarely progress to ESRD. Potential donors for
recipients with hereditary nephritis should be carefully screened and
offered genetic counseling. Patients should be examined for microhema-
turia, renal dysfunction, hearing impairment, and eye abnormalities.
Male relatives without hematuria or other abnormalities are suitable
donors. Female relatives without hematuria may be suitable donors;
however, a young women should consider the possibility that she may
have a child with the disease who may someday need renal transplanta-
tion. Genetic testing can be used to determine whether the woman is a
carrier. Female relatives with hematuria or other abnormalities should
probably not donate. Finally, both donors and recipients should be
informed that recipients with hereditary nephritis may develop anti-
glomerular basement membrane disease that could result in graft failure.
The standard dipstick test for hematuria is very sensitive, but a
positive result must be confirmed by microscopic e~amination.~ Patients
with isolated microscopic hematuria should probably undergo a urologic
evaluation to rule out malignancy. If this evaluation is negative, biopsy
may be considered. A high proportion of such patients are found to have
an abnormality on biopsy, that is, IgA nephropathy or thin glomerular
basement membranes, and these patients should probably not be donors.
However, if the biopsy is normal, the long-term prognosis is probably
excellent, and donation may still be considered.
Proteinuria is usually defined by greater than 150 mg/24 h total
protein excretion, or greater than 30 mg/24 h albumin excretion, and
proteinuria is usually a contraindication to d~nati on.~ However, occa-
sional patients with isolated postural proteinuria may be suitable candi-
dates. Pyuria should also be considered to be a contraindication unless
it can be unequivocally shown that there is a reversible cause, such
as cystitis.
Hypertension (blood pressure greater than 140/90 mm Hg) is at
least a relative contraindication to donation. Nephrectomy appears to
cause a small increase in blood pressure in normal individuals.6 Thus, it
is likely that nephrectomy may exacerbate blood pressure control in
individuals with hypertension. In addition, hypertension is a common
cause of ESRD, and it is possible that organ donation could accelerate
renal damage due to hypertension. In patients with borderline blood
pressure elevation, echocardiographic evidence of left ventricular hyper-
trophy may help in the diagnosis of hypertension.
Nephrolithiasis tends to be recurrent and can lead to obstruction,
infection, and ESRD. Therefore, nephrolithiasis is at least a relative
contraindication to kidney donation. However, a potential donor who
has passed only one stone, has been free of stone disease for at least 10
years, and has a negative pyelogram could be considered for donation
if a metabolic evaluation shows that the risk for future stone formation
is low.8
Many centers perform donor-specific blood transfusions to reduce
the risk of rejection after transplantation. If an angiogram is part of
PROSPECTIVE RENAL TRANSPLANT RECIPIENTS AND LIVING DONORS 37
the evaluation, donor-specific transfusions should be done prior to the
angiogram because some patients develop cytotoxic antibodies after
transfusion that may preclude donation. Traditionally, an angiogram of
both kidneys has been used to define the vascular anatomy and help in
selecting the better kidney for transplantation. Recently, spiral CT using
intravenous radiocontrast has proven equally effective, and the spiral
CT is associated with less morbidity and risk to the donor.,2 If both
kidneys have a single renal artery, the left kidney is usually selected
because it has a longer renal vein. However, if one kidney has two renal
arteries, the kidney with only one artery may be preferable. Occasionally,
asymptomatic, unilateral fibromuscular dysplasia may be encountered,
and it is tempting to transplant the involved kidney after surgically
removing the arterial lesion. Because the natural history of fibromuscular
dysplasia discovered incidentally is unknown, the risk of donating is
also unclear. However, at least some patients may develop fibromuscular
dysplasia in the contralateral kidney, so the decision to accept a donor
with incidentally discovered fibromuscular dysplasia is difficult.
Risk to the Recipient
Recipients and donors should be aware that kidneys from older
donors, especially over 60 years of age, may function less well than
kidneys from younger donors. The donors renal function, adjusted for
age and body size, should generally be normal. Although donor age
and renal function should be taken into account, it is difficult to specify
precise levels of age or renal function that should preclude donation.
The potential donor should be screened for infections that could be
transmitted to the recipient. In particular, the donor should be screened
for HIV, viral hepatitis, and active tuberculosis. Antibody titers of CMV
should be obtained to help assess the risk of transmitting CMV to the
recipient and the need for possible prophylactic therapy. An active
malignancy is an absolute contraindication to tran~plantation.~ However,
it is difficult to precisely define the time interval that a potential donor
with a history of a cured malignancy should wait before donating.*
EVALUATION OF POTENTIAL CADAVERIC DONORS
The Initial Evaluation
If no suitable living donor is available, transplant candidates must
rely on cadaveric kidneys. Most cadaveric kidneys are from donors who
have been declared brain dead. When a potential brain-dead donor
is available, hospital personnel should immediately contact the organ
procurement organization for help in assessing the appropriateness of
the potential donor and in approaching the family. Cadaveric donation
is most often successful if carried out as a cooperative effort between the
38 KASISKE
patients caregivers and professionals experienced in organ procurement.
However, the declaration of brain death should be made by physicians
who are not part of the transplant team, in order to avoid any potential
conflict of interest. Most states have laws goveming the definition of
brain death.
Some centers use kidneys from donors who are not brain dead but
who have been declared dead because their heart has stopped beating.
These non-heart beating donors may be used in controlled and
uncontrolled circumstances. Controlled, non-heart beating donors are
patients in whom efforts to prolong life have become futile, and life
support is discontinued in an intensive care unit setting. Uncontrolled
donation occurs when patients present to the emergency department,
often with severe brain trauma that falls short of a strict definition of
brain death. Kidneys from controlled, non-heart beating donors gener-
ally function better than those from uncontrolled donors. Great care
must be taken to guard against conflicts of interest between the potential
donors physicians and the organ procurement team. Strict moral, ethi-
cal, and legal criteria must be applied, and communication between
caregivers and the donors family is essential.
Minimizing the Risk to the Recipient of a Cadaveric
Kidney
Infection and cancer are contraindications to donation. The potential
cadaveric donor should be carefully screened for infections that may be
transmitted to the recipient. Patients with bacterial sepsis or other tissue-
invasive infections should generally be excluded. Patients with HIV are
also excluded from donation, as are hepatitis B antigen-positive patients.
More controversial is whether to exclude all potential donors who are
HCV antibody positive. Because HCV can be transmitted with trans-
plantation, most centers exclude HCV-positive donors. Generally, pa-
tients with any evidence of cancer cannot be donors. The exception is
the occasional patient with a (histologically confirmed) primary, nonme-
tastasizing brain tumor.
With the current shortage of cadaveric kidneys, the criteria for
accepting kidneys have expanded. Most centers avoid kidneys older
than 60 or younger than 6 years of age. However, a few centers are
using very old or very young kidneys and transplanting two kidneys
rather than one kidney into a single recipient. Some use older kidneys
but only in older recipients. It is important that the marginal nature of
such a kidney be carefully explained to the potential recipient and that
informed consent be obtained. Similarly, kidneys from donors with
slightly elevated serum creatinine or evidence of glomerulsclerosis on
biopsy are being used more often. However, care should be taken to
ensure that the recipient is aware that results with these marginal kid-
neys may not be as good as those with undamaged kidneys.
PROSPECTIVE RENAL TRANSPLANT RECIPIENTS AND LIVING DONORS 39
References
1. Alfrey EJ, Rubin GD, Kuo PC, et al: The use of spiral computed tomography in the
evaluation of living donors for kidney transplantation. Transplantation 59:643-645,
1995
2. Artero M, Biava C, Amend W, et al: Recurrent focal glomerulosclerosis: Natural history
and response to therapy. Am J Med 92375-383, 1992
3. BiaMJ, Ramos EL, Danovitch GM, et al: Evaluation of living renal donors. The current
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Saunders, 1995, pp 1137-1174
6. Kasiske BL, Ma JZ, Louis TA, Swan SK Long-term effects of reduced renal mass in
humans. Kidney Int 48:814-819, 1995
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Clinical practice guidelines. J Am SOC Nephrol 6:l-34, 1995
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donors: Clinical practice guidelines. J Am SOC Nephrol 72288-2313, 1996
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497, 1994
11. Ravine D, Gibson RN, Walker RG, et a1 Evaluation of ultrasonographic diagnostic
criteria for autosomal dominant polycystic kidney disease 1. Lancet 343:824-827, 1994
12. Rubin GD, Alfrey EJ, Dake MD, et al: Assessment of living renal donors with spiral
CT. Radiology 195:457462, 1995
13. Stephanian E, Matas AJ, Mauer M, et al: Recurrence of disease in patients retrans-
planted for focal segmental glomerulosclerosis. Transplantation 53:755-757, 1992
14. Terasaki PI, Ceckd JM, Gjertson DW, Takemoto S: High survival rates of kidney
transplants from spousal and living unrelated donors. N Engl J Med 333:333-336,1995
15. United States Renal Data System: USRDS 1996 Annual Data Report. Bethesda, The
National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes
of Health, 1996
Address reprint requests to
Bertram L. Kasiske, MD
Division of Nephrology, Department of Medicine
Hennepin County Medical Center
701 Park Avenue
Minneapolis, MN 55415