Failure to convert computer-identified possible Kidney Paired Donation (KPD) exchanges into transplants has prevented KPD from reaching its full potential. The purpose of this study is to analyze the reasons why computer-generated possible KPD exchanges fail to progress to successful transplants.

The Alliance for Paired Donation (APD) utilizes an optimization algorithm to generate possible KPD exchanges. Possible exchanges are presented to transplant centers for review, at which point they become formal offers. Each offer is composed of 1-11 individual, or 1-way, exchanges. When offers failed to progress to transplant, the reason for failure was documented.

From January 2008 through August 2014, 978 possible 1-way KPD exchanges were offered to transplant centers. Of these, 181 resulted in transplants, 268 failed for a specific identifiable reason, and the remaining 529 failed due to dependency on a 1-way within the same offer that failed for a specific identifiable reason. Several reasons for failure have occurred predictably, and were thus potentially preventable. These modifiable reasons for failure (MRFs) include positive crossmatch, competing offer outside the APD, and donor declined by transplant center. MRFs accounted for 57% of specific reasons for failure.

MRFs represent a significant challenge to all KPD registries. In order to decrease the frequency of transplant centers rejecting donors, the APD has begun presenting potential donors to transplant centers for review before a formal offer is made, thus allowing centers to decline donors prospectively. While a centralized tissue typing lab and stringent tissue typing requirements have been implemented, the APD pool has become increasingly saturated with highly sensitized patients, thereby increasing the probability of a positive crossmatch. Indeed, the percentage of the pool with PRA >80 has increased from 31% in 2008 to 47% in 2014. Many patients choose to enroll in multiple KPD registries to improve their chances of matching. While this is good for some patients, for others it results in wasted time and effort in generating futile exchanges involving patients already committed to alternative exchanges. These latter two MRFs highlight the need to expand the donor pool to increase options for highly sensitized patients, as well as the need for better coordination to avoid competing KPD offers.

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