Skip to main content

Advertisement

SpringerLink
Log in

Optimizing Efficiency in the Evaluation of Living Donor Candidates: Best Practices and Implications

  • Live Kidney Donation (K Lentine, Section Editor)
  • Published:
Current Transplantation Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

An inefficient living donor candidate evaluation process can be a barrier to timely living donor transplantation and optimal donor satisfaction. In this review, we examine the inefficiencies of the living kidney donor evaluation and make recommendations to optimize this process.

Recent Findings

There is increasing awareness that the living donor evaluation process is inefficient, but little research has been done to date. The time to complete the evaluation can be several or even many months. Avoidable delays can lead to dialysis initiation for pre-emptive transplant candidates, lengthen dialysis time for those patients on dialysis, and reduce donor satisfaction. Opportunities to improve efficiency include the choice, timing, sequencing of evaluation tests, procedures and consults, use of navigators, and monitoring of evaluation timeliness as a quality metric.

Summary

A more efficient evaluation is expected to result in better health outcomes for patients with kidney failure and incur substantial cost savings to the healthcare system.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance ••Of major importance

  1. Wolfe RA, Ashby VB, Milford EL, Ojo AO, Ettenger RE, Agodoa LYC, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med. 1999;341(23):1725–30. https://doi.org/10.1056/NEJM199912023412303.

    Article  CAS  PubMed  Google Scholar 

  2. Rabbat CG, Thorpe KE, Russell JD, Churchill DN. Comparison of mortality risk for dialysis patients and cadaveric first renal transplant recipients in Ontario, Canada. J Am Soc Nephrol. 2000;11(5):917–22.

    CAS  PubMed  Google Scholar 

  3. Ozcan H, Yucel A, Avşar UZ, et al. Kidney transplantation is superior to hemodialysis and peritoneal dialysis in terms of cognitive function, anxiety, and depression symptoms in chronic kidney disease. Transplant Proc. 2015;47(5):1348–51.

    Article  CAS  PubMed  Google Scholar 

  4. Whiting JF, Kiberd B, Kalo Z, Keown P, Roels L, Kjerulf M. Cost-effectiveness of organ donation: evaluating investment into donor action and other donor initiatives. Am J Transplant. 2004;4(4):569–73. https://doi.org/10.1111/j.1600-6143.2004.00373.x.

    Article  PubMed  Google Scholar 

  5. Tonelli M, Wiebe N, Knoll G, et al. Systematic review: kidney transplantation compared with dialysis in clinically relevant outcomes. Am J Transplant. 2011;11(10):2093–109.

    Article  CAS  PubMed  Google Scholar 

  6. Smith CR, Woodward RS, Cohen DS, et al. Cadaveric versus living donor kidney transplantation: a Medicare payment analysis. Transplantation. 2000;69(2):311–4. https://doi.org/10.1097/00007890-200001270-00020.

    Article  CAS  PubMed  Google Scholar 

  7. Nemati E, Einollahi B, Lesan Pezeshki M, Porfarziani V, Fattahi MR. Does kidney transplantation with deceased or living donor affect graft survival? Nephrourol Mon. 2014;6(4):e12182.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Moist LM, Fenton S, Kim JS, Gill JS, Ivis F, de Sa E, et al. Canadian organ replacement register (CORR): reflecting the past and embracing the future. Can J kidney Health Dis. 2014;1:26. https://doi.org/10.1186/s40697-014-0026-5.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Rodrigue JR, Schold JD, Mandelbrot DA. The decline in living kidney donation in the United States: random variation or cause for concern? Transplantation. 2013;96(9):767–73. https://doi.org/10.1097/TP.0b013e318298fa61.

    Article  PubMed  Google Scholar 

  10. Horvat LD, Shariff SZ, Garg AX. Global trends in the rates of living kidney donation. Kidney Int. 2009;75(10):1088–98. https://doi.org/10.1038/ki.2009.20.

    Article  PubMed  Google Scholar 

  11. U.S. Renal Data System. USRDS 2013 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States Natl Institutes Heal Natl Inst Diabetes Dig Kidney Dis 2013.

  12. Reese PP, Boudville N, Garg AX. Living kidney donation: outcomes, ethics, and uncertainty. Lancet. 2015;385(9981):2003–13. https://doi.org/10.1016/S0140-6736(14)62484-3.

    Article  PubMed  Google Scholar 

  13. Getchell LE, McKenzie SQ, Sontrop JM, Hayward JS, McCallum MK, Garg AX. Increasing the rate of living donor kidney transplantation in Ontario: donor- and recipient-identified barriers and solutions. Can J kidney Health Dis. 2017;4:205435811769866. https://doi.org/10.1177/2054358117698666.

    Article  Google Scholar 

  14. •• Graham JM, Courtney AE. The adoption of a one-day donor assessment model in a living kidney donor transplant program: a quality improvement project. Am J Kidney Dis November. 2017. https://doi.org/10.1053/j.ajkd.2017.07.013. This study reports on a quality improvement project to complete the living kidney donor evaluation in 1 day.

  15. •• Habbous S, Arnold J, Begen MA, et al. Duration of living kidney transplant donor evaluations: findings from 2 multi-center cohort studies. Am J Kidney Dis. 2018:(Accepted, Jan 11, 2018). This study reports the time to complete various steps in the living donor evaluation across multiple transplant centers.

  16. Sanner MA. The donation process of living kidney donors. Nephrol Dial Transplant. 2005;20(8):1707–13. https://doi.org/10.1093/ndt/gfh861.

    Article  PubMed  Google Scholar 

  17. Living Donor Kidney Transplantation 2020: A UK strategy. NHS. odt.nhs.uk/pdf/ldkt_2020_strategy.pdf. Accessed 30 Nov 2017.

  18. Thiessen C, Kulkarni S, Reese PP, Gordon EJ. A call for research on individuals who opt out of living kidney donation: challenges and opportunities. Transplantation. 2016;100(12):2527–32. https://doi.org/10.1097/TP.0000000000001408.

    Article  PubMed  Google Scholar 

  19. Moore DR, Feurer ID, Zaydfudim V, Hoy H, Zavala EY, Shaffer D, et al. Evaluation of living kidney donors: variables that affect donation. Prog Transplant. 2012;22(4):385–92. https://doi.org/10.7182/pit2012570.

    Article  PubMed  Google Scholar 

  20. Moore DR, Serur D, Rudow DL, Rodrigue JR, Hays R, Cooper M. Living donor kidney transplantation: improving efficiencies in live kidney donor evaluation-recommendations from a consensus conference. Clin J Am Soc Nephrol. 2015;10(9):1678–86. https://doi.org/10.2215/CJN.01040115.

    Article  PubMed  PubMed Central  Google Scholar 

  21. LaPointe Rudow D, Hays R, Baliga P, et al. Consensus conference on best practices in live kidney donation: recommendations to optimize education, access, and care. Am J Transplant. 2015;15(4):914–22.

    Article  CAS  PubMed  Google Scholar 

  22. • Lentine KL, Kasiske BL, Levey AS, et al. KDIGO clinical practice guideline on the evaluation and care of living kidney donors. Transplantation. 2017;101(8S Suppl 1):S7–S105. This is a set of evidence-based and expert-driven guidelines on living donor evaluations.

    Article  PubMed Central  Google Scholar 

  23. Spital A, Taylor JS. Primum non Nocere and living organ donation: a response to Dr. Klintmalm. Am J Transplant. 2008;8(6):1352–3. https://doi.org/10.1111/j.1600-6143.2008.02238.x.

    Article  CAS  PubMed  Google Scholar 

  24. Wright L, Faith K, Richardson R, Grant D. Ethical guidelines for the evaluation of living organ donors. Can J Surg. 2004;47(6):408–13.

    PubMed  PubMed Central  Google Scholar 

  25. Lapasia JB, Kong S, Busque S, Scandling JD, Chertow GM, Tan JC. Living donor evaluation and exclusion: the Stanford experience. Clin Transpl. 2011;25(5):697–704. https://doi.org/10.1111/j.1399-0012.2010.01336.x.

    Article  Google Scholar 

  26. Perlis N, Connelly M, D’A Honey JR, Pace KT, Stewart R. Evaluating potential live-renal donors: causes for rejection, deferral and planned procedure type, a single-centre experience. Can Urol Assoc J. 2013;7(1–2):41–5. https://doi.org/10.5489/cuaj.216.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Taylor LA, Bahreman N, Hayat MJ, Hoey F, Rajasekaran G, Segev DL. Living kidney donors and their family caregivers: developing an evidence-based educational and social support website. Prog Transplant. 2012;22(2):119–28. https://doi.org/10.7182/pit2012611.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Moore DR, Feurer ID, Zavala EY, Shaffer D, Karp S, Hoy H, et al. A web-based application for initial screening of living kidney donors: development, implementation and evaluation. Am J Transplant. 2013;13(2):450–7. https://doi.org/10.1111/j.1600-6143.2012.04340.x.

    Article  CAS  PubMed  Google Scholar 

  29. Richardson R, Connelly M, Dipchand C, Garg AX, Ghanekar A, Houde I, et al. Kidney paired donation protocol for participating donors 2014. Transplantation. 2015;99(10 Suppl 1):S1–S88. https://doi.org/10.1097/TP.0000000000000918.

    Article  PubMed  Google Scholar 

  30. Tierney J, Shaffer D. Transplantation of ABO A2 kidneys into O recipients: do IgM anti-A1 titers matter? Clin Transpl. 2015;29(4):379–82. https://doi.org/10.1111/ctr.12527.

    Article  Google Scholar 

  31. Crafter SR, Bell L, Foster BJ. Balancing organ quality, HLA-matching, and waiting times: impact of a pediatric priority allocation policy for deceased donor kidneys in Quebec. Transplantation. 2007;83(11):1411–5. https://doi.org/10.1097/01.tp.0000266580.19614.f7.

    Article  PubMed  Google Scholar 

  32. Mulley WR, Kanellis J. Understanding crossmatch testing in organ transplantation: a case-based guide for the general nephrologist. Nephrology. 2011;16(2):125–33. https://doi.org/10.1111/j.1440-1797.2010.01414.x.

    Article  PubMed  Google Scholar 

  33. Winters JL, Gloor JM, Pineda AA, Stegall MD, Moore SB. Plasma exchange conditioning for ABO-incompatible renal transplantation. J Clin Apher. 2004;19(2):79–85. https://doi.org/10.1002/jca.20002.

    Article  CAS  PubMed  Google Scholar 

  34. Mierzejewska B, Durlik M, Lisik W, et al. Current approaches in national kidney paired donation programs. Ann Transplant. 2013;18:112–24.

    Article  PubMed  Google Scholar 

  35. Reikie BA, Kroczak T, McGregor TB. Challenges for the travelling donor: variability between donor workup and donor surgery in the Canadian kidney paired exchange program. Transplant Proc. 2017;49(6):1232–6.

    Article  CAS  PubMed  Google Scholar 

  36. Ashlagi I, Gilchrist DS, Roth AE, Rees MA. Nonsimultaneous chains and dominos in kidney- paired donation-revisited. Am J Transplant. 2011;11(5):984–94. https://doi.org/10.1111/j.1600-6143.2011.03481.x.

    Article  CAS  PubMed  Google Scholar 

  37. Gentry SE, Montgomery RA, Segev DL. Kidney paired donation: fundamentals, limitations, and expansions. Am J Kidney Dis. 2011;57(1):144–51. https://doi.org/10.1053/j.ajkd.2010.10.005.

    Article  PubMed  Google Scholar 

  38. Bray M, Wang W, Song PX-K, et al. Planning for uncertainty and fallbacks can increase the number of transplants in a kidney-paired donation program. Am J Transplant. 2015;15(10):2636–45.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  39. Ferrari P, Fidler S, Woodroffe C, Tassone G, D’Orsogna L. Comparison of time on the deceased donor kidney waitlist versus time on the kidney paired donation registry in the Australian program. Transpl Int. 2012;25(10):1026–31. https://doi.org/10.1111/j.1432-2277.2012.01541.x.

    Article  PubMed  Google Scholar 

  40. Allen RDM, Pleass HCC, Woodroffe C, Clayton PA, Ferrari P. Challenges of kidney paired donation transplants involving multiple donor and recipient surgeons across Australia. ANZ J Surg. 2016; https://doi.org/10.1111/ans.13517.

  41. Allen R, Pleass H, Clayton PA, Woodroffe C, Ferrari P. Outcomes of kidney paired donation transplants in relation to shipping and cold ischaemia time. Transpl Int. 2016;29(4):425–31. https://doi.org/10.1111/tri.12719.

    Article  CAS  PubMed  Google Scholar 

  42. Henderson ML, Gross JA. Living organ donation and informed consent in the United States: strategies to improve the process. J Law Med Ethics. 2017;45(1):66–76. https://doi.org/10.1177/1073110517703101.

    Article  PubMed  Google Scholar 

  43. • Lam NN, Lentine KL, Garg AX. Renal and cardiac assessment of living kidney donor candidates. Nat Rev Nephrol. 2017;13(7):420–8. https://doi.org/10.1038/nrneph.2017.43. This is a review of the renal and cardiac evaluation for living donor candidates, comparing guidelines and suggesting areas for efficiency improvement.

  44. Delanaye P, Schaeffner E, Ebert N, et al. Normal reference values for glomerular filtration rate: what do we really know? Nephrol Dial Transplant. 2012;27(7):2664–72.

    Article  PubMed  Google Scholar 

  45. Baxter GM. Imaging in renal transplantation. Ultrasound Q. 2003;19(3):123–38.

    Article  PubMed  Google Scholar 

  46. Cosgrove DO, Chan KE. Renal transplants: what ultrasound can and cannot do. Ultrasound Q. 2008;24(2):77–87. https://doi.org/10.1097/RUQ.0b013e31817c5e46.

    Article  PubMed  Google Scholar 

  47. Burgos FJ, Pascual J, Marcen R, García-Navas R, Gómez V, Ortuño J. The role of imaging techniques in renal transplantation. World J Urol. 2004;22(5):399–404. https://doi.org/10.1007/s00345-004-0412-1.

    Article  PubMed  Google Scholar 

  48. el-Diasty TA, Shokeir AA, el-Ghar MEA, Gad HM, Refaie AF, el-Din ABS. Contrast enhanced spiral computerized tomography in live kidney donors: a single session for anatomical and functional assessment. J Urol. 2004;171(1):31–4. https://doi.org/10.1097/01.ju.0000099784.52825.8e.

    Article  PubMed  Google Scholar 

  49. Kok NFM, Dols LFC, Hunink MGM, Alwayn IPJ, Tran KTC, Weimar W, et al. Complex vascular anatomy in live kidney donation: imaging and consequences for clinical outcome. Transplantation. 2008;85(12):1760–5. https://doi.org/10.1097/TP.0b013e318172802d.

    Article  PubMed  Google Scholar 

  50. Halleck F, Diederichs G, Koehlitz T, et al. Volume matters: CT-based renal cortex volume measurement in the evaluation of living kidney donors. Transpl Int. 2013;26(12):1208–16.

    Article  CAS  PubMed  Google Scholar 

  51. Herts BR, Sharma N, Lieber M, Freire M, Goldfarb DA, Poggio ED. Estimating glomerular filtration rate in kidney donors: a model constructed with renal volume measurements from donor CT scans. Radiology. 2009;252(1):109–16. https://doi.org/10.1148/radiol.2521081873.

    Article  PubMed  Google Scholar 

  52. Huang N, Foster MC, Lentine KL, Garg AX, Poggio ED, Kasiske BL, et al. Estimated GFR for living kidney donor evaluation. Am J Transplant. 2016;16(1):171–80. https://doi.org/10.1111/ajt.13540.

    Article  CAS  PubMed  Google Scholar 

  53. Gaillard F, Flamant M, Lemoine S, et al. Estimated or measured GFR in living kidney donors work-up? Am J Transplant. 2016;16(10):3024–32.

    Article  CAS  PubMed  Google Scholar 

  54. Rodrigue JR, Pavlakis M, Danovitch GM, et al. Evaluating living kidney donors: relationship types, psychosocial criteria, and consent processes at US transplant programs. Am J Transplant. 2007;7(10):2326–32.

    Article  CAS  PubMed  Google Scholar 

  55. Sullivan C, Leon JB, Sayre SS, et al. Impact of navigators on completion of steps in the kidney transplant process: a randomized, controlled trial. Clin J Am Soc Nephrol. 2012;7(10):1639–45. https://doi.org/10.2215/CJN.11731111.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Transplant Ambassador Program “brings the patients to the patients.” Can-SOLVE CKD. 2017. https://cansolveckd.ca/2017/09/26/bringing-the-patients-to-the-patients/. Accessed 13 Dec 2017.

  57. Jacobs C, Thomas C. Financial considerations in living organ donation. Prog Transplant. 2003;13(2):130–6. https://doi.org/10.1177/152692480301300210.

    Article  PubMed  Google Scholar 

  58. Klarenbach S, Gill JS, Knoll G, Caulfield T, Boudville N, Prasad GVR, et al. Economic consequences incurred by living kidney donors: a Canadian multi-center prospective study. Am J Transplant. 2014;14(4):916–22. https://doi.org/10.1111/ajt.12662.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  59. Tushla L, Rudow DL, Milton J, Rodrigue JR, Schold JD, Hays R. Living-donor kidney transplantation: reducing financial barriers to live kidney donation—recommendations from a consensus conference. Clin J Am Soc Nephrol. 2015;10(9):1696–702. https://doi.org/10.2215/CJN.01000115.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Tong A, Chapman JR, Wong G, Craig JC. Perspectives of transplant physicians and surgeons on reimbursement, compensation, and incentives for living kidney donors. Am J Kidney Dis. 2014;64(4):622–32. https://doi.org/10.1053/j.ajkd.2014.02.019.

    Article  PubMed  Google Scholar 

  61. Hays R, Rodrigue JR, Cohen D, Danovitch G, Matas A, Schold J, et al. Financial neutrality for living organ donors: reasoning, rationale, definitions, and implementation strategies. Am J Transplant. 2016;16(7):1973–81. https://doi.org/10.1111/ajt.13813.

    Article  CAS  PubMed  Google Scholar 

  62. Warren PH, Gifford KA, Hong BA, Merion RM, Ojo AO. Development of the National Living Donor Assistance Center: reducing financial disincentives to living organ donation. Prog Transplant. 2014;24(1):76–81. https://doi.org/10.7182/pit2014593.

    Article  PubMed  PubMed Central  Google Scholar 

  63. Vlaicu S, Klarenbach S, Yang RC, Dempster T, Garg AX. Current Canadian initiatives to reimburse live organ donors for their non-medical expenses. Can J Public Health. 2007;98(6):481–3.

    PubMed  Google Scholar 

  64. CORR Annual statistics 2017. https://www.cihi.ca/en/corr-annual-statistics-2017. Accessed 17 July 2017.

  65. Hays R, Waterman AD. Improving preemptive transplant education to increase living donation rates: reaching patients earlier in their disease adjustment process. Prog Transplant. 2008;18(4):251–6. https://doi.org/10.1177/152692480801800407.

    Article  PubMed  Google Scholar 

  66. Jay CL, Dean PG, Helmick RA, Stegall MD. Reassessing preemptive kidney transplantation in the United States: are we making progress? Transplantation. 2016;100(5):1120–7. https://doi.org/10.1097/TP.0000000000000944.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  67. Kurowski A, Sańko-Resmer J, Wyzgał J, Kurowski A. Assessment of health-related quality of life of patients after kidney transplantation in comparison with hemodialysis and peritoneal dialysis. Ann Transplant. 2014;19:576–85.

    Article  PubMed  Google Scholar 

  68. Haller MC, Kainz A, Baer H, Oberbauer R. Dialysis vintage and outcomes after kidney transplantation: a retrospective cohort study. Clin J Am Soc Nephrol. 2017;12(1):122–30. https://doi.org/10.2215/CJN.04120416.

    Article  PubMed  Google Scholar 

  69. Okechukwu CN, Lopes AA, Stack AG, Feng S, Wolfe RA, Port FK. Impact of years of dialysis therapy on mortality risk and the characteristics of longer term dialysis survivors. Am J Kidney Dis. 2002;39(3):533–8. https://doi.org/10.1053/ajkd.2002.31403.

    Article  PubMed  Google Scholar 

  70. •• Habbous S, McArthur E, Begen MA, et al. Initiating maintenance dialysis prior to living kidney donor transplantation when a donor candidate evaluation is well underway. Transplantation. 2017:(accepted Dec 22, 2017). This study reports on the loss of potential preemptive transplants, as up to 1/3 of transplant recipients started dialysis despite having a living donor whose evaluation was at least 3 months underway.

  71. Wish JB. Introduction to quality improvement. Am J Kidney Dis 1998;32(6 Suppl 4):S161–4.

Download references

Funding

Steven Habbous is supported by the Canadian Institutes of Health Research Frederick Banting and Charles Best Canada Doctoral Scholarship. Dr. Amit Garg was supported by the Dr. Adam Linton Chair in Kidney Health Analytics and a Clinician Investigator Award from the Canadian Institutes of Health Research. Dr. Ngan N. Lam was supported by a Kidney Research Scientist Core Education and National Training Program (KRESCENT) New Investigator Award. Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (CAN-SOLVE CKD) is a patient-orientated research network to transform the care of people affected by kidney disease; CAN-SOLVE CKD was integral to highlighting this issue and providing some patient perspective.

Author information

Authors and Affiliations

  1. Department of Epidemiology and Biostatistics, Western University, London, ON, N6A 5C1, Canada

    Steven Habbous & Amit X. Garg

  2. Division of Nephrology, London Health Sciences Centre, London, ON, N6A5W9, Canada

    Amit X. Garg

  3. Institute for Clinical Evaluative Sciences, Toronto, ON, Canada

    Amit X. Garg

  4. Division of Nephrology, University of Alberta, Edmonton, AB, T6G 2G3, Canada

    Ngan N. Lam

Authors
  1. Steven Habbous
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Amit X. Garg
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ngan N. Lam
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ngan N. Lam.

Ethics declarations

Conflict of Interest

Dr. Garg received an investigator initiated award from Astellas, in partnership, to support a Canadian Institutes of Health Research grant in living kidney donation.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Live Kidney Donation

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Habbous, S., Garg, A.X. & Lam, N.N. Optimizing Efficiency in the Evaluation of Living Donor Candidates: Best Practices and Implications. Curr Transpl Rep 5, 55–63 (2018). https://doi.org/10.1007/s40472-018-0184-y

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40472-018-0184-y

Keywords

Search

Navigation