Kidney transplantation remains the gold standard for the treatment of end-stage kidney disease (ESKD). However, the persistent shortage of suitable donor organs has resulted in prolonged waiting periods and heightened mortality rates among transplant candidates. This pressing challenge underscores the need to expand the selection criteria for living kidney donors. Hypertension, the most prevalent global comorbidity, has historically been considered a contraindication to kidney donation due to concerns regarding potential renal injury and long-term health implications. Nevertheless, emerging evidence, including the recent study by Kim et al. [1], challenges this restrictive paradigm, suggesting that with meticulous monitoring, hypertensive individuals may safely serve as living kidney donors.

In this context, the evolution of clinical guidelines has emphasized the necessity of comprehensive, individualized risk assessments. The KDIGO (Kidney Disease: Improving Global Outcomes) guidelines, for instance, have pioneered a more nuanced approach to donor eligibility, integrating long-term risk projections alongside donor-specific factors [2]. These advancements represent a pivotal shift in transplant medicine, facilitating a more inclusive and ethically balanced donor selection process.

Kim et al. [1] analyzed data from 642 hypertensive and 4,848 normotensive kidney donors registered in the Korean Organ Transplantation Registry (KOTRY) between 2014 and 2020. The primary endpoints were changes in the estimated glomerular filtration rate (eGFR) and the development of proteinuria over a 5-year follow-up period. The study revealed no significant difference in the risk of mild or moderate eGFR decline between hypertensive and normotensive donors. This finding aligns with results from other studies, such as Ibrahim et al. [3], who demonstrated comparable renal function preservation in hypertensive donors. Furthermore, Lee et al. [4] observed comparable renal trajectories in treatment-naïve hypertensive individuals, although they noted that the risk of disease progression increases with higher baseline systolic blood pressure. Additional studies have investigated potential compensatory mechanisms that help preserve renal function following nephrectomy. For instance, Lenihan et al. identified adaptive hyperfiltration in the remaining kidney, which may account for the sustained renal function observed in some hypertensive donors over time [5].

A notable finding of the study was the significantly higher incidence of proteinuria among hypertensive donors (adjusted hazard ratio, 2.28; 95% confidence interval, 1.05–4.94). As a marker of glomerular injury, proteinuria raises concerns regarding long-term renal health. Ibrahim et al. [3] similarly emphasized this risk, particularly in light of revised hypertension definitions. Additionally, Dahle and Mjøen [6] highlighted that clinical outcomes may be contingent upon strict adherence to blood pressure management and rigorous follow-up protocols. These findings underscore the critical need for vigilant postdonation monitoring to mitigate the potential progression to chronic kidney disease.

Beyond renal outcomes, studies have demonstrated that hypertensive donors are at an elevated risk of developing cardiovascular disease (CVD) over time, particularly if hypertension remains untreated postdonation [4]. However, contemporary clinical guidelines advocate for individualized risk assessments to carefully balance these risks against the benefits of expanding the donor pool [2]. Moreover, research by Grams et al. [7] projected long-term ESKD risks among donors, further reinforcing the necessity of comprehensive risk calculators to inform donor selection. A Canadian cohort study by Dhalla et al. [8] further highlighted that hypertensive kidney donors with predonation albuminuria faced an increased risk of both CVD and renal complications following nephrectomy. Collectively, these findings suggest that predonation evaluations should incorporate comprehensive cardiovascular risk profiling in addition to standard renal assessments.

The studies summarized in Table 1 collectively illustrate the complexity of outcomes among hypertensive kidney donors. While numerous findings support the feasibility of donation in well-controlled hypertensive individuals, significant risks remain, including proteinuria, cardiovascular events, and graft loss. For instance, Kim et al. [1] reported no substantial decline in eGFR but noted a higher incidence of proteinuria. Similarly, Ibrahim et al. [3] found that long-term outcomes were comparable to those of normotensive donors, reinforcing the potential for safe donation with appropriate follow-up. In contrast, Lee et al. [9] observed a significant adverse impact on allograft survival in recipients of kidneys from hypertensive donors. This variability underscores the necessity of individualized donor assessments and rigorous long-term monitoring. The table outlines key study designs, findings, and recommendations, providing valuable insights to inform clinical decision-making and future research.

The findings of Kim et al. [1] carry significant implications for both clinical practice and guideline development. The absence of a substantial decline in eGFR suggests that hypertensive individuals may be considered for kidney donation, provided they undergo rigorous monitoring. However, the elevated risk of proteinuria emphasizes the necessity for enhanced postdonation surveillance [1]. Furthermore, identifying subgroups within the hypertensive donor population who may be at heightened risk is crucial. Notably, Kim et al.’s [1] subgroup analysis revealed that donors with lower body mass index and fasting blood glucose levels exhibited a higher incidence of proteinuria, suggesting that metabolic factors may play a critical role in influencing postdonation outcomes.

Future research should prioritize several key areas to enhance the understanding of long-term outcomes in hypertensive kidney donors. First, extended follow-up studies are essential to capture late-onset complications that may emerge years after donation. Additionally, further investigation into the effects of antihypertensive medications, particularly renin-angiotensin system inhibitors, is needed to assess their influence on donor health outcomes. Moreover, genetic and biomarker research should focus on identifying early predictive markers that may indicate an increased risk of adverse events in this population [8]. Finally, the impact of lifestyle modifications, both before and after donation, including dietary changes and exercise, warrants thorough evaluation to determine their role in mitigating long-term health risks [4].

In conclusion, the study by Kim et al. [1] contributes to the expanding body of evidence affirming the feasibility and safety of including hypertensive individuals in the kidney donor pool. By underscoring the significance of vigilant postdonation monitoring and individualized risk assessment, this study provides valuable insights that may inform more inclusive and optimized kidney transplantation strategies.