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Wednesday, March 19, 2014

Living Donor Outcomes in Kidney Trasnplantation

A major concern about living donors is the long-term impact of uninephrectomy on risk of hypertension, proteinuria, and chronic kidney disease. One of the more important recent reports regarding the long-term impact of living donation has been provided by Ibrahim and colleagues. This report described almost 3,700 kidney donors who donated kidneys over 44 years. At a mean of 12 years after donation, 85% of a subset of the living donors had a GFR of 60 ml/min or higher, 32.1% had hypertension, and 12.7% had albuminuria. Older age and a higher body mass index, but not a longer time since donation, were associated with both a lower GFR and hypertension. More time from donation was independently associated with albuminuria. Most importantly, the survival of kidney donors was similar to that of controls matched for age, gender, and ethnicity. ESRD developed in 11 donors, a rate of 180 cases per million persons per year, compared with a rate of 268 per million per year in the general population. Most donors had quality-of-life scores that were better than population norms, and the prevalence of coexisting conditions was similar to that among controls from the National Health and Nutrition Examination Survey (NHANES) who were matched for age, sex, race or ethnic
group, and BMI.

Ibrahim HN, Foley R, Tan L, Rogers T, Bailey RF, Guo H, Gross CR, Matas AJ: Long-term consequences of kidney donation. N Engl J Med 360: 459–469, 2009

Overall Outcomes for Living Kidney Donors
Accurate information about the effects of donor nephrectomy is important in counseling potential live kidney donors. Issues involve both the short-term risk – the risks of surgery and the immediate peri-operative period – and the long-term risks – overall health and specifically the function of the remaining kidney. Review of peri-operative mortality and long-term survival from registry data in over 80,000 live kidney donors from 1994 through 2009 revealed an overall 90 day mortality rate of 3.1 per 10,000 live donor nephrectomies. Surgical mortality was higher in men than women (5.1 vs. 1.7 per 10,000) and in African American/Hispanic compared with white donors (7.6 vs 2.6 per 10,000). Neither increased donor age, smoking, nor obesity (BMI > 30) was associated with higher surgical mortality. The long-term survival of living kidney donors was no different than that of age- and co-morbidity-matched National Health and Nutrition Examination Survey participants for all patients stratifies by age, sex, and race. Obesity is a common issue in potential live donors: a review of the OPTN database of over 5,000 live donors with known BMI data who donated over a 1.5 year period between July 2004 and December 2005 revealed that 40% were overweight, 17.8% were obese (BMI 30-35) and 4.7% were very obese (BMI >35). At baseline and at 6 month follow-up, higher BMI was associated with higher systolic BP, but changes in BP were similar across the groups. There were no apparent differences in decline in GFR or percent change in serum creatinine across these categories of obesity in 6 month follow-up. Others studies have shown that there is no greater decline in renal function in obese patients compared with non-obese patients. Lifetime risk of requiring renal replacement therapy after kidney donation is less than 1%.

Tavakol, MM, Vincenti, FG, Assadi, H, Frederick, MJ, Tomlanovich, SJ, Roberts, JP, Posselt, AM:
Long-term renal function and cardiovascular disease risk in obese kidney donors. Clin J Am Soc
Nephrol 4:1230-8, 2009

Nogueira, JM, Weir, MR, Jacobs, S, Breault, D, Klassen, D, Evans, DA, Bartlett, ST, Cooper, M: A study
of renal outcomes in obese living kidney donors. Transplantation 90:993-9, 2010

Reese, PP, Feldman, HI, Asch, DA, Thomasson, A, Shults, J, Bloom, RD: Short-term outcomes for
obese live kidney donors and their recipients. Transplantation 88:662-71, 2009

Axelrod, DA, McCullough, KP, Brewer, ED, Becker, BN, Segev, DL & Rao, PS: Kidney and pancreas
transplantation in the United States, 1999-2008: the changing face of living donation. Am J Transplant
10:987-1002, 2010

Davis, CL, Cooper, M: The state of U.S. living kidney donors. Clin J Am Soc Nephrol 5:1873-80, 2010

Segev, DL, Muzaale, AD, Caffo, BS, Mehta, SH, Singer, AL, Taranto, SE, McBride, MA, Montgomery,
RA: Perioperative mortality and long-term survival following live kidney donation. JAMA 303:959-66, 2010

Lentine, KL, Schnitzler, MA, Xiao, H, Saab, G, Salvalaggio, PR, Axelrod, D, Davis, CL, Abbott, KC,
Brennan, DC: Racial variation in medical outcomes among living kidney donors. N Engl J Med
363:724-32, 2010

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