Expanding living kidney donation: Lessons learned from the United States' seven decades-long experience

The performance of the first kidney transplant seven decades ago was surrounded by great uncertainty and even greater brilliance. The uncertainty was largely related to two major issues. First, whether the procedure would be successful considering the limited pharmacological options that were available to tame the recipient's immune system. Second, the short- and long-term consequences for the person donating a kidney. Decades later, we have been able to declare kidney transplantation as the most ideal treatment for those patients who have kidney failure. Not only does kidney transplantation prolong one's lifespan, but it also improves quality of life in both the physical and mental health domains.

More than 200,000 people have donated a kidney in the United States and more than a million people worldwide. Collectively, the odds of developing serious kidney problems after donation are 1 to 2% in the lifetime of the kidney donor. While this risk of kidney failure is higher than a comparable healthy person with two kidneys, it remains multiple folds lower than what is encountered by the general population. Perhaps one of the most striking statistics is the fact that the majority of those who have donated a kidney in the past do not have regrets about donation.

Despite these superb results achieved with kidney transplantation for the recipient and extremely favorable long-term outcomes for living kidney donors, the most pressing issue today is the lack of adequate kidneys for the tens of thousands of people who are waiting for this life-saving procedure. Multiple studies have shown that it would be extremely unlikely that each person can be transplanted, even if every person dying from a car accident, drug overdose or other conditions could become a deceased donor.

Expanding the pool of living kidney donors in a manner that continues assiduously is the overarching goal of living kidney donation. This expansion, however, can be achieved by making living kidney donation more accessible to people who have been typically excluded from donation. There are compelling data and evidence that our current exclusions of living kidney donors disadvantage many people who want to help their loved ones. One could argue that these arbitrary exclusions are a violation of the kidney donor candidate autonomy.

Our research over the last 20 years has demonstrated the safety of kidney donation in people who have well-controlled hypertension, well-controlled diabetes, are overweight, those with prior history of kidney stones and many other groups that have been typically excluded from kidney donation.

We believe the time has come where the main stakeholder, the kidney donor candidate, should become part of the decision making regarding the level of risk they are willing to endure to help their loved one. Combining kidney donors' autonomy with the state of our knowledge regarding the outcomes of kidney donors will undoubtedly ameliorate the current dire situation of patients with kidney failure. The principle of do no harm in the context of living kidney donation needs to be challenged and perhaps replaced with taking measured risk that is acceptable to the donor candidate.