A report from a high-volume single center indicated a survival benefit of receiving a kidney transplant from an HLA-incompatible live donor as compared with remaining on the waiting list, whether or not a kidney from a deceased donor was received. The generalizability of that finding is unclear. 
 
 In a 22-center study, we estimated the survival benefit for 1025 recipients of kidney transplants from HLA-incompatible live donors who were matched with controls who remained on the waiting list or received a transplant from a deceased donor (waiting-list-or-transplant control group) and controls who remained on the waiting list but did not receive a transplant (waiting-list-only control group). We analyzed the data with and without patients from the highest-volume center in the study. 
 
 Recipients of kidney transplants from incompatible live donors had a higher survival rate than either control group at 1 year (95.0%, vs. 94.0% for the waiting-list-or-transplant control group and 89.6% for the waiting-list-only control group), 3 years (91.7% vs. 83.6% and 72.7%, respectively), 5 years (86.0% vs. 74.4% and 59.2%), and 8 years (76.5% vs. 62.9% and 43.9%) (P<0.001 for all comparisons with the two control groups). The survival benefit was significant at 8 years across all levels of donor-specific antibody: 89.2% for recipients of kidney transplants from incompatible live donors who had a positive Luminex assay for anti-HLA antibody but a negative flow-cytometric cross-match versus 65.0% for the waiting-list-or-transplant control group and 47.1% for the waiting-list-only control group; 76.3% for recipients with a positive flow-cytometric cross-match but a negative cytotoxic cross-match versus 63.3% and 43.0% in the two control groups, respectively; and 71.0% for recipients with a positive cytotoxic cross-match versus 61.5% and 43.7%, respectively. The findings did not change when patients from the highest-volume center were excluded. 
 
 This multicenter study validated single-center evidence that patients who received kidney transplants from HLA-incompatible live donors had a substantial survival benefit as compared with patients who did not undergo transplantation and those who waited for transplants from deceased donors. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases.) 
 
 Supported by grants from the National Institute of Diabetes and Digestive and Kidney Diseases (R01DK098431 and K24DK10182801, to Dr. Segev; F32DK093218, to Dr. Orandi; and RC1DK086731, to Dr. Montgomery). 
 
 Disclosure forms provided by the authors are available with the full text of this article at NEJM.org. 
 
 Drs. Montgomery and Segev contributed equally to this article. 
 
 The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health or the Scientific Registry of Transplant Recipients. 

 Reuters Health - Transplanting a mismatched kidney from a living donor may lower the risk of death more than not doing a transplant at all, according to a new study that could open the door to more operations. 
 
 Surgeon Karim Zalazun looks at a monitor displaying a donor kidney for patient Adam Abernathy, who participated in a five-way organ transplant swap, in New York, August 1, 2012. REUTERS/Keith Bedford 
 
 A long-term study found that transplant recipients whose immune systems were technically incompatible to the donated kidney - because they had so-called anti-HLA antibodies - were more likely to be alive eight years later than people who did not receive a transplant or waited to get an organ from a deceased donor. 
 
 “We used to say if you had a compatible donor, you could do a transplant. Now you can say, if you have an incompatible donor, we still can make that transplant happen,” senior author Dr. Dorry Segev of John Hopkins University in Baltimore told Reuters Health. “That’s very exciting to those on the waiting list.” 
 
 Eight-year survival rates were almost 77 percent for 1,025 people who received an HLA-incompatible kidney from a live donor, 63 percent for 5,125 matched patients who remained on a waiting list for a kidney or received a kidney from a deceased donor and 44 percent for 5,125 people who remained on the waiting list without receiving a kidney. 
 
 “The paper is showing how much longer the patient will live compared to their next available option,” said Segev, who directs John Hopkins’ Epidemiology Research Group in Organ Transplantation. “Your next best option is waiting on the list for a compatible donor, and a lot of those patients will never find one.” 
 
 The study was done at 22 centers. It could help the more than 32,000 people in the United States who have anti-HLA antibodies and need a transplant. 
 
 “It’s all about timing,” said Dr. Sanjay Kulkarni, director of kidney and pancreas transplantation at Yale-New Haven Hospital and the Yale School of Medicine, who was not involved in the research. “The longer people are on dialysis before they have a transplant, the worse their survival,” he said. 
 
 “So if you have a living donor, instead of waiting five years for a compatible donor, if you can get a transplant from an incompatible donor in a couple of months, this paper suggests that that is beneficial, despite the fact that they have a higher rate of rejection,” he told Reuters Health. 
 
 “The implications of these results are revolutionary, especially when the numerous contradictory opinions raised by the transplant community are considered,” said Drs. Lionel Rostaing and Paolo Malvezzi of the Centre Hospitalier Universitaire Grenoble Alpes in La Tronche, France, in an editorial accompanying the study in the New England Journal of Medicine. 
 
 Desensitizing recipients can be very expensive, they said, and the immunosuppressive regimens required carry the potential of infection and cancer. In addition, living donors face a small but significant increase in their risk of end stage renal disease. 
 
 Nonetheless, Rostaing and Malvezzi write, using incompatible kidneys from living donors “may save lives and may be cost-effective over time.” 
 
 There is an added cost, but it is relatively small, Segev said. 
 
 Each patient’s immune system has to be desensitized to accept the incompatible kidney. Depending on antibody levels, “it can take a few days to a couple of weeks,” he said. “But compared to the cost of a transplant, it’s relatively low. If a transplant costs perhaps $100,000 and you add desensitization, it might be $110,000 to $120,000.” 
 
 There’s the additional cost of $10,000 or so each year for drugs to keep the immune system from rejecting the kidney. “But compared to $100,000 a year f dialysis,” he said, a transplant quickly becomes cost effective over time. 
 
 Kulkarni cautioned that the organ donation system was changed just over two years ago to make it easier for hard-to-match patients to get a kidney from a deceased donor. 
 
 Now “people are getting transplanted much quicker” so today’s survival rates may not be as dramatically different as they are in the new study, he said. “But I bet they still hold.” 
 
 SOURCE: bit.ly/24R0D0j New England Journal of Medicine, online March 9, 2016.
– Exciting news for people on transplant waiting lists: In a breakthrough that experts say could revolutionize kidney transplants, a new procedure called "desensitization" has allowed doctors to alter patients' immune systems and give them kidneys from living donors previously considered incompatible, reports the New York Times. Patients who received such kidneys were more likely to be alive eight years later than those who remained on dialysis or those who waited for a deceased donor, according to research published in the New England Journal of Medicine. Experts say the breakthrough could help tens of thousands of people who have antibodies hostile to transplanted organs, which makes finding compatible kidneys almost impossible in some cases. "We used to say if you had a compatible donor, you could do a transplant. Now you can say, if you have an incompatible donor, we still can make that transplant happen," senior study author Dr. Dorry Segev of Johns Hopkins University tells Reuters. "That's very exciting to those on the waiting list." The chances of rejection remain higher with the "incompatible" kidneys, but the research shows that getting a new organ quickly outweighs the benefits of spending years on dialysis waiting for a compatible one. Segev says "desensitization" comes at a cost—up to $20,000 for the procedure and thousands more every year for drugs —but it is extremely cost-effective when compared to $100,000 a year for dialysis. (This woman received a kidney from a friend's Tinder date.)