M. Cooper1, G. Vranic1, A. Gilbert1, J. Verbesey1 1Georgetown University Medical Center, Transplantation, Washington, DC, USA
Introduction: Non-directed donors (NDD), previously viewed as a program-specific asset, have been demonstrated a valuable resource that can “unlock” incompatible living donor (LD) transplant pairs. Recent advances in paired kidney exchange (PKE) suggest that NDD may facilitate a greater than expected number of transplants, with donors receiving additional protections via PKE participation. In 2019, the largest PKE clearinghouse in the US, the National Kidney Registry (NKR), transitioned NDD to the Family Voucher (FV) program, where LD may identify 5 family members to receive vouchers for a future transplant should they develop end-stage renal disease. An important aspect of the PKE progam is for each NDD shared to the national PKE program, an end-chain LD is allocated to the same center to assure program volumes. As a leading center in the NKR, our center performed a retrospective review of our NDD/FV donors in an effort to demonstrate the 'value' of NDD both nationally and for our incompatible pairs.
Methods: A retrospective cohort review of LD transplants was completed from 1/2015 to 12/2020. Additional data on PKE transplants utilized NKR data. Clinical characteristics of NDD were assessed including those in the FV program after 2019 and NKR Advanced Donation Program (ADP) donors who donate in advance of their intended recipient. Also included were data on recipients from the deceased donor list allocated end-chain LD.
Results: During the study period, 45 NDDs (15 in 2015-2018, 30 in 2018-2020) presented. NDD demographics: 51% male (n=23), 97.8% Caucasian (n=44), mean age 45.2 years, mean BMI 25.3. NDD blood types: 48.9% O, 40% A. NDD plus 28 ADP donors enabled 162 transplants. This included 36 highly sensitized (PRA > 80%) patients, including 15 with a PRA > 98%, and 71 DD waitlist patients that received compatible LD kidneys. For the highly sensitized patients, average wait time for PRA > 80% improved from 4.74 years to 3.33 months, and PRA > 98% improved from 4.33 years to 6 months. In calendar years 2019 and 2020, NDD and FV donors represent 25-27% of the NKR donor population; since 2020 virtually all NKR NDD entered the FV program.
Conclusion: These results demonstrate that a single center may realize a dramatic rise in volume with a concomitant decrease in wait time from full participation in national PKE. NDDs were diverse in age and gender, although almost universally Caucasian. Since the FV program benefits future generations while protecting donors, centers must inform potential AA donors of this option. The FV program offers donors a voucher in addition to other donor protections including travel and lost wage reimbursement and life insurance unavailable in comptible LD. Centers throughout the country must educate their patients to this option. Adding NDD to PKE has resulted in numerous highly sensitized patients throughout the US receive transplants while additonally benefitting candidates on the deceased donor waitlist.