Although criteria for living kidney donations have greatly evolved in recent years with acceptance of related and unrelated donors, an immunological incompatibility, between a living donor and his intended recipient, could impede up to 40% of such procedures. To avoid refusal of willing and healthy living donors, different strategies have emerged to overcome immunological incompatibilities. ABO incompatible kidney transplantation can now be achieved with identical outcomes to compatible/identical kidney transplantation and kidney paired donation is the safest way for HLA-incompatible patients to undergo kidney transplantation. Implemented with success in many countries either as national or multiple regional independent programs, kidney paired donation could include simple exchanges between any number of incompatible pairs, incorporate compatible pairs and non-directed donors to start a chain of compatible transplantations, lead to acceptance of ABO-incompatible matching, and integrate desensitizing protocols. Incorporating all these variations, kidney paired donation has been able to facilitate kidney transplantation in up to 49% of registered patients from incompatible pairs.