Deceased-donor initiated kidney exchange chaiins in Italy, after six years

 Kidney exchange in Italy is now making good use of deceased-donor initiated chains.

 

American Journal of Transplantation

Available online 10 August 2026

In Press, Journal Pre-proof

Original Article

Integrating Deceased and Living Donation: Six-Year Outcomes of the Italian Deceased-Donor–Initiated Kidney Paired Exchange (DEC-K) Program

Author links open overlay panel, , , , , , , , , , , , , , , , , , , …

 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.

... 

 "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

 

Deceased-donor-initiated kidney-exchange chains are performing well in Italy

 Here's a new report from Italy on initiating kidney exchange chains with a deceased donor.*  In Italy to date, 34 deceased donor initiated chains generated 84 transplants (34 from deceased donors  and 50 from living donors), including 56 among incompatible pairs and 28 to candidates on the waitlist.

Furian L., Di Bella C., Maggiore U., Fiaschetti P., Partelli S., Feltrin G. Integrating Deceased and Living Donation: Long-Term Outcomes of the Italian Deceased-Donor-Initiated Kidney Exchange (DEC-K) Program AJT_ 26/7S1, Volume 26, Issue 7, S1. The cover date will be July 2026. 

"Integrating deceased and living donation through deceased-donor (DD)-initiated chains can expand kidney transplant access in small paired exchange pools. The Italian DEC-K program allocates a DD kidney to initiate a chain (chain-initiating kidney, CIK) among incompatible living-donor (LD) pairs, ultimately returning a LD kidney to the national waiting list (WL). We report the first long-term national results of this donor organ allocation model.
 

"Methods: All DEC-K chains performed in Italy (2018-2025) were retrospectively analyzed. Recipients were stratified by kidney source (CIK vs LD).

...
"Results: Thirty-four DEC-K chains generated 84 transplants (34 DD and 50 LD), including 56 among incompatible pairs and 28 to candidates on the WL. Donor withdrawal occurred once. Four chains were terminated early after CIK transplantation due to newly developed contraindications to donation. At a median follow-up of 60 months, 1- and 3-year graft survival was 100% in both groups, while patient survival was 97.1% for CIK and 98.0% for LD. Three CIK and one LD recipients died with functioning graft (suicide, sepsis, urothelial carcinoma, and acute myocardial infarction, respectively). One CIK recipient experienced graft loss after 40 months due to chronic rejection. Adjusted eGFR trajectories were comparable between CIK and LD (P = 0.48). Chain-ending kidney recipients, with 4 graft loss overall (1 antibody-mediated rejection and 3 vascular thrombosis), showed outcomes comparable to LD (P = 0.64 for eGFR; P = 0.57 for graft survival).
 

"Conclusions: The DEC-K program proved feasible, safe, and effective in expanding transplant opportunities for incompatible and hard-to-match patients."

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* Some earlier posts on deceased donor initiated chains:

Sunday, April 3, 2022

Kidney Paired Donation Chains Initiated by Deceased Donors

Monday, November 22, 2021

A naturally occurring deceased-donor-initiated kidney exchange chain, by Maghen and Veale

Sunday, August 23, 2020

More on Deceased donors as non‐directed donors in kidney exchange chains

Tuesday, August 7, 2018

Deceased donor chains: Market design language is entering transplantation

Monday, April 11, 2016

Using deceased donor kidneys to start living donor kidney exchange chains

 

Four international kidney exchange programs: 3 achieve substantial success

 Here's a paper reporting on the experience of four cross-border kidney exchange programs, whose experience teaches an important lesson.  In particular (see the figure below), one of  the programs is run by Spain, Italy and Portugal, whose  total population of approximately 118 million people is far larger than the combined population of the other three*, but manages to do less than 5% of the total cross-border exchanges, far fewer than any of the others.  Despite its size, the Spain-Italy-Portugal program only tries to match hard-to-match patient-donor pairs with other hard-to-match pairs, unlike the other three programs.

 International Kidney Paired Donation Programs: Evolution and Practices of 4 Large Collaborations
Klimentova, Xenia PhD1; Domínguez-Gil, Beatriz MD, PhD2; Viana, Ana PhD1,3; Manlove, David PhD4; Andersson, Tommy PhD5; Ashkenazi, Tamar RN, PhD6; Berlakovich, Gabriela MD7; Böhmig, Georg A. MD8; Burton, Jo RN, PGDip9; Coll, Elisabeth MD, PhD2; Dittmer, Ian FRACP9; Fiaschetti, Pamela MD10; Fronek, Jiri MD, PhD11; Hughes, Peter D. MBBS, PhD12,13; Ivo da Silva, Margarida MD14; Mor, Eytan MD15; Viklický, Ondřej MD, PhD16; Weinreich, Ilse Duus BMLS17; Ferrari, Paolo MD, FRACP18,19
Transplantation ():10.1097/TP.0000000000005602, December 24, 2025. | DOI: 10.1097/TP.0000000000005602

"Plain Language Summary: Kidney paired donation (KPD) programs are organized in various countries to facilitate the donation of kidneys from willing but incompatible donors by matching them with pairs in similar situations. These programs often struggle with an accumulation of difficult-to-match recipients and small pools of incompatible pairs. To address this, several international collaborations have emerged to expand the pool sizes and increase the number of transplants by “exchanging” donors’ kidneys across countries. We identified 4 established international KPD programs, each supported by protocols and agreements signed by the participating parties. Each program is presented separately, detailing its historical establishment, operational aspects, and statistics on pool characteristics and performance. Following this, we provide a comparative analysis of key aspects across the 4 programs. Each program has its unique context and specificities. Even though 3 of 4 collaborations started just before the COVID-19 pandemic, they have collectively facilitated >450 transplants. This underscores the importance of further developing these collaborations to share practices and experiences, and to facilitate more transplants, particularly for difficult-to-match recipients. Three of the 4 presented collaborations are either fully operated or led by European countries. This highlights the crucial role of ongoing international cooperation in the development of KPDs, in particular in Europe. By further promoting collaboration among countries, we can facilitate pan-European exchanges and improve access to live kidney transplants for patients in need.

 ...

"A fundamental difference between the programs is their collaboration model. STEP, ANZKX, and the Czech-Austrian-Israeli collaboration operate as “merged pool” model, where all participating pairs are combined for joint matching runs. For STEP and ANZKX, no other matching runs are conducted by partners at any level (hospital or national), whereas in the Czech-Austrian-Israeli collaboration, the Austrian and Israeli partners report performing local exchanges whenever compatible pairs are identified.
 

"In contrast, KEPSAT uses a “sequential pool” model, where national matches are attempted first, and only unmatched pairs are entered into the international pool. It is recognized that the last 2 strategy strategies may lead to a fragmented market, potentially limiting matches for highly sensitized patients, as easier-to-match pairs are removed beforehand."

 It's ironic that a program that appears to be intended primarily to help hard-to-match pairs is organized in a way that limits them in this way.

The paper concludes on an optimistic note (with which I fully agree):

"In conclusion, ongoing international cooperation is essential for advancing KPD programs globally. Expanding cross-border exchanges and improving access to kidney transplants can greatly benefit patients worldwide. Additional strategies, such as NDADs, desensitization protocols, and the inclusion of compatible pairs, can further enhance the effectiveness of both national and international programs. Oversight of these initiatives is crucial to safeguarding the welfare of both donors and recipients, as well as to maximizing the success rates of kidney transplants.
 

"Looking ahead, new initiatives, and projects, funded by international health organizations, such as the European Kidney Paired Exchange Programme project (https://www.hnbts.hu/euro-kep/project), funded by EU4Health and starting in November 2024, aim to expand global collaboration among KPD programs, building on and strengthening existing partnerships. This increased international cooperation is expected to create additional opportunities for patients in need of kidney transplants worldwide, making life-saving transplants accessible to more individuals regardless of their geographic location."

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Earlier: Portuguese transplant docs noted the problem and argued for more global kidney exchange:

Tuesday, March 12, 2024 Kidney exchange between Portugal and Spain, and prospects for global kidney exchange

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*Notes on population:

Spain: 49 million; Italy 59 million; Portugal 10 million ; KEPSAT total pop =  approx 118 million

 Australia 28 million; NZ 5 million: ANZKX total pop approx 33 million

Austria: 9 million, Czech Republic  11 million, Israel 10 million: AT-CZ-IL total 30 million

Sweden: 11 million; Norway:  6 million; Denmark 6 million; Finland  6 million: STEP total approx 29 mil

Notes from Messina (kidney exchange and the Accademia Peloritana dei Pericolanti)

 We traveled last week from Prague to Sicily, for the Matching in Practice workshop in  Messina, which was rich in kidney exchange. I was glad to reconnect with the Director of the National Transplant organization, Dr. Giuseppe Feltrin, and with Professors Antonio Nicolò and Antonio Miralles.

But a funny thing happened first, at the University of Messina. I was inducted into the university's Accademia Peloritana dei Pericolanti, founded in the early 1700's, at a time when autocrats didn't look fondly on universities (imagine that!). The symbol of the Academy is a ship sailing in the Strait of Messina (between Scylla and Charybdis) with the motto "Inter utramque viam periclitantes," "Taking risks between both paths," reflecting (I was told) the perils of navigating the strait between scholarship and politics.  It seemed very appropriate for the times.

Here's the story in the local news: with a picture:

 

Matching Theory and Market Design: conference in Sicily.

 Here's the preliminary program for the

20th Matching in Practice Workshop  University of Messina, Department of Economics, Aula Magna 2, 15-16 May 2025

Thursday 15 May

9:00-9:15 Opening

9:15-11:00 Presentation session “Matching with externalities and equity concerns I” 

 Alexander Nesterov, Higher School of Economics  “Reserves in Targeted Admissions: A Mechanism Design Approach” 

 Guillaume Haeringer, Baruch College  “School Choice under Uncertainty: an Experiment” 

Antonio Romero Medina, Universidad Carlos III de Madrid  “Optimizing Daycare Enrollment: How To Avoid Early Applications”

11:00-11:15 Coffee break

11:15-13:00 Presentation session “Dynamic matching and incentives to participation I”

 Duygu Sili, Università degli Studi di Messina  “Costly Multi-Hospital Dynamic Kidney Exchange”

 Subhajit Pramanik, Università degli Studi di Padova  “A Dynamic Bargaining Framework for International Kidney Paired Exchange Program”

 Özgür Yilmaz, Koç University “Dynamically Optimal Kidney Exchange” 

13:00-14:00 Lunch

14:00-15:15 Seminar presented by the 2012 Nobel Prize in Economics Prof. Alvin Roth (Stanford University)  “The Economics of Kidney Exchange: Kidneys and Controversies”  (open to the public)

16:00-22:00 Departure to and walk across Taormina, with gala dinner to follow at Ristorante La Botte.

Friday 16 May

9:00-10:45 Presentation session “Matching with externalities and equity concerns II” 

Flip Klijn, Institute for Economic Analysis (CSIC) and Barcelona School of Economics  “Characterizing No-Trade-Bundled Top-Trading Cycles Mechanisms for Multiple-Type Housing Markets”

 Péter Biró, Institute of Economics, HUN-REN KRTK “Ex-post Stability under Two-Sided Matching: Complexity and Characterization”

 Emre Dogan, HSE University “Incentivizing Public Lawyers and Enhancing Fairness via Sorting in Adversarial Systems”

10:45-11:00 Coffee break

11:00-12:45 Presentation session “Dynamic matching and incentives to participation II”

 Pietro Salmaso, Università degli Studi di Napoli Federico II  “Rationalizable Conjectures in Dynamic Matching”

Johanna Raith, IHW – Leibniz Institute for Economic Research “College Application Choices in a Repeated DA Setting: Evidence from Croatia”

 Sonal Yadav, University of Liverpool “Teacher Redistribution in Public Schools”

12:45-13:40 Roundtable  “Organ-donor exchange programs, international comparison” Moderator Prof. Antonio Nicolò (Università degli Studi di Padova), with the participation of Prof. Alvin Roth (Stanford University) and Dr. Giuseppe Feltrin (National Transplant Center)

13:40-14:30 Farewell lunch.

 The MiP Workshop is an annual meeting organized by the Matching in Practice network of European researchers working in the research field of Matching Theory and Market Design.

This year’s MiP workshop is funded by the following projects: Prin2022 “Externalities and fairness in allocations and contracts” (CUP J53D23004650006 – ID 2022HLPMKN) and PrinPNRR2022 “Incentivizing participation of compatible pairs in Kidney Paired Exchange Programs” (CUP J53D23015460001- ID P2022P5CHH), both funded by the European Union – Next Generation EU.

The Organizing Committee includes the Messina Unit Manager of the aforementioned projects, Prof. Antonio Miralles Asensio, and the Principal Investigators of both funding projects, respectively Prof. Maria Gabriella Graziano (University of Naples Federico II) and Prof. Antonio Nicolò (University of Padua). External members of the Scientific Committee are Prof. Caterina Calsamiglia (IPEG and ICREA, Spain), Prof. Rustam Hakimov (Université de Lausanne, Switzerland) and Prof. Péter Biró (Hungarian Academy of Sciences, Hungary).

Kidney exchange in Italy and Europe

 In May, when I spoke at the  Istituto Superiore di Sanità. I was interviewed by TrendSanita, and that interview has just been published. (It's in Italian, but Google Translate works very well):

  A TrendSanità parla il premio Nobel 2012 per l’economia Alvin Eliot Roth: « Il nostro compito come economisti non è solo lavorare a come allocare al meglio risorse scarse ma, possibilmente, fare in modo che diventino meno scarse»  di Cesare Buquicchio  24 Ottobre 2024

["The 2012 Nobel Prize winner for economics Alvin Eliot Roth speaks to TrendSanità: «Our task as economists is not only to work out how to best allocate scarce resources but, possibly, to make them less scarce»}

"In an in-depth analysis of the Italian and international transplant system, Roth highlights the progress and the challenges that remain. " Italy reached the highest level in its history for organ donations in 2023 , but there is still a lot of work to do to bridge the gap between supply and demand, once again, an economic concept," he adds with a smile.

...

"Roth's vision for the future is clear: an integrated European system that allows for the optimization of organ exchanges across national borders, increasing the chances of finding compatible donors for each patient. An ambitious goal that requires not only technological innovation and medical coordination, but also a new understanding of the economic mechanisms that can make the transplant system more efficient. " Economics may seem distant from medicine, but when it comes to saving lives through better allocation of resources, economic principles become valuable tools at the service of public health ," concludes Roth."

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Earlier:

Tuesday, May 7, 2024

Kidney exchange in Italy, Europe and the U.S.: video of my talk in Rome

Italy criminalizes surrogacy from abroad

 Italy has banned its citizens from accessing surrogacy in other countries where it is legal.  It will be interesting to see how they enforce this. (But of course gay couples will have fewer opportunities to skirt the law than couples who could pretend to have had a pregnancy..)

The NYT has the story:

Italy Criminalizes Surrogacy From Abroad, a Blow to Gay and Infertile Couples. The new law was pushed by the party of Giorgia Meloni, Italy’s conservative prime minister. by Emma Bubola

"Italy passed a law on Wednesday that criminalizes seeking surrogacy abroad, a move the country’s conservative government said would protect women’s dignity, while critics see it as yet another crackdown by the government on L.G.B.T. families, as the law will make it virtually impossible for gay fathers to have children.

"Surrogacy is already illegal in Italy. But the government of Prime Minister Giorgia Meloni has vowed to broaden the ban to punish Italians who seek it in countries where it is legal, like in parts of the United States."

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Earlier:

Thursday, August 22, 2024  Surrogacy under continued attack in Italy

Surrogacy under continued attack in Italy

The language of repugnance is strong in these latest developments.

The NYT has the story:

Has Power Moderated Italy’s Leader? Not to Same-Sex Parents.  Prime Minister Giorgia Meloni has mostly shown a pragmatic streak abroad. But at home, her government is plunging many gay families into panic. 

"Surrogacy is already illegal if conducted in Italy. But the government of Prime Minister Giorgia Meloni wants to expand the prohibition. It has promoted a bill that would also punish Italians who make use of surrogacy even in places abroad where it is legal, like in parts of the United States. Those Italians who do could face up to two years in prison and be fined the equivalent of about a million dollars.

"Italy’s lower chamber of Parliament approved the bill last summer, and the Senate’s justice committee greenlighted it last month. The Senate is expected to vote on it as soon as the fall.

...

"No one can convince me that it is an act of freedom to rent one’s womb,”  [Prime Minister Meloni] said in the spring at an event in Rome. “No one can convince me that it is an act of love to consider children as an over-the-counter product in a supermarket.”

“Uterus renting is a shameful, inhuman practice,” she said. “It will become a universal crime.”

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Earlier

Wednesday, April 5, 2023

Surrogacy under siege in Italy

Talks to doctors and students in Italy

 I just returned from a busy trip to Italy, that began with a talk to physicians in Rome about kidney exchange, after which I moved on to talk to students in Padua.

Both were fun in different ways.  Here are some of the students gathered for a spritz after one of my talks in Padua.

The design of markets, in Padua (video)

Yesterday I had the pleasure of speaking about market design in the Aula Magna of the University of Padua, where Galileo lectured.  Below is a video. I start to speak around minute 14:20.

Update: here's a post-talk photo:

Kidney exchange in Italy, Europe and the U.S.: video of my talk in Rome

 Here is a video recording of my talk in Rome yesterday at the  Istituto Superiore di Sanità. There are some introductions by people with vast accomplishments in Italian transplantation and kidney exchange, Giuseppe Feltrin (director of the National Transplant Center), Antonio Nicolò (professor of Economic Theory at the University of Padua) and Lucrezia Furian (Kidney and Pancreas Transplant Surgery Unit - Department of Surgical, Oncological and Gastroenterological Sciences of the University Hospital of Padua)*. 

My talk begins at 27:55.

x

*Although her web page didn't yet reflect this, Dr. Furian was very recently promoted to the rank of Full Professor of Surgery.  Congratulations Lucrezia!