Evaluation of older living donors and outcomes

PURPOSE OF REVIEW: The widening gap between the demand for and supply of kidneys for transplantation has intensified the need to expand the living donor pool. At the same time, a growing proportion of individuals aged 65 years and older are being waitlisted for kidney transplantation. Living donor kidney transplantation remains the optimal therapy for end-stage kidney disease, and older living donor candidates represent a promising but underutilized resource. Although older donors typically present with greater medical complexity, their lifetime risk of developing end-stage kidney disease is comparatively low, allowing for more flexible acceptance criteria than those applied to younger donors. Despite a ninefold increase in the number of older living kidney donors over recent decades, they still comprise only 6-7% of all living donor transplants. RECENT FINDINGS: Recent evidence suggests that older donors experience adequate compensatory renal function after nephrectomy, and transplant recipients of kidneys from older donors achieve favorable outcomes. These findings highlight the potential to safely expand the donor pool by more effectively incorporating older adults. SUMMARY: In this review, we summarize age-related macro- and microscopic renal physiological changes relevant to donor evaluation. We then examine the literature on post-donation renal functional adaptation, cardiovascular risk, and all-cause mortality among older donors. Additionally, we compare age-specific glomerular filtration rate (GFR) thresholds used internationally to guide donor selection. Finally, we discuss future directions, including refining donor risk prediction models, standardizing age-adapted GFR criteria, and integrating biological rather than chronological markers of aging to better identify suitable older donor candidates.