In the 55 years that have followed the first successful living donor kidney transplant between identical twins, organ transplantation has become one of the medical miracles of our age. The controversies over removing kidneys from healthy donors remain. Within a few years living donor transplantation from first degree relatives became commonplace. In the early 1980's the first transplants from spouses were performed and with advances in immunosuppressive therapy the necessity for close HLA matching was overcome. Living donation from donors who were not biologically related, yet were typically closely emotionally related, became more frequent. Over time the closeness of emotional bond between donor and recipient that was deemed appropriate for donation became more tenuous. By the 1990's transplant from donors with no relationship at all to their recipients were performed in some programs. The identification, evaluation, and protection of these so-called "altruistic", "non-directed", or "good Samaritan" donors and other donors with a limited relationship to the recipient became the subject of intense scrutiny. The last decade has seen a change in the nature of the relationship between living donors and their recipients in the United States. In this respect the United States has taken the lead among developed countries, some of which prohibit biologically unrelated donation even from spouses. Unrelated donation now accounts for approximately 35% of all living donor transplant and in some programs nearly 50% of all living donors have varying degrees of 'unrelatedness'. All this has occurred in a legal environment that prohibits financial gain for the donors and with extensive evidence both of excellent psychosocial outcomes and long-term medical safety. At a time of increasing need for organ donors, both living and deceased, how can we best advance the practice of living donation, protect the health and welfare of living donors, and continue to provide an example to the rest of the world?

Keywords: Kidney Transplant, Organ Transplantation