A 44 year old Greek-Cypriot man is reviewed in an emotional renal outpatient clinic. His renal function hasbeen progressively deteriorating over the past 5 years secondary to poorly controlled type 2 diabetesmellitus. His eGFR is now 7 ml/min but continues to pass urine. Recent ultrasound scans have shown thathe would anatomically be suitable for a renal transplant. However, you explain that in the context of hisethnicity, there is an uncertain wait for suitability of organs, should the patient require to proceed down thispath. His 15 year old son, who is present with the patients two daughters and wife, offers his father a donorkidney due to the high likelihood of compatibility, which the patient would like to proceed with. He hasundergone a set of blood tests in your clinic:

Hb 8.9 g/dl

Platelets 178 * 10 /l

WBC 6.5 * 10 /l

Na 144 mmol/l

K 5.3 mmol/l

Urea 18.2 mmol/l

Creatinine 280 µmol/l

pH 7.32

What is the most appropriate next step?

Monitor renal function, discuss renal replacement therapy in 6 months time

Start haemodialysis today, discuss renal replacement therapy in 6 months time

Start preparation for haemodialysis and list for renal transplant on national transplant list

Start preparation for haemodialysis and list for renal transplant with the patients son's kidney

Palliation

The underlying cause of the patient's renal dysfunction is poorly controlled diabetes and unlikely to

Question 6 of 40

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improve spontaneously. He has no acute indications for acutely starting renal replacement therapy. Thetiming of renal transplantation is debated due to the variable rates of renal function decline betweenpatients but it is accepted that once the underlying pathophysiology is deemed irreversible and eGFR hasdeteriorated to less than 30, transplantation should be discussed. Palliation would be wholly inappropriate.

The key issue is with regards to the ethics of using the donor kidney of a minor, despite it likely to producethe best genetic match. Renal transplantation is a rigorous process and donors under 18 years of age arealmost never considered for renal transplantation, on the basis of validity of consent and autonomy in suchsituations . The patient should thus be placed first on the national register with preparations for renalreplacement therapy.

1. United Kingdom Guidelines for living donor kidney transplantation May 2011.

Renal replacement therapy

The timing of starting renal replacement therapy (RRT) in patients with end-stage chronic kidney disease(CKD) remains controversial. Patients usually begin dialysis when their glomerular filtration rate (GFR)reaches 10 ml/minute or 15 mL/minute if they are diabetic.

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