Tackling the shortage of donor kidneys: how to use the best that we have

Shortage of kidney donor is still a major limitation for renal transplantation programs. This review focuses on the emerging practices, adopted to increase transplant activities, of expanding the criteria for donor and recipient selection without exposing the recipient to the drawbacks of a graft with inadequate nephron mass. Expanding the donor pool inevitably led to consideration for kidney transplantation of organs from older donors or from donors with hypertension, diabetes or other renal diseases. To fit the reduced performance of these suboptimal organs with the renal requirement of the recipient, selection of recipients with reduced metabolic requirements or increase of nephron mass by simultaneous transplantation of two suboptimal kidneys in the same recipient have been pursued. However, a critical aspect of both approaches is to quantify functioning nephron mass provided to the recipient by pre-transplant kidney biopsies. Morphological parameters assessed on kidney biopsies at the time of donor evaluation may serve to quantify the preserved tissue and to discriminate chronic irreversible lesions from acute changes that may account for a transiently impaired renal function in the donor, but that may recover after transplant.