Clinician-to-Clinician Update Clinician-to-Clinician Update

Improving Access to Transplant for Patients with Incompatible Donors

July 2017

Paired kidney exchange programs are bringing together pairs of patients and living donors, improving the odds of identifying compatible matches and achieving better outcomes.Kidney paired exchange programs are giving patients with renal failure and willing, but incompatible donors improved access to transplantation. First established in the United States in the 2000s, databases of incompatible pairs were created in the effort to find suitable matches for donor-recipient pairs. Before paired exchange programs, most patients with incompatible living donors could only opt to join the nation’s waiting list for organs from deceased donors. Each year, however, deceased-donor kidneys become available for less than one-fifth of waiting patients, and increased time spent on dialysis increases the rate of complications from kidney disease.1 Patients who receive kidneys from living donors experience better overall health outcomes and greater longevity than do those who receive kidneys from deceased donors.2 The chance that a living-donor kidney will fail 5 years after transplant is half that of deceased-donor kidneys.1

Donors undergo tissue typing, and recipients are tested for antibodies against human leukocyte antigens (HLA), and their compatibility is then evaluated. Antibodies may develop to HLA after exposure through blood transfusion, pregnancy, or a prior organ transplant and can make a recipient “sensitized.” Sensitized patients face increased difficulty in finding compatible donors. Highly sensitized patients can pursue desensitization therapy prior to transplant, but transplant outcomes are inferior to those achieved with the use of compatible donor organs.3

July-2017-SOT-Consult-Issue-Feature-Article-Main-Image-20170605 UofMfhs 010
— University of Minnesota Health transplant surgeons Timothy Pruett, MD, (at left) and Ty Dunn, MD, confer at the Clinics and Surgery Center. Both serve on the physician team in the kidney transplant program.

The National Kidney Registry, the largest paired exchange program in the United States, expands the pool of potential donors for transplant patients. Donor and recipient blood type, tissue type, age, and other factors are used in computer algorithms to identify matches, which are then reviewed by transplant specialists. In the simplest scenario, 2 recipients with incompatible donors could swap donors and each receive compatible kidney transplants. An altruistic, or nondirected, donor can activate a chain that helps many patients.4 More complex exchanges can link multiple patients across the country; the longest chain so far triggered 35 paired exchanges.5

University of Minnesota Health physicians pioneered the evaluation and care of altruistic living kidney donors, performed the transplant program's first anonymous living donor kidney transplantation in 1999, and continues to lead the nation in experience with this type of donor. A participant in the National Kidney Registry, Alliance for Paired Donation, and UNOS Kidney Paired Donation Programs, the University of Minnesota Health Incompatible Kidney Transplant Program is among the most active in the country,6 leveraging paired donation to make living donor kidney transplant a reality for over 80 patients to date. The program’s listing strategy has also improved the odds of finding compatible donors for even the hardest to match, which results in improved patient outcomes. Even with a high percentage of sensitized patients among the program’s transplant recipients and use of prednisone-free maintenance immunosuppression, the program reports a low 5% rate of antibody-mediated rejection. Almost half of the kidney transplants performed by University of Minnesota Health surgeons involve living donors, and at 1 year postprocedure, 100% percent of those patients are alive with a functioning transplant.7


  1. OPTN/SRTR 2012 Annual Data Report: Kidney. Retrieved June 13, 2017.
  2. Terasaki PI, Cecka JM, Gjertson DW, et al. High survival rates of kidney transplants from spousal and living unrelated donors. N Engl J Med. August 10, 1995;333:333-336.
  3. Bentall A, Cornell LD, Gloor JM, et al. Five-year outcomes in living donor kidney transplants with a positive crossmatch. Am J Transplant. 2013;13(1):76-85.
  4. Ferrari P, Weimar W, Johnson RJ, et al. Kidney paired donation: principles, protocols and programs. Nephrol Dial Transplant. 2015;30(8):1276-1285.
  5. Nichols, K. Paired exchange record: 70 people, 35 kidneys. (Harrisburg, PA, affiliate ABC News) March 30, 2015.
  6. National Kidney Registry. Paired Exchange Results Quarterly Report. March 31, 2017. Retrieved June 19, 2017.
  7. Scientific Registry of Transplant Recipients. Minneapolis, MN: Chronic Disease Research Group of the Minneapolis Medical Research Foundation, 2017.

When to refer

The University of Minnesota Health kidney transplant program is among the largest in the nation. Above the 75th percentile in program volumes and experienced in managing highly sensitized and surgically complex patients, our program enjoys better-than-expected, risk-adjusted outcomes. We work hard to help patients find a living kidney donor, with almost half of our kidney transplant patients receiving a living donor kidney, giving them the best chance for a good outcome. When patients with kidney failure have willing but incompatible donors, our Paired Exchange Program (PEP!) can help them find a compatible living donor because we participate in several large national kidney paired exchange programs. For patients who are especially difficult to match due to immunologic issues, we provide desensitization therapy that can reduce the chance of organ rejection.

Multidisciplinary, Collaborative Care

Our skilled transplant surgeons partner closely with the referring physician to give patients the best odds for recovery from kidney failure. As a team, we confer with nephrologists to determine exactly when transplant is required, which extends patients’ health and longevity before and after transplant. The clinic’s specialized transplant coordinators regularly communicate with referring physicians and their patients to arrange care and education before and after surgery. Our multidisciplinary kidney team carefully monitors each donor and patient for immunological and blood group compatibility. When the donor and recipient are a poor match, our transplant coordinators and physicians partner with patients to discuss alternative options, such as paired exchange and desensitization therapy.

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