Advantages of the single-center model in domino transplant processes: Operational planning and management experience

Kidney transplantation is one of the most effective treatments for patients with end-stage renal disease. However, many regions face low deceased donor rates and limited ABO-compatible transplant availability, which increases reliance on living donors. These regional challenges necessitate the implementation of kidney paired donation (KPD) programs to overcome incompatibilities such as ABO mismatch or positive cross-matching, even when suitable and willing donors are available.

To evaluate the effectiveness of a single-center domino KPD model in both operational planning and clinical management processes and to assess its impact on clinical outcomes.

Between April 2020 and January 2024, we retrospectively evaluated patients enrolled in our center's domino kidney transplantation program. Donor-recipient pairs unable to proceed due to ABO incompatibility or positive cross-matching with their own living donors were included. Donors and recipients were assessed based on blood group compatibility, HLA tissue typing, and negative cross-match results. A specialized computer algorithm grouped patients into three-way, four-way, and five-way chains. All surgical procedures were performed on the same day at a single center.

A total of 169 kidney transplants were performed, forming 52 domino chains. These domino KPD transplants accounted for a notable proportion of our center's overall transplant activity, which included both living donor kidney transplants and deceased donor transplants. Among these chains, the primary reasons for participation were ABO incompatibility (74%), positive cross-matching (10%), and the desire to improve HLA mismatch (16%). Improved HLA mismatch profiles and high graft survival (96% at 1 year, 92% at 3 years) and patient survival (98% at 1 year, 94% at 3 years) rates were observed, as well as low acute rejection episodes.

The single-center domino KPD model enhanced transplant opportunities for incompatible donor-recipient pairs while maintaining excellent clinical outcomes. By providing a framework that addresses regional challenges, improves operational efficiency, and optimizes clinical management, this model offers actionable insights to reduce waiting lists and improve patient outcomes.