British Transplantation Society / Renal Association UK Guidelines for Living Donor Kidney Transplantation 2018

TRANSPLANT DEMOGRAPHICS Stable living donation rate representing approximately one third of total kidney transplantation. Near universal use of laparoscopic donor nephrectomy. 17% reduction in transplant waiting list largely driven by increased deceased circulatory death donation, the use of extended criteria donors, and developments within the UK Living Kidney Sharing Schemes to maximize the effectiveness of paired/pooled donation and nondirected altruistic donors. RISK FACTOR ASSESSMENT Updated thresholds for donation take account of the higher baseline glomerular filtration rate of men than women and are slightly less restrictive than previous recommendations. Updated pathway and recommended timeframes for donor assessment. Template screening questionnaire for the assessment of donor health. No upper limit for donation; however, careful risk factor assessment in donors older than 60. No formal upper limit of body mass index for donation, but increased risk when body mass index 30 to 35 kg/m2 and limited safety data greater than 35 kg/m2. Criteria for donor hypertension unchanged, but increased emphasis on ambulatory blood pressure monitoring and overall cardiovascular risk. Possibility of considering donation from patients with well-controlled type 2 diabetes with controlled risk factors and no target organ damage, subject to careful assessment of lifetime cardiovascular and renal risk. Use of stress echocardiography and/or computed tomography coronary angiography to evaluate potential donors at high cardiac risk. New recommendations relating to living donation from donors positive for HIV, hepatitis B and C, and hepatitis E. Formal genetic review recommended for potential donors with thin basement membrane disease, Alport syndrome, and focal segmental glomerulosclerosis. Updated recommendations regarding screening for complement deficiencies in atypical hemolytic uremic syndrome and C3 glomerulopathy. UK LIVING KIDNEY SHARING SCHEMES Increasing nondirected altruistic donation (10% of all living donor transplants) with default allocation of kidneys to create altruistic donor chains. Significant reduction in antibody-incompatible transplantation. Increasing use of kidney sharing schemes for compatible pairs to minimize age and human leukocyte antigen disparities where there are no immunological barriers to transplantation. Recommended template for the mental health assessment of the altruistic kidney donor. LONG-TERM OUTCOMES Reassuring data regarding long-term donor outcomes with regard to both renal function and mortality, with less than 1% risk of estimated glomerular filtration rate less than 30 mL/min or end-stage renal disease following donation. The above stated recognition that donor risk is marginally increased in higher risk groups such as black donors, young donors, obese donors, those with a family history of kidney disease, and relatives of recipients with renal failure secondary to immunological disease. Particular caution recommended in these potential donor groups. Recognition of increased obstetric risk in female donors of childbearing age. Recognition of the increasing use of extended criteria living donors and the need for long-term follow-up, with suggested models to facilitate this. Clarification of regulations and recommendations for assessment of potential donors nonresident in the UK, with an updated template letter for UK entry visa applications.1 ACKNOWLEDGMENTS We thank the many authors who contributed to this work.