*Purpose: We studied associations between kidney transplant recipient diagnosis and other factors and development of ESRD among related living kidney donors (LKDs).

*Methods: Using OPTN listing and transplant data and CMS dialysis data, we found 198 black or white 1st-degree relative LKDs who donated in the US 1994-2017 and developed ESRD. We used a Cox proportional hazards model to predict risk of ESRD in LKDs.

*Results: Twenty-year post-donation ESRD risk varied by both donor and recipient characteristics. After controlling for donor age, BMI, systolic blood pressure, eGFR, and neighborhood income at donation, we found a significant interaction between recipient diagnosis and donor race. Black donors had a 4-fold higher risk (p<0.001) of developing ESRD than white donors when their recipients had glomerular disease (GN); differences did not reach statistical significance when recipients had diabetes (DM; p=0.17) or hypertension (HTN; p=0.16). Among white LKDs, those whose recipients had HTN-related ESRD were at higher risk for ESRD than those whose recipients had GN (aHR:2.91, 95%CI: 1.71-4.96). Among black LKDs, however, ESRD risk was similar for those whose recipients had HTN vs GN (aHR:1.05, 95%CI: 0.62-1.8), but lower for those whose recipients had DM vs GN (aHR:0.50, p=0.09). Other recipient factors were not significant predictors of risk. Absolute risk varied greatly by donor race, sex, donation age, and recipient diagnosis.

*Conclusions: These new findings clarify variation in risk among different groups of LKDs and suggest that risk estimates from past research may not entirely capture ESRD risk from diagnoses that take several decades to develop.

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