The Unjustified Classification of Kidney Donors as Patients with CKD

Abstract

SummaryUnilateral nephrectomy for kidney donation results in loss of about 30% of baseline GFR, leaving some donors with GFR <60 ml/min per 1.73 m 2 , the threshold for the diagnosis CKD. This has resulted in insurability problems for some donors. This article reviews the definition of CKD, risks associated with CKD, and large follow-up studies on the vital status and risk of ESRD in kidney donors. It also provides evidence that kidney donors, despite having reduced GFR, are not at increased risk for CKD-associated morbidity and mortality. Epidemiologic studies, most with follow-up <10 years, have shown an association between GFR <60 ml/min per 1.73 m 2 and higher mortality and progression to ESRD. Low GFR in the absence of any other markers for kidney disease, however, conveys attenuated or minimal risk. Of note, studies of long-term kidney donor outcomes (6-45 years) have not shown excess mortality or ESRD. The limitation of the collective evidence is that the increased risks associated with GFR <60 ml/min per 1.73 m 2 were demonstrated in much larger cohorts than those reported for kidney donor outcomes, but donor outcome studies have substantially longer follow-up. On the basis of current findings, kidney donors with low GFR and no other signs of kidney disease should not be classified as having CKD. This is definitely not the reward they deserve, and, more important, the implications of reduced GFR in donors are not associated with unfavorable outcomes. In addition, the increasing number of patients who are interested in and are eligible for a kidney transplant has not been associated with a commensurate increase in the number of DD organs. This has resulted in a markedly longer waiting time on the list. The increasing waiting time for a DD transplant and the poor shortand mid-term results with dialysis have put increased emphasis on living donation. The major disadvantage of an LD transplant is the risk to the donor. Studies over the last three decades have noted a perioperative donor mortality rate of 3 in 10,000 (0.03%) and a major complication rate of ,1% (3-5). Laparoscopic nephrectomy is associated with quicker recovery than open nephrectomy but carries similar risk. To date, long-term follow-up studies report that donors, compared with controls, have similar or better survival rates, and perhaps lower rates of development of . In addition, donor quality of life after donation is excellent (15). Of concern, however, is that recent studies in the nondonor general population have suggested that reduced renal function is associated with increased cardiovascular and all-cause mortality; consequently, some former donors have had problems obtaining life and health insurance or are being forced to pay higher premiums (16,17). At the same time, some former donors with stable renal function have been labeled as having CKD. Herein, we review level of renal function after donation and the data on long-term survival and risk of ESRD after kidney donation. Definition of CKDMany observation studies have shown the a...

Renal Function Profile in White Kidney Donors: The First 4 Decades

“…First, that result might reflect the nature of GFRestimating models in this population. 4 We previously showed that only 15% of randomly selected donors had a measured iohexol GFR,60ml/min per 1.73 m 2 . 1, 5 We also previously showed that 60% of donors with an eGFR (by the CKD Epidemiology Collaboration [CKD-EPI] equation) ,60 ml/min per 1.73 m 2 had a measured GFR$60ml/min per 1.73 m 2 .…”

Living-Donor Kidney Transplantation

“…However, there will be groups of people for whom the Affordable Care Act is not expected to provide accessible insurance or adequate access to care after donation (i.e., those who cannot afford premiums, those who live in states that opted out of expanded Medicaid, undocumented immigrants). Albeit limited, data do indicate that living kidney donation may affect life insurability (27)(28)(29)32). Boyarsky and colleagues' singlecenter survey showed that of the 186 donors changing or initiating a life insurance application after donation, 46 (25%) reported difficulty (29).…”

Association of mGFR of the Remaining Kidney Divided by Its Volume before Donation with Functional Gain in mGFR among Living Kidney Donors

“…Compared with a deceased kidney donor, transplant from a living kidney donor is associated with longer graft and patient survival (3) as well as a markedly reduced waiting time for transplant. As noted in a recent review, the major disadvantage of living kidney transplantation is the risk for the donor (4). Although living kidney donation is now considered safe (5,6), epidemiologic studies have suggested that kidney donors are at increased risk for CKD (7), end stage CKD, and mortality (8,9).…”