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It shows that donor renege is rare and is not significant problem in modern kidney exchange practice. There is disparity on standard practice of kidney exchange in developed and developing World in term of non- anonymity. There is variable practice on anonymity before and after surgery in different countries.

Conditional approach[ 38 ]: When the donor-recipient pairs give consent for meeting after surgery, they are allowed to meet each other after surgery in some countries such as the United States of America[ 39 ] and the United Kingdom[ 40 ].

Nature Reviews Nephrology

In other countries, such as the Netherlands and Sweden[ 41 ], anonymity is absolute. Pronk et al[ 38 ] showed that most donor-recipient pairs who participated in anonymous donation process are in favour of a conditional approach to anonymity. Guidelines on how to revoke anonymity if both parties agree are needed and should include education about pros and cons of non- anonymity and a logistical plan on how, when, where, and by whom anonymity should be revoked.

Non-anonymous allocation[ 11 , 12 ]: Donor-recipient pairs are allowed to meet each other before allocation of donor for surgery and even after surgery. They can share medical reports of exchange donors before surgery and kidney transplant and donor surgery outcome after surgery.

Donor-recipient pairs do not choose their match but donor-recipient pairs may decline a match or can withdraw from participation in the kidney exchange program at any time, for any reason. Non-anonymous allocation has the potential of commercialization of organs in case of compatible donor-recipient pairs along with breach in privacy of donor-recipient pairs. Kute et al[ 11 , 12 ] reported that donor-recipient pairs are willing for non-anonymous allocation process in single center study of kidney exchange transplants in India. More long term prospective studies are required to explore the donor and recipient perspective on anonymity in living kidney donation in different socio-economic regions and countries.

The cold ischemia time is more detrimental in deceased donor kidney transplant than live donor kidney transplant. There is no statistically significant difference in live donor kidney transplant survival in shipped vs non-shipped kidney in data from various National registries Scientific Registry of Transplant Recipients registry in the United States, National Kidney Registry in the United States, and Australian kidney paired donation program. This is feasible strategy to improve the quality of matching such as HLA matching in kidney exchange program.

However, more studies are required to define long term safety of shipping donor kidneys and willingness of donor-recipient pairs to participate in donor travel vs kidney transport. In Canada with wide geographic distribution, donor travel is accepted and preferred over kidney transport whereas, in Australia kidney transport is accepted and preferred over donor travel.

Advantages of kidney transport are familiarity with the transplant team, presence of family and friends for logistical support. Disadvantage of kidney transport is the effect of prolong cold ischemia time on long term kidney allograft survival. Cold ischemia time is short in kidney exchange programs where donor travel is used. The Global Positioning System tracking devices can be used to monitor the location of shipped kidneys.


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Donor-recipient pairs should discuss the best option with the transplant team as per available resources. The participating transplant teams should make the decision by consensus about kidney donor travel vs kidney transport as per local resources and logistics. Donor travel rather than kidney transport is likely to be logistically simpler to execute in the Indian situation. Variations in practice for management of incompatible donor-recipient pairs will inevitably occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to a clinical situation.

There is need of clinical practice guideline document to be designed to provide information and assist decision-making in relation to kidney exchange vs desensitization. Each donor-recipient pairs should be given education, awareness, and counselling about risk, benefits and cost effectiveness of various renal replacement therapy options ABO incompatible kidney transplantation vs kidney exchange, deceased donor kidney transplantation and dialysis in an easy to understand format as early as possible in process of chronic kidney disease evaluation, treatment and transplant evaluation.

This counselling can be performed by member of transplant team during dialysis sessions.

Patients were encouraged for living donor kidney transplantation over deceased donor kidney transplantation. Patients with incompatible living donors should be encouraged for kidney exchange and ABO incompatible kidney transplantation depending on their phenotype. Infection is common cause of morbidity and mortality after kidney transplantation in developing world compared to developed world. Such easy to match pairs non-O group patients such as A donor and B recipient; B donor and A recipient and sensitised pairs should be encouraged for kidney exchange over ABO incompatible kidney transplantation and desensitization protocol[ 11 , 12 , 49 ].

If no match is found with kidney exchange in a reasonable period of time they can be undergo ABO incompatible kidney transplantation with equally good results but with greater number of treatments and cost.

Kidney transplantation: New strategies for longer organ preservation

For sensitized donor-recipient pairs with phenotypes that are both difficult-to-desensitize and difficult-to-match may benefit from a combination of kidney exchange and desensitization in which they are paired with a more immunologically suitable donor[ 49 ]. This will reduce waiting time for deceased donor kidney transplantation for patients with no living kidney donor. ABO incompatible kidney transplantation should continue to function in a complimentary way that enhances access to living donor kidney transplantation rather than competes with kidney exchange.

ABO incompatible kidney transplantation should be performed after obtaining written informed consent of donor-recipient pairs. Patients with economic constrains; pre-transplant infections and baseline high ABO titer may be excluded from ABO incompatible kidney transplantation.

Getting a kidney transplant: What you need to know

Figure 1 shows Stepwise Progress in Kidney Exchange. Financial incompatibility is much more common barrier to kidney transplantation than immunological incompatibility in developing countries in absence of universal access to health care for end-stage renal disease. Global kidney exchange increases access to living donor kidney transplantation for donor-recipient pairs from developing countries with financial incompatibility[ 50 , 51 ]. Global kidney exchange should be conducted in legal, transparent and an ethical way. Global kidney exchange will help rich donor-recipient pairs from developed countries with universal access to health care for end-stage renal disease and poor donor-recipient pairs from developing countries in absence of universal access to health care for end-stage renal disease.

It should run in a way that enhances access to living donor kidney transplantation with kidney exchange along with national and regional KPD program. The collaboration of single center, regional, National, International and Global kidney exchange program should aim to provide cost effective kidney transplantation with better long term outcome for all patients with end-stage renal disease. We believe that single center, regional, National kidney exchange program should be attempted before International and Global kidney exchange program to overcome transcultural and logistical issues with the later[ 52 , 53 ].

In addition, more studies are required for the definition of financial incompatibility and about willingness and feasibility of donor-recipient pairs from developing countries for International and Global kidney exchange program. Clearly, the heterogeneity in antigen-antibody profile of donor-recipient pairs from developing countries and developed countries increase access to living donor kidney transplantation for difficult to match and highly sensitised donor-recipient pairs.

The larger donor pool in International kidney exchange will increase HLA matching of donor-recipient pairs which is the best parameter to improve long- term kidney graft survival. Global kidney exchange appears to provide life-saving kidney transplantation to poor donor-recipient pairs from developing countries that otherwise could die due to economic constrain[ 50 - 53 ].


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An exchange donor program for adult living donor liver transplantation appears to be a feasible modality for overcoming donor-recipient ABO incompatibility[ 54 - 56 ]. Opportunity and necessity is the mother of invention. Suppose, there are two patients in developing countries with end stage kidney disease and end stage liver disease with no suitable living donors in family in area without deceased donor organ transplantation.

The morbidity and mortality of end stage kidney disease and end stage liver disease is very high in developing countries in absence of national health care insurance, deceased donor organ transplantation program and economic constrains. The organ trafficking is regularly reported in media in underdeveloped World. There is no other outcome for these patients other than death if they did not undergo organ transplantation. The life of these patients can be saved by exchanging liver of patient with end stage kidney disease with kidney of patient with end stage liver disease with optimum patient care before organ harvesting.

There is no better solution for such kind of patients other than exchange of organs liver vs kidney. The patient who participate in such exchange should be medically, psychosocially suitable, fully informed of the risks and benefits as a donor, competent, willing to donate and free of coercion. Let us be clear: The intention of such kind of exchange is to save human life and without exchange of organs liver vs kidney such patients will never going to receive organ transplantation. No alternative existed for such patients and millions more like them.

Such organ exchange even if inequitable would able to add years of life to patients who would have died without it. The mortality rate is at least 10 times higher in living donor liver donation with mortality rate of 0. There is regeneration of liver and not kidney in short period. The health care providers from developing and developed World including policy makers should come together to discuss challenges and solution to solve the disparity in access to organ transplantation in developing and developed World. This will be great service to mankind who are in real need. This could be an alternative to xenotransplantation and may serve as Nobel service to Mankind.

Kidney exchange transplantation has increased living donor kidney transplantation for end stage renal disease patients with chronological incompatibility and financial incompatibility. There is need of uniform algorithm for management of incompatible donor-recipient pairs. Advanced Search. This Article. Academic Rules and Norms of This Article.


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Citation of this article. Kidney exchange transplantation current status, an update and future perspectives. Corresponding Author of This Article. Jun 4, ].

Kidney transplant: New opportunities and challenges | Cleveland Clinic Journal of Medicine

L, Plaza JJ, et al. Long-term graft function changes in kidney transplant recipients. NDT Plus ;3 suppl 2 :ii2-ii8.

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