Carefully Screened Kidney Donors Have Normal Survival, Risk for ESRD

Laurie Barclay, MD

January 28, 2009

January 28, 2009 — Survival and risk for end-stage renal disease (ESRD) in carefully screened kidney donors are similar to those in the general population, according to the results of a study reported in the January 29 issue of the New England Journal of Medicine.

"The long-term renal consequences of kidney donation by a living donor are attracting increased appropriate interest," write Hassan N. Ibrahim, MD, from the University of Minnesota in Minneapolis, and colleagues. "The overall evidence suggests that living kidney donors have survival similar to that of nondonors and that their risk of [ESRD] is not increased. Previous studies have included relatively small numbers of donors and a brief follow-up period."

The investigators evaluated 3698 kidney donors who donated kidneys during the period from 1963 through 2007 for vital status and lifetime risk for ESRD. From 2003 through 2007, 255 donors were also evaluated for glomerular filtration rate (GFR), urinary albumin excretion, prevalence of hypertension, general health status, and quality of life.

Kidney donors had survival similar to that of control patients matched for age, sex, and race or ethnicity. Eleven donors developed ESRD, yielding a rate of 180 cases per million persons per year compared with 268 cases of ESRD per million per year in the general population.

Mean duration of follow-up was 12.2 ± 9.2 years after donation. At follow-up, 85.5% of the subgroup of 255 donors had GFR equaling or exceeding 60 mL/minute/1.73 m2 of body-surface area, 32.1% had hypertension, and 12.7% had albuminuria.

Predictors of GFR lower than 60 mL/minute/1.73 m2 and of hypertension were older age and higher body mass index but not longer time since donation. However, longer time since donation was an independent predictor of albuminuria.

Quality-of-life scores in most donors were better than population norms. Prevalence of coexisting conditions was similar to that for control patients from the National Health and Nutrition Examination Survey matched for age, sex, race or ethnicity, and body mass index.

"Survival and the risk of ESRD in carefully screened kidney donors appear to be similar to those in the general population," the study authors write. "Most donors who were studied had a preserved GFR, normal albumin excretion, and an excellent quality of life."

Limitations of this study include the assessment of only a small sample of all kidney donors to date, a possible response and survival bias, that most living donors are white, problems inherent in estimating GFR, that serum creatinine was calibrated at the time of measurement of the iohexol GFR but not at the time of donation, and lack of an ideal control group.

In an accompanying editorial, Jane C. Tan, MD, PhD, and Glenn M. Chertow, MD, MPH, from Stanford University School of Medicine in Palo Alto, California, suggest that these findings warrant "cautious optimism."

"The exceptionally high mortality rates associated with dialysis therapy (approximately 20% per year in the United States), along with impairments in physical and cognitive function, suggest that kidney transplantation from living donors would benefit most patients with ESRD," Dr. Tan and Dr. Chertow write. "A sufficient dose of functional nephrons should be transplanted to warrant the recipient's short-term risks associated with the surgery and long-term risks associated with immunosuppressive therapy. Moreover, if we are to expand living-donor transplantation by liberalizing the criteria for donor acceptance (i.e., allowing older persons or persons with hypertension, glucose intolerance, or other coexisting conditions to be included in a larger donor pool), we need to ensure the safety of the donors who are members of those possibly expanded populations."

The National Institutes of Health, the GeneralClinical Research Centers, and the Monica Libin Fund supported this study. Some of the study authors report various financial relationships with the Chronic Disease Research Group in Minneapolis, Roche, Affymax, Amgen, Luitpold Pharmaceuticals, Genzyme, 21st Services, Abbott, Janssen-Ortho, Medtronic, Astellas Pharma, Wyeth, Bristol-Myers Squibb, and/or Genzyme. Dr. Tan reports receiving a consulting fee from Entelos, and Dr. Chertow reports receiving research funding from Amgen.

N Engl J Med. 2009;360:459–469.

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