Altruistic-Donor Chain May Facilitate Renal Transplantation

Laurie Barclay, MD

March 13, 2009

March 13, 2009 — A nonsimultaneous, extended, altruistic-donor chain may facilitate renal transplantation, according to a report of a chain of 10 paired kidney donations published in the March 12 issue of the New England Journal of Medicine.

"Paired kidney donation is an evolving strategy for overcoming the barriers that confront patients with end-stage renal disease when the only living potential donors who are willing to donate to them are deemed to be unsuitable as donors for them owing to an incompatibility of blood type, of [human leukocyte antigen] crossmatch, or of both," write Michael A. Rees, MD, PhD, from the University of Toledo Medical Center in Ohio, and colleagues. "This report describes clusters of simultaneously performed transplantations, or single transplantations, in which the donor at the end of each cluster or single transplantation served as a 'bridge donor,' thus extending the interrupted chain at a later time. We refer to this type of arrangement as a 'nonsimultaneous, extended, altruistic-donor' (NEAD) chain."

This strategy may help overcome the problem of 2-way paired donations, in which, after one donor has given a kidney to the other pair's recipient, that recipient's coregistered donor may no longer be willing to donate a kidney in return. When an altruistic, or nondirected donation, starts a chain of transplantations, each subsequent donor makes the donation only after the coregistered recipient in his or her pair has already received a transplant. Although failing to donate in the middle of a chain would still be problematic, it would not irreparably harm the remaining pairs in the chain. This strategy also allows for chains of transplantations that are not performed simultaneously, which may help increase the number of transplantations performed.

In July 2007, a single altruistic donor (a donor without a designated recipient) started a chain of 10 kidney transplantations involving 6 transplantation centers in 5 states. Two large paired-donation registries coordinated these transplantations during a period of 8 months.

In 5 of the transplantations, the donors and their coregistered recipients underwent surgery at the same time, whereas in the other 5 transplantations, bridge donors continued the chain as long as 5 months after the coregistered recipients in their own pairs had received transplants. This chain of paired kidney donations, in which the transplantations were not necessarily performed at the same time, demonstrates the potential of this strategy.

"NEAD chains favor utility over justice, since greater weight is placed on generating more than one transplant from the altruistic donor's gift," the study authors write. "However, NEAD chains should still benefit patients on the list who do not have willing donors, because patients who are enrolled in paired donation programs are generally concomitantly added to the deceased-donor waiting list. Each subsequent transplantation in the chain would take a candidate for a kidney from a deceased donor off the waiting list, resulting in a shorter overall waiting time."

The Alliance for Paired Donation, Life Connection of Ohio, the University of Toledo, and the Charles T. Bauer Foundation supported this study. Additional partial support was by grants from the National Science Foundation and a Sloan Foundation Fellowship. Some of the authors report various financial arrangements with Novartis, Bristol-Myers Squibb, Wyeth, Astellas, and/or Genzyme.

N Engl J Med. 2009;360:1096–1101.

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