The altruistic elderly, a valuable but unrecognised kidney donor group. A case report of an 85-year-old unspecified kidney donor.

BACKGROUND: Kidney transplantation is the definitive treatment for end stage renal disease (ESRD), offering improved quality of life and survival benefit over remaining on dialysis. There is, however, a prevailing significant mismatch between patients awaiting transplantation and available donor kidneys. Over time, initial stringent donor criteria have broadened and organs from extended criteria donors (ECDs) and older donors are now being accepted for transplantation. The spectrum of living donors has also undergone a change from close family members to an increasingly non-related, non-directed altruistic donors, newly classified as 'unspecified' donors. Unspecified elderly donors could be a potential untapped resource to expanding the kidney donor pool globally. CASE PRESENTATION: We present a case of an 85 year and 8 months old individual, who donated to an unrelated non-directed matched recipient in the national deceased donor transplant waiting list with excellent donor and recipient outcomes at 7 years. CONCLUSION: To our knowledge she is one of the oldest reported unspecified living kidney donors in the world to date. This case illustrates that elderly donors in good health can come forward to donate, knowing that it is safe and valuable. Once the immediate perioperative challenges after kidney donation are managed, elderly donors rarely encounter long term sequelae. We therefore report this case to increase awareness and refocus attention of transplant teams on elderly donors as a potential untapped group to help address the organ shortage problem in renal transplantation.

A multicenter cohort study of potential living kidney donors provides predictors of living kidney donation and non-donation.

This multicenter prospective potential living kidney donor cohort study investigated which sociodemographic and other factors predict progression to living kidney donation or donor withdrawal as little is known on this topic. Therefore, we examined data on individuals undergoing living donor assessment at seven hospitals in the United Kingdom. Multivariable logistic regression was used to explore the relationships between donor and recipient characteristics and likelihood of kidney donation. A total of 805 individuals presented for directed donation to 498 intended recipients, of which 112 received a transplant from a living donor. Potential donors were less likely to donate if their intended recipient was female rather than male with an odds ratio of 0.60, a friend rather than relative 0.18, or had renal failure due to a systemic disease rather than another cause 0.41. The most socioeconomically deprived quintile was less likely to donate than the least 0.49, but the trend with deprivation was consistent with chance. Higher body mass index was associated with a lower likelihood of donation (odds ratio per each kg/m2 increase, 0.92). Younger potential donors (odds ratio per each year increase 0.97), those of nonwhite ethnicity 2.98, and friend donors 2.43 were more likely to withdraw from work-up. This is the first study in the United Kingdom of potential living kidney donors to describe predictors of non-donation. Qualitative work with individuals who withdraw might identify possible ways of supporting those who wish to donate but experience difficulties doing so.

Assessment of living kidney donors and adherence to national live donor guidelines in the UK.

BACKGROUND: As in most industrialized countries, living kidney donation has increased considerably in the UK and now amounts to 38% of the total UK kidney transplant activity. Living kidney donation guidelines have been formulated by the relevant national societies. We were interested to study whether or not renal units across the UK adhere to those guidelines and to delineate areas of inconsistency and controversy. METHODS: Twenty-four adult kidney transplant centres and 50 adult non-transplant renal units across the UK were contacted by a postal questionnaire from January to April 2011. RESULTS: Twenty-one of 24 (88%) transplanting units and 23 of 50 (46%) non-transplanting units responded. Eighty-one per cent of the responding transplanting units and only 30% of the non-transplanting units have a dedicated live donor clinic. Eighty-six per cent of all units are without a set upper age limit for donors, whereas 7% of units excluded all potential donors older than 70 years. Twenty per cent of units accept donors with body mass indices (BMIs) up to 35, whereas 9% of units did not have an upper limit for BMI. Thirty-two per cent of centres exclude hypertensive donors on more than one antihypertensive drug, whereas 64% of units exclude donors only if they are on more than two anti-hypertensive drugs. of units rely on a spot urine sample to assess proteinuria, while 30% of units still perform 24 h urine collection. Sixty one per cent of units perform computed tomography (CT) angiography to assess the renal vessels prior to donation, while 32% use magnetic resonance (MR) angiography. Seventy-five per cent of centres assess split kidney function by radionuclide testing in all cases, whereas 25% perform this test only if there is a discrepancy in kidney size. The practice of suspension of recipients with potential living donor from the deceased waiting list is also remarkably inconsistent, whereby some centres suspend once a decision for living donation has been made in principle, whereas others suspend the recipient only once a date for surgery has been agreed. CONCLUSIONS: We demonstrate significant variability in accepting living kidney donors, particularly regarding age, BMI, and hypertension. Infrastructure setting for living donation and the live donor assessment are also remarkably inconsistent across the UK. It remains unclear as to why nephrologists decide not to adhere to established guidelines and further research should aim to find the lacking evidence in areas causing inconsistency in living donor assessment.

Significance of ambulatory blood pressure monitoring in assessment of potential living kidney donors.

The most recent British Transplant Society (BTS) guidelines recommend that office blood pressure (BP) monitoring in living donors is sufficient for the assessment of hypertension (HTN) and those with BP >140/90 should be further assessed using ambulatory BP monitoring (ABPM). ABPM can detect diurnal and nocturnal variation in BP, thus it can identify masked HTN. The aim of the current study is to assess reliability of ABPM vesus office BP monitoring for assessment in living kidney donors. Office and ABPM of all potential kidney donors at a single center from April 2009 to March 2017 were retrospectively reviewed and compared. Age, sex, body mass index, kidney function, and echocardiography results were collected and analyzed. Two hundred and sixteen kidney donors were stratified based on their BP readings into four groups; group 1 (masked HTN: normotensive in office and hypertensive in ABPM), group 2 (sustained normotension: normotensive in office and in ABPM), group 3 (sustained HTN: hypertensive in office and in ABPM), group 4 (white-coat HTN: hypertensive in office and normotensive in ABPM). Thirteen percent of patients were diagnosed with masked HTN. Office systolic BP monitoring was significantly higher in patients older than 50 years old compared to other younger populations. However, this significant difference in systolic BP was diminished when assessment with ABPM was performed. In conclusion, ABPM is a reliable modality for the identification of masked HTN and white coat HTN. Masked HTN is correlated with increased risk of end organ damage and risk of death in potential kidney donors. Transplant physicians cannot rely solely on office BP monitoring in the assessment of potential living kidney donors. ABPM should be integral part of routine assessment of potential living kidney donors.