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  • Patients with an ABO-incompatible potential living donor or a crossmatch-positive living donor have traditionally been relegated to waiting on the deceased donor list.

  • While desensitization is available for some ABO-incompatible patients and some crossmatch-positive patients, it comes at the price of an increase in immunosuppression and the risks of infection and malignancies.

  • Kidney-paired donation (KPD) obviates the need for this excess immunosuppression by providing the recipient with an ABO-compatible donor or a donor to which they are not crossmatch positive.

  • Even with a KPD, it is at times difficult to find matches for the extremely highly sensitized patients, those with 98–100% calculated Panel Reactive Antibodies (cPRA). These patients may benefit from the combined approach of desensitization and KPD.

  • Currently KPD transplants account for 1000 transplants per year, about 15% of all living transplants in the United States. It is not uncommon now even for compatible pairs to enter KPD if the recipient wishes to obtain a younger or better-matched kidney.

  • It is estimated that with a fully functional national KPD program, 3000 extra transplants would be facilitated per year.


  • The idea of KPD was first introduced in 1986 by Dr. Felix Rapaport of New York when he suggested an international exchange of kidneys.

  • The first KPD program was initiated in South Korea in 1991. It was a single-center program, computer matching was not used, and 129 transplants were facilitated over 11 years.

  • The first exchanges in the United States were performed in 2000 in New England and at Johns Hopkins University.

  • The Dutch KPD program was initiated in 2004 utilizing seven centers throughout the country. Computer matching was initiated, and match runs were performed every 3 months. The Dutch center performed 128 transplants over 5 years. The transplants occurred simultaneously, and the donor traveled to the recipient center.

  • In the United States the New England Program for Kidney Exchange (NEPKE) was founded in 2004, followed by the Paired Donation Network (PDN) and the Alliance for Paired Donation (APD). The first nonsimultaneous extended altruistic donor (NEAD) chain was performed by Dr. Michael Rees of APD in 2007. The chain was 10 transplants long and occurred over several months.

  • The National Kidney Registry (NKR) was formed in 2008 and facilitated over 500 transplants in its first 4 years utilizing nondirected altruistic donors (NDDs) to start chains of various lengths. By late 2021, NKR had facilitated over 4300 transplants. Next, the United Network for Organ Sharing (UNOS) KPD pilot program was initiated in 2010, incorporating many features of the other exchanges.


  • Incompatible pairs of patients are enrolled in a KPD registry. Chains can be simple two- or three-way exchanges or longer. A NDD often starts a KPD chain, which ends with a bridge donor at the end, who can start another chain (see Figure 43-1). This ...

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