Tuesday, August 22, 2017

Global Kidney Exchange: a reply to some skeptics, forthcoming in the AJT

Our recent paper in the American Journal of Transplantation about the first Global Kidney Exchange chain was accompanied by a skeptical editorial, and has now also drawn some letters to the editor.  Our reply is forthcoming, and is now online here:

Global Kidney Exchange: Financially Incompatible Pairs Are Not Transplantable Compatible Pairs
M. A. Rees, S. Paloyo, A. E. Roth, K. D. Krawiec, O. Ekwenna, C. L. Marsh, A. J. Wenig, T. B. Dunn.   Accepted manuscript online: 31 July 2017

Here is the full text pdf file.

Here are the first sentences and the main paragraph.

"Honest debate makes ideas better; we appreciate our colleagues’ engagement. We agree with Wiseman and Gill that Global Kidney Exchange (GKE) must be conducted in an ethical manner that is sensitive to the possibilities of commodification and exploitation and, that it is important to be both careful with and transparent about how patient-donor pairs are selected from developing countries.1,2 We further agree that GKE should continue to be run in a way that enhances rather than competes with local medical services. However, Wiseman and Gill approached GKE from their American and Canadian perspective of near universal access to healthcare for end stage renal disease. They view GKE through a lens of commodification and exploitation...
"Let us be clear: without GKE the Filipino husband was never going to receive his spouse’s kidney. Without GKE, the husband was going to die, the wife was going to lose her spouse, and their son was going to be fatherless. That is exactly how the story was going to end without GKE. The goal of GKE is to change this fate for emotionally-related pairs referred by our medical collaborators in their home country when financial barriers prevent transplantation. Our selection process aims to provide a transplant for every GKE-eligible pair that creates enough savings to pay for a GKE transplant.  It is not scalable to propose that GKE could take place without consideration of the savings produced by transplanting patients in the United States. There are not unlimited philanthropic resources available to overcome the needs of patients facing financial barriers to transplantation. By creating and utilizing a portion of the savings produced by reducing the cost of dialysis in the United States through accelerated access to renal transplantation, GKE becomes scalable. However, the net savings produced by GKE must exceed the overall cost in order for US-based healthcare payers to participate. Thus, if we want to achieve GKE’s first goal: to help impoverished patients by overcoming financial barriers to transplantation, GKE must take account of the savings produced. We have now performed four GKE transplants—all funded by philanthropy. We simply evaluated every patient who presented for evaluation and moved forward with every instance where the projected savings from accelerated transplantation of American incompatible pairs in the Alliance for Paired Donation (APD) pool exceeded the cost of the GKE by an amount greater than the anticipated cost. To scale this concept, we are working to produce an ethical and legal process, built on sound business principles, so that it can scale to help as many rich and poor patients as possible. In this first case, an easy-to-match unsensitized blood type A GKE candidate with a blood type O donor easily produced more transplants/savings in the APD pool than without their participation.  No alternative existed for this Filipino pair and millions more like them.3 GKE did not exploit this Filipino couple—it provided the mechanism for the wife to literally save her husband’s life. They could not afford dialysis. Two months prior to travelling to the US and after their identification and evaluation for participation in GKE, their Filipino physician called to say that if the APD did not pay for the husband’s continued dialysis in the Philippines, that he was going to die as no additional funds were available to pay for dialysis. At a societal level, did American patients with access to dialysis really disproportionally benefit from the APD’s “exploitation” of this patient by paying for two months of dialysis in the Philippines? When the husband lived instead of dying, was the Filipino donor’s kidney really undervalued? We ask Wiseman and Gill to seriously consider whether the Filipino wife feels she disproportionately benefited American patients rather than her own family. For three years on Father’s Day the couple’s child has written our team to thank us for saving his daddy’s life. Two and a half years after this first GKE transplant, both the Filipino donor and recipient have normal renal function, countering the editorial’s accusation that “limited post-transplant care provided to the Filipino recipient were probably inequitable.” While the gratifying success of the first case does not guarantee the same outcome for all future patients, it does demonstrate how GKE—even if inequitable—is able to add years of life to patients who would have died without it."

There's a lot more that can be said, and I have an inkling that I'm going to have the opportunity to say a lot more, as there are going to be more critiques and objections.  Issues of repugnance deserve to be taken seriously.  The many positive responses (like this and this from Mexico) that GKE has received gives me cautious hope that we'll be able to move forward in a way that addresses the chief concerns and  commands broad support.  There are lots of families in which someone has kidney failure whose life could be saved by giving them access to a transplant through kidney exchange.
Here are all my posts on Global Kidney Exchange

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