TABLE 3.

Guidelines, consensus statements, and expert opinions written since 2010 and containing guidance on pregnancy risk in living kidney donors

Year of publication	Country/region	Funding body	Studies available at the time	Pre‐donation			Post‐donation	Recommendations
				Inquire about prior pregnancy complications	Inform of increased risk of post‐donation pregnancy complications	Seek alternative donors if the potential donor may still wish to have children	Specify post‐donation pregnancy follow‐up
National/International Clinical Practice Guidelines
Frutos and Cabello; Spanish Society of Nephrology (SEN) and Spanish National Transplant Organization (ONT) recommendations for living‐donor kidney transplantation 31
2010	Spain	SEN‐ONT	1,2,6–8	Yes	Informed consent form should state: “If you want to become pregnant after donation, you must inform your gynecologist as you are more likely to suffer from high blood pressure or diabetes during pregnancy.”		Yes. “Blood pressure, weight gain, and proteinuria must be closely monitored.”	“No additional risks have been described during the pregnancy of patients having donated a kidney… However, blood pressure, weight gain, and proteinuria must be closely monitored. In general, this is no different from what is normally recommended to any other pregnant woman.”
Richardson et al.: Canadian Kidney Paired Donation Protocol for Participating Donors 2014 32
2014	Canada	Canadian Blood Services' Living Donation Advisory Committee	1,2,6–8	Yes “[a] detailed description of the obstetrical history”.		Yes. [Exclude those] “with a history of toxemia in pregnancy and whose family is incomplete”.		Exclude from donation: “Premenopausal potential donor with a history of toxemia in pregnancy <10 years ago. [Those with] a history of toxemia in pregnancy in recurrent pregnancies. Premenopausal potential donor with a history of toxemia in pregnancy and whose family is incomplete”.
European renal best practice (ERBP); ERBP guideline on kidney donor and recipient evaluation and perioperative care 2015 33
2015	Europe	ERA‐EDTA	1–3,6–8	No	Yes	No	No	“There is no evidence for increased problems to conceive for women post/donation…. there is no evidence that nephrectomy results in serious adverse events during pregnancy. We recommend informing women of childbearing age that as they are selected from a very healthy subpopulation, donation increases their individual risk from below that of the general population, to that of the general population (1B)”
European Committee (Partial Agreement) on Organ Transplantation (CD‐P‐TO); Guide to the quality and safety of organs for transplantation 34
2018	Europe	Council of Europe / European directorate for the quality of medicines and healthcare	1–4, 6–10	No	Yes		No	Several studies have found that kidney donation is associated with increased incidence of hypertension as well as proteinuria. Females who have donated a kidney are at increased risk of pre‐eclampsia in subsequent pregnancies.
Lentine et al.; Summary of Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors 35
2017		KDIGO	1–3,6–8, 10	Yes, “enquire about prior hypertensive disorders of pregnancy (e.g., gestational hypertension, pre‐eclampsia, or eclampsia).”	Yes, “We suggest that women with childbearing potential be counseled about the effects donation may have on future pregnancies, including the possibility of a greater likelihood of being diagnosed with gestational hypertension or preeclampsia.”	“Women should not be excluded from donation solely on the basis of a desire to have children after donation.”	“We advocate that recommended post‐donation pregnancy care be available to all women worldwide, including any treatments needed for pregnancy complications.”	“Women with a history of a prior hypertensive disorder of pregnancy (which includes pre‐eclampsia) may be acceptable for donation if the long‐term post‐donation risks are acceptable. A decision to proceed with donation in the year after childbirth should consider the psychological and health needs of mother and child.”
Andrews et al.; BTS/RA Living Donor Kidney Transplantation Guidelines 2018 37
2018	UK	British Transplantat‐ion society and Renal Kidney Association	1–4,6–10	No	Yes. “It is recommended that women are informed of a potential greater risk of pregnancy induced hypertension following kidney donation which may require specialist antenatal care, but it does not appear to lead to adverse outcomes for either mother or offspring”	No	“Close monitoring of blood pressure, creatinine, and fetal well‐being are advisable in kidneys donors during pregnancy.” “Kidney donors may be offered Aspirin 75 mg daily for pre‐eclampsia prophylaxis.” “Report births post‐donation to the Living Donor Registry as ”a significant medical event“ at each annual review”	“Women must be informed of a greater risk of pregnancy‐induced hypertension following kidney donation.” “There is no evidence to support the benefits of right or left nephrectomy to prevent pregnancy‐induced hydronephrosis.”
Wiles et al., UK Renal association clinical practice guideline; pregnancy and renal disease 38
2019	UK	UK Renal Association	1–12	NA	NA	NA	NA	We suggest kidney donors are offered low dose aspirin (75 mg‐150 mg) to reduce the risk of pre‐eclampsia (2D).
Organ Procurement and Transplantation Network (OPTN) 36
2020 (updated)			1–12	Yes, “enquire about gestational diabetes.”	“Disclose to all female kidney donors: Risks of pre‐eclampsia or gestational hypertension are increased in pregnancies after donation.”			“Risks of pre‐eclampsia or gestational hypertension are increased in pregnancies after donation.”
Consensus statements
Maggiore et al.; Long‐term risks of kidney living donation: review and position paper by the ERA‐EDTA Descartes working group 39
2016	Europe	ERA‐EDTA Descartes	1–3,6–8		Yes			“Because the available studies point toward a somewhat higher risk of gestational hypertension and pre‐eclampsia, it is important to inform potential donors on this risk. It is, however, also important to note that such complications can be treated. In fact, overall outcome of pregnancies post‐donation in those studies was good.”
Lam et al.; Canadian Society of Transplantation and Canadian Society of Nephrology Commentary on the 2017 KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors 40
2020	Canada	Canadian Society of Transplantation and Canadian Society of Nephrology	1–12	Yes. ‘For female donor candidates with a history of a hypertensive disorder of pregnancy, a detailed description should be obtained’			“Female donors should be counseled to maintain general good health, ensure adequate follow‐up, and receive proper pre‐pregnancy counseling and prenatal care.”	Donor candidates with a mild hypertensive disorder during pregnancy, or a single event that occurred more than 10 years ago who have normal eGFR, normal blood pressure, and no microalbuminuria and who have completed their families …can be considered for living kidney donation. Female donor candidates with recurrent episodes of preeclampsia/eclampsia during subsequent pregnancies … should be excluded from donation.
Mandelbrot et al.; KDOQI US Commentary on the 2017 KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors 42
2020	US	National Kidney Foundation‐Kidney Disease Outcomes Quality Initiative (NKF‐NDOQI)	1–12	Yes “A careful pregnancy history that includes the presence, severity, and onset of preeclampsia is ..necessary in the evaluation of all female donors.”	Yes “Clinicians counseling these women can state that overall the rates of either gestational hypertension or preeclampsia increase from ~5% to 11%.”		“Individualized risk stratification is required and will influence appropriate pregnancy surveillance and preventative strategies. The need to share this portion of medical history with other members of the donor's health care team, especially obstetricians”
Expert opinions
Ahmadi et al. Shifting paradigms in eligibility criteria for live kidney donation: a systematic review 42
2015	the Netherlands		1–3,6–8					“On the basis of the literature that is available on this topic, there is no evidence to conclude women of childbearing age should be declined as potential kidney donors. However, one must bear in mind that comparison with the general population may be prone to confounding because live kidney donors are generally considered to be in better health. Most importantly the effects of donation on maternal and fetal outcomes should be part of the routine discussion about the risks of donation during the informed consent procedure. Quality of evidence available based on the GRADE tool was reported as poor. Level 4, grade of recommendation: C”
Sontrop & Garg; Considerations for LKD among women of child‐bearing age 43
2016	Canada	Expert opinion	1–3,6–8					“Potential donors with reproductive potential should be counseled on the possibility of a greater likelihood of GH or preeclampsia if they choose to donate a kidney but knowing that the probability of the most serious outcomes (stillbirth, neonatal death, maternal death) is extremely low.”
Hladunewich, Melamad and Bramham; Pregnancy across the spectrum of CKD 44
2016			1–3,6–8					“Female donors should be reassured.”
Lentine and Segev; Understanding and communicating medical risks for living kidney donors: A matter of perspective 45
2016	US		1–3,6–8					“For women of childbearing potential considering donation, we agree with recommendations of a recent AST LDCOP consensus statement that counseling should include the possibility of increased risk of gestational hypertension and pre‐eclampsia after donation compared with experience in otherwise similar healthy women. A balanced presentation, however, should also note that in available studies, most women had uncomplicated pregnancies after kidney donation.”