E D I T O RI A L KERALA MEDICAL JOURNAL

Swap Donation: New Hope for Transplant Patients

Published on 30th March 2018

The quest for transplantable organs is upmost in the pairs who want a lower lifetime mortality1,8 and longer
minds of any patient with irreversible organ failure lasting transplant.2
when they are placed in the transplant list. There is
a huge demand supply mismatch that makes this HISTORY14
problem a real concern for the potential recipient
and the family and well-wishers. The supply of organs Year Event
comes from related live donors, unrelated live donors
and deceased donors from brain dead donors. In India 1986 KPD first suggested by Rapaport
the potential renal recipients are nearly 1.5 lakhs yearly 1991 First KPD program started in South Korea by
whereas the annual kidney transplant rate is probably Dr. Park
ten thousand. The ratio is more alarming when liver
1999 First European KPD transplants performed in
transplant is considered.
Switzerland
The latest method to overcome this huge deficit is 2000 First KPD transplants performed in USA at the
the Swap Donation method. Kidney Paired Donation Rhode Island Hospital
(KPD) or Paired Exchange is an approach to live
donor kidney transplantation where patients with in- 2001 Hopkins completes KPD transplants and begins
compatible kidneys swap kidneys to receive a compati- first KPD program in USA
ble kidney. Ideally it is used where a potential donor is 2004 Dutch established first national KPD program
incompatible. Since better donor HLA and age match
is correlated with lower lifetime mortality1 and longer 2007 NEAD chain started by APD utilizing first
lasting kidney transplants,2 many compatible pairs bridge donor
are also participating in swap donations to get more 2007 Charlie Norwood Living Organ Donation Act
compatible kidneys. In the US, the National Kidney clarifies legality of KPD in USA
Registry organizes the majority of US KPD transplants
2008 National Kidney Registry organizes its first
including large swap series. It is also organized by
transplants on Valentine’s Day
UNOS3 and the Alliance for Paired Donation.4 Large
swap chains involving 60 pairs in 20125 and 70 pairs 2009 Hopkins leads first 16 patient multi-centre
in 20146 have been organized and completed. Domino Chain

More than one-third of potential living kidney donors 2010 UNOS organizes its first KPD transplants
who want to donate their kidney to a friend or family 2012 National Kidney Registry completes largest
member cannot donate due to blood type or antibody chain involving 60 participants
incompatibility.7 Traditionally, these donors would be
2014 National Kidney Registry sets new record with
rejected and the patient would lose the opportunity to
70 participant chain
receive a life-saving transplant. KPD overcomes donor-
recipient incompatibility by swapping kidneys between 2017 First Academic Paper published on “Chrono-
multiple donor-recipient pairs. KPD is also being used logical Incompatibility” outlining the ADP
to find better donor-recipient matches for compatible Voucher Program”

Cite this article as: Vasudevan S. Swap Donation: New Hope for Transplant Patients. Kerala Medical Journal. 2018 Mar 30;11(1):1–3.

Corresponding Author:
Dr Vasudevan S, Professor, Department of Urology, Government Medical College, Trivandrum; Chief Editor, IMA, KMJ.
E-mail:[email protected]
Kerala Medical Journal | January-March 2018 | Vol XI Issue 1 1
Vasudevan S. Swap Donation: New Hope for Transplant Patients

OUTCOMES Situation in India

Researchers have also discovered that better HLA The Swap Donation programme in India has been
matching not only leads to longer lasting transplants,2 active for at least 10 years now. Over 1000 cases have
but is also correlated with lower patient mortality been performed. The Institute for Kidney Diseases and
rates1,8,9 because better matched kidneys require less Research Centre Ahmedabad (IKDRC) has performed
immunosuppression and less immunosuppression over 300 cases.16 Apex Kidney Foundation in Mumbai
reduces nephrotoxicity and other negative side effects has the Apex Swap Transplant Registry.17 ASTRA is
from post-transplant anti-rejection medications. a database of patients who need kidney transplant
Equally important, better HLA matching reduces along with their family-donors who cannot donate
the number of antibodies that a transplant recipient their kidney because of blood group mismatch. This
will create making it easier to get a second, third or data base is scientific and credible. The computer
fourth transplant.10 This issue is critical for young generates swap pairs based on a few criteria like age
transplant recipients who have a life expectancy that is of the donor, lymphocyte crossmatch, etc. ASTRA will
longer than the expected graft survival (i.e. how long register patients and donors, search and match pairs
a transplanted kidney lasts). Deceased donor kidneys from the data pool and identity compatible donor-
typically last 5 – 15 years11 and living donor kidneys patient pairs.
typically last 10 – 30 years.11
Situation in Kerala
Compatible pairs
The Kerala Government has issued orders facilitating
When KPD first started, the focus was only on the performance of Swap donations. In a bid to end
enrolling incompatible donor-recipient pairs. As rampant organ trade and simultaneously assist in the
paired exchange grew and the process became faster conduct of more transplants for critically-ill patients,
and more reliable, patients with compatible donors the Kerala government is slated to introduce a method
that wanted a better match, began enrolling in KPD. of swap donation purely on altruistic means. Through
Researchers have identified that a better matched this programme, for example, a husband, incompat-
kidney is correlated with better outcomes. Specifically ible to donate his kidney for his wife, can donate for
a better matched kidney lasts longer2 and may allow a stranger of another family, provided anyone related
for a lower dosage of post-transplant immunosup- to the stranger can do the same in return for his wife.
pressive medications.2 Also a better matched kidney This will eliminate the problem of living donors who
transplant is correlated with a lower lifetime mortality are unable to donate to their own family members
rate.1,8,9 simply because they are incompatible medically.

For compatible pairs, not only does a better match While this mode of organ donation is done on a
lead to a better outcome, but it also directly helps minimal scale at select hospitals in the state, this is the
other patients with incompatible donors find a match first time it will be recorded and channelized by the
and get transplanted. A favourable blood type com- government through the Kerala Network for Organ
patible pair (i.e. O donor with non-O recipient) will Sharing (KNOS), the nodal agency that keeps a track
facilitate at least 1 and as many as 6 additional trans- of the patients waiting list for transplant of different
plants.12 Compatible pair participation is the fastest organs.
growing segment of KPD12 and holds the promise of
In February, the health and family welfare department
facilitating better matches for patients with compat-
of the state government issued guidelines for altruistic
ible donors while limiting KPD wait times to less than
and swap donation after the proposal was discussed
12 months for patients that have a cPRA less than
at a meeting of the Cadaver Transplantation Advisory
98%.
Committee (CTAC) on January 27.
Advanced Donation
“(When) there is more than one pair and if more than
Advanced Donation is the process of donating in one hospital is involved, the donor will have to travel
advance for a future patient who may develop renal to the recipient hospital, the donor organ removal must
failure 15-20 years later.13 This began in 2012 and be started simultaneously in both the hospitals. If there
expanded so rapidly that by 2017 Advanced Donation is more than one pair, donor-recipient matching will
accounted for nearly half of the chain starts in the be done by a computer-assisted matching algorithm
United States. which will be designed by NIC. The patients with

2 Kerala Medical Journal | January-March 2018 | Vol XI Issue 1

kidney failure, who have a blood group, compatible mal matching and helps find donors for pairs with
donor (near relative), but with positive lymphocyte no matching between the pairs. The experiences in
crossmatch, can be registered under Swap Donation Western nations, India and Kerala are discussed.
Registry,” the government order read.15
REFERENCES
The government has stressed that these cases of swap
donation have to be approved by the authorisation 1. 2007, Taoti Enterprises International | Web Design and Marketing |
committee of the hospital/district/state in which the www.taoti.com - August. “Compatible Pairs - National Kidney Reg-
istry - Facilitating Living Donor Transplants”. Retrieved 2016-08-26.
transplant is scheduled to be done. Swap donation is
2. Milner J, Melcher ML, Lee B, Veale J, Ronin M, D’Alessandro T,
only permitted among near relatives of the patients. et al. HLA Matching Trumps Donor Age: Donor-Recipient Pairing
Characteristics That Impact Long-Term Success in Living Donor
The objective is to remove middlemen who stand to Kidney Transplantation in the Era of Paired Kidney Exchange.
gain financially through organ trade. The government Transplant Direct. 2016 Jul;2(7):e85.
will take the role of a middleman to ensure the trans- 3. Ellison B. A Systematic Review of Kidney Paired Donation: Ap-
plying Lessons From Historic and Contemporary Case Studies
plants take place legally.
to Improve the US Model. Wharton Research Scholars [Internet].
2014 May 16;
Swap Liver transplantation
4. “About Alliance for Paired Kidney Donation: Matching Donors”.
Swap liver transplantation is performed when there is Retrieved 2016-09-12.

no donor whose blood type is compatible with the 5. Sack K. “60 Lives, 30 Kidneys, All Linked”. The New York Times
[Internet]. 2012 Feb 18 [cited 2018 Jul 30];
patient. Those whose blood type is incompatible but
6. Pitts; Louszko; Cappetta; Effron; Valiente (15 Apr 2015). “Chang-
wish to donate their liver to relatives may apply to ing Lives through Donating Kidneys to Strangers”. ABC News
transplantation centre to be prepared for swap trans- Nightline.
plantation. Some hepatic patients cannot receive 7. Segev DL, Gentry SE, Warren DS, Reeb B, Montgomery RA. Kid-
organs from their donors because of the blood incom- ney paired donation and optimizing the use of live donor organs.
JAMA. 2005 Apr 20;293(15):1883–90.
patibility. Between couples having the same problem,
8. Opelz G, Döhler B. Association of HLA mismatch with death with
the transplantation is possible from the donor of one a functioning graft after kidney transplantation: a collaborative
to recipient of the other. transplant study report. Am J Transplant. 2012 Nov;12(11):3031–8.
9. Cecka JM. Does flow cytometry crossmatch predict renal allograft
After performing all blood tests of the pairs, the outcome in patients with a negative antiglobulin crossmatch? Nat
weight and anatomy of their liver is examined. The Clin Pract Nephrol. 2007 Mar;3(3):136–7.
pairs found compatible are met under the supervision 10. Meier-Kriesche H-U, Scornik JC, Susskind B, Rehman S, Schold
of our liver transplantation coordinators. JD. A lifetime versus a graft life approach redefines the importance
of HLA matching in kidney transplant patients. Transplantation.
2009 Jul 15;88(1):23–9.
In swap transplantation, the surgeries of the donor and
11. Organ Procurement and Transplantation Network and Scientific
recipient are started at the same time and the livers are Registry of Transplant Recipients 2010 data report. Am J Trans-
simultaneously removed to perform the transplanta- plant. 2012 Jan;12 Suppl 1:1–156.
tion procedure. 12. National Kidney Registry - Facilitating Living Donor Transplants
[Internet]. [cited 2018 Sep 21]
13. Veale, Jeffrey L.; Capron, Alexander M.; Nassiri, Nima; Danovitch,
END NOTE Gabriel; Gritsch, H. Albin; Waterman, Amy; Del Pizzo, Joseph;
Hu, Jim C.; Pycia, Marek (September 2017). “Vouchers for Future
Author Information Kidney Transplants to Overcome “Chronological Incompatibility”
Vasudevan S, Professor, Department of Urology, Between Living Donors and Recipients”. Transplantation. 101 (9):
2115–2119.
Government Medical College, Trivandrum
14. Wikipedia. Kidney Paired Donation. [Internet]. 2018 [cited 2018
Chief Editor, IMA, KMJ. Aug 10].
Conflict of Interest: None declared 15. Kerala gears up to introduce swap donation to cut down on organ
trade. The Indian Express [Internet]. [cited 2018 Aug 10].
Editor’s Remarks: This article relates to the latest 16. Institute of Kidney Diseases and Research Centre Ahmedabad: In-
concept in voluntary organ donation. This method stitute of Transplantation Sciences [Internet]
is helping better outcomes for pairs with subopti- 17. Apex Swap Transplant Registry (ASTRA). [Internet]. [cited 2018 Sep 21]

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