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Addressing the ESRD Risks of the Young Living Kidney Donor: Putting “Normal for Now” into Practice

  • Live Kidney Donation (KL Lentine, Section Editor)
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Abstract

Individuals who are free of traditional clinical risk factors for kidney diseases at the time of living kidney donation have been thought to be at low risk of end-stage renal disease (ESRD) after donor nephrectomy. However, the reassuring low rates of ESRD in available donor follow-up studies have captured only the risks of very rapidly progressing kidney diseases that begin during the study interval, not the higher risks of diabetic ESRD and other slowly evolving diseases that are far more common over a lifetime. The natural histories and age-related characteristics of renal diseases in the general population predict considerable undetected risk, particularly for normal young individuals, who typically will not reach ESRD until late in life. This makes the low long-term absolute risks of ESRD after donation that are suggested by two recent studies problematic. But these studies also suggest an 8–11-fold increased relative risk from donation, which they are well-designed to capture. These relative risks have been attributed to loss of GFR at donor nephrectomy and are consistent with well-accepted GFR-related risks in the general population. These observations indirectly implicate low-normal predonation GFR as an important ESRD risk factor, particularly for young donors. Even if relative risks are half of published estimates, some currently acceptable young donors—especially black donors—will have significantly higher risk for ESRD over their remaining lifespans than many older candidates with minor renal risk factors who are currently denied donation. Selection practices must be reformulated to recognize a uniform, ethically defensible risk standard for acceptance and exclusion of living kidney donors.

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Acknowledgments

I am grateful to the editors for inviting this commentary and to the late Bernard Gert for his mentorship. Katrina Schreiber assisted with manuscript preparation.

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  1. Robert W. Steiner

    Present address: UCSD Center for Transplantation, 4520 Executive Drive, San Diego, CA, 92121, USA

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  1. Department of Medicine, The University of California at San Diego Center for Transplantation and the Division of Nephrology, University of California at San Diego School of Medicine, San Diego, CA, USA

    Robert W. Steiner

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Steiner, R.W. Addressing the ESRD Risks of the Young Living Kidney Donor: Putting “Normal for Now” into Practice. Curr Transpl Rep 3, 15–23 (2016). https://doi.org/10.1007/s40472-016-0083-z

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