Background More than 20,000 candidates for kidney transplantation in the United States are sensitized to HLA and may have a prolonged wait for a transplant, with a reduced transplantation rate and an increased rate of death. One solution is to perform live-donor renal transplantation after the depletion of donor-specific anti-HLA antibodies. Whether such antibody depletion results in a survival benefit as compared with waiting for an HLA-compatible kidney is unknown. Methods We used a protocol that included plasmapheresis and the administration of low-dose intravenous immune globulin to desensitize 211 HLA-sensitized patients who subsequently underwent renal transplantation (treatment group). We compared rates of death between the group undergoing desensitization treatment and two carefully matched control groups of patients on a waiting list for kidney transplantation who continued to undergo dialysis (dialysis-only group) or who underwent either dialysis or HLA-compatible transplantation (dialysis-or-tr...

https://www.nejm.org/doi/pdf/10.1056/NEJMoa1012376

Desensitization in HLA-incompatible kidney recipients and survival.

The 2017 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors is intended to assist medical professionals who evaluate living kidney donor candidates and provide care before, during and after donation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach and guideline recommendations are based on systematic reviews of relevant studies that included critical appraisal of the quality of the evidence and the strength of recommendations. However, many recommendations, for which there was no evidence or no systematic search for evidence was undertaken by the Evidence Review Team, were issued as ungraded expert opinion recommendations. The guideline work group concluded that a comprehensive approach to risk assessment should replace decisions based on assessments of single risk factors in isolation. Original data analyses were undertaken to produce a "proof-in-concept" risk-prediction model for kidney failure to support a framework for quantitative risk assessment in the donor candidate evaluation and defensible shared decision making. This framework is grounded in the simultaneous consideration of each candidate's profile of demographic and health characteristics. The processes and framework for the donor candidate evaluation are presented, along with recommendations for optimal care before, during, and after donation. Limitations of the evidence are discussed, especially regarding the lack of definitive prospective studies and clinical outcome trials. Suggestions for future research, including the need for continued refinement of long-term risk prediction and novel approaches to estimating donation-attributable risks, are also provided.In citing this document, the following format should be used: Kidney Disease: Improving Global Outcomes (KDIGO) Living Kidney Donor Work Group. KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Transplantation. 2017;101(Suppl 8S):S1-S109.

KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors.

https://repositorio.inesctec.pt/bitstream/123456789/3167/1/PS-06772.pdf

Operations Research in Healthcare: a survey

Patients needing kidney transplants may have donors who cannot donate to them because of blood or tissue incompatibility. Incompatible patient-donor pairs can exchange donor kidneys with other pairs only when there is a "double coincidence of wants." Developing infrastructure to perform 3-way as well as 2-way exchanges will have a substantial effect on the number of transplants that can be arranged. Larger than 3-way exchanges have less impact on efficiency. In a general model of type-compatible exchanges, the size of the largest exchanges required to achieve efficiency equals the number of types.

https://papers.ssrn.com/sol3/Delivery.cfm/SSRN_ID1290350_code286615.pdf?abstractid=1290350&mirid=4

Efficient Kidney Exchange: Coincidence of Wants in Markets with Compatibility-Based Preferences

In barter-exchange markets, agents seek to swap their items with one another, in order to improve their own utilities. These swaps consist of cycles of agents, with each agent receiving the item of the next agent in the cycle. We focus mainly on the upcoming national kidney-exchange market, where patients with kidney disease can obtain compatible donors by swapping their own willing but incompatible donors. With over 70,000 patients already waiting for a cadaver kidney in the US, this market is seen as the only ethical way to significantly reduce the 4,000 deaths per year attributed to kidney diseas.The clearing problem involves finding a social welfare maximizing exchange when the maximum length of a cycle is fixed. Long cycles are forbidden, since, for incentive reasons, all transplants in a cycle must be performed simultaneously. Also, in barter-exchanges generally, more agents are affected if one drops out of a longer cycle. We prove that the clearing problem with this cycle-length constraint is NP-hard. Solving it exactly is one of the main challenges in establishing a national kidney exchange.We present the first algorithm capable of clearing these markets on a nationwide scale. The key is incremental problem formulation. We adapt two paradigms for the task: constraint generation and column generation. For each, we develop techniques that dramatically improve both runtime and memory usage. We conclude that column generation scales drastically better than constraint generation. Our algorithm also supports several generalizations, as demanded by real-world kidney exchanges.Our algorithm replaced CPLEX as the clearing algorithm of the Alliance for Paired Donation, one of the leading kidney exchanges. The match runs are conducted every two weeks and transplants based on our optimizations have already been conducted.

/pdf/clearing-algorithms-for-barter-exchange-markets-enabling-1k2onsjvhb.pdf

Clearing algorithms for barter exchange markets: enabling nationwide kidney exchanges

ContextBlood type and crossmatch incompatibility will exclude at least one
third of patients in need from receiving a live donor kidney transplant. Kidney
paired donation (KPD) offers incompatible donor/recipient pairs the opportunity
to match for compatible transplants. Despite its increasing popularity, very
few transplants have resulted from KPD.ObjectiveTo determine the potential impact of improved matching schemes on the
number and quality of transplants achievable with KPD.Design, Setting, and PopulationWe developed a model that simulates pools of incompatible donor/recipient
pairs. We designed a mathematically verifiable optimized matching algorithm
and compared it with the scheme currently used in some centers and regions.
Simulated patients from the general community with characteristics drawn from
distributions describing end-stage renal disease patients eligible for renal
transplantation and their willing and eligible live donors.Main Outcome MeasuresNumber of kidneys matched, HLA mismatch of matched kidneys, and number
of grafts surviving 5 years after transplantation.ResultsA national optimized matching algorithm would result in more transplants
(47.7% vs 42.0%, P<.001), better HLA concordance
(3.0 vs 4.5 mismatched antigens; P<.001), more
grafts surviving at 5 years (34.9% vs 28.7%; P<.001),
and a reduction in the number of pairs required to travel (2.9% vs 18.4%; P<.001) when compared with an extension of the currently
used first-accept scheme to a national level. Furthermore, highly sensitized
patients would benefit 6-fold from a national optimized scheme (2.3% vs 14.1%
successfully matched; P<.001). Even if only 7%
of patients awaiting kidney transplantation participated in an optimized national
KPD program, the health care system could save as much as $750 million.ConclusionsThe combination of a national KPD program and a mathematically optimized
matching algorithm yields more matches with lower HLA disparity. Optimized
matching affords patients the flexibility of customizing their matching priorities
and the security of knowing that the greatest number of high-quality matches
will be found and distributed equitably.

/pdf/kidney-paired-donation-and-optimizing-the-use-of-live-donor-2o96w78krc.pdf

Kidney Paired Donation and Optimizing the Use of Live Donor Organs

ContextFirst 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.ObjectiveTo determine the feasibility and effectiveness of KPD for the management
of patients with incompatible donors.Design, Setting, and PatientsProspective 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.InterventionKidney paired donation and live donor renal transplantation.Main Outcome MeasuresPatient survival, graft survival, serum creatinine levels, rejection
episodes.ResultsA 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%).ConclusionsThis 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.

/pdf/clinical-results-from-transplanting-incompatible-live-kidney-30mra7k4kg.pdf

Clinical results from transplanting incompatible live kidney donor/recipient pairs using kidney paired donation.

Surgical Ventricular Restoration Versus Cardiac Transplantation: A Comparison of Cost, Outcomes, and Survival

https://www.academicpedsjnl.net/article/S1530-1567(05)60121-9/pdf

Brigitte Reeb

Papers

Kidney Paired Donation and Optimizing the Use of Live Donor Organs

Clinical results from transplanting incompatible live kidney donor/recipient pairs using kidney paired donation.

Surgical Ventricular Restoration Versus Cardiac Transplantation: A Comparison of Cost, Outcomes, and Survival

The burden of injury in preschool children in an urban medicaid managed care organization.