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The ever-increasing waiting times for deceased-donor kidneys have focused attention on living donation as a useful way to increase the supply of organs for transplant candidates (1). Many renal transplant centers now routinely accept donors with risk factors for developing future kidney disease, a group of patients that we term “complex living donors” (2,3). A lack of consensus about what constitutes an important risk factor and insufficient data about long-term outcomes for complex living donors have generated heated debate among transplant professionals over the ethics of allowing donation to proceed (4–6).A medical, ethical, and legal framework for protecting complex living donors therefore is important given the diverse, sometimes conflicting pressures that transplant centers are under to accept living donors. The devastating cardiovascular mortality of chronic kidney disease (CKD) has contributed to the sense that long waiting times for deceased donor kidneys represent a “crisis” in which transplant candidates may die before receiving an organ (7–10). Potential recipients and their families, referring nephrologists, or donors themselves may encourage transplant centers to accept complex donors (1). In addition, transplant centers often generate income, prestige, or media attention for hospitals, accelerating the expansion of transplant programs.In the United States, patients can readily access information about which hospitals have the most active centers (11). Volume counts in attracting transplant candidates. Hospital administrators may encourage or provide incentives to transplant groups to increase the number of transplants, including those that involve complex living donors (4).Complicating the debate about living donors with risk factors is nomenclature. Our discussion focuses on potential long-term medical risks to donor health. In his discussion of donors with hypertension, Matas (10) used the term “marginal living donors.” We have eschewed this term because of potential confusion with the concept of …

Creating a Medical, Ethical, and Legal Framework for Complex Living Kidney Donors