Expert highlights factors to consider in risk assessment for living donors
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Contending there are limitations to applying transplant guidelines provided by Kidney Disease: Improving Global Outcomes, a speaker highlighted several factors to consider when assessing risk for GFR decline in potential donors.
“The KDIGO framework utilizes three components for deciding whether to accept or decline a donation [based on the risk posed to the donor],” Emilio D. Poggio, MD, of the Cleveland Clinic, told the audience at the virtual American Transplant Congress. “These include donor factors, demographic factors, and a calculation of risk that is associated with the development of [end-stage kidney disease] ESKD in the lifetime of a subject who does not donate a kidney.”
The practical challenges to applying these guidelines, according to Poggio, include the following:
- calculation of ESKD risk prior to donation does not account for non-measurable risk factors and may not accurately predict risk after donation;
- range of GFR levels for acceptable donors is wide (between 60 mL/min/1.73 m2 and 90 mL/min/1.73 m2); and
- age and gender are not considered when determining “normal” GFR.
Here, Poggio asked: “The question is, ‘What are normal GFR levels in kidney donors? Why can’t we use the same cutoffs for all donors?’”
Poggio emphasized that the same GFR cutoffs cannot be used for all potential donors because GFR has different implications for people based on age.
“This is an important concept because a GFR of 90 [mL/min/1.73 m2] might not be the same for a younger donor vs. an older donor,” he said.
Age, according to Poggio, plays a big role in lower GFR and greater GFR decline after donation, with study findings suggesting younger donor age is associated with better GFR after donation (even after 40 years).
In addition, research shows a family history of ESKD predicts those at greater risk for GFR decline following kidney donation.
“GFR drops more for those who have family history of ESKD, which is also highly related to age,” Poggio explained. “The older we are, the less likely we’ll recover kidney function and the more pronounced the drop is if there is a history of kidney disease.”
Other factors associated with a lower GFR after donation include new onset diabetes, hypertension and proteinuria; male gender, history of hypertension and higher BMI are associated with greater GFR decline.
Poggio said it is difficult to obtain a precise GFR measurement during risk assessment that will lead to accurate predictions of future GFR decline. He suggested that all clinically available methods (such as iothalamate GFR, creatinine clearance, serum creatinine and cystatin C) be applied in combination with each other and with the identified factors.
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Poggio ED. How low can you go? Assessing GFR in living kidney donor candidates. Presented at: American Transplant Congress; June 4 - June 9, 2021. (virtual meeting).
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