Member Center Guidelines
The following guidelines are for all NKR Member Centers.
Living Donor Evaluation
The purpose of the evaluation and consent of the living donor is to maintain the highest degree of safety and transparency for the living donor. As a baseline, the Amsterdam Guidelines and the OPTN standards will be used for donor evaluations. Donor evaluations must be completed before a donor can be activated in the NKR. The donor center evaluation policies should be followed by the donor center and not be directed by the recipient center since the donor center is responsible for donor care. The receiving center may ask for additional testing to clarify issues related to the quality of the kidney or to ensure there is minimal risk of infectious disease transmission. Requests for additional donor testing should be made immediately upon crossmatch and donor record review commencement in order to avoid swap failures.
- Member Centers are encouraged to use the NKR donor chart format when uploading a donor chart.
- Basic Evaluation:
- Complete history and physical
- Height, weight, BMI
- Blood pressure at two different settings on different days
- General laboratory tests to assess:
- hematologic status
- fasting lipids and glucose
- liver status
- Age-appropriate evaluation for cancer
- Donor workups must be repeated in their entirety, every 12 months, except for CT angio, unless the first CT angio was abnormal.
- Kidney Evaluation:
- Urinalysis with microscopy
- Urine culture if indicated
- In addition to obtaining a creatinine based eGFR (or cystatin C based eGFR), donors should have a 24hr urine for creatinine clearance, or a measured GFR.
- Anatomic testing. If 3D volume of each kidney is available, it should be submitted to the NKR database.
- If the creatinine clearance comes back < 85 ml/min/1.73m2 or significantly lower than expected for age, a mGFR is recommended.
- The recommended minimum acceptable creatinine clearance per 1.73m2 or mGFR per 1.73m2 for donors age 60 and under is 80 ml/min/1.73m2, and for donors over age 60 is 75 ml/min/1.73m2.
- If there is > 10% difference in donor kidney volume (or Mag3 renal scan function) between the two kidneys, then the smaller kidney will usually be offered for donation.
- Proteinuria can be measured either by 24 hour or spot urine collection. The recommended range for urine albumin/creatinine ratio is less than 30 mg/g, and for urine protein/creatinine ratio is less than 0.25 (or 24 hour protein excretion of 250mg).
- Tuberculosis screening:
- Chest X-ray (CXR)
- Criteria for high risk donors: (based on history and physical):
- Birth or residence in a TB endemic country
- Close contacts of individuals with TB (household or family members)
- Donors who work or have resided in homeless shelters, correctional facilities, nursing homes, or hospitals
- History of IV drug use
- Evidence of granulomas or healed TB on CXR
- For donors meeting the criteria for high risk, we recommend interferon-gamma release assays (IGRAs) or tuberculin skin test (TST).
- Recipient center may choose to have additional testing performed upon match offer acceptance.
- Infectious disease screening:
- HIV 1, 2
- HBsAg, HBcAB, HBsAB
- Depending upon time of year and location-associated risk:
- Trypanosoma cruzi
- West Nile virus
- Suggested evaluation for donors at risk for metabolic syndrome or diabetes:
- Uric acid
- Glucose tolerance testing
- Stone Disease:
Donors may have documented stone events by providers, historical stone events with no documentation, or asymptomatic stones detected during the donor evaluation. The non-contrast images of the donor CT scan are the best test for identifying stones. Recommend donor risk assessment for recurrence of stones with a timed urine collection for minerals.
Suggested absolute contraindication for renal donation:
- Documented recurrent urinary stone events, >2 in the prior 5 years.
- Metabolic stone disease such as cystinosis, oxalosis, or uric acid renal stones.
- Recurrent urinary tract infections with infection stones (usually struvite).
- Diffuse Nephrocalcinosis.
Suggested relative contraindications for renal donation: in principle the donor should not be left with a kidney stone in the retained kidney. 1-2mm calcifications of the renal pyramids (termed Randall’s Plaques) that are detected on a CT scan in an otherwise normal donor are of less concern than stones.
- 2 documented stone events.
- A solitary kidney stone that can be removed at the time of donor nephrectomy.
- Bilateral kidney stones
- Persistent hyperparathyroidism
- Persistent abnormal urinary excretion on timed urine collections after treatment:
- Low urinary Citrate
- Abnormal urine pH
Standard Voucher Donation
To ensure that the NKR can find the best-matched recipient for every kidney donated through the Standard Voucher Program, the following guidelines are in effect for all Member Centers, and must be confirmed prior to activation in the NKR system:
- Donation start date must be three weeks from activation
- Donation end date must be at least three weeks from start date
Post Donation Follow-Up and Donor Complications
A post-donation follow-up should follow the policy described in CMS Pub. 100-02, Chapter 11, section 140.9, including:
- Donors should be made aware of their donation options.
- It is the responsibility of the center to educate the donors. Centers should fully explain the donation process to the donor and let them know what to expect, before, during and after surgery.
- Centers should ensure that donors can get appropriate time off from work.
- Centers should determine the donor’s availability for surgery and accurately enter it into the NKR system.
- Centers should ensure the donor is updated on a timely basis regarding where they are in the workup process, results of all medical tests and when they are activated in the NKR program.
- The center should inform the donor of the Donor Shield support and protections.