The risk of kidney failure requiring kidney replacement therapy is very low but not zero in people who have donated a kidney.

A study, published as a research letter in The MJA [link here], provides the first Australian estimate of kidney failure treated with KRT after living kidney donation and offers some useful data to support donor counselling and consent.

The study used national linkage of the Australia and New Zealand Living Kidney Donor Registry and the Australia and New Zealand Dialysis and Transplant Registry to identify living kidney donors who had donated a kidney between 2004 and 2024 and were subsequently initiated on KRT.

It found just three of 5,291 living kidney donors commenced KRT at a median of 13.27 years after donation – an incidence rate of 0.53 per 10,000 person-years. No donors required KRT within 10 years of donation.

“The very low incidence is consistent with the extremely careful donor selection criteria applied in Australia during the study period and the inherent healthy donor effect whereby living donors are among the healthiest individuals in the population,” the study said.

The investigators, Dr Melanie Wyld and Professor Kate Wyburn from the Royal Prince Alfred Hospital, said their findings were consistent with international data. For example, Aotearoa New Zealand had an incidence of KRT in living donors of 3.0 per 10,000 person-years.

The study found that renal cell carcinoma in the remaining kidney was the primary cause of kidney failure in two donors requiring KRT and hypertensive nephropathy in the third donor. One donor subsequently received a deceased donor kidney transplant.

They said events such as renal cell carcinoma were not predictable at the time of donation and cannot be prevented by donor selection alone.

“Because renal cell carcinoma is frequently asymptomatic until advanced, a low threshold for investigating urological symptoms or incidental findings in living donors is warranted,” they said.

“Earlier detection may enable nephron-sparing options such as partial nephrectomy, preserving function in single-kidney individuals. Alongside this, conventional cardiovascular and metabolic risk management should continue throughout the donor’s life.”

They concluded that KRT after donation was rare but late events can occur, “…reinforcing the need for lifelong follow-up.”

Call to reverse decline in living donors

Also in a perspective article in The MJA [link here], Dr Wyld, Professor Wyburn, and Professor Nicole Isbel from Brisbane’s Princess Alexandra Hospital, called for resuscitation of living donor kidney transplantation (LDKT) in Australia.

They said living donation was the optimal treatment for kidney failure but numbers had been declining since 2009 while deceased donation had increased.

“Living donors per million population (dpmp)—the international benchmarking standard that normalises for population size and growth—fell from 16.8 dpmp in 2008 to 9.5 dpmp in 2024,” they said.

“Had the 2008 dpmp rate been maintained, approximately 194 additional LDKTs would have been performed in 2024 and about 2,510 additional LDKTs would have been done cumulatively since 2009.”

Dr Wyld and colleagues said paired kidney exchanges which began in 2007 had helped more patients receive a compatible living donor transplant, and the decline in living donation would have been even steeper without them.

“Without understanding and addressing the barriers to LDKT, declines will likely persist, consigning more Australians to prolonged dialysis or to no transplant at all, with substantial loss of length and quality of life and higher health-system costs.”

To help improve LDKT, they called for:

• national clinical guidelines for donor assessment
• sustained collection of post-donation health outcomes
• increased community awareness of LDKT including via evidence-based, online resources
• compensation for living donors to reduce the financial burden of donation
• tailored education for health professionals with evidence-based information and local outcome data.