The first 52 global kidney exchange transplants: overcoming multiple barriers to transplantation
Michael Rees1,2, Alvin E. Roth3, Ignazio Marino4, Kimberly Krawiak5, Susan Rees1, Krista Sweeeney1, Ty Dunn6, Jeff Punch7, Michael Zimmerman8, Feroz Aziz24, Ali Abdul Kareem Al Obaidli1, Itai Ashlagi, Vaughn Whittaker, Aparna Rege, Rachel Forbes, Christian Kuhr, Ricardo Correa-Rotter, Citterio Franco, Obi Okwenna, Siegfredo Paloyo, Randall Sung, Joseph Leventhall, Eytan Mor, Jeffery Rogers, Miguel Tan, Laura Basagoitia, Matthew Ellis, Siddiq Anwar, Jacopo Romagnoli.
1The Alliance for Paired Kidney Donation, Toledo, OH, United States; 2Urology, University of Toledo, Toledo, OH, United States; 3Economics, Stanford University, Palo Alto, CA, United States; 4Thomas Jefferson University, Philadelphia, PA, United States; 5Law School, University of Virginia, Charlottesville, VA, United States; 6Surgery, University of Pennsylvania, Philadelphia, PA, United States; 7Surgery, University of Michigan, Ann Arbor, MI, United States; 8Surgery, University of Utah, Salt Lake City, UT, United States; 9Nephrology, Seha Kidney Care, Abu Dhabi, United Arab Emirates; 10Surgery, New York VA Hospital, New York, NY, United States; 11Surgery, Duke University, Durham, NC, United States; 12Nephrology, Duke University, Durham, NC, United States; 13Surgery, Vanderbilt University, Nashville, TN, United States; 14Urology, Virginia Mason, Seattle, WA, United States; 15Nephrology, Nutricion Hospital, Mexico City, , Mexico; 16Surgery, Catholic University Gemelli Hospital, Rome, Italy; 17Surgery, Philippine General Hospital, Manilla, Philippines; 18Surgery, Northwestern University, Chicago, IL, United States; 19Surgery, Sheba Medical Center, Tel Aviv, Israel; 20Surgery, Piedmont Hospital, Atlanta, Georgia; 21Nephrology, Pro Renal, Mexico City, , Mexico; 22Nephrology, Sheikh Shakbout Medical City, Abu Dhabi, United Arab Emirates; 23Engineering, Stanford University, Palo Alto, CA, United States; 24Nephrology, Aster, Kerala, India
Introduction: Many barriers currently stand in the way of achieving international kidney exchange including: financial, regulatory, logistical, cultural, immunological and legal barriers.
Methods: The Alliance for Paired Kidney Donation serves patients in 15 countries. Ten of these countries have participated in Global Kidney Exchange (GKE) transplants in which either living donors, their kidneys or recipients have traveled internationally to achieve successful living donor kidney transplantation (LDKT). In all cases, barriers were present that prevented LKDT in the donor or recipient country of origin.
Results: Between January of 2015 and February of 2022, GKE has produced 11 chains and 4 cycles that has provided LDKT for 17 international patients from 10 countries to be transplanted, as well as 35 LDKT for patients in the United States (US). GKE chains lengths have ranged from 1 to 11; cycles were length 2 or 3. Eight GKE transplants overcame immunologic barriers, 4 financial barriers, and 5 both immunologic and financial barriers. GKE has involved 19 US transplant centers across 18 states and 38% of recipients were minorities. For US recipients 11% had blood type (BT)-A, 57% BT-0, 17% BT-B, and 14% BT-AB; for international recipients 41% had BT-A, 53% BT-O and 6% BT-B. The PRA was 0-20% for 23 patients, 21-79% for 14 and > 80% for 15 (10 international). International pairs were funded by a combination of self-pay, insurance and philanthropy. Transplanting 35 US patients saved US healthcare payers $7-10M vs. dialysis. International recipients have 100% 3-year patient and graft survival and all international donors are alive and have normal creatinine and blood pressure.
Conclusion: GKE overcomes financial and immunological barriers to transplantation. Savings from avoided dialysis offers scalability. Our program ensures transparency of international pair selection, emphasis on donor safety, and assurance of longterm immunosuppression for recipients as prerequisites for sustainability.
