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Kidney Paired Donation
Michael A. Rees, M.D., Ph.D.Michael A. Rees, M.D., Ph.D.
Ohio Solid Organ Transplantation Consortium
OSOTC - Audrey B. Bohnengel, Ph.D.OSOTC - Audrey B. Bohnengel, Ph.D.
Children’s Hospital Cincinnati - Maria H. Alonso, M.D.Children’s Hospital Cincinnati - Maria H. Alonso, M.D.
Cleveland Clinic - David Goldfarb, M.D.Cleveland Clinic - David Goldfarb, M.D.
Ohio State University - Mitchell L. Henry, M.D.Ohio State University - Mitchell L. Henry, M.D.
Miami Valley Hospital - Scott Johnson, M.D.Miami Valley Hospital - Scott Johnson, M.D.
University Hospital Cleveland - Mark Aeder, M.D.University Hospital Cleveland - Mark Aeder, M.D.
University of Cincinnati - E. Steve Woodle, M.D.University of Cincinnati - E. Steve Woodle, M.D.
Akron City Hospital (Summa) - Tanmay Lal, M.D.Akron City Hospital (Summa) - Tanmay Lal, M.D.
Anchor Enterprises - Alan ReesAnchor Enterprises - Alan Rees
University of CincinnatiUniversity of Cincinnati - Johnathan Kopke Johnathan Kopke
Other ContributorsHarvard - Alvin Roth, Ph.D.Harvard - Alvin Roth, Ph.D.
Boston College - Tayfun Sönmez, Ph.D.Boston College - Tayfun Sönmez, Ph.D.
University of Pittsburgh - Utku Ünver, Ph.D.University of Pittsburgh - Utku Ünver, Ph.D.
Carnegie Mellon University - Tuomas Sandholm, Ph.D.Carnegie Mellon University - Tuomas Sandholm, Ph.D.
Carnegie Mellon University – David Abraham, B.S.Carnegie Mellon University – David Abraham, B.S.
Johns Hopkins University - Robert Montgomery, M.D, D. Phil.Johns Hopkins University - Robert Montgomery, M.D, D. Phil.
Johns Hopkins UniversityJohns Hopkins University - Dorry Segev, M.D.- Dorry Segev, M.D.
Johns Hopkins University - Sommer Gentry, Ph.D.Johns Hopkins University - Sommer Gentry, Ph.D.
Columbia University - Lloyd Ratner, M.D.Columbia University - Lloyd Ratner, M.D.
Massachusetts General Hospital - Frank Delmonico, M.D.Massachusetts General Hospital - Frank Delmonico, M.D.
University of North Carolina - Ken Andreoni, M.D.University of North Carolina - Ken Andreoni, M.D.
A Kidney Paired Donation
Donor A
Donor B
Recipient A
Recipient B
X
X
A Paired Kidney Donation
Strategy
Recipient 1 Recipient 2 Recipient 3 Recipient 4 Recipient 5
Donor 1 X X X X
Donor 2 X X X X
Donor 3 X X X X
Donor 4 X X X X
Donor 5 X X X X
• 100 donor - recipient pairs generates 4,950 potential paired exchanges.
Potential Donations = n(n-1)/2
0
1000
2000
3000
4000
5000
1 11 21 31 41 51 61 71 81 91 101
Number of Pairs
Number of Possible Exchanges
Number of Pairs Required
0
200
400
600
800
1000
1200
1400
1600
4 8 10 20 30 40 50 100 200 400 800
#D/R Pairs
#Matches
Theo 2p Theo 2+3p ISM PDs
Registrations per prior LRDs
0
20
40
60
80
100
120
140
0 5 10 15 20 25
# D/R Registrations
# LD Tx/Yr
R = 0.114
Point System
1. Wait time2. Distance3. Recipient vs. Donor Age Disparity4. Donor vs. Donor Age Disparity5. HLA Match6. Pediatric Bonus 7. PRA Bonus8. CMV/EBV Bonus9. Blood Group A/B Bonus
Category Points3+5/2326/2662/26
Data Entry Screens
Medical Reviewer Screens
All medically feasible matches from 41 pairs
Optimizing matching of 8 pairs
Number of transplants versus quality of the match
4 matches - 50 points 3 matches - 60 points
2-way Solution1 2 3
45
67
8
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2930313233343536
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5960
6162
63 64 65
3-way Solution1 2 3
45
67
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2930313233343536
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6162
63 64 65
4-way Solution1 2 3
45
67
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2930313233343536
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6162
63 64 65
Multiple Approach Solution
1 2 34
56
78
9
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2930313233343536
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6162
63 64 65
Overall Crossmatches to perform
1 2 34
56
78
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2930313233343536
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5960
6162
63 64 65
With 3 x-matches positive
1 2 34
56
78
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6162
63 64 65
All but one 2-way match lost1 2 3
45
67
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2930313233343536
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5960
6162
63 64 65
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.
Results to Date
• Registered pairs ABOi = 60% , 40% crossmatch incompatible.
• Registered candidates: PRA 80-100 % in 36%, 10-79% in 32 % and <10% in 29%
• First 32 transplant recipients PRA 80-100 % in 22%, 50-79% in 19%, 25-49% in 22% and <25% in 38%.
• Overall, 41% of the transplanted recipients had a PRA > 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.
The Never-Ending Altruistic Donor
Michael A. Rees, M.D., Ph.D.Michael A. Rees, M.D., Ph.D.
Paired Donation: Incompatible but willing living donors
The square cannot give to the circle
The circle cannot give to the square
Paired Donation: The square gives to the square, the circle to the circle
What if not done simultaneously?
Reneging is possible – with loss of the “bargaining chip” of the incompatible donor’s kidney
Common Situation: Not Reciprocal incompatibility
Altruistic Donor Chain
What if not done simultaneously?
Reneging is possible – but the “bargaining chip” of the incompatible donor’s kidney is not lost.
Therefore simultaneous procedures are NOT required.
Simultaneous Altruistic Donor Chain
DeceasedDonor
WaitingList
Never-ending Altruistic Donor
Start a new Altruistic Chain
Never-ending Altruistic Donor continues
Never-ending Altruistic Donor continues
Never-ending Altruistic Donor
The First Never-Ending Altruistic Donor Chain
O O A A B A A A A A
1Jul 2007
AZ
2Jul 2007
OH
3Sep 2007
OH
4Sep 2007
OH
5Feb 2008
MD
6Feb 2008
MD
7Feb 2008
MD
8Feb 2008
NC
9Mar 2008
MD
10Mar 2008
OH
62%
Cauc
WifeHusband
0%
Cauc
DaughterMother
23%
Cauc
MotherDaughter
0%
Cauc
BrotherSister
82%
Cauc
HusbandWife
78%
Hispanic
DaughterFather
64%
Cauc
WifeHusband
100%
Cauc
BrotherBrother
46%
AA
MotherDaughter
3%
Cauc
FriendFriend
Transplant Date:
Recipient's State:
Recipient's PRA:
Recipient's Ethnicity:
Recipient-to-DonorRelationship:
1 The initiating donor was an unpaired altruistic donor from Michigan.2 The recipient of Transplant 6 required desensitization to HLA DSA by T and B cell flow cytometry.3 The recipient of Transplant 9 required desensitization to blood group (AHG titer of 1:8).
Recipient's Sexand ABO type:
Donor's Sexand ABO type: AO AO B A A A AB A AB
1
2 3
Optimizing NEAD chain matching
12
3
4
5
6
78
9
10
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Each circle represents an incompatible donor/recipient pair
Who can donor 1 give to?
12
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6
78
9
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14
Who can donor 1 give to?
12
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78
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14
Who can donor 1 give to?
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78
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Who can donor 1 give to?
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Who can donor 1 give to?
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78
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1st
Who can donor 1 give to?
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4
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78
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1st
2nd
Who can donor 1 give to?
12
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78
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1st
2nd
3rd
Who can donor 1 give to?
12
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78
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1st
2nd
3rd
4th
Only pair 4 can give back
12
3
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78
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Can we do better?
12
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78
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1st
2nd
3rd
4th
All possible matches for pair 4
12
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78
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All possible matches for pair 4
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3
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6
78
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All possible matches for pair 4
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3
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6
78
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All possible matches for pair 4
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3
4
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6
78
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All possible matches for pair 4
12
3
4
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78
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1st
All possible matches for pair 4
12
3
4
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6
78
9
10
11
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13
14
1st
2nd
All possible matches for pair 4
12
3
4
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6
78
9
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14
1st
2nd
3rd
All possible matches for pair 4
12
3
4
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6
78
9
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14
1st
2nd
3rd
4th
The 4th best choice for both
12
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78
9
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14
4th
4th
Optimizing NEAD chain matching
12
3
4
5
6
78
9
10
11
12
13
14
Each circle represents an incompatible donor/recipient pair
Imagine that an altruistic donor gives to pair one
12
3
4
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6
78
9
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14
AD
Pair one’s donor converted to an “altruistic donor”
12
3
4
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6
78
9
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14
AD
AD
Pair one has four possible choices
12
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78
9
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1st
2nd
3rd
4th
AD
AD
Pair one’s converted “altruistic donor” can now give to pair 12
12
3
4
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6
78
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1st
AD
AD
Pair twelve’s donor converted to an “altruistic donor”
12
3
4
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6
78
9
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1st
AD
AD
AD
Pair twelve’s donor gives to the best possible match
12
3
4
5
6
78
9
10
11
12
13
14
1st
AD
AD
AD
1st
Pair eight’s donor converted to an “altruistic donor”
12
3
4
5
6
78
9
10
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13
14
1st
AD
AD
AD
1st
AD
NEAD chain matching improves both quantity AND quality of matches
12
3
4
5
6
78
9
10
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12
13
14
1st
AD
AD
AD
1st
AD
1st
Our Second NEAD chain
3 states, 3 time zones, 3 transplants
