Kidney exchange in Brazil, continued (with pictures)

 In August I posted about a trip to Brazil with Mike Rees where we traveled with Dr. Gustavo Ferreira, the director of transplantation at the hospital Santa Casa de Misericórdia de Juiz de Fora

Part of our trip was spent in the capital, Brasilia, talking to the government about extending Brazilian transplant law to allow kidney exchange, after which we went to Juiz de Fora.  Here's my blog post about that trip:  Kidney exchange in Brazil: prelude. 

That post concluded by saying "On Saturday we had an exciting finish to the trip, but it's not my story to tell yet, so I'll blog again after there is an official announcement."

Now Brazil's first three-way kidney exchange has been announced, as part of a clinical trial that I hope will help change Brazilian law to allow kidney exchange as a regular medical procedure.  The three donors and three recipients all did well, and left the hospital very shortly after the actual surgeries, but came back to tell their stories to the Brazilian news show Profissão Repórter (Professional Reporter). You can see the video here  https://globoplay.globo.com/v/12997336/

It's in Portuguese but you will quickly get the idea, presented even more briefly on Instagram by the transplant nephrologist Dr. Juliana Bastos here: https://www.instagram.com/reel/DA4JBVIsFta/?igsh=d2hnb3hoNjJxN2I4     where you can see the three incompatible patient-donor pairs rearrange themselves for the camera into the three-way exchange in which each patient received an organ from a compatible donor. (Dr. Bastos recently added a PhD to her MD, with a dissertation on kidney exchange.)

Here's another Instagram link to the video.

I had the privilege of observing parts of five of the six surgeries (three nephrectomies and three transplants), and some pictures are below.  

If someone directs a movie about this kind of transplant surgery, there will be two dramatic scenes, one in which the donated kidney is carried across the hall to the transplant operating room, and the second showing the moment the clamps are removed from the blood vessels of the transplanted kidney, so that it turns from grey to pink as blood returns to it. 

But here's a photo I took at  the start of what I think is the most dramatic moment of the surgery, as the artery from the kidney is just about to be connected to the artery of the recipient.

The artery from the donated kidney is the small white tube being pointed to by the instrument held in the fingers at the top right of the picture. Immediately in front of it--the long red tube--is the artery of the recipient, to which it must be connected so that blood can again flow to the kidney.  Notice that a small incision has already been made in the recipient's artery--this is where the two will be attached. The connection has to be perfect, so that the blood can flow without obstruction that could cause a clot.

The surgeon who first figured out how to do this kind of vascular surgery, Dr. Alexis Carrel, won the 1912 The Nobel Prize in Physiology or Medicine

I was able to follow the proceedings thanks to the running commentary offered to me by the Brazilian surgeons and by Mike Rees (who wasn't busy doing surgery). That wasn't the only kind of support Mike offered me in the OR (as I balanced on a pair of stools to better appreciate the commentary):

And here's a post-op picture of most of the big team that made it happen:

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Parabéns ao Gustavo e à Juliana! Congratulations. Your work and leadership can make a big difference not just to your patients, but to people all over Brazil.

#############

Earlier:

Monday, August 12, 2024

Kidney exchange in Brazil: prelude

Kidney exchange in Brazil: prelude

 Yesterday I flew home from a busy visit to Brazil, with Mike Rees and Dr. Gustavo Ferreira.  

On Wednesday we all traveled to the capital, Brasilia, meeting with government ministries and agencies about how to move kidney exchange forward there.

Our most promising meeting on Wednesday was with the company that organizes the hospitals associated with Brazil's Federal universities. We talked about research possibilities

Wednesday Aug 7: Brazilian Hospital Services Company

Our most important meeting was on Thursday with the Ministry of Health  We talked about how clinical trials of kidney exchange in Brazil could help guide changes in Brazil's organ transplant laws and regulations.

Thursday: Brazil Ministry of Health, August 8 2024

On Friday we traveled to Juiz de Fora where we participated in a transplant symposium at the Santa Casa hospital there

On Saturday we had an exciting finish to the trip, but it's not my story to tell yet, so I'll blog again after there is an official announcement.

Earlier:

Tuesday, February 27, 2024

Stanford Impact Labs announces support for kidney exchange in Brazil, India, and the U.S.

Kidney Exchange in Latin America and the Caribbean

 Kidney exchange isn't yet thriving in Latin America, but the basic infrastructure is in place. It would make a lot of sense to jumpstart kidney exchange by allowing cross border exchange, so that there would be a large enough pool of patient-donor pairs to make finding a match easy. Here's an article surveying the member countries of the Latin America and Caribbean Transplant Society.

Bastos, Juliana, David José de Barros Machado, Raquel Megale Moreira, Gustavo Fernandes Ferreira, and Elias David-Neto. "Kidney Paired Donation in Latin America and the Caribbean: An Update." Transplantation 108, no. 6 (2024): 1257-1258.

"we assess the situation of KPD in the countries affiliated with the Latin America and Caribbean Transplant Society (STALYC).

  

"Guatemala was the first country to publish a scientific report on KPD in 2018,8 with 4 kidney paired transplants performed between 2010 and 2017.

"Two reports from Argentina on local news websites reported 2-way exchanges involving 2 pairs in 20159 and 2018.10

"Costa Rica published a 2-way exchange on the hospital’s social media page in 2016,11 whereas a 2-way exchange transplantation was performed in Brazil in 2020.12

"Mexico is leading the reported KPD activity with a first experience involving 4 pairs in a chain beginning with an altruistic donor13 reported in 2019. A more recent publication reported on 22 pairs transplanted with longer chains and excellent results.14

"It is interesting to note that there are 6 countries—Panama, Ecuador, Venezuela, Peru, Chile, and Paraguay—with laws explicitly permitting KPD. Thus far, there has not been a report on KPD in those countries, which is likely due to the relatively recent publication of these legislations, all of which occurred after 2010.

...

"A recent publication has shed light on the potential of KPD in low-to-middle income countries (LMICs), strongly advocating for the promotion and encouragement of KPD programs, including considerations of cost advantages.17 Of additional relevance, valuable recommendations on initiating KPD programs in LMICs include starting with smaller chains, considering simultaneous surgeries, and implementing effective organ transport strategies.17 By adopting these strategies, LMICs can address compatibility issues and enhance their organ transplantation capabilities.

"Considering that KT is the superior and more cost-effective treatment option for patients with CKD, it is puzzling that the initiation of KPD programs remains limited in a region primarily composed of LMICs. Although some countries may have implemented KPD programs without publication, genuinely active programs beyond Mexico remain missing. It is crucial to emphasize that in most of these countries, deceased donor transplantation also falls significantly short of estimated needs.3,7 The entire infrastructure surrounding transplantation, including both living and deceased donors, continues to require substantial improvements. Particularly for KPD, initiatives such as educational campaigns for physicians, recipients, and donors, as well as investments in logistics and software in addition to a legal framework, need to be encouraged. Similar to KPD programs in Europe,5,18 collaborative efforts across countries could benefit smaller countries. Transplant societies, including STALYC, could play a vital role in supporting the advancement of paired donation, ensuring improved access to transplantation for their populations, especially with living donors."

Stanford Impact Labs announces support for kidney exchange in Brazil, India, and the U.S.

 Stanford Impact Labs has announced an investment designed to help the Alliance for Paired Kidney Donation (APKD) increase access to kidney exchange in Brazil, India, and the U.S.  Here are three related web pages...

1. Stanford Impact Labs Invests in Global Collaboration to Increase Access to Kidney Transplants.  $1.5 million over three years will support solutions-focused project led by Stanford’s Dr. Alvin Roth and the Alliance for Paired Kidney Donation (APKD)  by Kate Green Tripp

"Stanford Impact Labs (SIL) is delighted to announce a $1.5 million Stage 3: Amplify Impact investment to support Extending Kidney Exchange, a solutions-focused project established to increase access to lifesaving kidney transplants.

"The team, led by Stanford’s Dr. Alvin (Al) Roth, who shared the 2012 Nobel Prize in Economics for his work on market design, and the Alliance for Paired Kidney Donation (APKD) is working in close partnership with organ transplant specialists and medical centers in Brazil, India, and the U.S., including Santa Casa de Misericórdia de Juiz de Fora, the Institute of Kidney Diseases and Research Center and Dr. H L Trivedi Institute of Transplantation Sciences (IKDRC-ITS), and Walter Reed National Military Medical Center.

"Over the course of the next three years, the team aims to increase the number of transplant opportunities available to patients who need them by creating and growing kidney exchange programs in Brazil and India, where millions of people suffer from kidney disease yet exchange is minimal; and explore the effects of initiating donor chains with a deceased donor kidney (DDIC) in the U.S., an approach which could unlock hundreds more transplants each year.

..."

2. How Does Applied Economics Maximize Kidney Transplants? A project aimed at expanding kidney exchange and saving lives puts Nobel Prize-winning matching theory into practice.  by Jenn Brown   (including a video...)

"APKD uses open source software developed by Itai Ashlagi, Professor of Management Science and Engineering at Stanford University, to facilitate the matching process for its NEAD chains, and they currently average 5 non-simultaneous transplants per chain.

3. Extending Kidney Exchange

"In Brazil, our team has launched a kidney exchange program within Santa Casa de Misericórdia de Juiz de Fora and Hospital Clínicas FMUSP in São Paulo and aims to expand to facilitating exchanges between these centers and others with the ultimate goal of kidney exchange transitioning from a research project to an officially approved practice in Brazil.

"In India, our team has deployed kidney matching software and resources for growth to the Institute of Kidney Diseases and Research Center and Dr. HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS) to support kidney exchange programs. We aim to develop an evidence base for potential updates to organ transplantation laws that expand criteria for who can give and receive lifesaving kidneys.

"In the U.S., we are working with Walter Reed National Military Medical Center to test the use of deceased donor-initiated chains (DDIC) so as to generate hundreds of additional life-saving transplants each year that are not currently supported by today's practice of utilizing a deceased donor kidney to save the life of a single person on a transplant waitlist. "

 

Prison gangs, in Latin America and in the U.S.

 It's one thing to be able to capture and confine prisoners. When gangs are involved, it's quite another thing to control the prisons, or the ability of prisoners to continue to control gang activity outside of prison.

The NYT has the story, from Latin America:

In Latin America, Guards Don’t Control Prisons, Gangs Do. Intended to fight crime, Latin American prisons have instead become safe havens and recruitment centers for gangs, fueling a surge in violence. By Maria Abi-Habib, Annie Correal and Jack Nicas

"Inside prisons across Latin America, criminal groups exercise unchallenged authority over prisoners, extracting money from them to buy protection or basic necessities, like food.

"The prisons also act as a safe haven of sorts for incarcerated criminal leaders to remotely run their criminal enterprises on the outside, ordering killings, orchestrating the smuggling of drugs to the United States and Europe and directing kidnappings and extortion of local businesses.

"When officials attempt to curtail the power criminal groups exercise from behind bars, their leaders often deploy members on the outside to push back.

“The principal center of gravity, the nexus of control of organized crime, lies within the prison compounds,” said Mario Pazmiño, a retired colonel and former director of intelligence for Ecuador’s Army, and an analyst on security matters.

“That’s where let’s say the management positions are, the command positions,” he added. “It is where they give the orders and dispensations for gangs to terrorize the country.”

##########

I wrote a related post in November (see below) about a Brazilian prison gang, and received an illuminating email from Professor David Skarbek of Brown University, saying

"I enjoyed your blog post about the PPC Brazilian prison gang. I thought that you might be interested to know that the same phenomenon exists in the US as well. I'm attaching a piece I published in the American Political Science Review on the Mexican Mafia in Southern California."

Here's the link to that article:

Skarbek, David. "Governance and prison gangs." American Political Science Review 105, no. 4 (2011): 702-716.

Abstract: How can people who lack access to effective government institutions establish property rights and facilitate exchange? The illegal narcotics trade in Los Angeles has flourished despite its inability to rely on state-based formal institutions of governance. An alternative system of governance has emerged from an unexpected source—behind bars. The Mexican Mafia prison gang can extort drug dealers on the street because they wield substantial control over inmates in the county jail system and because drug dealers anticipate future incarceration. The gang's ability to extract resources creates incentives for them to provide governance institutions that mitigate market failures among Hispanic drug-dealing street gangs, including enforcing deals, protecting property rights, and adjudicating disputes. Evidence collected from federal indictments and other legal documents related to the Mexican Mafia prison gang and numerous street gangs supports this claim.

#########

Earlier

Tuesday, November 21, 2023

Balance of violence: prison-based criminal cartels, the case of Brazil's PCC.

Balance of violence: prison-based criminal cartels, the case of Brazil's PCC.

The vexed relationship between banned markets and black markets is perhaps nowhere clearer than when prison based gangs of convicted drug dealers are able to extend their empires outside of prisons. While national authorities are able to capture, convict and imprison gang leaders, those gangs retain the ability to organize violence not only inside prisons but outside of them, and hence operate national and international black markets as well.

The Guardian has the story:

How a Brazilian prison gang became an international criminal leviathan  by Tom Phillips

"The PCC – First Capital Command – arose in the country’s notoriously brutal penitentiaries 30 years ago but now controls a billion-dollar drug trade supplying much of Europe’s cocaine,

...

"For much of its 30-year existence the PCC has been considered a jailhouse fraternity, which recruited incarcerated “brothers” such as the Venezuelan by offering them protection within Brazil’s violent, overcrowded prisons. Created in August 1993, it grew into Brazil’s most feared criminal faction, conquering drug markets, smuggling routes, shantytowns and prisons across Brazil, including in far-flung corners of the Amazon. It also became a major player in other South American countries such as neighbouring Paraguay where the group has been blamed for multimillion-dollar armed robberies and bombings and targeted assassinations.

But over the past five years, investigators say the PCC – which the US now calls one of the world’s most powerful organized crime groups – has morphed into an even more formidable force after forging lucrative alliances with partners ranging from Bolivian cocaine producers to Italian mafiosi. Today, the group boasts tens of thousands of members and has a growing portfolio of interests, including illegal goldmines in the Amazon. It controls one of South America’s most important trafficking routes – linking Bolivia and Brazil to Europe and Africa – and is partly responsible for a tsunami of cocaine that has brought car bombings, assassinations and gunfights to parts of Europe.

...

"During the 1990s, the PCC tightened its grip on São Paulo’s prison system but largely flew under the radar until thousands of guards and visitors were captured during a massive 2001 uprising. Five years later the group again made headlines, bringing São Paulo to a virtual standstill with a wave of coordinated attacks on police that caused hundreds of deaths.

...

"Having dominated much of Brazil’s domestic drug market – and established a monopoly over São Paulo’s crime scene – Gakiya said the PCC began looking overseas in late 2016. Deals were struck with Italy’s most powerful mafia group, the ’Ndrangheta, as well as Serbian and Albanian mafias, and the PCC began shipping tonnes of cocaine from Brazilian ports to Europe.

...

"Marcola, 55, who is serving a 342-year prison sentence for murder, robbery and drug trafficking, is also not a man to be crossed. In late 2018, Gakiya decided to transfer him to a high-security federal prison after the discovery of an audacious multimillion-dollar plot to free him with the help of foreign mercenaries, helicopters and anti-aircraft guns. “I knew it might change my life but I also realized it needed doing,” the prosecutor said, admitting he did not consult his family first.

Gakiya was no stranger to death threats, but moving Marcola turned his life upside down. PCC leaders issued a “decree” calling for the prosecutor’s assassination, condemning Gakiya to a reclusive existence he compared to the life of Giovanni Falcone, the anti-mafia crusader assassinated in 1992. “I hope, of course, not to share the same fate as Falcone,” added Gakiya..."

Affirmative action in Brazilian universities: guest post by Inácio Bó

 Recent legislation in Brazil addresses university admissions with affirmative action that targets multiple characteristics that individuals may have (in different combinations), namely income, ethnicity, and the type of institution at which they studied. Early attempts to implement such a system produced undesirable outcomes, but recent legislation, informed by market design, is on the path to correcting this. Below, Inácio Bó brings us up to date:

Guest blog post by Inácio Bó

For many decades, Brazilian’s federal universities were—and still are— the top higher education institutions in the country. They had, however, a contradictory combination of circumstances: all of them were public-funded and tuition-free, but their students were overwhelmingly from a minority white higher socio-economic class. In response to that, in 2012 congress passed legislation mandating affirmative action in the access of all such institutions.

Orhan Aygün and I were at that time classmates pursuing our PhD in economics at Boston College. We spent days and weeks looking at the details of the structure of the rules for implementing the law, trying to better understand it. While working on some examples, we noticed that there could in principle be situations that were at odds with the intended objective of the law. Under some circumstances, black and low-income candidates would be rejected from positions where white and high-income candidates would be accepted, despite the former having higher entry-level exam grades than the latter. This  would be an outcome that goes in the opposite direction from the intended objective of helping black and low-income students attend these institutions.

The reason for this problem lies on the method used for implement the affirmative action law in the universities. Seats in each program in each university were split into groups of seats, including “open seats”, “black candidates”, “low-income candidates”, and “black and low-income candidates”. When applying for a program, a candidate would choose one of the alternatives for which she is eligible. The top candidates among those applying for each set of seats, ranked by their grade in a national exam, would be accepted. This method might, however, result in different levels of competition for different seats in the same program, resulting for example in tougher requirements for acceptance for “black and low-income” candidates than for “black” candidates, even if on average low-income candidates have lower grades overall.

In a paper published in the AEJ:Micro in 2021 (Aygün, Orhan, and Inácio Bó. 2021. "College Admission with Multidimensional Privileges: The Brazilian Affirmative Action Case." American Economic Journal: Microeconomics, 13 (3): 1-28.), we showed how this problem can be solved while still satisfying the text and spirit of the affirmative action law in Brazil with small changes in the way by which candidates are selected. (The idea is to order slot-specific priorities so that candidates with protected characteristics can compete for all of those slots for which their characteristics qualify them.) The paper also shows “smoking gun” evidence that these “unfair rejections” were taking place, showing that programs where the cutoff grades for acceptance for each subset of seats were compatible with these rejections constituted almost half of the programs offered across the nation.

While the article gained praise in the academic economic community, our hopes that it would reach the policymakers in Brazil were initially dashed. Despite having the chance of personally visiting the Ministry of Education in 2015 for two weeks, my attempts to talk with those in power were unsuccessful, and people to whom I explained some of our findings deemed its contents “critical of the government”.

 Especially in light of the political developments that took place in Brazil in the years that followed, I had mostly moved on from my hopes of seeing the changes we proposed being implemented.

Things started to change, however, around May of 2022. The staff from the office of representative Tábata Amaral, who is a prominent young politician with a focus on education, were having talks with Ursula Mello, now a professor at the Department of Economics at PUC-Rio in Rio de Janeiro, about some aspects of the affirmative action law related to her work. Given her knowledge about the AEJ:Micro paper, Ursula suggested that I join the discussions. A meeting where this happened even ended up in the press (https://www1.folha.uol.com.br/educacao/2022/05/pesquisadores-defendem-novo-algoritmo-no-sisu-para-nao-prejudicar-cotistas.shtml).

Adriano Senkevics, her co-author in related papers who works at the INEP—an agency connected to the Brazilian Ministry of Education in charge of evaluating educational systems—also joined.

In these discussions, it became clear that if we wanted our ideas to have any chance of gaining traction, we needed to write a policy-oriented paper, focused on the current Brazilian specifics, in Portuguese, and with policy-makers as the audience—not academics.

Adriano and I worked together in that project, now with a much more detailed dataset. We tailored the proposal to the updated law, which also included reservations for candidates with disabilities, and were finally able to quantify the negative impact of the failures we identified. Our estimates indicate that, in the selection process of 2019, at least ten thousand students were “unfairly rejected” from their applications, with more than 8 thousand being left unmatched to any university despite having an exam grade high enough to be accepted for less restrictive reserved seats. These numbers greatly exceeded our expectations, and made a clear political case for a change. The working paper went out in January of 2023 (“Proposal to change the rules for the occupation of quotas in the student entrance to federal institutions of higher education,” by Inácio Bó and Adriano Souza Senkevics).

While the theoretical arguments were already in the AEJ:Micro paper, the proposal had a greater and faster impact in the corridors of the Brazilian capital. Articles in the main newspapers in the country reported on the findings and the proposal (https://oglobo.globo.com/brasil/educacao/enem-e-vestibular/noticia/2023/03/quase-650-candidatos-para-uma-vaga-maiores-concorrencia-do-sisu-estao-entre-os-alunos-cotistas.ghtml

, https://oglobo.globo.com/brasil/antonio-gois/coluna/2023/02/reformar-o-sisu.ghtml

, https://www1.folha.uol.com.br/colunas/rodrigo-zeidan/2023/04/desenhando-mercados.shtml )

People were openly sharing the article on twitter with members of the ministry of education

(https://twitter.com/thiamparo/status/1621189953785839617?s=20 ,

https://twitter.com/mgaldino/status/1621008428763332612?s=20 ). We could feel the momentum.

In the months that followed, I started having regular interactions with members of the Ministry of Education. The text and zoom discussions involved technical and political aspects of changes in the law, which extended beyond the specific changes we suggested.

Different variations of the changes and some alternative proposals were considered. I had to run simulations while flying to deliver them before a meeting that the secretary had with the minister. I also had the incredible experience of joining a meeting at the “Casa Civil”—a department somewhat comparable to the prime minister in a parliamentary system—with the presence of secretaries from multiple ministries , where I presented our proposal and discussed some details and scenarios. Around that time, and without our knowledge, a senator presented a bill explicitly based on our proposal (https://www25.senado.leg.br/web/atividade/materias/-/materia/156995 ).

By the end of June, our belief that the changes would be implemented became stronger. Since our proposal was (by design) already compatible with the quotas law, its implementation could be done even in the absence of new legislation, and there was clear interest on the part of those in charge for making it happen.

A momentous event in this journey, however, took place on August 9th.

Because of a series of political circumstances, an urge to pass a renewed law for the affirmative action led to a bill proposed by Representative Dandara—the first member of congress who herself benefitted from the quotas law—to be brought to the floor for a vote.

Among other changes, it made the affirmative action policy permanent, changed the order in which seats are filled, and included text that should, in the following secondary legislation, include text that describes our proposal. As if emotions were not high enough, we had urgent calls to send the text of our proposal to members in the floor of congress minutes before the vote took place. And this resulted in the photo below, showing Dandara giving a speech before the vote, with a page from our paper in her hand.

The journey is not yet over. The bill must still pass the senate, and the legislation with the implementation details will follow. But I learned that these changes are made of so many steps that one has to choose one as the turning point. We believe that this is a good one.

The INEP (National Institute of Educational Studies and Research) thinks so too: (https://www.gov.br/inep/pt-br/assuntos/noticias/linha-editorial/inep-contribui-com-atualizacao-da-lei-de-cotas)

Interview in the Brazil Journal

 I was interviewed for the Brazil Journal by Giuliano Guandalini. The interview was conducted in English, but appears in Portuguese. We discussed controversial markets generally, including kidney exchange, which is not legal yet in Brazil.

Troca de rins. Drogas. Barriga de aluguel. Este Nobel sugere liberar tudo  (Kidney exchange. Drugs. Surrogacy...)

 Here's a snippet that comes through pretty clearly in retranslation back into English by Google Translate:

"In the US and many other countries, his work and that of other researchers has contributed to improving the waiting list for kidney transplants. In Brazil, we continue with the traditional system, with a long wait for donors. Why is it so difficult to make reforms of this kind in public services based on the teachings of modern economics?  

"A transplant always depends on an organ donation, whether from a dead person or a living individual. It is natural that family members and society in general are concerned about how this will be done in an ethical and careful manner. 

"Brazil does a lot of transplants. So there is no restriction on the medical capacity side so that more transplants can be done. But when we look at total kidney transplants in relation to population size, the number is not that big. 

"Meanwhile, there are thousands of people on dialysis because transplants have not been enough. The issue, therefore, is to allow more donations to occur in life, and changing kidneys is a way for people to help save someone they love. 

"Brazil may be one of the next countries to carry out the exchange of kidneys. Some experimental surgeries have already been performed, with legal authorization. Researchers will be able to gain support to perform more operations of this type and then, perhaps, society will be able to convince itself of the importance of changing kidneys. 

"What are the obstacles that prevent the adoption of organ exchange? Are they ethical, moral, religious issues? 

"A little bit of all those things. There are those concerned that poor and vulnerable people may have their organs stolen. Evidently, there must be complete assurance that this will not happen. But of course the poor would also like to save the lives of loved ones by giving them a kidney. "

Kidney exchange debate in Brazil

 A discussion of kidney exchange in Brazil began with this letter to the editor, describing how kidney exchange (aka kidney paired donation) could increase transplantation in Brazil:

Bastos, J., Mankowski, M., Gentry, S., Massie, A., Levan, M., Bisi, C., Stopato,C., Freesz, T., Colares, V., Segev, D. and Ferreira, G., 2021. Kidney paired donation in Brazil-A single center perspective. Transplant International: Official Journal of the European Society for Organ Transplantation.

"Kidney paired donation (KPD) represents a strategy for increasing the number of LDKT, offering an incompatible donor/recipient pair, the chance to exchange with another pair in the same situation [4]. In Brazil, KPD is still prohibited by law. We designed a study to show mathematically how KPD could increase LDKT in a single center in Brazil.

Several comments followed in a forum.. The name of the forum is ""Kidney Paired Donation is necessary in Brazil."  But not everyone agrees with that headline.

In particular, a letter to the editor from Mario Abbud-Filho & Valter Duro Garcia concludes that there are too many poor people in Brazil to allow kidney exchange:

 "We do not condemn the KPD strategy, but we disagree that it should be proposed in the actual Latin American context, where such great socioeconomic disparities do exist and could fuel organ trafficking and commerce."

That letter drew this rejoinder, in favor of kidney exchange by Marcelo Perosa:

"We do not understand the rationale behind the claim that KPD could stimulate organ trafficking and trade if the LD of an eventual KPD swap would be submitted to the same steps and rigor currently used for unrelated LDKT to be approved.

"The acceptance of KPD is growing around the world. It brings a potential technological development with advanced algorithms and softwares, unites clinicians, surgeons, immunologists in fruitful discussions and analysis of match runs, expanding and exchanging knowledge among multidisciplinary teams that currently work separately. KPD still has the beauty of not dividing, but joining efforts among different centers since the more groups participating, the more patients in the database and more matches are found.

"The main goal of KPD was to increase the chance of KT among highly sensitized (HS) patients, preventing the onerous treatment of desensitization. For a country with more limited economic resources like Brazil, KPD makes perfect sense for always contemplating compatible, cheaper, and more successful transplants."

And a final summation from two of the authors of the original paper:

Bastos, Juliana, and Gustavo Ferreira. "Kidney Paired Donation in Brazil-It is time to talk about it." Transplant International: Official Journal of the European Society for Organ Transplantation (2021), 01 Oct 2021, 34(10):1757-1758 DOI: 10.1111/tri.14025 PMID: 34431143 

"The history of kidney transplantation in Brazil began in 1965 when the first related living donor transplant. Since then, Brazil has established a public programme and now has the most extensive public kidney transplantation system in the world. Brazil has established a regulated, standardized and ethical organ procurement system, created awareness of transplantation in physicians and the public, upgraded facilities and standardized medical care, and enforced legislation for transplantation.

"The Aguascalientes document establishes that KPD and altruistic donation are acceptable. Its final recommendations also say that the country must provide access to transplantation based on ethical considerations and protect the most vulnerable population for a healthy transplant system [4]. We are failing to do that when we have a system that does not contemplate highly sensitized recipients, as shown by a recent Brazilian analysis: highly sensitized patients (PRA > 98%) had lower transplant rates (3.7% vs. 31.2%) and higher mortality (HR: 1.09, P = 0.05) in the waitlist when compared to nonsensitized patients [1]."

**********

Earlier related posts:

aturday, February 12, 2022

First kidney exchange in Brazil

Sunday, December 26, 2021

A call for kidney exchange in Brazil, in the Brazilian Journal of Nephrology

First kidney exchange in Brazil

 A first kidney exchange in Brazil, at Universidade de São Paulo, Hospital das Clínicas da Faculdade de Medicina, São Paulo, SP, Brasil, is briefly reported in the Brazilian Journal of Nephrology?

Pioneering Experience of First Kidney Paired Donation in Brazil by David José de Barros Machado, William Carlos Nahas, Elias David Neto, Braz. J. Nephrol. • 02 Feb 2022 • https://doi.org/10.1590/2175-8239-JBN-2021-0259

"The supply of kidneys from deceased and living donors in Brazil cannot meet the growing annual demand for transplants1. ABO incompatibility (ABOi) or positive complement-dependent cytotoxicity (CDC) crossmatch between the candidate recipient and the prospective donor is a major obstacle to living donor kidney transplant, and consequently many recipients remain on the waiting list for years.

"Since 2011, we have started the discussion and preparation for the implementation of a local KPD program at the Hospital das Clínicas - FMUSP. We discussed the topic internally with our Bioethics Commission, Medical Ethics Commission, Organ and Tissue Transplant Commission, and Clinical Board. In Brazil, Law No. 9,434 regulates the removal of organs, tissues, and parts of the human body for transplant purposes, without contemplating the activity of paired donation. Therefore, we proposed and obtained ethical approval (CAAE 83469418400000068) for a research project to assess the effectiveness of transplantation in patients with ABOi living donor or positive CDC/flow cytometry crossmatch by donor exchange. At the end of the medical, psychological, social, and immunological evaluation of the pairs and after the consent terms were signed, approval was obtained from the Ethics Committee that evaluates transplants with unrelated donors to perform the paired donation. Subsequently, we also obtained the approvals of the Public Prosecutor’s Office, the judicial approval and that of the General Coordination of the National Transplant System - Ministry of Health, for the first transplant with KPD in Brazil.

"On March 10, 2020, the 38-year-old recipient (recipient 1) with chronic glomerulonephritis, undergoing dialysis treatment, on a deceased transplant waiting list for 8 years and with the previous exclusion of 7 living donors, including his wife (donor 1), because of ABOi, received the kidney of the 45-year-old donor of the second pair. The second recipient, 57 years old, with chronic glomerulonephritis, undergoing dialysis treatment, on a deceased transplant waiting list for 1.9 years, and with exclusion of his only donor, wife (donor 2) because of ABOi, received the kidney from the 39-year-old donor of the first pair (donor 1). Pair anonymity was assured until the time of admission, as was reciprocal compatibility between the pairs and simultaneous surgery in 4 operating rooms, which allowed donors to withdraw consent at any time before anesthesia. After 12 months, recipients had adequate kidney function and their donors were doing well.

"Efforts to increase organ supply have a significant source of potential donors in the paired donation programs. Today, all countries that are world leaders in transplantation are practicing and developing this modality in an attempt to reach more and more recipients because of its excellent results"

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Earlier: 

Sunday, December 26, 2021

A call for kidney exchange in Brazil, in the Brazilian Journal of Nephrology

A call for kidney exchange in Brazil, in the Brazilian Journal of Nephrology

 Here's a call to allow kidney exchange in Brazil, to address the shortage of kidney transplants there.

Increasing transplantability in Brazil: time to discuss Kidney Paired Donation, by Juliana Bastos, David José de Barros Machado, and Elias David-Neto, Braz. J. Nephrol. • 17 Dec 2021 • https://doi.org/10.1590/2175-8239-JBN-2021-0141

"According to the 2020 Brazilian Dialysis Census, an estimated 45 thousand new patients started dialysis in the last year, totaling more than 144 thousand patients undergoing this therapy in the country. The estimated gross mortality of the patients varied between 18 and 20% in period 2016-2019.

"The number of KT performed in Brazil is increasing, although it is still less than half of the annual need estimated by the Brazilian Association of Organ Transplantation. Thus, the number of patients on the waitlist grows annually, having surpassed 26 thousand in 2020.

...

"Brazilian legislation does not contemplate the possibility of KPD. Law no. 9.434 from February 4, 1997 states that the removal of tissues, organs and body parts of a person in exchancge for payment or promise of reward, as well as for frivolous motives, constitutes a criminal offence37. Although organ exchange could be understood as a "promise of reward", it is evident that the law seeks to prohibit the commercialization of organs. In February 2020, a bill was implemented (95/2020) to add to the aforementioned law the following article: "For the effects of this Law, it shall not be considered commercialization the reciprocal donation of organs and tissues (exchange transplantation), so long as it does not involve any monetary benefits stemming from the act"; among other alterations, legitimizing the legality of KPD38. Similar legal obstacles have been overcome in other countries to encourage donor exchange28. It is important to remember that in KPD, all donors are non-relatives. According to national legislation, they must have prior legal approval, granted by the hospital ethics committee and the organ procurement center.

"In 2018, the Brazilian Federal Council of Medicine issued a statement opposing the implementation of KPD in Brazil39. The document stated, among other things, that KPD was a controversial concept, still in development and implemented only in a few countries; that it would incur high costs due to the logistical difficulties of the country, with its continental dimensions; that the increase in CIT could affect graft survival; that it would benefit only "a minimal part of the population"; and that it would jeopardize the credibility of the transplant program in Brazil39, an analysis that must be re-evaluated in light of currently reported data.

...

"We believe we have clarified in this review that, contrary to what has been said, KPD programs are no longer "controversial concepts in programs under development"(39 )but robust programs that are used almost everywhere in the world and show excellent results, comparable to other LDKT, despite focusing on a population with higher risk and a possible increase in CIT. Another critical issue relates to the main part of the affected population, the highly sensitized people who are sometimes referred to as non-transplantable. A national study in a single center estimated an increase of 7% in the total number of transplants with KPD (which is consistent with the results in the aforementioned countries), and an increase of more than 70% in the number of transplanted recipients with PRA > 80%41. If those figures were extrapolated nationally, for example, this would mean an increase of 420 LDKT in 2019.

"Thus, there seems to be no reason for Brazil not to join KPD, even if initially only locally and then implemented regionally/nationally according to the acceptance of the centers and the necessary logistical adaptation.

"At the HCFMUSP, KPD research seeks to determine the percentage of living donors rejected due to incompatibility and are eligible for KPD and to determine how many recipients would benefit from such a strategy. As part of this program, the first kidney exchange was carried out in Brazil in March 2020 and 28 additional pairs are currently under evaluation.

"Nowadays, all the leading countries in world are practicing this procedure and continue to develop it to include more recipients thanks to their excellent results.

...

"Finally, it is essential to emphasize that KPD also benefits those on the waitlist who do not have a donor, as it reduces the number of recipients waiting for an organ from a deceased donor. We believe that the Brazilian transplant program is mature enough to take up the challenge of starting a KPD program, primarily to benefit patients who have a low probability of receiving a transplant from a deceased donor."

Market design (I talk to the entering Ph.D. class at Escola Nacional de Administração Pública)

 Yesterday I gave what I think was the first lecture to the entering class of Ph.D. students at the Escola Nacional de Administração Pública (ENAP) in Brasilia.  I spoke about market design, using as my main examples school choice and kidney exchange.  Afterwards there was Q&A on a variety of subjects, including black markets and repugnance.

Here's a video (I start to speak around minute 8):

Successful birth in Brazil to a woman who received a uterus transplanted from a deceased donor

The Lancet reports the first known case of a live birth to a woman born without a uterus who received a transplanted uterus from a deceased donor.

Livebirth after uterus transplantation from a deceased donor in a recipient with uterine infertility

December 04, 2018 DOI:https://doi.org/10.1016/S0140-6736(18)31766-5

Background

Uterus transplantation from live donors became a reality to treat infertility following a successful Swedish 2014 series, inspiring uterus transplantation centres and programmes worldwide. However, no case of livebirth via deceased donor uterus has, to our knowledge, been successfully achieved, raising doubts about its feasibility and viability, including whether the womb remains viable after prolonged ischaemia.

Methods

In September, 2016, a 32-year-old woman with congenital uterine absence (Mayer-Rokitansky-Küster-Hauser [MRKH] syndrome) underwent uterine transplantation in Hospital das Clínicas, University of São Paulo, Brazil, from a donor who died of subarachnoid haemorrhage. The donor was 45 years old and had three previous vaginal deliveries. The recipient had one in-vitro fertilisation cycle 4 months before transplant, which yielded eight cryopreserved blastocysts.

Findings

The recipient showed satisfactory postoperative recovery and was discharged after 8 days' observation in hospital. 

...

The female baby weighed 2550 g at birth, appropriate for gestational age, with Apgar scores of 9 at 1 min, 10 at 5 min, and 10 at 10 min, and along with the mother remains healthy and developing normally 7 months post partum. The uterus was removed in the same surgical procedure as the livebirth and immunosuppressive therapy was suspended.

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In Brazil (where commercial surrogacy is apparently illegal, and legal surrogates must be family members of the intended mother), the urge to have one's own baby is nevertheless strong. 

See earlier post:

Wednesday, January 15, 2014

Womb transplants in Sweden (where surrogacy is illegal)