International cooperation for kidney exchange success

Abstract

Kidney exchange programs (KEPs) have been developed in different countries to overcome incompatibilities between living kidney donors and their intended recipients.1,2 The effectiveness of existing KEPs is limited due to the number of donor-recipient pairs registered, particularly in small countries, and the accumulation of difficult to match recipients (eg, hypersensitized and blood group 0).3 The first successful European binational cooperation to increase the size and might add genetic heterogeneity of the donor pool was carried out between Austria and Czech-Republic in 2016.4 Furthermore, a European Network for Collaboration on KEPs, under the scope of a COST action, has started to share best practices, enhance discussions, and set the basis for future international collaborations.2 We report the first transnational kidney exchange procedure carried out in the framework of an international cooperation managed and overseen by the National Transplant Organizations of Italy, Portugal, and Spain. These countries started their KEPs in 2006, 2010, and 2009, respectively.2 Authorities and centers developed a common protocol and rules in 2017. A minimum annual activity of 10 living kidney transplants and human leukocyte antigen laboratory accreditation by the European Foundation of Immunogenetics were required for centers to participate. Challenges posed by different native languages, sharing schemes (eg, in Portugal, unspecified donor chains and registration of compatible pairs are not allowed), procedures (eg, anonymity between pairs is not required in Italy), and coordination of logistics were addressed and overcome. Communication was performed in English, only incompatible pairs were registered in the international program, anonymity was set as a mandatory requirement, and an ad hoc check-list for the coordination of the process was established. The Spanish KEP software, which contains a registry of pairs and a matching algorithm, was modified to accommodate the needs of the international scheme. The Organización Nacional de Trasplantes coordinated the initiative. The main elements of the project are summarized in Table 1.TABLE 1.: Matching algorithm and operating protocolIn May 2018, a matching run was undertaken between 14 hospitals (10 Spanish, 3 Italian, and 1 Portuguese) that registered 110 incompatible pairs (79 Spanish, 17 Portuguese, and 14 Italian) due to human leukocyte antigen incompatibility in 101 cases, unmatched in their KEPs. Of the individuals registered, 71 patients and 54 donors were blood type O. Regarding sensitization, the number of patients with calculated panel reactive antibodies ≥ 80% was 78 (71%). A two-way exchange was identified between one pair at Fundación Puigvert in Barcelona, Spain, and one at Ospedale Cisanello in Pisa, Italy. Clinical data were shared and negative cell-based crossmatches were confirmed. The date of the crossed-transplants and logistical issues were agreed upon. The procedures took place in July 2018. Once recovered, kidneys were shipped between centers by private flight. Cold-ischemia time was <8 hours. A week later, recipients and donors were discharged without complications and good renal function. Anonymity was maintained at every moment. Kidney exchanges between countries with different languages, regulations, and daily practice are feasible. Refinements of this approach and the participation of other countries2 will fortunately enhance opportunities of transplantation for patients in need.