Understanding the Complexities of Kidney Transplantation
224
Analyzing long-term graft survival, excellent results were observed using the grafts
previously selected by biopsy.
Graft survival in recipients of histologically evaluated kidneys did not differ significantly
from that of grafts from younger donors previously evaluated with biopsy. On the other
side, survivals were strongly superior to that of elder grafts not pre-operatively evaluated
with biopsy.
Adopting this score, long-term survival of single or dual kidney grafts from donors older
than 60 years of age were similarly excellent, showing that systematic hystological approach
may help to expand the donor-organ pool for kidney transplantation without a
contemporaneous lack of results .
2.2.2 Karpinski score
A New study based on histological aspects (Karpinski et al., 1999) was performed on 57
allografts procured by 34 elderly donors (age 60 years) with hypertension and/or vascular
disease.
Graft survival of these patients was compared with the results of 57 control recipients
selected to have similar baseline demographics but receiving transplants from younger
donors.
Donor renal pathology was scored 0-3 (none to severe disease) in four areas (Table 3):
Glomerulosclerosis, tubular atrophy, interstitial fibrosis and vascular disease.
Vascular disease was composed by two different parameters (e.g. arteriolar narrowing and arterial
sclerosis).
The number of sclerotic glomerules was expressed as a percent of the total number of
glomerules available for evaluation.
For the vascular lesions, both arteries were evaluated separately. However, for the final
vascular score, the most severe lesion of either arterioles or arteries determined the final
grade. Each of the 4 compartments was given a score from 0 to 3; the total score was
expressed out of 12.

0 none globally sclerosed
1+ < 20% global glomerulosclerosis
2+ 20 to 50% global glomerulosclerosis
3+ > 50% global glomerulosclerosis
Tubular score
0 absent
1+ < 20% of tubuli affected
2+ 20 to 50% of tubuli affected
3+ > 50% of tubuli affected
Interstitial score
0 absent
1+ < 20% of cortical parenchyma replaced by fibrous connective tissue
2+ 20 to 50% of cortical parenchyma replaced by fibrous connective tissue
3+ > 50% of cortical parenchyma replaced by fibrous connective tissue
Vascular score
Arteriolar narrowing (or hyaline arteriolosclerosis)##
0 absent
1+ increased wall thickness but to a degree that is less than the diameter of the lumen
2+ wall thickness that is equal or slightly greater to the diameter of the lumen
3+ wall thickness that far exceeds the diameter of the lumen with extreme luminal
narrowing or occlusion
Arterial sclerosis (or intimal fibrous thickening-fibroplasia)##
0 absent
1+ increased wall thickness but to a degree that is less than the diameter of the lumen
2+ wall thickness that is equal or slightly greater to the diameter of the lumen
3+ wall thickness that far exceeds the diameter of the lumen with extreme luminal
narrowing or occlusion
# Only biopsies with at least 20 glomerules are considered for slide evaluation. ## For the vascular
lesions, both arteries are evaluated separately. However, for the final vascular score, the most severe
lesion of either arterioles or arterie determines the final grade.

No. of
patients
Dialysis-based definitions
Need for dialysis in the first week after transplant 41 259.251
Need for dialysis in the first week after transplant once hyperacute
rejection, vascular and urinary tract complications were ruled out
2 760
Need for dialysis after transplant 2 737
Need for dialysis in the first 10 days after transplant 1 41
Absence of life-sustaining renal function that requires dialysis on two
or more occasions within the first week after transplant
1 547
Donor Quality Scoring Systems and
Early Renal Function Measurements in Kidney Transplantation
227
Definitions No. of
studies
No. of
patients
Need for dial
y
sis in the first 7 da
y
s after transplant with specific
exclusion of single early post-operative dialysis performed for
hyperkalemia
1 319
Return to maintenance hemodial
y
sis within the first 4 da

rejection
1 291
Combination
Failure of serum creatinine to fall below pre-transplant levels, within 1
week regardless of the urine output
1 158
Patients with rise in serum Cr at 6–8 h post-operativel
y
or <300 cc of
urine despite adequate volume and diuretics
1 143
Dial
y
sis requirement after transplant or a serum creatinine 150
mol/L at Day 8
1 112
Urine output <1 L in 24 h and <25% fall in serum creatinine from
baseline in first 24 h post-transplant
1 244
Urine output <75 mL/h in first 48 h or failure of serum Cr to decrease
by 10% in the first 48 h
1 66
Need for dial
y
sis in the first week after transplant or failure of serum
creatinine to decrease within 24 h after transplant
1 104
Table 4. Different DGF definitions. Taken from Yarlagadda et al., 2008 (with modifications).
In the same study, 10 proposal of diagnostic technique to identify DGF were also proposed
(Figure 8). Starting from these grounds, we have stratified the early measures of graft

Fig. 8. Different clinical conditions that present as early graft dysfunction. (A) Current
definitions do not allow us to distinguish DGF from other causes of graft dysfunction. (B)
With an improved definition and/or diagnostic technique patients with DGF can be
correctly classified. Taken from Yarlagadda et al., 2008.
Donor Quality Scoring Systems and
Early Renal Function Measurements in Kidney Transplantation
229

Fig. 9. Left: Decline in creatinine within 2 weeks post-KT. Right: graft survival curves. IGF:
initial good function (CCR7 > 70%), DGF: delayed graft function (need for dialysis), SGF:
scarce graft function (CCR7 70% no dialysis). Taken from Johnston et al., 2007.
3.2 Urine-based definition
UO7
Urine output at post-KT day 7 (UO7) was recently proposed (Lai et al., 2010).
Equation: UO7 = total urine output on day 7 post-transplantation (mL)/weight (kg)/24
hours.
UO7 presented an elevated power for the prediction of 1-year graft function: at ROC
analysis, UO7 presented an elevated area under the curve (0.811) (Figure 10). A cut-off value
of 500 mL/24 h showed high sensitivity (98.5%). Fig. 10. ROC curves for post-KT day 1 urine output (UO1) and day 7 urine output (UO7)
according to 1-year graft function (eGFR 30 mL/min/1.73 m2). Taken from Lai Q et al,
2009.

conditions: at least 1-day persistent oligoanuria ( 500 mL/24 h) during the first week
or an increased, unchanged, or decreased by 30% 7-day serum creatinine as compared
with the pre-KT value.
Donor Quality Scoring Systems and
Early Renal Function Measurements in Kidney Transplantation
231
4. Comparison among the scoring systems
Many researches have been performed on the identification of pre- or early post-operative
clinical predictors of graft function; however, the great majority of them were based on
isolated studies, usually in the populations from which they were initially derived.
Moreover, only a small number of papers have focalized on their attention on the
comparison among the different scoring systems.
For example, a previously reported study (Schold et al., 2005) compared preoperative scores
(ECD, DDS and DRS), showing DRS was the best model for the prediction of graft survival
at multivariable analysis. In the same period, another study (Nyberg et al., 2005) showed the
superiority of DDS respect to ECD.
The first comparative analysis of preoperative and early post-operative scores (Moore et al.,
2007) tested the ability of these clinical variables to predict suboptimal early function
variably assessed by: DGF (dialysis requirement during the first week), DGF duration, slow
graft function (creatinine > 3 mg/dl on day 5) and creatinine reduction ratio on day 2.
Multiple regression analysis was performed on 217 consecutive renal transplant recipients:
DGF nomogram, DDS and ECD were compared. All scoring systems showed associations
with early graft function, although only DGF nomogram remained statistically significant in
the multiple regression model. However, the overall utility of the DGF nomogram in DGF
prediction was moderate.
Two years later, a new comparative study (Moore et al., 2009) focalized on its attention on
the role of pre- and post-KT models for the prediction of graft dysfunction: primary
outcome measures were creatinine at 12 months and the development of chronic kidney
disease stage 4T. The preoperative donor quality scores tested were: ECD, DDS, DRS and
DGF nomogram: the postoperative early function measures were: dialysis requirement and Fig. 12. (A) Kaplan-Meier survival curves for a combined variable of Donor Risk Score (DRS)
and the extended definition of delayed graft function (extDGF) for time to stage 4T chronic
kidney disease in all patients. (B) Kaplan-Meier survival curves for a combined variable of
Donor Risk Score (DRS) and serum creatinine at day 5 (Cr5) for time to stage 4T chronic
kidney disease in patients not requiring dialysis immediately postoperatively. Taken from
Moore et al., 2009.
Donor Quality Scoring Systems and
Early Renal Function Measurements in Kidney Transplantation
233

Fig. 13. Diagram shows distribution of early graft function. dDGF, dialysis-based definition
of delayed graft function; fDGF (or extDGF), functional definition of delayed graft function.
Taken from Moore et al., 2010.
Among creatinine-based models, Cr5 represented the “best” marker of early graft function
in patients who didn’t undergo a post-KT dialysis (Moore et al., 2009).
Indeed, the influence of pre- or post-KT dialysis on creatinine measurements independent of
allograft excretory function was too great a confounder to allow meaningful interpretation
of these parameters also in dialyzed patients.
Exclusive (Lai et al., 2010) or combined (Schnuelle et al., 2007) use of UO could be of some
benefit in a better evaluation of these patients: however, more consistent large studies on
this field are still required.
No comparative studies among clinical and histological scores have been reported. Studies
are needed for a better understanding of the effective role of histological features and its
comparison with pre- and immediately post-KT variables.
5. Conclusion
Donor scores, histological scores and early postoperative measures of renal allograft

972-978.
Gonwa, TA.; Mai, ML.; Smith, LB.; Levy, MF.; Goldstein, RM. & al. (2002).
Immunosuppression for delayed or slow graft function in primary cadaveric renal
transplantation. Use of low dose tacrolimus therapy with post-operative
administration of anti-CD25 monoclonal antibody. Clinical Transplantation, Vol.16,
No.2, (April 2002), pp. 144-149.
Govani, MV.; Kwon, O.; Batiuk, TD.; Milgrom, ML. & Filo RS. (2002). Creatinine reduction
ratio and 24-hour creatinine excretion on posttransplant day two. Simple and
objective tools to define graft function. Journal of the American Society of Nephrology,
Vol.13, No.2, (June 2002), pp. 1645-1649.
Halloran, PF. & Hunsicker, LG. (2001) Delayed graft function. State of the art. Summit
meeting, Scottsdale, Arizona, USA, November 10-11, 2000. American Journal of
Transplantation, Vol.1, No.2, (July 2001), pp. 115-120.
Humar, A.; Payne, WD.; Sutherland, DE. & Matas, AJ. (2000). Clinical determinants of
multiple acute rejection episodes in kidney transplant recipients. Transplantation,
Vol.69, No.11, (June 2000), pp. 2357-2360.
Irish, WD.; McCollum, DA.; Tesi, RJ.; Owen, AB.; Brennan, DC. & al. (2003). Nomogram for
predicting the likelihood of delayed graft function in adult cadaveric renal
transplant recipients. Journal of the American Society of Nephrology, Vol.14, No.11,
(November 2003), pp. 2967-2974.
Irish, WD.; Ilsley, JN.; Schnitzler, MA.; Feng, S. & Brennan, DC. (2010). A risk prediction
model for delayed graft function in the current era of deceased donor renal
transplantation. American Journal of Transplantation, Vol.10, No.10, (October 2010),
pp. 2279-2286.
Johnston, O.; O’Kelly, P.; Spencer, S.; Donohoe, J.; Walshe, JJ. & al. (2006). Reduced graft
function (with or without dialysis) vs immediate graft function – A comparison of
longterm renal allograft survival. Nephrology Dialysis Transplantation, Vol.21, No.8,
(August 2006), pp. 2270-2274.
Karpinski, J.; Lajoie, G.; Cattran, D.; Fenton, S.; Zaltzman, J. et al. (1999). Outcome of kidney
transplantation from high-risk donors is determined by both structure and

Nyberg, SL.; Baskin-Bey, ES.; Kremers, W.; Prieto, M.; Henry, ML. & al. (2005). Improving
the prediction of donor kidney quality: deceased donor score and resistive indices.
Transplantation, Vol.80, No.7, (October 2005), pp. 925-929.
Pessione, F.; Cohen, S.; Durand, D.; Hourmant, M.; Kessler, M. & al. (2003). Multivariate
analysis of donor risk factors for graft survival in kidney transplantation.
Transplantation, Vol.75, No.3, (February 2003), pp. 361-367.
Pirani, CL. & Salinas-Madrigal L. (1975). Evaluation of percutaneous renal biopsy.; In:
Kidney pathology decentenial.; 1966-1975; SC. Sommers; Norwalk CT (Ed.) ;
Appleton-Century-Crofts: 1975.
Pretagostini, R.; Lai, Q.; Poli, L.; Levi Sandri, GB.; Travaglia, D. & al. (2009). Predictive
characteristics of delayed graft function after expanded and standard criteria donor
kidney transplantations. Transplantation Proceedings, Vol.41, No.4, (May 2009), pp.
1149-1151.
Rao, PS.; Schaubel, DE.; Guidinger, MK.; Andreoni, KA.; Wolfe, RA. & al. (2009). A
comprehensive risk quantification score for deceased donor kidneys: the kidney
donor risk index. Transplantation, Vol.88, No.2, (July 2009), pp. 231-236.
Remuzzi, G.; Grinyò, J.; Ruggenenti, P.; Beatini, M.; Cole, EH. & al. (1999). Early experience
with dual kidney transplantation in adults using expanded donor criteria. Double
Kidney Transplant Group (DKG). Journal of the American Society of Nephrology,
Vol.10, No.12, (December 1999), pp. 2591-2598.

Understanding the Complexities of Kidney Transplantation
236
Remuzzi, G.; Cravedi, P.; Perna, A.; Dimitrov, BD.; Turturro, M. & al. (2006). Long-term
outcome of renal transplantation from older donors. New England Journal of
Medicine, Vol.354, No.4, (January 2006), pp. 343-352.
Rodrigo, E.; Ruiz, JC.; Piñera, C.; Fernández-Fresnedo, G.; Escallada, R. & al. (2004).
Creatinine reduction ratio on post-transplant day two as criterion in defining
delayed graft function. American Journal of Transplantation, Vol.4, No.7, (July 2004),
pp. 1163-1169.

Department of Surgery,
Division of Transplantation,
University of Wisconsin,
U.S.A.
1. Introduction
In 2003, Krieger et al. from our group published a manuscript which investigated the use of
pancreas grafts for transplantation in different UNOS regions in the United States (1). It was
reported that the utilization of pancreata showed a wide variation depending on the region.
To approach some degree of standardization, we calculated the ratio of pancreata used for
transplantation with the number of livers procured and transplanted. Using the data from
our own institution, we had experienced that at least 70% of liver donors should provide
acceptable pancreas grafts. The results of the study, however, demonstrated that in some
regions, less than 20% of liver donors yielded pancreas grafts. Ensuing discussion revealed
that the lack of established criteria to predict the outcome of pancreas transplantation based
on available donor criteria was one of the reasons many centers, in particular less
experienced programs, were hesitant to accept donors other than those expected to provide
excellent pancreas grafts, and therefore, outcomes. Since then, few publications have
addressed the correlation between available donor criteria and short- or long-term
outcomes. One single center report analyzing outcomes in 61 simultaneous pancreas-kidney
transplants (SPK) was published in 1995 by Douzdjian et al. (2), and a multi-center
European report by Vinkers et al. (3) attempted to establish a donor quality score. During
the preparation of this manuscript, the online version of a large-scale analysis using data
from the Scientific Registry of Transplant Recipients (SRTR) in 9,401 transplants from 2000
to 2006 became available for review (4).
The purpose of this manuscript is to report the donor characteristics in 1,000 consecutively
performed SPK transplants at a single center. Pancreas-kidney retrieval and donor
management, as well as donor evaluation, were performed by the same organ procurement
organization (UW OPO). Retrieval was performed by surgeons trained at our institution.
Using only donor data easily available to OPO personnel and surgeons, we attempt here to
provide straightforward guidelines regarding the acceptability of pancreas grafts. A unique

Statistical Analysis
For statistical analysis, continuous variables were summarized by reporting mean and
standard deviation, and categorical variables were summarized by reporting percentages.
Event rates were estimated using methods of Kaplan and Meier and compared between
groups using a log rank test. P<0.05 was considered significant. All analyses were
performed using SAS statistical software (SAS Institute, Inc., Cary, NC).
3. Results
For reporting purposes, the highest value among donor laboratory values was chosen for
our calculations. BMI was determined by weight at the time of admission. Vasopressor use
was defined as the use of any vasopressor at any time from the patient’s admission to the
time of the retrieval procedure. As expected, long-term outcomes for pancreas graft survival
correlated with donor age (Figure 1). Donor age as previously reported by others appears to
be a major risk factor. As previously reported by Fernandez, et al., young donors do
extremely well despite higher technical difficulties (7). The youngest SPK donor in our
experience was three years of age. These grafts should be placed into smaller recipients. BMI
also had a significant correlation with inferior long-term outcomes (Figure 2). Obese donors,
even in the younger age groups, have pancreata which are infiltrated by fatty tissue and
respond poorly to preservation. In addition, fat necrosis after transplantation may lead to
intra-abdominal fluid collections and subsequent abscess formation. Nevertheless, on

Donor Characteristics in1,000 Consecutive SimultaneousPancreas-Kidney Transplants

239
occasion a donor with a high BMI may have a normal-appearing pancreas which can be
safely used for transplantation.
Laboratory determinations such as amylase and lipase (p>0.08) have not shown any
correlation with outcomes, as previously reported by Odorico et al. in a smaller cohort (8).
In addition, maximum glucose levels have no predictive value. Glucose values often reflect
the resuscitation effort and may be skewed by the co-administration of other drugs such as
corticosteroids. In an unpublished study by our group, determination of HbA

Recently, the online version of a manuscript by Axelrod et al. was available for review (10).
SRTR data from over 9,401 pancreas donors were used to develop a Pancreas Donor Risk
Index (PDRI). As pointed out by Krieger (1), the authors emphasize that pancreas utilization
shows great regional variation in the United States and that donor selection is widely used
as a key factor to successful pancreatic transplantation. The study is based on retrospective
data from multiple centers using a variety of procurement techniques.
The uniqueness of this manuscript is that universal procurement and retrieval techniques
were used and that the implant team primarily consisted only of a small group of uniformly
trained surgeons. Our message is that the donor surgeon should not be discouraged from

Understanding the Complexities of Kidney Transplantation

240
exploring a donor with high amylase, lipase and glucose levels. Also, the use of
vasopressors should not be a reason to decline. Data by Bellingham et al. demonstrate that
the same criteria apply in DCD pancreas donors (11).
Using these simplified criteria (age and BMI) for evaluating prospective pancreas donors,
together with visual inspection of the graft, suitable pancreas grafts can be chosen to achieve
excellent long-term functional outcomes (12). Adequately trained OPO personnel and
procurement surgeons will be able to use these simple guidelines in order to maximize
potential utilization of pancreas donors.

Mean (range)
Age (years) 29 (3-60)


241

Fig. 1. Age and pancreas transplant outcome Fig. 2. BMI and pancreas transplant outcome

Understanding the Complexities of Kidney Transplantation

242
5. References
[1] Krieger NR, Odorico JS, Heisey DM, et al. Underutilization of pancreas donors.
Transplantation 2003;75:1271-6.
[2] Douzdjian V, Gugliuzza KG, Fish JC. Multivariate analysis of donor and recipient risk
factors for renal and pancreas allograft failure after pancreas-kidney
transplantation. Transplant Proc 1995;27:3128-9.
[3] Vinkers MT, Rahmel AO, Slot MC, Smits JM, Schareck WD. How to recognize a suitable
pancreas donor: a Eurotransplant study of preprocurement factors. Transplant Proc
2008;40:1275-8.
[4] Scientific Registry of Transplant Recipients [Internet]. www.ustransplant.org
[5] Sollinger HW, Odorico JS, Knechtle SJ, D’Alessandro AM, Kalayoglu M, Pirsch JD.
Experience with 500 simultaneous pancreas-kidney transplants. Ann Surg
1998;228:284-96
[6] Sollinger HW, Odorico JS, Becker YT, D’Alessandro AM, Pirsch JD. One thousand
consecutive simultaneous pancreas-kidney transplants at a single center with 22-
year follow-up. Ann Surg 2009;250:618-30.
[7] Fernandez LA, Turgeon NA, Odorico JS, et al. Superior long-term results of
simultaneous pancreas-kidney transplantation from pediatric donors. Am J
Transplant 2004;4:2093-101.

empirically on a temporary basis and might vary by country, region and institute. Here, we
summarize newly-developed guideline for the indication of living kidney donation which is
internationally accepted such as the consensus of Amsterdam forum guideline (Delmonico
F. 2005) and OPTN/UNOS guideline (Table 1). Then they were compared with the results of
survey of US transplant center concerning evaluating living kidney donors (Mandelbrot DA,
et al. 2007).
2.1 Age
There is no description of age limitation of living kidney donor in Amsterdam forum
guideline. However age younger than 18 years old is attributed to contraindication in
OPTN/UNOS guideline. Half of the institute did not set the upper limit of age, although
widely accepted upper limit is 65 years old and some other institute set the cutoffs of 55,
60,70 and 75 years old (Mandelbrot DA, et al. 2007).
2.2 Obesity
Obesity was defined by a body mass index (BMI) of >30 kg/m
2
. All potential donors should
have BMI determined at initial evaluation because of data suggesting an association
between obesity and kidney disease. In most guideline, BMI above 35 kg/m
2
is thought to
be contraindication especially when other comorbid conditions are present. And obese
patients should be encouraged to lose weight before kidney donation and should not to
donate if they have other associated comorbid conditions. According to the survey of US
transplant centers, about one-half of programs use a BMI cutoff of 35 kg/m
2
, while 10%

Understanding the Complexities of Kidney Transplantation
244
exclude donors with BMI over 30 kg/m

2
BMI>35kg/m
2
Obesity
<18 years oldno descriptionAge
OPTN/UNOS (2007)Amsterudam Forum (2005)
BMI: Body mass index, GFR: Glomerular filtration rate, SD: Standard deviation, CCr:
Creatinine clearance, BP: Blood pressure, ABPM: Ambulatory blood pressure monitoring,
FBS: Fasting blood sugar, BS: Blood sugar

Table 1. Contraindication for living kidney donor
2.3 Renal function
The first substantial issue is which measurement should be adapted to estimate renal
function of potential living donors. Creatinine clearance calculated by 24-hour urine
collections has been used most frequently, however, may under- or overestimate glomerular
filtration rate (GFR) in patients with normal or near normal renal function. Estimated GFR
values are easy way but not standardized in this population. These methods may be
replaced or supplemented by inulin clearance in cases of borderline GFR determination
although it is a complicated method. In most program, a GFR<80 ml/minute or 2 standard
deviations below normal (based on age, gender, and BSA corrected to 1.73/m
2
) generally
preclude donation (Delmonico F. 2005). According to the survey of US transplant center, few
programs now have no specific cutoff, and no programs use 40 or 60 mL/min/1.73 m
2
as
cutoffs (Mandelbrot DA, et al. 2007).
2.4 Proteinuria
Proteinuria should be assessed as a standard part of the donor work up. Dipstick
measurements of proteinuria are not enough in the assessment of a prospective living

with a history of diabetes or fasting blood glucose ≥126 mg/dl on at least two occasions or 2-
hour glucose with OGTT ≥200 mg/dl are thought to be contraindication for living kidney
donation in Amsterdam forum guideline. OPTN/UNOS guideline adapts more strict cutoff
level where 2hr BS≥140 are considered to be contraindication for living kidney donation.
According to the survey of US transplant center, almost one-half of programs exclude
donors based on elevated fasting blood glucose (FBG), but various cutoffs are used to define
‘elevated’ (from >100 mg/dl to >120mg/dl). Most programs exclude based on abnormal
oral glucose tolerance test or Type II diabetes.
2.8 Dyslipidemia
Dyslipidemia should be included along with other risk factors in donor risk assessment, but
dyslipidemia alone does not generally exclude kidney donation.
2.9 History of malignancy
Living kidney donors should be screened by standard medical guidelines to exclude
malignancy. A prior history of malignancy may only be acceptable for donation if prior
treatment of the malignancy does not decrease renal reserve or place the donor at

Understanding the Complexities of Kidney Transplantation
246
increased risk for end stage renal disease (ESRD) and if prior treatment of malignancy
does not increase the operative risk of nephrectomy. The history of melanoma, renal or
urological malignancy, choriocarcinoma, hematologic malignancy, lung cancer, breast
cancer and monoclonal gammopathy generally precludes living donation (Pham, PC, et al
2007).
3. Being donor with medical abnormality
Due to the extreme shortage of organ donors worldwide, the indications for live kidney
donation have been expanding in terms of medical status, and now include patients with
mild hypertension, older age, and mild decline of renal function. Individuals with isolated
medical abnormalities (IMAs) are undergoing living donor nephrectomy more frequently.
Knowledge of health risks for these living donors is important for donor selection, informed
consent and follow-up. One systematical review with living kidney donors with preexisting


Perioperative and Long-Term Safety of Living Kidney Donors
247
tolerance test (75g-OGTT). Survival rates in the GI group up to 20 years were equivalent
to those in the non-GI group. None of the patients with diabetes mellitus (75g-OGTT: DM
pattern, n=27) had developed severe diabetic complications or ESRD at a mean follow-up
point of 88±71 (range, 14-225) months. These results suggested that individuals who have
GI without diabetic complication may be able to donate their kidney safely with little
major morbidity if strict evaluation is performed before transplant (Okamoto M, et al.
2010).
3.4 Transplant outcomes from isolated medical abnormality (IMA) donors
According to the meta-analysis of 12 studies, recipients of kidneys from older donors had
poorer 5-year patient and graft survival than recipients of kidneys from younger donors.
However, few transplant outcomes were described for other IMA, namely, obesity,
hypertension, reduced GFR, proteinuria and hematuria. This disconnect between donor
selection and a lack of knowledge of recipient outcomes should give transplant decision-
makers pause and sets an agenda for future research (Iordanous Y, et al. 2009).
4. Perioperative issue in living kidney donation
The first major concern regarding living kidney donation is the incidence of perioperative
deaths and serious surgical complications. Although it is considered to be a relatively safe
procedure, risk of death for the donor is generally estimated as being around 0.02-0.03%.
Perioperative mortality and complications of donor nephrectomy including pulmonary
embolism, pneumothorax, and less seriously, wound infection, unexplained fever and
urinary tract infection will be described below.
4.1 Perioperative mortality
Donor safety is of paramount importance in living donor transplantation. Yet, living donor
deaths actually occur (Ratner LE, et al. 2010). According to the survey of 171 United States
kidney transplant centers, two donors (0.02%) out of 10,828 living donors died from surgical
complications between 1999 and 2001 (Matas AJ, et al. 2003). However, in separate report
from the various transplant center, there are little report of a donor death (Siebels M,et al.