Dottorato in Fisiopatologia Medica

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Renal function reserve (RFR) in living donor renal transplantation (LDRT)

Kidney transplantation confers a better quality of life and better survival compared with dialysis and is more cost-effective over the long-term. Living kidney donation (LKD) presents an important source of organs given the shortage of deceased donor kidneys. Growing confidence, based on satisfactory short- and long-term outcomes in living kidney donors (LKDs), has led to the inclusion of more borderline donors (i.e., older age, controlled hypertension, low-grade proteinuria, body mass index [BMI] up to 35) . In addition, the final decision of the transplant nephrologist in living donor selection is still highly dependent on estimated GFR, which is, however, not an ideal method to determine actual kidney function given the known factors affecting its accuracy (e.g., intake protein, muscle mass, physical activity, age, sex). Recent studies have highlighted poorer long-term outcomes in certain donor populations, such as those of African American or indigenous origin and obese donors. As all donors are generally well screened before donation, routine clinical parameters alone (blood pressure, urine protein, kidney function, body mass/size at the time of donation) have not been robust predictors of long-term risk in such donor populations .

Final acceptance of a living donor is, however, still highly dependent on GFR, which may be affected by multiple nonrenal factors (e.g., protein intake, muscle mass, physical activity, age, gender), and which when estimated, tends to underestimate measured GFR in LKDs .

After nephrectomy, the single kidney undergoes an adaptive increase in function of approximately 35%. The kidney's capacity to increase its glomerular filtration rate (GFR) in response to a higher functional demand is known as the renal functional reserve (RFR) .

Serum Creatinine level and GFR are the current standard tests to determine kidney function test (KFT). Since human kidneys don't always work at full capacity, thus the baseline GFR doesn't reflect full function of the kidney. Similarly, serum creatinine is not a sensitive measure for kidney injury or function. In healthy individuals the GFR physiologically increases in response to certain stresses or stimuli, such as protein loading. Renal function reserve (RFR) is defined as the difference between the maximal baseline GFR and the baseline GFR. The absence of a normal RFR can help to identify patients who are more susceptible to kidney injury .

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