Table 1.

Challenges Prior to and after Implementation

Anticipated Challenges	Potential Solutions
To develop appropriate DD-CIK allocation strategies	Priority for DD-CIK could be assigned between local pediatric candidates and local mismatched adults
To develop appropriate living donor allocation strategies	Living donor kidneys resulting from DD CIK chains should be allocated to the waiting list according to the existing deceased donor allocation protocol.
To resolve logistical barriers to allocation given the existence of multiple KPD Registries	Provides variances for one or more of the current registries to implement this strategy.
To prepare strategies to handle chains that unravel	Could be modeled after strategies developed by existing registries such as using CIKs to repair ongoing chains (3), or a KPD registry could be asked to end the next chain to the DD list.
To allocate and use living donor kidneys in a timely manner	Participating patients and donors must be completely prepared for surgery and fully informed of the additional risks associated with chains such as the potential for them to unravel.
To assess added benefit to the entire waiting list of using a kidney as DD CIK	One year after implementation of a trial the number and characteristics of the patients transplanted and their donors should be reviewed. The quality of the grafts could be compared using a living donor risk index analogous to the current deceased donor kidney risk index.
The limited number of participants in KPD registries and limited number of willing and healthy living donors.	Push forward adoption of best practices for both KPD and living donation as advocated by national consensus conferences in 2012 (13) and 2014 respectively. (16)