Risk appreciation for living kidney donors: another new subspecialty?

Quantitative estimates of the risk of end stage renal disease (ESRD) for living donors would seem essential to defensible donor selection practices, as the 'safe/unsafe' model for donor selection is not viable. All kidney donors take risk, and four fundamental, qualitative criteria should instead be used to decide when donor rejection is justified. These criteria are lack of donor education about transplantation, donor irrationality, lack of free and voluntary donation, and/or that donor acceptance would unavoidably threaten the public trust or the integrity of the center's selection procedures. Such a data-based selection policy, with explicit documentation of unbiased and comprehensive donor education, will help neutralize the center's self interest in a more defensible way than by rejecting 'complicated' kidney donors out of hand, and in a more practical way than by the creation of center-independent donor counselors or waiting for donor registries to come to fruition. Living kidney donors with isolated medical abnormalities comprise a sizable subset of at risk donors for whom center acceptance practices vary markedly. This population provides a paradigm opportunity for quantitative risk estimation and counseling.