dromlakhani DBD with Diabetes and/or Hypertension — Kidney Donor Eligibility
Use this skill when a brain-dead deceased donor has diabetes mellitus, hypertension, or both, and the team needs to decide whether the kidney is acceptable for transplantation, or whether procurement biopsy is needed.
This skill is kidney-focused. Heart-specific criteria are handled in a separate skill.
STEP 1 — Confirm the diagnosis is real
Before applying the checklist, confirm DM and/or HTN actually exists:
- Diabetes: FBS ≥126 mg/dl (7.0 mmol/L) on ≥2 occasions, OR 2-h OGTT ≥200 mg/dl (11.1 mmol/L), OR documented prior diagnosis on treatment.
- Hypertension: documented prior diagnosis, on antihypertensive treatment, or sustained BP elevation pre-arrest (not transient ICU spikes from raised ICP).
If neither is real → this skill doesn't apply.
STEP 2 — Apply the ISOT 2025 Table 4 checklist
The donor should ideally meet all of the following 14 criteria:
| # | Criterion | Threshold |
|---|---|---|
| 1 | Age | >55 years |
| 2 | DM type | NIDDM (non-insulin dependent) |
| 3 | Oral GLDs | ≤2 agents |
| 4 | DM duration | >3 years |
| 5 | Smoking | Non-smoker |
| 6 | Hypertension | None, OR controlled |
| 7 | BMI | <30 kg/m² |
| 8 | Fundus exam | Normal (no diabetic retinopathy) |
| 9 | End-organ / diabetic complications | None |
| 10 | Hyperlipidaemia | Well-controlled if present |
| 11 | UACR or UPCR | <30 mg/g or <200 mg/g |
| 12 | HbA1c | <7% on ≥3 occasions in past 2 years |
| 13 | GFR | ≥80 ml/min |
| 14 | Organ function | Normal |
Count how many criteria are met / not met / unknown.
STEP 3 — Generate the verdict
| Pattern | Verdict | Action |
|---|---|---|
| All 14 met | ✅ Suitable | Allocate to recipient with end-stage organ failure. |
| 1–3 minor criteria failed (e.g., BMI 30–32, mild hyperlipidaemia, smoking history but no end-organ damage) | ⚠️ Borderline | Procurement biopsy + case-by-case decision. ISOT explicitly allows case-by-case use. |
| Any major criterion failed: significant proteinuria (UACR ≥30), GFR <60, end-organ damage, moderate-severe retinopathy, BMI ≥35, IDDM with long duration, uncontrolled HTN | ❌ High risk — decline | Unless recipient outcome would otherwise be poor without transplant (e.g., highly sensitised, long waiting time). |
STEP 4 — Procurement biopsy if borderline
If kidney quality is uncertain after the checklist, request a procurement biopsy and apply the MAPI score (Maryland Aggregate Pathology Index).
- MAPI <7 → ~90% graft survival → use the kidney.
- MAPI 7–11 → intermediate → consider dual kidney transplant or single allocation to lower-risk recipient.
- MAPI >11 → high risk → discard or dual-kidney transplant only.
Cross-reference: see the mapi-score-calculator skill for the histological scoring system (glomerulosclerosis, tubular atrophy, interstitial fibrosis, arteriolar narrowing).
STEP 5 — Counsel the recipient
Required disclosures before transplant:
- Diabetic donor: minimally higher rates of DGF, primary non-function, acute rejection. Marginal difference in graft survival vs SCD. Recipient survival not significantly different.
- Hypertensive donor: similar to non-hypertensive ECD outcomes; HTN alone has minor impact on graft function.
- Counter-argument for the patient on dialysis: waiting on dialysis carries higher mortality than accepting a marginal diabetic kidney.
Document informed consent.
COUNTER-ARGUMENT — Don't reflexively decline a diabetic donor
A common mistake is to discard a kidney from any diabetic deceased donor. The data don't support this:
- USRDS data: Recipient survival from diabetic SCDs often exceeds that of non-diabetic ECDs. The "diabetic donor = bad kidney" reflex misallocates organs.
- UNOS data: Diabetic donor kidneys have only minimally increased risk of primary non-function, acute rejection, or DGF, with marginally lower graft survival.
- Reversibility: Early diabetic changes in donor kidneys (mesangial expansion, mild glomerulosclerosis) may be reversible post-transplant in non-diabetic recipients.
- Hypertension data: International registries show HTN in 15–20% of deceased donors; outcomes are largely indistinguishable from non-hypertensive donors when HTN is controlled.
Bottom line: The decision is "marginal vs no transplant", not "marginal vs perfect". For a recipient on dialysis with no other offers, a Table-4-compliant diabetic/hypertensive donor is almost always the better choice.
CLINICAL GUARDRAILS
- Don't decline on DM/HTN diagnosis alone — apply the 14-criterion checklist first.
- GFR ≥80 and UACR <30 are the two highest-yield filters — if these are clean, the kidney is usually usable.
- Insulin-dependent diabetes (IDDM) is a near-stop unless duration is short and end-organs intact.
- Procurement biopsy is the tiebreaker — use MAPI for objective grading.
- No upper BP cutoff is set by ISOT — judgment-based, prefer "controlled HTN" with no LVH or end-organ damage.
- Donors not meeting all criteria can still be considered case-by-case — the table is a guide, not a hard gate.
OUTPUT TEMPLATE
DONOR: [age, sex, DM type, DM duration, HTN status]
Comorbidity profile: [smoking, BMI, lipids, retinopathy, proteinuria, GFR, HbA1c]
Criteria met: __ / 14
Failed criteria: [list]
Unknown criteria: [list — request these]
Verdict: [Suitable / Borderline-biopsy / Decline]
Recommended action: [allocate / procurement biopsy + MAPI / decline]
Recipient counselling points: [DGF risk, graft survival, dialysis alternative]
SOURCE
Balwani MR, Kute VB, Shrimali J, et al. ISOT position statement on the feasibility of an organ for transplantation from brain-dead deceased donors: a Delphi consensus. The Lancet Regional Health – Southeast Asia 2025;39:100628. DOI: 10.1016/j.lansea.2025.100628
Specifically: Statement 7 and Table 4 (Eligibility criteria for selecting deceased donor with diabetes and/or hypertension).
Supporting evidence: USRDS, UNOS, and international registry data referenced in the ISOT consensus discussion.