Global Kidney Chains in PNAS by Nikzad, Akbapour, Rees and Roth

 Here's an article about extending kidney exchange globally. It's published as an open access article, so you can find the whole paper at the link.

Global kidney chains, by Afshin Nikzad, Mohammad Akbarpour, Michael A. Rees, and  Alvin E. Roth, PNAS September 7, 2021 118 (36) e2106652118; https://doi.org/10.1073/pnas.2106652118

Significance: Kidney failure is among the leading causes of death worldwide, and the best treatment is transplantation. However, transplants are in short supply because of shortfalls of transplantable organs and of finances. In the United States and some other countries, kidney exchange chains have emerged as a way to increase the number of transplants; patients who have a willing donor but cannot receive that donor’s kidney can each receive a compatible kidney from another patient’s intended donor. Such programs are much better developed within the borders of wealthy countries, which is of little help to patients in countries with limited kidney transplantation or exchange. This paper proposes and analyzes a way to extend kidney exchange chains to share the benefits globally.

Abstract: Kidney failure is a worldwide scourge, made more lethal by the shortage of transplants. We propose a way to organize kidney exchange chains internationally between middle-income countries with financial barriers to transplantation and high-income countries with many hard to match patients and patient–donor pairs facing lengthy dialysis. The proposal involves chains of exchange that begin in the middle-income country and end in the high-income country. We also propose a way of financing such chains using savings to US health care payers.

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"Concluding Remarks: Since the beginning of the twenty-first century, kidney exchange at scale has developed from a largely academic idea initially implemented at a small scale (5, 37) to a standard mode of transplantation in the United States (with well over 1,000 exchange transplants in 2019) and in several other countries. This has been an important development, with many milestones along the way including, crucially, developments in the design and implementation of kidney exchange chains. However, these accomplishments have been victories in a war that we are losing. At the turn of the century, there were in the neighborhood of 40,000 patients on the US waitlist for deceased donor organs, and today, there are close to 100,000.‡‡ The situation is similar elsewhere in the wealthy world. Over the same period, there has been a growth of kidney disease as a cause of death around the world (as developing countries have made progress in combating infectious disease), and there have begun to be high-quality transplant centers in middle-income as well as in rich countries, which nevertheless face obstacles—including important financial obstacles—to increasing the number of transplants they are able to deliver.§§

"Before the development of kidney exchange, the organization of transplantation developed largely within the national boundaries of wealthy countries. It was primarily focused on deceased donor transplants, and the scarcity of organs meant that the concentration of effort within single countries did not have a large impact on the total number of transplants achieved. (There are well-established efforts to share deceased donor kidneys across national borders in limited circumstances.) With the growth of kidney exchange, there are now some preliminary explorations of coordinating across borders between countries with existing kidney exchange programs, primarily concentrating on looking for exchanges between hard to match pairs who have been left unmatched in the within-country kidney exchange. GKE opens up this possibility to a much larger part of the world, including countries in which unmatched patient–donor pairs may have had financial rather than immunological barriers, and so, may be easier to match with hard to match pairs. Additionally, because kidney exchange chains have amplified kidney exchange wherever they have been implemented, global exchange chains offer a way to bring these advantages to a much larger group of patients and donors.¶¶

"While Medicare aims to insure all Americans against kidney disease, the same cost savings described here could be employed to fund care for foreign patients who are uninsured, including those who are undocumented immigrants who may not have entered the country legally (but may nevertheless be long-term residents).##

"Notice that if an international exchange works perfectly—i.e., when all of the patients and donors involved have successful surgeries, have excellent follow-up care, and are restored to active, long-lasting good health—then it will be easy to see the exchange as just another example of the success of standard kidney exchange in which all patients are from the same country. However, if the pair from the developing country was to return home and have bad health outcomes, it would look a lot like badly arranged black market transactions, which are justly condemned. So, to make kidney exchange work between developed and developing countries, exceptional care will have to be delivered to the developing country donors and patients, particularly since patients in poor countries—like their compatriots who have never suffered from kidney disease—can be expected to have somewhat worse health outcomes than otherwise comparable people in rich countries, no matter what efforts are made to give them the best possible postoperative care. International exchange may also require increased vigilance, compared with domestic exchange, to ensure that donors are not coerced or otherwise exploited. Consequently, the first element of a successful design for GKC is the choice of reliable international partners able to provide excellent care for patients and donors, both prospectively and postoperatively.

"The other three design elements proposed and explored in this paper involve starting a chain in a foreign country and having a bridge donor continue it in the United States; using a LIFO queue policy on the pool of patients assembled by, for example, a coalition of self-insured companies responsible for paying for their care; and having those savings finance the otherwise unfunded additional costs (compared with an entirely domestic chain) in both countries. As we have shown, such a program could operate at a significant scale, comparable with the number of domestic patients presently beginning lengthy dialysis annually. GKCs thus appear to present a scalable approach to cross-border kidney exchange and to increasing the availability of transplantation globally. They have the potential to become at least a first step toward providing a global solution to the global problem of kidney failure."