◐General Nephrology

(Living) donor evaluation and ECD, KDPI

Transplant約 6 分鐘8 個章節
  • KDIGO 2017 living donor指引〔PMID 28742762〕: 改以整體ESRD終身風險(含人口學與健康特徵綜合評估)評估donor(取代單一eGFR切點); HCV(+)→HCV(−)捐贈在DAA時代可行

1.Thorough history(CV, pulmonary, GI, GU, nephro, neuro, AIR, hema, onco, ID(含TOCC, exposures), metabolic, past medical history, drugs/substance, family history, psychosocial#

2.Lab evaluation類似recipient(劃線是NTUH有驗的)#

  • CBC/DC, Cre, BUN, electrolyte, iPTH, PT/PTT, GLUAC, HbA1C, lipid profiles, Alb, LFT, U/A, UPCR(KDIGO 2017: ≥300 mg/day 或 UACR≥30 mg/g 排除; 150–300 mg/day 個別化評估), 24hrs Ccr, (24-hour urine stone panel including calcium, oxalate, uric acid, citric acid, creatinine, phosphate, and sodium if history of nephrolithiasis), renal(high risk of RCC if RRT>10yrs), abdominal+pelvic echo(or CT/MRI)(會做abdominal MRI來看renal artery/vein的狀況), EKG, (TTE, thallium scan, CAG; depends on age and comorbidities(尤其S/S(+) or risk factors(+) or positive stress test; it is not clear whether screening asymptomatic patients prior to transplantation provides any benefit or which method of screening is optimal), (carotid Doppler), CXR, (lung functional test), (C+A+P CT), tumor markers/other cancer screen(+pap smears; +mammography(if>40 yrs old); +urine cytology if risk factors(+)如use of Endoxan, toxins=>cystourethrogram/cystoscopy if needed), MM titers, SOB, (EGD), (Colonoscopy(if >50 y/o)), screen brain MRA in ADPKD, VCUG/UDS if bladder dysfunction
    • 陳建嘉:有看過移植後donor的breast cancer跑到recipient身上的, 所以donor tumor surveilance要多詳細還未知
  • Blood typing with subtyping, Rh(not expressed on kidney tissue cell surfaces, 仍有一點影響), HLA(但隨著immunosuppression的進步, allograft survival with an unrelated, living donor is similar to that from a one-haplotype-matched, living donor)
  • Serology for MMR, HSV, VZV, EBV, CMV, HAV(why?), HBV, HCV, HTLV, HIV, BK virus, VDRL, TPHA
    • Toxoplasmosis, coccidioidomycosis, Strongyloides, Chagas, West Nile, Zika virus and histoplasmosis titers in endemic areas
  • PPD/IGRA
  • Pregnancy test(正在懷孕不能捐...)
  • Drug screen
  • Psychosocial evaluation(consult psychologists and social workers)

3.Contraindications by Organ Procurement and Transplant Network(OPTN)#

  • Age<18 y/o(台灣：捐贈者應為二十歲以上且有意思能力；十八歲以上得捐部分肝臟予五親等內親屬〔全國法規資料庫人體器官移植條例第8條〕) or mental retardation無法自己填同意書 or uncontrolled psychiatric disorder/drugs use
    • 【臺灣專科法規警語：特別法優於普通法】：自 2023 年 1 月 1 日起民法成年年齡雖下修為 18 歲，但《人體器官移植條例》為特別法，第 8 條第 1 項第 1 款維持明文規定活體捐腎須為二十歲以上且具有意思能力（18 歲以上僅得捐贈部分肝臟予五親等內親屬），民法 18 歲成年不得推翻器捐條例第 8 條門檻！
    • 台灣要五等血親內or配偶(要有子女or結婚兩年後or結婚一年後才診斷需要移植)才可捐
  • 懷疑donor被強迫
  • 懷疑非法交易
  • (relative)ABO/HLA incompatibility
    • 現在不是問題
  • BMI>35
  • eGFR<60 ml/min/1.73m^2
    • CKD EPi(Cre alone)公式會有誤差, 考慮用(核醫檢查) or (CKD EPi equation by Cre and cystatin C) or (Ccr)
    • eGFR 60-90ml/min/1.73m^2者應仔細評估ESRD風險, 權衡利弊
    • (也有人說GFR<80(Dr.蔡:<70~90, 但沒有絕對)不可捐)
  • Proteinuria(KDIGO 2017 架構: ≥300 mg/day 不可捐; 150–300 mg/day 個別化評估; urine Alb excretion>0.1g/d 需評估)
    • urine Alb excretion在0.03-0.1g/d者應仔細評估ESRD風險, 權衡利弊
  • Hematuria(>3-5 RBC/HPF)
    • 看是什麼原因, 若是GN, Alport's syndrome, TBMD, PCKD, cancer, stones(with abnormal metabolic surveillance)...等不可捐
      • TBMD也不行??因為其實也不是那麼benign...?
  • Nephrocalcinosis or bilateral kidney stones or recurrent nephrolithiasis(但history of stone with normal metabolic surveillance and no stone by image可當donor)
  • Marked urologic, renal vascular abnormalities(看外科)
  • Active infection
  • [cancer要"low" risk (<1%) of transmission or recurrence才可捐] Active malignancy, FH of RCC
  • Major comorbidities
  • (relative)DM or strong FH of DM
    • 目前建議type I DM不可捐, type II DM權衡利弊
  • Uncontrolled/resistant HTN or HTN with end organ damage(CV, LVH, retinopathy, proteinuria...)
  • Sickle cell disease不可捐; sickle cell trait 非絕對禁忌(KDIGO 2017: 個別化評估, 注意未來 ESRD/CV 風險與種族背景); coagulopathy 仍禁忌
  • Current pregnancy
  • 基本上三組living donor evaluation最後只有一組可過審查

4.F/U#

  • 1M, 3M, Q1y for 5y, then Q5y

5.Prognosis#

  • Living donor 15年 ESRD 風險：Muzaale(JAMA 2014; PMID 24519297)：活體捐贈者15年 ESRD 累積發生率為 30.8/10,000 (~0.3%)，顯著高於健康未捐贈對照組 3.9/10,000 (~0.04%)，但絕對風險增加幅度甚微〔PMID 24519297〕

    "Among live kidney donors, the estimated risk of ESRD at 15 years after donation was 30.8 per 10,000 donors compared with 3.9 per 10,000 in matched healthy non-donors (absolute risk increase, 26.9 per 10,000; P<0.001)." (Muzaale AD, et al. JAMA 2014; PMID 24519297)

  • 所以大概200-400人有一人會洗腎, 越年輕捐的人到死前越容易ESRD
  • 因為還是可能secondary FSGS due to hyperfiltration
  • 少一顆腎+hyperfiltration代償後, GFR約變成70%
  • OP mortality of living donor: 0.03%：Segev(JAMA 2010; PMID 20215610)：80,347名活體捐贈者90天內手術死亡率為 3.1/10,000 (0.031%)，長期死亡率與健康對照組無顯著差異〔PMID 20215610〕

    "In a national cohort of 80,347 live kidney donors in the United States, surgical mortality was 3.1 per 10,000 donors (0.031%), and long-term mortality was not significantly higher than that of matched healthy controls." (Segev DL, et al. JAMA 2010; PMID 20215610)

  • No increase of CV mortality or ACM after donation; 1.4% increase of gout
    • Reference:Understanding and Communicating Medical Risks for Living Kidney Donors: A Matter of Perspective(2017 JASN)

6.Expanded criteria donor(ECD)#

  • Definition(any)
    • Donor > 60 y/o
    • Donor 50-60 y/o with (≧2)
      • Death due to CVA
      • HTN
      • Terminal Cre>1.5
  • 70% greater risk of graft loss(vs. 10-39 y/o donor with terminal Cre<1.5 and death not due to CVA)

7.Kidney donor profile index(KDPI)#

  • 一種計算donor kidney品質的percentile(0-100%, 越低品質越好): US KAS 採 longevity-matching，將最優質 KDPI≤20% 之腎臟優先分配給預期存活最佳 EPTS≤20% 之候選受贈者〔PMID 38636649〕

8.Donation after cardiac death(DCD)#

  • outcomes比brain death捐的差一些

反向連結

General Nephrology · 腎專考試筆記 · 僅供學習參考