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Deceased Donor–initiated Chains

First Report of a Successful Deliberate Case and Its Ethical Implications

Furian, Lucrezia MD1; Cornelio, Cristina PhD2; Silvestre, Cristina MD, PhD1; Neri, Flavia MD1; Rossi, Francesca PhD2,3; Rigotti, Paolo MD1; Cozzi, Emanuele MD, PhD4; Nicolò, Antonio PhD5,6

doi: 10.1097/TP.0000000000002645
Original Clinical Science–General

Background. It has been suggested that deceased donor kidneys could be used to initiate chains of living donor kidney paired donation, but the potential gains of this practice need to be quantified and the ethical implications must be addressed before it can be implemented.

Methods. The gain of implementing deceased donor–initiated chains was measured with an algorithm, using retrospective data on the pool of incompatible donor/recipient pairs, at a single center. The allocation rules for chain-ending kidneys and the characteristics and quality of the chain-initiating kidney are described.

Results. The benefit quantification process showed that, with a pool of 69 kidneys from deceased donors and 16 pairs enrolled in the kidney paired donation program, it was possible to transplant 8 of 16 recipients (50%) over a period of 3 years. After obtaining the approval of the Veneto Regional Authority’s Bioethical Committee and the revision of the Italian National Transplant Center’s allocation policies, the first successful case was completed. For the recipient (male, aged 53 y), who entered the program for a chain-initiating kidney with a Kidney Donor Risk Index of 0.61 and a Kidney Donor Profile Index of 3%, the waiting time was 4 days. His willing donor (female, aged 53 y) with a Living Kidney Donor Profile Index of 2, donated 2 days later to a chain-ending recipient (male, aged 47 y) who had been on dialysis for 5 years.

Conclusions. This is the first report of a successfully completed, deliberate deceased donor–initiated chain, which was made possible after a thorough assessment of the ethical issues and the impact of allocation policies. This article includes a preliminary efficacy assessment and describes the development of a dedicated algorithm.

1 Kidney and Pancreas Transplantation Unit, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy.

2 IBM Thomas J. Watson Research Center, Yorktown Heights, NY.

3 Department of Mathematics, University of Padova, Padova, Italy.

4 Transplant Immunology Unit, Padua University Hospital, Padova, Italy.

5 Department of Economics and Management, University of Padova, Padova, Italy.

6 Department of Economics, School of Social Sciences, University of Manchester, Manchester, UK.

Received 23 May 2018. Revision received 24 December 2018.

Accepted 30 December 2018.

The authors declare no conflicts of interest.

This work was supported by Progetti Strategici di Ateneo—bando 2011, University of Padua: “KIDNEY—Incorporating patients’ preferences in kidney transplant decision protocols.”

L.F. had the original idea, designed the study, and wrote the article. C.C. designed the study and analyzed the data. C.S. and F.N. participated in data collection. F.R. analyzed the data. P.R. designed the study, performed the surgery, and contributed to data interpretation. E.C. interpreted the data and reviewed the article. A.N. designed the study and wrote the article.

Supplemental digital content (SDC) is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (

Correspondence: Lucrezia Furian, MD, Kidney and Pancreas Transplantation Unit, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, via Giustiniani 2, 35128 Padova, Italy. (

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