KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors

Abstract

The 2017 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors is intended to assist medical professionals who evaluate living kidney donor candidates and provide care before, during and after donation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach and guideline recommendations are based on systematic reviews of relevant studies that included critical appraisal of the quality of the evidence and the strength of recommendations. However, many recommendations, for which there was no evidence or no systematic search for evidence was undertaken by the Evidence Review Team, were issued as ungraded expert opinion recommendations. The guideline work group concluded that a comprehensive approach to risk assessment should replace decisions based on assessments of single risk factors in isolation. Original data analyses were undertaken to produce a “proof-in-concept” risk-prediction model for kidney failure to support a framework for quantitative risk assessment in the donor candidate evaluation and defensible shared decision making. This framework is grounded in the simultaneous consideration of each candidate's profile of demographic and health characteristics. The processes and framework for the donor candidate evaluation are presented, along with recommendations for optimal care before, during, and after donation. Limitations of the evidence are discussed, especially regarding the lack of definitive prospective studies and clinical outcome trials. Suggestions for future research, including the need for continued refinement of long-term risk prediction and novel approaches to estimating donation-attributable risks, are also provided.In citing this document, the following format should be used: Kidney Disease: Improving Global Outcomes (KDIGO) Living Kidney Donor Work Group. KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Transplantation. 2017;101(Suppl 8S):S1–S109.

Identifying Outcomes that Are Important to Living Kidney Donors

“…The recent Kidney Disease Improving Global Outcomes guidelines recommend informing donors of individualized risks and benefits including medical, surgical, psychosocial, and economic outcomes (6). They suggest communicating absolute risks and disclosing uncertainty in long-term outcomes (6). However, donors' strong motivations and the confidence in their safety pose additional barriers to comprehending information before donation (38)(39)(40).…”

“…Informed consent practices have been shown to vary widely across centers, particularly in terms of the information provided and use of methods to assess voluntariness and comprehension of information (37). The recent Kidney Disease Improving Global Outcomes guidelines recommend informing donors of individualized risks and benefits including medical, surgical, psychosocial, and economic outcomes (6). They suggest communicating absolute risks and disclosing uncertainty in long-term outcomes (6).…”

“…Living donation is considered ethically justified on the proviso that donors undergo rigorous medical screening and assessment, provide informed and voluntary consent after education about the potential risks and uncertainty regarding long-term outcomes, and have access to long-term health care (4)(5)(6). Understanding of the medical risks to living kidney donors is evolving, with the progressive publication of more robust long-term data (7)(8)(9).…”

Prescription opioid use before and after kidney transplant: Implications for posttransplant outcomes

“…(1, 2) Similarly, living donor candidates are carefully evaluated for medical and psychosocial suitability for donation. (3) Medication therapies are reviewed to assess treatment appropriateness and identify possible drug interactions that might occur after surgery. However, while substantial attention is invested in the evaluation clinic to identify traditional risk factors, we often overlook medications that might be markers for serious conditions, lack of adherence, or other behaviors that may affect patient and allograft survival.…”

Strategies for Increasing Knowledge, Communication, and Access to Living Donor Transplantation: an Evidence Review to Inform Patient Education

“…4 The 2017 Kidney Disease: Improving Global Outcomes (KDIGO) “Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors” recognizes that public awareness of opportunities for living donation should be improved through education. 5 While the need and benefits are clearly established, multiple barriers to living donor transplantation exist. Barriers include inadequate education and outreach, the complexity and potential inefficiencies in the living donor evaluation process, disincentives such as uncompensated costs for the donor, and ongoing needs to support and advance donor safety and risk assessment to sustain public trust in the donation process.…”