In the United States, the decline in living kidney donation over the last several years is indisputable. Since the peak in 2004 living kidney donation has declined in all but one year.

Moreover, recent trends indicate that the decline in living donation is most prominent among men, blacks, and younger and lower income adults, which may further exacerbate existing disparities in live donor kidney transplantation. It is tempting to attribute this decline to random variation and to assume the number of living donors will return to levels observed in 2004. However, despite novel programs to help patients find suitable living donors, national financial programs and state tax incentives for living donors, and heightened general public awareness of living kidney donation, there is considerable downward pressure on rates of living donation. In this presentation, we evaluate the impact that policy changes, shifting donor selection criteria, increased emphasis on performance oversight, an aging transplant population, and the larger economic crisis have had on living kidney donation rates. We believe that this persistent downturn in living donation should be cause for alarm within the transplant community, as it potentially leads to longer waiting times for transplantation, greater dialysis exposure, higher death rates on the waiting list, lower graft and patient survival for recipients, and higher overall healthcare costs for the care of patients with end-stage renal disease. To attenuate the decline in living kidney donation, we propose a multi-layered approach and offer specific recommendations that engage key stakeholders – transplant programs, the broader transplant community, and state and national governments. Systematic programmatic, scientific, policy, and legislative efforts to identify and remove barriers to living donation are needed to ensure that live donor kidney transplantation remains a viable option for patients with chronic kidney disease.

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