Living donor practices in the United States

Abstract

Living kidney donation is a common procedure in the United States. Substantial variation exists between transplant centers in their protocols and exclusion criteria for potential living donors. In the absence of clinical trial data to guide decisions about exclusion criteria, knowledge of current practices is an important first step in guiding the formulation of donor protocols and future studies. Certain trends in living donation practices have become apparent from surveys of transplant programs over the past few decades. Over the past 25 years, opposition to living unrelated donation in the United States has gone from strong to essentially nonexistent. With respect to donor age, programs have become less strict regarding upper age limits but stricter regarding younger donor candidates. Protocols regarding kidney function, blood pressure, and diabetes screening also continue to evolve. Although donor follow-up is mandated by the Organ Procurement and Transplantation Network for 2 years after donation, a majority of donors are lost to follow-up by 1 year. The most commonly cited barriers to donor follow-up include donor inconvenience, cost issues including reimbursement to care providers, and direct and indirect costs to donors. In this article, we review the current knowledge about living donor practices in the United States.

Figure 1

Trends in living versus deceased donors in the U.S. from 1998 to 2008. Note that the number of transplants performed from deceased donors was greater than the number of deceased donors, since many provide two kidneys.

Figure 2

Trends in living related versus living unrelated donors in the U.S. between 1999 and 2008.

Figure 3

Exclusion criteria by category of blood pressure. Reprinted with permission from Mandelbrot et al. Am J Transplant 2007.

Figure 4

Exclusion criteria based on BMI. Reprinted with permission from Mandelbrot et al. Am J Transplant 2007.

Figure 5

Degree of program flexibility in the application of donor selection criteria based on A) Younger donor age, B) Older donor age and C) Severity of recipient's medical condition. Reprinted with permission from Mandelbrot et al. Am J Transplant 2007.

Figure 6

A) Program expectations for postoperative follow-up times at the transplant center. B) For programs that recommend transplant center follow-up visits at specific times, what percentage of donors are actually seen at each time point? Reprinted with permission from Mandelbrot et al. Transplantation 2009.