Donor exchange programs in kidney transplantation: rationale and operational details from the north central donor exchange cooperative

Abstract

The increasing need for kidney transplants has led to innovations such as donor exchange programs. These programs offer transplant recipients with incompatible donors an opportunity to receive a compatible kidney. They also provide an alternative to costly desensitization protocols that have unproven long-term outcomes. Donor exchange programs have multiple options, including simple 2-pair exchanges, more complicated domino exchanges, or chain donations. The United States currently is limited by regional programs that provide for kidney donor exchanges. However, with the increasing public interest in and need for kidney transplants, general nephrologists will be approached with questions about these donor exchange programs. The goal of this review is to discuss donor exchange programs, including their role in expanding the donor pool, various types of exchanges, regional centers that provide these programs, and the process involved in patient enrollment. General knowledge of donor exchange programs will help providers in discussing options with patients approaching end-stage kidney disease and transplant.

Figure 1

Kidney Paired Donation whereby two potential transplant recipients exchange incompatible living donors, thereby resulting in two compatible recipient-donor pairs.

Figure 2

Non-directed donor can start a chain or domino of transplants for incompatible pairs. For logistical reasons, all transplants in a chain need not occur at the same time. The chain may continue endlessly until an incompatible donor decides not to donate and breaks a chain. The chain may be intentionally broken by donating to a patient on the deceased donor waiting list. When creating an endless chain, it is ideal not to stop a chain at an incompatible donor with AB blood type since that donor's kidney may only be accepted by a AB blood type recipient. Such a recipient with an incompatible donor is rare to find.