Utility of CT angiography for evaluation of living kidney donors

We reviewed our initial experience with helical computed tomography (CT) angiography in the evaluation of living kidney donors which, until now, has necessitated arteriography. Nineteen donors (12 women, 7 men) have had their renal anatomy evaluated solely by CT angiography preoperatively.All scans demonstrated normal collecting systems and single ureters. Five donors (26%) had supernumerary renal arteries. Fourteen donors had single, 4 donors had two, and 1 donor had three renal arteries. Helical CT demonstrated small polar vessels in several donors. Two donors (10%) had supernumerary renal veins. Accuracy of vascular anatomy defined on CT was 90% when confirmed at operation. Anatomically all CT findings were consistent with operative findings except in 1 donor who was found to have a 0.8 cm lesion near the renal hilum.At our institution, the total charges for selective renal arteriography are $3845 and for helical CT with three-dimensional (3-D) reconstruction are $1546. The amount of contrast dye (approximately 100 mL) is equivalent. Patients uniformly reported that the CT scan was a convenient and painless procedure.The accuracy of helical CT angiography is equivalent to arteriography in assessing renal vascular anatomy (with the additional benefit of imaging venous and parenchymal anatomy). Charges for helical CT are 59% less. There is greater patient acceptance and potentially less morbidity associated with the non-invasive nature of helical CT. We believe that CT angiography is the radiologic procedure of choice for the assessment of renal anatomy in potential living kidney donors.     

Multidetector CT angiography in live donor renal transplantation: experience from 156 consecutive cases at a single centre

The performance of multidetector computed tomography (CT) angiography was assessed in the pre-operative evaluation of live renal donors. Between July 1998 and March 2006, 156 consecutive patients underwent open donor nephrectomy following pre-operative multidetector CT angiography (MDCTA). Operative notes were compared with radiological reports and discrepancies identified. MDCTA missed five of 28 accessory arteries (four visible with hindsight), accuracy of 96%. Of 30 early-branching renal arteries, eight were missed (all visible with hindsight), accuracy 95%. MDCTA missed only one of 13 venous anomalies (accuracy 97%) and also missed the only duplicated collecting system: both were undetectable with hindsight. Following modifications to image acquisition and interpretation sensitivity, negative-predictive value and accuracy were significantly increased. The results were compared with pooled data from published studies of live donor imaging. This study and previous studies of MDCTA had improved sensitivity for arterial and venous anomalies over single detector CT angiography and MR angiography. We conclude that multidetector CT angiography is an accurate modality in the pre-operative evaluation of live renal donors. Regular communication between the transplant surgeon and the radiologist is paramount to improve reporting of surgically relevant anatomy. Mechanisms should exist for auditing and improving pre-operative imaging in any live donor programme.     

Intravenous digital subtraction angiography and helical computed tomography in evaluation of living renal donors

OBJECTIVES: The present study was carried out to evaluate the accuracy of helical computed tomography (CT) and intravenous digital subtraction angiography (IV-DSA) on anatomical assessment of renal vasculature for living renal donors. METHODS: Forty-two healthy potential renal donors were prospectively evaluated and 35 subsequently underwent donor nephrectomy after helical CT and IV-DSA evaluation. The vascular and non-vascular findings were compared between the findings on helical CT, IV-DSA and surgery. RESULTS: Ten prehilar branches and five accessory renal arteries were found at nephrectomy. Overall, operative findings agreed with the findings by IV-DSA in 89% and by helical CT in 83%. In delineating accessory arteries, IV-DSA had a sensitivity of 60% and specificity of 97%, whereas helical CT had a sensitivity of 40% and specificity of 100%. In delineating prehilar branches, IV-DSA had a sensitivity of 90% and specificity of 100%, whereas helical CT had a sensitivity of 70% and specificity of 100%. Accessory arteries and prehilar branches that were not detected by helical CT or IV-DSA, were less than 2 mm in diameter and did not require vascular reconstruction. Renal veins were delineated in 63% by IV-DSA, whereas they were clearly imaged by helical CT in all cases, including a case with a circumaortic renal vein. Non-vascular findings were obtained in 64% by helical CT, including two renal tumors. None of these findings were obtained by IV-DSA. CONCLUSION: Helical CT and IV-DSA provide comparably sufficient information on renal artery vasculature. However, helical CT provides significantly more information on venous and non-vascular findings as a single-imaging modality.     

Assessment of live kidney donors by magnetic resonance angiography: reliability and impact on outcomes

Abstract: Background:  Kidney allograft retrieval from live donors requires accurate determination of kidney anatomy prior to surgery, particularly the arterial supply. Traditionally, conventional angiography has been used to obtain this information. Magnetic resonance angiography (MRA) offers a non-invasive, cost-effective alternative, but has been considered to be less accurate. Despite this criticism, many centers have moved to MRA screening of potential kidney donors. The objective of this study is to evaluate our experience of the reliability of MRA in determining the arterial anatomy of living kidney donors as compared to the intra-operative findings.
Methods:  We performed a retrospective review of gadolinium-enhanced, ultra-fast, three-dimensional, spoiled gradient-echo MRA in live kidney donors in the Southern Alberta Transplant Program and compared these results with the intra-operative findings during nephrectomy, as the gold standard.
Results:  Of the 66 patients, an accessory renal artery was found intra-operatively in eight cases; two of which were erroneously diagnosed as normal by MRA. The negative predictive value for MRA was 0.97, false-negative rate was 0.25, and sensitivity was 0.75. No patient experienced side-effects from the MRA procedure. No donor needed conversion to open nephrectomy because of an undetected accessory renal artery. One allograft with an accessory renal artery developed thrombosis of the lower pole of the kidney despite arterial reconstruction. Kidney function in the recipient of this allograft was excellent and there was no urinary leak.
Conclusion:  In our hands, MRA determined the vascular anatomy of potential kidney donors with an acceptable negative predictive value of 97%.     

Screening for sickle trait among potential live kidney donors: policies and practices in US transplant centers.

Sickle cell trait is common in the United States (US) and associated with abnormalities of renal function. Little is known, however, about the potential risk of sickle cell trait to live kidney donors. Using an original questionnaire, we assessed the policies and practices of US renal transplant centers with regard to screening for sickle trait among potential live kidney donors. Fifty-four percent (137/252) of centers responded. Eighty-three percent (113/137) of transplant centers had no policy to screen donors for sickle trait. Thirty-four percent (46/135) of centers reported actually screening donors for sickle trait in practice. Thirty-seven percent (39/105) of centers reported excluding donors with sickle trait always or most of the time. High volume centers (>100 live donor transplants/year) were more likely to screen for sickle trait (Fisher's exact, P = 0.03), but not more likely to exclude potential donors with sickle trait from donating. Most US renal transplant centers do not screen donors for sickle trait. Wide variation is evident in center practice regarding exclusion of donors on the basis of sickle trait. Research into the potential impact of sickle trait on renal function after donation is needed to guide transplant clinicians.     

Preoperative evaluation of living kidney donors using multirow detector computed tomography: comparison with digital subtraction angiography and intraoperative findings

To assess the accuracy of multirow detector computed tomography (MDCT) for the evaluation of renal anatomy for preoperative donor assessment in living related kidney transplantation. MDCT-scans (4- and 16-slice-CT) of 51 consecutive living kidney donors (age, 51.6 +/- 9.7 years; range, 28-68 years) were analysed by three blinded observers and compared with digital subtraction angiography (DSA) and surgery. Contrast-enhanced MDCT was performed with 1 mm slice thickness reconstruction interval during arterial and venous phases. Supernumerary renal arteries, veins, early branching of vessels and abnormalities of the ureters were documented. The overall accuracy of computed tomography angiography (CTA) for detection and classification of surgically relevant arterial variants was 97% (99/102). The interpretation of 16-channel MDCT images was correct in all cases (accuracy, 100%), while the four-channel CTA had three incorrect results regarding the differentiation of early branching vessels from double renal arteries (accuracy, 93%). The overall accuracy of DSA was 91%. Renal vein abnormalities were correctly diagnosed with MDCT in 100% compared with 89% correct findings with DSA. There were three kidneys with incomplete ureter duplication, detected both with MDCT and DSA. MDCT demonstrated superior accuracy compared with non-selective DSA for the preoperative assessment of renal anatomy in living kidney donors; and for the distinction of supernumerary arteries versus early branching patterns, 16-channel CTA data were better than those of the four-channel system.     

亲属活体肾移植供者的安全性分析

目的 分析亲属活体肾移植供者手术前后的相关指标变化,探讨活体供者的安全性.方法对132例亲属活体供肾者进行心理和生理分析,包括尿常规、血生化、肾小球滤过率(GFR)、内生肌酐清除率(CCr)和生活质量等指标.结果 132例供肾者的生活质量评分与正常人群比较差异无统计学意义(P＞0.05).供肾切取术前供者血肌酐(SCr)为(78.33±15.94)μmol/L,术后7 d为(108.49±19.88)μmol/L(P=0.000);术后6个月为(112.47±20.38)μmol/L,与术后7 d比较差异无统计学意义(P=0.109).供肾切取术前供者CCr为(95.80±20.92)ml/min,术后7 d为(57.36±14.92)ml/min,与术前比较P=0.017;术后6个月为(65.49±8.25)ml/min,与术后7 d比较差异无统计学意义(P=0.619).术前双肾GFR为(74.08±18.51)ml/min,右肾GFR为(38.43±10.33)ml/min,供肾切取术后6个月保留右肾GFR为(56.49±13.01)ml/min,与术前双肾GFR比较,P=0.000;保留右肾GFR与术前自身比较代偿性增加47.0%.手术并发症包括脾脏包膜下出血1例,降结肠破裂1例,切口脂肪液化5例. 结论 术前对供肾者进行充分系统的医学心理学和生理学评估,严格履行风险告知义务,供受者术中规范操作,围手术期合理管理和建立严密的随访制度,可以有效提高亲属活体移植供肾者的心理和生理安全性.     

Risks and complications in 160 living kidney donors who underwent nephroureterectomy.

BACKGROUND: The rate of living donor renal transplantations has increased. However, in view of the possible complications, the question as to whether the condition of the recipient justifies operation of the donor still remains unanswered. The present retrospective study evaluates the perioperative and post-operative risks and complications for the donor at a single major transplantation centre. METHODS: From 1994 to 2001, 160 live donor nephroureterectomies were performed. The median age of living donors was 51 years (range 21-77 years); 19 patients were older than 61 years. After confirming blood group compatibility and negative cross-match, donors underwent an extensive medical and psychological examination. Comorbidities and anatomical features of the donor were evaluated and the impact they may have on the outcome was determined. The nephroureterectomies were performed transperitoneally, with the right kidney being preferred. Pre-operative, intraoperative and post-operative complications were documented. Serum creatinine levels as well as new-onset proteinuria or hypertension were used as criteria for assessing long-term renal function. RESULTS: Complications were observed in 41 donors: 35 were minor and six were major (splenectomy; revisions due to liver bleeding, incarcerated umbilical hernia or infected pancreatic pseudocyst; pneumothorax; and acute renal failure). No patient died. Multiple arteries (14 patients), significant renal artery stenosis (two patients) and additional risk factors (e.g. increased age and previous operations) did not affect the complication rate. In the post-operative follow-up period of 0.5-62 months (mean: 38 months), renal function remained stable in all donors. CONCLUSIONS: Living donor nephrectomy appears to be a safe intervention in specialized centres, where it entails a low morbidity for the donor. Even in high-risk donors, long-term complications were not observed.     

CT volumetry is superior to nuclear renography for prediction of residual kidney function in living donors

Living kidney donor evaluation commonly includes nuclear renography to assess split kidney function and computed tomography (CT) scan to evaluate anatomy. To streamline donor workup and minimize exposure to radioisotopes, we sought to assess the feasibility of using proportional kidney volume from CT volumetry in lieu of nuclear renography. We examined the correlation between techniques and assessed their ability to predict residual postoperative kidney function following live donor nephrectomy. In a cohort of 224 live kidney donors, we compared proportional kidney volume derived by CT volumetry with split kidney function derived from nuclear renography and found only modest correlation (left kidney R²=26.2%, right kidney R²=26.7%). In a subset of 88 live kidney donors with serum creatinine measured 6 months postoperatively, we compared observed estimated glomerular filtration rate (eGFR) at 6 months with predicted eGFR from preoperative imaging. Compared to nuclear renography, CT volumetry more closely approximated actual observed postoperative eGFR for Chronic Kidney Disease Epidemiology Collaboration (J‐test: P=.02, Cox–Pesaran test: P=.01) and Mayo formulas (J‐test: P=.004, Cox–Pesaran test: P<.001). These observations support the use of CT volumetry for estimation of split kidney function in healthy individuals with normal kidney function and morphology.     

Panning for gold: screening for potential live kidney donors.

BACKGROUND: Living donation is one method of addressing the gulf between supply and demand for kidney transplants. However, few manage to complete the extensive work up procedure. This study reviews the reasons for failure to complete the live donor renal assessment and suggests options, which may improve the situation. METHODS: Retrospective analysis of data collected over 5 years between 1997 and 2001 of all potential live donors entering the assessment programme. RESULTS: 189 (103 female, 86 male) potential donors entered the assessment process. Thirty-four (18%) actually donated comprising 17 (50%) siblings, nine (26%) parents and eight (24%) unrelated donors. Of the 155 who did not donate, 46 (30%) had blood group or immunological incompatibility and 42 (27%) withdrew. Twenty-three (15%) were medically unfit, mostly due to cardiovascular disease and 16 (10%) had insufficient renal function for safe donation. CONCLUSION: Live donor transplantation offers an attractive source of high quality organs, but considerable time and effort is required to realize this. Manipulation of immunological incompatibility, psychological assessment and counselling of those likely to withdraw may significantly enhance the yield. Support should also be provided for those unable to donate for whatever reason.     

Psychosocial evaluation of Chinese living related kidney donors

Zhao W‐Y, Zeng L, Zhu Y‐H, Wang L‐M, Zhou M‐S, Han S, Zhang L. Psychosocial evaluation of Chinese living related kidney donors.
Clin Transplant 2010: 24: 766–771. © 2009 John Wiley & Sons A/S. Abstract: Background: Although living kidney transplantation has numerous advantages over cadaveric transplantation, donor apprehension remains a problem. This study investigated psychosocial features and quality of life in Chinese living kidney donors after transplantation procedures. Methods: Participants were 84 donors interviewed during follow‐up after donation. Sociodemographic characteristics were evaluated by a 22‐item questionnaire. Social support, quality of life, depression, and anxiety were objectively measured with the Social Support Rating Scale for Chinese, the Short‐Form 36 Health Survey, the modified Beck Depression Inventory, and the Self‐Rating Anxiety Scale questionnaire, respectively. Results: All donors volunteered without pressure from families or recipients. Altruistic motives were the main impetus for donation, and donors had good social support. Living transplantation affected donors’ quality of life, with a slight negative effect on some physical aspects. There were no major depressive or anxiety disorders following donation. Conclusions: Living kidney donation was a generally positive experience without evidence of major psychological disturbance. However, considering the limited size and duration of our study, we recommend careful follow‐up of all donors. We also recommend provision of social support services and removal of financial disincentives for donors.     

Evaluation, selection, and follow-up of live kidney donors: a review of current practice in French renal transplant centres.

BACKGROUND: A resurgence of interest in the concept of live-donor renal transplantation has prompted a closer look at methods of live donor evaluation, selection, and follow-up. The aim of this study was to describe these methods in all 46 French renal transplant centres. METHODS: Questionnaires were sent to all chief renal physicians. RESULTS: The survey was completed by 78% of centres, which accounted for 95% of all live-donor renal transplants carried out in France in 1995 and 1996. There was a substantial variation in all three steps of live-donor management. For example, we observed variations in the screening for specific short- or long-term risk factors (especially cardiovascular or thrombotic risk factors and diabetes). In addition the exclusion criteria differed, especially the cut-off age for donation, which ranged from 45 to 75 years. The composition of teams evaluating and selecting potential donors and the role of the potential donors in the decision-making process varied greatly among centres. Finally, we observed less variation in the methods of donor follow-up. CONCLUSIONS: The current survey revealed a marked disparity in the management of live donors in France. It raises the question of whether these practices should be codified into a set of guidelines for live-donor transplantation.     

Comparison of accepted and unaccepted living kidney donors: one-center experience

Background: Kidney transplantation from living donors (LD) has stagnated in many countries. This study aimed to check whether correction of LD selection practice could increase the number of kidney transplantations.

Methods: From January 2003 to December 2012, 241 potential adult LD were evaluated in our hospital. Outcome (mortality and end-stage renal disease-ESRD) of accepted LD (182) was compared with unaccepted (59) donors.

Results: Mortality of LD was comparable with that for the standardized Serbian population (SMR?=?1.104; 95% CI (0.730–1.606). Among evaluated potential LD, almost every fourth had been unaccepted, but reasons were modifiable in 42.4% of them. In pre-donation period unaccepted donors were significantly older, measured glomerular filtration rate was lower, with higher 15-year and lifelong projected ESRD risks than accepted donors. Despite this, ten years outcome of both groups LD was similar: none of LD developed ESRD, 9.8% of accepted and 11.8% of unaccepted LD died (p?=?.803).

Conclusions: During an average of 101?months of follow-up mortality of accepted LD did not differ significantly as compared to the age standardized Serbian population and none of them developed ESRD. In examination of potential LD, the use of accurate and precise methods for kidney function estimation and the evaluation of risk for ESRD and mortality as well as treatment of modifiable contraindications for kidney donation are necessary.     

Economic and ethical impact of extrarenal findings on potential living kidney donor assessment with computed tomography angiography

To determine the prevalence and spectrum of extrarenal findings in a screening population of potential living kidney donors undergoing renal Computed tomography angiography (CTA) and evaluate their impact on subsequent patient management and imaging costs. Two radiologists retrospectively reviewed 175 consecutive renal CTA's performed for assessment of potential living kidney donors. Extrarenal radiological findings were recorded and classified according to high, medium, or low importance based on clinical relevance and the need for further investigations and/or treatment. The cost of additional imaging examinations was calculated using 2002 Canadian (British Columbia) reimbursements. There were 73 extrarenal findings in 71/175 (40.6%) of the potential kidney donors in the study population. Findings were categorized as of high clinical importance in 18 (10.3%) cases, including lung lesions, bowel tumors, and liver tumors and as medium importance in 31 (17.7%). Twenty-two (12.6%) individuals had findings categorized as low importance, probably of no clinical significance and requiring no follow-up. Further potential evaluation of the 49 patients (28%) with highly and moderately significant extrarenal findings may require an additional $6137 (mean $35.1 per each case of all the screened patients). Transplantation of a kidney from a living donor is an excellent alternative to cadaveric allografts. Potential living kidney donors are a highly selected population of healthy individuals, screened for significant past or current medical conditions before undergoing CTA. Despite this screening, potentially significant extrarenal findings (classified as high or medium importance) were revealed in 28% of patients. These patients may require further investigations and/or treatment. The referring physician and patient should be aware of such potentially high probability, which may require further nontransplant related evaluation and treatment. This has medical, legal, economic, and ethical implications.     

Evaluation of living related kidney donors in China: policies and practices in a transplant center

Zhao W‐Y, Zhang L, Han S, Zhu Y‐H, Wang L‐M, Zhou M‐S, Zeng L. Evaluation of living related kidney donors in China: policies and practices in a transplant center.
Clin Transplant 2010 DOI: 10.1111/j.1399‐0012.2010.01229.x.
© 2010 John Wiley & Sons A/S. Abstract: Background: Rigorous donor evaluation is essential for living related donor kidney transplantation (LRDKT). However, guidelines for living kidney donor evaluation are absent in China. The aim of this study is to describe the initial experience in the living kidney donor evaluation process in a single transplant center in China. Methods: The evaluation process of our center is sequentially divided into five steps: outpatient consultation and information, preliminary evaluation, comprehensive evaluation, final informed consent, and ethics committee oversight. Results: Between June 2007 and March 2009, 124 potential living donors were evaluated in our center, of whom 82 (66.1%) became effective donors and the remaining 42 (33.9%) were excluded. The exclusion reasons were related to clinical problems in 27 cases, psychosocial problems in seven cases, and suspected organ trading in eight cases. Conclusion: Although strongly forbidden by Chinese laws, organ trading remains a threat to the healthy development of LRDKT in China. To prohibit organ trading, the kinship between the donor and recipient should be carefully identified. Guidelines for living donor evaluation appropriate to the actual situation in China should be set up for the sake of safety and to protect the rights and interests of both donors and recipients.     

Magnetic resonance angiography for preoperative evaluation of potential kidney donors

BACKGROUND: Careful evaluation of the renovascular anatomy for living kidney donors is essential to optimize donor and recipient outcomes. Arteriography has been the standard for delineating the renovascular anatomy. However, this procedure is invasive. Magnetic resonance angiography (MRA) is an attractive, noninvasive alternative. The aim of this study was to evaluate the accuracy of MRA in potential living kidney donors. METHODS: A retrospective comparison of the preoperative MRA results with the intraoperative anatomy was performed in 189 living kidney donors. RESULTS: MRA interpretations correctly identified the vascular anatomy of the donor kidneys in 173 donors (91.5%). In the remaining 16 patients (8.5%), the MRA interpretation was inaccurate. In 10 patients, the MRA reported fewer arteries than the number encountered during the donor operation, whereas in six patients MRA reported more arteries than what found during operation. In seven patients, MRA supplied additional important anatomical information, including kidney size disparity, the presence of nephrolithiasis, the presence of a renal cyst, and renal artery stenosis. All kidneys were successfully transplanted. The misinterpretation of the MRA did not adversely affect the recipient outcome. CONCLUSION: The noninvasive MRA evaluation of donor renovascular anatomy is an acceptable substitute for traditional angiography.