• Paolo Ferrari and Marry de Klerk.
• Department of Nephrology, Fremantle Hospital, Perth, Australia. paolo.ferrari@health.wa.gov.au
• J. Nephrol. 2009 Nov 1;22(6):699-707.

IntroductionThe shortage of available deceased donors and the longer kidney transplant waiting lists in many countries around the world have placed greater emphasis on living donation (LD) as a means of meeting demand for transplantation in patients with end-stage kidney disease (ESKD).Methods And ResultsIncreased LD rates are also driven by less invasive approaches to donor nephrectomy and by the excellent long-term results. LD kidney transplant outcomes are equivalent, if not superior, to those from deceased donors, even when donor and recipient are not genetically related, as is the case with spousal donations, the most frequent cohort of LD. Approximately 30% of willing and otherwise appropriate kidney donor/recipient pairs are biologically incompatible and do not proceed to live donor transplantation. In recent years, a number of strategies have been introduced to expand living donation programs beyond the classical direct donation, to overcome immunological barriers of blood group or HLA sensitization of recipients. New strategies in LD include paired kidney exchange (PKE), altruistic donation, altruistic donor chains and list exchange programs. Other alternative programs are desensitization and transplantation across the blood-type barrier. Regular PKE programs operate nationally in The Netherlands and the United Kingdom, or regionally in South Korea, Romania, the United States and Australia.ConclusionsIf PKE were performed routinely using 2-way or 3-way PKE and altruistic donor chains, the rate of kidney transplants could increase by between 7% and 10%.

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