Written by:
Anoushka Pinto
A kidney transplant involves surgically replacing a diseased or non-functioning kidney with a healthy one from either a living or deceased donor. Donors can be genetically related, such as siblings or parents, or unrelated individuals motivated by kindness.
Unfortunately, the demand for kidney transplants far exceeds the available supply of living and deceased donors, resulting in long waiting times. There is a significant disparity between the number of patients needing transplants and the number of available organs. Hence, only a fortunate few receive kidneys from either living (related or unrelated) or deceased donors, with the major obstacles being the limited number of living donors and the long waiting lists for deceased donors.
When you need a kidney transplant, finding a well-matched living kidney donor can significantly enhance the success of the procedure. A closer match between the donor and recipient often results in the transplanted kidney lasting longer. This “match” refers to the biological compatibility between the two individuals, determined by evaluating blood type, tissue type, and crossmatching.
In this article, we will learn about the evaluation and matching process that determine the compatibility between a donor and recipient, leading to a successful kidney transplant in India.
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Types of donors
Deceased donor
A transplant carried out with a kidney from a deceased donor is called a cadaveric transplant. Deceased donors are individuals who have experienced brain death due to head trauma or a medical complication such as brain bleeding, or even cardiac issues. The organs are thus removed from the donor when they have been declared brain dead (DBD) or have experienced sudden cardiac death (DCD). Most organ donations, however, come from brain dead donors.
Due to the scarcity of deceased donors, many patients with chronic kidney disease (CKD) must remain on maintenance dialysis, even though they are eager to have a transplant. Their only hope lies in receiving a kidney from a living donor. Donating organs after death is a noble act that can save lives and help eliminate illegal organ trade, making deceased kidney donation the most ethical form of donation.
With the consent of their families, the organs of deceased donors are donated to patients in need. The medical and nursing teams involved in the patient’s care also help the family through the decision-making process for organ donation. Usually, patients on the transplant waitlist for a suitable deceased donor kidney endure long waits, sometimes spanning several years.
Eligibility criteria and exceptions for deceased kidney donors
To meet the growing demand for deceased kidney donors, some exceptions can be made to the eligibility criteria, which otherwise specifies healthy functioning kidneys at the time of death. These exceptions are known as Expanded Criteria Donors (ECD) and include:
Donors younger than 6 years old
Donors older than 60 years if other parameters are normal
Donors aged 51 to 59 years with two of the following risk factors:
- Cerebrovascular death
- Hypertension
- Serum creatinine levels above 1.5 mg/dl
A deceased individual cannot be a kidney donor if:
They had a long-standing kidney disease.
They are over the age of 70. However, they can be considered if their health parameters are otherwise optimal.
They actively did drugs. Drug abuse disqualifies a donor due to associated health risks.
They experienced significant reduction in urine output due to acute kidney failure.
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Living donor
Living kidney donation involves transplanting a kidney from a healthy individual to a person with kidney failure. Living donors can be family members or people with an emotional connection to the recipient, such as a spouse or friend.
Living kidney donation has been shown to provide better outcomes over dialysis, including improved quality of life, higher success rates, longer graft survival and reduced healthcare costs. It is widely accepted by law, religion, and bioethics, provided that the donor fully understands the consequences and makes the decision freely, without any external pressure or commercial influence.
Eligibility criteria and exceptions for living kidney donors
Age: Donors must be at least 18 years old and the upper limit is 65 years, though older individuals can still donate as long as they are in good health and have passed the necessary medical evaluations.
Health condition: Donors must be healthy, with no conditions like uncontrolled hypertension, diabetes, or chronic kidney disease.
No smoking or drug use: Donors should abstain from smoking and illicit drugs or substances.
No hypertension requiring treatment: No history of high blood pressure that requires medication.
Body weight: Candidates with a body mass index (BMI) over 35 are generally not considered, unless they are very muscular.
You are not eligible to be a living kidney donor if
You are under 18 years of age
Have severe hypertension
Have a family history of diabetes
Have a history of thrombosis and embolism
Have psychiatric issues
Suffer from heart or lung diseases
Are obese or have a BMI over 35
Recently suffered from or are battling high-risk cancer
Have significant kidney abnormalities
Have kidney stones
Have mild sleep apnea
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Evaluation process
1. Living donor
The evaluation process for living kidney donors is thorough, ensuring that potential donors are in good health and fully informed about the donation procedure. Here’s a breakdown of what to expect:
Medical history and physical examination
The medical history and physical exam are similar to an annual check-up with your doctor. The physician conducts a physical examination to ensure the donor’s overall health is good and there are no unusual risks associated with donation.
Blood tests
To measure the components of blood, detect infections, anemia and other-blood related conditions including diabetes and measuring cholesterol levels.
Kidney function tests
To assess how well the kidneys are filtering waste from the blood.
Liver function tests
These tests evaluate liver enzymes and bilirubin levels to ensure the liver is functioning correctly.
Urinalysis
This checks for abnormalities in the urine, such as protein, glucose, or blood, which can indicate kidney disease or infection.
Infectious disease testing
Screening for various infectious diseases that can affect a recipient post-transplant like Hepatitis B and C, HIV, Syphilis, Tuberculosis, Varicella-Zoster Virus (VZV) Cytomegalovirus (CMV), Epstein-Barr Virus (EBV), Parvovirus B19 and Toxoplasmosis.
Imaging tests
Basic imaging test like renal ultrasound and other detailed tests like computed tomography (CT Scan), magnetic resonance imaging (MRI), CT and angiogram, etc help evaluate kidney size and shape, map out the blood vessels of the kidneys, identify kidney stones or other obstructions in the urinary tract and analyse any structural abnormalities such as cysts or tumors. Chest X-rays and electric cardiograms (ECG) is used to rule out any lung diseases or abnormalities and to check for heart conditions and signs of damage.
Psychological evaluation
Ensuring the donor fully understands the risks and benefits and is emotionally prepared for donation. If there is a history of mental health issues or medication use, a consultation with a transplant psychiatrist may be required.
Consent
Obtaining fully informed consent from the donor, ensuring they are not under any pressure and understand the risks and benefits.
Colonoscopy
Donors over 50 may need this test to rule out colon cancer.
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2. Deceased donor
When evaluating potential deceased donors for kidney transplants, several criteria must be met to ensure the viability and success of the transplant. This evaluation process is thorough and meticulous, focusing on the donor’s overall health and the specific condition of their kidneys.
Mandatory diagnosis of brain death
A deceased kidney donor must be conclusively diagnosed with brain death, which means the irreversible loss of all brain function. This diagnosis requires comprehensive testing and confirmation by medical professionals. Ensuring brain death is crucial to ethically and legally proceed with organ donation.
Normal renal function
The deceased donor’s kidneys must have been functioning normally. This ensures that the transplanted kidney will be able to perform its necessary functions in the recipient’s body. Tests are conducted to check the creatinine levels and glomerular filtration rate (GFR) to assess kidney performance.
No hypertension requiring treatment
Donors should not have a history of hypertension that required treatment. Chronic high blood pressure can damage the kidneys over time, reducing their effectiveness as transplant organs. A detailed medical history and blood pressure records are reviewed to confirm this.
No diabetes mellitus
The presence of diabetes mellitus can lead to complications such as diabetic nephropathy, which affects kidney function. Potential donors with a history of diabetes are generally excluded to prevent these complications from affecting the transplant outcome.
No malignancies
Donors must be free of malignancies, except for primary brain tumors or treated superficial skin cancer. This is crucial to avoid the risk of cancer transmission to the recipient. A thorough medical examination and history check are conducted to rule out any current or past cancers.
No generalised viral or bacterial infections
The donor must not have any active generalized viral or bacterial infections. Such infections can compromise the health of the transplanted kidney and pose significant risks to the recipient. Blood tests and cultures are performed to detect any infections.
Acceptable urinalysis
A urinalysis is performed to check for any abnormalities in the donor’s urine, such as the presence of protein, blood, or signs of infection. This helps in assessing the health of the kidneys and ensuring they are suitable for transplantation.
Negative tests for transmittable diseases
The donor must test negative for certain infections that can be transmitted through organ transplants. These include syphilis, hepatitis, HIV, and human T-lymphotropic virus. Comprehensive blood tests are conducted to ensure the absence of these infections.
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Matching process
1. Living donor compatibility tests
When finding a potential living kidney donor, three main blood tests determine compatibility: blood typing, tissue typing (HLA typing), and crossmatching. Each of these tests plays a crucial role in ensuring the donor and recipient are a good match, minimizing the risk of rejection, and maximizing the success of the transplant.
Blood typing
Blood typing is the initial test to determine if the donor’s blood type is compatible with the recipient’s. Understanding blood type compatibility helps in determining whether the donor can proceed to the next stage of testing. There are four primary blood types—O, A, B, and AB, and compatibility follows these general rules:
Type O: Universal donors, can donate to any blood type (O, A, B, AB).
Type A: Can donate to recipients with type A or AB.
Type B: Can donate to recipients with type B or AB.
Type AB: Universal recipients, can receive from any blood type (O, A, B, AB).
The Rh factor (+ or -) is not relevant in kidney donation compatibility.
Tissue matching (HLA typing)
Tissue matching assesses the compatibility of the donor and recipient at the genetic level by examining human leukocyte antigens (HLAs). HLA are proteins found on the surface of most cells in the body. They play a key role in immune system function and organ transplant compatibility.
We inherit three HLA antigens from each parent. Siblings have a 25% chance of a perfect match (zero mismatch), while parents and children have at least a 50% match. A good HLA match can improve the long-term success of the transplant, although successful transplants can occur even with partial matches.
The recipient is tested for HLA antibodies, which can develop from blood transfusions, pregnancies, infections, or surgeries. These antibodies can attack the donor’s HLA antigens, leading to rejection. Regular testing is done to monitor these antibodies and ensure they are not present in high levels before the transplant.
Crossmatching
Crossmatching tests for the presence of antibodies in the recipient’s blood that might react against the donor’s cells. Blood from the donor and recipient is mixed, and the test checks if the recipient’s antibodies attack and kill the donor’s cells. Crossmatching is typically done twice—initially during the evaluation process and again just before the transplant surgery to confirm ongoing compatibility.
A positive crossmatch indicates that the recipient has antibodies against the donor’s cells, making the donor-recipient pair incompatible. On the other hand, a negative crossmatch causes no reaction between the recipient’s antibodies and the donor’s cells, indicating compatibility.
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2. Deceased donor compatibility tests
Allocation of kidneys from deceased donors to recipients is a meticulous process that ensures fairness and maximizes the success of transplants. Here’s how it’s done:
Blood group matching
Matching based on blood group is the primary criterion for allocating kidneys from deceased donors. For instance, a donor with blood group O is typically allocated to a recipient with blood group O, ensuring compatibility that reduces the risk of rejection. If there are no suitable recipients with the same blood group, the organ may be allocated to other compatible blood groups in a specific order: B, A, and AB (refer to table above).
Recipients with blood group AB can receive kidneys only from AB donors due to the universal compatibility of AB blood group recipients. However, in exceptional circumstances where no AB recipient is available, an AB donor kidney may be allocated to a recipient of another blood group (O, B, A) to prevent organ wastage and maximize transplant opportunities.
Scoring of individual patients
Each patient awaiting a kidney transplant is scored based on various factors to determine their priority for receiving an organ. These factors include:
Age: Younger recipients may receive higher scores due to potentially better long-term outcomes.
Age difference: Smaller age gaps between donors and recipients are preferred to optimize organ longevity.
Time on waiting list: Patients who have been waiting longer typically receive higher scores to reduce wait times and potential health deterioration.
Vascular access issues: Patients with difficult vascular access for dialysis may receive higher scores due to urgent need.
Previous graft failure: Patients who have experienced failed transplants are often prioritized for re-transplantation.
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Authorisation committee clearance
A non-related donor must obtain approval from an Authorization Committee established by the state before donating their kidney. The Authorization Committee (AC) plays a crucial role in overseeing living donor transplantations. It carefully evaluates each case to safeguard against any exploitation of the donor for financial gain and to prevent commercial transactions in organ transplants.
All proceedings of the Authorization Committee are recorded on video, and decisions are communicated to the involved parties within 24 hours of the hearing. In case of disagreement with the Committee’s decision, appeals can be filed with either the state or central government for further review. This ensures transparency, accountability, and ethical standards in the process of living kidney donations involving non-related donors.
How Milaap can help
Milaap facilitates kidney transplant procedures by enabling individuals to raise funds for their treatment expenses. Whether it’s covering the costs associated with matching and evaluation processes for kidney donors or supporting the financial needs of recipients, Milaap allows people to start fundraisers that make life-saving transplants possible.
If you’re looking to initiate a fundraiser to undergo a kidney transplant, Milaap provides a reliable platform to gather community support and raise the necessary funds. Start your fundraiser today!
Organ transplant success stories on Milaap
In times of need, support means everything, and with Milaap, you need not look any further. Milaap enables you to set up a fundraiser for any medical emergency within minutes, and you can easily raise funds for treatment expenses.
Do you know someone who could benefit from fundraising? Simply refer them to us and we’ll be happy to lend a hand.
Visit www.milaap.org or call us on +91 9916174848 to get started now.
For more information, write to us at cx@milaap.org.
