Monday, July 23, 2012

Should there be one kidney exchange or many, and which ones, and when?

The July issue of the Nephrology Times carries a story from the recent American Transplant Congress meetings, at which reports were given by the main kidney exchange networks and transplant centers: In National Paired Donation Pilot, Most Match Offers Declined

Ruthanne Hanto reported on the progress of the Organ Procurement and Transplantation Network (OPTN) Kidney Paired Donation (KPD) Pilot Program run by UNOS.
"The pilot has made about 240 matches since its first run on Oct. 27, 2010, but about 220 of the offers were declined, and only 19 of the matches led to transplantation."

The pilot program hopes to add bridge donors--donors who temporarily end a chain and donate later--at some future time.

In the meantime, the story covers an ongoing debate about whether having multiple kidney exchange networks is a good thing. There's general agreement that, run well, a larger network creates a thicker market which would produce more transplants. And the support of the OPTN, which deals with the nation's deceased donors, gives the pilot program enormous convening power, since they already have working relations with every transplant center in the country.

Nevertheless, the other programs have been vastly more successful in producing transplants, both for patients in general and for the most highly sensitized patients who now make up the majority of those  in kidney exchange networks. (It's hard to come by exact numbers, but we're talking two orders of magnitude--the pilot program so far accounts for about 1% of the kidney exchange transplants to date.) So the story quotes both Ruthanne Hanto and Stanford surgeon Marc Melcher as saying that, for the moment, it would be premature to try to close any of the successful networks down, not least because they are where the innovation is taking place.
(Melcher: “I think at some point most people agree that we need to have a national program. I think really the question is when, and when have we really learned enough about the right way to go.")

The story also quotes Hopkins surgeon Dorry Segev who reaches the opposite conclusion, and would apparently be glad to close down the independent networks: "There's a tremendous amount of competition among the various KPD providers in this country, and this competition is actually hurting the chances for those hardest-to-match patients.”  

My recent papers which have some bearing on this controversy, in the sense that they are about best practices pioneered in practice by other exchange networks (namely nonsimultaneous chains), are these:

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