*Purpose: Medically complex donors are increasingly being assessed for donation. Due to concern for donor safety, there is a wide variation amongst transplant providers in the acceptance criteria for these candidates. In this study, we review the reasons for declining living kidney donor candidates, identify trends and determine quality improvement initiatives to streamline the live kidney donor evaluation process.

*Methods: Data was collected retrospectively on all live donor (LD) candidates evaluated in donor clinic at our center from January 2019 to October 2020. Multiple medical reasons for donor denial were defined as the presence of 2 or more risk factors for progression to chronic kidney disease (CKD). Donor withdrawal was defined as a potential donor who was evaluated in clinic, but did not proceed with donation for various reasons.

*Results: 291 individuals were evaluated for potential living kidney donation, of which 63 % were female and 45% older than 50 years. Out of these LD candidates, 94 (32.3%) were approved for donation while 197 candidates (67.7%) were declined. The reasons for declining donor candidates are shown in Figure 1. About 46% potential candidates did not proceed for donation due to either the presence of multiple medical conditions (23.3%) or donor withdrawal from the evaluation process (22.8%). The most common risk factors for CKD were obesity, pre-diabetes and hypertension. Interestingly, 45/197 (22.8%) potential donors who withdrew from the donation process (Fig 2), 35% did not proceed with donation either due to recipient ineligibility or the recipient received a deceased donor transplant. 31% withdrew due to undefined personal reasons, 18% pulled out due to concern for CKD post donation despite being considered as an acceptable medical risk and 16% lost contact after the initial clinic visit with no further follow-up.

*Conclusions: Medical risk factors are widely recognized as a common reason for donor denial due to the lack of long-term safety data. However, we were surprised to find that donor withdrawal constituted a significant roadblock to donation. Further analysis revealed several modifiable factors that influenced donor decisions. In addition, we noticed variation among providers for acceptance criteria despite center-based guidelines for donor evaluation. To overcome these barriers , we propose a dedicated multi-disciplinary living donor team to identify risk factors that can be mitigated by donor education, counseling and primary care intervention. We believe that such a dedicated team will also avoid inter-provider variability and further streamline the process of live donor evaluation.

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