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A Potential Solution to Make the Best Use of a Living Donor–Deceased Donor List Exchange

2016; Elsevier BV; Volume: 16; Issue: 12 Linguagem: Inglês

10.1111/ajt.13974

1600-6143

Vivek Kute, H.V. Patel, Pankaj R. Shah, Pranjal Modi, V.R. Shah, Hargovind L. Trivedi,

Blood donation and transfusion practices

To the Editor: We read with interest the report by Melcher et al that proposed the utilization of deceased donor kidneys to initiate living donor kidney paired donation (KPD) chains (1.Melcher ML Roberts JP Leichtman AB Roth AE Rees MA. Utilization of deceased donor kidneys to initiate living donor chains.Am J Transplant. 2016; 16: 1367-1370Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar). Our experience of 300 living donor KPD transplantations in a single center in India showed that the use of blood group A and B donor-recipient pairs (DRPs) without a high level of donor specific antibody (DSA) should not be included in a living donor-deceased donor list exchange because they have a good chance of matching in KPD (2.Kute VB Shah PS Vanikar AV Increasing access to renal transplantation in India through our single-center kidney paired donation program: A model for the developing world to prevent commercial transplantation.Transplant Int. 2014; 27 (et al): 1015-1021Crossref PubMed Scopus (18) Google Scholar). The waiting times in conventional KPD programs are fairly short for this cohort (2.Kute VB Shah PS Vanikar AV Increasing access to renal transplantation in India through our single-center kidney paired donation program: A model for the developing world to prevent commercial transplantation.Transplant Int. 2014; 27 (et al): 1015-1021Crossref PubMed Scopus (18) Google Scholar). In a prospective review of 100 DRPs at our institution, 90% of the patients indicated that they would be willing to participate in a living donor KPD without financial reimbursement, but not in a living donor–deceased donor exchange program (unpublished data). Waterman et al (3.Waterman AD Schenk EA Barrett AC Incompatible kidney donor candidates' willingness to participate in donor-exchange and non-directed donation.Am J Transplant. 2006; 6 (et al): 1631-1638Crossref PubMed Scopus (36) Google Scholar) also reported similar findings. The half-life of living and deceased donor kidneys is 21.6 years and 13.8 years, respectively. We therefore believe that including A and B group patients in DRPs would be unfair, as some recipients may receive a deceased donor kidney rather than a living kidney. All patients with compatible, non-HLA-identical donors older than 45 years of age should be approached for participation in the KPD program (4.Bingaman AW Wright Jr, FH Kapturczak M Shen L Vick S Murphey CL. Single-center kidney paired donation: The Methodist San Antonio experience.Am J Transplant. 2012; 12: 2125-2132Crossref PubMed Scopus (72) Google Scholar). Compatible pairs (CPs) should be offered a better HLA-matched or younger kidney donor within a reasonable duration, perhaps within 3–6 months (4.Bingaman AW Wright Jr, FH Kapturczak M Shen L Vick S Murphey CL. Single-center kidney paired donation: The Methodist San Antonio experience.Am J Transplant. 2012; 12: 2125-2132Crossref PubMed Scopus (72) Google Scholar). Simulations using a small registry (46 incompatible pairs [ICPs] and 11 fully HLA-mismatched CPs) suggested that the majority of fully HLA-mismatched CPs were able to find a better-matched donor (5.Ferrari P, Cantwell L, Ta J, Woodroffe C, D'Orsogna L, Holdsworth R. Providing better-matched donors for HLA mismatched compatible pairs through kidney paired donation. Transplantation 2016; doi: 10.1097/TP.0000000000001196 [Epub ahead of print].Google Scholar). CPs increase the number of ICPs being matched by up to 50% with no reduction in matches among highly sensitized ICPs. In larger registries, the expected match rates would be even higher (5.Ferrari P, Cantwell L, Ta J, Woodroffe C, D'Orsogna L, Holdsworth R. Providing better-matched donors for HLA mismatched compatible pairs through kidney paired donation. Transplantation 2016; doi: 10.1097/TP.0000000000001196 [Epub ahead of print].Google Scholar). The median waiting time in the National Kidney Registry (the largest paired exchange program in the United States) for CPs is 21 days and 174 days for pairs that are very hard to match. Over 90% of the CPs were more likely to consider KPD if financial reimbursement for participation or an advantage to the recipient (younger donor or better HLA match) were provided within a reasonable time period (6.Hendren E Gill J Landsberg D Dong J Rose C Gill JS. Willingness of directed living donors and their recipients to participate in kidney paired donation programs.Transplantation. 2015; 99: 1894-1899Crossref PubMed Scopus (17) Google Scholar). To conclude, we suggest (1) excluding ABO blood group A and B DRPs, as they have a relatively shorter wait time in KPD programs and (2) encouraging compatible, non-HLA-identical pairs greater than 45 years of age to consider entering KPD programs with the expectation of obtaining a kidney from a better-matched or younger donor within a reasonable period of time. The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.