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

 

Kidney exchange in Mississippi (endorsed by celebrities)

 Mississippi Today has the story:

‘Kidney chains’ could save lives and billions of healthcare dollars, advocates say.  by Pat Boone, Robert Hays and Steve Young 

"Editor’s note: Entertainer Pat Boone, Pro Football Hall of Fame quarterback Steve Young and actor Robert Hays of “Airplane” fame signed on as authors of a guest essay provided by US Blood Donors.org for Mississippi Today on “Kidney Chains.”

"This guest essay, though, written from a national perspective is of special importance to MT Ideas since Mississippi is among the states with the highest number of kidney disease-related deaths per 100,000 adjusted for age, according to the National Center for Health Statistics.* 

"Hundreds of thousands of dialysis patients in the United States could receive lifesaving kidney transplants sooner if one simple idea became widely known: “kidney chains”— sequences of living-donor transplants that allow one donor to save multiple lives. 

The goal is simple: Make “kidney chains” a household phrase. 

Kidney chains allow living donors who are incompatible with their intended recipient to help initiate a sequence of transplants that can save multiple lives. The concept builds on Nobel Prize-recognized work** in market design and has already enabled thousands of lifesaving kidney transplants. 

 

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*Figure from the NCHS 

 

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** The video link is to the last three minutes of this 15 minute talk from 2014

Thursday, September 18, 2014  Kidney exchange at Google Zeitgeist 2014: 15 minute video

 

Kidney exchange in Germany can draw on the experience in other countries

 Here's an editorial arguing that as the recently legalized kidney exchange in Germany is implemented, attention should be paid to the controversies that have been encountered and addressed elsewhere, including those about non-directed donors, and the governance and transparency of transplant decisions.

 Benning L, Lu W, Budde K , Josephson, M.  Germany’s move toward kidney paired exchange and non-directed donation: governance lessons from abroad, Kidney International Reports, 2026 

"In 1986 F.T. Rapaport outlined a core idea behind kidney paired exchange: that a registry can coordinate incompatible donor-recipient pairs so that incompatibility becomes a solvable matching problem rather than a barrier to transplantation1. Today, forty years later, Germany is on the verge of making that coordination legally possible. In October 2025, the German federal cabinet approved a draft amendment to the Transplantation Act that would enable kidney paired exchange and non-directed anonymous living kidney donation, while strengthening donor protection and establishing the legal basis for a national program with a central matching function. If operationalized, Germany would move from a restrictive framework for living kidney donation, historically tied to a strict requirement of a close relationship between donor and recipient, toward a governance model that supports kidney exchange and donor chains at scale.

"This moment is internationally relevant because Germany now faces the same policy questions that have shaped kidney paired exchange implementation elsewhere. The impending change creates an opportunity to learn from other countries on key issues, including who should govern a registry, which safeguards ensure legitimacy, how to balance privacy and transparency regarding organ quality, and how to promote access without risking commercialization. Rather than being mere technical considerations, these questions are constitutive for the legitimacy and public trust required for kidney paired exchange to function as a public good. 

"Early debates about living kidney donation repeatedly straddled suspicion and admiration. In the 1970s, living non-related and particularly non-directed donors were sometimes portrayed in medical discourse as psychologically unstable or even pathological, raising concerns about whether such donors should be permitted to proceed2,3. 

...

" History offers two more lessons: (i) Donor protection and respecting donor agency are not mutually exclusive: psychosocial assessment, independent counseling, and rigorous consent procedures can reduce coercion and misunderstanding while still recognizing donors as autonomous agents making a deliberate moral choice. (ii) Public legitimacy is fragile and easily lost: If suspicion dominates, programs risk being viewed as illegitimate or unfair. If, on the other hand, enthusiasm and implementation moves faster than safeguards, programs risk scandal, backlash and, ultimately, lose public support. Germany’s 2012 transplant scandal, involving the manipulation of patient data to improve waiting-list positions, offers a cautionary example of how deficits in transparency and accountability can erode trust in transplantation more broadly and disrupt an entire program4."

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 There are many reviews of the international experience.  Below is a recent one from physicians at Erasmus University in the Netherlands:

Stijn C. van de Laar, Hidde A. de Heus, Annelies E. de Weerd, Matthijs F. Klaassen, Robert J. Porte, Robert C. Minnee Frank J.M.F. Dor, A Comprehensive Review of Strategies to Advance Kidney Exchange Programs and Optimize Effectiveness and Outcomes, Kidney International Reports, Volume 11, Issue 7, July 2026, 106539

"Living donor kidney transplantation (LDKT) offers superior graft survival and cost-effectiveness compared with deceased donor transplantation (DDKT), yet the availability of immunologically compatible living donors limits its reach. Kidney exchange programs (KEPs) can overcome these barriers by matching incompatible pairs through paired exchanges, domino chains, and nonsimultaneous extended altruistic donor (NEAD) chains. This review summarizes the evolution and current landscape of national and international KEPs. We examine operational challenges (cold ischemia time [CIT], logistical coordination, algorithmic fairness, and ethical and regulatory heterogeneity) and explore innovations in matching algorithms, international kidney exchange debates, and machine perfusion technologies. We conclude by proposing strategic priorities to optimize capacity, equity, and outcomes in future kidney exchange efforts. " 

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Earlier: 

Friday, March 27, 2026 Germany legalizes kidney exchange !!

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

 

Felix Salmon, at Bloomberg, reviews Moral Economics

  Felix Salmon, at Bloomberg, reviews Moral Economics, which starting today is now sold in stores (at least in the U.S.):

An Economist’s Case for Selling a Kidney.  In a new book, Nobel laureate Alvin Roth argues that decriminalizing taboo markets can save lives.  

He tells this story from the book:

"Roth gave a talk in 2017 at the Organ Donation Congress in Geneva about one such chain that started in 2015. A woman from the Philippines, known in the literature as FW, was willing to give up one of her kidneys to save the life of her husband, FM. The two flew to the US, where FM received a kidney from an altruistic donor in Georgia, and FW’s kidney was transplanted into a man in Minnesota. A friend of the Minnesota man, who had been willing to give up one of her kidneys to save his life, instead gave one to a man in Washington, whose father-in-law gave a kidney to a woman in Georgia, and so on. By the end of the year there had been 11 successful transplants, and the chain was still continuing.

" After his talk, Roth was confronted by a Spanish doctor who was deeply concerned about the potentially problematic implications of the economic inequality between the Philippines and the US. Roth pointed out that without the transplant, the patient would surely have died. Replied the Spanish nephrologist: “He should be dead!” Spain’s National Transplant Organization later denounced Roth as an organ trafficker.

"Roth tells this story in his most recent book, Moral Economics (Basic Venture, May 12), which, at least in part, is an attempt to apply the empiricism of economics to domains that are often resistant to such analysis. The opposition to the 2015 kidney chain, for instance, comes from nephrologists who have no problem with chains but who draw the line at international chains, or at least chains linking poor and rich countries."

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Much of the objection to cross-border kidney exchange appears to be fading, some of it was based on the idea that countries should be self-sufficient in transplants.

See earlier posts:

Friday, January 9, 2026  WHO Says Countries Should Be Self-Sufficient In (Unremunerated) Organs And Blood by Krawiec and Roth (now open source)

 

Friday, September 11, 2020  Global Kidney Exchange supported by the European Society of Transplantation's committee on Ethical, Legal, and Psychosocial Aspects of Transplantation .

Abundant, the movie about nondirected kidney donors, is now available for streaming.

 Abundant, the movie about (mostly) non-directed (mostly) kidney donors (but also some livers), is now available for streaming.

You can get it at https://abundantmovie.com/ 

You can see all my posts about the movie Abundant here. 

Kidney donation, in today's NYT

 Here's an article and an argument from a nondirected kidney donor, in today's NYT

 Want to Make a Difference? Donate Your Kidney.  by German Lopez, Feb. 2, 2026, 

"Nearly 50,000 people in the United States die each year because there are not enough kidneys for transplant, which adds up to more than double the number of annual murder victims. Hundreds of thousands more are on dialysis, a lifesaving but time-sucking and physically draining treatment. Humans need only one kidney to live, but we have two. Giving away my kidney, to a 23-year-old woman I didn’t know, has been the most fulfilling experience of my life.

...

"The chain is a wonderful, and fairly recent, innovation that has allowed many more people to get lifesaving transplants. Imagine three people — Patients A, B and C — need kidneys. B’s and C’s spouses are willing to donate, but Spouse B is a match for Patient A and Spouse C is a match for Patient B. They all agree to pull the trigger if a donor can be found for the remaining patient, C. An undirected donor can come in at that point to complete the chain of donations. The largest chain on record led to 126 transplants.

...

"I also learned about some of the health care system’s absurdities. As a gay man, I could donate my kidney but not my blood. The government prohibited blood donations from sexually active gay men until 2023, thanks to outdated fears about H.I.V. My kidney was fine, although the doctors had to inform the receiver that it was “higher risk.” Thankfully, the threat assessment did not deter the recipient from accepting my gay kidney.

...

My donation felt like a rejection of the day’s politics — and not just because it required overcoming some light homophobia. It felt like an act of defiance; I was plugging a small hole in a porous health care system while our leaders’ proposed cuts to Obamacare and Medicaid attempted to open a chasm."   

Heroines of organ donation

Last week I had the opportunity to see a screening of the movie Abundant, about non-directed organ donors, who have donated organs to strangers.  Here is a snapshot of me and two of the donors who tell their story in the film, Laurie Lee and Laura Diaz Moore.  They are both pretty inspiring.

 

 See also this story.

The End Kidney Deaths Act is reintroduced to the 119th Congress

 Resolved: lets be generous to nondirected kidney donors

H.R.2687 - To amend the Internal Revenue Code of 1986 to provide a refundable tax credit for non-directed living kidney donations.
119th Congress (2025-2026) |
Sponsor:    Rep. Malliotakis, Nicole [R-NY-11] (Introduced 04/07/2025)
Committees:    House - Ways and Means; Energy and Commerce 

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Earlier

Tuesday, January 21, 2025 The debate over compensating organ donors is heating up

Tuesday, August 13, 2024 End Kidney Deaths Act intoduced in Congress

 

 

Kidney exchange chain at Ohio State--a gift transforms 20 lives

 Here's a recent big kidney exchange chain, begun by a nondirected donor, involving patient-donor pairs all at OSU's medical center

The Columbus Dispatch has the story. (If I had written the headline, it would have said "transforming 20 lives," since many of the donors I've met have also been transformed.)

Ohio State Wexner sets record-breaking kidney 'donation chain,' transforming 10 lives   by Samantha Hendrickson

"On Dec. 13, Samantha Fledderjohann donated one of her kidneys to a stranger in need, and in the process, transformed 10 lives.

The 46-year-old was the first of a record-breaking "chain" of 20 surgeries over a two-day period at the Ohio State University Wexner Medical Center Comprehensive Transplant Center, both to remove and transplant kidneys from 10 living donors to 10 recipients. That means 10 people now have another chance to live more of their lives better and longer with a healthy kidney.

...

"The transplant swap begins with an "altruistic non-directed" donor like Fledderjohann, who saw a need for more kidney donors, and felt an internal pull to donate even without someone in mind

...

"The "chain reaction" continued, thanks to individuals like Carnahan staying on OSU's donor list despite not being a match for a loved one, instead extending that offer to a stranger in need.

...

"According to the Organ Procurement and Transplantation Network, there are 104,840 people on the transplant waitlist and 90,506 need a kidney in the United States, and 2,079 of them live in Ohio. Ohio State’s transplant center has performed more than 8,500 kidney transplants since 1967."