List of Abbreviations
Hb – hemoglobin
HBV — hepatitis B virus
HCV – hepatitis C virus
HLA – human leukocyte antigen, human major histocompatibility complex
IgG – immunoglobulin G
IgM – immunoglobulin M
BP – blood pressure
ALT – alanine aminotransferase
AST – aspartate aminotransferase
aPTT – activated partial thromboplastin time
HIV – human immunodeficiency virus
WHO – World Health Organization
GGT – gamma-glutamyl transpeptidase
DNA – deoxyribonucleic acid
RRT – renal replacement therapy
BMI – body mass index
CT – computed tomography
LN — laparoscopic nephrectomy
NMU — nomenclature of medical services
PSA – prostate-specific antigen
PCR – polymerase chain reaction
GFR – glomerular filtration rate
ESRD – end-stage renal disease
US – ultrasound examination
CKD – chronic kidney disease
CRF – chronic renal failure
CMV — cytomegalovirus
EBV — Epstein-Barr virus
ECG – electrocardiography
EchoCG – echocardiography
Terms and Definitions
Living (related) donor — an individual aged 18 years or older, legally competent, who has given consent to provide and/or has provided during their lifetime their donor organ or part of an organ for transplantation purposes.
Allograft — a donor organ obtained from a human who is not an identical twin to the recipient, which has been transferred into the recipient's body via surgical operation.
Potential kidney recipient — a patient with stage 5 chronic kidney disease who has no contraindications to kidney transplantation and is included in the waiting list.
Living kidney donation is a medical technology that includes examination, decision-making regarding feasibility, surgical intervention, subsequent treatment, and rehabilitation aimed at obtaining a functionally and anatomically suitable kidney from a living donor and its subsequent transplantation to another person with stage 5 chronic kidney disease (CKD).
Kidney transplant recipient is a patient who has undergone kidney transplantation and is undergoing a comprehensive set of therapeutic measures aimed at preventing renal graft dysfunction caused by such pathological processes as rejection, recurrent pathology, infectious complications, nephrotoxic drug effects, and others.
End-stage renal disease (ESRD) is a pathological condition characterized by a glomerular filtration rate (GFR) of less than 15 ml/min/1.73 m2, which corresponds to stage 5 CKD.
Kidney transplantation is a medical technology aimed at replacing irreversibly lost renal function, which includes surgical intervention as an essential stage consisting of moving a kidney obtained from another person (donor) into the recipient's body with the restoration of blood supply and urine outflow (Medical Service Nomenclature: "Kidney transplantation").
Chronic kidney disease is kidney damage or a decrease in their function for 3 months or more due to various etiological factors, the anatomical basis of which is the replacement of normal anatomical structures with fibrosis, leading to their dysfunction. The disease is classified into 5 stages, which differ in patient management tactics and the risk of developing end-stage renal disease and cardiovascular complications.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
These guidelines describe the technologies for obtaining an anatomically and functionally sound donor organ (kidney) from a living related donor for subsequent transplantation, involving a comprehensive medical examination, establishing the feasibility of kidney retrieval, nephrectomy, subsequent treatment, clinical stabilization, and rehabilitation. The overarching goal is to provide information on the safest possible procedure for harvesting a kidney from a living donor. In the Russian Federation, a living donor can only be a close relative. According to the legislation of the Russian Federation, a genetic relationship between the recipient and the donor is a mandatory condition for organ transplantation from a living person [1]. According to the Russian Transplant Society registry, about 200 living-related kidney transplants are performed annually in the country [2].
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
Living kidney donation is an iatrogenic condition resulting from the implementation of medical technology that includes examination, decision-making regarding feasibility, surgical intervention, subsequent treatment, and rehabilitation aimed at obtaining a functionally and anatomically suitable kidney from a living donor and its subsequent transplantation to another person with stage 5 chronic kidney disease. Removal of one of the paired organs reduces the mass of functioning nephrons, resulting in a decrease in the glomerular filtration rate (GFR), but should preclude the development of CKD.
1.3 Epidemiology of the Disease or Condition
According to the annual report of the world's leading provider of products and services for patients with chronic renal failure, more than 4.1 million patients with this condition worldwide regularly undergo dialysis [3], and by 2030 this number is estimated to increase to 5.4 million. In 2020, kidney transplantation was performed in 93 countries, with a total of 81,005 operations performed (10.4 operations per 1 million population) [4].
In 2024, a total of 73,483 patients with stage 5 CKD were on renal replacement therapy in Russia, of whom 56,324 (76.7%) patients received treatment with hemodialysis, 1,997 (2.7%) with peritoneal dialysis, and 15,162 (20.6%) patients were followed up with a functioning renal transplant [5]. The prevalence rate of renal replacement therapy in the Russian Federation in 2024 was 503.2 patients per 1 million population, including 385.7 for hemodialysis, 13.7 for peritoneal dialysis, and 103.8 for renal transplant [5]. The Russian Federation continues to see an increase in the number of patients on dialysis and the associated financial costs for the national healthcare system [6].
In 2024, a total of 1,943 kidney transplants were performed across 49 centers. Compared to 2023, the number of kidney transplants increased by 6.9% (+126). The number of deceased-donor kidney transplants in 2024 was 1,720. Living-related kidney transplants in 2024 were performed in 23 centers (46.9%), with a total of 223 procedures. Only 6 centers performed 7 or more operations per year: the V.I. Shumakov National Medical Research Center of Transplantology and Artificial Organs of the Russian Ministry of Health (106) and its branch (21), the Orenburg Regional Clinical Center of Surgery and Traumatology (15), the B.V. Petrovsky Russian Scientific Center of Surgery (9), the State Novosibirsk Regional Clinical Hospital (9), and the National Medical Research Center for Children's Health of the Russian Ministry of Health (7). Meanwhile, the V.I. Shumakov NMRCTAO and its branch performed 56.9% of all living-related kidney transplants in the Russian Federation (127). The average utilization rate of living kidney donation in 2024 was 11.5% of the total number of kidney transplants (compared to 10.8% in 2023) [2].
1.4 Features of Coding the Disease or Condition
Z52.4 – Kidney donor.
1.5 Classification of the disease or condition
Living related kidney donor.
ABO-compatible kidney donor / ABO-incompatible kidney donor.
1.6 Clinical presentation of the disease or condition
Because a living kidney donor is a practically healthy individual, the condition is not pathological and has no clinical presentation prior to nephrectomy. The main objective of the evaluation process for potential donors is to assess donor suitability and minimize potential health risks to the donor. This includes identifying contraindications to donation and potential clinical (physical and psychosocial) risks. Donors must be over 18 years of age, have undergone a complete medical examination, and have given free and conscious written informed consent [7] to undergo nephrectomy. Informed consent for donation must be obtained from the candidate in the absence of the prospective recipient, family members, and other individuals who could influence the decision to donate [8]. Organ retrieval from a living donor is permissible only if, according to the conclusion of the medical commission of a medical organization involving relevant medical specialists and formalized as a protocol, no significant harm will be caused to their health [1, 9].
Potential living donors must be evaluated in accordance with Order No. 519n of the Russian Ministry of Health dated July 29, 2022, "On approval of the Procedure for conducting a medical examination of a donor who has given written informed voluntary consent to the retrieval of their organs and (or) tissues for transplantation" [10]. It is necessary to determine the list of routine screening tests and additional studies. Evaluations should be performed in a logical sequence to protect the potential donor from unnecessary, especially invasive, procedures prior to the appropriate stage of assessment.
Advanced age is not an absolute contraindication to donation, but the medical evaluation of elderly donors must be particularly thorough to identify relative or absolute contraindications to living donation. Both the donor and the recipient should be aware that an elderly donor may be at a higher risk of perioperative complications. This is particularly noticeable in donors over 60 years of age. Overall, utilizing kidneys from older donors appears to be an equivalent or beneficial alternative to waiting for deceased-donor kidneys [11]. It has been demonstrated that the GFR of a living related donor's kidney is an important determinant of long-term renal graft function [12, 13, 14].
2. Diagnostics, medical indications and contraindications for diagnostic methods
2.1 Complaints and Anamnesis
Criteria for establishing a diagnosis are not applicable to a potential living related donor.
It is recommended that a potential living kidney donor undergo an initial clinical examination and consultation by a general practitioner (therapist) to identify any potential health abnormalities [8, 15, 16, 17, 18].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
It is recommended that potential donors undergo a psychiatric consultation if signs of legal incompetence are identified during the initial examination and consultation by a general practitioner (therapist) [7, 8, 15, 16, 17, 18].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
2.2 Physical Examination
It is recommended to perform an initial examination (consultation) by a surgeon for potential living kidney donors to rule out significant surgical pathology, identify previous surgical interventions, and plan radical nephrectomy (laparoscopic nephrectomy) [8,10,16,19,20,21,22].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
It is recommended that potential living kidney donors undergo an examination (consultation) by a dentist (general dentist), ophthalmologist, otolaryngologist, and obstetrician-gynecologist (for women) to identify any potential health abnormalities [8,10,16,20,21,22].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to assess the nutritional status of a potential living kidney donor to identify potential health abnormalities [8,15,22,23,24,25].
GCR BLEL 2Grade of Recommendations B (Level of Evidence – 2)
It is recommended to perform an initial examination (consultation) by a urologist for a potential living kidney donor to rule out urinary system disorders in women and urogenital system disorders in men [22,106,107,164].
Level of Recommendations CLevel of Evidence 3Level of Recommendation C (Level of Evidence – 3)
It is recommended to perform an initial examination (consultation) by an oncologist for female potential living kidney donors over the age of 40 [26-29,30].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to perform an initial examination (consultation) by a cardiologist for a potential living kidney donor to rule out cardiovascular pathology and hypertension [8,17,31,32,33,34,105].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is not recommended to consider individuals taking two or more antihypertensive medications and those with uncontrolled arterial hypertension as potential living kidney donors [22,104].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to perform an initial examination (consultation) by an endocrinologist for a potential living kidney donor to rule out endocrine system pathology [18,122].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
To rule out carbohydrate metabolism disorders, it is recommended to perform an oral glucose tolerance test or measure glycated hemoglobin levels in blood for potential donors with an elevated risk of type 2 diabetes mellitus: in the presence of a family history of diabetes mellitus, a history of gestational pyelonephritis, obesity, or elevated fasting blood glucose levels [8,27,35].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
2.3 Laboratory Diagnostics
Due to the fact that the main purpose of evaluating a potential living donor is to rule out occult acute or chronic diseases or pathological conditions that may serve as reasons for refusing living donation:
It is recommended to determine ABO blood groups and Rh factor (D antigen) for a potential living kidney donor to determine blood group compatibility/incompatibility between the donor and recipient [8,10,36,37,38,39,40,41,43,44].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to perform a complete blood count (CBC) with differential for a potential living kidney donor for the diagnosis and differential diagnosis of anemia [21,24,41,42,43,44,45, 46,117].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to perform a general clinical blood chemistry panel (including: determination of aspartate aminotransferase activity, alanine aminotransferase activity, gamma-glutamyl transferase activity, amylase activity, alkaline phosphatase activity, serum iron level, C-reactive protein level, total protein level, albumin level, urea level, uric acid level, creatinine level, total bilirubin level, conjugated (direct) bilirubin level, free (indirect) bilirubin level, blood glucose level, cholesterol level, total calcium level, inorganic phosphorus level, glycated hemoglobin level, and lipid metabolism panel) for a potential living kidney donor to diagnose metabolic disorders [8,10,21,27,35,43,44,47,48,49].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to measure blood sodium, potassium, and chloride levels, as well as acid-base balance and blood gases, for a potential living kidney donor to diagnose electrolyte disorders [21,27,43,44,47].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to perform a coagulogram (screening hemostasis test) (including fibrinogen level, antithrombin-III activity, plasminogen level, prothrombin index, and activated partial thromboplastin time (APTT)) for a potential living kidney donor to diagnose blood coagulation disorders [21,27,43,44,47,48].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to test for blood levels of CA 19-9 tumor marker, CA 242 tumor-associated marker, CA 72-4 tumor marker, carcinoembryonic antigen (CEA), CA 125 tumor marker (for women), total prostate-specific antigen (PSA) (for men over 45 years old), and free prostate-specific antigen (PSA) (for men over 45 years old) to rule out oncological pathology [10,27,28,30].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to measure thyroid-stimulating hormone (TSH) in the blood of all potential donors to rule out thyroid diseases [10,22].
LoE C (LoD – 5)
It is recommended to conduct an initial evaluation of potential kidney donors using estimated GFR expressed in mL/min/1.73 m2, calculated from blood creatinine levels standardized to the international reference standard (nephron function testing via creatinine clearance) / blood cystatin C levels, to rule out impaired renal filtration function [8,13,20,27,50-58,117,120,121].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to perform a urinalysis for a potential living kidney donor to diagnose renal dysfunction [8,10,21,47,59-63,121].
GCR BLEL 3Grade of Recommendation B (Level of Evidence – 3)
It is recommended to perform a microbiological (culture) urine test for bacterial pathogens using automated plating for all potential kidney donors to rule out urinary tract infections [10,22].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to determine 24-hour urine protein excretion in potential living kidney donors to detect proteinuria [10,21,48,59,60,64].
GCR BLEL 3Grade of Recommendation B (Level of Evidence – 3)
It is recommended to perform at least two urinalyses in potential living kidney donors to detect microhematuria [8,65-71].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to perform a urinalysis using the Nechiporenko method for all potential kidney donors to assess the level of hematuria and leukocyturia [10,22].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to perform qualitative PCR testing for Hepatitis B virus DNA in blood, qualitative PCR testing for Hepatitis C virus RNA in blood, molecular biology testing of blood for human immunodeficiency virus HIV-1 (Human immunodeficiency virus HIV-1), molecular biology testing of blood for cytomegalovirus (Cytomegalovirus), molecular biology testing of blood for Epstein-Barr virus (Epstein - Barr virus), detection of hepatitis B virus surface antigen (HBsAg) (Hepatitis B virus) in blood, detection of antibodies to hepatitis C virus (Hepatitis C virus) in blood, detection of IgM and IgG antibodies to human immunodeficiency virus HIV-1 (Human immunodeficiency virus HIV 1) in blood, detection of IgM and IgG antibodies to human immunodeficiency virus HIV-2 (Human immunodeficiency virus HIV 2) in blood, and nontreponemal tests for antibodies to Treponema pallidum (RPR, VDRL) (qualitative and semi-quantitative test) in blood serum of potential kidney recipients to prevent the transmission of infectious diseases that pose a threat to the life and health of the recipient [10,18,72-80].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to determine class I and II HLA antigens (genes) for the recipient and donor, and perform a crossmatch test for recipient immune antibodies against the donor's major histocompatibility complex antigens. If there are multiple potential living donors with no medical contraindications for donor nephrectomy, it is recommended to consider a relative with a compatible blood group (AB0) and the highest human leukocyte antigen (HLA) match as the living donor, which creates optimal conditions for a successful transplantation [8,81-89].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
2.4 Instrumental Diagnostics
It is recommended to perform a comprehensive ultrasound examination of the abdominal organs, kidney ultrasound, duplex scanning of the abdominal aorta, iliac and common femoral arteries, comprehensive pelvic ultrasound for women (transvaginal and transabdominal), and prostate ultrasound (for men over 45 years of age) in a potential living related kidney donor to rule out pathology of the abdominal cavity, retroperitoneal space, pelvic organs, visible renal pathology (agenesis, dystopia), and nephrolithiasis [8,10,17,27,28].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to perform duplex scanning of the renal arteries and duplex scanning of the lower extremity vessels (arteries and veins) in a potential living related kidney donor to rule out critical stenoses and floating thrombi in the vessels [8,10,21].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to perform targeted chest X-ray in a potential living related kidney donor to rule out thoracic pathology [10,21,35].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to perform an electrocardiogram (ECG) with interpretation and description of data in a potential living related kidney donor to identify existing foci of ischemia or cardiomyopathy [8,10,17,90,91,125].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to perform echocardiography (EchoCG) and, if indications are identified (anamnestic, clinical, laboratory, or instrumental), Holter ECG monitoring and an exercise stress test using an ergometer in a potential living related kidney donor to determine cardiac functional reserve [8,10,17,92,93].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to perform coronary angiography to assess the coronary bed in a potential living kidney donor with signs of myocardial ischemia [8,10,17,92,93].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended, in the presence of signs of arterial hypertension, to perform 24-hour ambulatory blood pressure monitoring to determine the severity and nature of arterial hypertension [8,10,17,31-34].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to perform duplex scanning of the extracranial segments of brachiocephalic arteries in a potential living kidney donor to rule out stenotic lesions [8,10,17].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to perform esophagogastroduodenoscopy in a potential living kidney donor [8,10,17] to rule out diseases of the esophagus, stomach, and duodenum.
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to perform spirometry (unforced respiratory volumes and flows) in a potential living kidney donor to rule out obstructive pulmonary diseases [8,10,17].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to perform an ultrasound examination of the thyroid and parathyroid glands in a potential living kidney donor to rule out structural disorders [8,10,17].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to perform computed tomography of the abdomen and retroperitoneal space with intravenous bolus contrast enhancement in a potential living related kidney donor to determine renal vascular anatomy, anomalies, renal neoplasms, and nephrolithiasis [8,10,17,21,94-99].
GCR BLEL 3Grade of Recommendation B (Level of Evidence 3)
It is recommended to perform dynamic renal scintigraphy with functional tests if the difference in kidney size exceeds 2 cm in a potential living related kidney donor to detect significant functional differences between the two kidneys [100-103].
GCR BLEL 3Grade of Recommendation B (Level of Evidence – 3)
2.5 Other Procedures
Additional examinations are performed if pathological conditions are identified during the evaluation according to the current clinical guidelines for the respective nosology.
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
3.1 Preoperative Preparation
It is recommended to administer antithrombotic agents and apply lower extremity compression stockings in a potential living related kidney donor to prevent thrombosis in accordance with general principles of thromboembolic complication prophylaxis [108-112].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to administer a single intravenous dose of a systemic antibacterial drug 1 hour before the skin incision in a living related kidney donor as perioperative antibiotic prophylaxis [113-118].
Level of Recommendations CLevel of Evidence 3Level of Recommendation C (Level of Evidence – 3)
It is recommended to provide preoperative hydration with electrolyte solutions for 2–4 hours before surgery and/or as a bolus during surgery in a living related kidney donor to improve hemodynamic stability during the surgical intervention [119-121,165].
GCR BLoE 1Grade of Recommendation B (Level of Evidence – 1)
3.2 Surgical Treatment
It is recommended to use laparoscopic or hand-assisted transperitoneal laparoscopic nephrectomy in a living donor to obtain a donor kidney suitable for transplantation [122-135].
GCR ALEL 1Grade of Recommendation A (Level of Evidence – 1)
In centers where experience with laparoscopic renal surgery is limited, it is recommended to perform open nephrectomy in a living related donor to obtain a donor kidney suitable for transplantation [123,125,126,127,129].
GCR ALEL 1Grade of Recommendation A (Level of Evidence – 1)
It is recommended to make an individualized decision on using a kidney from a living related donor during the preoperative evaluation of the donor and recipient in the presence of multiple renal arteries or anatomical anomalies to increase safety for living donors and improve transplant outcomes in recipients [8,122,127,136-138,146].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
It is recommended for a potential living kidney donor to choose the kidney with a single renal artery for transplantation, provided the functions of both kidneys are comparable, in order to minimize the risk of vascular complications during vascular anastomosis creation. This statement also applies to renal veins [8,17,136-138].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
4. Medical Rehabilitation and Sanatorium-Resort Treatment
4.1 General Issues of Rehabilitation After Kidney Donation
Following kidney donation, most individuals can return to normal daily activities within two to four weeks. Follow-up after kidney donation should focus on monitoring and maintaining general and renal health, including maintaining a healthy lifestyle (e.g., diet, weight maintenance, regular aerobic exercise), preventing potentially nephrotoxic exposures (e.g., tobacco use, nonsteroidal anti-inflammatory drugs, nephrotoxic medications), preventing conditions that can cause chronic kidney disease (e.g., hypertension, diabetes mellitus, cardiovascular disease), and timely treatment of such conditions if they develop after kidney donation. Hypertension is diagnosed more frequently in kidney donors than in individuals with comparable baseline health status, although this may partly reflect closer monitoring and earlier detection [8,139-141].
Early detection and treatment of conditions that potentially affect the decline in GFR can protect the donor from further deterioration of renal function or other health decline. Promotion of a healthy lifestyle should be carried out, including regular exercise, a healthy diet, and smoking cessation [8].
4.2 Reproductive Health in Kidney Donors
It is recommended to inform women of reproductive age planning children and expressing the desire to become a living donor that living kidney donation may affect future pregnancies, including a potentially higher probability of being diagnosed with gestational hypertension or preeclampsia [142-145].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
5. Prevention and Dispensary Observation
During the evaluation and preoperative preparation, it is recommended to inform potential kidney donors that the overall risk of developing chronic kidney disease may increase following kidney donation [147-154].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
It is recommended to perform a complete blood count (erythrocytes, platelets, leukocytes, total hemoglobin), general urinalysis, general clinical blood chemistry (total protein, albumin, creatinine, urea, ALT, AST activities), coagulation profile (fibrinogen, antithrombin-III, plasminogen, prothrombin index, APTT), as well as a physical and instrumental examination (ultrasound of the retroperitoneal space) in a living related donor in the early postoperative period (days 1–5) to detect any possible health abnormalities [8,17,155,156].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to have an annual follow-up visit (examination, consultation) with a general practitioner/internist for a living related kidney donor at their place of residence to detect any possible health abnormalities [155,156].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
It is recommended to inform women of reproductive age planning children who are living kidney donors about the potentially increased risk of pregnancy-induced hypertension following kidney donation, which may require specialized prenatal care [142-145,157,158].
GCR BLEL 3Grade of Recommendation B (Level of Evidence – 3)
6. Organization of Medical Care
The evaluation of a potential living donor is organized after obtaining informed consent in the prescribed manner [10]. Hospitalization of potential kidney donors is scheduled electively after clinical evaluation, a decision on surgery made by all members of the multidisciplinary team, or if inpatient further evaluation is required. The conditions for the surgery are: a genetic relationship with the recipient; availability of medical commission protocols from the medical organization confirming the necessity of kidney transplantation for the recipient and the feasibility of nephrectomy in the potential donor, indicating that no significant harm will be caused to their health [1,7,9].
Indications for elective hospitalization:
the potential donor's desire expressed in the form of voluntary informed consent for evaluation as a living kidney donor, in the prescribed form.
Indications for discharging the patient from the hospital:
absence of early postoperative complications that could affect the patient's health;
satisfactory function of the remaining kidney;
satisfactory psychoemotional status of the kidney donor;
availability of clear recommendations in the epicrisis for further patient follow-up.
7. Additional Information
7.1 Intraoperative Complications and Complications of the Early Postoperative Period
Nephrectomy in living donors, like any other intervention, is associated with potential complications and risks. However, the fact that the surgery is performed on a healthy patient heightens the significance of any complications. The list of potential complications must be included in the informed consent for surgery. According to official data, operative mortality ranges from 0.01% to 0.03%, regardless of surgical technique or donor status. A recent systematic review of complications in minimally invasive laparoscopic nephrectomy (190 studies) and meta-analysis (41 studies) described 32,308 laparoscopic nephrectomies. The rate of intraoperative complications among them was 2.2% (the most frequent complications being hemorrhage [1.5% of cases] and adjacent organ injury [0.8% of cases]), while postoperative complications occurred in 7% (infectious complications in 2.6% of cases, and hemorrhage in 1% of cases). The conversion rate was 1.1%, in half of the cases due to hemorrhage and in the other half due to adjacent organ injury. The reexploration rate was 0.6%, in the majority of cases for hemostasis or hematoma evacuation [152,159,160].
7.2 Complications in the Long-Term Postoperative Period
Long-term complications are most commonly related to the remaining kidney. Renal function declines immediately after nephrectomy and then improves over several years. However, in the long-term postoperative period, there are signs of functional reserve depletion [161,162]. Despite a persistent increase in the incidence of proteinuria and arterial hypertension, the incidence of stage 5 chronic kidney disease (0.4-1.1%) does not differ from the general population [151,163]. The risk of donor mortality in the long-term postoperative period does not differ from that of the general population of corresponding age with similar comorbidities [151,152].
Criteria for Evaluating the Quality of Medical Care
No. | Quality criteria | Performance assessment (yes/no) |
|---|---|---|
1 | Initial general practitioner examination (inspection, consultation) was performed | Yes/no |
2 | Initial surgical consultation and examination performed | Yes/no |
3 | Initial urological consultation and examination performed (including total blood PSA level testing and prostate ultrasound for men over 45 years of age) | Yes/no |
4 | Initial oncological consultation and examination performed for women over 40 years of age | Yes/no |
5 | Initial cardiological consultation and examination performed | Yes/no |
6 | Initial endocrinologist consultation (examination, assessment) performed | Yes/no |
7 | Determination of ABO blood groups and Rhesus antigen D (Rh factor) performed | Yes/no |
8 | A complete blood count (differential) was performed | Yes/no |
9 | General general-clinical biochemical blood test performed (including: determination of blood aspartate aminotransferase activity, determination of blood alanine aminotransferase activity, determination of blood gamma-glutamyl transferase activity, determination of blood amylase activity, determination of blood alkaline phosphatase activity, serum iron testing, serum C-reactive protein testing, total blood protein testing, blood albumin testing, blood urea testing, blood uric acid testing, blood creatinine testing, total blood bilirubin testing, conjugated [direct] blood bilirubin testing, free [indirect] blood bilirubin testing, blood glucose testing, blood cholesterol testing, total blood calcium testing, inorganic phosphorus testing, glycated hemoglobin testing) and lipid metabolism biochemical blood test | Yes/no |
10 | Blood sodium test, blood potassium test, blood chloride test, blood acid-base balance and blood gas analysis performed | Yes/no |
11 | GFR calculated | Yes/no |
12 | Coagulation panel performed (screening hemostasis test) (blood fibrinogen level, blood antithrombin-III activity, blood plasminogen level, prothrombin index, APTT) | Yes/no |
13 | Urinalysis (general clinical urine test) performed | Yes/no |
14 | 24-hour urine protein quantification performed | Yes/no |
15 | Nechyporenko urine test performed | Yes/no |
16 | Qualitative PCR test for hepatitis B virus (Hepatitis B virus) DNA in blood, qualitative PCR test for hepatitis C virus (Hepatitis C virus) RNA in blood, molecular biological blood test for human immunodeficiency virus HIV-1 (Human immunodeficiency virus HIV-1); molecular biological blood test for cytomegalovirus (Cytomegalovirus), molecular biological blood test for Epstein-Barr virus (Epstein-Barr virus), blood test for hepatitis B virus surface antigen (HBsAg) (Hepatitis B virus), blood test for antibodies to hepatitis C virus (Hepatitis C virus), blood test for IgM and IgG antibodies to human immunodeficiency virus HIV-1 (Human immunodeficiency virus HIV 1), blood test for IgM and IgG antibodies to human immunodeficiency virus HIV-2 (Human immunodeficiency virus HIV 2), and non-treponemal tests (RPR, VDRL) for antibodies to Treponema pallidum (qualitative and semi-quantitative test) in blood serum | Yes/no |
17 | Immunological workup performed: determination of class I and II HLA antigens (genes); recipient immune crossmatch against donor major histocompatibility complex antigens | Yes/no |
18 | Abdominal ultrasound (comprehensive) was performed. | Yes/no |
19 | Targeted chest X-ray performed | Yes/no |
20 | ECG recording was performed | Yes/no |
21 | Echocardiography, Holter heart rhythm monitoring, and an ergometer exercise stress test performed | Yes/no |
22 | Computed tomography of the abdominal cavity and retroperitoneal space with intravenous bolus contrast enhancement performed | Yes/no |
23 | Elastic compression of the lower extremities used | Yes/no |
25 | Systemic antibacterial drugs administered 1 hour prior to skin incision | Yes/no |
26 | Urinalysis (general clinical urine test), complete blood count (red blood cells, platelets, leukocytes, total blood hemoglobin), general biochemical blood test (total protein, albumin, creatinine, urea, aspartate aminotransferase, alanine aminotransferase activity), coagulation panel (screening hemostasis test) (blood fibrinogen level, blood antithrombin-III activity, blood plasminogen level, prothrombin index, APTT), physical examination and instrumental diagnostics (ultrasound of the retroperitoneal space) performed in the early postoperative period (days 1–5) | Yes/no |
References
Show references
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Appendix A1. Working Group Composition
Arzumanov Sergey Viktorovich | Head of the Transplantation and Renal Replacement Therapy Group, Lopatkin Research Institute of Urology and Interventional Radiology – branch of the National Medical Research Radiological Centre of the Russian Ministry of Health (Obninsk), MD, member of the Russian Transplantation Society |
|---|---|
Bykov Aleksandr Yu. | Chief Transplantologist of Novosibirsk Oblast, surgeon at the Organ Transplantation Surgical Department, State Novosibirsk Regional Clinical Hospital (Novosibirsk), PhD, member of the Russian Transplantation Society |
Galeev Shamil Rinatovich | Deputy Director – Head of the Volzhsky Branch of the National Medical Research Center of Transplantology and Artificial Organs named after Academician V.I. Shumakov of the Russian Ministry of Health (Volzhsky), Chief Transplantologist of the Southern and North Caucasian Federal Districts, MD, member of the Russian Transplantation Society |
Gichkun Olga Evgenyevna | Leading Researcher, Department of Regulatory Mechanisms in Transplantology, National Medical Research Center of Transplantology and Artificial Organs named after Academician V.I. Shumakov of the Russian Ministry of Health (Moscow), PhD, Associate Professor, member of the Russian Transplantation Society |
Gauthier Sergey Vladimirovich | Director of the National Medical Research Center of Transplantology and Artificial Organs named after Academician V.I. Shumakov of the Russian Ministry of Health (Moscow), Academician of the RAS, Chief Freelance Transplantologist of the Russian Ministry of Health, Chairman of the Russian Transplantation Society, MD, Professor, Academician of the RAS |
Zainutdinov Zainudin Musayevich | Head of the Clinic, Federal Research Center of Nutrition and Biotechnology (Moscow), Doctor of Medical Sciences |
Kurbangulov Ildar Raisovich | Surgeon at Surgical Department No. 1, National Medical Research Center of Transplantology and Artificial Organs named after Academician V.I. Shumakov of the Russian Ministry of Health (Moscow), PhD, member of the Russian Transplantation Society |
Malakhov Aleksey Gennadyevich | Surgeon at Surgical Department No. 1, National Medical Research Center of Transplantology and Artificial Organs named after Academician V.I. Shumakov of the Russian Ministry of Health (Moscow), member of the Russian Transplantation Society |
Mozheyko Natalya Pavlovna | Head of the Pathology Department, National Medical Research Center of Transplantology and Artificial Organs named after Academician V.I. Shumakov of the Russian Ministry of Health (Moscow), MD, member of the Russian Transplantation Society |
Saydulaev Dzhabrail Azizovich | Head of Surgical Department No. 1, Surgeon, National Medical Research Center of Transplantology and Artificial Organs named after Academician V.I. Shumakov of the Russian Ministry of Health (Moscow), PhD, member of the Russian Transplantation Society |
Sapozhnikov Arkady Davidovich | Deputy Head of the Branch for Medical Care Organization, Oncologist, Volzhsky Branch of the National Medical Research Center of Transplantology and Artificial Organs named after Academician V.I. Shumakov of the Russian Ministry of Health (Volzhsky), PhD, member of the Russian Transplantation Society |
Semchenko Sergey Borisovich | Head of the Center for Human Organ and Tissue Transplantation, Surgeon, Regional Clinical Hospital No. 1 of Tyumen Oblast (Tyumen), PhD, member of the Russian Transplantation Society |
Khomyakov Sergey Mikhailovich | Deputy Director – Head of the Center for Organizational and Methodological Guidance of Institutions Engaged in Activities Related to Human Organ and/or Tissue Transplantation, National Medical Research Center of Transplantology and Artificial Organs named after Academician V.I. Shumakov of the Russian Ministry of Health (Moscow), PhD, member of the Russian Transplantation Society |
Chebotareva Natalya Viktorovna | Head of the Center for Excellence in Nephrology Care, Head of the Nephrology Department, National Medical Research Center of Transplantology and Artificial Organs named after Academician V.I. Shumakov of the Russian Ministry of Health, MD, Professor, member of the Russian Transplantation Society |
Conflict of interest.
The working group declares no conflict of interest.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience of these clinical guidelines:
obstetricians-gynecologists;
anesthesiologists-intensivists;
cardiologists;
nephrologists;
general practitioners (family doctors);
healthcare organizers;
general practitioners (internal medicine);
urologists;
surgeons;
endocrinologists.
Table 1. Scale for grading levels of evidence (LoE) for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without sequential reference-standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Scale for assessing the levels of evidence (LE) for prevention, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitation interventions)
LoE | Definition |
|---|---|
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Scale for assessing grades of recommendation (GR) for prevention, diagnostic, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, diagnostic, therapeutic, and rehabilitative interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines
The update mechanism for clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
Order of the Russian Ministry of Health No. 519n of July 29, 2022, "On Approval of the Procedure for Medical Examination of a Donor Who Has Given Written Informed Voluntary Consent to the Removal of His/Her Organs and/or Tissues for Transplantation".
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
Who can be considered a living kidney donor?
A donor can be an individual aged 18 or older who has undergone a full medical examination, has been deemed fit for nephrectomy (removal of one kidney) for subsequent transplantation, and has a blood (genetic) relationship with the recipient (the person receiving the kidney). The willingness to donate one's kidney for a relative must be confirmed by voluntary consent in the prescribed form.
What does a living-related kidney transplantation surgery involve?
The surgery is performed under general anesthesia and consists of three stages:
The first stage is the extraction of one kidney from the donor. In many transplant centers, nephrectomy in a living donor is performed laparoscopically, i.e., through small punctures and small incisions on the abdomen, ensuring minimal trauma and rapid postoperative recovery. Open nephrectomy is also an option.
The second stage is the preparation of the harvested organ for transplantation.
The third stage is the transplantation of the kidney into the recipient, also performed under general anesthesia.
What are the advantages of living kidney donation over deceased donation?
The main advantages of living-related donor transplantation include superior short- and long-term recipient and graft survival rates, a more predictable and stable function of the transplanted kidney, and the absence of a long waiting period with the possibility of performing the transplantation before the initiation of renal replacement therapy. Living-related donor transplantation involves a very short period of cold storage of the kidney in a preservation solution, resulting in minimal injury to the graft. Furthermore, good human leukocyte antigen (HLA) compatibility between a related donor and recipient allows for a less aggressive post-operative immunosuppressive therapy. All of this yields better graft function and survival outcomes, with a significantly lower incidence of delayed graft function.
How long does a transplanted kidney function?
On average, half of the transplanted kidneys continue to function after 12–15 years, compared to 8–10 years for deceased donor kidney transplants. There are numerous cases where the function of the transplanted kidney remains satisfactory for 30 years or more. In addition, extensive experience has been accumulated with repeat kidney transplantations.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Information is not available.