Integrating deceased and living donation: six-year outcomes of the Italian deceased donor–initiated kidney paired exchange (DEC-K) program

: Using a deceased donor (DD) to initiate living donor (LD) exchange chains can expand access to kidney transplantation in recipients with an HLA- or ABO-incompatible LD. The Italian DD-initiated kidney paired exchange (DEC-K) program uses a DD kidney to start a chain among incompatible pairs, ultimately returning a LD kidney to the waiting list. We report the first long-term analysis of this approach worldwide. All DEC-K chains performed in Italy between March 2018 and May 2025 were analyzed. Thirty-four chains generated 84 transplants (34 chain-initiating kidneys, 22 from LD, 28 chain-ending kidneys) vs 17 transplants from a conventional kidney paired donation program in the same period. Five-year outcomes were similar between chain-initiating kidney and LD recipients (estimated glomerular filtration rate slope: -2.0 mL/min/1.73 m2/y, P = .37; graft survival: log-rank P = .28). Although this approach diverts blood group O DD kidneys from the general waiting list, potentially affecting nonsensitized candidates, it was designed to address the unmet needs of highly sensitized patients facing years of waiting. In the Italian setting, the DEC-K program successfully initiates LD chains from DD kidneys with outcomes equivalent to LD transplant; implementation should include monitoring of blood group-specific outcomes and a flexible design to accommodate health care system priorities.