Kidney transplantation, if not contraindicated, is the most preferred renal replacement therapy for patients with end stage renal disease. Generally, live related transplantation is associated with longer term survival of the transplantated kidney as well as the patient. However, it is associated with great physical and psychological challenges for the donor. Therefore, an exhaustive physical workup as well comprehensive psychological counselling go a long way for a happy donor as well as recipient. Laparoscopic donor surgery has helped reduce surgical morbidity and improve acceptance. Moreover, to avoid medicolegal issues, exhaustive documentation is necessary.

1. KIDNEY TRANSPLANTATION
DONOR EVALUATION
​Dr Mayank Mohan Agarwal
MBBS, MS, MRCS(Ed), ​DNB, MCh (PGIMER, Chandigarh)
VMMF and IAUA Fellowships Uro-Oncology, Pelvic Floor Reconstruction
(MSKCC, NY; UCLA, LA; WFUBMC, NC)​
Ex-Associate Professor of Urology (PGIMER, Chandigarh)
Consultant and Head of Urology
(Aster) Dr. Ramesh Cardiac and Multispecialty Hospitals Pvt. Ltd.
Guntur (AP), India

2. Introduction
• Why transplantation
• Why living donor transplantation
• Who can donate
• General evaluation of donor
• Urological evaluation of donor
• Post-operative care of donor

3. WHY TRANSPLANTATION?
Prolonged quantity of life
Better quality of life
- what one can eat / drink
- what one feels (nausea, anorexia, weakness)
Better control of co-morbidity
- hypertension
- dyselectrolytemia
Reduced overall cost of healthcare
- admissions for complications
- monthly maintenance cost

4. WHY LIVING DONOR
Deceased Living
Primary non-function 2.7% 1.4%
Delayed graft function 23.5% 3.4%
10 y graft survival 42.5% 59.6%
Conditional t ½ of grafts 14.7 y 26.6 y

5. WHAT ARE THE RISKS TO DONOR
Mortality 0.02–0.03 %
End-stage renal failure 0.018 % / Y
Hypertension 15–25 %
Bleeding 2.2 %
Bowel obstruction 1.0 %
Vascular injury 0.2 %
Open conversion 0.7–1.1 %
Reoperation 0.2 %
Blood transfusion 0.4 %
Wound infection 2.1 %
Urinary tract infection 4.5 %
Readmission 0.9–2.0 %
Hernia repair 0.8 %

6. TYPES OF LIVING DONORS
• BLOOD RELATED
• EMOTIONALLY RELATED
• GOOD SAMARITAN
• PAIRED DONORS

7. Legal Status in India: N.O.T.T.O
• GRANDPARENTS
• PARENTS
• SIBLINGS
• OFFSPRINGS
• SPOUSE
• EVERYBODY ELSE (including cousins)  “EMOTIONALLY RELATED”
GENETIC RELATIONSHIP : FORM 5
SPOUSE : FORM 6
OTHER THAN NEAR RELATIVES : FORM 3

8. Donor evaluation
• Communication
• Documentation
• Communication of documentation
• Documentation of communication
• Preservation of documentation

9. Donor evaluation
• Communication
• Documentation
• Communication of documentation
• Documentation of communication
• Preservation of documentation

10. STEP 1a: BLOOD GROUP COMPATIBILITY

11. STEP 1b: EDUCATION AND COUNSELING
• What is transplantation, why is it important to recipient and results of
graft function
• Quality of life of recipient
• Quantity of life of recipient
• Recipient’s death
• Failure of graft

12. STEP 1: EDUCATION AND COUNSELING
• What is transplantation, why is it important to recipient and results of
graft function
• What are the available alternatives
• Continuation of dialysis
• Wait on cadaveric donor list
• Increased morbidity and death during waiting

13. STEP 1: EDUCATION AND COUNSELING
• What is transplantation, why is it important to recipient and results of
graft function
• What are the available alternatives
• What are the side effects and complications on the self
• Generally very safe in short-term and long-term
• Early recovery with laparoscopic procedure
• Risk of identification of unknown malignancy, infection and lack of
presumed blood relation
• Risk of ESRD <0.02%/y Risk of death 0.03%

14. IS THE DONOR STILL WILLING
OBTAIN CONSENT FOR EVALUATION

15. STEP 2: PSYCHOSOCIAL EVALUATION
• By psychiatrist or
• Psychologist or
• Specifically trained social worker
PSYCHO SOCIAL
Mental health issues
High-risk behavior
Pressure

16. • ELIGIBILE AND WILLING?

17. STEP 3: MEDICAL EVALUATION
• IS HE / SHE APPARENTLY HEALTHY?
• IS THERE ANY HIDDEN
• INFECTION
• MALIGNANCY
• CHRONIC HEALTH CONDITION
• UROLOGICAL DISEASE
• IS IMMUNOCOMPATIBILITY ACCEPTABLE?
• WHICH KIDNEY IS RETRIEVABLE / TRANSPLANTABLE?
UROLOGIST
NEPHROLOGIST
REFERRALS

18. IS HE / SHE APPARENTLY HEALTHY?
• Detailed H & E
Medication - NSAIDS
Allergy – medications, others
Known medical comorbidity – HT, DM, HLP, CAD, CVA, thyroid, others
Addictions – smoke, alcohol, others
Symptoms – specific to heart, lung, brain, liver, kidney, genitourinary
system, gastrointestinal system, psychological
Family hx – metabolic syndrome
Female hx – menstruation, pregnancies, etc.
PROFORMA-BASED EVALUATION

19. IS THERE ANY HIDDEN
infection / chronic disease / malignancy
BASIC LABS
• Anemia? – complete blood picture
• Coagulopathy? – above + PT/INR + APTT
• Hepatic function? – LFT with proteins
• Renal function? – Na, K, creatinine, urea; 24H protein, creatinine
• Endocrine function? – lipid profile, F/PP BS, GTT, HbA1c, TFT
• Hypertensive? – 24h BP monitoring in high risk, else 3 measurements

20. IS THERE ANY HIDDEN
infection / chronic disease / malignancy
• Viral infection? – HIV, anti HCV, HBsAg, CMV, EBV
• Tuberculosis? – Manteux test / Gold Quantiferon
• Syphilis? – Rapid plasma reagin
• Urinary tract infection? – urine analysis and culture
• Stone disease? – uric acid, calcium, chloride / phosphorus, iPTH, 24H urine
profile
• Malignancy? – serum PSA, PAPs, mammography, colonoscopy

21. IS THERE ANY HIDDEN
infection / chronic disease / malignancy
BASIC RADIOLOGY
• Lung? – chest X ray PA view, PFT
• Heart? – ECG, Echo, TMT
• Abdomen? – USG whole abdomen, X ray KUB

22. • PERFECTLY HEALTHY – STANDARD CRITERIA DONORS
• SOME IMPREFECTIONS – EXPANDED CRITERIA DONORS
• hypertension well controlled on one medication
• single renal calculus
• borderline renal function
• microscopic hematuria
• impaired glucose tolerance (but not a diabetic)
• over 65y

23. • IF ELIGIBLE

24. IS IMMUNOCOMPATIBILITY ACCEPTABLE?
• HLA TYPING (CERTAIN INDICATIONS)
• CROSS MATCHING –
• LYMPHOCYTE
• ANTIBODY

25. IF ELIGIBLE

26. WHICH KIDNEY IS RETRIEVABLE /
TRANSPLANTABLE?
• Better one stays with the donor
• Anatomical tests –
CT KUB – triphasic
MR KUB with urography
• Functional tests for determining
differential function –
DTPA
DMSA

27. DONOR SURGERY
• LAPAROSCOPIC
• OPEN
LESS PAIN /BLEEDING
EARLY AMBULATION
LESS TISSUE TRAUMA
EARLY HEALING
COSMETIC ADVANTAGE
PSYCHOLOGICAL ADVANTAGE

28. POSTOPERATIVE CARE
• EARLY STOPPING ANTIBIOTICS (WITHIN 24 HOURS)
• GOOD PAIN RELIEF
• EARLY AMBULATION
• EARLY ORALS
• EARLY DISCHARGE POSTOPERATIVE LABS

29. Follow up protocol for donors after kidney
donation
• S. Creatinine on the day-1 post-surgery Urine output monitoring till the
day of discharge.
• Visits at 1 month, 6months, 12months, 24months, thereafter every two
yearly.
• Check blood pressure, weight, S.Creatinine, Urine RE, Hemoglobin and
blood sugar in all visits.
• At 6months, 12months, 24months and every 5years thereafter: 24 hour
urine protein and creatinine for creatinine clearance

30. General Advice
• Maintain healthy weight (BMI <25)
• Do regular exercise
• Eat healthy, balanced diet – avoid excessive salt, refined sugar, oily foods
• Avoid smoking altogether
• Alcohol intake should be limited
• Avoid over the counter analgesics (NSAIDs) and other nephrotoxic
medications
• Drink plenty of fluids and avoid dehydration (replenish fluids promptly
during excessive sweating, diarrhoea, etc.)
• Inform your kidney donor status when you consult any doctor

31. CONCLUSION
• Good selection
• Good documentation
• Good care
• Good follow up

32. • THANK YOU