*Purpose: Living kidney donors face increased risk of ESRD, although absolute risk remains low through 20 years postdonation. Informed consent for kidney donation depends on accurate estimates of postdonation ESRD risk.

*Methods: Using SRTR data 1987-2020, we modeled the association between donor characteristics and ESRD risk: age, sex, race (White/Black/Other), first-degree biological relationship to recipient, predonation systolic blood pressure, predonation eGFR, and BMI, with multiple imputation to handle missingness. We censored for mortality and fit race-stratified models to investigate interactions.

*Results: Among 158,304 donors, 589 experienced ESRD; 1.5% of donors experienced ESRD within 30 years postdonation. 30-year risk of ESRD was higher for first-degree related donors (1.6% vs 0.9%), men (2.1% vs 0.9%), and Black donors (3.6% vs 1.1% White/1.5% Other) (all p<0.01) (Figure). Older age was associated with increased ESRD risk among White donors but decreased risk among Black donors. In multivariate models, higher SBP, BMI>30, and history of cigarette use were associated with increased ESRD risk; predonation eGFR was not associated with risk (Table). The model predicted ESRD risk with C-statistic=0.71.

*Conclusions: ESRD risk through 30 years postdonation varies substantially by donor characteristics, and can be estimated based on predonation characteristics. Donor candidates with high predicted risk should be counseled about their ESRD risk and postdonation behaviors that can delay onset of ESRD.

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