Living Donor Evaluation and Surgery

Living donor evaluation and surgery is the process by which a healthy person who volunteers to donate an organ, most commonly a kidney but also a liver segment or lobe, is assessed for medical and psychosocial suitability and, if cleared, undergoes the donation operation. Its defining feature is that surgery is performed on a healthy individual for another person's benefit, so donor safety and informed, voluntary consent are paramount.

Definition

Living donor evaluation and surgery is the structured assessment of a prospective healthy donor's suitability followed, when appropriate, by the operative recovery of the donated organ or organ segment.

Scope

The topic covers the medical, surgical, and psychosocial evaluation that precedes living donation, the principle of minimizing donor risk, the surgical removal of the donated organ, and the long-term follow-up of donors. It is presented as a reference overview and not as an operative manual or individualized clinical advice.

Core questions

• Is the prospective donor healthy enough to donate with acceptably low short- and long-term risk?
• Is consent voluntary, informed, and free of coercion or undue inducement?
• What are the long-term health consequences of donation for the donor?
• How does living donation compare with deceased donation for the recipient?

Key concepts

• Donor safety and the principle of non-maleficence
• Voluntary informed consent
• Medical and psychosocial evaluation
• Living donor nephrectomy
• Long-term donor follow-up
• Residual organ function reserve

Mechanisms

Evaluation proceeds from confirming the donor's general health and the function and anatomy of the organ to be donated, through assessment of conditions that would raise the donor's future risk, to psychosocial review of motivation and consent. When the donor is cleared, the organ or organ segment is removed surgically, increasingly by minimally invasive approaches, and the donor's remaining organ reserve is relied upon to maintain normal function. Because the operation is performed on a healthy person, evaluation is structured around quantifying and minimizing the donor's perioperative and lifetime risk rather than treating disease.

Clinical relevance

Living donation expands the supply of organs and can offer recipients better outcomes than waiting for a deceased-donor organ, while exposing a healthy person to surgical risk; understanding how donors are evaluated clarifies how that balance is approached. This entry describes the evaluation framework for reference and is not a basis for individual donor selection or operative decisions.

Epidemiology

Living donation supplies a substantial share of kidney transplants in many programs and a smaller but important share of liver transplants. Reported perioperative mortality for living kidney donors is low, and long-term studies inform the counseling of donors about their future risk, which the KDIGO guideline frames in terms of estimated lifetime risk rather than a single threshold.

Evidence & guidelines

The KDIGO living kidney donor guideline (Lentine and colleagues, 2017) provides the contemporary framework for donor evaluation, risk assessment, and follow-up. The survival advantage of transplantation over dialysis (Wolfe and colleagues, 1999) motivates living donation, and Murray's 1958 series of twin transplants marks the historical origin of living-donor kidney transplantation.

History

Living-donor transplantation began with Joseph Murray's successful kidney transplant between identical twins in 1954, reported in his subsequent twin series, which removed the immunologic barrier by using genetically identical donors. As immunosuppression matured, living donation extended to unrelated donors and to partial-liver donation, and formal guidelines such as KDIGO later codified how donors should be evaluated and followed.

Debates

How should acceptable long-term donor risk be defined?

Guidelines have moved from fixed exclusion thresholds toward an individualized estimate of a donor's projected lifetime risk, but how much future risk is acceptable, and how it should be communicated, remains a matter of judgement.

Key figures

• Joseph Murray
• Krista Lentine
• Thomas Starzl

Seminal works

• lentine-2017
• wolfe-1999
• murray-1958

Frequently asked questions

Why is a living donor evaluated so extensively if they are healthy?

Because the surgery is performed on a healthy person for someone else's benefit, evaluation aims to confirm that donation can be done with acceptably low short- and long-term risk and that consent is fully informed and voluntary.

Can a person donate part of an organ other than a kidney?

Yes; living donation also includes donation of a segment or lobe of the liver, and the donated tissue or the donor's remaining organ reserve is relied upon to maintain function in both donor and recipient.