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Clinician-to-Clinician Update
To schedule a consultation, referral, or appointment:
Transplant Care
Clinics and Surgery Center
909 Fulton St. SE, Suite 300
Minneapolis, MN 55455

Paired Donation and Improving Access to Living-Donor Kidney Transplants

The rates of chronic kidney disease and end-stage renal disease have provoked a growing need for kidney transplantation, and the increasing prevalence of other diseases affecting the kidney, such as diabetes mellitus and hypertension, are likely to exacerbate this need.1 The availability  of suitable donor organs, however, remains well below need. Of the approximately 100,000 patients on the waiting list in 2016, only 19,000 received a  transplant.1,2 Efforts in facilitating donor-recipient matches have focused on improved histocompatibility testing and immunosuppressive therapies, and new initiatives have tested expanding the criteria for donor organs deemed suitable for transplant.3 Another strategy known as paired donation or  paired exchange brings together pairs of living donors and recipients in hopes of improving the odds of identifying suitable transplant matches. The  approach requires a high degree of care team and medical system coordination yet may offer the best outcomes for patients.1,5 

Illustration Mohammed Haneefa Nizamudeen
In paired donation, a kidney donor and intended but unmatched recipient agree to participate in a chain of coordinated transplants involving other  incompatible donor-recipient pairs. The donor’s organ goes to another patient, and the original intended recipient receives a kidney from another new  but matching donor. Paired donation also leverages the improved outcomes and rates of survival associated with living-donor transplants. At 1 year postprocedure, the survival rate for all kidney transplant patients is about 90%, but at 5 years, survival is 65% for those who’d received deceased-donor kidneys compared to 80% among those receiving organs from living donors.5 

Use of living-donor kidneys can shorten wait times for transplant recipients, and paired donation can minimize the risk of “orphaned” or unmatched  donor kidneys.5,6 It may also encourage living-organ donation since identifying compatible donors can present challenges, even for patients with  willing donors. Living-donor transplants, in fact, have decreased over the last decade with the largest decrease occurring among kidney transplants employing living, related donors.1,5 

Each donation in paired exchange programs has been shown to generate an additional 2 donors, creating a chain of donated organs to those in the  program. While paired-donation chains usually contain about 5 donations or fewer,6 they have been able to facilitate procedures for a remarkable  number of patients. The University of Minnesota Health transplant program was recently among the medical centers participating in a chain of 35 nondirected transplants, among the largest in the United States. 

The University of Minnesota Health transplant program has long supported living donor and paired exchange transplant efforts. It was the first in the United States to perform a kidney transplant from a nondirected living donor, and its paired exchange program PEP! has performed 150 paired donations  through July 2019. University of Minnesota Health physicians also have researched improved surgical procedures and drug regimens for transplant  patients7,8 and new approaches to promoting immune system tolerance of transplanted organs.9 The transplant program was among the first cohort  selected to participate in COIIN, a consortium launched to improve transplant procedures and expand access to transplant through a re-evaluation of criteria for viable donor organs.3 A new presidential Executive Order encouraging further research into treatments for advanced kidney disease may speed development of therapies, reduce transplant-associated costs, and support development of an artificial kidney, once funding is established.10


  1. Hart A, Smith JM, Skeans MA, et al. OPTN/SRTR 2017 Annual Data Report: Kidney. Am J Transplant. 2019;19(Suppl 2):19-123 doi: 10.1111/ajt.15274 
  2. Wang JH, Skeans MA, Israni AK. Current status of kidney transplant outcomes: dying to survive. Adv Chronic Kidney Dis. 2016;23(5):281-286 DOI: 10.1053/j.ackd.2016.07.001 
  3. Tosoc-Haskell H, Sisaithong K, Carrico R. The Collaborative Improvement and Innovation Network project to drive quality improvement. Curr Opin Organ Transplant. 2019;24(1):73-81 doi: 10.1079/MOT.0000000000000596. 
  4. Augustine J. Kidney transplant: New opportunities and challenges. Cleveland Clinic J Med. 2018;85(2):138-144. doi: 10.3949/ 
  5. Ferrari P. Weimar W, Johnson RJ, Lim WH, Tinckam KJ. Kidney paired donation: principles, protocols and programs. Nephrol Dial Transplant. 2015;30 (8):1276-1285 doi: 10.1093/ndt/gfu309 
  6. Cowan N, Gritsch HA, Nassiri N, Sinacore J, Veale J. Broken chains and reneging: a review of 1748 kidney paired donation transplants. Am J Transplant. 2017;17(9):2451-2457. doi: 10.1111/ajt.14343 
  7. Serrano OK, Kandaswamy R, Gillingham K, Chinnakotla S, Dunn TB, Finger E, et al. Rapid discontinuation of prednisone in kidney transplant recipients: 15-year outcomes from the University of Minnesota. Transplantation. 2017;101(10):2590-2598 doi: 10.1097/TP.0000000000001756 
  8. Serrano OK, Kirchner V, Bangdiwala A, Vock DM, Dunn TB, Finger EB, et al. Evolution of living donor nephrectomy at a single center: Long-term outcomes with 4 different techniques in greater than 4,000 donors over 50 years. Transplantation. 2016;100(6):1299-305 DOI: 10.1097/TP.00000000000001251 
  9. Singh A, Ramachandran S, Graham ML, et al. Long-term tolerance of islet allografts in nonhuman primates induced by apoptotic donor leukocytes. Nature Comm. 2019 Aug 2; 10, Article number: 3495. 
  10. Executive Order on Advancing American Kidney Health. 2019 July 10. Washington, DC: The White House. Accessed August 13, 2019.

When to refer

The University of Minnesota Health transplant program has more than 50 years of experience in the care of organ and cell transplant patients, including care for those receiving kidney, heart, lung, liver, islet, and pancreas transplants, among others. We manage one of the longest-established programs in the world and have cared for more than 12,000 transplant patients. A participant in the National Kidney Registry, Alliance for Paired Donation, and UNOS Kidney Paired Donation Programs, the University of Minnesota Health Incompatible Kidney Transplant Program is among the most active in the country. Our teams are highly skilled at treating patients who have disorders involving more than one organ, and our nephrology group has been consistently ranked as a top provider by national organizations. 

Our kidney transplant program has pioneered kidney transplants in children and in patients with diabetes, and it has transplanted kidneys in patients with concomitant diseases and in those requiring retransplantation. We have performed more than 9,000 kidney transplants. Our program also has experience in living-donor transplants, which can be done before a patient requires dialysis and provides better results. Our established paired exchange program PEP! is an option for those whose donors are not a match. The program has led to more than 150 paired donations to date. We also offer desensitization therapy for patients when identifying a precise donor match is difficult. Our experience and long-established nondirected donor program enabled us to participate in the longest multichain kidney transplantation in the United States. Our pioneering research and health care have dramatically improved transplant survival rates and post-transplant quality of life. 

To schedule a consultation or referral, call: 612-625-5115 or 800-328-5465. 

To find current clinical trials available through M Health providers, visit

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