Reasons for failing offers in a Kidney Paired Donation program: A 7-year analysis

Aim Computer-identified possible Kidney Paired Donation (KPD) exchanges are presented as offers to participating transplant programs and eventually converted into transplants. We evaluated reasons why these offers failed to progress into successful transplants. Methods/Results The Alliance for Paired Donation (APD) has an optimization algorithm to generate possible KPD exchanges, which are presented to transplant centers for their review as offers. Each offer may be composed of one to multiple 1-way exchanges. We tracked the progress in moving from offers to transplants and recorded the reason for failure. Between January 2008 and August 2014, the APD made 981 offers. Of these offers 181 resulted in transplants while 800 failed, namely 268 failed for specific reasons while 529 failed as they were dependent on the same 268 1-ways. Overall, specific reasons accounted for 57% of all failures with: 25% positive flow crossmatch (FXM); 13% competing offer outside the APD; and, 19% declined of donors by transplant centers (Fig. 1). Our detail analysis showed that the 25% positive FXM with negative virtual crossmatch (VXM) correlated with an increased number of highly sensitized patients: the pool of sensitized patients with a PRA u003e80% has increased from 31% in 2008 to 47% in 2014. Since many patients choose to enroll in multiple KPD registries some offers resulted in futile exchanges with patients already committed to alternative exchanges. Finally, donors were declined by transplant centers. To avoid these specific reasons for failure, the APD has begun pre-review consulting about donors and recipients prior to making a formal offer. Conclusions To prevent specific reasons for failure the APD has implemented the following changes: (1) testing of all donors for HLA-DQA, DPA and DPB; (2) expansion of the donor pool to increase options for highly sensitized patients; and (3) improved coordination with other KPD programs to avoid competing offers. Download full-size image