Living Kidney Donor Evaluation 2013

Transcription

1 Living Kidney Donor Evaluation 2013 David Serur, MD Medical Director, Kidney Transplantation Rogosin Institute, NYP Weill Cornell Marian Charlton RN CCTC Chief Transplant Coordinator New York Presbyterian - Weill Cornell Transplant Program

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3 Donor Mortality 0.03% Between October 1999 through December 2007, 14 living kidney donor died (out of 51,153 donors, 0.03%) within 30 days of donation. Davis, CL. Living Kidney Donors: Current State of Affairs. Advances in Chronic Kidney Disease, 2009

4 Is it Safe to Live With Only One Kidney?

5 Exclusion Criteria Age < 18 years (except in special circumstances as outlined by the American Academy of Pediatrics) Mentally incapable of making an informed decision Hypertension: Uncontrollable hypertension, evidence of end organ damage Diabetes Active malignancy, or incompletely treated malignancy Evidence of donor coercion Evidence of NOTA violation (illegal financial exchange between donor and recipient) Persistent infections or infections with drug resistant organisms Untreated psychiatric conditions, including suicide risk

6 Relative Contraindication Clinically significant cardiovascular disease Clinically significant pulmonary disease Microalbuminuria > 30 mg per day Proteinuria (protein in the urine) > 300 mg/24 hours Creatinine clearance or isotopic GFR within 1 standard deviations for age and gender History of cancer, including metastatic. History of nephrolithiasis Untreated or active substance abuse Lack of or insufficient family, caregiver, social, and/or economic support Strained donor/recipient relationship

7 Relative Contraindication Hypertension in a Caucasian younger than age 50 Hypertension in a Caucasian greater than age 50 on more than one anti-hypertensive medication Hypertension in a non-caucasian at any age Impaired fasting glucose with other features of the metabolic syndrome (low HDL and high triglycerides) in a < 50 year old Significant history of thrombosis or embolism Bleeding disorders BMI > 35

8 Short Term Complications The most common reasons for reoperation were bleeding, bowel obstruction, and hernia repair. Davis, CL. Living Kidney Donors: Current State of Affairs. Advances in Chronic Kidney Disease, 2009

9 Long Term Complications **There is no excess risk of ESRD in donors **Factors linked to a reduced GFR in donors are the same as those that have been observed in the general population namely, age and obesity Ibrahim HN, et al. Long-Term Consequences of Kidney Donation, NEJM 2009

10 Long Term Complications Ibrahim HN, et al. Long-Term Consequences of Kidney Donation, NEJM 2009

11 Expanded Criteria Live Donors Elderly donors Hypertensive donors Obese donors Donors with stones Donors with microscopic hematuria Pre-diabetes

12 Elderly Donors Rotterdam study 539 donors age < 60, vs > 60, single center Dols LFC, et al. Living Kidney Donors: Impact of Age on Long-Term Safety. AJT, 2011

13 DONORS WITH HYPERTENSION

14 Hypertension Family Risk If one of your parents is affected by high blood pressure, you have a 25% chance of developing the disease. The risk increases if both parents or if a parent and a sibling have hypertension. If both parents suffer from hypertension, your odds increase to 50%.

15 Gestational HTN 15,000 women F/U: women with recurrent hypertensive disorders in pregnancy are likely to have higher BMI, higher BP, worse lipids several years after pregnancy. 2 episodes pre-eclampsia 10 X chance of requiring BP meds later on Obstetrics & Gynecology: Volume 114(5), November 2009, pp

16 HTN and risk of ESRD Textor, et al. Transplantation Reviews: Volume 22, Issue 3, July 2008, Pages , Based on Hsu, et al. Arch Intern Med 165 (2005), pp

17 Obese Donors Concern about operative complications Hypertension and Diabetes Proteinuria

18 BMI and Risk ESRD 320 Hsu, et al. Body Mass Index and Risk for End-Stage Renal Disease. Ann Intern Med. January 3, 2006 vol. 144 no

19 Obesity 16 Donors with BMI 31-35, compared to non-obese, 10 yr F/U: **same GFR **same proteinuria **HTN was higher in the obese group (but same as obese with 2 kidneys). Tavakol MM, et al. Long-Term Renal Function and Cardiovascular Disease Risk in Obese Kidney Donors. CJASN, 2009

20 Donors with stones

21 Stone Disease 300 asymptomatic stone patients, avg age 62, stones 10 mm, 85% calcium stones, followed for 3 years Stone growth in 60%, intervention in 26% Stone size 4mm or less located in upper pole had least problems Urine and serum uric acid correlated with stone growth Conclusion: small, upper pole stones, negative metab W/U appear to be safest Progression of Nephrolithiasis: Long-Term Outcomes with Observation of Asymptomatic Calculi. J Endourology: 18 (6). 2004

22 Donor with microscopic hematuria

23 Microscopic Hematuria 10 potential donors with micro hematuria were biopsied 1 IGAN, 4 Thin BM disease, 2 Nl, 1 HTN changes, 2 other. 4/10 ended donating (2 Nls, 2 TBMD) Koushik R, et al, Transplantation, 2005

24 Donors at risk for DM 2

25 Spectrum of DM

26 Familial risk DM 3000 patients at Joslin 1990s: Type 2 diabetes is transmitted primarily through an affected parent (more often the mother). The diabetes risk in siblings of index cases without a history of diabetes in a parent was similar to that in the general population. Diabet Med Jan;19(1):41-50.

27 Risk of Type 2 DM after Gestational DM Gestational Diabetes in the United States 2 to 10 percent of pregnancies. Women who have had gestational diabetes have a 35 to 60 percent chance of developing diabetes in the next years. National Diab Information Clearinghouse (NIDDK)

28 DM Nephropathy 5100 type 2 diabetic patients enrolled in UKPDS, avg age 52, 82% white, 8%black. At ten years following diagnosis, the prevalence of microalbuminuria was 25%. Development and progression of nephropathy in type 2 diabetes: the United Kingdom Prospective Diabetes Study (UKPDS 64). Adler AI, Stevens RJ, Manley SE, Bilous RW, Cull CA, Holman RR, UKPDS GROUPSOKidney Int. 2003;63(1):225.

29 Diabetic Nephropathy in African Americans Type 2 diabetes mellitus is 1.4 to 2.2 times more prevalent in African Americans than whites. Plus higher rates of micro- vascular complications. 2-3 X rate of ESRD than whites Current Diabetes Reports 2004, 4:

30 Questions

31 Basic Evaluation (JSWG) Complete history and physical Height, weight, BMI BP at two different settings or 24 hr ABP General laboratory to assess: hematologic status coagulation electrolytes fasting lipids and glucose, hemoglobin A1C liver status CXR ECG Age and gender appropriate evaluation for cancer

32 Kidney Evaluation Urinalysis with microscopy; UC 24 hour urine for albumin excretion and creatinine clearance Anatomic Testing for anatomy definition (CT, MRA)

33 Infectious Disease Screen CMV EBV HIV 1,2 HBsAg, HBcAB, HBsAB HCV RPR Tuberculosis Depending upon time of year and location associated risk Strongyloides Trypanosoma cruzi West Nile Virus Toxoplasmosis

34 Social Evaluation SW, Financial, Psychiatrist Employment, health insurance status, living arrangements, social stability Smoking, alcohol and drug use/abuse and other high risk behavior Psychiatric illness, depression, suicide attempts

35 Cancer Screening Cervical Cancer Breast Cancer Prostate Cancer Colon Cancer Skin Cancer

36 CT Angio

37 Cornell Practice One day work-up : Brief meeting with TC to review the day, informed consent given to donor Blood work Meetings with: MD, TC, CSW, Advocate, financial Review of lab work Radiology- chest x-ray, CT scan EKG

38 Donor Nephrectomy SRTR 2010

39 Open donor Nephrectomy Donor Disincentives Incisional morbidity Pain cosmesis Prolonged recovery 4-12 weeks Lost wages Personal obligations Child care

40 Laparoscopic Live Donor Nephrectomy ( ) Advantages to donor Decreased morbidity Less postoperative pain Less incisional morbidity Better cosmesis Hastens return to normal activity Expansion of potential donor pool >900 cases at NYPH/Weill Cornell 4 conversions to open surgery

41 LaparoEndoscopic Single Site (LESS) Surgery Laparoscopic procedure through a single skin incision, possibly hidden in umbilicus Potential Advantages Less scarring/better cosmesis Move towards scarless surgery Quicker recovery Natural orifice surgery Fewer ports Eliminate trocar site pain Bowel herniation Umbilicus

42 Laparoscopic Live Donor Nephrectomy Frequent post-operative issues Abdominal bloating Shoulder discomfort Constipation Loss of appetite Pain Intravenous medication x 24 hours Oral pain medication on day #2 and at home Pain medication frequently prolongs above issues

43 Laparoscopic Live Donor Nephrectomy After surgery in hospital Day 1 Bladder catheter removed the morning after surgery Walking morning after surgery Clear liquid diet Day 2 Solid food Discharge home

44 Single Port

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46 Single Port

47 Robotic Nephrectomy

48 The Living Donor Coordinator Who are we? What do we do every day? Do we ever stop and think about these questions?

49 The Living Donor Coordinator Designated LD coordinator: Why have a LDC? Are there benefits to the donor? How does your center benefit?

50 The Living Donor Coordinator The Living Donor Coordinator will demonstrate knowledge and ability to facilitate living donation/transplantation, and will utilize that knowledge to coordinate the care of the living donor for evaluation and live organ donation. NATCO Core Competencies

51 Core Competencies Identifies appropriate live donor candidates. Understands the contra-indications to live donation. Interacts with appropriate staff to facilitate evaluation Identifies requirements for and maintains confidentiality of the living donor evaluation Primary source to ensure living donor has received informed consent Ensures process of informed choice according to transplant center protocol Coordinates with the multidisciplinary team the evaluation process for the potential living donor. Documents pertinent information to ensure continuity of care. NATCO Core Competencies

52 Core Competencies LDC applies knowledge of growth, development, educational and cultural background during live donor candidate and family interactions. Identifies Donor s: Learning needs Coping skills Decision making process Long term expectations Commitment regarding the donation process NATCO Core Competencies

53 Core Competencies Educates live donor and family on: Evaluation Donation Hospitalization Process Risks Benefits Educate the donor and family on : Potential short and long term implications to health after donation Follow up commitment both short and long term Identifies and responds to the educational, psychosocial, and economic needs of the live donor candidate and family during evaluation/surgical procedure and post operative course NATCO Core Competencies

54 Core Competencies Reviews with multidisciplinary team Participates in determination of donor's suitability to donate according to center protocol and OPTN/UNOS regulations Identifies contra-indications to donation Facilitates admission with donor and recipient Available to donor during perioperative period Assists with physical and emotional rehabilitation Discharge plan NATCO Core Competencies

55 Core Competencies Maintains/ensures communication with donor s primary care physician Other health care providers at donor s request Communicates throughout the evaluation, surgical procedure and post operative phase Verbalizes understanding of center protocol Acts as resource for internal and external health care providers Familiar with OPTN/UNOS regulations Designated LDC Provides improved outcomes for donors Continuity of care NATCO Core Competencies

56 Role of LDC in Paired Exchange Educate live donors, family, professional staff on paired exchange process Develop rapport with colleagues Coordinate and plan exchanges Review outside records Logistics planning Support donor and family throughout process Evaluate potential donor as bridge donor

57 Professional development Obtains and maintains ABTC certification Research Reviews and integrates into practice the current literature in the field of living donation Networks through professional organizations.