Living donor kidney transplantation: Why potential donors and recipients do not achieve it. Malatya Algorithm

Trasplante de riñón de donante vivo: por qué los donantes y receptores potenciales no lo logran. Algoritmo de Malatya

Kidney transplantation is the best treatment for end-stage renal disease (ESRD).(1) Ninety thousand-three hundred and six kidney transplants were performed worldwide in 2017, 63.5% of them were from deceased donors.(2) Although living donations, especially in a preemptive settings, have excellent outcomes, the proportion of live donor kidney transplantations (LDKT) has continued to fall. Despite its benefits, LDKT is the least common treatment option in the United States and does not exceed 2.5% of all transplantations in Poland.(3-4) Live kidney donors (LKDs) may face short and long term complications, such as death, kidney complications requiring intervention, and an increased risk of cardiovascular and renal diseases.(3, 5-7) The proportion of kidney complications including readmission, re-operation, vascular complications, and other complications requiring intervention at 6 weeks, 6 months, and 1 year were 5.4%, 7.4% and 8.9%, respectively.(3) In some countries, the level of organ donation is not sufficient due to medical, cultural, ethical and socioeconomic factors, and LKDs constitute the main source of donor kidneys. LKDs are the only source of organ donor pools in 13 countries (Armenia, Ethiopia, Georgia, Honduras, Jordan, Iceland, Kenya, Mongolia, Nigeria, North Macedonia, Pakistan, Sudan and Syria).(2)

Live kidney donor transplantations accounted for most transplant procedures at our center. This article considers the Malatya Algorithm in the selection of potential donors and recipients for LDKTs and aims to improve the efficacy of transplant programs by evaluating the causes of cancellations in LDKTs.

Two hundred and eighty-seven kidney transplantations were performed between November 2010 and September 2019. LDKTs accounted for 72.1% of the procedures. A total of 364 potential donors and 338 recipients were evaluated for LDKT. One potential donor applied for 314 recipients, 2 potential donors applied for 22 recipients, and 3 potential donors applied for 2 recipients. Of the 338 recipients, 207 (61.24%) underwent LDKT. Table 3 presents the reasons for LDKT cancellation. Most of the reasons (58.2%) were recipient-related, immunologically incompatible pairs constituted 38.84% of all cancellations. Immunological problems have dropped below 20% in the last 2 years (). Among medical problems, which interfered with transplantation, 7 recipients had malign diseases, 4 had active infections, 2 had complicated cardiovascular diseases and one had active ulcerative colitis.

Table 3
The causes of cancellation in live donor kidney transplantation

Figure 1.
The causes of cancellation in live donor kidney transplantation over the last ten years

Among 364 potential donors, 55 (15.10%) were rejected for kidney donation, of whom 24 (43.6%) were men and 31 (56.3%) were women. The mean age was 48.78 (range: 24-75) years. Of the 55 donors, 22 (40%) had kidney problems, while 20 (36.3%) refused to proceed to donation. Twelve donors had medical problems such as complicated cardiovascular and pulmonary diseases (n=5), complicated diabetes mellitus (n=3), infectious (n=1) and malign diseases (n=2) and ankylosing spondylitis (n=1). One donor had a high body mass index.

Of 131 recipients, who did not proceed to LDKT, 77 were on dialysis (62 on hemodialysis, 15 on peritoneal dialysis). Forty-four recipients (33.5%) underwent LDKT afterward, 17 (38.6%) of them were performed at our center. Most of those transplantations (75%) proceeded with different donors (Table 4). Eighteen patients (21.4%; 18/84) died while on the transplant waiting list, five deaths occurred during the evaluation process.

Table 4.
The characteristics of 44 recipients who underwent LDKT afterward

There were 538 potential recipients on the waiting list of our center. Like national data, in which LKDs are the main source of organs (78.47%),(9) LDKTs accounted for 72% of the 287 transplantations performed between November 2010 and September 2019. Among patients, who were evaluated for LDKTs, 21.4% died while awaiting an organ. Given the fact that mortality is higher among patients who have no LKDs, the development of novel strategies must be encouraged to increase the availability of donor organs.

The election of recipients for LDKTs is a standard process and does not differ among centers. However, relative contraindications for LKDs vary among centers. Donor evaluation is essential not only to eliminate the risk of complications for the donors, but to also increase the survival of both graft and recipient. At our center, evaluation of LKDs was conducted according to the principles set out by the Amsterdam Forum and 308 of 364 potential donors (84.6%) were approved for donation.

Most of the disqualifications were recipient-related (58.2%), immunologically incompatible pairs constituted a significant percentage (38.84%) of the cancellations. Although desensitization protocols have been used in accordance with current knowledge, immunological problems have only dropped below 20% in the last 2 years. To overcome immunologic barriers the public should be informed about the superiority of preemptive transplantation. Timely referral of patients to the transplant centers by the nephrologist and/or dialysis center specialists may reduce immunologic risk by preventing unnecessary blood transfusions. The paired-kidney exchange program (center-based, national-based, and international-based, like those in Europe)(10) should be adopted and implemented. Future research should also be supported.

The deceased donor kidney transplantation (DDKT) was the promising cause for LDKT cancellations (2.15%). The kidney problems of potential donors (15.7%) and the medical problems of both potential donors and recipients (18.7%) were not preventable reasons for LDKT cancellation and were not diagnosed at the initial stage because complex and invasive tests were carried out only after simple and essential investigations had confirmed transplant suitability.

The pairs' refusal of LDKT and/or preferences for other centers may increase the economic burden on the healthcare system. Each center proceeds with its own evaluation of both recipients and donors independent of any previous evaluation process. In the current study, 10 potential recipients preferred to go to other centers, 20 potential donors and 7 recipients did not want to proceed to the evaluation stage, this decision by 37 pairs (26.6% of all cancellations) therefore resulted in unnecessary increases in health expenditures. In addition to driving up healthcare costs, those pairs increased the workload of the transplant team. It was not determined why 20 potential donors and 7 recipients did not wish to proceed to evaluation and why 10 potential recipients preferred treatment at other centers. The pairs, especially the potential donors, must give informed consent completely voluntarily. No pressure should ever be brought to bear to persuade the pairs to become participants in LDKT. They should be adequately informed about LDKTs and the performance of the transplant center through a variety of modalities. Our transplant center adheres strictly to these rules. The Government/Social Health Insurance covers organ transplantations for both donor and recipient. This is thought to significantly reduce the potential economic burden that the pairs would otherwise incur and may account for their preferring other centers.

In conclusion, to reduce educational barriers to organ donation, several strategies should be employed, including public and professional meetings. In cases of organ shortage, all barriers to LDKT should be removed as far as is possible to encourage pairs to participate in available programs. Timely referral of patients to the transplant centers by the nephrologist and/or dialysis center specialists must be ensured. Transplant centers should invest in programs suitable for their resources and patients, such as paired-kidney exchange (center-based, national-based, and international-based), desensitization protocols, future research etc.