Living donor kidney transplantation has developed very heterogeneously worldwide despite excellent results and without taking into account the context of global organ shortage. Such a heterogeneity highlights persistent ethical issues, whereas organ trafficking is emerging as an organized transplant tourism reinforcing the need for strong national legal frameworks. Despite its powerful regulation system, which ensures standardization, transparency and accountability of support for donation, France remains reluctant to enlarge the circle of legal donors, whereas it would be the first step to give a greater role to living organ donation.