Advances in Understanding of Long-Term Living Kidney Donor Risks

Expansion of living kidney donation is needed to meet the increasing global need for kidney replacement therapy. Advances in the understanding of post donation health outcomes have confirmed that living donation in carefully selected donors is associated with 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 pre-donation or post-donation chronic kidney disease (CKD) risk factors 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 post-donation CKD risk factor and acute kidney injury as key determinants of post-donation 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 post donation care to ensure the optimal management of conditions that might compromise post donation kidney function, and to facilitate the ascertainment of information to better inform current and future living kidney donors should be prioritized.