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Original Investigation |

Risk of End-Stage Renal Disease Following Live Kidney Donation

Abimereki D. Muzaale, MD, MPH1; Allan B. Massie, PhD1; Mei-Cheng Wang, PhD2; Robert A. Montgomery, MD, DPhil1; Maureen A. McBride, PhD3; Jennifer L. Wainright, PhD3; Dorry L. Segev, MD, PhD1,2,4
[+] Author Affiliations
1Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
2Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
3United Network for Organ Sharing, Richmond, Virginia
4Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
JAMA. 2014;311(6):579-586. doi:10.1001/jama.2013.285141.
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Importance  Risk of end-stage renal disease (ESRD) in kidney donors has been compared with risk faced by the general population, but the general population represents an unscreened, high-risk comparator. A comparison to similarly screened healthy nondonors would more properly estimate the sequelae of kidney donation.

Objectives  To compare the risk of ESRD in kidney donors with that of a healthy cohort of nondonors who are at equally low risk of renal disease and free of contraindications to live donation and to stratify these comparisons by patient demographics.

Design, Settings, and Participants  A cohort of 96 217 kidney donors in the United States between April 1994 and November 2011 and a cohort of 20 024 participants of the Third National Health and Nutrition Examination Survey (NHANES III) were linked to Centers for Medicare & Medicaid Services data to ascertain development of ESRD, which was defined as the initiation of maintenance dialysis, placement on the waiting list, or receipt of a living or deceased donor kidney transplant, whichever was identified first. Maximum follow-up was 15.0 years; median follow-up was 7.6 years (interquartile range [IQR], 3.9-11.5 years) for kidney donors and 15.0 years (IQR, 13.7-15.0 years) for matched healthy nondonors.

Main Outcomes and Measures  Cumulative incidence and lifetime risk of ESRD.

Results  Among live donors, with median follow-up of 7.6 years (maximum, 15.0), ESRD developed in 99 individuals in a mean (SD) of 8.6 (3.6) years after donation. Among matched healthy nondonors, with median follow-up of 15.0 years (maximum, 15.0), ESRD developed in 36 nondonors in 10.7 (3.2) years, drawn from 17 ESRD events in the unmatched healthy nondonor pool of 9364. Estimated risk of ESRD at 15 years after donation was 30.8 per 10 000 (95% CI, 24.3-38.5) in kidney donors and 3.9 per 10 000 (95% CI, 0.8-8.9) in their matched healthy nondonor counterparts (P < .001). This difference was observed in both black and white individuals, with an estimated risk of 74.7 per 10 000 black donors (95% CI, 47.8-105.8) vs 23.9 per 10 000 black nondonors (95% CI, 1.6-62.4; P < .001) and an estimated risk of 22.7 per 10 000 white donors (95% CI, 15.6-30.1) vs 0.0 white nondonors (P < .001). Estimated lifetime risk of ESRD was 90 per 10 000 donors, 326 per 10 000 unscreened nondonors (general population), and 14 per 10 000 healthy nondonors.

Conclusions and Relevance  Compared with matched healthy nondonors, kidney donors had an increased risk of ESRD over a median of 7.6 years; however, the magnitude of the absolute risk increase was small. These findings may help inform discussions with persons considering live kidney donation.

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Figure 1.
Cumulative Incidence of End-Stage Renal Disease in Live Kidney Donors and Matched Healthy Nondonors

A, The shaded areas indicate 95% confidence intervals obtained by bootstrapping. Matched healthy nondonors were identified among participants in the third National Health and Nutrition Examination Survey and were drawn with replacement in light of a larger population of donors compared with healthy nondonors by bootstrapping (see the Methods section).

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Figure 2.
Cumulative Incidence of End-Stage Renal Disease in Live Kidney Donors

Estimates obtained using Kaplan-Meier methods and compared using log-rank tests. The y-axis scale shown in blue indicates the range from 0 to 40 events per 10 000.

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Figure 3.
Estimated Lifetime Risk of End-Stage Renal Disease in Matched But Unscreened Nondonors, Live Kidney Donors, and Matched Healthy Nondonors

Nondonors were identified among participants in the third National Health and Nutrition Examination Survey. Healthy nondonors were a subset of unscreened nondonors. Comparisons were made by bootstrapping.

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