Currently, many transplant centers reject prospective living kidney donors with mild hypertension or proteinuria. Steiner, in a recent article, opines that a 55 year old with an IMA (isolated medical abnormality) has a lower lifetime risk of end-stage renal disease than a younger potential living kidney donor. (emphasis mine)
In 20–30% of diabetic individuals, after about 15–20 years of diabets, proteinuria appears, and 5– 10 years later, most of this group will have progressed to ESRD. Thus, most of the patients who progressed to diabetic ESRD in 2006 developed diabetes some 25 years earlier, often in their 30s and 40s.
In summary, USRDS data suggest that most individuals who will go on to develop diabetes and diabetic nephropathy in later life will have normal donor medical evaluations at age 25, as will those who will typically develop other kinds of ESRD in later life.
If current life expectancy in the United States is about 78 years, and if 10–15% of the cumulative lifetime incidence of NODM (new onset diabetes) is between ages 55 and 65, only a small number of 55-year-old donors (a maximum of 10–15% of the entire group) would develop NODM in the decade after donating, and most of the subgroup that eventually developed diabetic renal disease would not live long enough to see ESRD.
We would only need to look successfully 10 years into the future to reduce the lifetime risk of these 55-year-olds by 75%. We would need to look 20 years into the future just to reduce the 24-year-old donor’s risk by about 10%. In summary, the younger the donor, the greater the remaining baseline lifetime risk for ESRD, and the less a ‘normal for now’ medical evaluation can foresee ESRD.
While not denying that hypertension is a risk factor for renal disease, the relatively low baseline ESRD risk of the nondiabetic 55-year-old normal donor added to the relatively low longterm ESRD risk of essential hypertension will not exceed the young white normal donor’s relatively high baseline 2–3% lifetime risk and the young black donor’s 7–8% lifetime risk for ESRD.
Middle aged donors as a group also may be in a better position to make realistic, mature judgments on the impact of eventual ESRD on their remaining lifetimes than are donors in their 20s, who may well not face ESRD for 40 years.
If they [transplant centers] accept young normal donors, they cannot categorically reject middle-aged mildly hypertensive donors as ‘too risky,’ when they in fact have the same or less risk as normal young donors. If centers categorically refuse these older donors because their baseline lifetime risk for ESRD is ‘too high,’ they cannot ethically accept any young donors. While this is clearly true for comparing risks for white young donors and white older donors, it is overwhelmingly so when comparing black young donors to white middle-aged donors. At present, centers may not be adequately assessing baseline ESRD risk of young ‘normal for now’ donor candidates and may have inadvertently adopted internally inconsistent donor selection standards
Steiner, R. (2010). ‘Normal for Now’ or ‘At Future Risk’: A Double Standard for Selecting Young and Older Living Kidney Donors American Journal of Transplantation, 10 (4), 737-741 DOI: 10.1111/j.1600-6143.2010.03023.x