Introduction: In a living donor kidney transplantation (LDKT) dominated transplant program, kidney exchange may be a cost-effective and valid alternative strategy to increase LDKT in countries with limited resources where deceased donation kidney transplantation (DDKT) is in the initial stages. There is a data scarcity of challenges and solutions for kidney exchange in the developing world. Here, we report our experience of 440 single-center kidney exchange transplantation to increase LDKT in India.

Methods: The study has been reviewed by the appropriate ethics committee and has therefore been performed in accordance with the ethical standards laid down in the Declaration of Helsinki as well as the Declaration of Istanbul. All donor-recipient pairs (DRP) gave their informed consent prior to their inclusion in the study. All pairs exchange kidneys of similar quality.

Results: Between January 2000 and February 2020, 6050 LDKT and 925 DDKT were performed at our single-center, 440 using kidney exchanges (8.5%) (350 male, 90 female recipients, and 345 female and 95 male donors). The reasons for joining kidney exchange among transplanted patients were ABO incompatibility (n = 313), sensitization (n = 88), and better HLA matching (n = 39). All donors were near relatives [wife (n=236), husband (n=58), mother (n=93), father (n=25), sister (n=11), brother (n=8), grand-parents (n=2), son (n=1) and others (n=6)]. There were 164 two-way (n =328), 23 three-way (n = 69), 4 four-way (n = 16), 1 five-way (n=5), 2 six-way and one ten-way kidney exchange (n = 12). The state of residence of DRP was our state (Gujarat=246), and other states (n=144). There was an overwhelming preponderance of female donors (wife and mother) but similar to our LDKT program. The graft survival, patient survival, biopsy-proven rejection rate, and graft function was similar to other LDKT outcomes. It is important to recognize that over the 20 years our kidney exchange program has evolved into a large, advanced program with innovative approaches to further increase LDKT. We credit the success of our kidney exchange program to maintaining a registry of incompatible pairs, counseling on kidney exchange, a high-volume LDKT program, and teamwork.

Conclusions: Kidney exchange is legal, cost-effective, and rapidly growing for facilitating LDKT with incompatible donors. This study provides large-scale evidence for the expansion of single-center LDKT via kidney exchange when national programs do not exist.