Kidney Transplant Exchanges Paired Donation and Chains

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Kidney Transplant ExchangesPaired Donation and
Chains

• Jeffrey L. Veale, MD
• Director, Donor Exchange Program

David Geffen School of Medicine at UCLA
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The Problem

• 70,000 people awaiting kidney transplants
• 13,000 transplants performed yearly
• List continues to expand secondary to obesity,
  diabetes and old age

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Options to Expand the Donor Pool

• Xenotransplantation
• Paying donors
• Lowering the bar
• Accepting more marginal kidneys ECD, DCD
• Utilizing incompatible donors

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Utilizing Incompatible Donors

• At least one third of patients with a willing
  living donor are excluded due to blood type and
  cross match incompatibility
• JAMA 2005 293 1883-1890
• 35 of any two individuals will be ABO
  incompatible
• 30 of recipients sensitized to allo-HLA due to
  previous transplants, pregnancies or transfusions

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Options

• Desensitization Program
• Paired SWAP Donation
• Chains
• Combination (of the above)

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Desensitization Programs

• Advantages
• Expands the donor pool
• Friend/loved one donates to intended recipient
• Disadvantages
• Average cost of desensitization 28 979
• JAMA 2005 293 1883-1890
• Unpredictable rate of accelerated rejection
• AJT 2004 4 1628-1634
• Decreased patient survival rates (5yr 87 vs
  94)
• AJT 2004 4 1089-1096
• Decreased graft survival rates (1yr 84 vs 96)
• AJT 2004 4 1089-1096
• Decreased 5 yr graft survival rates (69 vs 81
• AJT 2009 9 536-542 4 1089-1096

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Paired SWAP Donation

• First U.S. exchange performed under little
  publicity in 2000 at Rhode Island Hospital
• Slow to catch-on due to NOTA 1984 unlawful to
  acquire organ in exchange for valuable
  consideration
• Johns Hopkins and University of Cincinnati early
  pioneers
• 2007 Senator Specters bill valuable
  consideration does not apply to paired donation
• Opened the door for UNOS and individual centers
  to develop donor exchange programs

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LAs First Paired SWAP Donation

• .

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Paired SWAP Donation

• Advantages
• Expands the donor pool
• Greater sense of satisfaction by helping 2 people
• Disadvantages
• Donors anesthetized simultaneously
• Donors typically travel
• Challenging logistics
• Multiple operating rooms, surgeons, nurses
• Compared to chain transplantations
• Decreased quantity of matches
• Decreased quality of matches

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Chains

• Concept first proposed by Dr. Michael Rees, a
  Urologist at the University of Toledo
• First chain launched in July 2007 and thus far
  has facilitated 10 transplantations involving six
  transplant centers in five different states
• NEJM 2009 360 1096-1101

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First Transcontinental Chain
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Chains

• Advantages
• Potential for the largest expansion of the donor
  pool since the landmark brain death act in 1981
  (UDDA)
• Great sense of satisfaction by helping multiple
  people
• including patients who move into the vacated
  waiting list spots
• Donors dont need to be anesthetized
  simultaneously, therefore easier logistics
• West Coast Chain 16 operations at 4 centers
• Donors dont need to travel
• If donor fails to donate, chain ends but no
  irreparable harm to recipient

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Chains

• Other advantages
• Increased quantity and quality of matches when
  compared to Paired SWAP donation

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Chain

• Disadvantages
• Donate to a stranger instead of your loved one
• Some would argue an advantage, as greater
  emotional reward knowing multiple families
  benefited from donation
• Billing
• Much easier thanks to Debbie Mast (Stanford) and
  Nanci Flores (UCLA)

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Software-Matching Options

• Johns Hopkins
• New England Program for Kidney Exchange (NEPKE)
• Paired Donation Network (PDN)
• Alliance For Paired Donation (APD)
• Silverstone Solutions-Matchmaker
• National Kidney Registry (NKR)

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National Kidney Registry

• One of only two chain matching programs available
• Only pure chain matching program
• No cost
• 23 Centers
• Superior matching software causing some centers
  to join after being involved in other matching
  programs
• California members include
• CPMC, Loma Linda, Stanford, UCLA, UCSF
• Aetna2,500 patients on deceased donor waiting
  list
• In only 13 months facilitated 33 transplantations
• www.kidneyregistry.org Phone [phone]

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UNOS

• Fabulous when UNOS adopts exchange system
• Numerous examples why
• Kidney Paired Donation Pilot Program
• April Plan to finalize the proposal, likely only
  3 centers involved
• June Public comment
• Earliest implementation in late 2010
• Proposed matching software is from Johns Hopkins

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UNOS

• Difficulties adopting exchange system
• Problems with current database/computer system
• Large corporation takes time to move
• Committees unable to meet frequently, policy
  takes time
• Donor exchanges evolving rapidly
• Paired donations Multiple SWAPs Dominos
  Chains
• Remain focused on Paired Donation
• Anesthetized simultaneously
• Prefer donor travel to recipients hospital
• Complex Logistics
• Older software

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Los Angeles Transplant Programs

• Huge Potential
• Large pool (donation service area)
• 12 transplant centers in close proximity
• Cooperative environment
• One Legacy Support
• Experience with shipping living donor organs
• Potential to pioneer and set national standards
  for
• Mending broken chains with deceased donor kidneys
• Initiating chains with deceased donor kidneys

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First Steps for LA Transplant Programs

• 1.
• 2. Cooperation rather than competition between
  centers
• 3. Become comfortable with shipping living donor
  organs

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One Legacy Guidelines

• Recently passed by the Kidney/Pancreas Committee
  and Advisory Board
• Well-written advice for transplant programs
• How to begin?
• Finding a match
• One Legacy packaging and shipment
• Billing
• For more information contact Esther-Marie
  Carmichael or Miryam Mehra at One Legacy

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A New Paradigm

• At least one third of patients with a willing
  living donor are excluded due to blood type and
  cross match incompatibility
• Huge potential to expand the donor pool, rather
  than merely lowering the bar and accepting more
  organs of uncertain caliber (ECD, DCD)

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• When will the transplant societies, government
  agencies or society as a whole realize that we
  are mired in old paradigms. Attitudinal changes
  must take place to truly increase donation of
  high quality organs to make an impact on those
  dying on the waiting list
• Bromberg and Halloran (AJT 2009 9 11-13)

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Kidney Transplant ExchangesPaired Donation and
Chains

• Jeffrey L. Veale, MD
• Director, Donor Exchange Program

David Geffen School of Medicine at UCLA