*Purpose: The six components of the new strategy are Universal flexible assignments of unacceptable antigens (UA); individualized deletion of carefully selected UA; inclusion of compatible pairs (CP) for better HLA class II match (DRBI, DQB), better LKDPI score, and lower Eplet mismatch (EpMM) load; low-risk HLA desensitization; low-risk ABO-incompatible (ABO I) matching; and increasing the length of match cycles up to five pairs.

*Methods: We utilized high-frequency match run. The number of pairs in each match run never exceeded 65 pairs. The relative contributions of KPD candidates to our pool were: HLA I: 55-60%; ABO I: 15-20%; CP: 20-25%.

*Results: Between May 2016 – August 2021, and out of 111 cPRA 95-100% HLA I candidates, 63 (58%) were matched and transplanted (93% cycles and 7% chains). In all transplants, at least one component of our combined strategy contributed to successful matching. The average age of our transplant cohort was 50 years (range: 21-67); 52/63 (83%) were females, and 16/63 (25%) had a prior solid organ transplants. Over an average follow-up of 26 months (range: 1-72), patient survival was 97%, death-censored graft survival was 100%, incidence of AAMR was 0%; ACR was 18%. Average LKDPI score of the exchange donors was -3.3 (range: -44 to 42), average EpMM was 18 (range: 0-68) and the average percentage of HLA class II match was 65% (range: 0-100).

*Conclusions: Our combined KPD matching strategy at a single center yielded successful kidney transplantation to more than 50% of otherwise very difficult to match and transplant KPD candidates.

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