Living donor exchange programs: theory and practice.

BACKGROUND: The crisis in organ availability has triggered innovative approaches to meet a rapidly expanding worldwide demand for donor kidneys. HLA and ABO incompatibility represents one of the most significant barriers to optimizing the utilization of living donors. Kidney paired donation (KPD) allows patients with incompatible live donors to receive compatible or better-matched organs by exchanging donors. SOURCES OF DATA: The data presented in this review have been published and represent the most up-to-date sources of the theory and practice of KPD. AREAS OF AGREEMENT: There is wide agreement that in most cases the best transplant solution for a patient with an incompatible donor is to receive a compatible organ in a KPD. AREAS OF CONTROVERSY: There has been disagreement about the capacity of KPD to solve the incompatibility problem. However, it is now clear that not all phenotypes will benefit from KPD. GROWING POINTS: Combining KPD with desensitization greatly expands the boundaries of each of these modalities.