Are Transplant Chains the Answer to Our Kidney Deficit?

Melissa Laracy, 2017 PharmD Candidate
Published Online: Thursday, August 18th, 2016
Today, 99,478 of the 120,001(83%) of patients on the organ transplant waiting list in the United States still await a kidney transplant.1
 
In 2015, US surgeons transplanted only 17,800 kidneys.2 More patients remain on the waiting list than those receiving a transplant, and approximately 15% of those on the waiting list will die waiting.
 
Finding ways to improve the number of organ donors would increase the size of the deceased donor pool. Targeting the living donor pool by increasing the length and number of kidney transplant chains is another option.
 
To start these chains, altruistic individuals donate kidneys to complete strangers. This sets off a domino reaction, in which recipients’ loved ones donate to others in gratitude.3 In recent years, these chains have gained momentum, changing many patients’ lives.4,5
 
Transplant Types
Kidneys can come from living or deceased donors. Kidney registries use living donors in 3ways (Table 18) and prefer them because of long-term results and lower risks of complications and rejection.6
 
Kidneys from live donors last twice as long as those from deceased donors.7 In addition, identifying a living donor significantly shortens wait times. Although recipients may wait on the deceased donor waiting list (DDWL) for more than 5 years, the average wait time for a living donor match from the National Kidney Registry (NKR) is 5 months.1,8
 
Table 1: Living Kidney Donation Types8
Type Description
Direct ·      Occurs when the donor knows the recipient, is a compatible match, and donates to that individual
Paired exchange ·      Occurs if a potential donor is not a match for his or her intended recipient; an alternative known as paired exchange donation is possible.
·      Donor #1 donates his or her kidney to another recipient who will provide a compatible donor for recipient #1
·      Two incompatible pairs are matched to allow 2 otherwise-impossible transplants to occur
Altruistic ·      Occurs when a donor gives a kidney to a stranger, initiating a chain
·      Synonymous terms include nondirected and Good Samaritan donation
 
Transplant Surgery
It’s a fairly straightforward procedure. For donors, the operation can be performed laparoscopically with small incisions, a camera, and instruments that remove the kidney.9 It only takes 2 to 3 hours and patients are usually discharged after 2 nights in the hospital.8 The donor’s remaining kidney performs the work that both kidneys had prior, with no long-term health consequences.6
 
For the recipient, the operation is usually 2 to 4 hours.9 Once the kidney is placed into the abdomen, the surgeon sews the donor kidney’s renal artery and vein to the recipient’s external iliac artery and vein, allowing blood to flow properly. Then, the surgeon connects the donor ureter to the recipient’s bladder, allowing urine to pass through the kidney.10 Hospital recovery time is usually around 3 to 7 days, during which time the health care team monitors for kidney function and graft rejection. Patients also begin a regimen of antirejection medications for life.9
 
Among organ transplants, kidney transplants have some of the highest success rates. Ninety-seven percent of transplanted kidneys function normally after one month, and 83% function normally 3 years post-transplant.
 
Matching for Transplants
Several blood tests ensure donor-recipient compatibility. The first is blood type (A, B, O, or AB positive or negative),9 which must be either identical or compatible. Blood type O-negative is the universal donor, so any patient can receive a kidney from an O-negative donor. AB-positive is the universal recipient, so patients with AB-positive blood can receive a kidney from anyone.
 
After blood type is matched, the pathology lab performs tissue typing by identifying human leukocyte antigens (genetic markers on cells) in blood samples.9 Transplants with the best and longest success rates have perfect matches for all 6 antigens, but some degree of mismatch is allowed.
 
The pathology lab also conducts percent reactive antibody tests to assure compatibility, evaluating the recipient for antibodies that may have formed from a previous exposure to antigens. The more antibodies present, the more difficult it is to find a match.
 
A serum crossmatch determines if the donor and recipient are compatible. Donor cells are incubated in the recipient’s serum and if the recipient has antibodies against the donor’s cells, those cells will be destroyed and it will be termed a positive crossmatch. If this happens, the individuals are incompatible and a transplant is impossible. If, however, a patient’s samples pass all of these tests, then the pair is a match and the transplant can occur.
 
The transplant team considers many factors during the match process. One-third of willing donors are incompatible with their intended recipients.10 Traditional paired kidney donation has the potential to leave many of these pairs unmatched.  Kidney chains can be a solution to this problem.11 Paired exchange and altruistic donation not only increase the size of the kidney donor pool, but also stimulate additional compatible matches.5


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