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Risks of Living Kidney Donation
Despite declarations from the media and many medical professionals, being a living kidney donor is not as simple as donating a pint of blood. Even though most nephrectomies (kidney removals) are done laparoscopically, it is still major surgery and the loss of a crucial organ, the danger of which is compounded by the lack of national standards in regards to living organ donor evaluation, selection, and treatment.
Though the medical community has utilized living kidney donors for nearly 60 years, they have not followed or studied them comprehensively. An assessment of existing living kidney donor studies in 2006 revealed small sample sizes, selection bias and many other limitations and liabilities, stressing the need for a living donor registry. (56) This hasn't changed.
Despite some headlines and press releases in 2010 and perpetuated in 2011, there is NO long-term evidence that 'living donors live longer'. The claim originated from a transplant center's marketing department to promote a published study; neither the Ibrahim nor Segev articles are proof of anything long-term for living kidney donors (See here and here for more. This explains how the Ibrahim control group wasn't really like the LKD cohort at all.)
Meanwhile, UNOS/OPTN's own two-year database was declared 'woefully inadequate' and useless for research or analysis in 2009 by their own data task force.(136)
The following is a quick check-list of kidney donation's risks and complications. For more detailed research study results and information, click the link.
Death/Mortality of living kidney donors within 12 months of donation.
Post-Operative Complications for live kidney donors
Kidney Disease and Failure for information on living kidney donor chronic kidney disease & ESRD
Physical & some Psychosocial Risks for Kidney Donors:
Insurance, Health & Life. See Living Donor Expenses.
Kidney Failure, Chronic Kidney Disease, End-Stage Renal Disease (see here)
Martial/Relationship Conflict (family, recipient)
Pregnancy Post-donation (Also: infertility)
See Psychological Recovery Page for info on:
Depression(see also Self-Image/Self-esteem)
**There is evidence that 'young' donors (under 35) are at greater risk of developing nephrolithiasis (kidney stones), hypertension (high blood pressure) and Type II diabetes. (72)**
While it is highly unusual, sometimes the adrenal gland is removed during the donor nephrectomy (more likely in donations done many years ago). This should've be disclosed during the Informed Consent process.
The left adrenal gland's vein drains into the left kidney and then into the inferior vana cava. When the left kidney is removed, this vein is severed, which can leave the gland functionally impaired (218)*. Most internists or primary care physicians would not know to look for the symptoms of Addison's in living kidney donors so the disorder could go undetected for quite some time. (see topic #6752)*
Symptoms include but are not limited to:
- fatigue and weakness
- weight loss/loss of appetite
- low blood pressure/faintness
- salt cravings
-painful muscles and joints
*This pertains to left-side nephrectomies only. The right adrenal vein drains directly into the inferior vena cava, so a right kidney removal will leave the adrenal vein intact.
Of donors faced with adverse recipient outcomes, 13% felt the procedure had been a waste and 5% felt guilty (4) and of those whose recipient died, only 50% felt that their experience had been worth it (6). When assessed for hostility, donor scores at one and six months after donation were higher than pre-donation and control group scores (9).
6% and 24% felt that they had given up something for nothing in return.(2,3)
Bleeding requiring transfusion in 3.4% of living donors.(52)
Significant perioperative bleeding occurred in 1.6% of 1022 living donors. There were seven cases of renal artery laceration. Increased risk for a combined endpoint of intraoperative incidents, major complications and significant bleeding were seen in relation to laparoscopic surgery (88)
Patients in all stages of CKD are considered in the “highest risk group” for development of cardiovascular disease and CKD is recognized as a cardiovascular risk equivalent (174). In fact, a 10% decrease in GFR has been proven to significantly increase cardiovascular mortality and morbidity (206)
Of those diagnosed with chronic kidney malfunctions, more people actually die of heart disease than renal failure... Even early onset of kidney disease partners with a dramatic increase in the risk of suffering heart attack and stroke.
The risks of death resulting from cardiovascular disease and all causes were higher for persons with renal insufficiency during 16 yr of follow-up. These associations were consistently identified for white, male, female, nonsmokers, smokers, subjects with and without diabetes, and subjects without a history of cardiovascular disease. The results suggest that the risks of death resulting from cardiovascular disease and from all causes may increase progressively from the onset of renal dysfunction through end-stage renal disease. According to recent studies, there are more than 5 million persons in the United States with renal insufficiency. Therefore, renal insufficiency may result in a greater burden of cardiovascular disease in the population than does end-stage renal disease(95)
An investigation of the natural history of disease in a large cohort of patients with CKD stages 2 to 4 demonstrated that death was a more likely outcome than progression to kidney failure in every stage of CKD. Thus, most patients in the earlier stages of CKD do not progress to kidney failure because of mortality due to cardiovascular disease; consequently, in studies of patients with earlier stages of CKD, cardiovascular disease is a major “competing outcome or risk” with kidney failure.(174)
Five years after undergoing a radical nephrectomy (complete removal of kidney and surrounding tissue), patients had a 25% increased risk of cardiac death. (99)
Even mild degrees of kidney insufficiency and albuminuria have been associated with increased risks for cardiovascular disease. (85, 95)
Renal sufficiency, even mild, is associated with increased risks of hypertension, proteinuria and cardiovascular morbidity. (95)
From American Heart Association: Kidney disease can represent either a cause or a consequence of Cardiac Vascular Disease. For [one] example, electrolyte imbalances in renal disease can lead to cardiac arrhythmias.
A lower level of kidney function is associated with a marked increase in the probability of ASCVD (atheroschlerosis cardiovascular disease) over five years. We also found that level of kidney function (even in the range of 60 to 89 ml/min) is an independent risk factor for ASCVD and de novo ASCVD outcomes. Finally, we noted that ASCVD risk may increase more sharply at lower levels of GFR. (97)
The increased cardiovascular risk of those with chronic kidney disease has been associated with disturbances in calcium, phosphate, vitamin D and parathyroid balances. (216)
CHYLOUS ASCITES: (aka Lymphatic Ascites) A rare disorder involving obstruction of the drainage of the abdominal lymph glands which results in abdominal accumulation of milky white fluid.
Chylous ascites needs to be considered as a potential complication of LDN owing to skeletonizing of the adjacent lymphatics of the renal artery and vein.(44,28)
- In a review of Chylous Ascites reported in the literature, incidence of the complication after LDN (laparascopic donor nephrectomy) ranges from .4% to 1.28%. (98)
- All reports indicate the complication occurred after the left kidney was removed. (98)
- All reports of the complication required hospital readmission. (98)
Some living donors experience chronic pain around the scar or incision site. In one study, the surgical scar caused chronic pain for 2% of living donors (4).
One woman's story.
9% of living kidney donors in one study reported bodily pain that interfered with their normal work 'quite a bit of the time' (5).
A 2009 German study of 58 living kidney donors, 34% suffered from chronic postoperative pain 22 months (range 9-57 months) after nephrectomy, and in 55% of these cases the pain interfered with daily life activities. (89)
Persistent pain was reported by 44.1% of 86 living kidney donors 3 years post-donation (91)
Surgery and recovery were more painful than expected for 34% of donors.(4)
Peritoneal adhesions are responsible for 25% of patients with chronic pain (217). Pain is caused by the restriction of organs within the abdomen. Note: all patients who've undergone abdominal surgery; not just living organ donors.
A disease of the pancreas, Diabetes is the biggest 'kidney killer' in the U.S. Obesity and age increase the risk of acquiring diabetes.
1% of 274 living donors at one center had diabetes at follow-up (4)
70% of 61 Living Donors have expressed socioeconomic concerns before making the decision to donate. (33)
29% worried about financial ramifications of time missed from work, 10% about childcare, 2% about job security and another 2% about future health insurance coverage. Prospective donors who did not ultimately donate reported similar concerns. (34)
Estimates of out of pocket expenses associated with donation range from $550 to $20 000.(35)
There was no difference in recuperation time between open and
laparoscopic nephrectomy as reported by donors.(28)
Almost all donors claim costs for transportation and lodging, paid for personally. Donors traveling from outside of the state to the transplant center accounted for 32% of the population. Many donors also realized costs from childcare, related to their surgery and recuperation.(28)
23% living donors reported negative financial consequences. However, moderate financial problems (such as lost work time, medical bills not covered by insurance or other personal expenses) were experienced by 19% and severe problems by 4% of the donors, and 9% reported that being a kidney donor had a negative impact on the ability to obtain health, life or disability insurance.(4)
Furthermore, 8% were concerned about medical costs and 14% were worried about loss of income.(10)
The strongest correlates of donor dissatisfaction included perceived damage to finances (4).
19% of living donors had moderate financial problems, while 4% reported severe financial consequences. Severe problems consisted of loss of work, loss of income, and mounting bills they were unable to pay. (5)
Readmission rate was higher for LN (1.6%) versus open (0.6%) donors (P 0.001), almost entirely as a result of an increase in gastrointestinal complications in LN/laparoscopic donors. (29)
Drugs to treat gastrointestinal disorders, primarily reflux oesophagitis and dyspepsia, accounted for another 6.73% (only one-year post-donation).(28)
Although mostly minor, bowel complications occurred in our laparoscopic series with an incidence of 1.3% compared with a reported incidence of 0% with open surgery. (51)
Knoepp et al.(45) reported an unusual complication after LDN, that of retroperitoneal hernia of the small bowel at the nephrectomy site.
Perioperative complications and wound healing issues were reported by 23.07% of the donors, including two hernias (28).
One living donor's experience.
The current relative risk for hypertension after kidney donation is reported at 1.5–1.9 times the risk for a comparable two-kidneyed person . The direct relationship between hypertension and renal dysfunction is well established. In fact, hypertensive nephrosclerosis is considered one of the major causes of ESRD (95).
A comparison all of the living donors in Ontario, Canada, from 1993 through 2005 to controls matched for age, sex, income, and use of non-physician health care reported a significant increase in the number of living donors with hypertension (16.3%) compared with the control group (11.9%). (85)
According to 'Annals of Internal Medicine' 2006, volume 145, issue 3, page 185, a examination of 48 studies from 28 countries revealed that living kidney donors will see an average increase of 5-mm in blood pressure within five to ten years after donation over that anticipated by aging alone. (181)
A study published in Hypertension in 2006 studied Pulse Wave Velocity, a measure of aortic stiffness, a marker of cardiovascular risk independent of age, atherosclerosis, blood pressure, drug treatment, and presence of native kidneys in kidney transplant patients. The researchers found significantly higher PWW in kidney donors as compared to non-donors at follow-up.
A longitudinal review of living donors who donated between 1963 and 1982*, tested first in 1984 and again in 1994 revealed 74.5% with hypertension in '94 compared with 36% in '84. All 14 men & 12 of 13 women were over 55. Expected hypertension in general population was 24/47 but actual results were 35/47. (106)
*the selection criteria for being a living donor was much stricter then than it is now
4.8% of living donors reported they were treated for hypertension at either 3, 6, 9 months or 1yr post-donation.(28) One year post-donation, 6.73% of living donors were on anti-hypertensives.(28)
31-year review of 370 Living Donors found 15% incidence of hypertension.(14)
Of 167 living kidney donors from 1983-1995 at The Cleveland Clinic as of 1997, 9 (5%) had hypertension.(4)
Thirty donors (38.4 %) were investigated. Of these, 25 of had normal blood pressure and 5 were hypertensive, needing antihypertensive treatment. The average age was higher in the hypertensive group (60.2/53.25 years). The time interval since transplantation was longer in the hypertensive group than in the normal one. (1)
Wound infection developed in 3.7% of donors.(88)
Five years after undergoing a radical nephrectomy (complete removal of kidney and surrounding tissues), patients had a 17% increased chance of death from an infection. (99)
Donors reported that they did not feel any better about themselves after donation.(1)
6% and 24% felt that they had given up something for nothing in return. (2,3)
(See Psychological Recovery for more...)
MARITAL CONFLICT (or familial/relationship conflict)
13% believed donation caused conflict with the spouse. 1 donor ascribed donation as the reason for their divorce. Conflict with the family was reported by 22% of living donors (4)
A third of divorce(e)s cited donation as a reason for separation (131)
10% of 65 living related kidney donors in Germany experienced family conflicts.
(See Grief page for more...)
One of the risks of any hand-assisted laparoscopic surgery is the possibility of cutting or damaging nerves. Some living donors have reported permanent numbness, pain, and paralysis of the back and lower extremities.
A retrospective examination of 553 obese kidney donors found the laparoscopic nephrectomy 'generally safe in selected donors', but encouraged more in-depth and long-term research. Another recent study still leaves many unanswered questions regarding the long-term consequences of and increased risks of obesity in living donors, including hypertension and kidney disease.
2009 Norwegian study found an increased risk of wound infection in living donors with a body mass index over 25 (88).
Whereas it has been long accepted that obesity might lead to proteinuria and worsening hypertension, the development of more advanced kidney dysfunction has not been demonstrated until recently. Hsu and colleagues, in a study of over 320,000 adult members of Kaiser Permanente who volunteered for screening health check-ups between 1964 and 1985, demonstrated over a 700% increase in the adjusted risk of ESRD in subjects with a BMI greater than 40. Even more disturbing is the emerging link between obesity and the development of renal cell carcinoma, especially in women (174)
Perioperative complications and wound healing issues were reported by 23.07% of the donors, including two cases of pancreatitis.(28)
Most organ transplant organizations will state that kidney donation has not been shown to affect the completion of a safe pregnancy and childbirth. However, the issue has not been well researched.
The pregnancy of a kidney donor will automatically be considered 'high risk'. This risk increases exponentially with the age of the birth mother. Also, it is recommended a kidney donor wait at least six months post-surgery before getting pregnant.
To better understand how pregnancy affects the kidneys and renal system, as well the pregnancy in women with kidney disease, click here.
Pregnancy is a time of net salt and water retention, with 50% increase in plasma volume
and glomerular filtration rate (GFR), associated with single nephron hyperfiltration (See Kidneys). Animal studies have demonstrated that reduced nephron mass is related to an increase in blood pressure and protein excretion in late pregnancy. In addition, human studies report higher rates of HDP (hypertensive disorders of pregnancy) in women with preexisting kidney disease. After donor nephrectomy, the GFR of the remaining kidney increases by 40%, and its response to hormones such as angiotensin II is altered.(79)
April 2009 study of 1085 living donor pregnancies at U. of Minnesota - fetal and maternal outcomes and pregnancy outcomes after kidney donation were similar to those reported in the general population, but inferior to pre-donation pregnancy outcomes. (in other words, outcomes were worse post-donation than pre-donation):
Post-donation (vs. pre-donation) pregnancies were associated with a lower likelihood of full-term deliveries (73.7% vs. 84.6%) and a higher likelihood of fetal loss (19.2% vs. 11.3%).
Post-donation pregnancies were also associated with a higher risk of gestational diabetes (2.7% vs. 0.7&), gestational hypertension (5.7% vs. 0.6%), proteinuria (4.3% vs. 1.1%) and preeclampsia (5.5% vs. 0.8%).
Women who had both pre- and post-donation pregnancies were also more likely to have these adverse maternal outcomes in their post-donation pregnancies.(78)
Norwegian study in April 2009:
A normal pregnancy is characterized by an increase in renal blood flow and glomerular filtration rate (GFR). In previous donors, the nephrons of the remaining kidney are already hyperfiltering, which has raised concerns about future pregnancies in female donors. It may be particularly relevant since it is conceivable that increase of blood pressure and loss of kidney function in donors may predispose for hypertensive pregnancy disorders and other complications (77)
The researchers analyzed the women's pre- and post-donation pregnancies. 106 post-donation pregnancies in 69 kidney donors found a higher rate of gestational hypertension (2.8%) pregnancies after donation as opposed to 1.8% before donation, as well as a higher incidence of preeclampsia in post-donation pregnancies (5.7% in comparison to 2.6%). (77)
And here is a critical analysis of both Ibrahim & Reister (77,78)
Donor nephrectomy is not detrimental to the prenatal course or outcome of future pregnancies. It was recommended, however, to delay pregnancy until at least 2 months after nephrectomy to assess renal compensation prior to conception. (42, 43) [note: these two studies have been criticized for their small sample sizes and self-reporting and retrospective natures.]
As for infertility post-living kidney donation:
Injury to the peritoneum (the membrane that surrounds the abdominal organs and lines the abdominal cavity) can result in adhesions (fibrous tissue) which can inhibit ovum (egg) transportation. It is estimated that 20-30% of infertile women have adhesions. (217)
PROTEINURIA: aka Albuminuria or Urine Albumin
Proteinuria is defined as excreting protein in urine. Most proteins are too big to be filtered through the kidneys, but will leak when the filters (glomeruli) are damaged. Proteinuria can be preceded by traces of microalbumin in the urine.
Excretion of even small amounts of albumin in the urine may portend serious future events, such as Chronic Kidney Disease and progressive renal dysfunction (95) Read more here.
Kido's case studies found LKDs were more likely to develop persistent proteinuria than non-donors, and no pre-donation risk factors existed (67)
One year post-donation, perioperative complications and wound healing issues were reported by 23.07% of the donors, including one living donor with proteinuria. (28)
A study in the Journal of Endourology indicates that 9.6% of men suffer from Ipsilateral Orchialgia on average 5 days post-surgery (223).
This pain/swelling, sometimes up to grapefruit size, seems to occur mainly in the left testicle, and more commonly in men who have undergone vasectomies. It can abate within a few weeks, but in at least one severe case, more than two years post-donation, "searing pain like an intentional kick" exists during specific movements or activities. Surgery is sometimes necessary to alleviate the symptoms.
Some possible causes:
Testicular varicose vein
Reduction/cut-off in the blood supply to the left testicle (which is already compromised during the vasectomy)
Hydrocele aka water on the testicle (symptoms reported up to 4+ years post-donation)