Why Living Kidney Donation?

Someone who has kidney failure–often called End Stage Renal Disease (ESRD)–has three options for treatment: dialysis, a transplant from a deceased person, or a transplant from a living person.

Why is a transplant from a living person — known as living kidney donation — a consideration? First, dialysis is only a temporary solution. While someone can remain on dialysis for many years, it is not a cure. It is also time consuming with treatments as frequent as three times a week for four hours each time.

Transplantation from a deceased donor is a good alternative to dialysis, but the number of donated organs does not keep up with demand. United Network of Organ Sharing (UNOS), the organization responsible for allocating donated organs for transplant, reports there are more than 100,000 people waiting for a kidney transplant, and that number increases daily. Yet, there are only about 20,000 kidney transplants from deceased donors each year. Consequently, living donation is seen as a way to address the gap.

There are several reasons why living kidney donation is an important consideration:

  • Transplantation has been shown to be less costly than dialysis over the long run.
  • The waiting time for a transplant recipient can be significantly reduced.
  • The procedure can be scheduled at a time convenient for both the donor and recipient.
  • The quality of the donated organ tends to be better than organs from deceased donors.

All of these factors have yielded positive results for recipients. There is less rejection and lower doses of anti-rejection drugs. The transplanted kidney, or “graft,” has better odds of surviving if it is from a living donor, as show in the following UNOS data for kidney transplants in the U.S:

Kidney Graft Survival Rates

Time after donation
From deceased donors
From living donors
One year 93% 98%
Three years 85% 93%
Five years 74% 86%

Types of Living Donation

There are several different types of living donation:

  • Directed donation. Directed donation is where the living donor names who the recipient will be. The recipient may be a blood relative, a spouse, a friend, a co-worker, or some other acquaintance. Most living donations are directed.
  • Non-directed donation. In non-directed donation, the living donor does not specify the recipient. Instead, the recipient is selected from a list of compatible people on a kidney waiting list. This form of donation sometimes is called “anonymous,” “altruistic,” or “Good Samaritan” donation because the donor and recipient do not know each other at the time of donation.
  • Paired exchange or chain donation. In this situation, there are two (or more) donor/recipient pairs where the donors are not able to donate to the intended recipients because of blood types that aren’t compatible. However, the donor in one pair is compatible with the recipient of the other pair, and vice versa, allowing the donor of one pair to donate to the recipient of the other pair. In a growing number of situations, more than two donor/recipient pairs are linked in an extended “chain” of donation. These chains have included as many as 35 donor/recipient pairs.Here’s an example of a paired exchange. Assume in the first donor/recipient pair, the donor, Jim, is blood type A and the person he’d like to donate to, Lisa, is blood type B. Jim can’t donate to Lisa because they have incompatible blood types. In the second pair, the donor, Niki, is blood type B and she’d like to donate to Mike, but he’s blood type A. They are incompatible. Paired exchange provides the solution: Jim donates to Mike (both blood type A), and Niki donates to Lisa (both blood type B). Organizations have been formed to facilitate the matching of donor/recipient pairs. As a result, the number of paired exchanges and chain donations has increased significantly. More information on the paired exchange organizations can be found on the LDO kidney links page.
  • Advanced donation. Also called a “voucher” donation, advanced donation can be used when the best time for a living donor to donate is before the time an intended recipient needs a transplant. That is, someone with kidney disease now may not yet need a transplant but has someone who is willing to donate now. This is called “chronological incompatibility” — the time when the donor is willing to donate is different from the time when the intended recipient needs the kidney. What happens is the living donor donates now to someone needing a kidney. The living donor’s intended recipient (who does not need a kidney now) is then given a voucher. The voucher provides that the intended recipient will be given priority to receive a living donor kidney in the future. Here’s an example. Assume there is a child who has chronic kidney disease and is expected to need a kidney transplant 15 years from now. The child’s grandfather is willing to donate but worries he may not be able to donate 15 years from now. So the grandfather donates now to a different recipient and the child receives a voucher for a future living donor transplant. The program is available in the U.S. and is administered by the National Kidney Registry. Therefore, the vouchers are used only for transplants provided through them. Details on the program can be found here.

Who Donates?

Currently there are about 6,000 to 7,000 living kidney donors each year in the U.S. They come from all walks of life, ethnicities, ages, and locations. Interestingly, about 60% are female.

A History of Living Kidney Donation

Below is a timeline of key events in the history of living kidney donation.

1954. Living kidney donation begins with the donation by Ronald Herrick to his identical twin, Richard. The procedure was performed by Dr. Joseph E. Murray at Peter Bent Brigham Hospital in Boston, MA. Being identical twins was an advantage because there was no risk of rejection–the tissue types were identical. The procedure was a success, and Richard lived a healthy life until his death eight years later of causes unrelated to the donation. Ronald Herrick passed away in 2010 at age 79 following heart surgery.

1972. Medicare expands to include individuals with End Stage Renal Disease, covering dialysis and transplants. The expanded coverage also includes all of a living donor’s reasonable preparatory, operation, and post-operation expenses.

1982. Professor Guy P. J. Alexandre establishes a living donor transplant program for incompatible blood types using plasmapheresis.

1984. The U.S. government passes the National Organ Transplantation Act (NOTA), establishing the Organ Procurement and Transplantation Network (OPTN), which is currently managed by United Network for Organ Sharing (UNOS). NOTA also outlaws the buying and selling of organs. The law states that living donors cannot be compensated except for the expenses of travel, housing, and lost wages.

1995. Laparoscopic nephrectomy is pioneered as a less invasive procedure, and has since replaced “open nephrectomy” as the most common form of living donation surgery.

1996. Medical teams begin an experimental living kidney donation process that uses the donor’s bone marrow to minimize or even eliminate the recipient’s need for anti-rejection drugs. The technique, called chimerism, has the donor donate bone marrow, which is used to change the recipient’s immune system. Anti-rejection drugs are used at first, but eventually the recipient does not need them. Research continues but the process is still considered experimental and is not available.

1999. The Organ Donor Leave Act is passed providing paid leave to U.S. federal government employees of seven days for bone marrow donation and 30 days for organ donation.

2000. The U.S. Department of Health and Human Services establishes the Advisory Committee on Organ Transplantation (ACOT) to advise the Secretary on organ donation, procurement, allocation, and transplantation. Over the years, ACOT issues many recommendations, some of which are related to living organ donation.

Living Donors Online, formed by and for living donors, begins services with a mission to improve the living donation experience.

The number of living kidney donors exceeds the number of deceased donors for the first time. The situation continues through 2004.

2004. A group of transplant professionals release “The Consensus Statement of the Amsterdam Forum on the Care of the Live Kidney Donor” that provides recommendations for international standards of care for living kidney donation.

The Organ Donation and Recovery Improvement Act passes, establishing the National Living Donor Assistance center to help defray travel and subsistence expenses for living donors with limited financial resources.

2007. Centers for Medicare and Medicaid Services publishes its “Final Rule” containing the requirements U.S. transplant centers must meet to participate in Medicare. The provisions include minimum standards for living donor transplants including the content of “informed consent” materials and a requirement for having an independent living donor advocate.

The U.S. government clarifies that paired donation is not considered “valuable consideration” for purposes of the National Organ Transplantation Act.

2009. Johns Hopkins performs the first living donor nephrectomy through a female donor’s vagina to reduce scarring and speed donor recovery.

2010. California becomes the first state to require private employers to provide paid leave of five days for bone marrow donation and 30 days for organ donation.

OPTN completes its first kidney paired donation transplant as part of a national pilot program. The program used a national network of transplant centers to find and match paired donors.

2013. A long-term prospective medical research project on living kidney donation, The Assessing Long-Term Outcomes of Living Donation (ALTOLD), publishes its initial findings: “A Prospective Controlled Study of Kidney Donors: Baseline and 6-Month Follow-Up.”

2015. The three-year results of the ALTOLD study are published: “A Prospective Controlled Study of Living Kidney Donors: Three-Year Follow-up.”

2017. National Kidney Registry begins their advanced (or “voucher”) donation program.

An international group of medical transplant specialists, Kidney Disease: Improving Global Outcomes (KDIGO), issues “KDIGO Clinical Practice Guidelines on the Evaluation and Care of Living Kidney Donors.”

2019. Living kidney donation in the U.S. reaches a new high of 6,866 donors.

2020. The nine-year results of the ALTOLD study are published: “A Prospective Controlled Study of Metabolic and Physiologic Effects of Kidney Donation Suggests that Donors Retain Stable Kidney Function Over the First Nine Years.”

The COVID-19 global pandemic reduces the number of U.S. living kidney donors to 5,238, the lowest level since 1999.

For the latest news and information on living donation, visit the Living Donation in the News section of the LDO message board.

About Living Kidney Donation