Background. Living donor kidney exchange is now performed in several Countries. However, no information is available on the practical problems inherent to these programs. Here, we describe Our experiences with 276 Couples enrolled in the Dutch program. Methods. Our protocol consists of five steps: registration, Computerized matching, crossmatching, donor acceptation, and transplantation. We prospectively collected data of each step of the procedure. Results. Of the 276 registered pairs we created 183 computer-matched combinations. However, 62 of 183 recipients proved to have a positive crossmatch with their new donor, which was not predicted by the screening results of the recipient centers. Alternative solutions were found for 39 couples, resulting in a total of 160 new combinations with negative crossmatches. Thereafter, because of 22 individual clinical problems, the exchange procedure had to be discontinued for 51 couples while only for 19 of them alternative solutions were found. At the end of day, 128 patients had received exchange kidneys, 55 were transplanted outside the program, 59 are still oil the crossover waitlist, and 34 had left the program for medical or psychological reasons. Conclusion. A living donor kidney exchange program is a dynamic process. Many clinical hurdles and barriers are encountered that for a large part were not foreseen but should be taken into account When programs are initiated based on computer simulations. Success is dependent oil a flexible organization able to create alternative solutions when problems arise. Centralized allocation and crossmatch procedures are instrumental in this respect.