What is kidney paired exchange?
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- Potential donors and recipients have transplant evaluation to make sure that they're healthy enough to have surgery. Non-directed donors who do not have a recipient can also get evaluated.
- If both the donor and recipient are eligible and want to be part of a paired kidney donation, they talk with the transplant center and can choose to register with one or more of the KPD programs that the center takes part in.
- Once a pair is cleared, their medical data is entered into a confidential database of registered recipient and donor pairs waiting to be matched.
- A computer program does the matching to get the highest number of matched pairs and the best matches. It also takes specific groups in to account, such as children and hard-to-match recipients.
- When the computer finds a matching swap or chain, the transplant center notifies the recipients and donors.
- Donors undergo donation surgery and their kidneys travel to the receiving center where recipients undergo transplant surgery.
Donors and recipients have blood tests to see if they are good matches. KPD matches pairs based on 3 factors: blood type, tissue type, and crossmatching. Matching on these factors lowers the chance of rejection.
Blood type matching: Everyone has a blood type of either O, A, B, or AB. The donor and recipient must have blood types that are compatible, as shown here:
Tissue type (HLA) matching: Blood tests can show the tissue (HLA) type of the donor and recipient and the level of HLA antibodies in the recipient’s blood. Antibodies are proteins in the blood that help the body fight disease. A recipient with HLA antibodies is sensitized to that HLA type, which means that the recipient has antibodies to those cells and tissues with that HLA type.
Crossmatching: Blood tests can also show if the recipient has antibodies against the donor’s cells. When antibody levels are high, the recipient’s body will attack the donor organ. This is called a positive crossmatch.
- Positive crossmatch = Incompatible: If a donor and their intended recipient are incompatible, transplant isn’t possible for this pair. KPD is the best option to get a transplant.
- Negative crossmatch = Compatible: If a donor and their intended recipient are compatible, transplant is possible for this pair. They can get a transplant through direct donation or KPD.
Your donor evaluation can take a few months to a year, depending on your health and how quickly your center can schedule your tests. Then, you must register with the KPD program of your choice through your transplant center. No KPD program can guarantee the exact wait time for a match to form and for you to be called for donor surgery.
In general, if you are taking part as an incompatible pair, the average wait time is 3–6 months. If you have a difficult-to-match blood or tissue type, it can take longer. For example, certain blood types may have to wait 12–18 months. A few people may not find a match.
During the KPD process, there are problems that could prevent the process from moving forward or cause it to take longer, such as:
- As a donor, you may choose to change your mind about taking part at any time
- If you have a hard-to-match blood or tissue type, it may take longer to find a compatible recipient
- A change in your health may prevent you from moving forward with donation
Also, if you have any health conditions that prevents donation, you will not be allowed to move forward.
Sometimes unexpected events prevent a donor kidney from being transplanted. A failed swap or chain happens when a donor donates, but their original intended recipient does not get a kidney. This is very rare, and KPD programs take steps to manage any failures.
If your intended recipient does not get a kidney after you have donated, most KPD programs will give your recipient priority in the system. The program will make every effort to find a new match and move forward with transplant as soon as possible. However, the recipient does not get priority on the deceased donor waiting list.
No KPD program can guarantee that the intended recipient will get a kidney. If the recipient has a hard-to-match blood or tissue type or is highly sensitized, matching will be harder and may take longer.
Transporting (or shipping) organs is a normal part of most KPD programs. The donor center ships the donated kidney to the recipient center, by ground or air transportation. Most KPD programs use GPS devices to track all donated kidneys that they ship to another transplant center. This helps to prevent them from being lost.
A 2018 study of 2,363 shipped living donor kidneys found that shipping kidneys did not affect the length of time the kidney worked in the long run.
The voucher program (Advanced Donation) allows donors to donate a kidney when convenient and their intended recipient gets a voucher to use months or years later. There are 2 types of vouchers:
- Short-term (standard) voucher: Given when a donor donates for an intended recipient who will likely need a transplant within the next year. For example, a teacher may choose to donate during the summer months on behalf of a recipient who is getting stronger to prepare for transplant in the fall.
- Long-term (family) voucher: Given when a donor donates on behalf of a recipient who is not currently in need a transplant and may never need one. For example, a grandparent may donate for a child with polycystic kidney disease (PKD) who does not yet need a transplant.
- With the family voucher, the donor can designate up to 5 people to be voucher holders, if any of them may need a kidney in the future. However, only 1 of the 5 can redeem the voucher.
- Non-directed donors may choose this type of voucher.
To redeem their voucher, the voucher holder may select any transplant center that takes part within the NKR’s network. Then, the NKR’s matching services try to find a living donor kidney for the recipient.
Faith and living donation
Special protections for patients and donors
- 90-day kidney replacement policy: If an NKR recipient’s new kidney fails within 90 days of transplant, they may be able to get priority in the NKR program for a replacement kidney
- Coverage for out-of-state fees: The NKR will pay any out-of-state-fees for the donor surgery to the donor center if costs cannot be billed to Medicare. In general, the recipient’s insurance covers the donor’s medical costs.
- Priority to get a kidney if theirs fails: If an NKR donor’s remaining kidney ever fails, they will get priority in the NKR program to receive a living donor kidney. They will also get priority on the national deceased donor wait list.
- Donor Shield Protections: The NKR provides certain protections to all donors who take part in an NKR swap, regardless of whether they donated through a Donor Shield Program Center. These protections include:
- Pay back for up to 4 weeks of lost wages (money they would have earned from work if they didn’t have to take time off), with up to $1,500 per week
- Travel, lodging, and mileage reimbursement of up to $2,000 for donors and their travel companion
- Life insurance with a $500,000 principal sum
- Disability insurance with up to $1,500 per week for up to 52 weeks
- Legal support
- Coverage to pay for medical costs of donor complications during surgery that insurance companies won’t cover
To find a Donor Shield Program Center, visit kidneyregistry.org/living_donors.php#donor-shield
Risks & benefits of KPD
For donors, KPD offers a way to help a friend, family member, or even a stranger in need of a kidney. Some of the benefits of becoming a donor are:
- Help a loved one get a kidney faster: KPD shortens the wait time compared to the deceased donor waitlist and directed donation, so your loved one can get a kidney transplant sooner. The longer a patient stays on dialysis waiting for a transplant, the poorer the transplant outcome.
- Better transplant outcomes for your recipient: Through KPD, recipients can improve their match options, leading to better transplant outcomes.
- Help a loved one who is hypersensitized or a rare blood type to get a kidney: The large pools of patient and donor pairs used in KPD allow for matches to be found even for patients who are hypersensitized, have a rare blood type (O blood type), or other challenging factors for matching.
- Help other kidney patients: By taking part in KPD, you will have helped other kidney patients get a matching kidney. You can feel good knowing that you helped others.
- More control over when you donate: Special programs, such as Advanced Donation, let you choose when to donate. For example, you could donate in the summer months and get a voucher for your intended recipient. Your recipient can use the voucher to get a kidney when they need one later.
Many of the risks are the same as they would be through directed donation, but some are specific to KPD, such as:
- Loss of privacy if your name appears on your matched recipient’s insurance benefits information
- Rarely, the kidney you donate could be lost or damaged during transportation between donor and recipient transplant center
- It may take time to find a recipient for you to donate to, or for a chain to form
- If you have a hard-to-match blood or tissue type, it may take a lot longer to find a recipient for your kidney
- You may have to wait longer to donate to your identified match, due to coordinating and scheduling multiple surgeries
- After you donate, an unexpected issue may prevent the recipient from receiving the kidney
- Your recipient pair (your original intended recipient) might not get a transplant immediately due to an unexpected issue with the matched donor’s kidney that is found during or after surgery
If you have questions or concerns, talk to your donor advocate or social worker at the transplant center.
Normally, doctors remove the kidney through an opening only a few inches long. If there are problems, the opening may have to be larger and recovery time takes longer. Donors may have some short-term problems from surgery, such as:
- Bloating
- Feeling sick to their stomach
- Scars and pain
- Feeling tired and weak
More serious problems from surgery happen in less than 5% of donors (less than 1 in 20 donors). The surgical team does everything they can to avoid these problems. These could include:
- Problems from being put to sleep, such as confusion, pneumonia, stroke, or heart attack
- Infection
- Fever
- Bleeding and blood clots
The risk of death is less than 3 in 10,000 donors — that’s much less than 1% of donors.
Medicare or the kidney patient’s private insurance will cover the donor’s medical costs. However, most insurance companies don’t cover:
- Time off from work or the cost of childcare
- Meals
- Parking and gas
- Hotel costs during testing, surgery, and recovery
- Travel costs if the paired donor travels to the matched recipient transplant center
Sometimes insurance companies will limit the time they cover medical costs if there are complications during surgery. They may also ask the donor for a co-payment. While these are rare, they can happen. Some KPD programs will step in to cover these costs.
Donation can sometimes change the donor’s ability to get or afford health, disability, or life insurance. Donors may also have issues getting work in military service, law enforcement, aviation, and fire departments.
There are also programs that can help pay for donors’ costs during KPD to overcome any financial challenges, such as:
- The National Living Donor Assistance Program (NLDAC): Provides reimbursement of travel and certain other expenses to people being evaluated for and donating living organs. The program prioritizes people who could not otherwise afford to donate. Donors qualify based on the recipient’s yearly household income, and both the recipient and the donor must complete an application. Visit livingdonorassistance.org
- American Living Organ Donor Fund: A 501(c)(3) non-profit public charity dedicated to serving living organ donors by helping them overcome financial burdens with organ donation. Visit helplivingdonorssavelives.org
- The National Kidney Registry Donor Shield Program: Provides various financial and legal protections for donors who donate at any NKR Donor Shield Center. This includes:
- Up to 4 weeks’ pay lost wages (money they would have earned from work if they didn’t have to take time off), with up to $1,500 per week
- Travel, lodging, and mileage reimbursement of up to $2,000 for donors and their travel companion
- Disability insurance
- Legal support
- Coverage for medical costs or complications not covered by the recipient’s insurance. Visit kidneyregistry.org/living_donors.php#donor-shield
- The American Kidney Fund: The American Kidney Fund’s Safety Net Program provides small grants to help donors with out-of-pocket costs related to donation, including lodging, travel, or lost wages. The program provides a maximum grant of $100 per year for donors for up to 5 years after donation. Visit kidneyfund.org/financial-assistance/information-for-patients/#safety_net_grants
Only you can decide if taking part in KPD is right for you. Here are some things other potential donors considered to make their decision. Check any reasons that feel important to you.
KPD might not be right for you if you:
- Are not comfortable with your kidney going to a stranger
- Don’t want to deal with an unknown timeline for KPD
- Have an intended recipient who isn’t willing to receive a kidney from someone they don’t know
- Aren’t willing to face the possibility of a broken chain or swap
KPD might be right choice for you if you:
- Want to help a loved one but you were not a good match for them • Want to help other kidney patients to also get transplants
- Don’t mind donating a kidney to a stranger who you may never meet
If KPD might be the right choice for you, check which next steps you’re ready to take:
- Share your decision with your recipient pair
- Ask your transplant center what KPD programs they have available (some only take part in one program)
- Decide with your recipient pair which KPD program you want to take part in