Post ATC post

Well, I'm back from the American Transplant Congress in Seattle, and it was quite nice to see multiple sessions on various aspects of kidney exchange, which has now graduated to the status of one of the standard ways of arranging kidney transplantation.

Here's the ATC's coverage of my Sunday talk: Keynote: Medical Community, Economist Collaboration Essential in Kidney Exchange

Alvin E. Roth, PhD: ‘Economics is about more than money and prices. It's also about organization, cooperation and coordination.'

If ever an endeavor existed that calls for careful, thoughtful collaboration, it is paired kidney exchange. Nobel laureate economist Alvin E. Roth, PhD, addressed the challenges in such exchanges and what economists can bring to this collaboration when he delivered Sunday's Keynote Lecture, "Kidney Exchange: An Economist's Perspective."

"Many things must happen to bring kidney transplant donors and recipients into the operating room," said Dr. Roth, the Craig and Susan McCaw Professor of Economics at Stanford University and the George Gund Professor Emeritus at Harvard University. "For some of those things, it has proven beneficial to look beyond the boundaries of the medical community to economists and market designers. Economics is about more than money and prices. It's also about organization, cooperation and coordination. 

Interdisciplinary collaboration is common in market design because market designers help experts in specific areas organize to achieve their goals. Dr. Roth said some remarkable transplant surgeons have collaborated with him and his colleagues in the ongoing effort to increase transplantation through exchange.

Even more collaboration will be required to coordinate among the multiple organizations involved in kidney exchange. A collaborative system that encompasses the largest pool of patients theoretically would produce the most transplants, but large organizations can be bureaucratic and inhibit innovation if not properly structured, he said. Some of the fastest-moving, entrepreneurial, innovative transplant organizations have been arranging the most transplants.

"Collaboration among kidney exchange programs is going to be important," Dr. Roth said. "However, we will have to put some careful thought in how to do it." 

In discussing logistics, he praised the non-directed, non-simultaneous donor chain as an innovation that has allowed the exchange of more kidney donations and has led to an increasing number of transplants. The chain begins with a non-directed donor, i.e. one who does not have an intended recipient and who donates to a patient in the kidney exchange pool of patient-donor pairs. That patient's donor continues the chain by donating to another patient in the pool, and so on, typically ending in a donation to a patient who has no donor.

"The ability to make non-simultaneous donations has allowed these chains to become quite long," Dr. Roth said. "That, in turn, has produced many more kidney transplants, which can include more of the most highly sensitized patients."

As more transplant centers have become adept at kidney exchange, there is a growing tendency for them to hold back their easy-to-match patients from the centralized kidney exchange pools to match these patients in their own centers. The consequence has been that hard-to-match patients are overly represented in kidney exchange pools.

"Easy-to-match patients in the mix are good for hard-to-match patients," Dr. Roth said. "We need to find ways to make it reasonable for the easy-to-match pairs to be in the large kidney exchange pools."

Finance also is an issue. Kidney exchange involves collaboration among hospitals, each of which may have different charges for nephrectomies, for example. One solution may involve developing a standard acquisition charge to make live kidney donation as uniform as it already is for deceased donor kidneys.

And expect kidney exchange design to remain in flux.

"The design of how kidney exchanges are organized is an ongoing process that has to change in reaction to changes in how transplant centers behave and what the patient pool looks like," Dr. Roth said. "We shouldn't think of it as something that is fixed in time but something that requires constant attention."