Application of the 2017 KDIGO Guideline for the Evaluation and Care of Living Kidney Donors to Clinical Practice

Abstract

The Kidney Disease: Improving Global Outcomes (KDIGO) 2017 "Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors" was developed to assist medical professionals who evaluate living kidney donor candidates and provide care before, during, and after donation. This guideline Work Group concluded that a comprehensive approach to donor candidate risk assessment should replace eligibility decisions on the basis of assessments of single risk factors in isolation. To address all issues important to living donors in a pragmatic and comprehensive guideline, many of the guideline recommendations were on the basis of expert consensus opinion even when no direct evidence was available. To advance available evidence, original data analyses were also undertaken to produce a "proof-of-concept" risk projection model for kidney failure. This was done to illustrate how the community can advance a new quantitative framework of risk that considers each candidate's profile of demographic and health characteristics. A public review by stakeholders and subject matter experts as well as industry and professional organizations informed the final formulation of the guideline. This review highlights the guideline framework, key concepts, and recommendations, and uses five patient scenarios and 12 guideline statements to illustrate how the guideline can be applied to support living donor evaluation and care in clinical practice.

Keywords: Consensus; Data Analysis; Demography; Donor nephrectomy; Guideline; Kidney Diseases; Living Donors; Living donation; Patient-centered care; Renal Insufficiency; Risk Assessment; Risks; kidney; kidney transplantation; risk factors.

Figure 1.

The Kidney Disease: Improving Global Outcomes framework to accept or decline donor candidates on the basis of a transplant program’s threshold of acceptable projected lifetime risk of kidney failure, quantified as the aggregate of risk related to demographic and health profile and donation-attributable risks. The decision by a transplant program to accept or decline a donor candidate is grounded on whether an individual’s estimated projected postdonation lifetime risk is above or below the threshold set (dotted line) by the transplant program. Lifetime risk is composed of estimated risk in the absence of donation (i.e., related to donor demographic and health characteristics as denoted in blue and pink, respectively) and estimated risk attributable to donation (green). The threshold may vary across transplant programs, but the same threshold should apply to all donor candidates at each program. For example, candidate A would be acceptable because the estimated projected postdonation risk is far below the threshold. Candidate B could be accepted with caution because the estimated projected postdonation risk is close to the threshold, and candidate C would be unacceptable because the estimated postdonation projected risk is far above the threshold. BMI, body mass index. Reprinted from ref. , with permission.

Figure 2.

Five patient scenarios illustrate application of the KDIGO evaluation framework and guideline recommendations. These case scenarios illustrate use of a sample of recommendations from 19 guideline chapters. ADPKD, autosomal dominant polycystic kidney disease; BMI, body mass index.

Figure 3.

Following a stepwise approach in assessment of GFR and application to donor candidate selection facilitates efficiency. eGFRcr is the initial test in most donor candidates. eGFRcys may be the preferred initial test for candidates with variations in non-GFR determinants of eGFRcr: for example, variation in muscle mass or diet. Interpretation of eGFR should include consideration of the probability that measured GFR (mGFR) is above or below thresholds for decision making (http://ckdepi.org/equations/donor-candidate-gfr-calculator). Very high likelihood that mGFR is <60 ml/min per 1.73 m² is justification to decline without further evaluation. Confirmatory tests are as follows: mGFR or mCrCl is required in the United States. Elsewhere, eGFRcr-cys can be acceptable if mGFR or mCrCl is not available and if eGFRcys was not used as the initial test. Repeat eGFRcr can be acceptable if none of the others confirmatory tests are available but is not preferred. Inconsistent test results suggest inaccuracy of one or more tests, which should be discarded or repeated. To use GFR to estimate long-term kidney failure risk, long-term estimated projected risk of kidney failure is compared with the transplant program’s threshold for acceptable risk. Long-term risk in the absence of donation can be estimated from demographic and health characteristics, including GFR (http://www.transplantmodels.com/esrdrisk). Additional risk attributable to donation is currently thought to be approximately 3.5–5.3 times higher than risk in the absence of donation, but there is substantial uncertainty, especially in younger donor candidates, and we suggest caution in decision making. Postdonation kidney failure risk above the program’s acceptance threshold is justification to decline the candidate. Candidates with risk below the threshold are acceptable to the program and they make their own decision whether to proceed with donation. Colors are blended together to signify the thresholds for decision making that are imprecise. Modified from ref. , with permission. eGFRcr, eGFR using serum creatinine; eGFRcys, eGFR using serum cystatin C; eGFRcr-cys, eGFR using both serum creatinine and serum cystatin C; mCrCl, measured creatinine clearance; mGFR, measured glomerular filtration rate.

Figure 4.

Following a stepwise approach in the evaluation of microscopic hematuria in living kidney donor candidates facilitates efficiency. AER, albumin excretion rate; hpf, high-power field; RBC, red blood cell. Reprinted from ref. , with permission.