1. Kidney Paired Donation Michael A. Rees, M.D., Ph.D.

2. Ohio Solid Organ Transplantation Consortium OSOTC - Audrey B. Bohnengel, Ph.D. Children’s Hospital Cincinnati - Maria H. Alonso, M.D. Cleveland Clinic - David Goldfarb, M.D. Ohio State University - Mitchell L. Henry, M.D. Miami Valley Hospital - Scott Johnson, M.D. University Hospital Cleveland - Mark Aeder, M.D. University of Cincinnati - E. Steve Woodle, M.D. Akron City Hospital (Summa) - Tanmay Lal, M.D. Anchor Enterprises - Alan Rees University of Cincinnati Johnathan Kopke University of Cincinnati - Johnathan Kopke

3. Other Contributors Harvard - Alvin Roth, Ph.D. Boston College - Tayfun Sönmez, Ph.D. University of Pittsburgh - Utku Ünver, Ph.D. Carnegie Mellon University - Tuomas Sandholm, Ph.D. Carnegie Mellon University – David Abraham, B.S. Johns Hopkins University - Robert Montgomery, M.D, D. Phil. Johns Hopkins University- Dorry Segev, M.D. Johns Hopkins University - Dorry Segev, M.D. Johns Hopkins University - Sommer Gentry, Ph.D. Columbia University - Lloyd Ratner, M.D. Massachusetts General Hospital - Frank Delmonico, M.D. University of North Carolina - Ken Andreoni, M.D.

4. A Kidney Paired Donation Donor A Donor B Recipient A Recipient B X X

5. A Paired Kidney Donation

6. Strategy 100 donor - recipient pairs generates 4,950 potential paired exchanges.

7. Potential Donations = n(n-1)/2

8. Number of Pairs Required

9. Registrations per prior LRDs R = 0.114

10. Point System 1.Wait time 2.Distance 3.Recipient vs. Donor Age Disparity 4.Donor vs. Donor Age Disparity 5.HLA Match 6.Pediatric Bonus 7.PRA Bonus 8.CMV/EBV Bonus 9.Blood Group A/B Bonus CategoryPoints 3+ 5/2 3 2 6/2 6 2/2 6

15. Data Entry Screens

16. Medical Reviewer Screens

18. All medically feasible matches from 41 pairs

19. Optimizing matching of 8 pairs

20. Number of transplants versus quality of the match 4 matches - 50 points3 matches - 60 points

21. 2-way Solution

22. 3-way Solution

23. 4-way Solution

24. Multiple Approach Solution

25. Overall Crossmatches to perform

26. With 3 x-matches positive

27. All but one 2-way match lost

28. Results to Date The Alliance for Paired Donation incorporated in August 2006 and began enrolling transplant centers in October 2006. Currently over 70 transplant programs in 24 states participate and over 30 more are considering partnering with the APD. Since March 2007, the APD has performed 32 paired donation transplants with 2 more scheduled. In the January match run there were 145 pairs and we have found potential matches for 22 patients involving 12 transplant centers.

29. Results to Date Registered pairs ABOi = 60%, 40% crossmatch incompatible. Registered candidates: PRA 80-100 % in 36%, 10-79% in 32 % and <10% in 29% First 32 transplant recipients PRA 80-100 % in 22%, 50-79% in 19%, 25-49% in 22% and <25% in 38%. Overall, 41% of the transplanted recipients had a PRA > 50%. Registered candidates blood type: O in 53%, A in 25 %, B in 18% and AB in 4%. First 32 transplant recipients blood type: O in 38%, A in 41 %, B in 19% and AB in 3%. Donor blood type was O in 38%, A in 41%, B in 14% and AB in 8% of the first 32 donors.

30. The Never-Ending Altruistic Donor Michael A. Rees, M.D., Ph.D.

31. Paired Donation: Incompatible but willing living donors

32. The square cannot give to the circle

33. The circle cannot give to the square

34. Paired Donation: The square gives to the square, the circle to the circle

35. What if not done simultaneously?

36. Reneging is possible – with loss of the “bargaining chip” of the incompatible donor’s kidney

37. Common Situation: Not Reciprocal incompatibility

38. Altruistic Donor Chain

39. What if not done simultaneously?

40. Reneging is possible – but the “bargaining chip” of the incompatible donor’s kidney is not lost. Therefore simultaneous procedures are NOT required.

41. Simultaneous Altruistic Donor Chain Deceased Donor Waiting List

42. Never-ending Altruistic Donor Start a new Altruistic Chain

43. Never-ending Altruistic Donor continues

45. Never-ending Altruistic Donor

46. The First Never-Ending Altruistic Donor Chain

47. Optimizing NEAD chain matching 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Each circle represents an incompatible donor/recipient pair

48. Who can donor 1 give to? 1 2 3 4 5 6 7 8 9 10 11 12 13 14

49. Who can donor 1 give to? 1 2 3 4 5 6 7 8 9 10 11 12 13 14

50. Who can donor 1 give to? 1 2 3 4 5 6 7 8 9 10 11 12 13 14

51. Who can donor 1 give to? 1 2 3 4 5 6 7 8 9 10 11 12 13 14

52. Who can donor 1 give to? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 st

53. Who can donor 1 give to? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 st 2 nd

54. Who can donor 1 give to? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 st 2 nd 3 rd

55. Who can donor 1 give to? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 st 2 nd 3 rd 4 th

56. Only pair 4 can give back 1 2 3 4 5 6 7 8 9 10 11 12 13 14

57. Can we do better? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 st 2 nd 3 rd 4 th

58. All possible matches for pair 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14

59. All possible matches for pair 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14

60. All possible matches for pair 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14

61. All possible matches for pair 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14

62. All possible matches for pair 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 st

63. All possible matches for pair 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 st 2 nd

64. All possible matches for pair 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 st 2 nd 3 rd

65. All possible matches for pair 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 st 2 nd 3 rd 4 th

66. The 4 th best choice for both 1 2 3 4 5 6 7 8 9 10 11 12 13 14 4 th

67. Optimizing NEAD chain matching 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Each circle represents an incompatible donor/recipient pair

68. Imagine that an altruistic donor gives to pair one 1 2 3 4 5 6 7 8 9 10 11 12 13 14 AD

69. Pair one’s donor converted to an “altruistic donor” 1 2 3 4 5 6 7 8 9 10 11 12 13 14 AD

70. Pair one has four possible choices 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 st 2 nd 3 rd 4 th AD

71. Pair one’s converted “altruistic donor” can now give to pair 12 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 st AD

72. Pair twelve’s donor converted to an “altruistic donor” 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 st AD

73. Pair twelve’s donor gives to the best possible match 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 st AD 1 st

74. Pair eight’s donor converted to an “altruistic donor” 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 st AD 1 st AD

75. NEAD chain matching improves both quantity AND quality of matches 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 st AD 1 st AD 1 st

76. Our Second NEAD chain

77. 3 states, 3 time zones, 3 transplants