*Purpose: Understanding the decline in kidney function after live donor nephrectomy can inform the counselling and selection of donor candidates and guide the follow-up care of prior donors.

*Methods: We conducted a retrospective matched cohort study of living kidney donors in Alberta, Canada between 2002 and 2016 using linked healthcare administrative databases. We matched 604 donors to 2,414 healthy non-donors from the general population on age, sex, year of cohort entry, urban residence, and estimated glomerular filtration rate (eGFR by CKD-EPI equation) before cohort entry (nephrectomy date for donors and randomly assigned date for non-donors). The primary outcome was rate of eGFR change over time (median follow-up 7 years, maximum 15 years).

*Results: The median age was 43 years, 64% were women, and the baseline (predonation) eGFR was 100 mL/min/1.73 m². Overall, from 6 weeks onwards, the slope of the eGFR increased by +0.32 mL/min/year (95% CI +0.17 to +0.46) in donors and decreased by -0.88 mL/min/year (95% CI -0.96 to -0.79) in non-donors (p<0.001). There was no significant difference in the slope of the eGFR in donors based on age or predonation eGFR category. The change in eGFR between 6 weeks to 2 years, 2 to 5 years, and ≥5 years onwards in donors was +1.05, +0.61, and -0.09 mL/min/year, respectively.

*Conclusions: The function in the remaining kidney of a living donor initially increases by 1 mL/min/year due to hyperfiltration; however, this begins to plateau by 2 to 5 years postdonation. In contrast, non-donors experience a steady age-related decline of 1 mL/min/year.

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