https://www.ovid.com/jnls/transplantjournal/fulltext/10.1097/tp.0000000000005764~donor-mentoring-in-private-kidney-paired-donation-programs (https://www.ovid.com/jnls/transplantjournal/fulltext/10.1097/tp.0000000000005764~donor-mentoring-in-private-kidney-paired-donation-programs)
Donor Mentoring in Private Kidney Paired Donation Programs: The Need for Transparency and Accountability
Transplantation 110(7):p e1555-e1556, July 2026. (https://www.ovid.com/jnls/transplantjournal/toc/2026/07000) | DOI: 10.1097/TP.0000000000005764
To the Editor—Living kidney donors have had an enormous positive impact on transplantation, offering thousands of patients improved quality and length of life. The transplant community has long sought to reduce disincentives to living donation, as described by Leonberg-Yoo et al,1 and we strongly support programs that provide financial, educational, and emotional assistance to potential donors. The establishment and continued federal support of the National Living Donor Assistance Center exemplify the importance of this mission.2
We commend the development of donor mentoring initiatives within kidney paired donation (KPD) programs, which aim to provide peer support to individuals considering donation. However, it is important to recognize that some KPD organizations, such as the National Kidney Registry, operate as private organizations (POs) with distinct governance structures, priorities, and commercial interests. These objectives may not always fully align with those of transplant centers or the broader transplant community, potentially creating gaps in transparency and accountability within a process that directly affects donors and recipients.
We recently encountered a concerning example that illustrates the ethical tensions inherent when donor mentors are employed by private KPD organizations. A blood group O donor was contacted by a donor mentor affiliated with a private KPD organization. During a routine text message check-in, the mentor initiated a discussion promoting voucher donation, emphasizing that voucher donors receive priority within the system. The mentor provided hyperlinks to quarterly reports highlighting trends in voucher utilization and the prioritization afforded to voucher donors.
The donor described the interaction as uncomfortable and "pushy," and subsequently contacted our transplant center for guidance. Notably, the communication focused on system-level benefits and prioritization metrics but did not explore critical clinical and ethical considerations specific to this donor-recipient pair.
The discussion was insufficiently individualized and appeared framed toward a preferred outcome. The donor's preferences and the potential downsides of voucher donation were not explored. The mentor did not ask how the donor would feel if they proceeded with voucher donation and their intended recipient never received a transplant. The discussion lacked any reference to recipient factors that could influence the advisability of voucher donation, including sensitization or recipient comorbid conditions. There was also no discussion about why KPD was being used. Often the donor can donate directly to a recipient (eg, compatible pair), but may decide to enter a KPD pool temporarily to see whether the recipient could receive a transplant with improved size or HLA matching. Finally, the average wait times for a recipient to receive a transplant after voucher donation were not mentioned.
This interaction raises concern about whether the mentor's guidance was fully centered on the donor-recipient pair or instead influenced, even indirectly, by organizational incentives to increase voucher participation. When donor mentors are employed by entities that operationally benefit from particular forms of donation, even well-intentioned communication can create perceived or actual conflicts of interest. Transparency regarding these structural incentives, along with a clear commitment to individualized donor-centered mentoring, is essential to maintaining ethical integrity in these situations.
Honesty and transparency are fundamental to the practice of medicine.3 The transplant process, like POs themselves, contains many moving parts, not all of which pertain directly to patient care. Transparency without thoughtful and responsible information disclosure may be counterproductive; excessive or unfocused information can obscure what is most relevant to donors. Transparency is "ethically enabling" only when it provides accurate, pertinent information while minimizing the risk of misunderstanding or misinformation.3
"Accountability is the real prize [of transparency]."4 Accountability is essential to ensuring that organizations uphold their mission and ethical obligations. In this context, the responsibility for accountability to implement changes that meaningfully improve transparency rests with POs. Such efforts can strengthen processes for transplant centers, donors, and recipients alike, fostering the trust required for centers to rely on both the organizations themselves and the information they provide. Accountability, as an ethical principle, requires appropriate disclosure.3 A key concern with donor mentoring programs administered by private KPD organizations is the risk of inadvertent misinformation that prioritizes the needs of the organization over the individual donor's clinical circumstances.
All transplant centers share a fundamental duty to respect donor autonomy and ensure donor safety throughout the evaluation and donation process.5 While KPD programs share these goals, their focus on innovations such as voucher or remote donation may introduce situations in which donors receive differing messages depending on the source of guidance. Donors should be informed of all available options, and this information must be delivered in a balanced, unbiased, and transparent manner.
As stewards of living donor trust, the transplant community must ensure that innovation proceeds with appropriate oversight. Any perception that donor education or support is influenced by business interests risks eroding public confidence in living donation programs, with potentially far-reaching consequences that could discourage future donors.