Fasting before living-kidney donation: effect on donor well-being and postoperative recovery: study protocol of a multicenter randomized controlled trial

Background One of the main effectors on the quality of life of living-kidney donors is postoperative fatigue. Caloric restriction (CR) and short-term fasting (STF) are associated with improved fitness and increased resistance to acute stress. CR/STF increases the expression of cytoprotective genes, increases immunomodulation via increased anti-inflammatory cytokine production, and decreases the expression of pro-inflammatory markers. As such, nutritional preconditioning by CR or STF represents a non-invasive and cost-effective method that could mitigate the effects of acute surgery-induced stress and postoperative fatigue. To investigate whether preoperative STF contributes to a reduction in fatigue after living-kidney donation, a randomized clinical trial is indicated. Methods We aim to determine whether 2.5 days of fasting reduces postoperative fatigue score in subjects undergoing living-kidney donation. In this randomized study, the intervention group will follow a preoperative fasting regime for 2.5 days with a low-dose laxative, while the control group will receive standard care. The main study endpoint is postoperative fatigue, 4 weeks after living-kidney donation. Secondary endpoints include the effect of preoperative fasting on postoperative hospital admission time, the feasibility of STF, and the postoperative recovery of donor and recipient kidney function. This study will provide us with knowledge of the feasibility of STF and confirm its effect on postoperative recovery. Discussion Our study will provide clinically relevant information on the merits of caloric restriction for living-kidney donors and recipients. We expect to reduce the postoperative fatigue in living-kidney donors and improve the postoperative recovery of living-kidney recipients. It will provide evidence on the clinical merits and potential caveats of preoperative dietary interventions. Trial registration Netherlands Trial Register NL9262. EudraCT 2020-005445-16. MEC Erasmus MC MEC-2020-0778. CCMO NL74623.078.21

Living kidney donation and reasons for denial: A report from a Brazilian single-center cross-sectional study

Chronic kidney disease is increasingly more prevalent worldwide, and kidney transplant remains the best option for patient survival. Living kidney transplants (LKT) pose advantages over deceased donor transplants, such as longer graft survival, lower ischemia time, and better HLA match. However, LKT is not always attainable for multiples reasons, with the absence of a suitable living donor being a significant barrier. Therefore, meticulous donor screening must be performed in order to guarantee donation safety. We examined medical appointments of living kidney donors evaluated at Hospital do Rim, São Paulo, between January and December 2020. Reasons for not proceeding with the donation were evaluated and were categorized as medical, surgical, immunological, psychosocial, or other. A total of 506 donor -receptor pairs were enrolled for evaluation during the study period. More than half of screened donor -receptor pairs (N=296, 58.5%) were not considered feasible for LKT. The primary cause for refusal was medical contraindication (32.1%), followed by immune (21.3%) and social (19.3%) causes. In addition, a considerable proportion of patients voluntarily withdrew themselves at variable time points during the evaluation process (N=79). In our center, most patients did not meet the criteria for kidney donation owing to medical reasons, similarly to other centers, and this reflects the importance of meticulous donor screening. In addition, the current Covid -19 pandemic affected the living transplant program, contributing to delayed complete donor and receptor evaluation.

Perception Regarding Live Kidney Donation in the General Population of South Korea

This study aimed to know how the general population recognizes live kidney donation in Korea. Participants were randomly selected from the general population after proportional allocation by region, sex, and age. Selected participants received a questionnaire that included demographic information, socioeconomic and marital statuses, prior recognition of live donor KT, expected changes after donation, and the need for support after donor nephrectomy. Among the 1,000 participants from the web-based survey, 83.8% answered they fully understood living donor KT, 81.1% knew about them, and 51.1% were willing to donate. Various complications after nephrectomy and deterioration in health after donation were the most significant reasons for those reluctant to donate. Most agreed that the government should provide social and economic support to living kidney donors, especially after exposure to the description of donor nephrectomy. Financial support, including surgery and regular medical check-up costs, was the most preferred government support. The Korean general population seemed aware of the value and safety of kidney donation, although only half of them were willing to donate due to concerns about possible complications. Most participants agreed on social and economic support for living kidney donors, especially surgery-related costs.

Kidney Paired Exchanges and Variants

Given the growing gap between the demand and supply of kidneys needed for transplantation, and the better outcomes of living versus deceased donor kidney transplants, living kidney donation is being more aggressively endorsed and promoted. Traditionally, living kidney donors were ABO- and HLA-compatible with their recipients, with whom they were genetically and/or emotionally related. When a living donor-recipient pair is not compatible, there is growing acceptance of employing alternative living donor transplantation strategies such as paired kidney exchanges and domino chains. This chapter addresses the ethical and policy issues that are raised by participation in kidney paired exchanges and domino kidney chains. Specific attention is given to the participation of histocompatible donor-recipient pairs in these programs when the donor could just donate directly. Justice and other ethical issues raised by advance donor programs and list-paired exchanges are also discussed.

Perception Regarding Live Kidney Donation in the General Population of South Korea

Background: It is necessary to know how the general population recognizes live kidney donation in Korea, where living donor kidney transplantations (KT) are the mainstream.Methods: Participants were randomly selected from the general population after proportional allocation by region, sex, and age. Selected participants received a questionnaire that included demographic information, socioeconomic and marital statuses, prior recognition of live donor KT, expected changes after donation, and the need for support after donor nephrectomy.Results: In total, 1,000 participants responded to the web-based survey. After reading the detailed explanation, 83.8% of the respondents answered that they fully understood living donor KT. Among the participants, 811(81.1%) answered that they knew about living donor KT, and 51.1% were willing to donate. Various complications after nephrectomy (54.4%) and deterioration in health after donation (69.1%) were the most important reasons for those who were reluctant to donate, and the possibility of a decrease in economic activities after donation accounted for 33.8%. Overall, 73.2% were more likely to agree that the government should provide social and economic support to living kidney donors; this number increased to 81.3% after exposure to the description of donor nephrectomy (P<0.001). Financial support, including surgery (74.2%) and regular medical check-up costs (70.1%), was the most preferred government support.Conclusions: The Korean general population seemed to be aware of the value and safety of kidney donation, although only half of them were willing to donate due to concerns about possible complications. Most participants agreed on social and economic support for living kidney donors, especially for surgery-related costs.

Comparison of CT Volumetry versus Nuclear Renography for Predicting Remaining Kidney Function After Uninephrectomy in Living Kidney Donors

Computed tomography (CT) and nuclear renography are used to determine kidney procurement in living kidney donors (LKDs). The present study investigated which modality better predicts kidney function after donation. This study included 835 LKDs and they were divided into two subgroups based on whether the left-right dominance of kidney volume was concordant with kidney function (concordant group) or not (discordant group). The predictive value for post-donation kidney function between the two imaging modalities was compared at 1 month, 6 months, and > 1 year in total cohort, concordant, and discordant groups. Split kidney function (SKF) measured by both modalities showed significant correlation with each other at baseline. SKFs of remaining kidney measured using both modalities before donation showed significant correlation with eGFR (estimated glomerular filtration rate) after donation in the total cohort group and two subgroups, respectively. CT volumetry was superior to nuclear renography for predicting post-donation kidney function in the total cohort group and both subgroups. In the discordant subgroup, a higher tendency of kidney function recovery was observed when kidney procurement was determined based on CT volumetry. In conclusion, CT volumetry is preferred when determining procurement strategy especially when discordance is found between the two imaging modalities.

Practice Patterns in the Acceptance of Medically Complex Living Kidney Donors with Obesity, Hypertension, Family History of Kidney Disease, or Donor-Recipient Age Discrepancy

Background To assess the practice patterns of the acceptance of medically complex living kidney donors (MCLKDs). Methods We distributed a survey to nephrologists and transplant surgeons (TS) across the world through major international transplant societies. The survey contained questions regarding obesity, abnormal blood glucose profile, mild hypertension, donor-recipient age discrepancy, or family history of kidney disease of unknown etiology. Results In total, 239 respondents from 29 countries (42% were nephrologists and 58% were TS).Most respondents would allow donations from obese donors, especially if they intended to lose weight but would be cautious if these donors had abnormal blood glucose or family history of diabetes mellitus. In hypertensive donors, future pregnancy plans mattered in decisions regarding the acceptance of female donors. Most respondents would allow young donors but would be more cautious if they had a future risk of hypertension or a family history of kidney disease of unknown etiology. They would also allow donations from an older person if prolonged waiting time was anticipated. We found multiple areas of consensus of practice among the diverse members of international transplant societies, with some interesting variations among nephrologists and TS. Conclusions This survey highlights the practice patterns of the acceptance of MCLKDs among the international community. In the absence of clear guidelines, this survey provides additional information to counsel kidney donors with these conditions.

Remnant renal volume can predict prognosis of remnant renal function in kidney transplantation donors: a prospective observational study

Background Safety and survival during and after donor nephrectomy (DN) are one of the main concerns in living kidney donors (LKDs). Therefore, kidney (left/right) to be procured should be determined after considering the difficulty of DN, as well as the preservation of remnant renal function (RRF). In this prospective study, we investigated the roles of computed tomography volumetry (CTV) in split renal function (SRF) and established a predictive model for RRF in LKDs. Methods We assessed 103 LKDs who underwent DN at our institute. The Volume Analyzer SYNAPSE VINCENT image analysis system were used as CTV. RRF was defined as the estimated glomerular filtration rate (eGFR) 12 months after DN. The association between various factors measured by CTV and RRF were investigated, and a role of CTV on prediction for RRF was assessed. Results The median age and the preoperative eGFR were 58 years and 80.7 mL/min/1.73m2, respectively. Each factor measured by CTV showed an association with RRF. The ratio of remnant renal volume to body surface area (RRV/BSA) could predict RRF. In addition, RRV/BSA could predict RRF more accurately when used together with age and 24-h creatinine clearance (CrCl). Conclusions Our findings suggest that RRV/BSA measured by CTV can play an important role in predicting RRF, and a comprehensive assessment including age and CrCl is important to determine the kidney to be procured.

Racial/ethnic and prior willingness disparities in potential living kidney donors’ self-assessed responses to advancing American kidney health regulation

Background Racial/ethnic disparities in living donor kidney transplantation (LDKT) are large, and rates of LDKT may be limited by indirect costs of living donation. A 2019 Executive Order– Advancing American Kidney Health (AAKH)– sought to remove indirect costs through an expanded reimbursement program. We examine how potential living kidney donors in the U.S. believe regulation stemming from the AAKH initiative will impact their living donor evaluation likelihood, how these beliefs vary by minority race/ethnicity and prior willingness to be evaluated, and how differences are explained by ability to benefit or knowledge and attitudes. Methods Data from a 2019 online survey (Families of Renal Patients Survey) were used. Respondents are U.S. adult (> 18 years) members of the Qualtrics Survey Panel who reported having relatives with weak or failing kidneys (N = 590). Respondents’ likelihood to be evaluated for living kidney donation are measured by self-report. Prior willingness is measured by past donation-related actions and current attitudes. Ability to benefit is measured by self-reported labor force participation and financial strain. Transplant knowledge is measured by self-report and a knowledge test, and transplant-related attitudes are measured by self-report. Average marginal effects of minority race/ethnicity and prior willingness for response to each provision in fully-adjusted models were estimated. Formal tests of mediation were conducted using the Karlson, Holm, and Breen (KHB) mediation model. Stata/MP 14.2 was used to conduct all analyses. Results Majorities of all groups report favorable responses to the provisions stipulated in AAKH regulation. Responses to provisions are significantly associated with race/ethnicity and prior willingness, with racial/ethnic minorities and those not previously willing to be evaluated less likely to report favorable responses to these provisions. Prior willingness differences are partially explained by group differences in ability to benefit and transplant-related knowledge and attitudes, but racial/ethnic differences largely are not. Conclusions Regulation stemming from the AAKH initiative is likely to effectively promote LDKT, but may also exacerbate racial/ethnic disparities. Therefore, the regulation may need to be supplemented by efforts to address non-financial obstacles to LDKT in racial/ethnic minority communities in order to ensure equitable increases in LDKT rates and living donor support.