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Robert A. Montgomery, MD, DPhil; Andrea A. Zachary, PhD; Lloyd E. Ratner, MD; Dorry L. Segev, MD; Janet M. Hiller, RN; Julie Houp; Mathew Cooper, MD; Louis Kavoussi, MD; Thomas Jarrett, MD; James Burdick, MD; Warren R. Maley, MD; J. Keith Melancon, MD; Tomasz Kozlowski, MD; Christopher E. Simpkins, MD; Melissa Phillips, MD; Amol Desai; Vanessa Collins; Brigitte Reeb; Edward Kraus, MD; Hamid Rabb, MD; Mary S. Leffell, PhD; Daniel S. Warren, PhD

JAMA. 2005;294:1655-1663.

Context  First proposed 2 decades ago, live kidney paired donation (KPD) was considered a promising new approach to addressing the shortage of organs for transplantation. Ethical, administrative, and logistical barriers initially proved formidable and prevented the implementation of KPD programs in the United States.

Objective  To determine the feasibility and effectiveness of KPD for the management of patients with incompatible donors.

Design, Setting, and Patients  Prospective series of paired donations matched and transplanted from a pool of blood type or crossmatch incompatible donors and recipients with end-stage renal disease (6 conventional and 4 unconventional KPD transplants) at a US tertiary referral center (between June 2001 and November 2004) with expertise in performing transplants in patients with high immunologic risk.

Intervention  Kidney paired donation and live donor renal transplantation.

Main Outcome Measures  Patient survival, graft survival, serum creatinine levels, rejection episodes.

Results  A total of 22 patients received transplants through 10 paired donations including 2 triple exchanges at Johns Hopkins Hospital. At a median follow-up of 13 months (range, 1-42 months), the patient survival rate was 100% and the graft survival rate was 95.5%. Twenty-one of the 22 patients have functioning grafts with a median 6-month serum creatinine level of 1.2 mg/dL (range, 0.8-1.8 mg/dL) (106.1 µmol/L [range, 70.7-159.1 µmol/L]). There were no instances of antibody-mediated rejection despite the inclusion of 5 patients who were highly sensitized to HLA antigens due to previous exposure to foreign tissue. Four patients developed acute cellular rejection (18%).

Conclusions  This series of patients who received transplants from a single-center KPD pool provides evidence that recipients with incompatible live donors, even those with rare blood type combinations or high degrees of HLA antigen sensitization, can receive transplants through KPD with graft survival rates that appear to be equivalent to directed, compatible live donor transplants. If these results can be generalized, broader availability of KPD to the estimated 6000 patients with incompatible donors could result in a large expansion of the donor pool.

Author Affiliations: Departments of Surgery (Drs Montgomery, Segev, Cooper, Burdick, Maley, Melancon, Kozlowski, Simpkins, Phillips, and Warren, Mss Hiller, Collins, and Reeb, and Mr Desai), Medicine (Drs Zachary, Kraus, Rabb, and Leffell and Ms Houp), and Urology (Drs Kavoussi and Jarrett), Johns Hopkins University School of Medicine, Baltimore, Md; and Department of Surgery, Columbia University, New York, NY (Dr Ratner). Dr Cooper is now with the Department of Surgery, University of Maryland, Baltmore. Dr Kozlowski is now with the Department of Surgery, University of North Carolina, Chapel Hill. Dr Phillips is now with the Department of Surgery, University of Virginia, Charlottesville. Mr Desai is now with the College of Medicine, University of Illinois, Chicago.

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