EXPERIMENTAL AND CLINICAL TRANSPLANTATION

Abstract Preemptive related living donor kidney transplant carries the best outcomes for pediatric patients with end-stage kidney disease. Donor age, sex, and comorbidities are to be considered in selecting donors, including marginal extended criteria donors. Kidney size and number of vessels, to match recipient weight and vasculature, are also important parameters. Genetic screening is occasionally required according to the recipient’s primary disease. Posttransplant, follow-up and assessment of living related donors are mandatory to evaluate not only the clinical parameters but also to assess quality of life and social and psychological status. In a 1-year follow-up of 50 donors at Abo El-Reesh Hospital (Cairo, Egypt), there were no significant changes in serum creatinine versus glomerular filtration rate (at normal levels), a 16% elevation of blood pressure, and a tendency of impaired glucose tolerance among female donors. Donors reported positive social and psychological effects. Prompt donor selection before transplant is crucial, and posttransplant care and follow-up are mandatory.

Key words : Donor outcomes, Extended criteria donors, Genetic screening, Quality of life, Renal transplant

Despite increases in kidney transplant activities worldwide, there has been an exponential increase of patients with advanced end-stage renal disease who require renal replacement therapy, resulting in an expansion of patients on wait lists for transplant due to organ shortages.^1,2 Donor selection and allocation have traditionally been based on HLA, with its documented impact on patient and graft survival. HLA matching must consider the best selection options to resolve the issues of acceptable, crossreacting antigen groups, permissible mismatches, and unacceptable mismatches. Implementation of HLA eplet and epitope matching would be a further advance in the utilization of HLA matching.³The detection of the recipient’s specific immune reactivity to donor alloantigens, whether by solid-phase or cell-based assays, is a cornerstone in the management of pretransplant sensitization reactivity and posttransplant outcomes.⁴

Impact of Donor Age and Donor Risk Factors

Although most guidelines consider the presence of normal kidney function mandatory for living kidney donation, several risk factors are not crucial barriers for donation, including body mass index, controlled hypertension, and prediabetes, among other factors that allow consideration of extended criteria donation.⁵ Younger donor age has been shown to have a beneficial effect on long-term graft survival, with younger age also better for younger recipients.^6-8 However, when the overall beneficial outcomes of transplant are considered, guidelines do not put any age limit for living donation.⁵ Although older donor age has shown a marginal, yet significant, effect on lower levels of graft function in the short term, this has not been encountered in the long term. The impact of other donor risk factors on graft outcomes, whether over the short or long term, was insignificant.⁹

Safety of Donation

Although reports of survival after donation indicate better outcomes compared with the general population, this outcome may carry some bias because of better donor selection criteria that exclude gross risk factors.⁸ Donor nephrectomy may pose transient effects on kidney function of donors, showing a transient, early postoperative increase in the urinary protein excretion and low molecular weight protein markers of tubular injury (including α1- and α2-microglobulins and retinol binding protein). A modest reduction of estimated glomerular filtration rate, as measured 1 year after donation, has also been reported.¹⁰

The possibility of progression in renal impairment may be more frequently encountered among Black donors than among White donors as well as more pronounced among male donors.⁷ This signifies the need for meticulous risk stratification and selection of donors with the utmost care after donation.

The concept of altruistic donation has shown positive impacts on psychological and social factors and quality of life, with reasonable safety.¹¹

With the increased need to treat patients with end-stage renal disease by transplant, whether from deceased or living sources, there have been a shortage of available organs and an increased number of patients on wait lists for transplant. With proper evaluation and risk assessment of individuals who are potential living kidney donors, donation is reasonably safe and should be encouraged hand in hand with enhancing deceased organ procurement. There is no age limit among the risk stratification guidelines for living kidney donation. Crucial needs of donors include their long-term follow-up to monitor the expected clinical and psychosocial impacts of donation and providing them with the best care deserved.

Volume: 20 Issue: 8 August 2022 - Supplement - 4

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