*Purpose: To avoid the potential for unbalanced altruism for the participation of CP in KPD programs, we sought to define clear criteria for their inclusion and to provide objective metrics for the benefits they derive from participation.

*Methods: We included CP with poor or no HLA match in our KPD pool. Poor HLA match was defined as 6/8 HLA mismatch (HLA A, B, DRBI, DQB matching scheme) or 3/4 HLA mismatch in class II (DRBI, DQB matching scheme). Metrics of benefits to their recipients were: better HLA class II match; better LKDPI score; lower Eplet mismatch (EpMM) load; and avoidance of homozygous mismatch with the exchange donor, as compared with the original donor. The relative contributions of KPD candidates to our pool were: HLA incompatible (HLA I):60%; ABO Incompatible (ABO I): 15%; and CP: 25%.

*Results: Between January – November 2021, 17/67 (22%) of KPD transplants were CP. All were transplanted via 2-4 way cycles. The average age was 35 years (range; 18-63), and 8/17 (47%) were females. CP participation facilitated 19 KPD transplants for cPRA 63-99.8% HLA I candidates and one ABO I candidate. Comparing the exchange donor with the original donor, the average positive delta changes for HLA class II match, LKDPI score, and EpMM load were 47% (range: 0-75%), 22 (range: 0-56%), and 14 (range: 0-33%) respectively. None of CP transplants had homozygous mismatch with their exchange donor.

*Conclusions: CP can achieve balanced altruism for their participation in KPD programs: facilitating transplants of difficult-to-match and transplant KPD candidates on one hand, and providing better quality transplants (better HLA matches and LKDPI scores and lower EpMM loads) for their intended recipients on the other hand.

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