OPTN Living Kidney Donor Medical Evaluation Checklist

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Living Kidney Donor
Medical Evaluation Checklist

OPTN policy changes for living donation, effective February 1, 2013, (with most recent revision February 1, 2014), created national standards for the evaluation and informed consent of all living kidney donors. Programs may use this checklist to review their donor evaluation process and determine if it contains all the required elements as specified in OPTN Policy 14.0. The ‘OPTN Reference’ column indicates throughout the checklist which specific policy section applies.

The evaluation must be performed by one of the following:   
   Recovery hospital physician – OR
   Recovery hospital surgeon
The medical evaluation must assess the following:   
General History   
   Personal history:
   Hypertension
   Lung disease
   Heart disease
   Gastrointestinal disease
   Autoimmune disease
   Neurologic disease
   Genitourinary disease
   Hematologic disorders
   Bleeding or clotting disorders
   Cancers
   Infections
   Other
   Kidney-specific personal history:
   Kidney disease
   Proteinuria
   Hematuria
   Kidney injury
   Diabetes, including gestational diabetes
   Nephrolithiasis
   Recurrent urinary tract infections
   Active and past medications with special consideration for known nephrotoxic medication
   Allergies
Family History   
   Coronary artery disease
   Cancer
   Kidney-specific
   Kidney disease
   Diabetes
   Hypertension
   Kidney cancer
Social History   
   Occupation
   Employment status
   Health insurance status
   Living arrangements
   Social support
   Smoking, alcohol, and drug use/abuse
   Criteria to assess increased risk for disease transmission as defined by the 2013 PHS Guideline
   Psychiatric illness
   Depression
   Suicide attempts
Physical exam   
   Height
   Weight
   BMI
   Exam of all major organ systems
   Blood pressure
   Taken on at least 2 separate occasions – OR
   24-hour or overnight BP monitoring
General lab tests   
   Blood type and screen x2
   CBC with platelet count
   Prothrombin time (PT) or International Normalized Ratio (INR)
   Partial Thromboplastin Time (PTT)
   Metabolic testing
   Electrolytes
   BUN
   Creatinine
   Transaminase levels
   Albumin
   Calcium
   Phosphorus
   Alkaline phosphatase
   Bilirubin
   HCG quantitative pregnancy test for premenopausal women w/o surgical sterilization
   Chest x-ray
   Electrocardiogram (ECG)
Other metabolic testing   
   Fasting blood glucose
   Fasting lipid profile
   Cholesterol
   Triglycerides
   HDL cholesterol
   LDL cholesterol
   Glucose tolerance test and/or glycosylated hemoglobin in first degree relatives of diabetics and high-risk individuals
Kidney-specific tests   
   Urinalysis/urine microscopy
   Urine culture if clinically indicated
   Measurement of urinary protein and albumin excretion
   Measurement of GFR by isotopic methods – OR
   Creatinine clearance calculated from 24-hour urine collection
   Develop and comply with a protocol for polycystic kidney disease or other inherited renal disease as guided by family history
   24-hour urine stone panel (if patient has nephrolithiasis or history of it) (>3 mm)
   Calcium
   Oxalate
   Uric acid
   Citric acid
   Creatinine
   Sodium excretion
Anatomic assessment   
   Radiologic imaging (may include CT angiogram or MR angiogram
Screening for transmissible disease   
   Infectious disease testing
   CMV antibody
   EBV antibody
   HIV 1, 2 antibody
   HepBsAg (Hep B surface antigen)
   HepBcAB (Hep B core antibody)
   HepBsAB (Hep B surface antibody)
   HCV antibody
   RPR
   TB (if potential donor is at risk for infection)
   Intradermal PPD - OR
   Interferon Gamma Release Assay (IGRA)
   Additional infectious disease testing (if from endemic area)
   Strongyloides
   Trypanosoma cruzi
   West Nile
Cancer screening: Recovery hospital must develop and comply with protocols consistent with  the American Cancer Society (ACS) to screen for;   
   Cervical cancer
   Breast cancer
   Prostate cancer
   Colon cancer
   Skin cancer
   Lung cancer
Required exclusion criteria:      
   Less than 18-years-old AND mentally incapable of making an informed decision
   Uncontrollable HTN or history of HTN with evidence of end stage organ damage
   HIV
   Diabetes
   Active malignancy or incompletely treated malignancy
   High suspicion of donor coercion
   High suspicion of illegal financial exchange between donor and recipient
   Evidence of acute symptomatic infection (until resolved)
   Diagnosable psychiatric conditions requiring treatment before donation, including any evidence of suicidality

This checklist contains required elements found in OPTN Policy 14.0 that pertain to medical evaluations for the living donor patient. Use of this checklist is not required, nor does its use guarantee an assessment of compliance upon site survey. The checklist can be used as a tool for members in the development of their site-specific templates, tools, and internal policies and procedures.  Use of this checklist does not replace the need to thoroughly document completion of all elements required by OPTN policy.
01/23/14