Cbc

VDRL/RPR, HbsAg, HCV antibody, EBV titer, CMV titer, HIV Glucose tolerance test if patient is diabetic Urinalysis and urine culture, pregnancy test

24-hour urine collection for protein and creatinine clearance (on two occassions) Chest x-ray, EKG, cardiac echo/noninvasive stress test for donors greater than 50 years of age/if indicated.

Pap smear /mammogram for female donors

Psychiatric evaluation

IVP and arteriogram vs. CT scan angio doing so. Furthermore, potential donors should not be coerced into the evaluation process. Frequently, motivated individuals who are considering live renal donation will accompany the transplant recipient to his or her initial pretransplant evaluations. Ideally, the issue of living donation should be brought to the potential donor by the patient, and not the patient's nephrologist or members of the transplant team. However, both the transplant team and nephrologist should be willing and able to facilitate discussion of donation if assistance by the patient is requested.

The initial donor evaluation should attempt to screen out those individuals who are not suitable candidates (Table E11.2). Living donors typically range in age between 18 and 65 years of age; juveniles are rarely considered for donation, while the elderly usually have an unacceptably higher risk of general anesthesia and surgery. Blood typing and crossmatch are cost-effective screening tests commonly used early in the donor evaluation. Individuals who are blood -group incompatible, or who demonstrate a positive crossmatch with the recipient, are ruled out without further expensive testing. A complete history and physical examination can then proceed with an appropriate blood group compatible and crossmatch negative candidate.

It is imperative that potential donors be excluded on medical grounds when it is believed that there may be a risk of unrecognized kidney disease, or there exist medical conditions which increase the risk of both short and long term morbidity and mortality from the donor procedure. Table E11.2 lists criteria frequently cited for exclusion of potentially compatible donors. These criteria are not absolute; when findings are borderline, it is always appropriate to exclude the candidate in the name of donor safety. Relative contraindications peculiar to laparoscopic kidney donation include prior left colonic or splenic surgery, retroperitoneal inflammatory processes (i.e., diverticulitis), and obesity. Precise definition of

Table E11.2. Potential contraindications for living kidney donors (adapted from refs. 18,19)

ABO incompatibility

Positive crossmatch

Age less than 18 or over 65

Malignancy

Infection

Hypertension (> 140/90 mm Hg) Diabetes

Proteinuria (> 150 mg/24 hrs)

Renal disease or reduced renal function (creatinine clearance < 80 ml/min)

Microscopic hematuria

Urologic abnormalities in donor kidneys

Nephrolithiasis

Increased medical risk of surgery Inability to give informed consent Psychiatric contraindications renal anatomy with intravenous pyelogram plus conventional angiography, or highresolution CT scan angiography is the final step in the donor evaluation and should be performed after medical clearance of the transplant recipient. Published reports of laparoscopic donation support the limited use of the left kidney to maximize the length of renal vein, and to avoid posttransplant vascular.15 The presence of multiple renal arteries is not a contraindication to the use of the left kidney. If for any reason the left kidney is not suitable to donate, then open right nephrectomy may be performed.

There is often concern about the long-term effects of donation in relatives of patients with hereditary kidney disease, most notably polycystic kidney disease and hereditary nephritis. In families with polycystic kidney disease, a negative ultrasound or CT scan in individuals greater than 30 years of age safely rules out the disease and permits donation. When a family history of hereditary nephritis or Alport's syndrome is documented, it is usually inherited in an X-linked pattern. Donation is best limited to male relatives without hematuria or other Alport's -associated abnormalities or to those female relatives without hematuria. Females relatives with hematuria or other associated abnormalites are not suitable donors. Both donors and recipients in families with hereditary nephritis need to be advised of the risk of disease recurrence and subsequent graft failure.

It is essential that the voluntary nature of the kidney donation be preserved during the entire evaluation process. A psychological assessment of the donor early on may prove valuable in this regard. Health care workers should protect individuals who decide not to donate by offering to tell the patient's family and friends that the donor is not suitable on medical grounds.

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