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Ethical Considerations Informed Consent Living Donor Research Living Kidney Donor

8-11x increased risk of kidney failure too low

Not surprisingly, researchers are still debating living kidney donors’ risk of end stage renal disease or kidney failure. The two most damning studies say that LKDs have an 8-11x increased risk ESRD as compared to their well-matched, two-kidneyed counterpart. Of course, the pro-living donor people tried to minimize these findings, calling it a “modest” 1% absolute lifetime risk. The fact that most people, meaning the public, has no idea what that really means, certainly helps in their information manipulation.

 

Steiner agrees that the prior studies’ findings are not absolute, but only because they tend to lump all living kidney donors together as a monolith. He asserts that certain classes of kidney donors assume a much *hgher* risk of end-stage renal disease than previously stated. If the risk of ESRD is due to the loss of nephrons at the time of donation (the conclusion of the aforementioned research) then LKDs under the age of 35 have a much *higher* risk than those older than 35, because they’re living more of their life without a Renal Reserve. Their already reduced nephrons will be damaged and become dysfunctional through disease, damage, toxins and age.

He also states that African-American donors and those with lower pre-donation GFRs are at a higher than previously stated risk. African-American folks have a much higher incidence of diabetes, the largest cause of kidney failure in the US, so this squares with all other data.

Too many transplant centers are still using the “one size fits all” pre-donation GFR cut-off, which severely harms LKDs who fall on the lower end of the spectrum. In 2010, a Consensus document on LKD medical evaluation called for a predonatoin GFR based on sex, age and Body Surface Area, but the members of OPTN (transplant centers and others who profit from transplant) removed it from the proposal. Steiner advocates a much higher predonation GFR cut-off, and utilizing older donors with minor medical abnormalities.

 

 

 

Steiner, R. (2016). Moving closer to understanding the risks of living kidney donation Clinical Transplantation, 30 (1), 10-16 DOI: 10.1111/ctr.12652

Categories
Ethical Considerations Informed Consent Living Donor Research Living Donor Risks Living Kidney Donor

Understanding Kidney Donors’ Increased Kidney Failure Risk

By now, we’ve all seen the studies stating that living kidney donors have an 8-11x increased risk of kidney failure as compared to their well-matched, two-kidneyed cohort. And you’ve probably seen the transplant industry’s spin on that data, their sputtering “Well, but, the *absolute* risk is still really, really low”

But is it?

Steiner attempts to answer that question, at least some of it, by breaking down the overall risk into its important pieces-parts. He says:

 

“The 1% lifetime post-donation risk in the US study requires medical screening to predict ESRD in 96 of 100 candidates. This is particularly unlikely in the 30–35% of candidates under age 35, half of whose lifetime ESRD will occur after age 64. Many experts have attributed the increased relative risks in these studies to loss of GFR at donation, which ultimately means that high–normal pre-donation GFRs will reduce absolute post-donation risks.”

“Young vs. older age, low vs. high–normal pre-donation GFRs, black race, and an increased relative risk of donation all predict highly variable individual risks, not a single “low” or “1%” risk as these studies suggest.”

A uniform, ethically defensible donor selection protocol would accept older donors with many minor medical abnormalities but protect from donation many currently acceptable younger, black, and/or low GFR candidates.

I encourage everyone to read the whole thing. Your health may depend on it.

 

 

Steiner, R. (2016). Moving closer to understanding the risks of living kidney donation Clinical Transplantation, 30 (1), 10-16 DOI: 10.1111/ctr.12652

Categories
Follow-Up Living Donor Research Living Donor Risks Living Kidney Donor

Surgical Complications of Living Kidney Donation

WARNING: It’s imperative to remember that during the years of this analysis (2008-2012), more than 1/3 of living kidney donors were reported “lost” to follow-up. Many living donors with post-donation problems have reported that their transplant center denied their symptoms were related to the donation, and refused to treat them. It’s not a stretch to assume these same centers never reported those symptoms to OPTN as they were required to do. It’s best to assume the numbers below are *under*estimates of the true incidence of donation surgical complications.

 

“Overall, 16.8% of donors experienced a perioperative complication, most commonly gastrointestinal (4.4%), bleeding (3.0%), respiratory (2.5%), surgical/anesthesia-related injuries (2.4%), and “other” complications (6.6%)”

African Americans had increased risk of any complication.

Other significant correlates of Clavien grade IV or higher events included obesity, predonation hematologic and psychiatric conditions, and robotic nephrectomy

Annual center volume >50 was associated with lower risk.
Ak?nc?, S. (2016). Re: Perioperative Complications after Living Kidney Donation: A National Study Journal of Urological Surgery, 3 (3), 103-103 DOI: 10.4274/jus.2016.03.023

Categories
Living Donor Research Living Donor Risks Living Kidney Donor

Male and BMI higher risk 5 years post-donation

A single center analysis of 77 living kidney donors 5 or more year post-donation has found that men and those with high BMI are at higher risk of low GFR (kidney function < 60), hypertension, and proteinuria; all symptoms of eventual kidney failure.

Unfortunately, I couldn’t access the complete article, so I don’t know if there’s a correlation between pre-donation levels and this post-donation result. However, it’s been previously established that folks with high BMI may already be hyperfiltrating pre-donation, which means their capacity for “compensation” post-donation is already maximized. So, this result just adds to that literature.
Bello, R., Bello, V., Rosa, T., Junqueira, L., Freitas, E., & Veiga, J. (2015). Male Gender and Body Mass Index Are Associated With Hypertension and Reduced Kidney Function 5 or More Years After Living Kidney Donation Transplantation Proceedings, 47 (10), 2816-2821 DOI: 10.1016/j.transproceed.2015.10.041

Categories
Living Donor Research Living Kidney Donor

Once Again, Ship Kidneys Not Donors

During a 44 month period in Australia, 84 kidneys were transported for transplantation at a different center (16 were transplanted at the same center).

” A spontaneous fall in serum creatinine by at least 10% within 24 h was observed in 85% of recipients, with no difference between nonshipped and shipped kidneys.

There was no difference in recipients of nonshipped compared with shipped kidneys with regard to serum creatinine at 1 month, 1-year graft survival, or patient survival ”

 

 
Allen, R., Pleass, H., Clayton, P., Woodroffe, C., & Ferrari, P. (2016). Outcomes of kidney paired donation transplants in relation to shipping and cold ischaemia time Transplant International, 29 (4), 425-431 DOI: 10.1111/tri.12719