Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney...

31
Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital

Transcript of Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney...

Page 1: Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital. Overview ...

Paired Kidney Exchange / Kidney Paired Donation

Colm C. Magee, MD, MPHRenal Unit, Beaumont Hospital

Page 2: Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital. Overview ...

OverviewOverview

•• DefinitionDefinition

•• The The howhow, , whywhy, , whowho and and wherewhere of PKEof PKE

•• Types of PKETypes of PKE

•• Advantages / disadvantagesAdvantages / disadvantages

•• PKE for our patientsPKE for our patients

•• Recent casesRecent cases

Page 3: Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital. Overview ...

DefinitionDefinition

•• Exchange of kidneys between 2 pairs of Exchange of kidneys between 2 pairs of (each pair a living donor + recipient)(each pair a living donor + recipient)

•• Typically, the pair cannot donate / transplant Typically, the pair cannot donate / transplant directly because of incompatibility of:directly because of incompatibility of:

ABO / HLA / bothABO / HLA / both

Page 4: Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital. Overview ...

How?How?

Page 5: Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital. Overview ...

020406080

100120140

0 250 500 750 1000 1250# of

KP

D tr

ansp

lant

s

0

100

200

300

400

0 250 500 750 1000 1250

# in

dat

abas

e Donors

Recipients

Paired Donation Numbers are Related to Size of Database

Bingaman et al. N Engl J Med 2010; 363(11):1091-2.

Days

Page 6: Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital. Overview ...

Why? Why?

•• Significant % of ESRD pts will have an Significant % of ESRD pts will have an ABOiABOi living donor living donor

•• Significant % of ESRD pts are sensitized Significant % of ESRD pts are sensitized and have an and have an HLAiHLAi living donor living donor

•• LD transplant options for these pts are LD transplant options for these pts are thus very limitedthus very limited

•• PKE offers another mechanism to allow PKE offers another mechanism to allow LD transplantationLD transplantation

Page 7: Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital. Overview ...

Why? Why?

•• Still receive a LD transplantStill receive a LD transplant

•• Circumvent problem of Circumvent problem of incompatabilityincompatability

•• Less Less immunosuppressionimmunosuppression

•• Lower risk of rejection and allograft lossLower risk of rejection and allograft loss

•• Less costlyLess costly

•• Ultimately, more transplantsUltimately, more transplants

Page 8: Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital. Overview ...

Who? Who?

•• Potentially anyone eligible for transplant Potentially anyone eligible for transplant who has a willing but incompatible living who has a willing but incompatible living donordonor

Expanding now to include:Expanding now to include:

•• Altruistic living donorsAltruistic living donors

•• Pairs who are compatible but might benefit Pairs who are compatible but might benefit from a different living donorfrom a different living donor

Page 9: Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital. Overview ...

Where?Where?

•• S Korea, IndiaS Korea, India

•• USA, Canada, USA, Canada,

•• Netherlands, UKNetherlands, UK

•• AustraliaAustralia

•• In some countries the donor travels, in In some countries the donor travels, in others the kidney travelsothers the kidney travels

•• Legal issuesLegal issues

Page 10: Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital. Overview ...

Increasing Complexity of LDIncreasing Complexity of LD

•• NonNon--simultaneous donation / transplantationsimultaneous donation / transplantation

•• Legal issuesLegal issues

•• Geographic issues (long distances)Geographic issues (long distances)

•• Use of internet, social mediaUse of internet, social media

•• AustraliaAustralia

•• ChainsChains

•• DominosDominos

•• Altruistic donorsAltruistic donors

•• Compatible donors!Compatible donors!

Page 11: Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital. Overview ...

Paired Kidney Exchange: ChainsPaired Kidney Exchange: Chains

Page 12: Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital. Overview ...

Domino Paired Kidney Exchange:Domino Paired Kidney Exchange:

Page 13: Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital. Overview ...

NY Times…..Started with altruistic donor.

Page 14: Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital. Overview ...

BRIEF REPORTA Nonsimultaneous, Extended, Altruistic-

Donor ChainRees et al. N Engl J Med 2009; 360:1096-

1101

Page 15: Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital. Overview ...

Results to DateResults to Date

Netherlands: de Klerk et al. Netherlands: de Klerk et al. ClinClin Trans 2010:Trans 2010:

•• 20042004--2010: 422 pairs registered2010: 422 pairs registered

•• Central H+I labCentral H+I lab

•• Matches found for 218 (50%)Matches found for 218 (50%)

•• 167 (40%) received a 167 (40%) received a transpanttranspant

Australia: Ferrari et al., Transplantation 2012Australia: Ferrari et al., Transplantation 2012

•• 38% received a PKE transplant38% received a PKE transplant

•• 35% of these had PGEN >90%35% of these had PGEN >90%

Page 16: Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital. Overview ...

7%

24% enrolled in the UK pool have been transplanted

A: 36%B: 24%AB: 21%O: 18%

Page 17: Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital. Overview ...
Page 18: Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital. Overview ...

DisadvantagesDisadvantages

Transplant may never happen. Why?Transplant may never happen. Why?

•• MatchrunsMatchruns not successfulnot successful

•• MatchrunMatchrun successful but transplant does successful but transplant does not proceed not proceed

•• Still difficult for ABOStill difficult for ABO--O or highly sensitized O or highly sensitized pts to find a matchpts to find a match

•• Donor issues ariseDonor issues arise

•• Recipient issues ariseRecipient issues arise

Page 19: Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital. Overview ...

Other DisadvantagesOther Disadvantages

•• Prolonged waiting for a transplantProlonged waiting for a transplant

•• Stress of waiting for the Stress of waiting for the matchrunmatchrun resultsresults

•• Costs of evaluating many Costs of evaluating many potentialpotential LDsLDs

•• Preserving anonymityPreserving anonymity

•• Poor outcome with 1 of the transplants?Poor outcome with 1 of the transplants?

•• Donor withdrawal (very rare)Donor withdrawal (very rare)

Page 20: Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital. Overview ...

PKE for Irish PatientsPKE for Irish Patients

Page 21: Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital. Overview ...

020406080

100120140

0 250 500 750 1000 1250# of

KP

D tr

ansp

lant

s

0

100

200

300

400

0 250 500 750 1000 1250

# in

dat

abas

e Donors

Recipients

Paired Donation Numbers are Related to Size of Database

Bingaman et al. N Engl J Med 2010; 363(11):1091-2.

Days

Page 22: Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital. Overview ...

Practical AspectsPractical Aspects

• Currently referring adult pts to 2 centres in UK: Coventry (RH), Royal Free (GJ)

• HSE, in principle, are agreeable to this

• Consider in all cases where there is a suitable / willing donor who is either ABO or HLA incompatible

• Remember the donor might have been previously rejected because of ABOi

• So…ask your pt about interested family members / friends

Page 23: Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital. Overview ...

Identify recipient + donor (1 or 2)

HSE Approval

Donor + Recipient outpatient appt in UK centre

Donor evaluation in Ireland

Enrollment in UK-PKE

Successful matchrun

Transplant

Page 24: Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital. Overview ...

What if What if matchrunmatchrun not successful?not successful?

• Try and enroll an ABO-O donor, if possible!

• Do at least 3 matchruns

If no success after 3, consider:

• Expanding number of acceptable mismatches

• Finding a ‘near perfect’ rather than perfect donor

• Direct donation and limited form of desensitization (only if low DSA)

Page 25: Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital. Overview ...

Model 1: Kidney exchange beweenpair 1 (orange) and pair 2 (green) circumvents problem of positive crossmatch that exists within pair 2

ABO-A ABO-O

ABO-O ABO-AX

Neg Xmatch Neg Xmatch

Pos Xmatch

ABO-AABO-O

ABO-O ABO-AXXX

Neg Xmatch Weak Pos Xmatch

Strongly Pos Xmatch

Highly Sensitized Highly Sensitized

Model 2: Kidney exchange beweenpair 1 (orange) and pair 2 (green) circumvents problem of highly positive crossmatch and allows transplant from ‘relatively compatible’ donor

ABO-A

Page 26: Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital. Overview ...

Case 1: ABO incompatible donorCase 1: ABO incompatible donor

•• MN, 59 year old femaleMN, 59 year old female

•• ABOABO--O; PGEN 0%O; PGEN 0%

•• LD is ABOLD is ABO--B, HLA 1B, HLA 1--11--2 mismatch2 mismatch

Options?Options?

Page 27: Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital. Overview ...

Case 2: ABO and probably HLA Case 2: ABO and probably HLA incompatible donorincompatible donor

•• GB, 50 year old femaleGB, 50 year old female

•• ABOABO--O; PGEN 99%O; PGEN 99%

•• LD is ABOLD is ABO--AA

Options?Options?

Page 28: Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital. Overview ...

Case 2: ABO and HLA incompatible Case 2: ABO and HLA incompatible donorsdonors

•• DM, 51 year old male with ESRD due DM, 51 year old male with ESRD due to ADPKDto ADPKD

•• ABOABO--O, PGEN 99%O, PGEN 99%

•• 2 interested living donors: but ABO or 2 interested living donors: but ABO or HLA incompatible or bothHLA incompatible or both

Page 29: Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital. Overview ...

Take Home PointsTake Home Points

• In approx 30% of cases, the LD will not be suitable by ABO or HLA

• Always consider PKE in this situation

• Don’t forget to ask about others interested in donation who were turned down before

• Ultimately, a range of options will be needed for many pts: acceptable mismatch program, PKE, limited desensitization, ABOitransplant

Page 30: Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital. Overview ...

Solving the ‘stable marriage problem’: If you have a group of men, and a group of women, could an algorithm be designed which would pair everyone up with a stable match?

Page 31: Paired Kidney Exchange / Kidney Paired Donation · 2013-02-04 · Paired Kidney Exchange / Kidney Paired Donation Colm C. Magee, MD, MPH Renal Unit, Beaumont Hospital. Overview ...

Thanks toThanks to

•• Dr Dr AislingAisling Courtney, Nephrology, Courtney, Nephrology, BelfastBelfast