Pranjal KASHIV, Manish BALWANI, Khushboo SAXENA, Vivek B. KUTE, Sanjay P. KOLTE, Gustavo FERREIRA, David THOMSON, Medhat ASKAR, Hari Shankar MESHRAM, Krista L. LENTINE
Experimental and Clinical Transplantation - 2026;24(4):293-301
Objectives: Compatible donor-recipient pairs are increasingly participating in kidney paired donation programs despite eligibility for direct living donor kidney transplant. Beyond addressing overt incompatibility, inclusion of compatible donor-recipient pairs is a strategy to optimize donor-recipient matching, mitigate major anatomical or immunologic disadvantages, and enable multiway or extended exchange chains. Evidence from national and regional registries has suggested that compatible donor-recipient pair participation expands the effective donor pool and improves access for highly sensitized and other hard-to-match recipients. We conducted a structured synthesis of global literature examining compatible pair participation in kidney paired donation programs, focusing on reported clinical outcomes, program-level effects, ethical considerations, and operational models. We comprehensively searched PubMed, Embase, Scopus, and the Cochrane Library and identified studies published between January 2000 and June 2025 reporting on compatible donor-recipient pairs that had specific data. From our search, we included 24 studies from North America, Europe, Asia, and Australia, which encompassed >2500 compatible donor-recipient pairs. Across programs, compatible donor-recipient pairs comprised a proportion of kidney paired donation transplants and were associated with increased program activity. Where reported, participation was driven by the pursuit of superior outcomes, including improved HLA matching, access to younger or lower-risk donors, or avoidance of specific immunologic mismatches, alongside altruistic considerations. Short-term patient and graft outcomes for recipients of compatible donor-recipient pairs were comparable to conventional living donor kidney transplants in reported cohorts. Overall, the evidence supported strategic inclusion of compatible pairs to enhance kidney paired donation program capacity and improve access for highly sensitized and hard-to-match recipients without compromising short-term outcomes.
