The cardiovascular evaluation of candidates for living kidney donation.

Most studies concluding that living kidney donation does not increase cardiovascular risk have been conducted in low-risk cohorts. As transplant programs increasingly encounter medically complex donors, careful consideration of long-term cardiovascular risks is essential. There is significant variation among institutions in the practices regarding the selection of living donors. This comprehensive review examines the existing evidence on post-donation cardiovascular outcomes, and prevalent risk factors in the donor candidate population including older age, hypertension, prediabetes, diabetes, obesity, dyslipidemias and metabolic syndrome. The use of atherosclerotic cardiovascular risk calculators for coronary artery disease screening and medical optimization is discussed. Data on outcomes with commonly encountered electrocardiographic and echocardiographic abnormalities identified on screening tests in the donor population are essentially non-existent. To address this gap, we review the literature on their prevalence, natural history and outcomes in the general population. Extrapolating from these data, we make recommendations on risk stratification, decision-making regarding donor selection and follow up. Uncertainties in the context of living kidney donation are highlighted. This review underscores the importance of informed consent, and the need for ongoing research regarding long-term cardiovascular effects of kidney donation in higher-risk individuals.