*Purpose: Despite advances in diagnostics and therapeutics, kidney allograft survival rates have not increased considerably. Kidney For Life (KFL) through NKR aims to increase access for a zero-low eplet mismatch living donor kidney transplant, hence better allograft survival through the lifetime of the patient, via a national paired donation program. Through our participation in KFL via NKR, we sought to add value to CLD. We hypothesized that CLD pairs in KFL(intervention group) would obtain a lower eplet mismatches through swap when compared to their original intended donors and CLD direct donor pairs (control group), without prolonging their wait times.

*Methods: CLD from June 2020 onwards were consented for KFL. Eplet mismatch data were collected both for original CLD pairs, and CLD swap donor in KFL. For CLD direct pairs, outside of KFL, eplet mismatch data was collected as well (control group) (Figure 1). Human Leukocyte Antigen (HLA) DQ/DR eplet mismatch risk score were classified as in Figure 2. For all KT, induction immunosuppression was changed from thymoglobulin to Simulect for cPRA ≤ 20%, with no recurrent disease as primary etiology, and zero to low eplet mismatch scores.

*Results: 35 Living KT; 26 were CLD, 9 were incompatible CLD (ICLD) were performed. Out of 26 CLD: 46.2% underwent KFL swap donation; 53.8% underwent direct donation outside of KLP. Table 1 shows the baseline characters of CLD direct donation, CLD swap and ICLD . High eplet mismatch risk scores for CLD swap pairs were significantly lower than original pair donor (1 vs 10, p = 0.05) and when compared with CLD direct donation outside of KFL (1 vs 7, p = 0.02) (Figure 3). The average wait time for CLD swap pair in KFL was 1 month versus 6.5 months (p=0.007, Figure 4) for ICLD pairs in KFL, using latter as a reference. Thymoglobulin was replaced with Simulect in 5 of the 10 CLD swap pair, and only for 2 of the CLP direct donation. Allograft survival was not significantly different between the groups (Figure 5).

*Conclusions: KFL shifts the paradigm by directing focus at lifetime benefit to recipients and donors rather than a narrow focus on the proximate transplant episode. KFL adds value to CLD by offering swap donor to significantly reduce eplet mismatches, when compared to original CLD and CLD direct donor without prolonging wait times. Induction immunosuppression was significantly and successfully changed to simulect, which has cost savings and potential downstream less infectious complications without allograft compromise.

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