Because kidney paired donation (KPD) is a young practice, there exists no detailed inventory of the history of paired exchanges, the activities of operating KPD organizations, or recommendations for improvement. This paper attempts to address each of these considerations by providing a comprehensive analysis of KPD. The first section gives a brief background on KPD, including a review of kidney compatibility and the forms of KPD. The second details the history and distinctive features of KPD programs, internationally and within the United States. Next, the third section presents case studies of national pairing organizations and individual transplant centers, highlighting differences and similarities that may explain variations in performance. Finally, the fourth section identifies the three major challenges facing the growth of KPD in the US – the balkanization of patient pools, lack of coordination among transplant centers, and positive cross match disruptions – and offers recommendations based on institutional best practices to mitigate each. Information on the history of KPD and recommendations were compiled through an extensive literature review. Many of the details included in the case studies were garnered from interviews with representatives from transplant centers and pairing organizations.