Paired Kidney Exchange Program Research Articles

V-210.3: Paired kidney exchange program: A utilitarian service to the underserved populations in the northern great plains of the United States.

V-210.3: Paired kidney exchange program: A utilitarian service to the underserved populations in the northern great plains of the United States.

Sex and Gender Disparities in Living Kidney Donation: A Scoping Review.

Women are more likely than men to be living kidney donors. We summarized the evidence concerning the reasons behind sex and gender disparities in living kidney donation (LKD). A scoping review of quantitative and qualitative evidence on reasons for sex and gender disparities in LKD was conducted from inception to March 2023. Of 1123 studies screened, 45 were eligible for inclusion. Most studies were from North America, Europe, and Central Asia (n = 33, 73%). A predominance of women as living donors (55%-65%) was observed in 15 out of 18 (83%) studies. Reasons for sex and gender disparities in LKD included socioeconomic, biological, and cognitive or emotional factors. A gendered division of roles within the families was observed in most studies, with men being the primary income earner and women being the main caregiver. Fear of loss of income was a barrier to male donation. Human leukocyte antigen sensitization through pregnancy in female recipients precluded male partner donation, whereas female donation was supported by altruism and a positive attitude toward LKD. Sex imbalance in LKD is prevalent, with a predominance of women as living donors. Such disparities are driven by societal and cultural perceptions of gender roles, pregnancy-induced sensitization, and attitudes toward donation and at least some of these factors are modifiable. Donor compensation to support predonation assessments and income loss, implementation of innovative desensitization treatments, promotion of paired kidney exchange program, and targeted educational initiatives to promote equitable living donation may help to close the gender gap in LKD.

The benefit to waitlist patients in a national paired kidney exchange program: Exploring characteristics of chain end living donor transplants

Nondirected kidney donors can initiate living donor chains that end to patients on the waitlist. We compared 749National Kidney Registry (NKR) waitlist chain end transplants to other transplants from the NKR and the Scientific Registry of Transplant Recipients between February 2008 and September 2020. Compared to other NKR recipients, chain end recipients were more often older (53 vs. 52years), black (32% vs. 15%), publicly insured (71% vs. 46%), and spent longer on dialysis (3.0 vs. 1.0years). Similar differences were noted between chain end recipients and non-NKR living donor recipients. Black patients received chain end kidneys at a rate approaching that of deceased donor kidneys (32% vs. 34%). Chain end donors were older (52 vs. 44years) with slightly lower glomerular filtration rates (93 vs. 98ml/min/1.73m2 ) than other NKR donors. Chain end recipients had elevated risk of graft failure and mortality compared to control living donor recipients (both p<.01) but lower graft failure (p=.03) and mortality (p<.001) compared to deceased donor recipients. Sharing nondirected donors among a multicenter network may improve the diversity of waitlist patients who benefit from living donation.

Meeting Report: First State of the Art Meeting on Gender Disparity in Kidney Transplantation in the Asia-Pacific.

Meeting Report: First State of the Art Meeting on Gender Disparity in Kidney Transplantation in the Asia-Pacific.

ABO-Incompatible Living-Donor Kidney Transplantation in a Developing Country: A Multicenter Experience in Malaysia

Malaysia has a low deceased-donor donation rate and has not embarked on a paired kidney exchange program; therefore, ABO-incompatible and HLA-incompatible transplantation remain the main contributor to the sustainability of the national kidney transplantation (KT) program. There were 26 cases of ABO-incompatible KTs performed from 2011 to 2018 in 3 major transplant centers, namely, Hospital Kuala Lumpur, University Malaya Medical Centre, and Prince Court Medical Centre. We collected perioperative and follow-up data through June 2019. The desensitization protocol varies and is center specific: the localized Japanese protocol and Swedish protocol with a target anti-A/B isoagglutinin titer of 16 or 32 on the day of transplant. The induction and tacrolimus-based maintenance protocol was nearly identical. The median follow-up time was 62.3 months (interquartile range, 37.0-79.7). Fifteen subjects had the highest predesensitization anti-A/B titer of ≥32 (57.7%). The acute cellular rejection and antibody-mediated rejection incidence were 12.5% (3 cases) and 8.3% (2 cases), respectively. Patient, graft, and death-censored graft survival rates were 96.2%, 92.3%, and 96.0%, respectively, 1 year post-living-donor KT (LDKT) and 96.2%, 87.2%, and 90.7%, respectively, 5 years post-LDKT. Our experience shows that ABO-incompatible LDKT using a suitable desensitization technique could be a safe and feasible choice for LDKT even with varied desensitization regimens for recipients with relatively high baseline isoagglutinin titers.

In Search of a Better Outcome: Opting Into the Live Donor Paired Kidney Exchange Program.

Background:Live donor (LD) kidney transplantation is the best option for patients with end-stage kidney disease (ESKD). However, this may not be the best option if a patient’s donor is older and considerably smaller in weight. Patient (A) with a less than ideal donor (Donor A) might enter into a live donor paired exchange (LDPE) program with the hopes of swapping for a better-quality organ. A second patient (B) who is in the LDPE may or may not benefit from this exchange with Donor A.Methods:This medical decision analysis examines the conditions that favor Patient A entering into the LDPE compared to directly accepting a kidney from their intended donor, as well as the circumstances where Patient B also benefits by accepting a lower-quality organ.Results:Under select circumstances, a paired exchange could benefit both Patients A and B. For example, a 30-year-old Patient A with a lower-quality donor might gain 1.201.521.84 quality adjusted life years (QALYs) by entering into a LDPE for a better-quality kidney, whereas a 60-year-old Patient B might gain 0.931.031.13 QALYs by accepting Donor A’s kidney rather than waiting longer in the LDPE. The net benefit (or loss) of entering the LDPE differs by recipient age, donor organ quality, likelihood of Patient B being transplanted in LDPE, and likelihood of Patient A finding an ideal donor in the LDPE.Conclusion:This study shows there are ways to increase live donor utilization and effectiveness that require further research and potentially changes to the LDPE process.

Renal Transplantation in Mansoura, Egypt.

Renal Transplantation in Mansoura, Egypt.

Organ Donation in Uzbekistan: Achievements and Prospects for Further Development.

Here, we describe the current situation regarding organ transplant in Uzbekistan. The legalization of paired-kidney exchange programs for donors with incompatible blood types in Uzbekistan will allow more opportunities for organ donation. The phased implementation of the transplant program with that of deceased-donor organ transplant can be carried out only with the involvement of public, cultural, and religious figures, and not only health professionals, to permanently shift the paradigm in the population.

Organ Procurement and Transplantation in Italy

Organ Procurement and Transplantation in Italy

A novel method to increase the kidney donor pool: A fusion model linking the deceased donor waitlist to a paired kidney exchange program

Aim: To merge the deceased donor (DD) and the paired kidney exchange (PKE) allocation processes, creating a fusion model. Materials and Methods: One of the DD kidneys are allocated to the first patient on the DD wait-list and the other kidney is allocated to the PKE registry to initiate a chain of swap transplants. The last donor of this PKE chain donates his kidney back to the second patient on the DD wait-list. Results: There was a 28.1% (P

Banking on Living Kidney Donors-A New Way to Facilitate Donation without Compromising on Ethical Values.

Public surveys conducted in many countries report widespread willingness of individuals to donate a kidney while alive to a family member or close friend, yet thousands suffer and many die each year while waiting for a kidney transplant. Advocates of financial incentive programs or "regulated markets" in kidneys present the problem of the kidney shortage as one of insufficient public motivation to donate, arguing that incentives will increase the number of donors. Others believe the solutions lie-at least in part-in facilitating so-called "altruistic donation;" harnessing the willingness of relatives and friends to donate by addressing the many barriers which serve as disincentives to living donation. Strategies designed to minimize financial barriers to donation and the use of paired kidney exchange programs are increasingly enabling donation, and now, an innovative program designed to address what has been termed "chronologically incompatible donation" is being piloted at the University of California, Los Angeles, and elsewhere in the United States. In this program, a person whose kidney is not currently required for transplantation in a specific recipient may instead donate to the paired exchange program; in return, a commitment is made to the specified recipient that priority access for a living-donor transplant in a paired exchange program will be offered when or if the need arises in the future. We address here potential ethical concerns related to this form of organ "banking" from living donors, and argue that it offers significant benefits without undermining the well-established ethical principles and values currently underpinning living donation programs.

Optimizing Outcomes in Pediatric Renal Transplantation Through the Australian Paired Kidney Exchange Program.

Kidney paired donation (KPD) programs offer the opportunity to enable living kidney donation when immunological and other barriers prevent safe directed donation. Children are likely to require multiple transplants during their lifetime; therefore, high-level histocompatibility and organ quality matching are key priorities. Details are given for a cohort of seven pediatric renal transplantations performed through the Australian Kidney Exchange (AKX), including barriers to alternative transplantation and outcomes after KPD. Reasons for entering the KPD program were preformed donor-specific antibodies to their registered donor in five cases, ABO mismatch, and avoidance of the risk of exposure to hepatitis B virus. Four recipients were highly sensitized. All patients received transplants with organs of lower immunological risk compared with their registered donors. HLA eplet mismatch scores were calculated for donor-recipient pairs; three patients had improved eplet mismatch load with AKX donor compared with their registered donor. All grafts are functioning, with a mean estimated glomerular filtration rate of 77 mL/min/1.73 m2 (range 46-94 mL) and a follow-up range of 8-54 months, and no patient experienced clinical or histological rejection. KPD is a viable strategy to overcome many barriers to living donation for pediatric patients who have an otherwise suitable donor and provides an opportunity to minimize immunological risks.

Prolonged Ischemic Time, Delayed Graft Function, and Graft and Patient Outcomes in Live Donor Kidney Transplant Recipients.

The association between prolonged cold ischemic time (CIT) and graft and patient outcomes in live donor kidney transplant recipients remains unclear. The aims of this study were to examine the association of CIT with delayed graft function and graft loss in live donor kidney transplant recipients and those who participated in the Australian Paired Kidney Exchange program using data from the Australia and New Zealand Dialysis and Transplant (ANZDATA) registry. Of 3717 live donor transplant recipients between 1997 and 2012 who were followed for a median of 6.6 years (25 977 person-years), 224 (25%) experienced CIT >4-8 h. Donor age was an effect modifier between CIT and graft outcomes. In recipients who received kidneys from older donors aged >50 years, every hour of increase in CIT was associated with adjusted odds of 1.28 (95% confidence interval [CI] 1.07-1.53, p = 0.007) for delayed graft function, whereas CIT >4-8 h was associated with adjusted hazards of 1.93 (95% CI 1.21-3.09, p = 0.006) and 1.91 (95% CI 1.05-3.49, p = 0.035) for overall and death-censored graft loss, respectively, compared with CIT of 1-2 h. Attempts to reduce CIT in live donor kidney transplants involving older donor kidneys may lead to improvement of graft outcomes.

Medical record convergence for hla reporting across the enterprise

Aim One of Mayo Clinic’s missions is to standardize care through an integrated clinical practice. Reporting histocompatibility results is very complex and HLA labs have different ways of interpreting results. By standardizing across the three sites we improve the interchangeability of test results, reduce resources to support our practice, provide the best standard of care for our patients and support for our physicians for the Mayo paired kidney exchange program. Methods Integration was defined as: Each lab will use HistoTrac as the lab management system. HistoTrac will interface with the lab integrated system (LIS) for processing of orders and reporting results to the medical record. Each lab will report the same discreet result values and interpretive reports. Each lab will use the same vendor and lot number if possible for antibody and typing tests. A project group was created which includes: a director and technical specialist from each site, a business analyst, and a computer programmer. This team worked together using conference calls and web meetings to establish standardization for reporting HLA typing, antibody and crossmatch results. Results The results reported at each site will use the same test definitions, reporting templates, and will be transferred to the LIS. We encountered some obstacles due to: lab practice differences, transplant policies and business requirements. The convergence effort is still ongoing at each site: MN: update reporting and implement interpretive reports AZ: implement an interface to the LIS and update interpretive reports FL: implement HistoTrac with an interface to the LIS and update interpretive reports Conclusion All histocompatibility data and interpretive reports will be available in the medical record at each mayo site. Convergence of reporting test results will improve the communication and understanding when evaluating a patient while making the process cost effective. The next step in convergence is reporting to one medical record at all three sites. Download full-size image

Transplant professionals' proposals for the implementation of an altruistic unbalanced paired kidney exchange program.

Kidney recipients in the O blood group are at a disadvantage in kidney exchange programs (KEPs) because they can only receive an organ from O blood group donors. A way to remedy this unfair situation is through altruistic unbalanced paired kidney exchange (AUPKE) where a compatible pair (CP) consisting of an O donor and a non-O recipient is invited to participate in a KEP. There is no established AUPKE program in Canada. The aim of this study was to gather transplant professionals' views on the conditions necessary for the implementation of an AUPKE program. Nineteen Canadian transplant professionals took part in semistructured interviews. The content of these interviews was analyzed using a qualitative data analysis method. Respondents' recommendations focused on the following: (i) the logistics of AUPKE (e.g., not delaying the transplantation for the CP, retrieving organs locally, providing a good quality organ to the CP, and maintaining anonymity); (ii) the transplantation teams (e.g., establishing a consensus among members and ensuring sufficient resources); (iii) information provided to CPs; and (iv) research (e.g., looking into all transplant options for O recipients, studying all potential impacts of KEPs and AUPKE). The respondents in our study made the following recommendations for the implementation of an AUPKE program: (i) CPs should not be disadvantaged, (ii) measures should be taken to ensure that all transplant team members agree to participate and that there are sufficient resources for implementation, (iii) comprehensive information should be provided to the CP, and (iv) further research is needed on AUPKE.

Transplantation in highly HLA-sensitized patients: challenges and solutions

Transplantation in highly HLA-sensitized patients: challenges and solutions Irene K Kim, Ashley Vo, Stanley C Jordan Transplant Immunotherapy Program, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA Abstract: Despite better understanding of the impact of development of the human leukocyte antigen (HLA) antibody and numerous advancements in immunosuppressive therapy, the ability to successfully transplant highly sensitized patients remains a significant challenge. As the percentage of the waiting list becomes increasingly populated with highly sensitized patients, there is a growing demand for effective strategies to manage these patients. Over the past 20 years, desensitization therapies have been modified and developed, and are mainly utilized at transplant centers that have developed expertise. In addition, recognition that the highly sensitized patient population is disadvantaged on the transplant waiting list has led to recent changes in national kidney allocation policy. Furthermore, creative strategies, such as enrollment of sensitized patients into paired kidney exchange programs, have been developed to find compatible matches for these patients. The goal of this article is to address some of the specific challenges related to transplanting the highly sensitized patient at a high-volume transplant center with experience in desensitization and to review established and emerging solutions to help this patient population. Keywords: human leukocyte antigen, antibodies, desensitization, high-dose intravenous immunoglobulin, rituximab

Computer-Aided Altruistic Unbalanced Paired Kidney Exchange: A Pilot Software.

Paired kidney exchange (PKE) is a proposed solution to antibody barriers to direct donation, avoiding the risks and costs associated with desensitization protocols. Our Centre performed the first PKE in Italy in 2005. Unfortunately, balanced PKE programs invariably leads to stagnation of blood group O recipients. In order to solve them, inclusion of compatible pairs in PKE programs has been implemented, leading to so-called altruistic unbalanced PKE (auPKE) programs. The increasing complexity of multi-centre auPKE programs demands a dedicated software and an appropriate algorithm to ensure fairness and use of optimal solutions. We report here the design and beta-testing of “Transplant manager”, the first software dedicate to solving single patients or entire pools using balanced or auPKE programs. The whole set of parameters taken into account to accept and rank solutions can be customized by the end-user.Figure: No Caption available.The pair universus is divided into 3 subgroups: perfectly compatible pairs, suboptimally compatible pairs (those who can gain something from the donor swap in terms of donor age, DSA level, anthropometric match or predicted renal function), and incompatible pairs. The software also automates calculation of several immunological parameters (HLA matching, match probability within the pool, calculated PRA, and estimated renal function and graft survival according to UNOS-validated nomograms. Our project has received the 2013 Julia Bodmer Award by the European Federation of Immunogenetics, and is currently under consideration for endorsement by the South Transplant Alliance.

Single-Center Experience of Paired Kidney Exchange: Effects On Outcomes With Variable Shipping Distance and Cold Ischemic Time.

Background: National paired kidney exchange programs benefit patients, but there is a paucity of data on the impact of cold ischemic time (CIT) and shipping distance on transplant outcomes. Methods: This is a single-center study examining outcomes of 53 consecutive cases of paired kidney exchange (2011-2014). One-year actuarial survival rates were determined by Kaplan-Meier analyses. Results: Recipients of paired kidney exchanges received grafts either from our center (n=13, 24.5%) or were shipped from an outside hospital (n=40, 74.5%). For shipped kidneys, the average CIT was 12.5 h (±3.9 h), and the average distance shipped was 1045 mi (±465 mi). Kaplan-Meier one-year actuarial graft survival rates were not statistically different between shipped and non-shipped kidneys, 92% vs 90%, p=0.96, Figure 1. The rate of DGF for shipped kidneys was 10% (4/40) vs 0% (0/13) for non-shipped NKR kidneys (p=0.25). Multivariate analyses controlling for donor age, PRA, HLA match did not demonstrate a statistically significant association between DGF and CIT (p=0.11) and distance shipped (p=0.17). However, the one-year actuarial graft survival rates of kidneys with and without DGF were, 50% and 95.0%, respectively (p=0.01), Figure 2. Conclusions: A statistically insignificant, but clinically significant rate of DGF was observed in living donor kidneys received from external programs. This risk of DGF was not related to CIT and shipping distance in a multivariate analysis. Importantly, DGF was found to be associated with diminished 1-year kidney graft survival. Further study is needed to fully determine the impact of distance and CIT on outcomes of transplants in national paired exchange programs.Figure: No Caption available.Figure: No Caption available.

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Aim The method of choice in most of the HLA laboratories for the identification of anti HLA antibodies is the solid phase assay Luminex technology. This method is very sensitive and it is being used for virtual crossmatching as well as for paired kidney exchange (PKE) programs. The most challenging factor for the paired kidney exchange programs is the high sensitization level of the listed couples determined by Luminex-IgG MFI. Now it is increasingly believed that the complement fixing donor specific antibodies (DSA) are the more clinically relevant than non-complement fixing antibodies. In this study we determined impact of using Luminex C1q instead of Luminex-IgG in the pool of the couples listed in our PKE program. Methods A cohort of 12 patients was chosen randomly from the total of 28 couples constituting our HLA incompatible PKE program. All samples were tested by Luminex-IgG and Luminex-C1q (One Lambda) for HLA class I and II antibodies. The unacceptable antigens listed in the PKE are those with more than 6000 MFI for HLA-A,B,DR and DQ. For HLA-C it was 10000 MFI. Results The percentage of complement fixing antibodies detected for HLA class I and II were 36% and 35% respectively. When the unacceptable antigens entered in the PKE program were those Luminex-IgG positive, there were no exchangeable pairs. However when the unacceptable antigens entered in the PKE program were only those C1q positive, we found four one-way exchangeable pairs. Conclusions Our data suggest that we should consider listing unacceptable antigens in the PKE program using the Luminex-C1q positive instead of Luminex-IgG positive. Listing unacceptable antigen in the PKE program solely based on Luminex-IgG will deprive many patients from being transplanted with compatible pairs.

The silence of Good Samaritan kidney donation in Australia: a survey of hospital websites

It is common for living donor candidates to use the Internet as a tool to enhance their decision-making process. Specifically, the websites of transplant hospitals can potentially be a vital source of information for those contemplating living donation. In an effort to explore the low incidence of Good Samaritan kidney donation (donations to strangers) in Australia, two raters conducted a nine-attribute website content analysis for all hospitals which participate in these transplants (n=15). Overall, the concept of living donation is relatively silent on Australian hospital websites. Only four hospitals mention their living donor program, and only one mentions their Good Samaritan program. No site linked directly to Australia's AKX Paired Kidney Exchange Program - the only program which facilitates pair and chain transplants in Australia. Further, information about deceased donation is nearly absent as well. An individual with the altruistic desire to donate will generally find scant or absent information about donation at the website of their local transplant hospital, although this information could easily be present as an educational tool which supports the consent process. Using a hospital website to educate the public about a clinical service should not be viewed as ethically problematic (solicitation), but rather an ethical essential.