Deceased Donor–initiated Chains: First Report of a Successful Deliberate Case and Its Ethical Implications

Abstract

Background: The utilization of deceased donor kidneys to initiate chains of living donor kidney paired donation (KPD) has been proposed, although the potential gain of this practice needs to be quantified and the ethical implications must be addressed before starting its application. Methods: The gain of implementing deceased donor-initiated chains has been measured through a mathematical algorithm, using retrospective data on the pool of donor/recipient incompatible pairs at a single Center. Allocation rules of chain ending kidneys and characteristics/quality of the chain initiating kidney (CIK) are described. Results: the quantification of benefit analysis showed that with a pool of 69 kidneys from deceased donors and 16 pairs enrolled in the KPD program, over a period of 3 years it is possible to transplant 8/16 recipients (50%). Following the approval of the Bioethical Committee of the Veneto Region and the revision of the allocation policies by the Italian National Transplant Center, the first successful case has been performed. The waiting time of the recipient (male, 53 yo) after entering the program for the CIK with a kidney donor risk index (KDRI) equal to 0.61 and a kidney donor profile index (KDPI) of 3%, was 4 days. His willing donor (female, 53 yo) with a living kidney donor profile index (LKDPI) of 2, donated 2 days later to a chain ending recipient (male, 47 yo,) who had been on dialysis for 5 years. Conclusions: This is the first report of a deliberate deceased donor-initiated chain, which has been successfully performed. This has been made possible thanks to an extensive phase of evaluation of the ethical issues and allocation policy impact. This paper includes a preliminary efficacy assessment and the development a dedicated algorithm.

Deceased donors as nondirected donors in kidney paired donation

“…In this article, we considered the simplest of possible chains created by the DD‐CIK, where the donation to a candidate in the KPDP is followed by a donation by that candidate's LD to the DD waitlist. There would be possibilities of longer chains, 20‐22 and we are investigating these, but this simplest case is of interest in its own right because each transaction involving a DD‐CIK is typically concluded in a few days. In addition, we have demonstrated that this approach results in a substantial increase in the number of transplants achieved.…”

“…There would be possibilities of longer chains, [20][21][22] and we are investigating these, but this simplest case is of interest in its own right because each transaction involving a DD-CIK is typically concluded in a few days. In addition, we have demonstrated that this approach results in a substantial increase in the number of transplants achieved.…”

“…There are many variations that could be considered that involve different selections of DD-CIKs or different ways of handling DD-CIK donations. 21,22,24 For example, one could divert a smaller pro- Candidates with CPRA ≥ 98% are currently given priority in the OPTN allocation system. 25 It would be possible to prioritize in the allocation sequence, CPRA ≥ 98% candidates in the KPDP over CPRA ≥ 98% candidates generally.…”

“…Utilizing deceased donor chain-initiating kidneys (DD-CIK) has the potential advantage of leveraging additional transplants resulting from a DD kidney. [20][21][22][23][24] In the simplest case, a DD-CIK is donated to a KPD candidate, whose paired donor, by prior agreement, subsequently donates to the waitlist, thus generating 2 transplants instead of one.…”

“…Various authors have suggested using deceased donor kidneys to initiate chains of transplants within a KPDP, where the donor of the last candidate transplanted would give back to the waitlist. Utilizing deceased donor chain‐initiating kidneys (DD‐CIK) has the potential advantage of leveraging additional transplants resulting from a DD kidney 20‐24 . In the simplest case, a DD‐CIK is donated to a KPD candidate, whose paired donor, by prior agreement, subsequently donates to the waitlist, thus generating 2 transplants instead of one.…”