Personal Viewpoint: Risk stratification and counseling of living kidney donor candidates with prediabetes

The consideration of individuals with prediabetes for living kidney donation remains challenging, largely due to the lack of consensus on how best to evaluate the degree of impaired glucose homeostasis and the long-term risk of developing diabetes mellitus, a significant risk factor for kidney disease. Traditional biomarkers such as hemoglobin A1c lack sensitivity for early detection of impaired glucose homeostasis, while the oral glucose tolerance test, although more informative, has only moderate reproducibility for identifying impaired fasting glucose and impaired glucose tolerance. Notably, many individuals with normal hemoglobin A1c and fasting plasma glucose levels may still be at elevated risk for progression to diabetes. In this personal viewpoint, we highlight the utility of published prognostic markers/indices derived from oral glucose tolerance test data to improve risk stratification for living kidney donor candidates with impaired glucose homeostasis. We also propose a list of high-risk markers that can help identify living kidney donors who are at increased risk for diabetes mellitus.