**1. Introduction**

The therapeutic promise of transplanting organs from cadaveric donors, as envisioned by the pioneers of transplantation, has never been kept because the demand for cadaveric organs has by far exceeded the supply.

Besides the fact that renal transplantation is the optimal treatment for patients with end stage renal disease, it provides benefits to the society as a whole as well as to the recipients. Yet, the donor shortage poses a significant challenge to the transplant community and bare unfavor‐ able consequences: prolonged waiting time and compromise patient survival. Sustained efforts were done during times to increase both the deceased donor and living donor pool.

The expanded criteria donors also known as non-traditional donors has been credited to lessen the current shortage of grafts available for transplantation by providing more grafts. Any such attempt is a two-edged sword since it increases the outcome risk of the suboptimal grafts.

Criteria for living donation were more restrictive compared with cadaver donation but such reluctance to use living donor marginal grafts is declining since transplantation is a better option than dialysis.

Expansion criteria allows transplantation of grafts from deceased donors at the extreme age (above 60 and below 16), with history of hypertension, diabetes or malignancy, hemodynam‐ ically unstable, non-heartbeating, seropositive for hepatitis B or C, with systemic infections, at high-risk for HIV infection, reduced renal function, anatomic anomalies, or injuries [1].

The waiting list for transplant organs continues to grow and many patients continues to die while waiting or become unsuitable for organ transplantation. Consequently, many patients with end stage organ failure are no longer relaying on the waiting list for cadaver transplan‐ tation. There is a trend not only to reconsider the living donor but also to turn the attention toward spouses, friends or even strangers as possible donors. From medical point of view, all

these are acceptable alternatives due to advances in immunosuppression which have elimi‐ nated the requirement for a perfect genetic match for a successful organ transplantation. In many US transplant centers, the number of kidneys obtained from living donors has exceeded the number of kidneys obtained from cadaver [2].

pragmatic, there is a philosophic fallacy in this approach. The important issues regarding the donor, in addition to medical suitability, are whether the donor understands the risk of nephrec‐ tomy and whether the donor freely consents. The risk for the donor is the same regardless of the donor's relationship to the recipient and regardless of the recipient's outcome. The risk for the surgeon,thatis thedeathofthedonor,isnolessdevastatingforthesurgeonifthepatientisaclose

Policies and Methods to Enhance the Donation Rates

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Usually, the potential living donor is the one who initiates the discussion about donation, although the recipient or the physician can also rise the issue. The donor than meets with the nephrologist, transplant surgeon, social worker, and transplant coordinator. All donors are informed of the risks and benefits of the transplantation compared with the dialysis and the risks to themselves by donating a kidney, on both short and long term [3, 4]. 1995 data of US practices founded that reported mortality rate for living donors to be 0.03% and the morbidity rate to be 0.23%. It is important to screen any relative of a patient with familial renal disease (polycystic kidney disease, hereditary nephritis) for evidence of occult signs and symptoms, in order to exclude such donors [5]. On the other hand, kidneys with minor renal abnormalities can be used safely, once it is determined that function of the such kidneys could not be impaired

Initial evaluation of all potential donors consists of blood and tissue typing. Usually, those with ABO incompatibility are excluded; compatibility with the Rh factor is unnecessary. All blood group compatible donors are then tested with the T lymphocyte cross-match. A negative cross-match will allow further consideration for donation. In the case of multiple potential donors, the better the antigen match, the grater is the likelihood of being selected for donation, if all other testing are within normal limits. In general, as long as the donor and the recipient have a negative T cell cross-match, the operation can be cared out. This is true for both related and non-related donors who are ABO compatible. Many centers perform a mixed lymphocyte reaction (MLR) as part of the routine evaluation, but the importance of this test has decreased

Further evaluation for a potential donor consist of a complete medical history and a complete physical examination, routine laboratory, testing, and serologic evaluation for EBV, herpes virus, CMV, HIV, and hepatitis B and C viruses. Urinalysis and culture along with 24 hour urine collection for creatinine clearance and protein excretion, are included as part of the routine evaluation. If there is any concern regarding a borderline hypertensive pressure reading, the blood pressure should be measured on the least three and as many as ten separate occasions. Once all laboratory testing has been performed, the next step is renal arteriography with an excretion faze to visualize the collecting system. This eliminate the need for intrave‐ nous pyelography. Such testing can be performed on an outpatient basis. Nowadays spiral CT scan has been used routinely instead of conventional angiography in all centers. The use of magnetic resonance (MR) angiography is also growing in importance. Donors are judged

relative to the recipient than if the donor is a stranger.

with the introduction of better immunosuppression.

unsuitably for a variety of reasons (2).

**2.1. Evaluation of the living donor**

after transplantation [6].

Although organs from living donors can be transplanted safely, concerns about the protection of well-being of such donors has prompted the transplantation community to develop a consensus statement, emphasizing that a living donor should be competent, willing to donate an organ, and free of coercion.

Regardless of donor type and graft quality, one should keep in mind that never should be transplanted grafts with a heightened potential for the development of a progressive disease.

Since the rules are continuously evolving, the approach to use of each graft and recipient selection should be done with caution in order to obtain acceptable results.
