Donor Criteria Consensus Sought in Canada
MONTREAL—A team is hammering out consensus criteria across Canada for assessment and acceptance of donors involved in the Living Donor Paired Exchange (LDPE) registry run by Canadian Blood Services.
An important objective of these criteria is to streamline donor assessment so that donors who live far from recipients do not have to be assessed twice: once at the center closest to their home and again at the center where the recipient will undergo transplantation. This is a common dilemma in the LDPE, which pairs unrelated donors and recipients across the country.
The hope is that once the standards are set for the LDPE they will be applied to everyone who seeks to be a kidney donor in Canada. This is the first time such a consensus has been sought anywhere in the world. If a consensus is reached, centers in Canada would be able to ship donor kidneys to the recipients' transplant center.
“Right now there's a moratorium on shipping kidneys because Health Canada requires uniform assessment and acceptance criteria for the centers at which the donor is worked up and donating, and that's not necessarily a great situation for donors,” David Landsberg, MD, Chair of the Living Donor Advisory Committee (LDAC) that is spearheading the project, told attendees of the Canadian Society of Nephrology's 2013 annual meeting. “But as soon as we have national standards and everybody does the same assessment, we can start to ship the kidneys.”
National standards should also reduce the number of chains that collapse because donors do not meet the acceptance criteria of the center at which they were to donate, he pointed out. Between 2009 when the LDPE was created and April 3, 2013, 39 chains collapsed, only six of which were repaired, contributing to a total of 16 completed chains. In most of the cases the chain collapses were due to the recipient's center declining the donor.
The first phase in the harmonization process is arriving at a consensus for assessment and acceptance of living donors for the LDPE. Then they will adjust their consensus donor assessment and acceptance criteria based on the evidence included in the KDIGO (Kidney Disease – Improving Global Outcomes) guidelines for donor assessment and acceptance, which are slated to be completed in 2014, Dr. Landsberg said.
There are five working groups within LDAC, covering all of the areas of donor assessment and acceptance. All members of LDAC met in Toronto on April 11-12.
“We had a pretty dynamic engagement of differing opinions at that meeting,” Dr. Landsberg said. “The central areas in which there are currently disparate donor-acceptance criteria are impaired fasting glucose, future diabetes risk, hypertension, glomerular filtration rate (GFR) cutoffs, body mass index, and the cardiac and microscopic hematuria workups.
Among the areas in which the LDAC members have come to a consensus is that donors over age 50 who have hypertension that is well-controlled on one blood pressure medication and no evidence of target organ damage are acceptable donors. In addition, they agreed that having a body mass index over 35 is a contraindication to donation, with heavily muscled men being a possible exception. The GFR cutoffs (mL/min/1.73 m2) they set as being acceptable for donation are greater than 90 for donors aged 18-30 years, greater than 85 for those aged 31-40 years, greater than 80 for those aged 41-65 years, and greater than 75 for anyone over 65.
“We'll now package our recommendations, bring them to each transplant center, and get feedback and buy-in from the centers,” Dr. Landsberg said. “We'll be influenced and guided by the American guidelines when they come out, but we want to achieve consensus before that. I think that in three years the harmonization will be completed and we'll be shipping kidneys.”