Introduction: Living renal donors with unfavorable medical or surgical characteristics referred to as complex donors(CD) should not be excluded from donation in a resource poor setting like Sri Lanka where chronic dialysis is costly and deceased donor programme is still at its infancy. Although the outcomes with such grafts can be marginally inferior to those of standard criteria donors(SD), they have survival advantages over wait–listed dialysis patients. However it has raised concerns as to which acceptance criteria should be deemed safe. 

Method: A retrospective study was conducted at Sri Jayawardenapura General hospital, from January 2013 to December 2022. All donors who underwent laparoscopic/open donation were analyzed. The following were categorized as medically complex donors: age >60 yrs (M1), BMI >30 kgm-2 (M2), Blood pressure > 140/90 mmHg (M3), eGFR < 60 ml/min/1.73m2(M4), Impaired glucose tolerance(M5) -PPBS 140-179 mg/dl with HbA1c 5.7%-6.3%, asymptomatic microalbuminuria(M6) 30-300mg/L, non-visible hematuria (M7) - urine RBC>5 HPF while multiplicity of vessels(S1), co-existent visceral aneurysm(S2), bifid pelvis with duplex ureters(S3), solitary nephrolithiasis(S4), renal cyst>5cm (S5) were categorized as surgically CD. We compared the outcomes of the CD against SD as well as their graft outcomes. 

Results: 235 donor nephrectomies were carried out, of which 76 (32.3%) were CD. The observed complexity was M1 to M7; 6,9,2,2,1,1,3 and S1 to S5; 37,1,2,10,2 respectively. From surgical complex group backbench reconstructive techniques comprised of bifid and trifid trousering in 12, separate implantation of 3, ligation of small upper polar artery in 2, concomitant splenic artery aneurysm repair with spleen preservation in one. Duplex ureters were anastomosed using brickker method. Ex vivo calyceal stone were removed using flexible cystoscopy through a pyelotomy. All but three kidneys (SD=1, CD=2) which had delayed graft function all others began to function within one month. Two kidneys had to be explanted due to mycotic aneurysms within the first month. All donors were followed up according to standard protocol for a minimum of one year. At mean follow up at 54 months there were 2 reported deaths (SD=1, CC=1) which were unrelated to kidney donation. Adverse medical issues were reported in 10 patients (SC=4, CD=6). There was a significant fall of eGFR in both groups but no statistical significance was evident (P=0.09). The overall functional graft survival at follow up for SD =81.4% and CD=82.1%.

Conclusion: Marginal medical donors must be used cautiously but should not be excluded altogether from donation in setting where alternative renal replacement therapy is not easy to find. Among complex surgical donors those with complex vascular or ureteral anatomy and isolated stones, provided recipients with good quality grafts and should not be precluded from donation.