Kidney exchange transplantation current status, an update and future perspectives

Table 1 Types of kidney exchange

Simultaneous anonymous 2-way kidney exchange

3-way, 4-way, n-way exchange[13]

Compatible pair[14,21]

Non-simultaneous kidney exchange[16]

Non-simultaneous extended altruistic donor and domino[18]

Kidney exchange + desensitization therapy[15]

Kidney exchange + ABO incompatible transplant[18]

Acceptable mismatch transplant

Use of A2 donor to O patients[18]

Living donor-deceased donor list exchange[19]

National kidney exchange[20]

International kidney exchange[17]

Global kidney exchange[18]

Table 2 Key features of success in single center kidney exchange program in India

Education, awareness, counselling of about risk and benefits of available transplant options[11-23]
Kidney exchange registry of incompatible pairs
Dedicated transplant team to overcome logistic problems
Uniform evaluation, care and follow-up
Complete work up of pairs before allocation avoids chain collapse
Standardization of HLA laboratory
Robust Immunological evaluation prevents unequal outcome in pairs
Non-anonymous allocation increases trust between pairs and transplant team
Exchange kidney of similar quality
Bonus for difficult to match and better HLA matched pairs
Use of short (≤ 4-way exchange) vs long chain minimises logistic problems
Simultaneous surgeries avoid risk of donor reneging
Improve program using key features of other successful programs
Legal, ethical, fair, transparent, equitable and patient centric policy by Competent Authorities

HLA: Human leukocyte antigen.

Table 3 Key features of national kidney exchange program

Country[3-10]	Key features of kidney exchange program
Australia[3-4]	High transplant rate for highly sensitized, HLA-incompatible pairs due to accepting ABO-incompatible donor matching with ABO titers ≤ 1:64, high-resolution HLA identification and virtual cross match
Canada[5]	Non-directed anonymous donors facilitate 62% of transplants
South Korea	Favourable due to less sensitized, more compatible pairs, more non-directed anonymous donors, non-O > O patients
United Kingdom[8]	Low transplant rate due to less use of altruistic donor, restriction on long chain, permit only ≤ 3-way exchange, donor travel
Johns Hopkins University, United States	Kidney exchange + desensitization increases transplant rate for difficult to match and difficult to desensitize pairs
San Antonio, United States[10]	Use of compatible pairs and A2 donors increases transplant rate even in single canter program
National kidney registry, United States	Longer chain are used in matching
Donor vs kidney transport	Donors travel is preferred in Netherlands and Canada, kidney transport is preferred in United Kingdom and Australia
Alliance for paired donation, United States	Global kidney exchange

HLA: Human leukocyte antigen.

Table 4 Strength and weakness of international kidney exchange

Strength	Weakness
Increase access to better and effective health care of end stage renal disease patients for transplantation	Inequalities between donor recipient pairs from participating countries result from differences in regulatory, legal and reimbursement policy. Increase inequality and inequity in participating countries particularly for low/middle income countries
Quality of medical care increase from existing and participating National programs	Logistics are complex in immunological evaluation of pairs, management of clinical data and simultaneous surgery
Increase pool size, optimization and diversity of pairs increase quality of matching, number of transplants and increase transplant rate for difficult to match pairs who remain unmatched within their own country	Emerging less well established programs are likely to benefit less than well-funded established program. Limiting development of national program to become self-sufficient in organ donation and transplantation
Mutual learning between different National programs. Promote collaboration, best practice and spread of kidney exchange in interested countries	Adequate financial support for effective and equitable follow-up must be available in low/middle income countries
	Risk for donor recipient pairs with less adequate health care system to manage medical complications and long term follow up care
Facilitate legal, ethical expansion of kidney exchange program with International organ donation and transplantation community	Risks reducing the effectiveness and equity of existing well established program due to practical, logistical and organisational considerations associated with trans-national kidney exchange program
Dialysis is replaced with kidney exchange which is best and cost effective living donor kidney transplantation	Reputational risk and loss of public trust interest confidence in organ donation and transplantation if international kidney exchange involve Nations without appropriate legal and ethical policy to support best practice

Table 5 Advantages of global kidney exchange[50-53]

2-7 million people die World-wide from kidney failure due to poverty. Helping some of these poor patients would be good. GKE helps only those patients who have exhausted all the solutions in their home country and increases transplant opportunity for poor patients from low/middle income countries who are otherwise exposed to death[61-62]

GKE wants to support poor patients from low/middle income country legally, ethically, fairly and transparently following the rules established by the National Competent Authorities of each country

GKE does not induce donation but removes the financial barrier to donation for a willing donor recipient pairs where donor’s motivation is altruistic and unpaid

Everybody wins in GKE: Low/middle income country’s donor and recipient, low/middle income country’s pre-and post-transplantation health care system, high income country’s recipient, health care payers and high income country’s Government and taxpayers

GKE can send high income country patient to high quality low/middle income country transplant centers, instead of reverse. This would be less expensive and build local infrastructure in low/middle income country and access to kidney transplantation to more low/middle income country patients

There can be oversight by organizations such as the World Health Organization and the Transplantation Society with strong International governance that is consistent with the highest ethical and legal standards

GKE: Global kidney exchange.