Kidney Paired Donation

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Kidney Paired Donation
Michael A. Rees, M.D., Ph.D.
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Ohio Solid Organ Transplantation Consortium
OSOTC - Audrey B. Bohnengel, Ph.D. Childrens
Hospital Cincinnati - Maria H. Alonso,
M.D. Cleveland Clinic - David Goldfarb,
M.D. Ohio State University - Mitchell L. Henry,
M.D. Miami Valley Hospital - Scott Johnson,
M.D. University Hospital Cleveland - Mark
Aeder, M.D. University of Cincinnati - E. Steve
Woodle, M.D. Akron City Hospital (Summa) -
Tanmay Lal, M.D. Anchor Enterprises - Alan
Rees University of Cincinnati - Johnathan Kopke
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Other Contributors
Harvard - Alvin Roth, Ph.D. Boston College -
Tayfun Sönmez, Ph.D. University of Pittsburgh -
Utku Ünver, Ph.D. Carnegie Mellon University -
Tuomas Sandholm, Ph.D. Carnegie Mellon University
David Abraham, B.S. Johns Hopkins University -
Robert Montgomery, M.D, D. Phil. Johns Hopkins
University - Dorry Segev, M.D. Johns Hopkins
University - Sommer Gentry, Ph.D. Columbia
University - Lloyd Ratner, M.D. Massachusetts
General Hospital - Frank Delmonico,
M.D. University of North Carolina - Ken
Andreoni, M.D.
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A Kidney Paired Donation
Donor A
Recipient A
X
Donor B
Recipient B
X
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A Paired Kidney Donation
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Strategy

• 100 donor - recipient pairs generates
• 4,950 potential paired exchanges.

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Potential Donations n(n-1)/2
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Number of Pairs Required
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Registrations per prior LRDs
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Point System
Category
Points
1. Wait time 2. Distance 3. Recipient vs. Donor
Age Disparity 4. Donor vs. Donor Age
Disparity 5. HLA Match 6. Pediatric Bonus 7. PRA
Bonus 8. CMV/EBV Bonus 9. Blood Group A/B Bonus
3 5/2 3 2 6/2 6 6 2/2 6
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Data Entry Screens
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Medical Reviewer Screens
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All medically feasible matches from 41 pairs
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Optimizing matching of 8 pairs
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Number of transplants versus quality of the match
4 matches - 50 points
3 matches - 60 points
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2-way Solution
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3-way Solution
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4-way Solution
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Multiple Approach Solution
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Overall Crossmatches to perform
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With 3 x-matches positive
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All but one 2-way match lost
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Results to Date

• The Alliance for Paired Donation incorporated
  in August 2006 and began enrolling transplant
  centers in October 2006.
• Currently over 70 transplant programs in 24
  states participate and over 30 more are
  considering partnering with the APD.
• Since March 2007, the APD has performed 32
  paired donation transplants with 2 more
  scheduled.
• In the January match run there were 145 pairs
  and we have found potential matches for 22
  patients involving 12 transplant centers.

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Results to Date

• Registered pairs ABOi 60 , 40 crossmatch
  incompatible.
• Registered candidates PRA 80-100 in 36,
  10-79 in 32 and lt10 in 29
• First 32 transplant recipients PRA 80-100 in
  22, 50-79 in 19, 25-49 in 22 and lt25 in
  38.
• Overall, 41 of the transplanted recipients had
  a PRA gt 50.
• Registered candidates blood type O in 53, A
  in 25 , B in 18 and AB in 4.
• First 32 transplant recipients blood type O in
  38, A in 41 , B in 19 and AB in 3.
• Donor blood type was O in 38, A in 41, B in
  14 and AB in 8 of the first 32 donors.

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The Never-Ending Altruistic Donor
Michael A. Rees, M.D., Ph.D.
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Paired Donation Incompatible but willing living
donors
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The square cannot give to the circle
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The circle cannot give to the square
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Paired Donation The square gives to the square,
the circle to the circle
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What if not done simultaneously?
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Reneging is possible with loss of the
bargaining chip of the incompatible donors
kidney
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Common Situation Not Reciprocal incompatibility
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Altruistic Donor Chain
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What if not done simultaneously?
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Reneging is possible but the bargaining
chip of the incompatible donors kidney is not
lost.
Therefore simultaneous procedures are NOT
required.
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Simultaneous Altruistic Donor Chain
Deceased Donor Waiting List
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Never-ending Altruistic Donor
Start a new Altruistic Chain
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Never-ending Altruistic Donor continues
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Never-ending Altruistic Donor continues
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Never-ending Altruistic Donor
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The First Never-Ending Altruistic Donor Chain
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Optimizing NEAD chain matching
Each circle represents an incompatible
donor/recipient pair
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Who can donor 1 give to?
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Who can donor 1 give to?
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Who can donor 1 give to?
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Who can donor 1 give to?
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Who can donor 1 give to?
1st
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Who can donor 1 give to?
1st
2nd
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Who can donor 1 give to?
1st
2nd
3rd
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Who can donor 1 give to?
1st
4th
2nd
3rd
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Only pair 4 can give back
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Can we do better?
1st
4th
2nd
3rd
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All possible matches for pair 4
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All possible matches for pair 4
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All possible matches for pair 4
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All possible matches for pair 4
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All possible matches for pair 4
1st
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All possible matches for pair 4
2nd
1st
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All possible matches for pair 4
3rd
2nd
1st
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All possible matches for pair 4
4th
3rd
2nd
1st
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The 4th best choice for both
4th
4th
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Optimizing NEAD chain matching
Each circle represents an incompatible
donor/recipient pair
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Imagine that an altruistic donor gives to pair one
AD
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Pair ones donor converted to an altruistic
donor
AD
AD
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Pair one has four possible choices
AD
AD
1st
4th
2nd
3rd
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Pair ones converted altruistic donor can now
give to pair 12
AD
AD
1st
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Pair twelves donor converted to an altruistic
donor
AD
AD
1st
AD
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Pair twelves donor gives to the best possible
match
AD
AD
1st
AD
1st
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Pair eights donor converted to an altruistic
donor
AD
AD
1st
AD
1st
AD
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NEAD chain matching improves both quantity AND
quality of matches
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Our Second NEAD chain
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3 states, 3 time zones, 3 transplants