|Year : 2018 | Volume
| Issue : 1 | Page : 6-10
Kidney paired donation program, a national solution against commercial transplantation?
Mohamed E Elrggal1, Mona Tawfik2, Mohammed A Gawad1, Hussein A Sheasha3
1 Nephrology Department, Kidney and Urology Center, Alexandria, Egypt
2 Nephrology Department, Mansoura Nephrology and Dialysis Unit (MNDU), Mansoura, Egypt
3 Nephrology Department, Mansoura Urology and Nephrology Center (UNC), Mansoura University, Mansoura, Egypt
|Date of Submission||02-Jan-2018|
|Date of Acceptance||13-Mar-2018|
|Date of Web Publication||02-May-2018|
Dr. Mohamed E Elrggal
23, Mohamed Safwat Street, Kafr-Abdo, Alexandria
Source of Support: None, Conflict of Interest: None
End-stage renal disease is a growing health problem worldwide. Renal transplantation provides a better patient survival and quality of life compared with other means of renal replacement therapy. There is a serious shortage of transplantable kidneys, especially in countries where deceased donation is not allowed. Kidney paired donation (KPD) is a novel program applied to expand the donor pool, increase kidney transplantation rates, and allow a better donor recipient matching specially for sensitized patient. It permits living kidney transplantation in a short waiting time with better graft survival compared with those with deceased kidney transplantation. This review article aims to highlight the importance of KPD program as a promising solution for organ shortage and commercial transplantation. It also discusses the idea of implementing such programs in Egypt and offers future suggestions that may help its establishment.
Keywords: kidney paired donation, kidney transplantation, living donation
|How to cite this article:|
Elrggal ME, Tawfik M, Gawad MA, Sheasha HA. Kidney paired donation program, a national solution against commercial transplantation?. J Egypt Soc Nephrol Transplant 2018;18:6-10
|How to cite this URL:|
Elrggal ME, Tawfik M, Gawad MA, Sheasha HA. Kidney paired donation program, a national solution against commercial transplantation?. J Egypt Soc Nephrol Transplant [serial online] 2018 [cited 2019 Mar 21];18:6-10. Available from: http://www.jesnt.eg.net/text.asp?2018/18/1/6/231747
| Why we need it?|| |
Organ shortage and long duration on the national waiting lists are major problems facing the transplant community. As per the US Organ Procurement and Transplantation Network, ∼116 thousand patients currently need an organ transplant . Every 10 min, a patient is added to the transplant list and ∼20 patients die each day while waiting for a transplant . Multiple efforts have been tried to expand the number of living kidney donors including ABO incompatible transplantation through desensitization protocols, incentive program for living donation , expanded donation criteria program, kidney paired donation (KPD) ,, and altruistic donation (nondirected living kidney donation).
| History|| |
KPD program started initially in the Netherlands and South Korea in 1986 , and then expanded to the US during the past decade. In US, the national Organ Procurement and Transplantation Network initiated a national KPD pilot program and has arranged 155 kidney transplants since its inception on 27 October 2010 till October 2015 . During this program, half of the recipients who have been candidates for transplantation received a transplant within 6 months from the time of enrollment . In Canada, KPD program completed 543 transplants by November 2017 . In Turkey, KPD managed to increase living kidney transplant by 5% which encouraged the government to establish an international paired exchange kidney transplantation program .
| Kidney paired donation principles|| |
In KPD, potential living donors who are either ABO or human leukocytic antigen (HLA) incompatible with their intended recipients participate in a donor pool, resulting in expanded availability of organs . This involves the matching of the living kidney donor with a recipient who is immunologically compatible from another donor/recipient pair in the KPD donor pool ([Figure 1]). KPD can also help a compatible pair find a better match (e.g. a 5/6 mismatch to 2/6 mismatch) which will subsequently improve the graft survival ,,. The other pair will also benefit if they were incompatible by finding a compatible donor, in other words, compatible pairs can facilitate transplants for other incompatible pairs.
|Figure 1 Paired exchange donation: recipient A would receive a kidney from donor B and vice versa.|
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| Ethically|| |
The exchange of living donor kidneys between incompatible pairs was considered acceptable among participants of a consensus conference on living organ donation ,. Participants suggested that both transplant procedures be performed simultaneously to avoid the hazard of one donor declining after the other donor procedure has been performed. Participants also refused to consider this as commercial as suggested by some authors who are opposed to this approach .
| Types of donor exchanges|| |
Rapaport  first described the simplest type of KPD, where two donors exchange kidneys so that their two candidates can each receive a compatible transplant. The donor operations are usually started simultaneously ([Figure 1]).
Another form is the nondirected donor or the altruistic donor (i.e. a donor without a designated recipient) can initiate a chain of paired kidney exchange which may be either open or closed ended ([Figure 2]). The process of transplantation in a chain of paired kidney donation does not necessarily occur at the same time (nonsimultaneous, extended, altruistic-donor chain, NEAD ), and it may continue infinitely unless one donor decides not to donate .
KPD may be limited by the need to transplant both pairs at the same time. To overcome this problem, an advanced donation program (ADP) has been proposed as a kidney paired exchange separated in time ([Figure 3]). ADP cases allow donors to donate their kidney before their intended recipient receives a kidney or even needs a kidney . ADP may help donors donate in advance even before their intended recipients need transplantation. There is no guarantee that the donors’ intended recipients can be matched and transplanted after that, but the program tries its best to find a donor as soon as the patient needs it. A recent report described a chain of 47 transplant cases facilitated by 10 donors participating in the ADP .
|Figure 3 Advanced donation program: time-limited donor undergoes nephrectomy before paired recipient has an identified established donor.|
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| Global kidney exchange program|| |
Recently, Rees et al.  proposed the global kidney exchange (GKE) program in which biologically compatible but ‘financially incompatible’ living donors and recipients from developing countries may overcome their financial constrains through participation in a chain of donation in the USA, facilitating both their own transplantation as well as other American transplantation. The healthcare savings generated by removing USA patients from dialysis would be used to cover the cost of transplantation and post-transplant care including immunosuppressant drugs for the recipient in their home country for a period of 5 years. Rees et al.  reported the first GKE transplantation, when a Filipino pair had their recipient transplanted in the USA with an American donor’s kidney at no cost to him, whereas the donor provided her kidney to an American recipient. This was performed as part of a three-way NEAD chain, which was extended thereafter to provide a total of 11 total transplantations over 1 year. However, there are several ethical considerations against the expansion of the GKE program plus logistic and cultural constrains ,.
So far in the middle east, KPD programs have not been well established. Recently, Professor Khalid Almishari delivered a very exciting plenary lecture about the Saudi promising experience with KPD program to overcome the high sensitization and matching barriers in Saudi patients with end-stage renal disease (ESRD) (7th ISN-EMAN Update Congress in Nephrology, 13–16 December 2017, Dubai, UAE).
| Kidney paired donation outcomes|| |
Outcomes of KPD transplantation were comparable to those of live-related kidney transplantation over 2-year follow-up after transplantation . In one study, 134 KPDs were performed over 3 years, including two-way and three-way exchanges. Only three episodes of rejection occurred but no graft loss occurred owing to rejection. In this study, paired donation mostly influenced highly sensitized recipients as 44% had calculated panel reactive antibody levels greater than 80% . In another study, KPD allowed transplantation after a median of 157 days from listing in the program and enabled pre-emptive transplantation in eight patients . Chains initiated by nondirected donors (altruistic) facilitated 272 kidney transplants through KPD program, all by the National Kidney Registry .
| Importance of kidney paired donation implementation in Egypt|| |
In Egypt, available live related kidney donors are much less than the required for patients with ESRD; therefore, commercial transplantation is present and active. Moreover, waiting time in the available national transplant centers is increasing, for example, in Mansoura Urology and Nephrology Center, the waiting time is estimated currently to be ∼1.5 years. To overcome organ shortage in Egypt, efforts should be directed to establish a successful national KPD program.
In Egypt, with the absence of deceased transplantation, national altruistic donation program, and the nonfamiliarity with ABO incompatible transplantation (in addition to its high cost), KPD appears to be one of the promising alternatives to overcome organ shortage and expand the living unrelated donor pool (see [Table 1] for steps to implement a national KPD program).
|Table 1 Suggestions for establishing a national kidney paired donation program framework in Egypt|
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Further operational steps of the program can be discussed after program establishment, including offering KPD for all incompatible pairs, acquiring special consent from the pair to share their information with other contributing centers, entering their information (age, ABO, HLA, and PRA) into the database, performing virtual cross-match using Luminex technology, and then proceeding to actual cross-match if a donor was found. These steps can be reviewed  and adjusted according to national laws and regulations.
| Conclusion|| |
KPD program has many advantages as follows: (a) an increase in the number of kidneys available for transplantation; (b) avoidance of the risks and costs of desensitization strategies designed to remove antidonor antibodies (thus permitting transplantation despite ABO incompatibility); (c) decrease waiting time on national transplant list; and (d) provision of living donor grafts, which are usually superior to cadaveric ones. Countries that do not approve deceased donation like Egypt, should search for ways to increase the donor pool for patients with ESRD and to prevent commercial transplantation. One of the most encouraging methods is to establish a national KPD program. Rules and regulations should be set to prevent corruption, to ensure the justice in using donor organs, and to build a trust with the patients and the donors, so they can apply for the program, which will result in its expansion and success. 
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Israni AK, Halpern SD, Zink S, Sidhwani SA, Caplan A. Incentive models to increase living kidney donation: encouraging without coercing. Am J Transplant 2005; 5:15–20.
Spital A. Increasing the pool of transplantable kidneys through unrelated living donors and living donor paired exchanges. Semin Dial 2005; 18:469–473.
Delmonico FL. Exchanging kidneys − advances in living-donor transplantation. N Engl J Med 2004; 350:1812–1814.
Rapaport FT. The case for a living emotionally related international kidney donor exchange registry. Transplant Proc 1986; 18(Suppl 2):5–9.
Tuncer M, Tekin S, Yuksel Y, Yücetin L, Dosemeci L, Sengul A et al.
First international paired exchange kidney transplantations of Turkey. Transplant Proc 2015; 47:1294–1295.
Foster BJ, Dahhou M, Zhang X, Platt RW, Hanley JA. Relative importance of HLA mismatch and donor age to graft survival in young kidney transplant recipients. Transplant J 2013; 96:469–475.
Koukoulaki M, Kitsiou V, Balaska A, Pistolas D, Loukopoulos I, Drakopoulos V et al.
Immunologic prognostic factors of renal allograft survival. Transplant Proc 2014; 46:3175–3178.
Süsal C, Opelz G. Current role of human leukocyte antigen matching in kidney transplantation. Curr Opin Organ Transplant 2013; 18:438–444.
Ross LF, Rubin DT, Siegler M, Josephson MA, Thistlethwaite JR, Woodle ES. Ethics of a paired-kidney-exchange program. N Engl J Med 1997; 336:1752–1755.
Abecassis M, Adams M, Adams P, Arnold RM, Atkins CR, Barr ML et al.
Consensus statement on the live organ donor. JAMA 2000; 284:2919–2926.
Menikoff J. Organ swapping. Hastings Cent Rep 1999; 29:28–33.
Rees MA, Kopke JE, Pelletier RP, Segev DL, Rutter ME, Fabrega AJ et al.
A nonsimultaneous, extended, altruistic-donor chain. N Engl J Med 2009; 360:1096–1101.
Akkina SK, Muster H, Steffens E, Kim SJ, Kasiske BL, Israni AK. Donor exchange programs in kidney transplantation: rationale and operational details from the north central donor exchange cooperative. Am J Kidney Dis 2011; 57:152–158.
Wall AE, Veale JL, Melcher ML. Advanced donation programs and deceased donor-initiated chains − 2 innovations in kidney paired donation. Transplantation 2017; 101:2818–2824.
Flechner SM, Leeser D, Pelletier R, Morgievich M, Miller K, Thompson L et al.
The incorporation of an advanced donation program into kidney paired exchange: initial experience of the national kidney registry. Am J Transplant 2015; 15:2712–2717.
Rees MA, Dunn TB, Kuhr CS, Marsh CL, Rogers J, Rees SE et al.
Kidney exchange to overcome financial barriers to kidney transplantation. Am J Transplant 2017; 17:782–790.
Kute V, Jindal RM, Prasad N. Kidney paired-donation program versus global kidney exchange in India. Am J Transplant 2017; 17:2740–2741.
Wiseman AC, Gill JS. Financial incompatibility and paired kidney exchange: walking a tightrope or blazing a trail? Am J Transplant 2017; 17:597–598.
Tuncer M, Tekin S, Yücetin L, Şengül A, Demirbas A. Comparison of paired exchange kidney transplantations with living related kidney transplantations. Transplant Proc 2012; 44:1626–1627.
Bingaman AW, Wright FH, Kapturczak M, Shen L, Vick S, Murphey CL. Single-center kidney paired donation: the Methodist San Antonio experience. Am J Transplant 2012; 12:2125–2132.
Leeser DB, Aull MJ, Afaneh C, Dadhania D, Charlton M, Walker JK et al.
Living donor kidney paired donation transplantation: experience as a founding member center of the National Kidney Registry. Clin Transplant 2012; 26:E213–E222.
Melcher ML, Leeser DB, Gritsch HA, Milner J, Kapur S, Busque S et al.
Chain transplantation: initial experience of a large multicenter program. Am J Transplant 2012; 12:2429–2436.
Glorie K, Haase-Kromwijk B, van de Klundert J, Wagelmans A, Weimar W. Allocation and matching in kidney exchange programs. Transpl Int 2014; 27:333–343.
Irwin FD, Bonagura AF, Crawford SW, Foote M. Kidney paired donation: a payer perspective. Am J Transplant 2012; 12:1388–1391.
[Figure 1], [Figure 2], [Figure 3]