What Are the Dangers of Donating a Kidney?

Donating a kidney is one of the safest major surgeries a healthy person can undergo, but it is still major surgery with real risks that extend well beyond the operating room. The chance of dying during or shortly after the procedure is extremely low, fewer than 1 in 10,000 donations in recent years, and serious surgical complications happen in fewer than 3 percent of cases. The longer-term picture, however, is more nuanced: donors face modestly elevated risks of high blood pressure, reduced kidney function, and, for women who become pregnant after donating, higher rates of gestational hypertension and preeclampsia. There are also financial, psychological, and social consequences that receive far less attention than the medical ones.

What Happens During and Right After Surgery

The operation to remove a kidney from a living donor is called a nephrectomy. Minor complications such as wound infections, pneumonia, and urinary retention are fairly common, showing up in roughly 10 to 22 percent of donors depending on the study and how “minor” is defined.¹² Major complications, meaning those that require a return to surgery or intensive care, occur in fewer than 3 percent of donors.¹ The risk of dying from the procedure itself has dropped over time. A study tracking 30 years of U.S. living donor nephrectomies found that perioperative mortality fell from about 3 per 10,000 donations in the 1990s and 2000s to fewer than 1 per 10,000 in the most recent decade.³

Most donor nephrectomies today are performed laparoscopically, meaning through several small incisions rather than one large one. Randomized trials consistently show that the laparoscopic approach leads to less pain, shorter hospital stays, and a faster return to work compared with traditional open surgery.⁴⁵ In one trial, the median hospital stay was two days after laparoscopic surgery versus four days after an open procedure, and donors who had the laparoscopic approach reported significantly less physical fatigue six weeks later.⁴ Another trial found that a year after surgery, physical function remained better in the laparoscopic group, with complication rates roughly similar between techniques.⁶ The laparoscopic method does involve longer operating times and a slightly longer period when the kidney is without blood supply during removal, but this has not translated into worse outcomes for the recipient’s transplanted kidney.

Chronic Pain After Donation

One danger that gets surprisingly little airtime is lingering pain. While most donors heal without lasting discomfort, a meaningful minority report chronic pain months or years later. A study of over 300 donors who had hand-assisted laparoscopic nephrectomy found that about a quarter reported some degree of chronic pain at a median follow-up of about 19 months, and roughly a third reported pain of any intensity at the incision site.⁷ Complaints tended to arise during bending or exercise, and about 10 percent of donors needed painkillers during the follow-up period. A smaller study found that about a quarter of responding donors still had chronic surgical pain, with roughly 12 percent describing it as severe and disabling.⁸

A systematic review that pooled results across multiple studies placed the average prevalence of chronic post-surgical pain after laparoscopic nephrectomy lower, around 6 percent at a mean follow-up of six years, and identified severe early postoperative pain, prior abdominal surgery, and preexisting back pain as possible predictors.⁹ The wide range in reported numbers likely reflects differences in how pain is measured and how long after surgery donors are surveyed. The takeaway is that chronic pain is not rare and is probably underrecognized. In one series of 500 laparoscopic nephrectomies followed for an average of about 33 months, nine donors had prolonged pain or nerve-related sensations at the surgical site.¹⁰

How the Remaining Kidney Adapts

When you lose one kidney, the other picks up much of the slack through a process called compensatory hyperfiltration: the remaining kidney enlarges slightly and increases its filtering capacity. In one study of 45 healthy donors, the average compensatory increase was about 20 mL/min in filtering rate, which limited the overall loss in kidney function to roughly a third rather than a half.¹¹ How well the remaining kidney compensates varies from person to person. Research shows that donors whose single-kidney filtering rate rises more robustly in the first weeks after surgery tend to maintain better kidney function five and even ten years later.¹² Conversely, donors whose kidney function recovers poorly in the first month face a substantially higher risk of eventually dropping below the clinical threshold for chronic kidney disease.¹³

Age and arterial health play roles here. Older donors and those with stiffer arteries tend to show less compensatory hyperfiltration, meaning their kidney function after donation settles at a lower level.¹¹ This does not automatically spell trouble, but it means the margin for absorbing future insults to kidney health is thinner.

Long-Term Risk of Kidney Failure

The question most prospective donors want answered is whether they might eventually need a transplant themselves. The honest answer: the absolute risk is very small, but it is higher than it would have been had they not donated. A landmark study published in the New England Journal of Medicine found that the 15-year risk of kidney failure among U.S. donors was roughly 3.5 to 5.3 times higher than the projected risk had those same individuals kept both kidneys.¹⁴ That sounds alarming in relative terms, but the absolute rate remains low. A systematic review and meta-analysis found that the incidence of end-stage kidney disease in donors was about 0.5 events per 1,000 person-years.¹⁵ In practical terms, for a healthy 40-year-old who donates, the lifetime chance of reaching kidney failure remains well under one percent, but it is not zero, and it is measurably above zero.

Blood Pressure and Heart Health

Whether donating a kidney raises blood pressure has been debated for decades, and the evidence is genuinely mixed. On one hand, a large single-center study following over 4,000 donors for a mean of about 17 years found that roughly 27 percent developed hypertension, with the rate climbing from 4 percent at five years to about half of donors by 40 years of follow-up. Hypertension in that cohort was linked to worse kidney function, cardiovascular disease, and death.¹⁶ On the other hand, a carefully controlled study comparing donors directly to matched healthy nondonors found no meaningful difference in hypertension rates: about 17 percent in both groups over a follow-up period, with nearly identical annual increases in blood pressure consistent with normal aging.¹⁷ A prospective study measuring 24-hour ambulatory blood pressure found no significant difference between donors and controls at 12 months.¹⁸

The discrepancy likely comes down to controls. Studies without a well-matched comparison group tend to find higher hypertension rates among donors, but those donors are also aging, gaining weight, and doing all the things that raise blood pressure in everyone. When donors are compared to equally healthy people who did not donate, the difference shrinks or disappears. That said, a Norwegian study did find a statistically higher odds of ischemic heart disease among donors compared with healthy controls, though no increased risk of stroke, cancer, or diabetes.¹⁹ The cardiovascular picture is therefore not fully settled, and lifelong monitoring remains important.

Pregnancy After Donation

For women who may become pregnant after donating, the data consistently point to higher rates of gestational hypertension and preeclampsia. A large U.S. study found that gestational hypertension or preeclampsia occurred in about 11 percent of post-donation pregnancies compared with 5 percent in matched nondonors.²⁰ A study from Norway reported similar rates, and the meta-analytic estimate places the risk at roughly twice that of nondonors.¹⁵ A Korean population-based study found even higher rates of gestational hypertension or preeclampsia among donors, about 9 percent versus under 2 percent in nondonors.²¹

Post-donation pregnancies have also been associated with higher rates of gestational diabetes, proteinuria, and gestational hypertension in a large U.S. database study.²² Reassuringly, rates of preterm birth, low birth weight, and stillbirth do not appear significantly different between donors and nondonors, and maternal death among donor pregnancies has not been observed in the major studies.²⁰ The elevated preeclampsia risk is something transplant programs now specifically counsel women about before donation, and it is a factor worth weighing carefully if future pregnancies are planned.

Psychological Consequences

Most donors report that their quality of life stays the same or improves after donating, and donor regret is uncommon. A systematic review of the psychological literature found that quantitative studies consistently showed stable or better quality of life and very low regret rates, though qualitative studies revealed more complicated emotional experiences, where a donor could simultaneously regret aspects of the process while still recommending donation.²³ In a large survey, about 2 percent of donors reported regretting their decision, roughly 6 percent screened positive for anxiety, and about 4 percent for depression.²⁴

One significant psychological risk factor is what happens to the recipient. When the transplanted kidney fails or the recipient dies, the emotional fallout for donors can be substantial. Among unrelated donors whose recipients died, the risk of being diagnosed with depression was roughly two to three times higher than among donors whose recipients were doing well. The same was true after graft failure.²⁵ Donors who screened positive for anxiety were also more likely to express regret.²⁴ These findings underscore the value of psychological screening and post-donation support, which many programs still do not provide consistently.

Financial and Insurance Risks

The nonmedical costs of donation often catch people off guard. Lost wages from recovery time, travel to and from the transplant center, and caregiver expenses all add up. A systematic review of the economic consequences of living kidney donation identified a risk that few prospective donors anticipate: difficulty obtaining or keeping health and life insurance after donation. Among over 3,500 donors surveyed across multiple studies, about 4 percent reported difficulty with health insurance and about 10 percent reported difficulty with life insurance following their donation. In at least two documented cases, insured donors had their policies cancelled after changing jobs.²⁶

In the United States, the recipient’s insurance typically covers the surgical costs, but indirect expenses like lost income, childcare, and travel are the donor’s responsibility. A consensus conference convened to address these issues recommended standardized wage reimbursement and legislative protections for donors’ employment and insurability, acknowledging that the economic climate may itself contribute to declines in living kidney donation rates.²⁷ Some federal and state protections exist, but they remain patchy, and many donors remain unaware of what assistance is available.

Who Faces Higher Risks

Not all donors start from the same baseline. Age, weight, race, and genetic factors all shape the risk profile after donation.

Older donors tend to show a steeper initial decline in kidney function, but studies tracking them over a decade found no cases of function dropping to dangerously low levels or requiring dialysis, provided they passed rigorous screening beforehand.²⁸ Another comparative analysis found no significant differences in perioperative complications or long-term survival between older and younger donors.²⁹ Obese donors face a faster decline in kidney function and higher rates of diabetes and high blood pressure after donation, though in a large study with over 20 years of follow-up, obesity did not lead to excess end-stage kidney disease.³⁰

Racial disparities in post-donation outcomes are well documented and concerning. Compared with white donors, Black donors have been found to face higher risks of hypertension, drug-treated diabetes, and chronic kidney disease after donation. End-stage kidney disease, while still uncommon, was more frequent among Black donors; findings were similar for Hispanic donors.³¹ Part of this disparity appears tied to a specific genetic variant. Black individuals who carry high-risk versions of the APOL1 gene had lower kidney function at a median of 12 years after donation, with faster annual decline compared to Black donors without the high-risk genotype.³² A separate study found that Black donors with the APOL1 high-risk genotype had more than twice the risk of eventually dropping below an eGFR of 45 compared to Black donors without it, prompting researchers to argue that all Black living donor candidates should undergo APOL1 genotyping for better risk assessment.³³ This kind of genetic testing is not yet standard everywhere, but the evidence for making it routine is growing.

The Follow-Up Problem

One of the less visible dangers of kidney donation is what happens after the transplant center discharges you. Donor follow-up is notoriously patchy. A qualitative study of donors found that many did not see themselves as patients needing ongoing care, sometimes because they felt invincible after being told they were healthy enough to donate, and sometimes because they did not want to burden the medical system.³⁴ Others reported feeling abandoned by the hospital once the recipient’s transplant was complete, with the recipient receiving regular follow-up while the donor was essentially left on their own. Themes of neglect, disconnection from the healthcare system, and lack of financial support recurred across donor accounts.

From the institutional side, studies show that dedicated performance-improvement programs at transplant centers do significantly increase both donor follow-up rates and reporting compliance, but these programs require resources that not all centers invest in.³⁵ One study found that few health behaviors changed from before to after donation, with only the rate of medical checkups increasing significantly.³⁶ International guidelines now emphasize that the donor evaluation should include a long-term follow-up plan, with risk assessment based on each candidate’s full demographic and health profile rather than any single factor in isolation.³⁷

Rare Surgical Complications That Surface Later

Beyond the immediate perioperative period, a few uncommon complications can appear weeks, months, or even years after donation. Small bowel obstruction caused by internal hernias is a recognized late complication of laparoscopic donor nephrectomy, arising from the soft-tissue gap left where the kidney was removed.³⁸ In a series of 500 laparoscopic donor nephrectomies, one donor required surgery for bowel obstruction due to adhesions, and two developed incisional hernias during an average follow-up of about 33 months.¹⁰ These are rare events, but they can be serious in an otherwise healthy person who might not suspect a donation-related cause when abdominal symptoms arise years later. Donors should be aware that unusual abdominal pain warrants medical attention and should mention their donation history.

Nondirected Donors and Psychological Outcomes

A growing number of kidney donations come from people who volunteer without having a specific recipient in mind, sometimes called altruistic or nondirected donors. This raises a natural question: do these donors face different psychological risks than people donating to a loved one? The largest prospective study comparing nondirected and specified (directed) kidney donors in the United Kingdom found no differences in psychosocial or physical outcomes over 12 months, and regret rates were similar.³⁹ Nearly all nondirected donors in one survey reported participating in other altruistic activities before deciding to donate, suggesting this is typically an extension of an existing pattern rather than an impulsive act.⁴⁰ The concern that nondirected donors might be psychologically vulnerable or prone to regret does not appear to be borne out by the data so far, though evaluation guidelines still call for thorough psychosocial screening to ensure the decision is well considered.⁴¹

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