Stepwise Risk Stratification for Future Diabetes Among Living Kidney Donor Candidates

This page summarizes the stepwise approach used in the calculator (Step 1–4). It is intended for clinician-facing education and counseling support.

STEP 1. Identify Donors Who Should Undergo Oral Glucose Tolerance Test (OGTT)

• Fasting plasma glucose (FPG) ≥100 and <126 mg/dL
• Hemoglobin A1c (HbA1c) 5.7–6.4%
• History of gestational diabetes mellitus
• History of pancreatitis
• BMI ≥25 kg/m² (≥23 for Asian Americans) plus one or more of the following:
• Metabolic dysfunction–associated steatotic liver disease (MASLD)
• Hypertension ≥130/80 mm Hg or on treatment
• Dyslipidemia (HDL <35 mg/dL or triglycerides >250 mg/dL)
• Polycystic ovary syndrome (PCOS)
• First-degree relative with type 2 diabetes
• High-risk ethnicity (e.g., African American, Hispanic/Latino, Native American, Asian American)

STEP 2. Assess for Metabolic Syndrome (ATP III Criteria)

Metabolic syndrome is present if three or more of the following are met:

• Waist circumference >102 cm (men) or >88 cm (women)
• Triglycerides ≥150 mg/dL
• HDL cholesterol <40 mg/dL (men) or <50 mg/dL (women)
• Blood pressure ≥130/85 mm Hg or on treatment
• Fasting plasma glucose ≥100 mg/dL

STEP 3. Assess for High-Risk Prognostic Markers on OGTT (Including Metabolic Syndrome)

One or more of the following findings indicate high risk for future diabetes:

• IGT + 1-hour plasma glucose >155 mg/dL + metabolic syndrome (risk: 52.8%)
• Combined IFG and IGT (risk: >50%)
• IFG + 1-hour plasma glucose >155 mg/dL + metabolic syndrome (risk: 37.8%)
• IGT or IFG + 1-hour plasma glucose >155 mg/dL + HbA1c 6.0–6.4%
• IGT or IFG + 1-hour plasma glucose >155 mg/dL + IGI ≤ 0.82 and/or 1st-phase insulin release ≤ 899 pmol/L

STEP 4. High-Risk Group: Determine Eligibility by Age

Age-based recommendations for high-risk donor candidates:

• Age <40 years – Not a candidate (high risk)
• Age 40–49 years – Consider only if able to reverse high-risk prognostic markers with weight loss on repeat OGTT
• Age ≥50 years – Can be accepted after risk mitigation with 5–10% weight loss