Guidelines for Living Donor Kidney Transplantation

291 Pages·2017·3.62 MB·English

by  Lisa Burnapp

The Voice of Transplantation in the UK
Guidelines for
Living Donor Kidney
Transplantation
Consultation Draft
Fourth Edition
January 2018
BTS LDKT Guidelines 4th Edition
Consultation Draft, December 2017
United Kingdom Guidelines
© British Transplantation Society www.bts.org.uk
BRITISH TRANSPLANTATION SOCIETY

UNITED KINGDOM GUIDELINES
FOR
LIVING DONOR KIDNEY TRANSPLANTATION

Fourth Edition
January 2018

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CONTENTS

1 INTRODUCTION AND OBJECTIVES 5
1.1 Introduction 5
1.2 Scope of the Guidelines 6
1.3 Process of Writing and Methodology 6
1.4 Editorial Committee 7
1.5 Contributing Authors 7
1.6 Disclaimer 10
1.7 Declarations of Interest 10
1.8 Grading of Recommendations 11
1.9 Abbreviations 11

2 LEGAL FRAMEWORK 15
2.1 The Human Tissue Act 2004 15
2.2 The Human Tissue Authority (HTA) 16
2.3 The European Union Organ Donation Directive 16
2.4 Consent for the Remova l of Organs from Living Donors 16
2.5 Types of Living Kidney Donation Permitted by the Legislation 17
2.6 Requirements for Transpl ants involving a Living Donor 18
2.7 Prohibition of Commerci al Dealings in Human Material 19
2.8 Reimbursement of Expenses 21
2.9 Exceptional Circumstances 21
2.10 The Human Tissue (Scotland) Act 2006 22

3 ETHICS 25
3.1 Ethics 25
3.2 Key Ethical Principles in Livin g Donor Transplantation 25
3.3 The Recipient Perspective 26
3.4 The Donor Perspective 27
3.5 The Transplant Team Perspective 28
3.6 Expanding the Living Donor Pool 29
3.7 The Child or You ng Person as a Living Donor 29
3.8 The British Transplantation S ociety (BTS) Ethics Committee 29

4 SUPPORTING AND INFORMING THE POTENTIAL DONOR 31
4.1 Confidentiality 32
4.2 Informing the Potential Donor 33
4.3 Informed Consent for Living Kidney Donation 34
4.4 Donor Identity 38
4.5 Patient Advocacy 39
4.6 Independent Translators 40
4.7 Psychological Issues 41
4.8 Death and Transplant Failure 44

5 DONOR EVALUATION 47
5.1 Introduction 47
5.2 Donor Evaluation: Summary 50
5.3 ABO Blood Gro uping and Crossmatch Testing 56
5.4 Medical Assessment 57
5.5 Assessment of Renal Function 62
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5.6 Donor Age 75
5.7 Donor Obesity 81
5.8 Hypertension in the Donor 86
5.9 Diabetes Mellitus 94
5.10 Cardiovascular Evaluation 101
5.11 Proteinuria 106
5.12 Non-Visible Haematuria 112
5.13 Pyuria 119
5.14 Infection in the Prospective Donor 121
5.15 Nephrolithiasis 135
5.16 Haematological Disease 142
5.17 Familial Renal Disease 147
5.18 Donor Malignancy 155

6 SURGERY: TECHNICAL ASPECTS, DONOR RISK AND
PERI-OPERATIVE CARE 167
6.1 Introduction 168
6.2 Assessment of Renal Anatomy 169
6.3 Peri-Operative Mortality 172
6.4 Peri-Operative Morbidity 172
6.5 Long-Term Mortality 174
6.6 Pre-operative Care and Preparation 174
6.7 Donor Nephrectomy 177

7 HISTOCOMPATIBILITY TESTING FOR LIVING DONOR KIDNEY
TRANSPLANTATION 187
7.1 Assessment of Donor -Recipient HLA Mismatch Status 189
7.2 Identification and Characterisation of Alloantibodies 190
7.3 Pre-transplant Donor -Recipient Crossmatch Test 192
7.4 Selection of Suitable Donor -Recipient Pairs 194
7.5 Antibody Incompatible Living Donor Transplantation 195

8 EXPANDING THE DONOR POOL 198
8.1 Paired/Pooled Living Donation 199
8.2 Altruistic Donation (Directed and Non -directed) 206
8.3 Antibody Incompatible Donation 215
8.4 Appendix: Mental Health Assessment of Altruistic Kidney Donors 218

9 LOGISTICAL CONSIDERATIONS 231
9.1 Reimbursement of Living Donor Expenses 231
9.2 Donors who are Non-UK Residents 233
9.3 Prisoners as Living Donors 234
9.4 Appendix: Template Letter for Potential Overseas Donors 239

10 DONOR FOLLOW-UP AND LONG-TERM OUTCOME 243
10.1 Long-Term Outcome Following Living Kidney Donation 244
10.2 Arrangements for Follow -up 247
10.3 The Unsuitable Donor 251
10.4 Pregnancy following Kidney Donation 252

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11 RECIPIENT OUTCOME AFTER LIVING DONOR KIDNEY
TRANSPLANTATION IN ADULTS 255
11.1 Living versus Deceased Donor Transplantation 256
11.2 Extended Criteria Living Donors 256
11.3 Transplantation versus Dialysis 257
11.4 High Risk Recipients 258

12 RECURRENT RENAL DISEASE 262
12.1 Introduction 263
12.2 Diabetic Nephropathy 264
12.3 Primary Focal Segmental Glomerulosclerosis 264
12.4 IgA Nephropathy 266
12.5 Membranous Nephropathy 266
12.6 Amyloidosis 267
12.7 Systemic Lupus Erythematosus 268
12.8 ANCA Associated Systemic Vasculitis 268
12.9 Goodpasture’s Disease 269
12.10 Alport Syndrome 269
12.11 Mesangiocapillary Glomerulonephritis 270
12.12 Haemolytic Uraemic Syndrome 272
12.13 Primary Hyperoxaluria 273
12.14 Cystinosis 274

13 LIVING DONOR KIDNEY TRANSPLANTATION IN CHILDREN 279
13.1 Introduction 279
13.2 Donor Selection 280
13.3 Recipient Considerations 281
13.4 Surgery 282

14 APPENDIX
14.1 Conflicts of Interest 286
14.2 Search Strategies 287

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1 INTRODUCTION AND OBJECTIVES

1.1 Introduction

Kidney transplantation from a living donor , when available, is the treatment of choice
for most patients with end stage renal disease, offering optimum patient and graft
survival and the chance to avoid long periods on the transplant waiting list. Living
donor transplantation also offers a small proportion of complex patients the
opportunity to benefit from a transplant that they might otherwise not have received
from the deceased donor waiting list; or, following entry into the UK Living Kidney
Sharing Schemes (UKLKSS), a better quality or better matched kidney that might
otherwise have been available.

For all these reasons, and the opportunity to expand the kidney donor pool, living
kidney donation has been vigorously promoted over the last 20 years.A t the time of
writing, approximately 1 in 3 kidney transplants performed in the UK are from living
donors. The latest national statistics show that there were 998 living kidney donor
transplants in the UK in 2016-17 (1). Of 926 adult donor transplants, 421 were
related, 232 were unrelated, 18 were HLA incompatible, 65 were ABO incompatible,
109 were paired/pooled, and 81 were altruistic donor transplants . 36% of the
patients transplanted from living donors were tranpslanted pre-emptively,
i.e. without a need for dialysis (1).

The expansion of the UKLKSS has represented a significant change in practice
since the last edition of this guidelin,e not least by reducing the needf or antibody-
and ABO-incompatible transplantation. In parallel, increasing confidence in the
safety of living kidney donation has permitted the expansion of the potential donor
pool; to date, the oldest living kidney donor in the UKw as aged 85.

Nonetheless, it must be recognised that living kidney donation carries some risk.
The welfare of the donor remains paramount, and vigilance in donor care and
management is essential to ensure that appropriate safeguards are in place to
protect individuals and to inspire public confidence. These guidelines are intended
to act as a resource for the transplant community, and to help promote the safe
practice of living donor kidney transplantation.

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1.2 Scope of the Guidelines

This guidance relates only to living donor kidney transplantation and reflects a
growing body of evidence, incorporating aspects of clinical practice that are relevant
to both adult and paediatric settings. These include the ethical and medico-legal
aspects of donor selection, medical and pre-operative donor evaluation,
identification of high risk donors, the management of complications, and expected
outcome. Scenarios that present an increased level of risk to the potential recipient,
such as antibody incompatible transplantation, recurrent disease and
transplantation in the context of other co-morbidities, are also included. In addition,
guidance is provided on the most appropriate investigations to be considered to
assist clinical decision-making, and the best surgical approaches when faced with
different clinical scenarios.

1.3 Process of Writing and Methodology

The original ‘UK Guidelines for Living Donor Kidney Transplantation’ were
commissioned by the British Transplantation Society (BTS) and the Renal
Association (RA) as part of a wider initiative to develop ‘Best Practice’ guidance for
clinicians involved in the area of transplantation. Initially published in 2000 (2) and
revised in 2005 (3) and 2011 (4), the guidelines have achieved international repute.
This fourth edition has used the framework of previous editions but has been
significantly updated in the light of new data and changing practice. It has been
produced with wide representation from UK colleagues and professional bodies and
patients involved in both donor and recipient management.

In updating these guidelines, areas of particular interest were identified with input
from clinicians and patient representatives in the relevant fields. A systematic review
of the relevant literature and synthesis of the available evidence was undertaken by
selected relevant clinical experts. This was followed by peer group appraisal and
expert review. Draft proposals were amended by the editorial committee and the
appropriate levels of evidence added to recommendations. Wider consultation with
the transplant community was undertaken by e-mail. The penultimate draft of the
document was placed on the BTS website in January 2018 for a four week period
of open consultation, to which patient and transplant groups were actively
encouraged to contribute. The final document was posted in March 2018.
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Where available, these guidelines are based on published evidence, and the
evidence and recommendations have been graded for strength except where the
published studies are descriptive. With a handful of exceptions, conference
presentations have not been included and the publication cut-off date for evidence
was July 2017.

It is anticipated that these guideli nes will nex t be revised in 2023 .

1.4 Editorial Committee

Dr Peter A Andrews MD FRCP
Consultant Nephrologist & Clinical Lead for Transplantation, SW Thames Renal &
Transplantation Unit, St Helier Hospital, Surrey
Reader in Renal Medicine, University of London
Chair of BTS Standards Committee

Ms Lisa Burnapp RN MA
Consultant Nurse, Living Donor Kidney Transplantation, Guy’s & St Thom as’ NHS
Foundation Trust, London
Lead Nurse - Living Donation, Organ Donation and Transplantation, NHS Blood and
Transplant (NHSBT)

1.5 Contributing Authors

Dr Peter Andrews MD FRCP, Consultant Nephrologist & Reader in Renal Medicine,
SW Thames Renal & Transplantation Unit, St Helier Hospital, Surr ey
Dr Richard Baker PhD FRCP, Consultant Nephrologist, St. James’Us niversity
Hospital, Leeds
Prof Simon Ball PhD FRCP, Consultant Nephrologist, Queen Elizabeth Hospital,
Birmingham
Dr Kate Bramham PhD MRCP, Consultant Nephrologist ,King’s College Hospital,
London
Mr Tim Brown FRCS, Consultant Transplant uSrgeon, BelfastC ity Hospital, Belfast .
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Ms Lisa Burnapp RN MA, Lead Nurse, Living Donation, NHS Blood and Transplant
& Consultant Nurse, Living Donor Kidney Transplantation, Guy’s & St Thomas’
NHS Foundation Trust, London
Prof Jamie Cavenagh MD FRCP FRCPath, Consultant Ha ematologist, Barts and
the London NHS Trust , London
Mr Marc Clancy PhD FRCS, Consultant Transplant Surgeon, Queen Elizabeth
Hospital, Glasgow
Dr Aisling Courtney MPhil FRCP, Consultant Nephrologist , Belfast City Hospital ,
Belfast
Dr Sam Dutta, MS FRCS, Consultant Transplant Surgeon, Nottingham City
Hospital, Nottingham
Dr Robert Elias MD FRCP, Consultant Nephrologist, King’s College Hospital NHS
Foundation Trust, London
Dr Anthony Fenton MRCP, Speciality Registrar, Queen Elizabeth Hospital,
Birmingham
Prof Susan Fuggle DPhil FRCPath, Consultant Clinical Scientist, Oxford Transplant
Centre, Oxford
Mr Keith Graetz DM FRCS, Consultant Transplant and General Surgeon,
Wessex Kidney Centre, Portsmouth
Dr Siân Griffin PhD FRCP, Consultant Nephrologist, University Hospital of Wales,
Cardiff
Dr Brendan Healy MRCP MRCPath, Consultant in Microbiology and Infectious
Diseases, University Hospital of Wales, Cardiff
Dr Rachel Hilton PhD FRCP, Consultant Nephrologist, Guy’s & St Thomas’ NHS
Foundation Trust, London
Dr Gareth Jones PhD FRCP, Consultant Nephrologist, Royal Free Hospital, London
Dr Graham Lipkin MD FRCP, Consultant Nephrologist, University Hospitals
Birmingham NHS Foundation Trust, Birmingham
Dr Adam Mclean DPhil FRCP, Consultant Nephrologist & Transplant Physician,
West London Renal & Transplant Centre, London
Prof Nizam Mamode MD FRCS, Professor of Transplant Surgery , Guy’s & St
Thomas’ NHS Foundation Trust, London
Ms Hanna Maple PhD MRCS, SpR in Transplant Surgery, Guy’s & St Thomas’ NHS
Foundation Trust, London
Dr Stephen Marks MRCP FRCPCH, Reader and Consultant in Paediatric
Nephrology, Great Ormond Street Hospital for Children NHS Foundation Tru,s t
London
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Dr Emma K Montgomery MRCP, Consultant Nephrologist, Freeman Hospital,
Newcastle
Dr Peter Nightingale PhD, Statistician, University Hospitals Birmingham NHS
Foundation Trust, Birmingham
Mr Jonathan Olsburgh PhD FRCS(Urol), Consultant Transplant & Urological
Surgeon, Guy’s & St Thomas’ NHS Foundation Trust, London
Professor Michael Peters MD FMedSci, Professor of Applied Physiology, Brighton
and Sussex Medical Schoo l, Brighton
Dr Michael Picton PhD FRCP, Consultant Nephrologist, Manchester Royal
Infirmary, Manchester
Dr Stephen Potts FRCP sych FRCPE, Consultant in Transplant Psychiatry, Royal
Infirmary of Edinburgh , Edinburgh
Dr Nicola Price DPhil FRCPath, Consultant Virologist, University Hospital of Wales,
Cardiff
Dr Richard Sandford PhD FRCP, Honorary Consultant in Medical Genetics,
University of Cambridge , Cambridge
Dr Alastair Santhouse FRCP FRCPsych , Consultant Psychiatrist in Psychological
Medicine, South London and Maudsley NHS Foundation Trust, London
Prof Neil Sheerin PhD MRCP, Professor of Nephrology, Newcastle University ,
Newcastle
Ms Lisa Silas RN MSc, Advanced Nurse Practitioner, Living Kidney Donation, ABO
and Recipient Workup, Guy’s & St Thomas’ NHS foundation Trust , London
Ms Karen Stevenson PhD FRCS , Consultant Transplant Surgeon , Queen Elizabeth
Hospital, Glasgow
Dr Craig Taylor PhD FRCPath, Director of Histocompatibility and Immunogenetics,
Cambridge University Hospital NHS Foundation Trust , Cambridge
Dr Raj Thuraisingham MD FRCP, Consultant Nephrologist, Barts and the London
NHS Trust, London
Dr Nicholas Torpey PhD FRCP, Consultant Nephrolog ist, Addenbrooke’s Hospital,
Cambridge
Dr Caroline Wroe, Consultant Nephrologist, PhD MRCP, South Tees Hospitals NHS
Foundation Trust, Middlesborough

Helpful contributions to draft versions of this guideline were also made by the
following:
Prof Derek Manas, Professor of Transplant Surgery, Newcastle
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