Living donor kidney transplantation (LDKT) offers superior graft survival and costeffectiveness compared to deceased donor transplantation (DDKT), yet the availability of immunologically compatible living donors limits its reach.Kidney Exchange Programs (KEPs) can overcome these barriers by matching incompatible pairs through paired exchanges, domino chains, and non-simultaneous extended altruistic donor (NEAD) chains.This review summarizes the evolution and current landscape of national and international KEPs.We examine operational challenges (cold ischemia time, logistical coordination, algorithmic fairness, ethical and regulatory heterogeneity) and explore innovations in matching algorithms, international kidney exchange debates, and machine perfusion technologies.We conclude by proposing strategic priorities to optimize capacity, equity, and outcomes in future kidney exchange efforts.
Laar et al. (2026) studied this question.