Advances in immunosuppressive therapy, refinement in surgical techniques and in public awareness, altruism, and goodwill have allowed an increase in the number of living donor kidney transplantation; whereby, virtually all biological related, unrelated and medically and psychosocially suitable individuals can be considered as donors [1
]. Live donor surgery is elective and easier to organise prior to starting dialysis than when the renal donor is a cadaver. In addition, living donor transplants have the advantage of being performed with minimal delay, thereby permitting preemptive transplantation (transplantation prior to dialysis). There is also increasing evidence that patients who undergo preemptive transplantation have improved graft survival compared to those who undergo a period of dialysis before transplantation [7
]. Because of superior results with living kidney transplantation, efforts including the usage of “medically complex living donors” are made to increase the availability of organs for donation [8
]. The term “complex living donor” was used first by Reese et al. [9
] in the International Forum on the Care of the Live Kidney Donor which was held on April 2004 in Amsterdam [7
]. The objective of this meeting was to develop international consensus on the standard of care and define the responsibility of the transplant community for the live kidney donor [7
]. The term “complex living donor” is probably preferred for all suboptimal donors where decision making is a problem due to the lack of sound medical data or consensus guidelines. After this meeting, complex living donors were categorized based on certain risk factors (). The risk of end-stage renal disease (ESRD) in complex living donors is not clear yet. The evaluation of a potential renal allograft in living donors varies from country to country. In this review we would like to present the major issues in the evaluation process of medically complex living kidney donor.
Risk factors associated with complex living donor.
1.1. Informed Consent
First of all, to avoid conflict of interests, the proposed donor should be carefully evaluated by a physician not involved in the care of the proposed recipient. The physician must confirm that the patient's wish to donate is voluntary. Informed consent is a core value in living kidney donation. Prior to donor nephrectomy, the potential donor must be informed of [10
] the following.
- The nature of the evaluation process.
- The results and consequences/morbidity of testing, including the possibility that the conditions that may be discovered can impact future healthcare, insurability, and social status of the potential donor.
- The risks of operative donor nephrectomy, as assessed after the complete evaluation. These should include, but not be limited to the risk of death, surgical morbidities, changes in health and renal function, impact upon insurability/employability, and unintended effects upon family and social life.
- The responsibility of the individual and the social system in the management of discovered conditions (e.g., if the donor is discovered to have tuberculosis, the donor should undergo treatment, the community has a responsibility to help the donor secure proper care with referral to an appropriate physician).
- The expected transplant outcomes (favorable and unfavorable) for the recipient and any specific recipient conditions which may impact upon the decision to donate the kidney.
- Disclosure of recipient specific information which must have the assent of the recipient.
- Alternative renal replacement therapies available to the potential recipient.
Additionally, the potential donor should be capable of understanding the information presented in the consent process.