Donation, Not Disease! A Multiple-Hit Hypothesis on Development of Post-Donation Kidney Disease

Abstract

Purpose of ReviewThe risks following living kidney donation has been the subject of rigorous investigation in the past several decades. How to utilize the burgeoning new knowledge base to better the risk assessment, education, and health maintenance of donors is unclear. We review the physiologic and epidemiologic evidences on the post-donation state and submit a multiple-hit hypothesis to reconcile the finite elevation in risk of kidney disease after donation with the benign course of most kidney donors.Recent FindingsThe risk of end-stage kidney disease is higher in kidney donors compared to similarly healthy non-kidney donors. Nonetheless, post-donation kidney disease is uncommon and arises mostly in the setting of other “hits”—either a “first hit” present at birth or a “second hit” acquired later in life.SummaryThe transplant community’s focus should be directed toward (1) personalized risk assessment to inform consent before donation and (2) preventing and treating development of “second hits” following kidney donation.

Postdonation eGFR and New-Onset Antihypertensive Medication Use After Living Kidney Donation

“…PCD offers useful surrogate measures of medically-treated clinical conditions among donors. For now, while we do not believe donors have a “disease” and advocate strongly against misclassification that leads to insurance discrimination, 6 we do believe that donors should have access to health care and engage in long-term follow-up, including monitoring and early treatment of any medical comorbidity, such as hypertension that arises after donation, to help ensure optimal long-term health outcomes.…”

“…4 Yet, despite >60 years of experience with living donation, the consequences for donors of this nephron loss and lower eGFR remain unclear. A diagnosis of chronic kidney disease (CKD) not only implies that living kidney donors have similar cardiovascular morbidity and mortality risks to patients with native kidney CKD, 5,6 but inappropriate diagnoses of CKD may also create insurability problems for these otherwise healthy individuals. 5,7 Given that >1 in 4 donors have an eGFR below 60 mL/min/1.73 m 2 following donation, 8 the clinical implications of reduced eGFR in donors must be elucidated.…”

Outcome Measures Used to Report Kidney Function in Studies Investigating Surgical Management of Kidney Tumours: A Systematic Review

“…2B). Competing risks of adverse functional outcomes should be kept in mind when interpreting the results of studies with a longer follow-up duration, as the number of deaths may begin to introduce a bias, or CKD may be the result of a subsequent acute event and not a direct consequence of surgery [63].…”

Evaluation and care of international living kidney donor candidates: Strategies for addressing common considerations and challenges

“…Clearly, follow‐up plans will have different implications for international donors from countries with well‐established universal health care than for international donors from countries with rudimentary (if any) healthcare access. The transplant program should outline recommendations for long‐term care to support the health and well‐being of the donor and should serve as a resource to address questions from primary care physicians after the donor's return to their country of origin . A plan should be developed to address both medical and psychosocial postdonation concerns.…”