Paired kidney exchange transplantation – pushing the boundaries

Abstract

Summary The scarcity of living organ donors makes it imperative to develop newer innovations to optimize and maximize the utilization of the available pool. ABO and HLA sensitization are important immunological barriers in renal transplant and can potentially lead to rejection of almost one‐third of the willing living donors. Paired kidney exchange (PKE) is a rapidly growing method used to overcome these barriers and has grown in popularity over the last three decades since its introduction in 1986. Evolution of the matching strategies and use of complex algorithms has led to increase in the number of possible matches thereby benefiting multiple recipients. The use of altruistic donors and compatible pairs has also helped in increasing the possible exchanges. This review provides an in‐depth analysis of the evolution, the present global scenario, and the future of PKE. It also discusses the recent trends of advanced donation, trans‐organ paired exchange and global kidney exchange and the associated ethical concerns.

A Historical Cohort in Kidney Transplantation: 55-Year Follow-Up of 72 HLA-Identical, Donor-Recipient Pairs

“…One aspect of transplantation this study highlights is the potentially salutatory effects of kidney exchanges. Kidney exchange mechanisms allow for the broader sharing of grafts from living donors in order to improve overall “compatibility”—including HLA matching—between donor and recipient [ 31 ]. Indeed, in silico simulations have shown that exchange programs have the potential to decrease HLA mismatch between donor and recipient [ 32 ].…”

Strategies to Overcome HLA Sensitization and Improve Access to Retransplantation after Kidney Graft Loss

“…Genetically related donors have better HLA matches [ 90 ], ischemia-reperfusion injury tends to be lower which decreases the exposure to HLA antigens [ 91 ], IS after first graft loss can be maintained in higher doses [ 31 ] and desensitization protocols are more effective [ 92 ]. Living donation also allows kidney-paired donation for AB0 or HLA incompatible pairs, with similar outcomes to direct living donation [ 93 , 94 ].…”

Paired kidney donation: are we going beyond reasonable limits in living-donor transplantation?

“…Although controversial, the growth of this model has been based on two pillars: the option for carrying out a transplant from a deceased donor is remote, due to the progressive growth of the waiting list; and both life quality and expectancy provided by transplantation are much better than what is provided by dialysis 9 . This modality of transplantation, which started more than 20 years ago, was first performed with the exchange between two pairs in the same center in South Korea, in 1991 10 , then followed by the chain of exchanges between several pairs, also in the same center, followed by geographic expansion, until reaching international status, using the same criteria as local exchanges [11][12][13][14][15][16] .…”

“…This modality of transplantation, which started more than 20 years ago, was first performed with the exchange between two pairs in the same center in South Korea, in 1991 10 , then followed by the chain of exchanges between several pairs, also in the same center, followed by geographic expansion, until reaching international status, using the same criteria as local exchanges 11 - 16 .…”