Long-Term Outcomes of Laparoscopic Donor Nephrectomy – A Single-Centre Experience

Introduction

Renal transplantation (RTx) is the most effective treatment for end-stage renal disease (ESRD), offering superior survival and quality of life compared to dialysis. With an increasing global shortage of cadaveric grafts due to the rising number of ESRD, living kidney donation has become increasingly important and is associated with better outcomes than deceased donor transplantation.^1-3 The contribution of living donors varies widely across regions, from <5 to >70% of all transplants, while in India, >95% of RTx rely on living donors.² Since donation involves surgery in a healthy individual without direct medical benefit, ensuring donor safety is a fundamental ethical and clinical responsibility, particularly as the eligibility criterion expands.^4,5

Overall, outcomes for living donors are considered favourable,^6,7 yet concerns remain about potential risks such as hypertension (HTN), proteinuria, reduced renal function, diabetes (T2DM), and the development of chronic kidney disease (CKD). These issues highlight the importance of systematic monitoring. Despite the growing number of living donations, there is limited information from India, and many donors worldwide receive inadequate follow-up.^8-10 Long-term evaluations, typically 5–10 years post-laparoscopic donor nephrectomy (LDN), provide important insights into renal adaptation, overall health, and psychosocial well-being, thereby supporting donor counselling and program planning. International guidelines recommend annual monitoring of renal function, blood pressure, and metabolic health.^11,12 In some countries, lifelong follow-up and priority for transplantation in the event of ESRD are provided.¹³ We aim to evaluate the clinical and functional outcomes in living kidney donors in terms of recent trends in hemoglobin, rate of decline in eGFR, new-onset T2DM, HTN, and mortality rates.

Materials and Methods

This retrospective hospital-based observational study was conducted after Institutional Ethics Committee approval and in accordance with the Declaration of Helsinki. The research/study was approved by the Institutional Review Board at Muljibhai Patel Society for Research in Nephro-Urology, number EC/1019/2024, dated 27 February 2024. All voluntary living kidney donors who underwent LDN between January 2013 and December 2017 were identified from institutional records. Donors lost to follow-up, uncontactable, or with incomplete records were excluded.

Baseline demographic and clinical variables were recorded. Socioeconomic variables such as education, income, occupation, and insurance status were not systematically captured in the study database. Donor selection was performed according to institutional protocols based on the Amsterdam Forum criteria for living kidney donation. Donors were contacted telephonically and invited for follow-up evaluation. Renal function data were obtained from medical records at predefined intervals and at the most recent available follow-up (2023–2025). Follow-up duration was calculated from the date of nephrectomy to the last follow-up or death, whichever occurred earlier. The latest follow-up was defined as the most recent documented clinical and laboratory assessment between 2023 and 2025 for surviving donors, and the last available renal function measurement prior to death for deceased donors. Renal function was assessed using serum creatinine and eGFR, calculated using the CKD-EPI 2021 creatinine equation. Given the limited validation of this equation in single-kidney individuals, eGFR findings are presented as longitudinal trends. ΔeGFR was defined as pre-operative eGFR minus eGFR at the latest follow-up; therefore, positive values represent a greater decline in renal function. Proteinuria was assessed using a urine dipstick. Results were graded as negative, 1+, 2+, 3+, and 4+; a value of ≥1+ (∼ ≥30 mg/dL) was considered positive. Assessment was based on a single measurement, and confirmatory quantitative testing was not performed. HTN and T2DM were defined by the requirement of regular pharmacologic therapy.

Results

A total of 683 living kidney donors who underwent LDN between 2013–2017 were screened; 41 were excluded due to loss to follow-up. A total of 642 donors were included in the final analysis. The mean age at donation was 48.1 ± 10.4 years, and females comprised 71.9% (n = 462). Left-sided LDN was performed in 591 donors (92.05%).The participant flow is shown in Figure 1. The mean preoperative BMI was 25.9 ± 4.05 Kg/m². At baseline, 58 (9.0%) were hypertensive, 20 (3.1%) diabetic, 12 (1.8%) hypothyroid, and 20 reported addictions, mainly smoking or alcohol use. The mean follow-up duration was 113 ± 19 months, with a median of 115 months (9.6 years)(IQR 98–128), ranging from 14–143 months.

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Figure 1: Participant flow diagram demonstrating donor selection and inclusion in mortality and renal outcome analyses.

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Discussion

Our study complements data on long-term follow-up of donors from Ibrahim (US, n=3,698),¹⁴ Mjøen (Norway, n=1,901),¹⁵ and regional studies from Pakistan and Taiwan.^16,17

The cohort’s demographic profile mirrors global trends in terms of baseline comorbidities and the post-operative hemoglobin decline.^18-20 The trajectory of kidney function decline followed by partial recovery is consistent with the well-described phenomenon of compensatory hyperfiltration and structural hypertrophy of the remaining kidney.^14,15,21-28

Only 5.3% donors had eGFR <45 mL/min/1.73 m² at final follow-up, which is lower than rates reported by Kasiske (8%)²⁹ and Boudville et al. (12%).³⁰ Importantly, none progressed to dialysis or ESRD during follow-up, in contrast to low but measurable risks reported by Muzaale (0.31% at 15 years)³¹ and Mjøen (0.47%).¹⁵

Age-related differences in ΔeGFR were modest and predictable. Younger donors showed greater absolute numerical decline, likely due to higher baseline renal function and greater scope for adaptive hyperfiltration, whereas older donors demonstrated smaller numerical losses, consistent with reduced baseline eGFR and diminished hyperfiltration capacity.^14,32 In multivariable analysis, BMI was not independently associated with long-term ΔeGFR (pre-operative eGFR andlatest follow-up eGFR, aligning with findings from the RELIVE cohort and Nehus et al.^32,33 The multivariable model explained only a modest proportion of variance in ΔeGFR, suggesting that long-term renal adaptation after donation is influenced by multiple unmeasured factors like genetic predisposition, dietary factors, socioeconomic determinants, post-donation lifestyle changes, and variations in long-term medical follow-up, which were not systematically captured in this study.

Female sex was independently associated with greater ΔeGFR. This finding should be interpreted cautiously, as biological differences, baseline nephron mass, and sociocultural patterns influencing donor selection may all contribute. Given the predominance of female donors in India, this observation highlights the importance of ensuring equitable donor counselling, long-term follow-up, and protection against potential gender-based disparities in living donation practices.^34,S1,S2

Donors with pre-existing HTN or T2DM demonstrated lower unadjusted mean eGFR values at follow-up, consistent with prior observations that metabolic and vascular risks may influence renal reserve.^15,24,35 However, after multivariable adjustment in our cohort, neither HTN nor T2DM was independently associated with long-term eGFR decline. Textor et al. reported that hypertensive donors exhibited a mean post-donation eGFR of 61 ± 2 mL/min/1.73 m², compared to 68 ± 1 mL/min/1.73 m² in normotensive donors at 6–12 months, emphasizing early functional differences in donors with a higher blood pressure.²⁶ These findings suggest that in carefully selected donors, baseline comorbidities may affect absolute renal function values but may not independently drive progressive decline.

New-onset HTN occurred in 16.8% of donors, consistent with prior meta-analyses and long-term studies.^14-17,30The age-adjusted prevalence of HTN in the Indian population ranges between 25–30%, as per recent national surveys.^S3 Similarly the development of new-onset T2DM was comparable to other regional cohorts^14,16 Importantly, prior studies suggest that donation itself may not independently increase T2DM risk.^13,

Proteinuria was noted in 3.9% of donors, mostly mild. Rates in the literature range from 2–12%^{14,23,26,S5,S6} and our lower estimate likely reflects the single dipstick methodology. These variable outcomes underscore the importance of routine urinalysis in donor follow-up, as recommended by KDIGO and AST guidelines.^11,12

Long-term mortality remained low with no deaths directly attributable to donation. This aligns with international evidence.^{20,14, S7-S10} In contrast, a Norwegian study suggested slightly higher long-term mortality.¹⁵ Such divergent results propagate the need for robust, region-specific data and continued surveillance, particularly as post-donation comorbidities accumulate with age.

This study is limited by its retrospective design, which may lead to missing or inconsistent records. Follow-up data were heterogeneous: some donors underwent continuous surveillance until the most recent follow-up, whereas others were contacted only after prolonged loss to follow-up, leading to variability in outcome assessment. Although only ∼6% of donors were lost to follow-up, adverse outcomes may be over-represented in this group, leading to an underestimate of the true risks. eGFR was estimated using the CKD-EPI 2021 creatinine equation, which has limited validation in single-kidney individuals. Socioeconomic variables were not systematically captured, limiting assessment of potential social gradients in donor selection, follow-up, and outcomes. Additionally, the predominance of female donors may have influenced the observed gender differences in comorbidities. Cause-of-death data were unavailable in a substantial proportion of deceased donors, limiting definitive attribution of mortality outcomes. The relationship of donors to their respective recipients was not delineated in the study. Finally, the absence of a non-donor control group restricts direct comparison of donor outcomes with the general population.

In conclusion, LDN was associated with acceptable long-term outcomes. Donors showed expected and generally acceptable decline in eGFR and a low prevalence of new onset proteinuria Overall, the findings support the favorable long-term safety of LDN in carefully selected donors, with a small subset experiencing significant decline or metabolic complications.