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Transplant programs have historically used varied evaluation and selection criteria for living donors such that transplant organizations and government transplant agencies have started to devolop guidelines for programs to follow (e.g., UK transplant, the American Society of Transplantation, the American Society of Transplant Surgeons, New York State, and United Network for Organ Sharing [UNOS]).[64–68] The elements necessary in the consenting process are available on the UNOS website, those for the psychological evaluation are shown in Box 85-2 and those for the medical evaluation in Box 85-3.[67,69] Detailed consent is of utmost importance due to the increasing dependence on living donation and because during 2006 in the United States, 21.6% of living donors were unrelated to the recipient (Fig. 85-3) (www.health.state.ny.us/nysdoh/liver_donation/pdf/liver_donor_report_web.pdf).

Box 85-2 

Required Components of the Living Donor Psychosocial Evaluation

To accomplish the goals of the psychosocial evaluation, the following components must be included.[69]

  a.    History and current status: Obtain standard background information regarding such areas as the prospective donor's educational level, living situation, cultural background, religious beliefs and practices, significant relationships, family psychosocial history, employment, lifestyle, community activities, legal offense history, and citizenship.
  b.    Capacity: Ensure that the prospective donor's cognitive status and capacity to comprehend information are not compromised and do not interfere with judgment; determine risk of exploitation.
  c.    Psychological status: Establish the presence or absence of current and previous psychiatric disorders, including but not limited to mood, anxiety, substance use, and personality disorders. Review current or previous therapeutic interventions (counseling, medications); physical, psychological or sexual abuse; current stressors (e.g., relationships, home, work); recent losses; chronic pain management. Assess repertoire of coping skills to manage previous life or health-related stressors. A focus on the extent of anxiety and depression is needed.
  d.    Relationship with the transplant candidate: Review the nature and degree of closeness (if any) to the recipient (e.g., how the relationship developed) and whether the transplant would impose expectations or perceived obligations on the part of either the donor or the recipient.
  e.    Motivation: Explore the rationale and reasoning for volunteering to donate (i.e., the “voluntariness”) including whether donation would be consistent with past behaviors and apparent values, beliefs, moral obligations, or lifestyle and whether it would be free of coercion, inducements, ambivalence, impulsivity, or ulterior motives (e.g., to atone or gain approval, to stabilize self-image, to remedy psychological malady).
  f.     Donor knowledge, understanding, and preparation: Explore the prospective donor's awareness of any potential short- and long-term risks of surgical complications and health outcomes, both for the donor and the transplant candidate; recovery and recuperation time; availability of alternative treatments for the transplantation candidate; financial ramifications (including possible insurance risk). Determine that the donor understands that data on long-term donor health and psychosocial outcomes continue to be sparse. Assess the prospective donor's understanding, acceptance, and respect for the specific donor protocol (e.g., willingness to accept potential lack of communication from the recipient, willingness to undergo future donor follow-up).
  g.    Social support: Evaluate significant other, familial, social, and employer support networks available to the prospective donor on an ongoing basis as well as during the donor's recovery from surgery.
  h.    Financial suitability: Determine whether the prospective donor is financially stable and free of financial hardship, has resources available to cover financial obligations for expected and unexpected donation-related expenses, is able to withstand time away from work or established role including unplanned extended recovery time, has disability and health insurance.
  i.     Discussion with the donor support person.

Box 85-3 

Medical Evaluation of the Living Kidney Donor

  1.    Donor typing to determine the risk of acute transplant failure
  a.    ABO blood group typing 2
  b.    HLA typing
  c.    Crossmatch

  2.    General history and physical examination
  a.    History specifically includes evaluation of family history of kidney disease, diabetes, hypertension, birth weight if possible, gestational diabetes, birth weight of offspring, clotting disorders or deep venous thrombosis, use of nonsteroidal anti-inflammatory drugs (e.g., ibuprofen, indomethacin), urinary tract infections, nephrolithiasis, chronic infections, cancer and kidney injury; prospective donors should be asked whether they have dental coverage and have had a dental examination recently
  b.    Physical examination including blood pressure (done three times at three different times; if possible, it is preferable to perform a 24-hour blood pressure monitor); height; weight; calculated body mass index; waist circumference; a search for evidence of heart, lung, liver, and blood vessel disease; abnormal lymph nodes; and large spleen
  c.    Medical psychological evaluation and social history should include questioning about alcohol intake, smoking history, substance use and abuse, history of mental illness and treatment used

  3.    General laboratory tests: complete blood count with platelet count, prothrombin time/partial thromboelastin time, more detailed evaluation if there is a history of coagulation disorders, comprehensive panel (electrolytes, transaminase levels, albumin, calcium, phosphorus, alkaline phosphatase, bilirubin), human chorionic gonadotropin quantitative pregnancy test if younger than 55 years, urine toxicology screen, serum protein electrophoresis in those older than 60 years
  4.    Cardiovascular: heart and blood vessel tests
  Chest radiograph
  Echocardiogram and/or exercise stress test if the prospective donor is more than 50 years old or has risk factors (hypertension, smoking, hyperlipidemia, family history, exercise shortness of breath) or physical findings that demonstrate increased risk of heart disease including, but not limited to, the following: borderline blood pressure, abnormal electrocardiogram, abnormal chest radiograph, murmur
  Pulmonary function tests for smokers

  5.    Renal-focused evaluation
  Urinalysis, looking for protein and cells in the urine
  Urine culture (if symptoms or abnormal urinalysis)
  Protein excretion: 24-hour urine for protein and/or microalbumin excretion or protein-to-creatinine ratio and/or albumin-to-creatinine ratio 2; if one is abnormal, repeat
  If protein detected, evaluation for postural proteinuria by split urine collection over 24 hours (8 hours recumbent and 16 hours active)
  Serum creatinine
  Glomerular filtration rate (GFR) measurement: clearance testing, 24-hour urine for creatinine clearance measurement or preferably a measured clearance using urine or plasma clearance of iothalamate, iohexol, or other suitable marker. GFR should be expressed per 1.73 m2. Calculated GFR measurements using the serum creatinine are not felt to be adequate. GFR should be within 2 SD for age or be calculated to be at 40 mL/min/1.73 m2 at age 80.
  Screen for polycystic kidney disease as indicated by family history, ultrasound scan if older than 30 years, linkage genetic testing if younger than age 30

  6.    Metabolic-focused evaluation
  Fasting blood glucose
  Uric acid
  Thyroid-stimulating hormone
  Fasting lipid profile (cholesterol, triglycerides, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol)
  Determine the number of elements of the metabolic syndrome that are present; obtain consent for risk if three or more risk factors
  If at increased risk for diabetes (family history of diabetes, gestational diabetes, or elevated triglyceride levels, perform an oral glucose tolerance test and include calculations for insulin secretion/insulin resistance index
  Hemoglobin A1C

  7.    Infection
  Cytomegalovirus, Epstein-Barr virus, herpes simplex virus, varicella-zoster virus
  Human immunodeficiency virus types 1 and 2
  Human T-lymphotropic viruses 1 and 2
  Hepatitis B surface antigen
  Hepatitis B core antibody IgM/IgG
  Hepatitis B surface antibody
  Hepatitis C virus
  Rapid plasma reagin
  Toxoplasmosis, depending on exposure risk
  Geographically determined testing: coccidiomycosis, Strongyloides, Trypanosoma cruzi, malaria, human herpesvirus 8
  Consider human herpesvirus 6 and West Nile virus

  8.    Anatomic evaluation
  Determine which kidney is the safest to remove and which kidney (the one with the best function) is to be left with the donor. Additionally, the presence of abnormal liver, nodes, adrenal glands, and spleen can be determined.
  a.    The test of choice will depend on the local radiological expertise and surgical preference but may include a computed tomography angiogram, magnetic resonance angiogram, or angiogram. It may also be advised to perform an abdominal ultrasound scan to evaluate liver for fatty infiltration and unexpected abnormalities of the liver, pancreas and spleen if a full abdominal computed tomography or magnetic resonance imaging scan is not performed.
  b.    Renal scan with differential renal function

  9.    Cancer screening
  Determines that the donor does not need both kidneys to help with tolerance of anticancer treatment and that the donor does not have a tumor that would be transferred to the recipient
  Testing to be performed depending on gender, age, or family history
  a.    PAP for all women
  b.    Mammogram for all women over 40 or according to family risk
  c.    Prostate-specific antigen test for all men older than 50; for all African American men older than 40, or if from a high-risk family
  d.    Colonoscopy for all donors older than 50 or younger according to family history
  e.    Chest computed tomography for those with a history of smoking

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Optimally, the team evaluating the living kidney donor should include a …