The Rationale for Living Donor Kidney Transplantation

Successful kidney transplantation provides a new lease on life. The majority of kidneys used for transplantation become available upon the death of a donor (DD). This is mainly due to the small numbers of kidneys from living donors. In other parts of the world, living donors account for the majority of transplanted kidneys. In the US the number of living donor kidneys has changed little over recent years and accounts for only around 20% of all transplants. This article will describe the rationale for receiving a kidney from a living donor.

Key takeaways:
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    Both the short term and long-term results of transplantation using kidneys from living donors are superior to those from deceased donors.
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    Being a living kidney donor has little risk and tremendous potential impact on the recipient’s longevity and quality of life.
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    Waiting times for patients needing a deceased donor kidney can be as long as 2 ½ - 3 years. By contrast, a transplant from a living donor can be planned so it is done at a convenient time for the donor and when the recipient is medically stable.
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    Although living donors contribute to the total number of kidneys available for transplantation, the majority is from deceased donors. A greater pool of living donors will not only improve outcomes for the recipients but also increase the likelihood of shortening the time until a kidney becomes available for patients on the waiting list.

The number of available DD kidneys is gradually increasing but remains woefully inadequate given that there are more than 90,000 US patients on the DD waiting list. Living donors can safely undergo surgery to remove one of their kidneys and living donor kidney transplants have superior outcomes compared to those from a DD.


Kidney transplantation began as a highly technical specialty for carefully selected patients in a limited number of expert centers. Today, it is widely available to those with late kidney failure or on dialysis. Despite this, it is fair to say that one of the biggest obstacles to getting a kidney transplant is the limited supply of kidneys.

There are two types of kidneys for transplantation: from a living donor (LD), or one that has been donated after death (a deceased donor or DD). There wasa 20% increase of available DD kidneys for transplantation between 2017 and 2021 but this is not sufficient to meet the current demand. During the same time, the percent of kidneys from living donors has not appreciably changed (see figure).

chart showing source of transplanted kidney
Figure 1. The annual number of Living and Deceased Donor kidneys transplanted in the US

As a result, around 90,000 patients in the US await a transplant and many die before a kidney becomes available. Increasing the number of LD kidneys for transplantation is one obvious solution.

Although transplanted kidneys rarely function “forever”, outcomes continue to improve with new discoveries, medications, and techniques. One consistent observation in the kidney transplantation field is that kidneys from living donors do better in both the short and long-term compared to those from deceased donors.

Who can become a kidney transplant living donor?

LD kidneys from family members, relatives, or friends comprise almost all LD transplants. There also are a small number of altruistic donors who are willing to provide non-directed donations of one of their kidneys. This means that the kidney is donated as a gift to someone in need.

Individuals must meet several requirements to be eligible as a donor. Overall, they must have two normal functioning kidneys, be in good physical and mental health, not be obese orhave a condition or disease that would adversely affect their health or kidney function in the long-term.

There also are several specialized blood tests to evaluate the “match” of the donated kidney to the recipient. A particularly special situation arises when there is an optimal match with the recipient. These are most often siblings of the patient.

What are the benefits of an LD kidney transplant?

To the donor:

  • Donors almost universally enjoy amazing self-esteem as someone who has saved and changed the life of a spouse, family member, or friend. Donation of a kidney is truly a gift of life.
  • Overall, complications from donor surgery are uncommon and the risk of death is around one per 16,000 procedures.
  • Spouses or family members who have participated in the patient’s care during the time of kidney failure and dialysis generally have less stress, more independence, and quality time.
  • Donors who also are the principal caregivers may be able to resume a full-time career or job, as well as enjoying household stability and better family finances.
  • Overall, removing a kidney has not been shown to affect the donor’s lifespan.

To the recipient:

Data gathered over the last several decades compare LD and DD kidney transplants. It has been shown that:

  1. Having an LD kidney for transplantation eliminates the waiting time for a kidney which may be 2 ½ to 3 years or more.
  2. An LD kidney ends the need for dialysis. The lifespan of patients receiving an LD kidney is significantly longer than those who receive a DD kidney or remain on dialysis.
  3. Compared to DD transplants, LD kidneys begin to function more quickly and function longer. 80% to 90% of LD kidneys continue to function after five years compared to less than 70% for DD kidneys. On average, LD kidneys last 15 to 20 years and 10 to 15 years for DD kidneys.
  4. In general, LD recipients have fewer episodes of rejection and require lower doses of posttransplant immunosuppressive medications.

There also are several other indirect but important benefits of an LD kidney. Living donor kidneys increase the available pool of DD kidneys thereby shortening the waiting time for those awaiting a kidney from a DD. In terms of the considerable costs and medical risks of long-term dialysis, LD kidneys can diminish the number of transplanted patients who end up returning to dialysis.

Finding a living donor

Most living donors are family members or spouses. Once they realize that a transplant is needed, potential donors often step forward. Nonetheless, discussions of LD transplantation with a family member or close friend can be very awkward. There are numerous helpful resources available that can assist you in feeling comfortable raising the issue with a potential donor.

Financial costs for the donor

The recipient’s Medicare or private health care will pay most of the costs for the donor. Specifically, these include:

  • The donor’s medical evaluation, laboratory and x-ray studies, and tissue matching with the recipient.
  • Surgery to remove the kidney.
  • Medical or surgical care in the period following donation.

Some expenses may not be covered. These include:

  • Wages and time lost due to the donation process. When available, sick leave may help to diminish your expenses. The Family and Medical Leave Act will also protect your job during qualifying absences.
  • Incidental expenses during the transplant evaluation and donation processes. These include travel and housing expenses and childcare. Living donors should inquire whether the hospital offers reduced or no cost housing.

Note that a living donor can get considerable support through several programs that include the American Transplant Foundation, National Kidney Registry Donor Shield Center, and the National Living Donor Assistance Center.

There are also numerous websites for the exchange of information between potential donors. The hospital’s transplant social worker or financial counselor can help you take advantage of these and other programs.

One of the biggest obstacles to getting a kidney transplant is the limited supply of kidneys. Kidneys from living donors do better in both the short and long term compared to those from deceased donors. Individuals must meet several requirements to be eligible as a donor, including having two functional kidneys. Living donor kidneys also increase the available pool of DD kidneys, thereby shortening the waiting time for those awaiting a kidney from a DD.


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