The Dutch Living Donor Kidney Exchange Program

textabstractKidney transplantation is the optimal option for patients with an end-stage renal disease. The first successful transplantation with a living genetically related donor has been performed since 26 October 1954, when an identical twin transplant was performed in Boston. In the years that followed, efforts to enable non-twin transplants unfortunately failed because effective immunosuppression was not yet available. It took until the early sixties after the discovery of azathiopirine that also deceased donor kidney transplantations became possible. In the eighties of the last century the wait time for a kidney transplant was approximately one year. Since that time the success rate of organ transplantation has significantly improved which attracted large numbers of transplant candidates. As the number of deceased organ donors did not increase, the wait time on the list steadily grew and at the moment patients in most Western countries face wait times up to 5 years before a deceased donor kidney is offered. Unfortunately an increasing proportion of them will never be transplanted because their clinical situation deteriorates to such an extent that they are delisted or die on the wait list. For the Netherlands we estimate that this proportion is approximately 30%. A strategy to expand the kidney donor pool includes the use of non-heart beating (NHB) donors. Educational programs in the Netherlands have resulted in an increase in the number of kidney transplants derived from NHB donors from almost 20% in the year 2000 to 43% in 2004, while in the years that followed the numbers of NHB donors stabilized. So the NHB donors have not led to expansion of the deceased kidney donor pool. Possibly substitution from heart beating to non heart beating donation procedures took place, resulting from pressure on the facilities of intensive care units. In the Netherlands, it has been suggested that the main reason for our failure to increase the number of deceased organ donors is the lack of donor detection. This is certainly not the case; both in 2005 and in 2006 almost all potential donors in the Netherlands (96%) were recognized as such and for the vast majority (86%) our national donor registry was consulted. The problem is not donor detection but the high refusal rate by the next of kin, which is inherent to our legal system. Our organ donation act dictates an opt-in system, and therefore all adult citizens are asked to register their consent for the use of their organ for transplantation purpose after death. In the Netherlands approximately 25% of the adults are now registered as potential donors, 15% have explicitly refused and thus for 60% it remains unknown. Especially in case of potential donors of the latter category high refusal rates up to 70% haven been found. Apparently next of kin argue that while the possibility was given to everybody to register as donor, their relative did not do so, therefore they are unaware of consent and thus reluctant to give permission for donation. We feel that an opt-out organ donation system would be very much helpful to expand the deceased kidney donor pool. However, we are aware that even if all potential deceased donors became actual donors, there still would be a shortage of donor kidneys. Therefore the use of kidneys from living donors is an obvious way to go. These transplants result in a superior unadjusted graft survival compared to deceased donor kidneys. It has been calculated that the difference in 10 years survival between living and deceased donor kidney transplantation is 34 %