Kidney exchange in Italy is now making good use of deceased-donor initiated chains.
Original ArticleIntegrating Deceased and Living Donation: Six-Year Outcomes of the Italian Deceased-Donor–Initiated Kidney Paired Exchange (DEC-K) Program
ABSTRACT
Using a deceased donor (DD) to initiate living-donor (LD) exchange chains can expand access to kidney transplantation in recipients with an HLA or ABO incompatible living donor. The Italian DD-initiated Kidney Paired Exchange (DEC-K) program uses a DD kidney to start a chain among incompatible pairs, ultimately returning a LD kidney to the waiting list. We report the first long-term analysis of this approach worldwide. All DEC-K chains performed in Italy between March 2018 and May 2025 were analyzed. Thirty-four chains generated 84 transplants (34 chain initiating kidneys CIK, 22 from LD, 28 chain-ending kidneys CEK) versus 17 transplants from conventional Kidney Paired Donation (KPD) program in the same period. Five-year outcomes were similar between CIK and LD recipients (eGFR slope: −2.0 mL/min/1.73m2/year, P=0.37; graft survival: log-rank P=0.28). While this approach diverts blood-group O DD kidneys from the general waiting list, potentially affecting non-sensitized candidates, it was designed to address the unmet needs of highly sensitized patients facing years of waiting. In the Italian setting, the DEC-K program successfully initiates LD chains from DD kidneys with outcomes equivalent to LD transplant; implementation should include monitoring of blood-group-specific outcomes and flexible design to accommodate healthcare system priorities.
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"DISCUSSION
The six-year DEC-K experience demonstrates that DD-initiated KPD chains are highly effective in small national pools such as Italy’s, which include about 70 incompatible pairs at a time. Because closed-loop exchanges rarely provide enough matches, especially for blood group O or highly sensitized recipients, open chains initiated by DDs can convert a single graft into multiple sequential transplants without simultaneous multi-center surgery. In our program, 34 DDs generated 84 transplants, corresponding to a threefold increase compared to conventional loops in the Italian KPD. Broader enrollment could further enhance impact, although participation remains limited by concerns about receiving a DD kidney while the paired LD proceeds, underscoring the need for transparent counseling and clear communication about outcomes and equity.
The rationale for DEC-K aligns with models proposed by Melcher and later implemented by Furian, in which a SCD kidney is allocated to an incompatible pair whose LD subsequently donates to another recipient, propagating the chain21, 23, 29. Similar donor-driven chains were pioneered in the United States, where Rees demonstrated that a single altruistic donor could initiate a ten-transplant sequence14. Mathematical modeling by Wang et al.23 supports this approach, showing that allocating just 2-3% of DD to initiate KPD chains could generate several hundred additional transplants annually, with maximum benefit for highly sensitized and blood-group O candidates23. In countries with rare or restricted altruistic donation and small KPD pools, such as Italy, DD initiation is the only practical way to generate compatible matches. Over the past decade, only ten non-directed donors enabled 30 transplants and unlocked 21 incompatible pairs, substantially fewer than DEC-K.
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Earlier:
Monday, April 11, 2016 Using deceased donor kidneys to start living donor kidney exchange chains
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