Multiple Reasons for Living Donor Denial: A Single Center Experience

Introduction

Living donor kidney transplantation (LDKT) is the preferred treatment for end stage kidney disease because it leads to better survival than either dialysis or deceased donor transplantation. Despite high numbers of potential donors, the rate of LDKT continues to stagnate. To address this, transplant centers have considered liberalizing eligibility criteria for living donors. To understand the impact that changing any criterion might have on increasing the acceptance rate of living donors, we analyzed the primary reasons for denial at our center.

Materials and Methods

In this single-center retrospective study at UCLA Medical Center, medical records of all potential living donors presenting to the living donor selection committee from 2009 to 2014 were reviewed, with reasons for donor denial coded. Previous screening confirmed no history of diabetes mellitus, hypertension before the age of 50, hypertension ≥ 50 years old, taking more than one anti-hypertensive drug, having a body mass index (BMI) ≥35, or malignancy other than skin cancer. Prior to selection committee presentation, they had also undergone HLA testing, were histocompatible with their recipient, completed transplant evaluation, and were committed to donation. Denials after committee review were categorized as medical, surgical, or social by two coders. Both absolute and relative contra-indications were included. Multiple reasons could be coded per case. Coder disagreement was resolved through discussion.

Results

Of 1370 individuals, after committee review, 55% (760) were accepted as potential donors, 16%(225) required further workup, and 28% (385) were denied, 84% for multiple reasons (Table). The median number of reasons for denial per potential donor was two (IQR, 2–3), but some were denied for as many as nine reasons. The most common reasons were medical: young age (<25 years old), family history of diabetes in a first degree relative, another medical issue, and pre-diabetes or diabetes. The top social reason was a prior history of psychiatric illness other than depression, and the top surgical reason was evidence of a renal lesion. Thirty-eight percent (148) had denials in multiple categories.

Table.

Reasons for denying potential living donors, categorized by medical (grey), surgical (white), and social (blue).

UCLA-specific absolute contraindications to donation include pre-diabetes/diabetes, fatty liver, hematuria, hypertension in patients <50 years old or in those ≥ 50 years old on more than one anti-hypertensive, and obesity (BMI ≥30). Of the 385 denied donors, 132 (34%) had at least one absolute contra-indication, with only 30 (8%) having more than one (Figure).

Figure Legend.

Reasons for denying potential living donors. A. Categories of reasons potential donors were denied. B. Number of reasons for denial per potential donor.

History of diabetes in a first-degree relative is not an absolute contraindication, yet it was the second leading reason for denial (N=82). All individuals denied for a family history of diabetes had additional reasons for denial, most often young age (N=50, 61%). Notably, 42 (51%) potential donors with a family history of diabetes also had an absolute contraindication to donation.

Since some centers allow obese individuals to donate, we looked at the other reasons obese potential donors were denied. Of the 41 donors denied for obesity, only six (15%) had no other reasons for denial. Eighteen (44%) were also denied for either pre-diabetes/diabetes, hypertension, or fatty liver, which would have also disqualified them.

Discussion

Of these cases, the selection committee denied almost one-third of potential living donors, most due to reasons spanning multiple categories. Previous studies have described similar primary reasons potential kidney donors were denied (1–5). Specifically, others found that 17–40% of potential donors were denied for non-immunological reasons, with hypertension, prediabetes/diabetes, and obesity among the leading medical reasons for non-donation. While previous studies propose that allowing medically complex donors to donate could increase the rate of LDKT substantially, we find that the increase would be modest due to the presence of multiple absolute and/or relative contraindications.

This study is only a single-center study, with data on potential recipients and their outcomes not available. There is selection bias in that we did not include donors who were screened out before the evaluation committee, including histo-incompatible donors. Even with these limitations, the findings reflect the experience of one of the top five US centers for LDKT. It is also, to our knowledge, the first to document multiple reasons for denial per potential donor.

In conclusion, nearly a third of potential living donors were denied, most for multiple reasons. Modifiable opportunities to increase living donors might include medically monitored life style alterations or relaxing acceptance criteria for older donors. However, effective interventions to increase the rate of acceptance of potential donors must be multi-faceted since addressing single causes for living donor candidate rejection is unlikely to clear many potential donors for donation.