**2. The living donor**

The use of living donors for renal transplantation was critical for the early development of the field, and in fact, preceded the use of cadaveric donors. At the moment, 20-22% of all kidney transplants performed in the world were done with grafts from living donors. Most donors are related genetically to the recipient, but there is an increasing percentage of cases, where donors are genetically unrelated and includes spouses, friends, or other emotionally related individuals. As it is known, ethical guidelines mandate that the living donors should not be coerced and there will be no evidence of financial profit for the donor. As a consequence, the donation should be considered "a gift of extraordinary value". It is known that the use of living donors has been associated with a higher success rate than that seen with cadaveric donation. Due to a higher demand for transplantation and the lack of a parallel increase in the number of available cadaveric organs, living donation is the only solution for some patients to avoid long times on waiting list, and occasionally, even the need of dialysis (1).

> Better results (both long and short-term) Consistent early function and easier management Avoidance of long waiting time for transplantation Less aggressive immunosuppressive regimens Emotional gain to donor

#### **Table 1.** Advantages of living donation

There is a remote risk of catastrophic outcome of the living donor (1 in 3200 patients), but most transplantcentersandsurgeonsacceptthis.Somecentersacceptonlylivingrelateddonors;others accept related as well as unrelated donors. These centers come to turns with the possibility of harming living donors by being highly selective in their acceptance of donors. While surgically

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

### **2.1. Evaluation of the living donor**

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

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

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

The use of living donors for renal transplantation was critical for the early development of the field, and in fact, preceded the use of cadaveric donors. At the moment, 20-22% of all kidney transplants performed in the world were done with grafts from living donors. Most donors are related genetically to the recipient, but there is an increasing percentage of cases, where donors are genetically unrelated and includes spouses, friends, or other emotionally related individuals. As it is known, ethical guidelines mandate that the living donors should not be coerced and there will be no evidence of financial profit for the donor. As a consequence, the donation should be considered "a gift of extraordinary value". It is known that the use of living donors has been associated with a higher success rate than that seen with cadaveric donation. Due to a higher demand for transplantation and the lack of a parallel increase in the number of available cadaveric organs, living donation is the only solution for some patients to avoid

> Better results (both long and short-term) Consistent early function and easier management Avoidance of long waiting time for transplantation Less aggressive immunosuppressive regimens Emotional gain to donor

There is a remote risk of catastrophic outcome of the living donor (1 in 3200 patients), but most transplantcentersandsurgeonsacceptthis.Somecentersacceptonlylivingrelateddonors;others accept related as well as unrelated donors. These centers come to turns with the possibility of harming living donors by being highly selective in their acceptance of donors. While surgically

selection should be done with caution in order to obtain acceptable results.

long times on waiting list, and occasionally, even the need of dialysis (1).

the number of kidneys obtained from cadaver [2].

136 Current Issues and Future Direction in Kidney Transplantation

an organ, and free of coercion.

**2. The living donor**

**Table 1.** Advantages of living donation

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 after transplantation [6].

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 with the introduction of better immunosuppression.

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 unsuitably for a variety of reasons (2).

#### **Absolute**

donor be at least 10 years older than the age of the recipient at the time of diagnosis of the diabetes. The measurement of the haemoglobin A1c and anti-islet antibodies also can be included in the evaluation of any potential related living donor for a recipient with diabetes. Unexplained microscopic hematuria may be an indication of an underlying renal disease such as glomerulonephritis, but it may not be detected before donation. Finding as few as three red cells per high power field may appear unimportant at first but may be an indicator of potential

Policies and Methods to Enhance the Donation Rates

http://dx.doi.org/10.5772/55245

139

History of thrombembolism or thromboflebitis places the potential donor at increased risk of pulmonary embolism and therefore it precludes donation. This is also true for patients with heart disease, or history of malignant neoplasia. Obesity may be a relative contraindication for any potential donor, if it is more than 30% above ideal body weight. These individuals should be advised to loose the excess body weight before the transplant is scheduled, to decrease the

Patients with clinically significant psychiatric disorders should be fully evaluated by a psychiatrist to established that the donor understands and agrees to the proposed procedure. Once a full evaluation has been performed, if examination of the donor's kidney vascular supply and drainage system reveals an abnormality, it must be decided whether the risk imposed on the donor or the recipient are too great. With regard to vascular abnormalities we tend to use donor kidneys with three or more arteries if there is a good immunological correspondence and a strong determination for donation and if dialysis tolerance of the recipient is bad [7,8]. Abnormalities such as aneurisms, renal artery stenosis, fibro-muscular dysplasia, if limited in sized and area, can often be resected, repaired, or excised on the back table. Such pathological addition should bee limited to one kidney, living as a rule, the normal

Excision and reconstruction of such abnormalities is, in a sense, a of form of treatment of this donors, although care must be taken to avoid living either the donor or the recipient with less

Once the evaluation has demonstrated that there are no abnormalities serious enough to exclude donation, the donor can be admitted to the hospital after a spiral CT scan was performed. Many insurance companies are now restricting admissions to the day of the operation. In such cases intravenous hydration can be given overnight on an outpatient basis, or started on arrival at the hospital. Such hydration is important to help ensure adequate diuresis during the donor operation. Preoperative assessment by the anesthesiologist and the

The donor is instructed preoperatively on the use of spirometer, and on the use of leg support stockings and the sequential compression device system to prevent venous stasis. After entering the operating room and before the incision, the patient should receive a dose of intravenous antibiotic. Although preoperative skin cleaning is recommended; hair clipping is

pain management team can make for a more comfortable postoperative recovery.

kidney in place. Given this caveats, it may be possible to use such donors [9].

risk of pulmonary embolism or cardiac complications.

future problems.

than a perfect outcome.

**2.2. Preoperative management**

avoid until just before incision.


**Table 2.** Exclusion criteria for living donors

Anyone at risk for the development of acquired renal disease should be excluded.This includes individuals with diastolic blood pressure constantly above 90 mm Hg, or who required hypertensive medication to control their blood pressure.

History of hypertension is not by itself a reason for exclusion if the donor is normotensive and off medication, but the donor should be carefully examined for preexisting renal disease or for the risk of development of renal disease later in life.

Potential donors for siblings with diabetes routinely undergo a five hours glucose tolerance test, and 24 hour urine specimen must be free of proteinuria. Some centers require that the donor be at least 10 years older than the age of the recipient at the time of diagnosis of the diabetes. The measurement of the haemoglobin A1c and anti-islet antibodies also can be included in the evaluation of any potential related living donor for a recipient with diabetes. Unexplained microscopic hematuria may be an indication of an underlying renal disease such as glomerulonephritis, but it may not be detected before donation. Finding as few as three red cells per high power field may appear unimportant at first but may be an indicator of potential future problems.

History of thrombembolism or thromboflebitis places the potential donor at increased risk of pulmonary embolism and therefore it precludes donation. This is also true for patients with heart disease, or history of malignant neoplasia. Obesity may be a relative contraindication for any potential donor, if it is more than 30% above ideal body weight. These individuals should be advised to loose the excess body weight before the transplant is scheduled, to decrease the risk of pulmonary embolism or cardiac complications.

Patients with clinically significant psychiatric disorders should be fully evaluated by a psychiatrist to established that the donor understands and agrees to the proposed procedure.

Once a full evaluation has been performed, if examination of the donor's kidney vascular supply and drainage system reveals an abnormality, it must be decided whether the risk imposed on the donor or the recipient are too great. With regard to vascular abnormalities we tend to use donor kidneys with three or more arteries if there is a good immunological correspondence and a strong determination for donation and if dialysis tolerance of the recipient is bad [7,8]. Abnormalities such as aneurisms, renal artery stenosis, fibro-muscular dysplasia, if limited in sized and area, can often be resected, repaired, or excised on the back table. Such pathological addition should bee limited to one kidney, living as a rule, the normal kidney in place. Given this caveats, it may be possible to use such donors [9].

Excision and reconstruction of such abnormalities is, in a sense, a of form of treatment of this donors, although care must be taken to avoid living either the donor or the recipient with less than a perfect outcome.

#### **2.2. Preoperative management**

**Absolute** Lack of discernment Alcohol or drug addiction Age less than 18 years Hypertension: blood pressure over 140/90 mm Hg requiring medication Diabetes: abnormal glucose tolerance test or HbA1c Proteinuria: over 300 mg/24 hours Abnormal glomerular filtration rate: creatinine clearance less than 75 mL/min. Microscopic hematuria of unexplained cause History of thrombosis or thrombembolism Medical significant illness: chronic lung disease, recent malignant tumor, heart disease, vascular collagen disease, History of bilateral kidney stones Family history of autosomal dominant polycystic kidney disease (ADPKD), unless ultrasound or CT scan is normal and age is over 30 years Familial history of renal cancer Bilateral fibromuscular arterial dysplasia Long-term use of nephrotoxic drugs HIV positive Hepatitis B antigen-positive to a negative recipient or unprotected Other severe infections **Relative** Anatomic abnormalities of the donor's kidney: vascular or urological Obesity: 30% or more above ideal weight Young donor with a first degree relative with type I diabetes or renal disease Significant previous abdominal surgery Single history of unilateral renal stone disease ABO incompatible Positive cross-match Smoking Psychiatric disorders

138 Current Issues and Future Direction in Kidney Transplantation

Anyone at risk for the development of acquired renal disease should be excluded.This includes individuals with diastolic blood pressure constantly above 90 mm Hg, or who required

History of hypertension is not by itself a reason for exclusion if the donor is normotensive and off medication, but the donor should be carefully examined for preexisting renal disease or for

Potential donors for siblings with diabetes routinely undergo a five hours glucose tolerance test, and 24 hour urine specimen must be free of proteinuria. Some centers require that the

**Table 2.** Exclusion criteria for living donors

hypertensive medication to control their blood pressure.

the risk of development of renal disease later in life.

Once the evaluation has demonstrated that there are no abnormalities serious enough to exclude donation, the donor can be admitted to the hospital after a spiral CT scan was performed. Many insurance companies are now restricting admissions to the day of the operation. In such cases intravenous hydration can be given overnight on an outpatient basis, or started on arrival at the hospital. Such hydration is important to help ensure adequate diuresis during the donor operation. Preoperative assessment by the anesthesiologist and the pain management team can make for a more comfortable postoperative recovery.

The donor is instructed preoperatively on the use of spirometer, and on the use of leg support stockings and the sequential compression device system to prevent venous stasis. After entering the operating room and before the incision, the patient should receive a dose of intravenous antibiotic. Although preoperative skin cleaning is recommended; hair clipping is avoid until just before incision.
