Living-donor kidney transplant (LDKT) is the treatment of choice for patients with advanced kidney disease. Kidney paired donation (KPD), originally proposed to overcome immunological barriers, has now evolved to address biological and chronological incompatibilities and reduce financial disincentives. This strategy has allowed the maximization of the number of LDKTs. In 2021, of the 5,971 LDKTs performed, 1,115 (18.6%) were facilitated by KPD. Although KPD programs vary in size and structure, privately owned KPD programs dominate the landscape.