The Italian DEC-K program (March 2018–May 2025) was analyzed to evaluate 6-year outcomes of using deceased donor (DD) kidneys to initiate living donor exchange chains for recipients with HLA- or ABO-incompatible living donors.
34 chains generated 84 transplants vs. 17 from conventional kidney paired donation in the same period; 5-year graft survival and eGFR slope (−2.0 mL/min/1.73 m²/year) were equivalent between chain-initiating DD kidney recipients and living donor recipients (log-rank P = .28; slope P = .37).
Use of blood group O DD kidneys may disadvantage nonsensitized candidates on the general waiting list; single-country program design may limit generalizability; no full-text comparative control arm was reported.
DD-initiated kidney paired exchange chains can nearly 5× the transplant yield compared to conventional paired donation while achieving living-donor-equivalent outcomes; programs should monitor blood group O–specific waiting list impacts and build in flexible allocation safeguards.
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