Modality Selection.” Peritoneal Dialysis International 33, no. 3: 233–41. Bridgespan Group. 2019. “Reforming Organ Donation in America: Saving 25,000 Lives per Year and $13 Billion in Taxpayer Funds over Five Years.” https://www.bridgespan.org/bridgespan/Images/articles/refor Long-term risks for kidney donors Geir Mjen1 , Stein Hallan2,3, Anders Hartmann1 , Aksel Foss1 , Karsten Midtvedt1 , Ole Øyen1 , Anna Reisæter1 , Per Pfeffer1 , Trond Jenssen1 , Torbjrn Leivestad4 , Pa˚l- Dag Line1 , Magnus Øvrehus2 , Dag Olav Dale1 , Hege Pihlstrm1 , Ingar Holme5 , Friedo W. Dekker6 and Hallvard Holdaas1 1 Department of Transplant Medicine, Oslo University Hospital, Oslo, Norway; 2 Department of Nephrology, St Olav University Hospital, Trondheim, Norway; 3 Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; 4 Norwegian Renal Registry, Department of Transplant Medicine, Oslo University Hospital, Oslo, Norway; 5 Department of Preventive Medicine, Oslo University Hospital, Oslo, Norway and 6 Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands Previous studies have suggested that living kidney donors maintain long-term renal function and experience no increase in cardiovascular or all-cause mortality. However, most analyses have included control groups less healthy than the living donor population and have had relatively short follow-up periods. Here we compared long-term renal function and cardiovascular and all-cause mortality in living kidney donors compared with a control group of individuals who would have been eligible for donation. All-cause mortality, cardiovascular mortality, and end-stage renal disease (ESRD) was identified in 1901 individuals who donated a kidney during 1963 through 2007 with a median follow-up of 15.1 years. A control group of 32,621 potentially eligible kidney donors was selected, with a median follow-up of 24.9 years. Hazard ratio for all-cause death was significantly increased to 1.30 (95% confidence interval 1.11–1.52) for donors compared with controls. There was a significant corresponding increase in cardiovascular death to 1.40 (1.03–1.91), while the risk of ESRD was greatly and significantly increased to 11.38 (4.37–29.6). The overall incidence of ESRD among donors was 302 cases per million and might have been influenced by hereditary factors. Immunological renal disease was the cause of ESRD in the donors. Thus, kidney donors are at increased long-term risk for ESRD, cardiovascular, and all-cause mortality compared with a control group of non-donors who would have been eligible for donation. Kidney International (2014) 86, 162–167; doi:10.1038/ki.2013.460; published online 27 November 2013 KEYWORDS: cardiovascular events; end-stage kidney disease; kidney donation; kidney transplantation; mortality risk Living donor kidney transplantation is the preferred treatment for end-stage renal disease (ESRD), because it is associated with improved graft and patient survival compared with transplantation from a deceased donor.1 Living kidney donation, however, requires that healthy individuals voluntarily undergo major surgery with no physical health benefit to themselves. Although rare, perioperative mortality does occur during organ retrieval from living donors and have been estimated to occur in 0.2% of liver donors and 0.03% of kidney donors.2,3 Less serious perioperative risks are accepted and well documented.3,4 Kidney donation inevitably leads to reduced renal function and is associated with an increase in proteinuria, as well as a rise in blood pressure (BP) greater than that attributable to normal aging.5,6 These factors are associated with an increased risk for cardiovascular and all-cause mortality in the general population.7–9 Follow-up studies of living organ donors have not reported increased cardiovascular and all-cause mortality, but results may have been confounded by selection bias in the control groups. In most studies, controls were selected from the general population, which includes adults with medical conditions that would make them ineligible for kidney donation.10–12 As a result, these controls would have been less healthy than the living donors and an effect of organ donation on all-cause and cardiovascular mortality could have been underestimated. Three studies have included control groups selected to have comparable health status to the living donors, and each of these demonstrated no increase in cardiovascular disease or mortality over a follow-up time of approximately 6 years.3,13,14 It is possible, however, that living donors may be at increased risk of death for many years beyond the period that has been investigated to date. Thus an analysis with a longer follow-up time may be necessary to examine the possible impact of living donor nephrectomy. Occurrence of ESRD in living donors has also been observed long term after kidney donation although the absolute number of cases presented has been very low, and it is uncertain whether the statistical assessment used has been sufficient. clinical investigation http://www.kidney-international.org & 2013 International Society of Nephrology Correspondence: Hallvard Holdaas, Section of Nephrology, Department of Transplant Medicine,