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

Paired Exchange Program Unites Kidney Donors and Recipients

July 2017

Contributed by Ty B. Dunn, MD

Human leukocyte antigen (HLA) antibody testing uncovers a patient’s reactivity to a donor kidney and is used to minimize the risk of rejection and to improve outcomes of transplantation. Current immunoassays used for pretransplant testing have improved sensitivity and specificity over older methods.1 In this case, a young patient is identified as having become sensitized to a previously compatible donor. Participation in a paired exchange program locates a living donor for this patient and another patient awaiting kidney transplant.

Patients

A male patient in his 70s with renal failure was referred for evaluation to the University of Minnesota Health Solid Organ Transplant Clinic to be considered for kidney transplant. He was scheduled to start dialysis for chronic kidney disease. A female donor had volunteered to donate 1 of her kidneys to the patient; however, her blood type was incompatible, making her unsuitable for donation directly to him. He was listed for a deceased donor transplant, with a wait time estimated at 3–5 years.

A woman had been previously approved for direct kidney donation to a young man. She was blood type O (universal donor). He received a blood transfusion and developed strong antibodies against her tissue type, which resulted in them becoming an incompatible pair. While other donors were being evaluated for this now hard-to-match young man, he was listed for a deceased donor transplant, with a wait time estimated at 5 years.

July-2017-SOT-Consult-Issue-Case-Study-KidneyCrosssection
— Cross section illustration of kidneys. Pixologicstudio ©iStock

Management

The donors and recipients had been previously educated about the short- and long-term health benefits of living donor kidney transplant. Each donor-recipient pair was interested in finding a path to living donation and transplant. Each recipient had no other available living donors, and the donor and recipient agreed to enroll in the M Health Paired Exchange Program (PEP!). The program includes donors and recipient pairs who are willing to exchange kidneys with other pairs once a match is found. The program participates in several national kidney paired exchange programs because a large pool of donors increases the likelihood of finding a match.

The female with blood type O was identified as a match to the older male recipient. His blood-type incompatible donor was a tissue- and blood-type match for the young man. The pairs were strangers to each other, but agreed to the exchange. Both donors had surgery simultaneously, and their kidneys were transplanted into the compatible recipients on the same day. Recipients achieved timely living donor kidney transplants and avoided further dialysis. Their original donors made living donor kidney transplantation possible for them, even though they were not a match.

Discussion

It is uncommon to find a compatible match between 2 donor-recipient pairs at a single hospital.2 Nevertheless, patients who can receive kidneys from living donors enjoy the best outcomes.3 In this case, blood- and tissue-type incompatibility were resolved when donors agreed to exchange organ recipients. The donors and recipients each had uneventful recoveries and are all doing well.


References

  1. Konvalinka A and Tinckam K. Utility of HLA antibody testing in kidney transplantation. JASN. 2015;26(7):1489-1502.
  2. Glorie K, Haase-Kromwijk B, van de Klundert J, et al. Allocation and matching in kidney exchange programs. Transpl Int.. 2014;27(4):333-43.
  3. 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.
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