[Living donor kidney transplantation: new modalities and future directions]

Due to the scarce supply of deceased donor kidneys, living donor kidney transplantation is becoming an increasingly important resource of organs for patients with end-stage renal disease. Laparoscopic nephrectomy, now the most common form of surgical procedure, produces better cosmetic results, less pain, and shorter hospital stay compared to open surgery. Therefore it represents an incentive to improve rates of living kidney donation. Since surgery is scheduled in advance, living donor kidney transplantation offers an unique opportunity to overcome immunological barriers, such as ABO-incompatibility and HLA-incompatibility. Unfortunately, unlike ABO-incompatibility, HLA-incompatibility (i.e. kidney transplantation in a recipient with positive complement-dependent cytotoxic or flow-cytometric crossmatch against the donor) it still leaves many unresolved issues nowadays, concerning the long-term efficacy, safety, and costs of the current treatment protocols. Kidney paired donation represents the ideal solution to immunological barriers, since it avoids the costs and side effects associated with ABO- and HLA-incompatible kidney transplantation. Living donor kidney transplantation also represents the ideal condition for developing tolerance-induction protocols. Indeed, a dramatic progress in this line of research has recently been made with the publication of the results of an apparently safe and efficacious protocol inducing durable high-level hematopoietic chimerism in recipients of living donor kidney transplantation.