Transplant Medicine · Supplementary · from Transplant Medicine

Case 1: Living Donor Kidney Transplant Evaluation

Patient Presentation

Demographics: 42-year-old female accountant

Chief Complaint: "My kidneys have failed and I need a transplant — my sister wants to donate"

History of Present Illness: This 42-year-old female accountant with end-stage renal disease (ESRD) secondary to IgA nephropathy presents to the transplant center for living donor kidney transplant evaluation. She was diagnosed with IgA nephropathy by renal biopsy at age 28 after presenting with recurrent episodes of gross hematuria coinciding with upper respiratory infections. Despite treatment with ACE inhibitors and a course of corticosteroids, her kidney function progressively declined over 14 years.

She initiated hemodialysis via a left upper arm arteriovenous fistula 10 months ago when her GFR fell to 8 mL/min/1.73m2. She currently receives in-center hemodialysis three times weekly (Monday/Wednesday/Friday) for 4-hour sessions. She tolerates dialysis reasonably well but reports significant fatigue on dialysis days, limiting her ability to work full-time. She has been listed on the deceased donor kidney transplant waiting list for 6 months with an estimated wait time of 5-7 years in her region.

Her 39-year-old sister has volunteered as a potential living kidney donor. The sister is ABO-compatible (both blood type A+), and preliminary crossmatch is negative. The donor evaluation is being conducted in parallel. The patient has been counseled on the benefits of preemptive or early living donor transplantation, including superior graft survival compared to deceased donor transplantation.

Past Medical History:

• ESRD secondary to IgA nephropathy (on hemodialysis for 10 months)
• Hypertension (secondary to CKD)
• Secondary hyperparathyroidism
• Anemia of chronic kidney disease
• Left upper arm AVF (functioning well, adequate flow)
• No prior transplants or pregnancies
• No history of malignancy
• Hepatitis B and C negative, HIV negative

Medications:

• Amlodipine 10 mg daily
• Losartan 100 mg daily (held on dialysis days)
• Epoetin alfa 6,000 units IV three times weekly at dialysis
• Iron sucrose 100 mg IV monthly
• Calcitriol 0.25 mcg daily
• Sevelamer 800 mg three times daily with meals
• Cinacalcet 30 mg daily
• Aspirin 81 mg daily
• Atorvastatin 20 mg daily

Social History:

• Accountant, currently working part-time due to dialysis schedule
• Non-smoker, never smoked
• No alcohol use
• No illicit drug use
• Single, no children
• Supportive family including potential living donor (sister)
• Excellent health insurance coverage
• Lives independently in a single-story condominium

Family History:

• Mother with hypertension and type 2 diabetes
• Father died of myocardial infarction at age 65
• Sister (potential donor) is healthy, age 39
• No family history of kidney disease other than the patient

Physical Examination

• Vital Signs: BP 142/88 mmHg (pre-dialysis), HR 76 bpm, RR 14/min, Temp 36.7°C, SpO2 98% on room air, BMI 23.5, Weight 62 kg (dry weight)
• General: Well-appearing female in no acute distress. Appears well-nourished
• HEENT: Pale conjunctivae. No oral lesions. Dentition in good repair
• Neck: No JVD, no bruits, no lymphadenopathy
• Cardiac: Regular rate and rhythm, no murmurs, no friction rub
• Lungs: Clear to auscultation bilaterally
• Abdomen: Soft, non-tender, non-distended. No hepatosplenomegaly. No surgical scars. Bilateral iliac fossae accessible for transplant placement
• Vascular Access: Left upper arm brachiocephalic AVF with palpable thrill and audible bruit. No signs of infection or steal syndrome
• Extremities: Trace bilateral pedal edema. No skin lesions. Peripheral pulses 2+ bilaterally
• Skin: No rashes, no lesions suspicious for malignancy

Workup and Results

Laboratory Studies:

Imaging/Additional Studies:

• Echocardiogram: Normal LV function (LVEF 60%), no significant valvular disease, no LVH. RVSP 28 mmHg (normal)
• Dobutamine stress echocardiogram: No inducible wall motion abnormalities (adequate cardiac risk assessment for transplant surgery)
• CT abdomen/pelvis with contrast (pre-transplant planning): Small bilateral kidneys (8 cm bilaterally). Patent iliac vessels bilaterally suitable for anastomosis. No renal masses. No abdominal aortic aneurysm. Intact urinary bladder
• Voiding cystourethrogram: Normal bladder capacity (400 mL), no vesicoureteral reflux, complete bladder emptying
• Chest X-ray: No active pulmonary disease. Normal cardiac silhouette
• Colonoscopy (age-appropriate screening): Normal, no polyps
• Cervical cancer screening: Pap smear normal, HPV negative
• Mammogram: BI-RADS 1, negative

Donor Evaluation Summary (Sister, age 39):

• Blood type A+, crossmatch negative with recipient
• HLA typing: 1-haplotype match (shared one HLA haplotype)
• GFR (iothalamate clearance): 105 mL/min/1.73m²
• 24-hour urine protein: 85 mg (normal <150 mg)
• CT angiography: Single left renal artery, single right renal artery. Left kidney selected for donation (single artery, smaller kidney)
• Medical clearance: No hypertension, no diabetes, BMI 24, non-smoker, normal glucose tolerance test, normal psychosocial evaluation
• Independent donor advocate: Confirmed voluntary donation without coercion

Clinical Image

Diagram illustrating the living donor kidney transplant surgical anatomy, showing donor nephrectomy and transplant placement in the recipient's iliac fossa with vascular and ureteral anastomoses. Source: Educational illustration.

Diagnosis

End-Stage Renal Disease Secondary to IgA Nephropathy, Approved for Living Donor Kidney Transplantation

Key Diagnostic Criteria:

• ESRD requiring dialysis (GFR <10 mL/min/1.73m²) with biopsy-proven IgA nephropathy
• Completed recipient evaluation: adequate cardiac function, no active infections, no malignancy, patent iliac vessels, functional bladder, PRA 0%
• Completed donor evaluation: adequate renal function (GFR 105), favorable anatomy (single renal arteries), no medical contraindications, voluntary informed consent with independent donor advocate
• Negative crossmatch and ABO compatibility

Treatment Plan

1. Preoperative preparation:

• Final crossmatch within 48 hours of transplant
• Dialysis session the day before surgery to optimize volume and electrolyte status
• Immunosuppression induction: Basiliximab (anti-IL-2 receptor antibody) 20 mg IV on day 0 and day 4
• Discontinue ACE inhibitor 48 hours before surgery
• DVT prophylaxis with sequential compression devices

1. Surgical procedure: Living donor laparoscopic left nephrectomy (donor surgery). Recipient surgery: right iliac fossa transplant with renal artery anastomosis to external iliac artery, renal vein to external iliac vein (end-to-side), Lich-Gregoir ureteroneocystostomy with double-J ureteral stent
2. Immunosuppression protocol:

• Induction: Basiliximab (day 0 and day 4)
• Maintenance: Tacrolimus (target trough 8-12 ng/mL for first 3 months, then 5-8 ng/mL), mycophenolate mofetil 1000 mg twice daily, prednisone taper (starting 500 mg methylprednisolone intraoperatively, taper to prednisone 5 mg daily by 3 months)

1. Postoperative monitoring: Hourly urine output (expect immediate graft function with living donor), daily creatinine, tacrolimus trough levels every 2-3 days initially, Doppler ultrasound of graft on postoperative day 1 and if any concern for vascular complications
2. Infection prophylaxis: Trimethoprim-sulfamethoxazole (Pneumocystis and UTI prophylaxis for 6-12 months), valganciclovir (CMV prophylaxis for 3-6 months given CMV D-/R+ would be needed if applicable), nystatin oral suspension (candida prophylaxis for 3 months)
3. Long-term surveillance: Transplant clinic weekly for first month, biweekly for months 2-3, monthly for months 4-12, then every 3 months. Monitor creatinine, tacrolimus levels, urinalysis, BK virus PCR (months 1-12), CMV PCR, metabolic panel. Protocol surveillance biopsy at 3 and 12 months (center-specific). Screen for post-transplant diabetes, malignancy, and cardiovascular disease
4. Recurrent IgA nephropathy monitoring: IgA nephropathy recurs histologically in 30-50% of transplants but causes clinically significant graft loss in <10%; monitor with protocol biopsies and urinalysis for proteinuria/hematuria

Key Learning Points

• Living donor kidney transplantation provides superior outcomes compared to deceased donor transplantation: better 1-year and 5-year graft survival rates (97% and 90% vs. 93% and 78%), immediate graft function, planned surgery, and avoidance of prolonged dialysis exposure
• A comprehensive recipient evaluation includes cardiac risk assessment, malignancy screening, infection screening, vascular imaging, urologic evaluation, and psychosocial assessment to identify and mitigate perioperative risks
• The donor evaluation must include independent donor advocacy to ensure voluntary, informed consent without coercion, along with thorough medical, surgical, and psychosocial assessment
• Panel Reactive Antibody (PRA) reflects the recipient's degree of HLA sensitization; a PRA of 0% indicates no preformed anti-HLA antibodies and the lowest immunologic risk for transplantation
• IgA nephropathy can recur in the transplant, but clinically significant graft loss from recurrence is uncommon (<10%); it should not preclude transplantation, though patients should be informed and monitored

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