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Letters to the Editor

International Kidney Paired Donation

Garonzik-Wang, Jacqueline M.1; Sullivan, Brigitte1; Hiller, Janet M.1; Cass, Valerie2; Tchervenkow, Jean2; Feldman, Liane2; Baran, Dana2; Chaudhury, Prosanto2; Cantarovich, Marcelo2; Segev, Dorry L.1,3; Montgomery, Robert A.1

Author Information
doi: 10.1097/TP.0b013e3182a68879


We report a 10-way domino transplant (Fig. 1), which was initiated in September 2009 and concluded in July 2010. The uniqueness of this chain was that it included the international exchange of kidneys between the United States and Canada. The chain was initiated by an altruistic donor and included three hospitals, four flights, one international exchange, and one pediatric recipient. The international donor and recipient procedures were performed at McGill University (Montreal, Quebec, Canada) and Johns Hopkins University (Baltimore, MD). Both organs were transported via chartered international flights with cold ischemia times of less than 6 hr, which included not only procurement and travel time but also time for customs clearance. Donor-related expenses were charged at the institution where donation occurred.

Schematic illustration of international domino-paired donation chain. Three institutions participated in this 10-way KPD, which resulted in 10 successful living-donor renal transplants. Intended donor (D)–recipient (R) pairs are depicted on the face of the same domino. Actual donor–recipient pairs are indicated by the colored arrows that correspond to the month of the transplant. The chain was initiated by a nondirected donor (D1) who underwent nephrectomy and donated to the first recipient (R1) on September 8, 2009 at Johns Hopkins (Baltimore, MD). Both international donors were shipped on chartered flights, had less than 7 hr of cold ischemia time, and functioned immediately.

Additional arrangements were necessary to account for a newly developed United Network for Organ Sharing (UNOS) policy. UNOS Policy 3.3.7 was implemented shortly before this planned kidney paired donation (KPD). This policy required that all living-donor kidneys be recovered at Organ Procurement and Transplantation Network member centers in the United States (1). We requested a waiver, given the imminent donor procurement date, allowing this KPD to proceed as planned and requested that UNOS revisit this policy, with such international exchanges in mind. To proceed, we were required to provide a detailed list of McGills’ living-donor protocols, along with written proof that we verified that McGill complied with these protocols. Additionally, McGill University agreed to follow the UNOS policy for living-donor follow-up to ensure that the donor care met certain standards. Currently, all recipients are alive with functioning grafts.


Connolly et al. (2) recently highlighted the advantages of international cooperation and organ sharing in KPD. Successful KPD hinges on a sufficient number of donor–recipient pairs to maximize match rates (3–5). This is especially true for broadly sensitized patients who are searching for rare donor genotypes found in large KPD pools (6). Expansion of KPD practices to include international registries would be the most logical way to increase the donor pool. Currently, active KPD registries exist in many countries including the United States, Canada, the United Kingdom, The Netherlands, Korea, and Spain. KPD sharing between Canada and the United States is logistically tenable due to a shared border, language, and relatively short travel distances. In fact, a chartered flight from Baltimore to Montreal is shorter than many of the current flights for live-donor organ transport in other areas of the United States, which have resulted in prompt allograft function (7). Additionally, the American Society of Transplantation, the American Society of Transplant Surgeons, and the Canadian Society of Transplantation share close collaboration and similar philosophical understandings. It seems logical that the transplant centers in the United States and Canada would benefit by combining KPD pools and allowing more patients to be transplanted. We would suggest re-looking at this UNOS policy with revisions in mind to allow for international exchanges with centers that have regulations and mission to that of UNOS.

In 2009, we demonstrated the feasibility of international participation in a KPD chain by performing a 10-way exchange starting with a nondirected donor, which included one Canadian donor–recipient pair. Both donor and recipient operations were performed simultaneously, requiring meticulous planning to minimize cold ischemia time while transporting the organs on international flights. Factoring time for customs clearance was something that had not previously been a part of organ transport logistics. Additionally, because this exchange occurred before guidance from the Centers for Medicare & Medicaid Services encouraging donor costs to follow a donated kidney to the recipient hospital, donation costs were directed to the donation center. If this exchange were to happen today, arrangements would need to be made with the international donation center to determine how to handle these expenses. This exchange allowed for both centers to successfully transplant sensitized recipients.

In the past two decades, KPD has allowed many highly sensitized patients to identify suitable matches and undergo transplantation, greatly improving their life expectancy, quality of life, and reducing their cost of care (8). New methods to increase KPD pools would only further enhance match rates especially for the most highly sensitized. Expansion of KPD to geographically related countries is the next logical step. The transplant community must act now to remove barriers to a broader implementation of international sharing of KPD lists to further optimize the potential of this modality.

Jacqueline M. Garonzik-Wang


Brigitte Sullivan1

Janet M. Hiller1

Valerie Cass2

Jean Tchervenkow2

Liane Feldman2

Dana Baran2

Prosanto Chaudhury2

Marcelo Cantarovich2

Dorry L. Segev1,3

Robert A. Montgomery1

1 Division of Transplant Surgery

Department of Surgery

Johns Hopkins University School of Medicine

Baltimore, MD

2 Multi-Organ Transplant Program

McGill University Health Center

Montreal, Quebec, Canada

3 Department of Epidemiology

Johns Hopkins School of Public Health

Baltimore, MD


1. Center Acceptance and Transplant of Organs from Living Donors: United Network for Organ Sharing, OPTN/UNOS Living Donor Committee, Policy 3.3.7; 2009.
2. Connolly JS, Terasaki PI, Veale JL. Kidney paired donation—the next step. N Engl J Med 2011; 365: 868.
3. Gentry SE, Montgomery RA, Segev DL. Kidney paired donation: fundamentals, limitations, and expansions. Am J Kidney Dis 2011; 57: 144.
4. Segev DL, Gentry SE, Warren DS, et al. Kidney paired donation and optimizing the use of live donor organs. JAMA 2005; 293: 1883.
5. Roth AE, Sonmez T, Unver MU. Kidney paired donation with compatible pairs. Am J Transplant 2008; 8: 463.
6. Montgomery RA, Lonze BE, Jackson AM. Using donor exchange paradigms with desensitization to enhance transplant rates among highly sensitized patients. Curr Opin Organ Transplant 2011; 16: 439.
7. Segev DL, Veale JL, Berger JC, et al. Transporting live donor kidneys for kidney paired donation: initial national results. Am J Transplant. 2011; 11: 356.
8. Montgomery RA, Lonze BE, King KE, et al. Desensitization in HLA-incompatible kidney recipients and survival. N Engl J Med 2011; 365: 318.
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