Long-Term Risk of ESKD in Kidney Donors with Diabetes Mellitus Using eGFR 6 Months after Donation

Background: Traditionally,diabetes mellitus was considered contraindication for kidney donation.Guidelines now recommend evaluation of such donors on case-to-case basis.Estimated GFR at 6 months post-donation(eGFR6) may be surrogate for long-term risk of ESKD.As per a study, 15-year cumulative incidence of ESKD with eGFR6 >70 ml/min was estimated to be 11.7/10000 donors against 33.7/10000 donors if eGFR6< 50ml/min. We demonstrate potential safety of donors with diabetes using eGFR6. Methods: Potential kidney donor with diabetes mellitus were evaluated only after exploring other voluntary family members’ feasibility to donate.As per KDIGO recommendations,older diabetic candidates with well-controlled glycemia,not requiring insulin & without end-organ damage were considered.Donors were deemed eligible only if pre-donation projected 15-year-risk of ESKD was <1% as estimated by ESRD-Risk tool for living kidney donors(NYU Langone’s Center for Surgical & Transplant Applied Research(C-STAR)).Independent assessment of potential donors by Internal Hospital Medical Board was also done. Results: 345 patients received kidney transplantation from Jan 2019 to Dec 2023. 9 kidney donors with diabetes (mean age-60.7yrs),with follow-up of > 6months were included.8 donors were detected to have diabetes during work-up for donation & 1 had been diabetic for 5 years and 5 had hypertension.Mean HbA1C was 6.7%.Mean pre-donation creatinine was 0.75 mg/dl(eGFR- 92.84 ml/min), urine albumin-creatinine ratio was 20.29.Mean DTPA-GFR of retained kidney was 41.42 ml/min. Mean follow up was 20.6 months (6-48 mon).Average eGFR at 6 months was 59.8 ml/min.Only 1 donor (aged 72 years) had eGFR6 < 50ml/min (38 ml/min).On her last-follow-up at 24 months,she continues to do well (creatinine-1.29,UACR <30). Graft outcomes were good. Only 1 graft was lost to plasma-cell rich rejection at 6 months post-transplant.Another patient who was biopsied 2 weeks after transplant had mild ATN,which recovered gradually.None of these patients had histopathological changes of diabetic nephropathy. Conclusion: Our study demonstrates safety of diabetic kidney donors using eGFR6 as a surrogate for long-term risk of ESKD.More long-term studies are required to substantiate this risk. In certain exceptional circumstances,donation from diabetic donors may be considered, considering intangible effects of recipient health on donor well-being.