Transplant with an incompatible kidney can be better than waiting for a perfect match

John Murphy, MDLinx | March 10, 2016

Patients who received kidney transplants from incompatible live donors had a substantially higher long-term survival rate compared with patients who waited for transplants from deceased donors as well as those who waited and never received a transplant, according to a multicenter study published March 10, 2016 in The New England Journal of Medicine.

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Incompatible kidney transplant benefits

Incompatible live donor kidney transplantation has almost twice the survival rate of waiting for a deceased donor kidney transplant, Johns Hopkins researchers reported. (Photo: Johns Hopkins Medicine)

Many people have the long-held perception that well-matched organs are the best opportunity for candidates awaiting transplants. However, more than 20,000 Americans who are on the waiting list for kidney transplantation have human leukocyte antigen (HLA) antibodies, which makes finding a compatible donor nearly impossible, said lead author Dorry Segev, MD, PhD, Director of the Epidemiology Research Group in Organ Transplantation at Johns Hopkins University School of Medicine, in Baltimore, MD.

“That’s a lot of people who could have a better chance at surviving if they are allowed to move forward with incompatible live donor transplantation,” Dr. Segev said.

The results of this study showed that patients with donor-specific HLA antibodies have a survival rate of 76.5% at 8 years if they undergo a kidney transplant from an incompatible living donor, compared to a 62.9% survival rate in patients who waited for, and eventually received, a transplant from a deceased donor, or 43.9% if they remained on dialysis but didn’t receive a transplant.

“In other words, receiving a kidney from an incompatible live donor was associated with an absolute increase of 13.6 percentage points in the survival rate at 8 years as compared with remaining on the waiting list or receiving a transplant from a deceased donor, and an absolute increase of 32.6 percentage points as compared with remaining on the waiting list and not receiving a transplant from a deceased donor,” the authors wrote.

In a 2011 article, Dr. Segev and colleagues had shown the benefits of incompatible live donor kidney transplantation performed solely at Johns Hopkins.

For this larger study, the investigators assessed the survival rates of 1,025 incompatible live donor kidneys recipients in 22 centers across the US, and compared these patients to matched controls drawn from the Scientific Registry of Transplant Recipients.

The researchers found that recipients of kidney transplants from incompatible live donors had a higher survival rate than either the waiting-list-or-transplant control group or the waiting-list-only control group at all time points (1 year, 3 years, 5 years, and 8 years).

“For the first time, we have definitively shown that incompatible live donor kidney transplantation provides almost twice the survival of a patient’s next best option. This is great news for patients who have healthy, willing live donors but who have been relegated to the waiting list because of HLA incompatibilities,” Dr. Segev said. “Through this study, we now know that those donors can donate today, those transplants can happen, and those lives can be saved.”

The investigators cautioned that managing HLA incompatibilities in these patients is complicated, and carries higher risks of serious side effects and organ failure than with compatible transplants.

Furthermore, desensitization therapy for donor-specific antibodies can be expensive. However, Dr. Segev noted, dialysis is more expensive. “Incompatible transplantation is essentially one-tenth of the price of dialysis for a patient stuck on the waitlist,” he said. “This study underscores the importance of innovative treatment options, such as incompatible live donor transplantation.”

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