Living kidney has major advantages over deceased donor kidney. In general, recipients of living kidney benefit from shorter waiting time, higher likelihood of preemptive transplantation, lower risk for delayed graft function (DGF), and has superior graft survival with a half-life of 12 to 15 years compared to 9 to 11 years for deceased donors.¹

A living donor evaluation is the process intended to protect the donor and to ensure that the donor is healthy enough to undergo surgery with minimal risk of developing adverse medical, psychosocial, and financial outcome after kidney donation.

The donor’s physician must balance a “do no harm” position with the autonomy of the donor, and carefully discuss the potential risks of donation.

The Organ Procurement and Transplantation Network (OPTN) has developed policies for all U.S. transplant centers and the minimum kidney donor suitability requirements and has incorporated these within existing global policies for all living donors prior to kidney donation.

OPTN requires informed consent, an independent living donor advocate (ILDA), blood typing report, medical evaluation, psychosocial evaluation, and a follow-up after kidney donation.^2,3

Informed consent is a core value in living donor evaluation based on the long-standing and widely held ethical principles.

The donor must have the ability to understand the risks, benefits, and consequences of donation and the capacity to make decision.

The donor must be willing to donate, free from inducement and coercion.

The donor should be informed of all of the following³:

The ILDA is a person or a team who is not involved in the potential recipient evaluation and is independent of the decision to transplant the potential recipient.³

The transplant center must provide ILDA for the donor to help the donor during evaluation process and to advocate the rights of the donor.

The ILDA must fulfill the qualification and training requirements including knowledge of living organ donation, transplantation, medical ethics, informed consent, and the potential impact of family or other external pressure on the living donor’s donation.⁴

ABO blood typing should be drawn on two separate occasions prior to donation to reduce risk of unintended blood type incompatible transplantation.³

ABO subtyping is performed to evaluate anti-A antibodies in recipients with blood type B or O receiving a kidney from donors with blood type A.

A2 kidney has a very low A antigen expression in the renal cortex and the entire vascular bed endothelium. This low A antigen expression in A2 kidney allows recipients of blood type B or O to receive a kidney from A2 donor if recipient has low anti-A titers.

The rhesus (Rh) factor is of little concern because it is not expressed on endothelial cells.

Transplant programs routinely performed human leukocyte antigen (HLA) typing in order to counsel the patients about matching and graft survival.

This includes HLA typing for major histocompatibility complex (MHC) class I (A, B, C) and MHC class II (DP, DQ, DR).

HLA matching is traditionally recorded as the number of A, B, and DR mismatched antigens.

For example, if a donor and a recipient share the same A, B, and DR antigens, this would be a 0A, 0B, 0DR mismatch.

Poor HLA matching does not preclude living kidney transplant as it still offers better graft survival than deceased donor kidney transplant with zero antigen mismatches.

Recipients with anti-HLA antibodies are at a higher rate of graft rejection.

Living donor psychosocial evaluation must be performed by a psychiatrist, psychologist, master’s prepared social worker, or clinical social worker.³

Psychosocial evaluation is performed for the following main reasons:

Significant psychiatric problems are generally considered a contraindication for donation.

The medical evaluation must be done by a physician or surgeon experienced in living donation.

Its purpose is to ensure that the donor is healthy enough to undergo the surgical procedure and that the donor is medically eligible for kidney donation.

Eligibility for kidney donation includes:

OPTN requirements for living donor medical evaluation are as listed in Tables 27-1 and 27-2.^3,5,6,7

Absolute exclusion for living kidney donation defined by the OPTN and relative exclusion criteria which may be variable between transplant centers are listed in Table 27-3.³

OPTN has defined absolute exclusion criteria when donor is both less than 18 years old and incapable of making decision.

Currently there is no absolute upper age limit for donation but the older donor has a higher likelihood of complications; therefore it is important to consider other comorbidities when evaluating older donor, particularly coronary artery disease.

A 2007 survey reported that most programs accepted candidate without upper limit of age.⁸

Long-term graft survival from older living donor is better than elderly deceased donor and similar to young deceased donor.

Hypertension is a contraindication for donation when the donor has uncontrolled hypertension or history of hypertension with end organ damage (e.g., microalbuminuria >30 mg/day, impaired renal function, cardiovascular events such as myocardial infarction or stroke, left ventricular hypertrophy).

Selection criteria for hypertension are more flexible especially if donor is older. The decision to accept the donor with hypertension should be individualized based on lifetime predicted end-stage renal disease (ESRD) risk to take into consideration.

Many centers allow mild hypertension that is controlled with one medication.