Risks in life after living kidney donation.

Kidney transplantation, particularly from a living donor, is considered the treatment of choice for selected patients with end-stage renal disease (ESRD). A successful transplantation not only provides a better quality of life but also a survival advantage to the transplanted patient [1]. The superior results which can be achieved with kidney transplantation from living donors and the limited supply of organs from deceased donors are the two major reasons for the increase in living-related kidney transplantation in the USA, Europe and worldwide in the past 30 years [2, 3]. When compared to deceased donor transplantation, living donor kidneys not only provide better long-term patient and graft survival rates but also result in shorter wait times on the waiting list as well as an opportunity for early or even pre-emptive transplantation [4]. Most conveniently, transplant surgery can be performed electively during daytime and the graft usually shows initial function postoperatively. As living kidney donation began to gain wider acceptance in all transplant centres, there was an enormous concern in terms of safety for the donor beginning with the medical evaluation prior to kidney donation, the risk of the operative procedure itself and the long-term medical and psychosocial consequences of uninephrectomized patients. Since the data available on the long-term medical outcomes in a complex situation such as kidney donation is still limited, the manuscript of Lam et al. [5] in the current issue of this journal about the risk of acute dialysis in living kidney donors further contributes to our understanding and risk assessment when dealing with living kidney donation. They assume that a reduced kidney function confers a higher risk of acute kidney injury in different settings such as sepsis and try to find an answer whether this is true for those patients with reduced renal mass after living donation. In their population-based matched cohort study, Lam et al. reviewed the medical records of living donors from 1992 to 2009 and linked the information with health care databases to compare the risk of acute renal failure of 2027 living donors with that of the normal population (20 270). In this particular study, the observed rate of acute dialysis did not show any significant difference between kidney donors and the normal population and therefore can be reassuring in relation to the practice of living donation in terms of risk for the donor. Nevertheless, it needs to be emphasized that it is mandatory to make living-related kidney transplantation as safe as possible for both the recipient and the donor. Therefore, it must be ensured that every prospective living donor has to undergo a thorough medical, psychological and social evaluation prior to kidney donation, as recommended by the Amsterdam Forum [6].