Facilitating More Transplants with Kidney Exchanges and Chains

By Stuart Flechner, MD

It took 26 hospitals and 2.5 months. But as of March 26, 2015, 35 people received kidneys from 35 donors in the largest kidney transplant chain to date in the United States. Cleveland Clinic surgeons removed or transplanted kidneys for four of the 70 participants.

A member center of the National Kidney Registry (NKR) since 2011, Cleveland Clinic has successfully transplanted 34 kidney recipients (and counting) through an NKR paired exchange or chain.

Trading for more compatible kidneys

The NKR helps those waiting for a transplant swap a kidney from their willing but less compatible donor for a more compatible kidney from another donor. The less compatible kidney is then used to transplant a better matching recipient elsewhere. The exchange is a win for everyone.

Participants most often trade kidneys in pairs. However, occasionally, an altruistic (or non-directed) donor will set off a cascade of transplants, with each recipient required to have a partner donor willing to “pay it forward” by contributing a kidney to the chain.

Better matches mean better outcomes

Potential kidney recipients who register with the NKR through a member center have a better chance of finding a compatible donor more quickly. The more precise the HLA antigen match, the more likely the success of the graft.

Better donor-recipient matches have contributed to these improved outcomes reported by the NKR:

• NKR graft survival (98 percent at one year; 93.2 percent at three years) exceeds that of other U.S. living donor transplants (97 percent at one year; 91.7 percent at three years).
• NKR patient survival (99.2 percent at one year; 97.2 percent at three years) exceeds that of other U.S. living donor transplants (98.5 percent at one year; 96.5 percent at three years).

How kidney exchange works at a top NKR center

Cleveland Clinic is one of the top centers for transplants through the NKR, with 10 transplants in 2014 (six already in 2015). We were also one of the most successful centers in 2014, with 100 percent of NKR patients matched and transplanted. That achievement is partly due to careful selection of both donors and recipients who are ready for immediate transplant.

At Cleveland Clinic:

• Our transplant selection committee vets each donor and recipient. We ensure they are well informed of the process so there are no late dropouts. We keep their transplant evaluations updated at all times.
• We enter medical information for each donor-recipient pair on the NKR website. When matches are made, we thoroughly review the other pair’s medical records and exchange blood samples for donor crossmatching.
• All transplants performed in 2014 were ABO compatible, and all recipients had a negative crossmatch with their donor. It’s only in extreme situations that we ever accommodate weak incompatibilities.

Through our living donor evaluation process, if we identify someone willing to start a chain by becoming an altruistic donor, we enter them individually on the NKR website. One altruistic donor can trigger from two to more than 30 transplants around the nation. In trade, at the end of the chain, we receive a donor kidney back for one of our patients.

Paired exchange: helping more people

More NKR paired exchanges will increase the percentage of living donor transplants, which have significantly higher success rates than deceased donor transplants. In addition, finding a living donor can shorten a patient’s time on the wait list. (Average wait time for a deceased donor kidney is currently three to five years.) Receiving a kidney from a living donor also frees deceased donor kidneys for others, making the wait list move faster.

At Cleveland Clinic, we immediately introduce NKR paired exchange when evaluating new patients and donors for kidney transplant. Almost any live donor-recipient pair should seek out paired exchange if they are incompatible (or only moderately compatible) but otherwise viable candidates for transplant.

The NKR’s paired exchange program helps unlock incompatibilities in other pairs and ultimately helps many patients. It’s a community effort. Also, any altruistic donor should consider starting a chain through the NKR in order to help as many patients as possible and expand the impact of his or her gift.

Dr. Flechner is a professor of surgery in the Kidney Transplant Program at Cleveland Clinic’s Glickman Urological & Kidney Institute.