Thoughts on kidney donations

Or, how I failed to donate my kidney

June 4, 2025

I was eating phở in the city center when the call came. The EM study had been done.

"Bad news," my nephrologist said. "You have a kidney disease."

The words hit harder than the spicy broth. After more than nine months of tests, blood draws, and even a kidney biopsy, my journey to donate a kidney to my friend had just come to an abrupt end.

Let’s rewind to where this all began.

The Decision

When Effective Altruism volunteer Mikko mentioned that his kidney transplant was showing signs of chronic rejection, I jumped and offered him my kidney. I had read Dylan Matthew’s kidney donation story, Scott Alexander’s kidney donation story, and had taken part in a discussion on estimating the level of kidney demand in Finland in a local EA discussion group that had at least one Finnish doctor involved.

The statistics were reassuring. Kidney donations are very safe with a perioperative death rate of around 0.03% to 0.06%. You will have a slightly increased risk of kidney-related issues later in life (1-2% likelihood of kidney failure), and there is also some weak evidence that suggests people who donate a kidney have very slightly shorter life expectancy than those who have both kidneys intact.

The QALY Trade-off

There are multiple attempts to calculate what the quality-adjusted life year (QALY) trade for a kidney donation actually is, and to me it looks like donating a kidney is by default similar to buying around 4-5 QALYs to someone else at a cost of 0.3-1 QALY to yourself. Dan Wahl generated a nice table below from a paper that uses a Markov model simulation of recipient outcomes in QALYs.

If for any reason you are incompatible with the recipient, or if you are donating to a stranger, you might be able to enroll into and trigger a donation chain, in which case the QALY trade is even more beneficial (10-20 QALYs, according to Scott Alexander).

The biggest expected cost for most people reading this article is loss of income during the recovery period of around three weeks. From an impartial perspective the cost of a single QALY is cheap. GiveWell reviews and estimates cost-effectiveness of global poverty and health interventions, and places the cost of counterfactually saving one human life at around $3000 in 2024. They don’t operate on a cost-per-QALY basis, but it seems reasonable to assume that a donation of a few hundred probably buys more than 5 QALYs. This means that for most the loss of income is greater than the amount of QALYs gained.

This, unfortunately, means that donating a kidney by itself is not an effective altruistic intervention from an impartial perspective for most people who live in developed countries. There is a plethora of reasons why people should consider donating regardless:

1. Supply and demand don’t meet. There are more people who require kidneys than there are altruistic people who are willing to give theirs, and there is a strict process one needs to go through before they are allowed to donate. Arguments for why we might want to subsidize donations are quite strong, but the simplest implementations have strong backlash. A reasonable way to allow one to sell their kidney might be a delayed tax credit after donating, which would avoid the failure-mode of struggling people selling their kidney for quick cash.¹ My nephrologist was deeply saddened by the fact that Finnish people have donated less in the previous couple of years, and there is currently more demand than cadaver kidneys alone can meet.

2. Philosophical clarity. There are plenty of philosophical objections to most ways of doing good. However, almost all reasonable value systems would say that donating a part of your body to save a life is indubitably good and virtuous. A person who takes animal suffering extremely seriously might bring up the meat-eater problem, but it would go starkly against common-sense morality to say that one should let saveable people slowly die in dialysis in order to prevent future increases in animal suffering² — a bullet a few of us are willing to bite. As another EA said to me: “There are better ways to reduce meat-consumption than deny someone a kidney.”

3. Visceral altruism. Any charitable intervention has an element of detachment. A donated euro converted to an insecticide-treated malaria net saves a life in Sub-Saharan Africa, while you sit around in your office job. When we donate to prevent existential risks or other bad things in our long-term future, the level of detachment is even higher. If you just work and donate a portion of your income, are you just outsourcing the altruism? If you are, are you even doing good? The answer is of course a resounding yes, you are doing good, but as any neurotic do-gooder knows the question will keep gnawing at you. By donating a kidney, you not only get a higher degree of certainty over your actions being good, you are also as close to the raw, visceral actuality of Actually Helping as possible.

4. Normalizing positive-sum altruistic trade is probably good. The categorical imperative says that you should try to do actions you would prefer everyone to do, and a world where everyone would make a QALY-trade with an exchange rate of 1:5 would probably be incredibly much better than the world where we live now. Consider leading by example!

5. Donating a kidney brings intrinsic value to the recipient, and instrumental value to you. The three little scars on your stomach and back are forever a mark of you actually caring and taking significant action to prevent someone from having to suffer the torture of dialysis for multiple years. You can use the power of those three little scars to make your voice reach even further, to do even more good in the future.

Many thoughtful people have also made good arguments for why it might or might not be an EA thing to donate your kidney, see 1, 2, 3, 4 that were also highlighted by Scott. Some additional ones: 1, 2. Those excited to donate might want to also consider signing up for their local bone marrow registry, which appears plausibly more effective than donating a kidney³.

My Journey Begins

Right off the bat: my experience with the whole kidney donation process has been extremely positive. Donation coordinators have been extremely responsive, everyone has treated me with kindness, and everything was done with higher speed than I am used to with Finnish public healthcare. I am getting actual answers from physicians without prompt-engineering!

This might have been due to an accidental physician jailbreak, though, as the coordinator appeared to immediately understand that I had done quite a lot of reading, and had a good understanding of the risks and realities of kidney donation, flagging this to subsequent physicians.

In Finland, the kidney donation process is 100% free⁴⁵, and the process goes roughly as follows:

1. Call a kidney donation coordinator and tell them that you want to donate your kidney.

2. Huge amount of blood tests.

3. Glucose tolerance test (refrain from eating for 12 hours and then give a urine sample).

4. Kidney ultrasound and a lung x-ray.

5. A regular doctor’s check-up.

6. More lab tests, primarily testing for coagulation and certain viral antigens.

7. Blood cross-test with the recipient.

8. Glomerular Filtration Rate (GFR) test, where you give a urine sample, drink a slightly radioactive drink, give 5 blood samples every 30 minutes, and then give another urine sample after 2.5 hours

9. A CT scan of your kidney. Long-term, this is probably the most risky part of the kidney donation process, although this is less risky than what Scott estimated (see updated calculations below).

10. Gamma imaging of your kidney function, where you’ll be pumped with some more radioactive fluids that is followed with a gamma camera until it reaches your bladder through your kidneys.

11. Another doctor’s visit. They really want to make sure you know what you are doing.

12. A psychiatric evaluation, first through phone and then in-person.

13. The actual surgery.

14. Recovering in hospital for 3-5 days.

15. Recovering home for 3-6 weeks.

In reality some of these steps might be taken out of order, and you might need to re-do some of them in case you end up generating weird or wonky values.

The system is not without its faults, though. The biggest issue appears to be the lack of concurrency; Mikko managed to get other donor candidates, but the system refused to proceed with their screening processes until they had determined that the primary candidate (me) was incompatible. This might avoid human drama (if multiple candidates are deemed fully compatible, who donates the kidney?), and the health care system would rather not do some of the more expensive tests on multiple people if only one of the candidates is giving their kidney (it is unclear to me if this strategy is cheaper than keeping someone in dialysis for multiple months).

Next day after my initial call I got the process rolling and gave a bunch of bloodwork and a urine sample. All values look great, except for a microscopic, barely registered amount of red blood cells in my urine. Odd, but not too worrisome. The process continues.

Fixing Scott’s CT Scan Calculations

After the initial steps were completed in the span of a couple months, it is finally time to scan my kidney. I try to request an MRI instead of a CT scan, and refer to Scott’s ex-girlfriend’s estimate of 1/660 risk of dying of cancer from the CT scan radiation dose.

To quote Scott:

The screening exam involves a “multiphase abdominal CT”, a CAT scan that looks at the kidneys and their associated blood vessels and checks if they’re all in the right place. This involves a radiation dose of about 30 milli-Sieverts. The usual rule of thumb is that one extra Sievert = 5% higher risk of dying from cancer, so a 30 mS dose increases death risk about one part in 660. There are about two nonfatal cases of cancer for every fatal case, so the total cancer risk from the exam could be as high as 1/220

Surprisingly, my run-through of the CT scan risk calculations ends up on the desk of a Helsinki lead nephrologist, who then consults with other doctors with domain knowledge.

For living donors, a CT scan is not there just for getting a clear image of the anatomy of the kidney. For that an MRI would be enough (however, an MRI would not be useful for the surgeon without reconstruction. Surgeons generally appear more comfortable with CT scans). A CT scan is also useful for mapping possible contraindications, especially when it comes to latent malignities.

The studies Scott refers to are from 2009 and 2010. The field of imaging has improved since then, and an abdominal CT scan in a developed country and an up-to-date hospital is around 9.3 mSv (not 30). From this we can assume the risk of death from radiation is around 1/2220 — not an insignificant risk considering how safe the surgery itself is.⁶

Thirty-Year Trends in Perioperative Mortality Risk for Living Kidney Donors was highlighted as a particularly useful overview on risks.

Overall, the worry about substantial risk from the screening process seems less warranted. It might also be useful to assume that the likelihood of dying of cancer in the future might also be smaller due to medical advances in treatment. I happily received my radiation dosages.

The Troubles

The process continues, and I passed a psychiatric evaluation (history with depression was not considered an obstacle since depression is considered a common health condition in Finland — a "kansantauti" as we say. Grim, but reasonable). Our blood types were a match, and it looked increasingly likely that I can donate. Hurray!

The Microhematuric Mystery

A doctor calls me up after I’ve given even more blood and urine for testing. Apparently there was still microscopic amounts of blood in my urine. Even though the amount is very, very small, there shouldn’t really be any.

I kept giving more samples in the upcoming weeks. Each time I tested positive for microhematuria, but with no other values out of the reference range. Wtf?

At this point the doctor said that this no longer seems normal, and we needed to thoroughly figure out where the blood is coming from before we continued with the donation process.

“How do we do that?”, you might ask. Well, the easiest place to check is the bladder. I will spare you the details on how this is done, but for those who are curious I encourage you to check this Wikipedia article. Mikko, I hope you appreciate the lengths I went to donate my kidney to you.

Luckily, my bladder and all related piping & tubing looked very healthy. Yippee! Did this mean that I was now good to go?

No.

This meant that the blood might be coming from the kidney.

The Kidney Biopsy

I was given a referral for a kidney biopsy. The biopsy was a simple and quick, moderately invasive operation where they stuck a very scary-looking needle through my back, and pulled out two samples of my kidney.

The doctor seemed initially a bit uncertain over whether or not they had enough of the glomerular tissue from the surface of the kidney. Sometimes they put the needle too deep (it is not unheard of to accidentally pierce the kidney).

I was given five days of sick leave with a prescription for paracetamol. People often start working after a few days, but I was still aching quite badly after a week. After going to the emergency room I found out this was due to internal bleeding, whoops. I probably wasn’t resting hard enough, and now had half a liter of blood pooled up inside of me — enough to make my hemoglobin drop. Luckily the bleeding had stopped and they let me go back home after half a day in the hospital. Makes for a fun story, though.

After one more week I was up and about my normal life.

The Final Verdict

Couple of weeks later my nephrologist called me and said that the biopsies looked great, although they hadn’t yet done some specific electron microscope study on the sample. We were good to continue the donation process!

• Blood cross-test: cleared!

• GFR tests: cleared!

• A gazillion more blood and urine samples: given!

The only things left to do were gamma imaging and the surgery itself. I was cautiously excited.

And then came that phone call at the phở restaurant.

Understanding Thin Basement Membrane Disease

The EM study revealed I have thin basement membrane disease (TBMD). TBMD is a genetic condition where the filtering membrane in your kidney is thinner than normal. This causes microscopic amounts of red blood cells to leak into your urine (explaining my microhematuria) and means that I have an elevated risk of developing chronic kidney disease and/or kidney failure later in life. Current scientific understanding says that it can progress into more serious Alport syndrome.

TBMD sufferers also shouldn’t get LASIK, since the same proteins that compose the kidney basement membrane also compose the epithelial basement membrane. But I had already gotten LASIK, with bad results and chronic dryness/pain problems.

Yes, it turns out trying to give away a kidney is how you discover you shouldn’t have lasered your eyes. D’oh!

Based on a quick literature review it appears that a TBMD sufferer is especially unfit to donate a kidney if:

• They have proteinuria.

• They have an unstable eGFR (<90 ml/min/1.73m²)

• Disease stability is unknown

• They have family history of chronic kidney disease

• They have COL4A3 and COL4A4 gene mutations, which increase the likelihood of progressing into Alport syndrome.

For me the only relevant part is the last one. I requested genetic testing to determine if I have those specific mutations, and hope that after a few years of monitoring they might be able to reconsider whether or not I can donate my kidney. I don’t think it is very likely, though.

The Silver Linings

I received thousands of euros worth of medical workup:

• Extensive blood panels and urinalasysis

• CT scan and imaging studies

• Kidney biopsy and electron microscopy

• Genetic testing (pending)

• Multiple specialist consultations

This free medical workup revealed a condition that could have silently damaged my kidney for decades. The early detection means I can now:

• Avoid NSAIDs and other nephrotoxic medications

• Monitor kidney function regularly

• Monitor my blood pressure

• Limit protein intake if needed

Lessons Learned from a Failed Donation

My failed kidney donation reminded me of something important about trying to do good: the most valuable outcome isn’t always the one you planned. I set out to save a life and instead discovered a condition that could have silently damaged my kidneys for decades. The thousands of euros worth of medical tests I received for free revealed information that may add years to my life.

This experience crystallized why kidney donation occupies a unique space in the EA landscape. Yes, the QALY math doesn't pencil out compared to malaria nets. But kidney donation offers something the EA movement often lacks: visceral, personal, irrefutable evidence that you tried to help another human being directly. No philosophical objections, no uncertainty about impact, no abstractness. Just you, a surgery, and someone freed from dialysis.

I've spent years optimizing my charitable giving, calculating expected values, and wrestling with the abstract nature of doing good at scale. There's always been a nagging voice asking whether I'm truly helping or just partaking in intellectual exercises about helping. The kidney donation process (even failed) was more effective at silencing that voice than any of my donations or effective giving (trial) pledges. The physical reality of lying on a table while someone pushed a biopsy needle through my back, the weeks of recovery, the cancer risks I accepted weren't abstractions, spreadsheets, or bank transfers.

The three small scars I'd planned to carry as proof of my altruism have been replaced by the knowledge that I tried, pushed through almost a year of testing, and discovered important things about my own health in the process. And perhaps most importantly, I learned that the Finnish kidney donation system works surprisingly well. A refreshing change from the frustrating stories coming out of the US! Our system is rigorous, free, and catches conditions that might otherwise go undiagnosed.

The End

So here's my call to action: get tested. Not because it's the most cost-effective intervention (it's not), but because we need more people willing to make this trade. Because your kidney might save someone from years of dialysis. Because you might discover something important about your own health. Because in a world of abstract charitable giving, sometimes we need to offer something deeply personal.

And Mikko? I'm sorry I couldn't give you my kidney. But I hope someone else reading this can.

Encouragement:

• The process is incredibly safe (0.03-0.06% mortality)

• You'll receive comprehensive free medical testing

• You might discover important health information

• [Finland-specific:] The Finnish system is surprisingly efficient and supportive

Caution:

• Account for 3-6 weeks of recovery time

• Consider lost income in your calculations

• Be prepared for unexpected medical discoveries

• The screening process itself has non-negligible risks

• Not everyone who wants to donate will qualify

1. I think legalizing compensation or tax break schemes for donating your kidney would be very good, and all developed countries should definitely look into implementing a responsible kidney donation compensation strategy. In the US, it is also legal to compensate people who donate their blood and plasma. A single donation usually carries a reward of $100+. I would love to see this custom spread to other countries — donating the reward to an effective charity would probably multiply the amount of good a blood or plasma donation would do!

2. A Finnish reader referred to the philosopher Pentti Linkola for similar anti-human lines of thought. His work relies a great deal on Malthusian traps, population forecasts that were later proven inaccurate, and a deeply optimistic, naturalist view on wild-animal suffering — a topic where I suspect he might be devastatingly wrong. Sometimes common philosophical arguments against donating can simply be just incorrect.

3. See Silas Strawn’s bone marrow donation experience here.

4. This does not, however, include covering lost pay for recovery period. This is bad, since some people can't afford to take multiple weeks off work to recover from donating a kidney. I think we should incentivize donating kidneys by covering lost pay for recovery period; keeping people in dialysis is very expensive, and I wouldn't be surprised if covering lost pay is significantly cheaper than paying for dialysis.

5. Sometimes they accidentally sent me bills regardless, but I was able to get them voided by calling customer service numbers printed on them. Annoying, but understandable due to different cities in the capital region using different patient record systems.

6. Another part of the screening process is getting an X-ray of your lungs, which also doses you with around “9 mSv of radiation”, making the total amount of radiation received around 18.3 mSv, which is still almost half less than the 30 mSv mentioned by Scott. The chest X-ray value came from a nurse instead of a team of nephrologists and radiologists. The nurse reported a 9 mSv dose, which seems unusually high for a chest X-ray (around 0.02 to 0.1 mSv according to Google), which is why I am putting this in a footnote. The number given to me just sounds straight up wrong. Maybe they meant to say 0.09 mSv. Additionally, a lung X-ray might not be a standard step in the donation process everywhere, so please discount if necessary.