Kidney Paired Donation Registry Research Articles

Patient and Graft Survival After A1/A2-incompatible Living Donor Kidney Transplantation.

Background.ABO type B and O kidney transplant candidates have increased difficulty identifying a compatible donor for living donor kidney transplantation (LDKT) and are harder to match in kidney paired donation registries. A2-incompatible (A2i) LDKT increases access to LDKT for these patients. To better inform living donor selection, we evaluated the association between A2i LDKT and patient and graft survival.Methods.We used weighted Cox regression to compare mortality, death-censored graft failure, and all-cause graft loss in A2i versus ABO-compatible (ABOc) recipients.Results.Using Scientific Registry of Transplant Recipients data 2000–2019, we identified 345 A2i LDKT recipients. Mortality was comparable among A2i and ABOc recipients; weighted 1-/5-/10-y mortality was 0.9%/6.5%/24.2%, respectively, among A2i LDKT recipients versus 1.4%/7.7%/22.2%, respectively, among ABOc LDKT recipients (weighted hazard ratio [wHR], 0.811.041.33; P = 0.8). However, A2i recipients faced higher risk of death-censored graft failure; weighted 1-/5-/10-y graft failure was 5.7%/11.6%/22.4% for A2i versus 1.7%/7.5%/17.2% for ABOc recipients (wHR in year 1 = 2.243.565.66; through year 5 = 1.251.782.53; through year 10 = 1.151.552.07). By comparison, 1-/5-/10-y wHRs for A1-incompatible recipients were 0.631.966.08/0.390.942.27/0.390.831.74.Conclusions.A2i LDKT is generally safe, but A2i donor/recipient pairs should be counseled about the increased risk of graft failure and be monitored as closely as their A1-incompatible counterparts posttransplant.

Crossing borders to facilitate live donor kidney transplantation: the Czech-Austrian kidney paired donation program - a retrospective study.

Kidney paired donation (KPD) is a valuable tool to overcome immunological barriers in living donor transplantation. While small national registries encounter difficulties in finding compatible matches, multi-national KPD may be a useful strategy to facilitate transplantation. The Czech (Prague) and Austrian (Vienna) KPD programs, both initiated in 2011, were merged in 2015. A bi-national algorithm allowed for ABO- and low-level HLA antibody-incompatible exchanges, including the option of altruistic donor-initiated domino chains. Between 2011 and 2019, 222 recipients and their incompatible donors were registered. Of those, 95.7% (Prague) and 67.9% (Vienna) entered into KPD registries, and 81 patients received a transplant (95% 3-year graft survival). Inclusion of ABO-incompatible pairs in the Czech program contributed to higher KPD transplant rates (42.6% vs. 23.6% in Austria). After 2015 (11 bi-national match runs), the median pool size increased to 18 pairs, yielding 33 transplants (8 via cross-border exchanges). While matching rates doubled in Austria (from 9.1% to 18.8%), rates decreased in the Czech program, partly due to implementation of more stringent HLA antibody thresholds. Our results demonstrate the feasibility of merging small national KPD programs to increase pool sizes and may encourage the implementation of multi-national registries to expand the full potential of KPD.

The Role of Desensitization in Kidney Paired Donation

Kidney paired donation (KPD), desensitization, and prioritization in the deceased donor kidney allocation system (KAS) are current options to facilitate kidney transplant in difficult-to-match, highly sensitized patients. KPD participation has increased while new desensitization tools are developed. We review these trends and discuss the combined role of desensitization and KPD. According to the National Kidney Registry (NKR), KPD utilizing desensitization decreased while the number of highly sensitized KPD transplants and deceased donor transplants increased over the past decade. This is likely because of large KPD registries and the national allocation of deceased donor kidneys that allow highly sensitized patients to find compatible matches without the need for desensitization. Highly sensitized patients with incompatible living donors should be entered into a KPD registry while simultaneously considered for deceased donor transplant. Those patients who do not find a compatible match within a year should be considered for desensitization.

Utilization of deceased donor kidneys to initiate living donor chains

Utilization of deceased donor kidneys to initiate living donor chains

P135 Living donor kidney paired donation transplantation: First report from Kingdom of Saudi Arabia

Aim Kidney paired donation (KPD) is an effective way to transplant patients with willing but incompatible donors. We report our experience with KPD through development of local Registry for incompatible pairs. Methods 62 recipients & their incompatible donors plus 3 non-directed donors were entered into KPD registry. Incompatibility was due to ABO-incompatibility (ABOi) in 25% & HLA-incompatibility (HLAi) in 75%. Patients with HLAi had cPRA between 60–99%. Antibodies with MFI of ⩾ 3000 by SAB assay were listed as unacceptable antigens. We used balanced, unbalanced & non-directed anonymous donors (NDAD). ABOi donors were accepted if patients had low titer ( ⩽ 16) of Isohemagglutinins. Amenable DSA for desensitization are those weak, single or multiple that yielded negative or weakly positive flow cross match ( Results 23 candidates (37%) were transplanted, enabling pre-emptive transplant in 1 patient. The longest chain was seven -ways domino chain initiated by a NDAD & ended in transplant of deceased donor listed patient with multiple access failure. Additional desensitization was used for 9 patients due to DSA and/ or positive FXM. 1 patient received TPE due to anti ABO antibody titer of 16. We had one case of DGF, AMR occurred in 2 patients & 1 patient had ACR. Graft function was good through follow-up time of 6–18 months but one patient died 8 months post-transplant due to refractory sepsis. Conclusions Although our series is early with 62 patients, transplant rate is excellent compared to other old programs(Netherlands, UK, & Canada) where the transplant rate were 37%, 29%, 44% respectively. This might be attributed to involving NDAD, accepting ABOi & combining desensitization for low level DSA in selected patients. Considering that 75% of the patients were highly sensitized yet received living transplants with excellent results, our experience demonstrates promising short-term outcomes. However, longer follow-up is needed to assess the impact of KPD on organ shortage & the outcome of highly sensitized patients transplanted through KPD program.

Historical Matching Strategies in Kidney Paired Donation: The 7-Year Evolution of a Web-Based Virtual Matching System

Failure to convert computer-identified possible kidney paired donation (KPD) exchanges into transplants has prohibited KPD from reaching its full potential. This study analyzes the progress of exchanges in moving from "offers" to completed transplants. Offers were divided into individual segments called 1-way transplants in order to calculate success rates. From 2007 to 2014, the Alliance for Paired Donation performed 243 transplants, 31 in collaboration with other KPD registries and 194 independently. Sixty-one of 194 independent transplants (31.4%) occurred via cycles, while the remaining 133 (68.6%) resulted from nonsimultaneous extended altruistic donor (NEAD) chains. Thirteen of 35 (37.1%) NEAD chains with at least three NEAD segments accounted for 68% of chain transplants (8.6 tx/chain). The "offer" and 1-way success rates were 21.9 and 15.5%, respectively. Three reasons for failure were found that could be prospectively prevented by changes in protocol or software: positive laboratory crossmatch (28%), transplant center declined donor (17%) and pair transplanted outside APD (14%). Performing a root cause analysis on failures in moving from offer to transplant has allowed the APD to improve protocols and software. These changes have improved the success rate and the number of transplants performed per year.

Reasons for failing offers in a Kidney Paired Donation program: A 7-year analysis

Aim Computer-identified possible Kidney Paired Donation (KPD) exchanges are presented as offers to participating transplant programs and eventually converted into transplants. We evaluated reasons why these offers failed to progress into successful transplants. Methods/Results The Alliance for Paired Donation (APD) has an optimization algorithm to generate possible KPD exchanges, which are presented to transplant centers for their review as offers. Each offer may be composed of one to multiple 1-way exchanges. We tracked the progress in moving from offers to transplants and recorded the reason for failure. Between January 2008 and August 2014, the APD made 981 offers. Of these offers 181 resulted in transplants while 800 failed, namely 268 failed for specific reasons while 529 failed as they were dependent on the same 268 1-ways. Overall, specific reasons accounted for 57% of all failures with: 25% positive flow crossmatch (FXM); 13% competing offer outside the APD; and, 19% declined of donors by transplant centers (Fig. 1). Our detail analysis showed that the 25% positive FXM with negative virtual crossmatch (VXM) correlated with an increased number of highly sensitized patients: the pool of sensitized patients with a PRA >80% has increased from 31% in 2008 to 47% in 2014. Since many patients choose to enroll in multiple KPD registries some offers resulted in futile exchanges with patients already committed to alternative exchanges. Finally, donors were declined by transplant centers. To avoid these specific reasons for failure, the APD has begun pre-review consulting about donors and recipients prior to making a formal offer. Conclusions To prevent specific reasons for failure the APD has implemented the following changes: (1) testing of all donors for HLA-DQA, DPA and DPB; (2) expansion of the donor pool to increase options for highly sensitized patients; and (3) improved coordination with other KPD programs to avoid competing offers. Download : Download full-size image

Identifying Opportunities to Increase the Throughput of Kidney Paired Donation.

Although kidney paired donation (KPD) has led to thousands of transplants, the 2012 KPD Consensus Conference concluded that more could be done. Perceptions are that a large number of match offers never resulted in transplantations, and unfruitful matches have both financial and emotional costs. To describe, quantify, and analyze the unrealized match offers, we studied the matching process from registration to transplantation in the National Kidney Registry, a large KPD registry, over a 25-month period. Of the 3,180 match offers, 454 were turned down. The most common reasons were the donor was not acceptable (50%) and their recipient had unacceptably high donor-specific antibodies (28%). Of the 2,228 accepted offers, 1,335 advanced to the cell-based cross-match stage because 893 of these were part of chains that fell through. Fifty-five of 887 recorded cell-based cross-matches were positive, 20 donors were unacceptable, and 22 recipients had unacceptably high donor-specific antibodies. Six hundred ninety transplantations were performed. Despite the success of KPD, by analyzing the matching process, we identify several strategies to increase the number of KPD transplantations, including recruiting more participants, processing the match offers more quickly at the transplant center level, enhancing the donor preselection tools, improving communication between centers and the registries, and combining desensitization with KPD.

Four years of experience with the Australian kidney paired donation programme.

New approaches to increase kidney transplantation rates through expansion of live donor kidney transplantation have become necessary due to ongoing shortage of deceased donor organs. These strategies include desensitization in antibody-incompatible transplants to overcome the barrier of blood group incompatibility or human leucocyte antigen antibodies between recipient and donor and kidney paired donation (KPD) programmes. In KPD, a kidney transplant candidate with an incompatible live donor joins a registry of other incompatible pairs in order to find potentially compatible transplant solutions. To match the largest possible number of donor-recipient pairs while minimizing immunologic risk, KPD programmes use sophisticated algorithms to identify suitable matches with simultaneous two-way or more complex multi-way exchanges as well as including non-directed anonymous donors to start a chain of compatible transplantations. Because of the significant immunologic barriers when fewer donor options are available, the optimal solution for difficult-to-match, highly sensitized patients is access to more potential donors using large multi-centre or national KPD registries. This review focuses on the first 4 years of experience with the Australian multi-centre KPD programme that was established in October 2010.

International Kidney Paired Donation

International Kidney Paired Donation

Comparison of Time on the Cadaveric Kidney Donor Waitlist Versus Time on the Kidney Paired Donation Registry in the Australian Program

Introduction: A kidney paired donation (KPD) program can help patients who have a blood group or HLA incompatible live donor to find an immunologically suitable donor. However, a small number of patients in the pool and a high level of sensitization may prevent them to find suitable matches in a KPD program. The aim of this analysis was to compare waiting time for a KPD match to the waiting time on the deceased donor waitlist (DDWL) and the occurrence of matching in the DDWL for patients who were registered in both programs. Methods: In Australia DDWL patients are matched to potential deceased donors based on HLA antigen matching rules and time on dialysis, with a national priority listing for those with peak PRA >80%. In the KPD program matching is based on acceptable mismatches excluding donors from matching to recipients with DSA >2000 MFI for any class I or II antibodies, ignoring HLA antigen matching. Data on first dialysis, number of matches in the DDWL, entry into the KPD program and KPD match and transplant dates were assessed in 26 KPD recipients in the Australian program. Results: HLA-incompatibility accounted for 90% of the 53 patients in the KPD registry and 58% had a cPRA >75%. Of the 26 patients who received a KPD transplant, 5 were pre-emptive recipients and 21 were recipients who were listed in the DDWL. Time on dialysis was 808±646days (maximum 2003 days) in patients on the DDWL. Time on dialysis was longer for patients with PRA 50-75% compared to >75% (1199±684 vs 575±497days, P< 0.001). Of patients on the DDWL 10 had never been matched with a deceased donor (waiting time 345±237days) and 11 had been matched on average 3±5 times (waiting time 1227±615days, P< 0.0001 vs. never matched) and 3 of these patients had been matched >13 times each. In those patients transplantation was not undertaken because of positive crossmatch. After being registered in the KPD program patients who progressed to KPD transplant had been listed on average for 95±68days (P< 0.0001 compared to time on DDWL) with a range of 13-294days. Conclusion: Our data suggest that in sensitized patients allocation based on HLA-antigen matching is ineffective and is associated with frequent positive XM results. KPD allocation using an approach based on acceptable mismatches is effective in identifying suitable live donors for some recipients within a relatively short time-frame.

Comparison of Time on the Cadaveric Kidney Donor Waitlist Versus Time on the Kidney Paired Donation Registry in the Australian Program

Comparison of Time on the Cadaveric Kidney Donor Waitlist Versus Time on the Kidney Paired Donation Registry in the Australian Program

Comparison of time on the deceased donor kidney waitlist versus time on the kidney paired donation registry in the Australian program

In the Australian kidney paired donation (KPD) program matching is based on acceptable mismatches, whereas deceased donor waitlist (DDWL) patients are allocated kidneys based on HLA antigen matching rules. Herein, we compared waiting time for a KPD match to the waiting time on the DDWL and the occurrence of matching in the DDWL for patients who were registered in both programs. Data on first dialysis, matches on the DDWL, KPD program entry, matches and transplant dates were assessed in 26 KPD recipients of the Australian program. There were 22 recipients who were listed in the DDWL and received kidney transplants by KPD. Time on dialysis until KPD transplantation was 808 ± 646 days. Eleven patients had never been matched with a deceased donor (waiting time 345 ± 237 days) and 11 had been matched on average 3 ± 5 times (waiting time 1227 ± 615 days, P < 0.0001 vs. never matched), but did not progress to transplantation because of positive crossmatch or class II donor-specific antibody. Mean time from registration in the KPD program until kidney transplantation was 153 ± 92 days (P < 0.0001 vs. DDWL). KPD allocation using the acceptable mismatch approach is effective in identifying suitable live donors for some recipients within a relatively short time-frame.