Photo Credit: VectorMine

Patients who underwent living donor kidney transplantation via a kidney exchange program had graft survival similar to patients with direct living donors.

Patients who underwent living donor kidney transplantation (LDKT) via a kidney exchange program (KEP) had similar long-term graft survival as patients who received kidneys from direct living donors (non-KEP), according to study results published in the Clinical Journal of the American Society of Nephrology.

“Transplantation via KEP offers a viable alternative for patients lacking compatible donors, avoiding specific and invasive pre- and post-transplant treatments,” researchers wrote. “KEP’s similar survival rate to non-KEP suggests prioritizing KEP LDKT over deceased donor kidney transplantation, desensitization, and dialysis.”

The finding stemmed from an analysis of graft outcomes for patients who underwent LDKT through a KEP compared with those who did so through direct donors. The analysis included 7536 LDKTs between 2004 and 2021. Among them, 9%, or 694 LDKTs, were facilitated through a KEP.

Graft Survival & Function

The study team observed similar 10-year death-censored graft survival for KEP (0.916 survival probability) and non-KEP (0.919 survival probability) LDKTs. They found differences in rates of 5-year rejection (12% for KEP vs 7% for non-KEP) and patient survival (84% for KEP vs 90% for non-KEP), but the significance disappeared in propensity-score matched cohorts.

Risk factors for a lower likelihood of graft survival included donor age older than 60, re-transplantations, extended dialysis vintage, higher panel reactive antibodies, and nephrotic syndrome as the cause of end-stage kidney disease.

The study found that delayed graft function affected 13% of KEP patients compared with 6% of non-KEP patients in the propensity-score matched cohort. Risk factors included older donor age, donor obesity, dialysis vintage, and recipients transplanted via KEP.

Implications for Clinical Practice

Noting the superior outcomes with KEPs compared with published outcomes for deceased donor kidney transplantation, transplantation after desensitization, and dialysis, researchers proposed a sequential approach for patients with end-stage kidney disease.

They advised seeking a compatible living donor for direct LDKT first. If a living donor cannot be found, they recommended KEP enrollment. If a KEP is not feasible, desensitization transplantation should be pursued, followed by deceased donor kidney transplantation if other options fail. Maintenance dialysis should be the last resort, per the approach.

“Thus, we advocate for the broad adoption of KEP and establishment in regions lacking such programs,” they wrote, “alongside initiation and expansion of international collaborations.”