The kidney transplant from a living donor is an essential intervention to treat end-stage renal disease, a condition of great relevance in Europe and worldwide, affecting millions of people. Various factors such as diabetes, hypertension, obesity, and population aging contribute to the increase in this condition. This transplant modality stands out for its better clinical outcomes compared to deceased donor transplants, as kidneys from living donors have greater longevity, reduce the need for retransplants, shorten waiting lists, and improve patients’ quality of life, in addition to lowering overall healthcare costs. The first kidney transplant from a living donor was performed in 1954 between identical twins in the United States.1 Over time, the practice extended to non-related donors, thanks to research demonstrating similar survival rates between genetically related and unrelated donors. In Europe, the Action Plan on Organ Donation and Transplantation promoted living donation, leading to a 17% increase in the number of transplants. To increase access to kidney transplantation from living donors, it is important to consider several key aspects as: Education and information to promote kidney donation from living donors, information and education programs targeted at patients and their families are required (these campaigns should highlight the benefits of donation for the recipient and the safety for the donor), multidisciplinary work since the participation of multidisciplinary teams is fundamental in kidney transplantation. Nephrology, nursing, and psychology professionals play an essential role in identifying potential donors and optimizing procedures.2 Identified obstacles include the lack of communication between dialysis and transplant teams, the absence of standardized protocols, and cultural, linguistic, and psychosocial barriers. Furthermore, storytelling is an emerging strategy to promote kidney donation, particularly when it is based on real-life experiences of donors and recipients. This educational technique aims to reduce fears, increase understanding, and encourage acceptance of living donation. Although more studies are needed, initial results indicate that storytelling can change attitudes and behaviors. It is crucial to highlight the fundamental role of informed consent in living kidney donation. Donors must receive clear information about short- and long-term risks, surgery, and possible complications. This process must ensure the donor's full understanding and freedom to decide, free from external pressures. While surgical risks are low, it is essential for the medical team to supervise the entire process and provide psychological support before, during, and after the intervention. There are several types of living kidney donation: directed, altruistic, paired exchange donation and chain donation however, certain fundamental ethical principles that govern living kidney donation may be compromised, such as the principles of autonomy, justice, beneficence, and non-maleficence. Autonomy ensures the donor's free decision, while justice seeks equity in access to transplantation. The principles of beneficence and non-maleficence guarantee that the benefits to the recipient outweigh the risks assumed by the donor. Another major concern is the possible commercialization of organs, which is internationally prohibited. However, financial compensation or indirect benefits could compromise the autonomy of the most vulnerable donors. Regulations on living donation must prevent exploitation and protect equity and altruism.3 In global catastrophe situations like the COVID-19 pandemic, kidney transplantation practices were affected, especially living donation, as it was considered an elective surgery. Measures were adopted to reduce activity, impacting recipients’ quality of life and increasing waiting lists. Vaccination of donors and recipients was fundamental to resuming activity.4 Today, new techniques have emerged to overcome ABO incompatibility between donor and recipient, known as desensitization. This technique allows transplants even when blood types do not match. Although it involves risks associated with immunosuppression, it improves equity in transplant access and increases the availability of organs. Then, kidney transplantation from a living donor is an effective treatment alternative for chronic kidney disease. Despite ethical, legal, and operational challenges, its benefits for the recipient and society make it the most efficient option for kidney replacement. Multidisciplinary work, education, and appropriate regulation are key to its success and to promoting fair, safe, and altruistic donation. A systematic review of scientific articles analyzing the ethical dilemmas of organ donation is presented. This study aims to integrate the ethical perspective into daily clinical practice, train healthcare professionals, and highlight in the scientific literature the ethical issues that influence medical decision-making.

The aim of this study is to identify and thoroughly analyze the most common ethical dilemmas associated with living donor kidney transplantation, describing the types of ethical dilemmas identified in the literature, such as equity in access, informed consent, and conflicts of interest, examining the perspectives of different stakeholder groups, such as doctors, patients, donors, and regulators, to contextualize ethical dilemmas from various viewpoints; and analysing the strategies and protocols used in clinical practice to address these dilemmas in an ethical and fair manner.

A systematic review of the literature was conducted following the PRISMA model, consulting the Pubmed, Scopus, and Mendeley databases. A combined search strategy was used with MeSH terms and keywords related to ethical dilemmas in living donor kidney transplantation. The included studies had to address ethical dilemmas related to living donor kidney transplantation, be published in peer-reviewed scientific journals, and be written in English, Italian, or Spanish. Studies that did not focus on ethical dilemmas, abstracts, editorials, letters to the editor, or those not available in full text were excluded (Fig. 1). The study selection was performed in two stages: first, titles and abstracts were reviewed, and then full texts of the studies meeting the inclusion criteria were examined. A single reviewer performed the selection, and discrepancies were resolved by consulting a second reviewer. Information was extracted on the year of publication, study location, title, objective, study design, research methods, results, and conclusions. In Pubmed, 847 results were identified, of which 22 studies were selected. In Scopus, 207 results were obtained, with 15 studies selected, and in Mendeley, 29 results were identified, with 7 studies selected. In total, 49 studies were selected for the review (Table 1). The review was conducted in accordance with international ethical standards, such as the Declaration of Helsinki and the Declaration of Oviedo, ensuring respect for autonomy, informed consent, data confidentiality, and risk minimization. Although ethical committee approval was not required for this study, the fundamental ethical principles for scientific research were followed. Local regulations on data protection and good clinical practices were also considered, maintaining an ethical approach throughout all stages of the review.

Fig. 1.

Flow PRISMA methodology.

This systematic review included 49 articles that primarily evaluated the ethical aspects of living donor kidney transplantation and some demographic characteristics. Of the studies analyzed, 47% were conducted in the Americas, with 71% of them in the United States and the rest in Brazil, Argentina, and Canada. In Europe, 27% of the studies were conducted, with Italy accounting for 50% of them. Other European countries, such as Germany, Sweden, Switzerland, and Spain, represented 8% each. 9% of the studies were from the United Kingdom and Asia (China, Japan, Pakistan). Additionally, 6% of the studies were conducted in international collaboration (Figs. 2 and 3). The articles highlight the complexity of the ethical dilemmas surrounding of living donor kidney transplantation, emphasizing the need for multidisciplinary approaches and unified protocols to address both current and future challenges. The ethical issues found vary depending on geographic location, study design, and specific objectives. Living donor kidney transplantation poses multiple ethical challenges (Fig. 4). The principle of beneficence requires ensuring that the benefits outweigh the risks, while the principle of non-maleficence mandates minimizing potential harm. Van Dellen D et al. highlight the importance of equity in access to transplants and the individualization of the process to overcome preventive barriers.5 The principle of justice is also frequently addressed, particularly in the allocation of organs. The review shows that, in some countries, there are racial and gender inequalities in donation. Ross LF et al. highlight the underrepresentation of the Black race and the overrepresentation of women as donors, evidencing an equity issue.6

Fig. 2.

Worldwide distribution diagram for the chosen studies.

Fig. 3.

Details specific to America and Europe for the chosen studies.

Fig. 4.

Most frequent ethical dilemmas in the reviewed studies.

The review includes proposals to improve ethics in living donor kidney transplantation. Grossi et al. propose a model of informed consent based on three phases: preoperative information, psychosocial evaluation, and final consent.19 Lederer et al. recommend a prior educational process to ensure donors fully understand the risks.20 Perea et al. highlights the need for coordinated ethical management in living kidney donation.21 They propose the collaboration of various healthcare professionals and compliance with strict legal requirements, such as legal age, mental competence, and access to complete and understandable information. This systematic review mainly highlights that the informed consent is the cornerstone of ethics in living donor kidney transplantation, guaranteeing the autonomy, dignity, and respect of patients. The review reveals the need to integrate emotional, social, and psychological aspects into the consent process, in addition to the usual surgical risks. Issues of equity, anonymity, exploitation, and transplant tourism also stand out as significant ethical challenges. In general, the findings of this review underscore the need to develop robust ethical frameworks to address emerging issues in living donor kidney transplantation, promoting fair, equitable practices centered on respect for the autonomy of both the donor and the recipient.22 Living donor kidney transplantation has emerged as a crucial therapeutic option for patients with end-stage renal disease. Results show that there is a largest proportion of living-donor transplants originate in chronic kidney disease units, rather than in dialysis units. This could be due to the fact that patients managed in this stage, are more likely to be referred the living-donor transplant option than those in dialysis unit. Patients in dialysis units, often experience delays in referral for transplantation, so they accumulate more comorbidities and are less likely to identify a living donor option.

Despite its clear benefits for recipients, the ethical complexity of this procedure should not be overlooked. This systematic review of 49 studies explores the various ethical dilemmas associated with living donor kidney transplantation, offering a broad perspective on the issues involving both donors and recipients.

The review shows a strong geographic concentration of studies in the United States and Europe, reflecting greater development and access to living donor kidney transplantation programs in these regions, as well as growing interest in its ethical analysis. Most studies were published between 2019 and 2023, indicating recent dynamism in research on this topic. The significant disparity in the rate of living-donor kidney transplants worldwide, particularly the difference between Spain and other countries, may be attributed to multiple factors. Among these, Spain's strong emphasis on deceased-donor kidney transplantation plays a central role, along with strict policies aimed at preventing issues such as coercion or commercialization in living-donor transplants. Additionally, the country has a highly coordinated deceased-donor transplant system, while there is a notable lack of information and promotion regarding living-donor kidney transplantation.54,55 We propose some strategies to increase the rate of living-donor kidney transplants in accordance with current legal and ethical regulations (Table 2).

Moreover, the need for expanding the ethical analysis is highlighted, as recent advancements, such as ABO incompatible desensitization, generate new dilemmas that require more attention. The included methodological studies cover a wide range, from case analyses to quantitative and qualitative studies, enriching the understanding of the ethical aspects of living donor kidney transplantation. The most recurrent ethical dilemmas identified in the review include issues of beneficence and non-maleficence, where the risks and benefits for both donors and recipients are evaluated. A central issue is the nephrectomy performed on a healthy donor, which involves additional risks, but also emotional and psychological benefits for both the donor and the recipient, who receives a renal therapy that improves their quality of life. Another relevant dilemma is equity in access to living donor kidney transplantation, as demographic disparities in race, gender, and geographic location are observed. This highlights the need for a fair and non-discriminatory distribution of organs. In this regard, advanced age is often a reason for excluding patients from living-donor kidney transplantation, despite the lack of clinical guidelines supporting such exclusion. While doctors may offer alternative treatments, this reflects a persistent problem of misinformation. Importantly, using age alone as an exclusion criterion is neither clinically nor ethically justified. Both the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) and the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) state that older recipients can gain significant survival and quality-of-life benefits from transplantation—especially from living donors—even when the donor is also older. Patient and donor autonomy must be respected, highlighting the need for thorough, unbiased informed consent that includes all options and their respective risks and benefits. In conclusion, decisions should be based on individual assessment, not age alone.

Regarding anonymity and confidentiality, the balance between protecting the donor's privacy and ensuring transparency and preventing coercion is emphasized.56 Informed consent is one of the key ethical pillars in living donor kidney transplantation, and the review notes that, due to the inherent risks of organ donation, it is crucial for donors to fully understand the potential risks and benefits of the process. Furthermore, concerns about organ commercialization and coercion are addressed, highlighting the need to prevent the exploitation of vulnerable donors. The global crisis of the COVID-19 pandemic is also discussed in the studies, emphasizing the importance of maintaining solid ethical principles during extreme situations. Additionally, innovations in donation strategies, such as kidney exchange and ABO incompatible desensitization, which expand transplant options, are explored but also pose dilemmas regarding equity and associated risks. From a Spanish perspective, an article reviewed emphasizes the need for ethical and coordinated management of living donor kidney transplantation, highlighting the importance of informed consent and minimizing risks for donors. The review also emphasizes the need for continuous ethical training to address the challenges posed by living donor kidney transplantation. This review reflects on the importance of having adaptable ethical frameworks that can address emerging dilemmas, encourage public dialog, and promote interdisciplinary collaboration. The findings of this review largely align with the existing literature, but contribute a systematic and updated vision of living donor kidney transplantation ethics, providing a foundation for future research and more ethical and equitable practices.

We need robust and adaptable ethical frameworks that can address new challenges and emerging technologies, as well as global crises, ensuring responsible ethical decision-making, highlighting the importance of ethical education, promoting dialog about living donor kidney transplants. This is crucial to increase understanding and enable informed decisions by donors, recipients, and healthcare professionals, while promoting fair and equitable practices. Moreover, we need interdisciplinary collaboration since a joint effort is required between healthcare professionals, bioethicists, philosophers, lawyers, and representatives of civil society to comprehensively evaluate ethical dilemmas and develop effective solutions. Due to complexity of the ethical landscape, living donor kidney transplant presents a wide range of ethical dilemmas, such as beneficence, non-maleficence, equity, anonymity, informed consent, and organ commercialization, all of which must be carefully considered in each case. Thus, it is crucial to ensure that access to living donor kidney transplants is fair and equitable, without discrimination based on race, gender, or geographical location, and to promote a transparent, non-discriminatory system. This review wants to give a continuous and reflective ethical approach which is needed to address new dilemmas and ensure that practices remain aligned with ethical principles as the practice of living donor kidney transplantation evolves.

IRM: Conceptualization, bibliographic analysis, results and discussion.

JLC: Methodological design and discussion.

This systematic review did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

None declared.