PURPOSE OF REVIEW:Living kidney donation is the preferred choice for renal transplantation due to superior short-tem and long-term recipient, patient, and graft survival. However, living donor safety is essential, and in-depth donor evaluation is required to minimize donor risk. Kidney stone disease is prevalent in the general population, and many kidney donor candidates have had recent or remote stone events. This review will explore the prevalence, causes, and required steps in donor evaluation for stones to maintain donor safety. RECENT FINDINGS:In the United States, the prevalence of kidney stones is about 10% but reported to be about 2-8% among kidney donor candidates. These include asymptomatic, symptomatic, and incidental stones found on CT imaging, which can now detect small calcifications of 1-2 mm or less. These images may also over represent punctate calcifications, which are Randall's plaques in the renal papillae that do not represent active stone disease. SUMMARY:Current data support donation when the donor does not have metabolic risk factors for stones and the retained kidney is stone free. Using the above guidelines, recurrent stone disease in donors or stone-related complications in recipients are uncommon, limited to a few percentage of patients.

FORUM Transpl Int, 24 July 2023 https://doi.org/10.3389/ti.2023.11752

In this issue of the journal, two papers are being published side by side regarding the discovery of occult life-threatening illnesses during the living donor kidney evaluation. The first, THE LIVING DONOR EVALUATION AS A LIFE-SAVING EVENT, looking at the Pittsburgh experience,waspublished in abstract formandpresented as aposter at the TTSmeeting in Berlin, 2012. The second, LIVINGKIDNEYDONOR EVALUATION IS ASSOCIATED WITH EARLY IDENTIFICATION OF LIFE-CHANGING DIAGNOSIS IN POTENTIALLY HEALTHY DONOR CANDIDATES, is based on an experience from Tubingen, Germany. Both papers describe an incidence of unsuspected cancer and other serious medical diseases in otherwise asymptomatic individuals who thought themselves to be healthy enough to donate a kidney. Taken together, these two experiences describe a similar phenomenon in the United States and Europe, that the work-up for the potential living donor is a potentially life-saving event. The donor is likely to be disqualified to donate, but the discovery of a cancer or an important medical problem, while unusual, is likely to lead to an earlier diagnosis and more successful definitive treatment/management of the surgical or medical problem. This potential benefit needs to be factored

This retrospective review of the largest United States kidney exchange reports characteristics, utilization, and recipient outcomes of kidneys with simple compared to complex anatomy and extrapolates reluctance to accept these kidneys. Of 3105 transplants performed, only 12.8% were right kidneys and 23.1% had multiple renal arteries. 59.3% of centers used fewer right kidneys than expected and 12.1% transplanted zero right kidneys or kidneys with more than 1 artery. Five centers transplanted a third of these kidneys (35.8% of right kidneys and 36.7% of kidneys with multiple renal arteries). 22.5% and 25.5% of centers currently will not entertain a match offer for a left or right kidney with more than one artery, respectively. There were no significant differences in all-cause graft failure or death-censored graft loss for kidneys with multiple arteries, and a very small increased risk of graft failure for right kidneys versus left of limited clinical relevance for most recipients. Kidneys with complex anatomy can be used with excellent outcomes at many centers. Variation in use (lack of demand) for these kidneys reduces the number of transplants, so systems to facilitate use could increase demand. We cannot know how many donors are turned away because perceived demand is limited.

Increasing numbers of compatible pairs are choosing to enter paired exchange programs, but motivations, outcomes, and system‐level effects of participation are not well described. Using a linkage of the Scientific Registry of Transplant Recipients and National Kidney Registry, we compared outcomes of traditional (originally incompatible) recipients to originally compatible recipients using the Kaplan–Meier method. We identified 154 compatible pairs. Most pairs sought to improve HLA matching. Compared to the original donor, actual donors were younger (39 vs. 50 years, p < .001), less often female (52% vs. 68%, p < .01), higher BMI (27 vs. 25 kg/m², p = .03), less frequently blood type O (36% vs. 80%, p < .001), and had higher eGFR (99 vs. 94 ml/min/1.73 m², p = .02), with a better LKDPI (median 7 vs. 22, p < .001). We observed no differences in graft failure or mortality. Compatible pairs made 280 additional transplants possible, many in highly sensitized recipients with long wait times. Compatible pair recipients derived several benefits from paired exchange, including better donor quality. Living donor pairs should receive counseling regarding all options available, including kidney paired donation. As more compatible pairs choose to enter exchange programs, consideration should be given to optimizing compatible pair and hard‐to‐transplant recipient outcomes.

Nondirected kidney donors can initiate living donor chains that end to patients on the waitlist. We compared 749 National Kidney Registry (NKR) waitlist chain end transplants to other transplants from the NKR and the Scientific Registry of Transplant Recipients between February 2008 and September 2020. Compared to other NKR recipients, chain end recipients were more often older (53 vs. 52 years), black (32% vs. 15%), publicly insured (71% vs. 46%), and spent longer on dialysis (3.0 vs. 1.0 years). Similar differences were noted between chain end recipients and non-NKR living donor recipients. Black patients received chain end kidneys at a rate approaching that of deceased donor kidneys (32% vs. 34%). Chain end donors were older (52 vs. 44 years) with slightly lower glomerular filtration rates (93 vs. 98 ml/min/1.73 m2 ) than other NKR donors. Chain end recipients had elevated risk of graft failure and mortality compared to control living donor recipients (both p < .01) but lower graft failure (p = .03) and mortality (p < .001) compared to deceased donor recipients. Sharing nondirected donors among a multicenter network may improve the diversity of waitlist patients who benefit from living donation.

BACKGROUND AND OBJECTIVES:In the United States, kidney paired donation networks have facilitated an increasing proportion of kidney transplants annually, but transplant outcome differences beyond 5 years between paired donation and other living donor kidney transplant recipients have not been well described. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS:Using registry-linked data, we compared National Kidney Registry (n=2363) recipients to control kidney transplant recipients (n=54,497) (February 2008 to December 2017). We estimated the risk of death-censored graft failure and mortality using inverse probability of treatment weighted Cox regression. The parsimonious model adjusted for recipient factors (age, sex, black, race, body mass index ≥30 kg/m2, diabetes, previous transplant, preemptive transplant, public insurance, hepatitis C, eGFR, antibody depleting induction therapy, year of transplant), donor factors (age, sex, Hispanic ethnicity, body mass index ≥30 kg/m2), and transplant factors (zero HLA mismatch). RESULTS:National Kidney Registry recipients were more likely to be women, black, older, on public insurance, have panel reactive antibodies >80%, spend longer on dialysis, and be previous transplant recipients. National Kidney Registry recipients were followed for a median 3.7 years (interquartile range, 2.1-5.6; maximum 10.9 years). National Kidney Registry recipients had similar graft failure (5% versus 6%; log-rank P=0.2) and mortality (9% versus 10%; log-rank P=0.4) incidence compared with controls during follow-up. After adjustment for donor, recipient, and transplant factors, there no detectable difference in graft failure (adjusted hazard ratio, 0.95; 95% confidence interval, 0.77 to 1.18; P=0.6) or mortality (adjusted hazard ratio, 0.86; 95% confidence interval, 0.70 to 1.07; P=0.2) between National Kidney Registry and control recipients. CONCLUSIONS:Even after transplanting patients with greater risk factors for worse post-transplant outcomes, nationalized paired donation results in equivalent outcomes when compared with control living donor kidney transplant recipients.

To the Editor: We read with interest the Editorial by Kulkarni and Ladin1Kulkarni S, Ladin K. Ethical principles governing organ transplantation apply to paired exchange programs [published online ahead of print 2020]. Am J Transplant. https://doi.org/10.1111/ajt.15807.Google Scholar raising concern about the use of end-chain kidneys within the framework of kidney paired donation (KPD) by the National Kidney Registry (NKR). The NKR represents a voluntary commitment by participating transplant centers to share patients, kidneys, medical acumen, surgical skills, hospital quality, transport logistics, organ preservation, and laboratory testing, each of which is essential to facilitate successful live donor transplantation. The requirements to share kidneys within the NKR are based on real-world experience that has evolved since the inception of the consortia in 2008. NKR decisions are based on ethics, and monitored by a medical board comprising physicians, surgeons, nurse coordinators, experts in histocompatibility, and donor patients, all with experience in end-stage renal disease(ESRD)/transplant practice. Medical board policies are developed by consensus building and conform to all existing rules mandated by Centers for Medicare & Medicaid Services and United Network for Organ Sharing. Medical board policies are known to participating members through monthly reports and published on the NKR website. The medical board prioritizes the repair of swap failures, especially those that result in a negative outcome for many patients. Our recent publication highlights how protections for early graft loss from donor injury was developed regardless of a center’s level of participation in the NKR.2Verbesey J, Thomas A, Ronin M, et al. Early graft losses in paired exchange: experience from 10 years of the National Kidney Registry[published online ahead of print 2020]. Am J Transplant. https://doi.org/10.1111/ajt.15778.Google Scholar It was designed to improve patient experience, instill trust, and support growth in KPD. The degree to which transplant centers establish comfort with these practices is no doubt learned over time with increasing participation. The greater the participation, the greater the opportunity to transplant more difficult to match pairs at a particular center. As an extreme example, without vigorous participation in KPD, how would a center find a kidney for a hyperimmunized O recipient, when none has been located after years of waiting on a deceased donor wait list, even with established priorities? Vigorous participation in KPD offers a way forward for those recipients with incompatible live donors stuck in the void of waiting for a kidney. As determined by the growth of the NKR, maximal participation includes entering both easier and more difficult to match pairs, accepting end of chain offers that may be less desirable (by age, anatomy, or blood group), entering compatible pairs supporting advanced donation, and entering all nondirected donors into the system. These have been the building blocks for “all in” centers. The goal is always to support the precept “a center gives a kidney a center gets a kidney back.” It is not an ethical conflict injustice or lack of respect for personal decision-making when a center chooses to participate fully in KPD. Other centers may choose to limit their participation to lower levels of comfort with the program. Lower levels of participation, such as the withholding of blood group O nondirected donors for local center use, can be viewed as restricting opportunities for other incompatible pairs and thus be in conflict with the principle of distributive justice. It is difficult to support such practices with similar payback offers as those centers demonstrating a greater commitment and exhibiting more altruistic behavior. It was always assumed and has been clearly demonstrated in actual practice that greater levels of participation become self-sustaining and generate enthusiasm in those centers as they expand their experience. The sharing of kidneys, especially when they unlock the opportunities to transplant difficult to match patients at other centers has been a remarkable feature of KPD, offering a gratification multiplier to nondirected donors supporting their decision to donate. Taken together these approaches have resulted in expanded opportunities for living donors and recipients that compare favorably to the demographic distribution in the United States.3Flechner SM Thomas AG Ronin M et al.The first 9 years of kidney paired donation through the national kidney registry: characteristics of donors and recipients compared to national live donor transplant registries.Am J Transplant. 2018; 18: 2730-2738Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar,4Leeser D Thomas AG Shaffer A et al.Excellent outcomes with challenging patients: 10 year outcomes in the national kidney registry.CJASN. 2020; 15: 228-237Crossref Scopus (16) Google Scholar The authors raise an important point about the level of transparency and consistency needed for our patients and the transplant community in KPD practice. There are many reasons that patients select a certain transplant center. These include, in part, prior experience, location, reputation, published outcomes, insurance network coverage, and so on. Over the years, some transplant centers have had earlier access to preferred drugs or technology, often due to risk taking in the developmental stages by such early adopters. At a center level, “all-in” KPD participation may be considered early adopter behavior for future standard practice. Perhaps, levels of KPD participation should be one factor that transplant donors and recipients receive when they are selecting a transplant center. Is it perhaps time for a national consensus on reporting KPD activity? Although debate and ethical considerations contained herein will continue, the results of the NKR must not be overshadowed. Transparency in program policies, outcomes, and decision-making as presented in this latest manuscript on early allograft losses are both in publication and ongoing. Donor and recipient’s needs are served while altruism, stewardship, collegiality, and cooperation shine and inclusion is the rule. The NKR and its medical board seek clarity for all programs and patients wishing to participate and welcome ongoing dialogue and collaboration. The authors of this manuscript have no conflicts of interest as described by the American Journal of Transplantation.

Cooperative kidney paired donation (KPD) networks account for an increasing proportion of all living donor kidney transplants in the United States. There are sparse data on the rate of primary nonfunction (PNF) losses and their consequences within KPD networks. We studied National Kidney Registry (NKR) transplants (February 14, 2009 to December 31, 2017) and quantified PNF, graft loss within 30 days of transplantation, and graft losses in the first-year posttransplant and assessed potential risk factors. Of 2364 transplants, there were 38 grafts (1.6%) lost within the first year, 13 (0.5%) with PNF. When compared to functioning grafts, there were no clinically significant differences in blood type compatibility, degree of HLA mismatch, number of veins/arteries, cold ischemia, and travel times. Of 13 PNF cases, 2 were due to early venous thrombosis, 2 to arterial thrombosis, and 2 to failure of desensitization and development of antibody-mediated rejection (AMR). Given the low rate of PNF, the NKR created a policy to allocate chain-end kidneys to recipients with PNF following event review and attributable to surgical issues of donor nephrectomy. It is expected that demonstration of low incidence of poor early graft outcomes and the presence of a "safety net" would further encourage program participation in national KPD.

The National Kidney Registry (NKR) Advanced Donation Program enables living donors the opportunity to donate altruistically, or in advance of a potential recipient's transplant, and to receive a voucher that can be redeemed for a future transplant facilitated by the NKR. Family vouchers allow a donor to identify multiple individuals within their immediate family, with the first person in that group in need of a transplant being prioritized to receive a kidney. An increase in vouchers introduces concerns that demand for future voucher redemptions could exceed the supply of available donors and kidneys. A Monte Carlo simulation model was constructed to estimate the annual number of voucher redemptions relative to the number of kidneys available over a 50-year time horizon under several projected scenarios for growth of the program. In all simulated scenarios, the number of available kidneys exceeded voucher redemptions every year. While not able to account for all real-life scenarios, this simulation study found that the NKR should be able to satisfy the likely redemption of increasing numbers of vouchers under a range of possible scenarios over a 50-year time horizon. This modeling exercise suggests that a donor family's future needs can be satisfied through the voucher program.

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation & Vascular Surgery I (PD54)1 Apr 2019PD54-02 ASSESSING THE EFFECT OF RENAL AUTOTRANSPLANT ON CHRONIC KIDNEY PAIN USING A VALIDATED PAIN QUESTIONNAIRE Molly DeWitt-Foy*, Mohamed Eltemamy, Rathika Ramkumar, Alyssa Crow, Tianming Gao, Alvin Wee, Stuart Flechner, and Venkatesh Krishnamurthi Molly DeWitt-Foy*Molly DeWitt-Foy* More articles by this author , Mohamed EltemamyMohamed Eltemamy More articles by this author , Rathika RamkumarRathika Ramkumar More articles by this author , Alyssa CrowAlyssa Crow More articles by this author , Tianming GaoTianming Gao More articles by this author , Alvin WeeAlvin Wee More articles by this author , Stuart FlechnerStuart Flechner More articles by this author , and Venkatesh KrishnamurthiVenkatesh Krishnamurthi More articles by this author View All Author Informationhttps://doi.org/10.1097/01.JU.0000557055.31863.59AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVES: Renal autotransplant (RA) may be used in select patients with chronic renal pain after all other means of pain control have been exhausted. Because this procedure is relatively rare, and because the indications and outcomes are subjective, success rates are difficult to assess. We aimed to determine the effectiveness of RA in the management of refractory chronic kidney pain. METHODS: Chart review was completed of all patients who underwent RA at our institution between 2004 and 2018 for an indication of chronic pain. Demographics, medical and surgical history, operative details, and complications were recorded. Patients were mailed an information sheet and those who agreed to participate completed a validated Brief Pain Inventory (BPI) that included assessment of pain and analgesic use. Univariate analysis was performed, and a linear regression model was fit to each univariate model. RESULTS: A total of 98 patients underwent 114 RA, of which 31 were completed for a primary indication of chronic pain. Pre and postoperative pain scores and medications were assessed via the BPI. The average age at surgery was 34 (range from 16 to 48 years). The mean change in average pain was -3.3 points. There was improvement in the average pain scores after 22 (71%) RA, no change after 6 (19.4%), and worse pain after 3 (<1%). Complete discontinuation of opioids was achieved in 21 patients, and 8 patients continued opioid medications at a lower dosage than prior to surgery. Postoperative pain medication information was not available for one patient. On univariate analysis ipsilateral renal surgery and recent renal function were significantly associated with change in mean pain score. The improvement in pain score for patients without a history of prior surgery on the same kidney was 3.31 units better than for those with a history of surgery on the same kidney (SE 1.17, p=0.009). Similarly, a lower creatinine at most recent follow up was associated with greater improvement in average pain score, by 4.02 units per each 1.0 mg/dL difference in creatinine (SE 1.85, p = 0.039). Preoperative psychiatry evaluation, successful preoperative pain block, operative time, gender, age, pain etiology, and use of ureteral stenting were not predictive of an improvement in postoperative pain score. CONCLUSIONS: We describe 31 RA completed at one institution for an indication of refractory chronic severe renal pain. The majority of patients had improvement in pain scores postoperatively, with 70% reporting discontinuation of all opioid medications. Higher postoperative creatinine and history of ipsilateral renal surgery were associated with less improvement in pain. Source of Funding: None Cleveland, OH© 2019 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 201Issue Supplement 4April 2019Page: e1005-e1005 Advertisement Copyright & Permissions© 2019 by American Urological Association Education and Research, Inc.MetricsAuthor Information Molly DeWitt-Foy* More articles by this author Mohamed Eltemamy More articles by this author Rathika Ramkumar More articles by this author Alyssa Crow More articles by this author Tianming Gao More articles by this author Alvin Wee More articles by this author Stuart Flechner More articles by this author Venkatesh Krishnamurthi More articles by this author Expand All Advertisement PDF downloadLoading ...

The decision to retransplant a patient who has lost a first renal allograft due to documented nonadherence (NA) to the medical regimen and/or their prescribed immunosuppressive drug therapy is one of the most vexing issues in the clinical practice of kidney transplantation. Very often documenting NA is challenging because circumstances and individual episodes are imprecise and involve both voluntary and involuntary behaviors. These episodes are further complicated by the commonly associated youth of these patients and a likely further need for transplantation even when adherence is observed. It is important to update the impact of NA on kidney transplant outcomes as best as possible and try to offer guidance on how to proceed when such patients are encountered. The present study from Australia offers a window into current outcomes when recipients who exhibited NA as the reason for first graft loss are retransplanted. They demonstrated that a selected group of such patients (perhaps 1/3) can have a successful outcome after retransplantation with heightened vigilance. Although further NA behavior was exhibited in many. Selecting these candidates remains more art than science, and new approaches should be shared among transplant centers worldwide.