Electronic Thesis and Dissertation Repository


Doctor of Philosophy


Epidemiology and Biostatistics


Garg, Amit X


Background: Living kidney donation is the ideal treatment for many patients with kidney failure. However, the living donor evaluation process has been criticized by patients and healthcare providers as inefficient. In the present research, we evaluated the inefficiency of the living donor evaluation process.

Methods: We conducted a scoping review of the literature and obtained data from large administrative datasets (1256 living donors) and medical chart review (849 prospectively recruited living donors across 12 transplant centres plus retrospective analysis of 1065 living donor candidates from a single centre).

Results: The median time to complete the entire evaluation was 9-11 months for donors and 4.3 months for candidates who were declined or withdrew from the evaluation. Up to 35% of recipients who could potentially have received a pre-emptive transplant (avoided dialysis entirely) started dialysis before transplantation, costing the healthcare system $8.1M for dialysis alone. Shortening the evaluation time by only 10% translated to an annual cost savings of at least $1.3M in Ontario due to averted dialysis costs and up to 38 intended recipients each year could have received a transplant they otherwise did not receive (17% increase in living donor transplantation). The cost to the healthcare system was $3,641 for the donor evaluation, $11,695 for the donor surgery (including perioperative costs), and $933 for the first year post-donation. There are many reasons that may contribute to a longer living donor evaluation. Donation through kidney paired donation prolonged the time until donation by 6 months. The evaluation time was doubled if the intended recipient started dialysis part-way through the donors’ evaluation. Finally, every month delay in the recipient referral extended the time until donation by 0.4-0.9 months and increased the likelihood that the recipient would start dialysis before transplant. Between-centre differences were observed for evaluation times and donation costs.

Conclusions: The living donor evaluation is time-consuming, resulting in potentially avoidable unintended adverse consequences to donor candidates, their intended recipient, and the healthcares system. Potential strategies to improve the efficiency of this process include eliminating unnecessary or redundant tests, evaluating multiple donor candidates simultaneously, performing 1-day evaluations, and promoting earlier recipient referrals.