Caterina Di Bella, Umberto Maggiore, Pamela Fiaschetti, Roberta Angelico, Ugo Boggi, Barbara Buscemi, Giorgia Comai, Paola Donato, Mariano Ferraresso, Fiorella Gastaldon, Gabriele Guglielmetti, Enrico Minetti, Giacomo Mori, Antonio Nicolò, Vera Paloschi, Stefano Partelli, Jacopo Romagnoli, Fabio Vistoli, Massimo Cardillo, Emanuele Cozzi, Giuseppe Feltrin, Lucrezia Furian, Italian Kidney Paired Donation Study Group
Using a deceased donor (DD) to initiate living-donor (LD) exchange chains can expand access to kidney transplantation in recipients with an HLA or ABO incompatible living donor. The Italian DD-initiated Kidney Paired Exchange (DEC-K) program uses a DD kidney to start a chain among incompatible pairs, ultimately returning a LD kidney to the waiting list. We report the first long-term analysis of this approach worldwide. All DEC-K chains performed in Italy between March 2018 and May 2025 were analyzed. Thirty-four chains generated 84 transplants (34 chain initiating kidneys CIK, 22 from LD, 28 chain-ending kidneys CEK) versus 17 transplants from conventional Kidney Paired Donation (KPD) program in the same period. Five-year outcomes were similar between CIK and LD recipients (eGFR slope: -2.0 mL/min/1.73m2/year, P=0.37; graft survival: log-rank P=0.28). While this approach diverts blood-group O DD kidneys from the general waiting list, potentially affecting non-sensitized candidates, it was designed to address the unmet needs of highly sensitized patients facing years of waiting. In the Italian setting, the DEC-K program successfully initiates LD chains from DD kidneys with outcomes equivalent to LD transplant; implementation should include monitoring of blood-group-specific outcomes and flexible design to accommodate healthcare system priorities.