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Altruistic Donor Chain

A non-directed altruistic donor (NDAD) chooses to donate into the paired/pooled donation (PPD) scheme to create a chain of transplants. This is the preferred option for NDADs because more transplantation opportunities are created from a single donation. The donated kidney is allocated to a recipient in the paired/pooled scheme and, in turn, the donor registered with that recipient donates to another recipient and so on. The chain ends when the last donor donates to a recipient on the national transplant list.

All eligible NDADs (i.e. those who have completed donor assessment and have Human Tissue Authority (HTA) approval) have an opportunity to ‘opt in’ to initiate an altruistic donor chain (ADC) in a living donor kidney matching run (LDKMR), instead of donating directly to a recipient on the national transplant (deceased donor (DD)) list. When the NDAD donates into the PPD scheme, the donation potentially triggers one or more paired donations, ending the chain with a donation back to the national transplant list. (Figure 1). A ‘short’ ADC includes one PPD pair; a 'long' ADC includes more than one PPD pair.

Key points
  • High priority patients on the DD list take precedence (approx 8% of altruistic donor kidneys) and all NDAD kidneys are offered to these patients first, even if the NDAD has opted to take part in the quarterly LDKMR. A high priority patient is defined as a patient appearing in Tiers A to C of the DD matching run (including clinically urgent paediatric patients).
  • The preferred option for the NDAD is the 'opt in' to maximise the transplant yield but all NDADs can 'opt out' at the point of registration with NHS Blood and Transplant (NHSBT).
  • If the ADC falls through, the NDAD can choose to donate directly to the DD list to avoid delay or to choose to wait for the next Living Donor Kidney Matching Runs (LDKMR).
  • All donor operations in the PPD and ADC schemes will be performed as per arrangements agreed by NHSBT Kidney Advisory Group.
  • Special considerations must be specified relating to the donor/kidney to be donated that are relevant to the acceptance of a donated kidney.
Altruistic Donor Chain - direct to waiting list, short altruistic donor chain and long altruistic donor chain

Summary of Arrangements for Non-Directed Altruistic Donation  with Altruistic Donor Chains

    • Donor assessment and preparation for donation as per UK Guidelines and local transplant centre protocol, including mental health assessment. See the British Transplantation Society Standards and Guidelines.
    • HTA approval process via local Independent Assessor and HTA panel.
    • Donor has the opportunity to ‘opt-in’ to Altruistic Donor Chain (ADC) or ‘opt-out’ and donate directly to the national transplant list and is registered with Organ Donation and Transplantation (ODT), NHS Blood and Transplant (NHSBT). Deadlines for registration of new donors ‘opting- in’ to the scheme are provided by ODT and circulated via named Living Donor Co-ordinator (LDC) and histocompatibility and immunology (H&I) contacts in transplant centres.
    • Opt-in to ADC Donor first ‘matched’ for possible high priority recipient (Tiers A-C) or clinically urgent paediatric recipient on national transplant list before entering into the next LDKMR for an ADC.
    • Donors Entering into an ADC ‘Confirmation of Inclusion report’ sent to named LDC and H&I contacts in transplant centres prior to LDKMR to positively confirm all eligible NDADs for inclusion in the LDKMR and co-ordinate responses from across regional networks.
    • Confirmation of inclusion to ODT to be made by named LDC transplant centre contact up to 12 working days prior to the LDKMR for donors with special considerations and up to 5 working days prior to the LDKMR for donors without special considerations.
    • 10 working days prior to LDKMR, special considerations relating to donor +/- kidney that are relevant to the acceptance of a donor kidney by the recipient centre circulated by ODT to named LDC contacts. Clinical teams to agree acceptance or refusal of a potential donor kidney if matched to an identified recipient. LDC contacts to report decision to ODT by LDKMR deadline specified by ODT (usually 1 day prior to LDKMR).
    • LDKMR performed by ODT in conjunction with the University of Glasgow to identify suitable pairs in optimal exchanges - see LDKMR matching process. 'Matching Run Report' sent to named LDC and H&I contacts in transplant centres for dissemination and co-ordination across regional networks.
    • Recipients in paired/pooled scheme identified in possible ADCs suspended from national transplant list by ODT until initial immunological crossmatch results confirm compatibility of donors and recipients. Crossmatch testing to be co-ordinated by the named LDC and H&I contacts and results notified to ODT (ideally within 7-14 days of LDKMR).
    • Once compatibility is confirmed between paired/pooled recipient(s) and NDAD, the recipient on the national transplant list at the end of the ADC is indentified and crossmatching performed to confirm compatibility.
For suitable ADC donor-recipient pairs
    • HTA approval process via local Independent Assessor and HTA panel for paired/pooled donor-recipient pairs.
    • Date of surgery scheduled between centres to facilitate simultaneous surgery for all 'pairs' to conform to clinical standard of 8 weeks from notification of matches to scheduling of surgery. Anonymity as for PPD.
    • Final crossmatch tests according to agreed protocol prior to scheduled date of surgery.
    • Suitable storage and transport of kidneys arranged by named LDC contacts in transplant centres.
If the ADC does not proceed
    • The NDAD will either donate to a recipient on the national transplant list (see NDAD pathway) or may choose to wait for the next quarterly LDKMR to create an ADC
    • Paired/pooled donor-recipient pairs will revert to PPD pathway for ‘unsuitable pairs’

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