The Dutch living donor kidney exchange
Kidney transplantation is the best treatment option for patients with end-stage renal disease (ESRD). Patient survival and quality of life are better after transplantation than on dialysis. In most Western countries however, patients face waiting times up to 5 years before a deceased donor kidney is offered. The shortage of deceased organ donors has stimulated the use of kidneys from living donors. Apart from a shorter waiting time, living donor kidney transplantation also results in superior graft survival. However, kidney donation by a living donor is not always possible due to blood group incompatibility or / and the presence of antibodies against donor tissue in the recipient. A Living Donor Kidney Exchange Program can offer a solution for these unfortunate donor-recipient pairs. In an exchange program the donor of an ESRD patient A donates a kidney to patient B, while the donor of patient B simultaneously donates a kidney to patient A. In a more sophisticated form, even more than two couples can be involved in the exchange procedure.
The aim of the exchange program is to increase access of patients with renal failure to a transplant from a living donor. To realise this goal, the eight transplant centers in the Netherlands achieved, together with the Dutch Transplant Foundation (NTS), a cross over exchange program, based on mutual trust. All transplant centers agreed on a protocol which includes rules for donor screening, recipient donor pair registration, allocation and immunological, surgical and follow-up procedures. The donor travels to the recipient center and the surgical procedures are scheduled simultaneously. As the independent competent authority without direct patient care, the NTS received all relevant data of donor and recipient pairs and performs the actual matching in a fair and unbiased way. A central laboratory is responsible for the cross matches between newly coupled donors and recipients. It ensures that highly qualified experts perform all cross-matches in a certified laboratory and avoids sending blood samples to all participating centers.
The NTS runs a computer match procedure every three months. The computer match program is able to create match combinations up to four donor-recipient pairs. Couples are selected based on 6 pre-set criteria: maximum number of patients, blood type identity, difficulty to match, short chains, recipients spread over multiple centers, and waiting time on dialysis. From January 2004 till December 2014 685 donor-recipient pairs were registered. The median input of new pairs per year was 61 (49-77). In these 11 years of our living donor kidney exchange program 529/685 (77%) of the participating recipients underwent a transplantation Approximately half of them (263/529) received a kidney within the exchange program of which 55% were immunized patients. Of the 266 recipients transplanted outside the program, 90 were transplanted through the domino paired donation procedure in which an altruistic donor donates to the recipient of the unsuccessful donor-recipient pair and the donor in turn donates a kidney to the next compatible recipient on the deceased donor wait list. The innovative and successful Dutch Kidney Exchange Program has inspired many other countries to develop similar programs.