From Evidence to Action in Living Kidney Donor Transplantation

Current rates of living donor kidney transplantation (LDKT) vary considerably worldwide. In the United States, LDKT accounted for approximately 21% of kidney transplants in 2023, with a rate of 18–21 per million population (pmp), whereas Canada reports a national rate of 12–15 pmp, representing approximately 30% of kidney transplants.1,2 Globally, the proportion of LDKT is the highest in Turkey, Saudi Arabia, and South Korea, whereas most European countries are dominated by deceased donor transplantation.3 Despite the clinical advantages of LDKT, rates in North America and Europe have plateaued or declined, with persistent disparities among non-White and socioeconomically disadvantaged populations. Evidence supports several approaches to increase LDKT, with the strongest data for educational interventions, patient navigation, kidney paired donation (KPD), culturally competent care, and nondirected donation (Table 1). Targeted educational interventions—particularly those engaging family and social networks—double to triple donor inquiries and increase donor evaluations.4 Patient navigation has demonstrated up to nine-fold increases in donor screening and seven-fold increases in donor approval, while reducing racial disparities.5 KPD now accounts for approximately 20% of US LDKTs and improves access for highly sensitized patients.6 Culturally tailored interventions can triple LDKT rates compared with generic education.7 Nondirected donation has also expanded access to LDKT and benefits hard-to-match recipients.8 A large pragmatic trial of multicomponent models, Enhance Access to Kidney Transplantation and Living Kidney Donation, show mixed success, highlighting the need for nationally coordinated and equity-focused implementation.9 Table 1 - Strategies to increase living donor kidney transplantation Strategy Evidence of Effectiveness Equity Impact References Educational interventions Meta-analyses and RCTs show approximately 2×–3× increase in donor inquiries, evaluations, and LDKT rates. Social network-inclusive models are most effective Limited effect in minorities unless culturally tailored Sandal et al., 20194 Patient navigation 7×–9× increase in donor screening and approvals; mitigates racial disparities Particularly effective in Black patients Locke et al., 20205 KPD Accounts for approximately 20% of US LDKTs; doubles transplant chance for sensitized/minority patients Improves access for women and non-White recipients Kumar et al., 20256 Culturally competent care Culturally tailored interventions triple LDKT rates among Hispanic patients Reduces disparities in underrepresented groups Gordon et al., 20227 Nondirected donation Initiates chains averaging 4–6 transplants each; safely expands donor pool Increases access for highly sensitized recipients Jan et al., 20228 Multicomponent interventions Cluster RCT (EnAKT LKD) ↑ evaluations but no significant ↑ in completed LDKTs Potential if implementation fidelity is high Garg et al., 20239 EnAKT LKD, Enhance Access to Kidney Transplantation and Living Kidney Donation; KPD, kidney paired donation; LDKT, living donor kidney transplantation; RCT, randomized controlled trial. In this issue, Leonberg-Yoo et al. evaluate the impact of National Kidney Registry (NKR) programs designed to reduce disincentives to living kidney donation.10 Using data from 103 US transplant centers, the investigators found that implementation of Donor Connect, an outreach and communication platform that facilitates follow-up with potential donors to improve conversion from initial registration to evaluation, was associated with a significant increase in registration conversion rates (from 8.4% to 18.4%). The Remote Donor Program, which allows donors to complete much of their evaluation and testing closer to home, substantially reduced travel burden by a median of almost 600 miles. Donor Shield, a program that provides reimbursement for travel, lodging, and lost wages, along with protections for complications, provided financial reimbursement to more than half of participating donors, who were more racially diverse and more likely to live further from transplant centers. This complements and extends previous evidence on strategies to increase LDKT. Similar to educational interventions, Donor Connect achieved measurable increases in donor activation through improved communication, although its low-cost, system-level design offers greater scalability than resource-intensive education programs. Its impact is also consistent with patient navigation models, but Donor Connect likely requires far less personnel investment. The Remote Donor Program echoes the equity gains of KPD, culturally competent care, and nondirected donation by expanding access for geographically distant and racially diverse donors, thereby reducing structural barriers to LDKT. Finally, the synergistic integration of communication, logistical, and financial supports in the NKR approach contrasts with the limited transplant yield seen in the multicomponent Enhance Access to Kidney Transplantation and Living Kidney Donation trial,9 suggesting that donor-centered design and national coordination may be critical to converting increased evaluations into completed transplants. Very importantly, this study demonstrates how donor-focused interventions can operate synergistically when implemented at scale. Donor Connect represents a relatively low-cost, high-yield strategy; by improving communication with prospective donors and facilitating follow-up, it addresses one of the most common drop-off points in the donation pathway. The immediate increase in registration conversion following its launch illustrates how modest system adjustments can yield measurable results. This is important because many previous interventions have been resource-intensive (e.g., full patient navigation models), limiting scalability. By contrast, Donor Connect demonstrates that even incremental engagement strategies can have population-level impact when adopted across multiple centers simultaneously. The Remote Donor Program further highlights the central role of logistics in shaping donor participation. Long travel distances have long been associated with a lower likelihood of completing evaluation, yet most transplant systems have been slow to redesign evaluation processes around the donor's convenience. By reducing median travel burden by almost 600 miles, this program shows how removing geographic barriers can broaden the donor pool, particularly for individuals outside urban centers. It also reflects broader trends toward telemedicine and distributed testing, which accelerated during the coronavirus disease 2019 pandemic. The finding that remote donors were more racially diverse and more geographically distant underscores the program's potential as an equity-promoting intervention. Donor Shield complements these efforts by addressing the financial realities of donation. That more than half of participants accessed reimbursement demonstrates both the ubiquity of cost barriers and the importance of transparent, standardized supports. Although previous studies have shown financial neutrality is necessary but insufficient to increase donation, embedding reimbursement within a broader bundle of logistical and communication supports may explain the stronger uptake seen here. This integrated approach is particularly noteworthy, as it echoes calls from the transplant community for donor-centered, multicomponent models that do not rely on a single intervention. Perhaps the most important contribution of this study is the demonstration that donor-centered innovations can be deployed nationally, across diverse transplant centers, and yield consistent gains. The NKR model illustrates the benefits of centralized coordination and standardization. At the same time, the study reinforces the need for more rigorous evaluation designs, including adjustment for unmeasured confounding and center-level practices. Prospective studies with equity-focused end points will be crucial to confirm that these gains translate into sustained increases in completed living donor kidney transplants across all populations. Together, these donor-centered innovations—spanning remote evaluation, logistical support, and cost reimbursement—demonstrate measurable improvements in donor engagement and access and highlight how systematically addressing disincentives can expand the living donor pool and enhance equity in transplantation. As with all retrospective analyses, important limitations should be acknowledged. No statistical methods were used to adjust for potential confounding or selection bias in program participation—Donor Connect participants, for example, may differ in unmeasured motivation or health literacy from nonparticipants. Missing data and the retrospective study design also limit causal inference, and potential center-level outreach practices could confound observed program effects. Despite these constraints, the dataset is unique and provides valuable insight into the impact of innovations designed to facilitate living donation. As we seek to reverse stagnant trends in LDKT, the evidence is clear: Donor-centered innovations that remove disincentives, reduce logistical and financial burdens, and promote equitable access are essential. The findings from this study illustrate how targeted programs can translate willingness to donate into action, particularly among diverse and geographically distant populations. To achieve sustained growth in LDKT, national strategies must prioritize standardization, scalability, and equity—ensuring that every motivated donor can give, and every eligible recipient has the chance to benefit.