Global kidney exchange should expand wisely

Favorable Living Donor Kidney Transplantation Outcomes within a National Kidney Exchange Program: A Propensity Score-Matching Analysis

Key Points

KEP recipients have comparable long-term graft survival to direct living donor kidney transplantation recipients, which underscores the need to prioritize KEP over other's therapies. Our outcomes can be achieved regardless of whether the donor travels or the graft is transported, offering flexibility in program implementation.

Background

KEPs (kidney exchange programs) facilitate living donor kidney transplantations (LDKTs) for patients with incompatible donors, who are typically at higher risk than non-KEP patients because of higher sensitization and longer dialysis vintage. We conducted a comparative analysis of graft outcomes and risk factors for both KEP and non-KEP living donor kidney transplants.

Methods

All LDKTs performed in The Netherlands between 2004 and 2021 were included. The primary outcome measures were 1-, 5-, and 10-year death-censored graft survival. The secondary outcome measures were delayed graft function, graft function, rejection rates, and patient survival. We used a propensity score–matching model to account for differences at baseline.

Results

Of 7536 LDKTs, 694 (9%) were transplanted through the KEP. Ten-year graft survival was similar for KEP (0.916; 95% confidence interval, 0.894 to 0.939) and non-KEP (0.919; 0.912 to 0.926, P = 0.82). We found significant differences in 5-year rejection (12% versus 7%) and 5-year patient survival (KEP: 84%, non-KEP: 90%), which was nonsignificant after propensity score matching. Significant risk factors of lower graft survival included high donor age, retransplantations, extended dialysis vintage, higher panel reactive antibodies, and nephrotic syndrome as the cause of ESKD.

Conclusions

Transplantation through KEP offers a viable alternative for patients lacking compatible donors, avoiding specific and invasive pre- and post-transplant treatments. KEP's similar survival rate to non-KEPs suggests prioritizing KEP LDKTs over deceased donor kidney transplantation, desensitization, and dialysis. However, clinicians should consider the identified risk factors when planning and managing pre- and post-transplant care to enhance patient outcomes. Thus, we advocate for the broad adoption of KEP and establishment in regions lacking such programs, alongside initiation and expansion of international collaborations.

Kidney paired donation in developing countries: A global perspective

PURPOSE OF REVIEW

We review the key principles of kidney paired donation (KPD) and discuss the status and unique considerations for KPD in developing countries.

RECENT FINDINGS

Despite the advantages of KPD programs, they remain rare among developing nations, and the programs that exist have many differences with those of in developed countries. There is a paucity of literature and lack of published data on KPD from most of the developing nations. Expanding KPD programs may require the adoption of features and innovations of successful KPD programs. Cooperation with national and international societies should be encouraged to ensure endorsement and sharing of best practices.

SUMMARY

KPD is in the initial stages or has not yet started in the majority of the emerging nations. But the logistics and strategies required to implement KPD in developing nations differ from other parts of the world. By learning from the KPD experience in developing countries and adapting to their unique needs, it should be possible to expand access to KPD to allow more transplants to happen for patients in need world-wide.

The Impact of Cold Ischaemia Time on Outcomes of Living Donor Kidney Transplantation in the UK Living Kidney Sharing Scheme

OBJECTIVE

To assess the impact of CIT on living donor kidney transplantation (LDKT) outcomes in the UKLKSS versus outside the scheme.

BACKGROUND

LDKT provides the best treatment option for end-stage kidney disease patients. end-stage kidney disease patients with an incompatible living donor still have an opportunity to be transplanted through Kidney Exchange Programmes (KEP). In KEPs where kidneys travel rather than donors, cold ischaemia time (CIT) can be prolonged.

METHODS

Data from all UK adult LDKT between 2007 and 2018 were analysed.

RESULTS

9969 LDKT were performed during this period, of which 1396 (14%) were transplanted through the UKLKSS, which we refer to as KEP. Median CIT was significantly different for KEP versus non-KEP (339 versus 182 minutes, P < 0.001). KEP LDKT had a higher incidence of delayed graft function (DGF) (2.91% versus 5.73%, P < 0.0001), lower 1-year (estimated Glomerular Filtration Rate (eGFR) 57.90 versus 55.25 ml/min, P = 0.04) and 5-year graft function (eGFR 55.62 versus 53.09 ml/min, P = 0.01) compared to the non-KEP group, but 1- and 5-year graft survival were similar. Within KEP, a prolonged CIT was associated with more DGF (3.47% versus 1.95%, P = 0.03), and lower graft function at 1 and 5-years (eGFR = 55 vs 50 ml/min, P = 0.02), but had no impact on graft survival.

CONCLUSION

Whilst CIT was longer in KEP, associated with more DGF and lower graft function, excellent 5-year graft survival similar to non-KEP was found.

Global kidney chains

Kidney failure is among the leading causes of death worldwide, and the best treatment is transplantation. However, transplants are in short supply because of shortfalls of transplantable organs and of finances. In the United States and some other countries, kidney exchange chains have emerged as a way to increase the number of transplants; patients who have a willing donor but cannot receive that donor’s kidney can each receive a compatible kidney from another patient’s intended donor. Such programs are much better developed within the borders of wealthy countries, which is of little help to patients in countries with limited kidney transplantation or exchange. This paper proposes and analyzes a way to extend kidney exchange chains to share the benefits globally.

Kidney failure is a worldwide scourge, made more lethal by the shortage of transplants. We propose a way to organize kidney exchange chains internationally between middle-income countries with financial barriers to transplantation and high-income countries with many hard to match patients and patient–donor pairs facing lengthy dialysis. The proposal involves chains of exchange that begin in the middle-income country and end in the high-income country. We also propose a way of financing such chains using savings to US health care payers.

Popular repugnance contrasts with legal bans on controversial markets

We study popular attitudes in Germany, Spain, the Philippines, and the United States toward three controversial markets-prostitution, surrogacy, and global kidney exchange (GKE). Of those markets, only prostitution is banned in the United States and the Philippines, and only prostitution is allowed in Germany and Spain. Unlike prostitution, majorities support legalization of surrogacy and GKE in all four countries. So, there is not a simple relation between public support for markets, or bans, and their legal and regulatory status. Because both markets and bans on markets require social support to work well, this sheds light on the prospects for effective regulation of controversial markets.