In a paper published in the journal Transplantation, experts share new guidelines and a risk projection tool to offer better advice about comprehensive risk assessment and care for living kidney donors. The new recommendations evaluate factors like demographics, blood pressure and smoking as a whole, rather than in isolation. The guidelines are the culmination of many years’ work by medical specialists on the Kidney Disease: Improving Global Outcomes (KDIGO) international work group.

To date, clinical practice guidelines and regional policies recommended consideration of one risk factor at a time in the assessment of living donor candidates – for example, separate candidacy criteria are offered for blood pressure, obesity and smoking that regard each of these factors in isolation. The evidence supporting past recommendations is also limited by frequent foundation in data from general populations (whose baseline health status differs from healthy donors), often using surrogate endpoints. Ultimately, poor understanding of comprehensive risk has led to inconsistent donor selection practices.

This month, the KDIGO international work group published a new “Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors.” Developed by a work group of international practitioners and co–chaired by Krista Lentine, MD, PhD, professor of internal medicine at Saint Louis University and medical director of living donation at the SSM Health Transplant Center at Saint Louis University Hosptial, and Amit Garg, MD, PhD, professor of medicine at Western University in Ontario, Canada, the guideline advances a new framework for donor candidate evaluation grounded in the simultaneous consideration of the combined impact of each candidate’s profile of demographic (i.e., age, sex and race) and health characteristics (e.g., kidney function, blood pressure, body mass index, smoking status) on their risk of serious adverse outcomes after donation.

With the collaboration of the Chronic Kidney Disease Prognosis Consortium, original data analyses were undertaken to produce a “proof–in–concept” risk–prediction model for kidney failure in healthy persons tailored for the individual’s demographic and health profile. This model was published separately in the New England Journal of Medicine and is now available as an online risk projection tool (www.transplantmodels.com/esrdrisk).

“We believe this new framework changes the paradigm for quantitative risk assessment in the donor candidate evaluation and supports defensible shared decision–making,” said Lentine.

“Improving the safety and transparency of donor selection is critical for advancing living donation and transplantation within a defensible system of practice,” said Garg.

The guideline offers recommendations across the continuum of donation–related care including the psychosocial evaluation, approaches to the donation surgery, ethical and policy considerations, and post–donation follow–up. Importantly, the work group identified ongoing knowledge gaps and provides recommendations for future research.

“We see this work as starting point, and advocate strongly for continued efforts to improve the precision, tailoring and generalizability of prediction of all risks relevant to donors,” Garg notes.