Hypertension after living kidney donation: incidence, predictors, and consequences

Living donor (LD) kidney transplantation is the optimal treatment for elective end-stage kidney disease (ESKD) patients. However, concerns about the long-term health risks for donors, including hypertension, remain incompletely defined. We aimed to determine the incidence and predictors of hypertension after kidney donation and to assess its association with estimated glomerular filtration rate (eGFR) trajectories over time. We conducted a retrospective cohort study of 300 LD who underwent nephrectomy between 1998 and 2020, after excluding those with pre-donation hypertension. Donors were followed for a mean of 6.4 ± 4.5 years The primary outcome was the development of de novo hypertension, defined by office blood pressure measurements exceeding 140/90 mmHg or initiation of antihypertensive therapy. Predictors of post-donation hypertension were evaluated using Cox regression analysis, and the association with longitudinal changes in eGFR was assessed using linear mixed-effects models. Hypertension developed in 30% of the cohort, with an incidence of 21% at 5 years and over 50% at 15 years post-donation. Higher body mass index (BMI) (HR 1.074 per Kg/m2, P = 0.039), dyslipidemia (HR 1.959, P = 0.035), and elevated systolic (HR 1.030 per mmHg, P = 0.009) and diastolic blood pressure (HR 1.036 per mmHg, P = 0.039) were independently associated with an increased risk of hypertension post-donation. The development of hypertension was associated with a modest but statistically significant decline in eGFR over time (-0.03 vs. +0.40 ml/min/year, P = 0.026). No donor progressed to ESKD during follow-up and cardiovascular events were rare in the cohort. In conclusion, hypertension was a frequent complication post-donation in this Southern European cohort and was associated with modifiable risk factors, as higher BMI and dyslipidemia. While the associated decline in renal function over time is modest, these findings highlight the importance of long-term monitoring and proactive management of cardiovascular risk factors in living kidney donors. These results should inform pre-donation counseling, post-donation follow-up strategies, and further research into interventions that may mitigate hypertension risk while preserving donor health.