Background: Our center has established a very large single center kidney paired donation (KPD) program. A significant barrier to KPD transplant has been the unbalanced blood types in the KPD pool which develops over time, including many blood type O recipient candidates and many non-O donor candidates. Additionally, highly sensitized recipient candidates are in competition for rare donor HLA types. Computer modeling has shown that KPD can be significantly expanded by participation of compatible pairs, particularly to enrich the pool of O donors and utilize donors with rare HLA types. Here we report our experience utilizing compatible pairs as a part of our KPD program. Methods: All recipients with consented incompatible donors were entered into our KPD database. In addition, compatible pairs with older donors that were not HLA identical were approached for consent into the database. Compatible recipients were only offered a kidney from a younger exchange donor. Results: Since February 2009, 23 compatible pairs have been utilized in KPD transplants at our single center, including 14 2-way exchanges, 5 3-way exchanges and 4 chain exchanges (chain lengths 10-23 recipients.) Of the compatible pairs, 8 recipients were blood type O and 15 were non-O; 21 donors were blood type O, 1 was type A2 and 1 blood type A1. In marked contrast, of the incompatible pairs which benefited, 20 recipients were blood type O and 3 were non-O; 10 donors were blood type O, 11 were blood type A1 and 2 blood type B. Of the compatible KPD recipients, none were sensitized, whereas of the incompatible recipients 15 were sensitized, 9 with cPRA >80%. All compatible KPD recipients were transplanted with younger kidney donors. The median age of compatible donors was 57 years whereas the median age of incompatible donors was 29 years. Patient and allograft survival are 100% for both compatible and incompatible groups, median follow up 28 months. The compatible KPD option was viewed as favorable by the majority of pairs approached for consent. Conclusions: This is the largest reported experience of compatible pairs utilized in KPD. When employed in a large KPD program, compatible pairs with O donors significantly expand KPD options for both blood type incompatible pairs and highly sensitized recipients. Utilization of compatible pairs should be expanded nationally to increase the opportunity for incompatible pairs to be transplanted through KPD.

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