Living kidney donor assessment: challenges, uncertainties and controversies among transplant nephrologists and surgeons

Allison Tong^1,2, Germaine Wong^1,2,3, Jeremy Chapman³, Jonathan Craig^1,2

¹Sydney School of Public Health, The University of Sydney, Sydney, Australia, ²Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia, ³Centre for Transplant and Renal Research, Westmead Hospital, Sydney, Australia

Background: The assessment of living kidney donors presents unique ethical challenges and complex psychosocial implications. This study aimed to ascertain the perspectives of transplant nephrologists and surgeons on living kidney donor assessment.

Methods: Semi-structured, face-to-face interviews were conducted with 110 transplant nephrologists and surgeons from 43 transplant units in 12 countries from Europe, Australasia, and North America. 

Results: The challenge of defining acceptable risk to the donor was central to five themes identified (Figure): burden of responsibility (personal accountability, policing morality, democratic decision making, meeting legal obligations, optimizing outcomes and innovation, relinquished control); medical protectiveness (prognostic uncertainty, scepticism of donor risk perception, avoidance of undue coercion, concerns for dubious motivations and coercion, safeguard donor well-being, ethical information disclosure); respecting donor autonomy (facilitate informed-decision making, concede to donor risk acceptance, benefit of the doubt, donor mandate to maintain health, acceptable altruism); driving ideologies (preserving equity, championing living donation, cognisance of anti-paternalism); and contextual pressures (evolving donor demographic, resource limitations). 

Conclusions: Living kidney donor assessment involves complex interactions between safeguarding the donors’ welfare and respecting their autonomy. In our opinion, authoritative and well-described transplant unit and public policy positions that make explicit the considerations which are often implicit, may reduce the uncertainty within which donors are assessed.

Figure 1