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Commentary

Benefits of Kidney Transplantation or Living Donation?

Gaillard, François MD, PhD1

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doi: 10.1097/TXD.0000000000000999
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Worldwide, transplants from living kidney donors represented 34 % of the 91 465 kidney transplantations in 2018.1 Yet, in geographic areas without deceased-donor programs, living kidney donation represented the majority of kidney transplants.

Over the past 10 y, our understanding of the consequences of living kidney donation was transformed. Two independent studies evidenced an increased risk of end-stage renal disease (ESRD) for donors compared with healthy nondonors in Norway2 and in the United States.3 In addition, living kidney donation was associated with an increased risk of gestational hypertension or preeclampsia.4,5 Consequently, risk factors for ESRD, in a subset of the general population6 or in living kidney donors,7,8 were identified, and ESRD risk calculators were developed. Based on these findings, guidelines were formulated to facilitate the evaluation and the care of living kidney donors.9,10 The recent literature added a significant amount of evidence on the future risks for living kidney donors. Although all the guidelines acknowledge that the candidate to donation should be informed of the risks and benefits of donation, scientific evidence for the benefit of living kidney donation is lacking.11,12 Reese et al11 and Van Pilsum Rasmussen et al12 both advocated for the consideration of potential benefits of donation for living kidney donors.

In 2018, Reese et al13 compared 43 individuals who were turned down for living kidney donation to 128 living kidney donors at a single center. They found that being turned down for living kidney donation was not associated with quality of life, depression, or financial stress, compared with donors. There tended to be differences in qualitative assessment of quality of life.

The same year, Rodrigue et al14 reported the evolution of psychosocial outcomes at 1, 6, 12, and 24 mo after donation in a population of 193 living kidney donors recruited between 2011 and 2013 at 6 different transplant centers in the United States. In this study, the incidence of new-onset mood disturbance (16%), fear of kidney failure (21%), body image concerns (13%), and life dissatisfaction (10%) was low. However, results from this study are presented as a stability of mood situation after donation compared with predonation. The study was not designed to evaluate potential benefits of living kidney donation, and the proportion of donors who were caregiver-partners was not evaluated.

In the present issue of Transplantation Direct, Van Pilsum Rasmussen et al15 compared the evolution of caregiver burden and relationship quality between dyads of patient-partners and caregivers-partners after the initiation of dialysis and after renal transplantation. This study highlights the difficulty of including caregiver-partners in retrospective studies: of the 417 eligible patients with a caregiver-partner, only 86 caregiver-partners participated. The authors acknowledged that the limited number of participants and the retrospective design are limitations to this study.

The most prominent result is that caregiver-partners experienced significant improvements in their quality of life and relation after renal transplantation of the patient-partner. In particular, caregiving burden and sexual relationships returned to predialysis levels. These results suggest that kidney transplantation of the patient-partner is associated with a benefit for the caregiver-partner. Noteworthy, this study was not conducted exclusively among caregiver-partners who donated a kidney. Hence, the benefits of kidney transplantation on the caregiver-partner quality of life are not adjusted for living kidney donation. In particular, it is unknown whether changes in the quality of life of caregiver-partners who donated a kidney were different (after transplantation of their patient-partner) from the changes in quality of life of caregiver-partner who did not donate.

Beyond the balanced information of candidates to donation, between risks and benefits, the question of integrating expected benefits as a part of living kidney donor screening remains unanswered. To date, no guideline integrates the expected benefits as part of predonation evaluation. Yet, according to the results from this study, benefits seem tangible and support further research in a population of living kidney donors.16 This is a first step toward deciphering the potential benefits of living kidney donation.

References

1. Global Observatory on Donation and Transplantation. Available at http://www.transplant-observatory.org/. Accessed February 24, 2020.
2. Mjøen G, Hallan S, Hartmann A, et al. Long-term risks for kidney donors. Kidney Int. 2014; 861162–167. doi:10.1038/ki.2013.460
3. Muzaale AD, Massie AB, Wang MC, et al. Risk of end-stage renal disease following live kidney donation. JAMA. 2014; 3116579–586. doi:10.1001/jama.2013.285141
4. Garg AX, Nevis IF, McArthur E, et al.; DONOR Network. Gestational hypertension and preeclampsia in living kidney donors. N Engl J Med. 2015; 3722124–133. doi:10.1056/NEJMoa1408932
5. O’Keeffe LM, Ramond A, Oliver-Williams C, et al. Mid- and long-term health risks in living kidney donors: a systematic review and meta-analysis. Ann Intern Med. 2018; 1684276–284. doi:10.7326/M17-1235
6. Grams ME, Sang Y, Levey AS, et al.; Chronic Kidney Disease Prognosis Consortium. Kidney-failure risk projection for the living kidney-donor candidate. N Engl J Med. 2016; 3745411–421. doi:10.1056/NEJMoa1510491
7. Massie AB, Muzaale AD, Luo X, et al. Quantifying postdonation risk of ESRD in living kidney donors. J Am Soc Nephrol. 2017; 2892749–2755. doi:10.1681/ASN.2016101084
8. Ibrahim HN, Foley RN, Reule SA, et al. Renal function profile in white kidney donors: the first 4 decades. J Am Soc Nephrol. 2016; 2792885–2893. doi:10.1681/ASN.2015091018
9. British Transplantation Society, The Renal AssociationGuidelines for Living Donor Kidney Transplantation. 2018. 4th ed. Available at https://bts.org.uk/wp-content/uploads/2018/07/FINAL_LDKT-guidelines_June-2018.pdf. Accessed April 2, 2020
10. Lentine KL, Kasiske BL, Levey AS, et al. KDIGO clinical practice guideline on the evaluation and care of living kidney donors. Transplantation. 2017; 1018S Suppl 1S1–S109. doi:10.1097/TP.0000000000001769
11. Allen MB, Abt PL, Reese PP. What are the harms of refusing to allow living kidney donation? An expanded view of risks and benefits. Am J Transplant. 2014; 143531–537. doi:10.1111/ajt.12599
12. Van Pilsum Rasmussen SE, Henderson ML, Kahn J, et al. Considering tangible benefit for interdependent donors: extending a risk-benefit framework in donor selection. Am J Transplant. 2017; 17102567–2571. doi:10.1111/ajt.14319
13. Reese PP, Allen MB, Carney C, et al. Outcomes for individuals turned down for living kidney donation. Clin Transplant. 2018; 3212e13408. doi:10.1111/ctr.13408
14. Rodrigue JR, Schold JD, Morrissey P, et al.; KDOC Study Group. Mood, body image, fear of kidney failure, life satisfaction, and decisional stability following living kidney donation: findings from the KDOC study. Am J Transplant. 2018; 1861397–1407. doi:10.1111/ajt.14618
15. Van Pilsum Rasmussen SE. Kidney dyads: caregiver burden and relationship strain among partners of dialysis and transplant patients. Transplant Direct. In Press
16. Lentine KL, Lam NN, Segev DL. Risks of living kidney donation: current state of knowledge on outcomes important to donors. Clin J Am Soc Nephrol. 2019; 144597–608. doi:10.2215/CJN.11220918
Copyright © 2020 The Author(s). Transplantation Direct. Published by Wolters Kluwer Health, Inc.