*Purpose: Patients with nutcracker syndrome (NCS) are often presented with multiple treatment pathways, including interventional and surgical options. In those who elect native nephrectomy, consideration of medical necessity living donation (MNLD) rather than traditional renal autotransplant (RAT) is offered to this unique population of patients at the University of Utah.

*Methods: Over the past nine years, there have been 107 patients evaluated by our MD team for possible NCS. This MD team includes interventional radiology, transplant surgery, urology, and vascular surgery. 97 patients were deemed appropriate for native nephrectomy, most often followed by RAT (95). As our program matured, in 2019, we began presenting the option of MNLD rather than RAT where medically appropriate and without increased risk to the potential donor. After informed discussions, including considering all the risks and benefits associated with each procedure, 2 patients opted for medical necessity living donation rather than RAT.

*Results: The first patient was a 49-year-old female diagnosed with NCS and Superior Mesenteric Artery Syndrome. This MNLD kidney graft was offered to a 51-year-old female with end-stage renal disease based on a standard UNOS cross-match listed at our institution. The second patient was a 40-year-old female diagnosed with NCS and Median arcuate ligament syndrome and had asked that her donation prioritize a pediatric recipient. A 9-year-old female with ESRD NYOD on our pediatric kidney transplant waitlist was deemed to be an excellent size and HLA-matched candidate for this MNLD. Outcomes for both donors were excellent with no significant differences compared to their matched counterparts who elected RAT. Both MNLD recipients experienced immediate graft function and the proper IRB approvals were obtained for research.

*Conclusions: MNLD should be discussed with NCS syndrome patients in whom native nephrectomy is offered as their best option for relief of their symptomatology. Certainly, appropriate informed consent for both the donor and the recipient must be considered. Further, the programmatic, financial, and outcome metrics of MNLD must be explored as they become a more viable option in the context of the MD approach to NCS.

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