Advances in Understanding of Long-Term Living Kidney Donor Risks: A Review

Expansion of living kidney donation is needed to meet the increasing global need for kidney replacement therapy. Advances in the understanding of postdonation health outcomes have confirmed that living donation in carefully selected donors is associated with a low absolute risk of kidney failure of 50 per 10,000 after 20 years. However, information about lifetime risks, heterogeneity of risk, and the long-term safety of donors with chronic kidney disease risk factors before or after donation remains incomplete. This uncertainty likely contributes to the global stagnation in living-donor kidney transplantation. This review outlines the evolution of living kidney donor risk assessment, including the exclusion of hyperfiltration injury as a significant contributor to kidney failure after donation and the importance of postdonation chronic kidney disease risk factors and acute kidney injury as key determinants of postdonation kidney health. Given the low absolute risk of kidney failure, the review will identify policy and practice considerations needed to safely expand living kidney donation. Dedicated funding for postdonation care to ensure the optimal management of conditions that might compromise postdonation kidney function and facilitate the ascertainment of information to better inform current and future living kidney donors should be prioritized.