Evaluation and Counseling of Living Kidney Donor Candidates

The evaluation of living kidney donor candidates is a complicated process to determine eligibility for donation and ensure that candidates are well-informed of postdonation risks, along with any uncertainty in risk estimations. The 2017 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors provided recommendations to assist transplant programs in the evaluation and care of donors before, during, and after donation. In this review, we highlight new research that has changed the landscape of the evaluation and counseling of donor candidates. In 2021, a race-neutral equation for eGFR aimed to promote health equity; however, relying solely on this measure to assess kidney function may lead to more Black candidates being excluded from living kidney donation. The role of genetic testing in the evaluation of donor candidates continues to evolve as evidence accumulates about the higher risk of kidney failure among biologically related donors. Recent recommendations emphasize targeted evaluation for familial monogenic kidney diseases and suggest offering apolipoprotein L1 genotyping to living kidney donors of African ancestry, although the implications of apolipoprotein L1 results for donor eligibility is an area of ongoing research and debate. In 2025, North American guidelines revised the BP threshold for diagnosing and treating hypertension from ≥140/90 to ≥130/80 mm Hg. This will have implications in the assessment of donor candidates, who may be more likely to be declined for donation or put on hold until these new BP targets are reached. Finally, new evidence supports that male donor candidates should be informed of the higher risk of testicular-related complications postdonation compared with nondonors. Policy makers, guidance workgroups, and transplant programs will need to consider how these findings influence local practices related to the evaluation, counseling, and care of donor candidates.