Four international kidney exchange programs: 3 achieve substantial success

 Here's a paper reporting on the experience of four cross-border kidney exchange programs, whose experience teaches an important lesson.  In particular (see the figure below), one of  the programs is run by Spain, Italy and Portugal, whose  total population of approximately 118 million people is far larger than the combined population of the other three*, but manages to do less than 5% of the total cross-border exchanges, far fewer than any of the others.  Despite its size, the Spain-Italy-Portugal program only tries to match hard-to-match patient-donor pairs with other hard-to-match pairs, unlike the other three programs.

 International Kidney Paired Donation Programs: Evolution and Practices of 4 Large Collaborations
Klimentova, Xenia PhD1; Domínguez-Gil, Beatriz MD, PhD2; Viana, Ana PhD1,3; Manlove, David PhD4; Andersson, Tommy PhD5; Ashkenazi, Tamar RN, PhD6; Berlakovich, Gabriela MD7; Böhmig, Georg A. MD8; Burton, Jo RN, PGDip9; Coll, Elisabeth MD, PhD2; Dittmer, Ian FRACP9; Fiaschetti, Pamela MD10; Fronek, Jiri MD, PhD11; Hughes, Peter D. MBBS, PhD12,13; Ivo da Silva, Margarida MD14; Mor, Eytan MD15; Viklický, Ondřej MD, PhD16; Weinreich, Ilse Duus BMLS17; Ferrari, Paolo MD, FRACP18,19
Transplantation ():10.1097/TP.0000000000005602, December 24, 2025. | DOI: 10.1097/TP.0000000000005602

"Plain Language Summary: Kidney paired donation (KPD) programs are organized in various countries to facilitate the donation of kidneys from willing but incompatible donors by matching them with pairs in similar situations. These programs often struggle with an accumulation of difficult-to-match recipients and small pools of incompatible pairs. To address this, several international collaborations have emerged to expand the pool sizes and increase the number of transplants by “exchanging” donors’ kidneys across countries. We identified 4 established international KPD programs, each supported by protocols and agreements signed by the participating parties. Each program is presented separately, detailing its historical establishment, operational aspects, and statistics on pool characteristics and performance. Following this, we provide a comparative analysis of key aspects across the 4 programs. Each program has its unique context and specificities. Even though 3 of 4 collaborations started just before the COVID-19 pandemic, they have collectively facilitated >450 transplants. This underscores the importance of further developing these collaborations to share practices and experiences, and to facilitate more transplants, particularly for difficult-to-match recipients. Three of the 4 presented collaborations are either fully operated or led by European countries. This highlights the crucial role of ongoing international cooperation in the development of KPDs, in particular in Europe. By further promoting collaboration among countries, we can facilitate pan-European exchanges and improve access to live kidney transplants for patients in need.

 ...

"A fundamental difference between the programs is their collaboration model. STEP, ANZKX, and the Czech-Austrian-Israeli collaboration operate as “merged pool” model, where all participating pairs are combined for joint matching runs. For STEP and ANZKX, no other matching runs are conducted by partners at any level (hospital or national), whereas in the Czech-Austrian-Israeli collaboration, the Austrian and Israeli partners report performing local exchanges whenever compatible pairs are identified.
 

"In contrast, KEPSAT uses a “sequential pool” model, where national matches are attempted first, and only unmatched pairs are entered into the international pool. It is recognized that the last 2 strategy strategies may lead to a fragmented market, potentially limiting matches for highly sensitized patients, as easier-to-match pairs are removed beforehand."

 It's ironic that a program that appears to be intended primarily to help hard-to-match pairs is organized in a way that limits them in this way.

The paper concludes on an optimistic note (with which I fully agree):

"In conclusion, ongoing international cooperation is essential for advancing KPD programs globally. Expanding cross-border exchanges and improving access to kidney transplants can greatly benefit patients worldwide. Additional strategies, such as NDADs, desensitization protocols, and the inclusion of compatible pairs, can further enhance the effectiveness of both national and international programs. Oversight of these initiatives is crucial to safeguarding the welfare of both donors and recipients, as well as to maximizing the success rates of kidney transplants.
 

"Looking ahead, new initiatives, and projects, funded by international health organizations, such as the European Kidney Paired Exchange Programme project (https://www.hnbts.hu/euro-kep/project), funded by EU4Health and starting in November 2024, aim to expand global collaboration among KPD programs, building on and strengthening existing partnerships. This increased international cooperation is expected to create additional opportunities for patients in need of kidney transplants worldwide, making life-saving transplants accessible to more individuals regardless of their geographic location."

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Earlier: Portuguese transplant docs noted the problem and argued for more global kidney exchange:

Tuesday, March 12, 2024 Kidney exchange between Portugal and Spain, and prospects for global kidney exchange

 ######### 

*Notes on population:

Spain: 49 million; Italy 59 million; Portugal 10 million ; KEPSAT total pop =  approx 118 million

 Australia 28 million; NZ 5 million: ANZKX total pop approx 33 million

Austria: 9 million, Czech Republic  11 million, Israel 10 million: AT-CZ-IL total 30 million

Sweden: 11 million; Norway:  6 million; Denmark 6 million; Finland  6 million: STEP total approx 29 mil

Notes from Messina (kidney exchange and the Accademia Peloritana dei Pericolanti)

 We traveled last week from Prague to Sicily, for the Matching in Practice workshop in  Messina, which was rich in kidney exchange. I was glad to reconnect with the Director of the National Transplant organization, Dr. Giuseppe Feltrin, and with Professors Antonio Nicolò and Antonio Miralles.

But a funny thing happened first, at the University of Messina. I was inducted into the university's Accademia Peloritana dei Pericolanti, founded in the early 1700's, at a time when autocrats didn't look fondly on universities (imagine that!). The symbol of the Academy is a ship sailing in the Strait of Messina (between Scylla and Charybdis) with the motto "Inter utramque viam periclitantes," "Taking risks between both paths," reflecting (I was told) the perils of navigating the strait between scholarship and politics.  It seemed very appropriate for the times.

Here's the story in the local news: with a picture:

 

Matching Theory and Market Design: conference in Sicily.

 Here's the preliminary program for the

20th Matching in Practice Workshop  University of Messina, Department of Economics, Aula Magna 2, 15-16 May 2025

Thursday 15 May

9:00-9:15 Opening

9:15-11:00 Presentation session “Matching with externalities and equity concerns I” 

 Alexander Nesterov, Higher School of Economics  “Reserves in Targeted Admissions: A Mechanism Design Approach” 

 Guillaume Haeringer, Baruch College  “School Choice under Uncertainty: an Experiment” 

Antonio Romero Medina, Universidad Carlos III de Madrid  “Optimizing Daycare Enrollment: How To Avoid Early Applications”

11:00-11:15 Coffee break

11:15-13:00 Presentation session “Dynamic matching and incentives to participation I”

 Duygu Sili, Università degli Studi di Messina  “Costly Multi-Hospital Dynamic Kidney Exchange”

 Subhajit Pramanik, Università degli Studi di Padova  “A Dynamic Bargaining Framework for International Kidney Paired Exchange Program”

 Özgür Yilmaz, Koç University “Dynamically Optimal Kidney Exchange” 

13:00-14:00 Lunch

14:00-15:15 Seminar presented by the 2012 Nobel Prize in Economics Prof. Alvin Roth (Stanford University)  “The Economics of Kidney Exchange: Kidneys and Controversies”  (open to the public)

16:00-22:00 Departure to and walk across Taormina, with gala dinner to follow at Ristorante La Botte.

Friday 16 May

9:00-10:45 Presentation session “Matching with externalities and equity concerns II” 

Flip Klijn, Institute for Economic Analysis (CSIC) and Barcelona School of Economics  “Characterizing No-Trade-Bundled Top-Trading Cycles Mechanisms for Multiple-Type Housing Markets”

 Péter Biró, Institute of Economics, HUN-REN KRTK “Ex-post Stability under Two-Sided Matching: Complexity and Characterization”

 Emre Dogan, HSE University “Incentivizing Public Lawyers and Enhancing Fairness via Sorting in Adversarial Systems”

10:45-11:00 Coffee break

11:00-12:45 Presentation session “Dynamic matching and incentives to participation II”

 Pietro Salmaso, Università degli Studi di Napoli Federico II  “Rationalizable Conjectures in Dynamic Matching”

Johanna Raith, IHW – Leibniz Institute for Economic Research “College Application Choices in a Repeated DA Setting: Evidence from Croatia”

 Sonal Yadav, University of Liverpool “Teacher Redistribution in Public Schools”

12:45-13:40 Roundtable  “Organ-donor exchange programs, international comparison” Moderator Prof. Antonio Nicolò (Università degli Studi di Padova), with the participation of Prof. Alvin Roth (Stanford University) and Dr. Giuseppe Feltrin (National Transplant Center)

13:40-14:30 Farewell lunch.

 The MiP Workshop is an annual meeting organized by the Matching in Practice network of European researchers working in the research field of Matching Theory and Market Design.

This year’s MiP workshop is funded by the following projects: Prin2022 “Externalities and fairness in allocations and contracts” (CUP J53D23004650006 – ID 2022HLPMKN) and PrinPNRR2022 “Incentivizing participation of compatible pairs in Kidney Paired Exchange Programs” (CUP J53D23015460001- ID P2022P5CHH), both funded by the European Union – Next Generation EU.

The Organizing Committee includes the Messina Unit Manager of the aforementioned projects, Prof. Antonio Miralles Asensio, and the Principal Investigators of both funding projects, respectively Prof. Maria Gabriella Graziano (University of Naples Federico II) and Prof. Antonio Nicolò (University of Padua). External members of the Scientific Committee are Prof. Caterina Calsamiglia (IPEG and ICREA, Spain), Prof. Rustam Hakimov (Université de Lausanne, Switzerland) and Prof. Péter Biró (Hungarian Academy of Sciences, Hungary).

Kidney exchange in Italy and Europe

 In May, when I spoke at the  Istituto Superiore di Sanità. I was interviewed by TrendSanita, and that interview has just been published. (It's in Italian, but Google Translate works very well):

  A TrendSanità parla il premio Nobel 2012 per l’economia Alvin Eliot Roth: « Il nostro compito come economisti non è solo lavorare a come allocare al meglio risorse scarse ma, possibilmente, fare in modo che diventino meno scarse»  di Cesare Buquicchio  24 Ottobre 2024

["The 2012 Nobel Prize winner for economics Alvin Eliot Roth speaks to TrendSanità: «Our task as economists is not only to work out how to best allocate scarce resources but, possibly, to make them less scarce»}

"In an in-depth analysis of the Italian and international transplant system, Roth highlights the progress and the challenges that remain. " Italy reached the highest level in its history for organ donations in 2023 , but there is still a lot of work to do to bridge the gap between supply and demand, once again, an economic concept," he adds with a smile.

...

"Roth's vision for the future is clear: an integrated European system that allows for the optimization of organ exchanges across national borders, increasing the chances of finding compatible donors for each patient. An ambitious goal that requires not only technological innovation and medical coordination, but also a new understanding of the economic mechanisms that can make the transplant system more efficient. " Economics may seem distant from medicine, but when it comes to saving lives through better allocation of resources, economic principles become valuable tools at the service of public health ," concludes Roth."

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

Earlier:

Tuesday, May 7, 2024

Kidney exchange in Italy, Europe and the U.S.: video of my talk in Rome

Italy criminalizes surrogacy from abroad

 Italy has banned its citizens from accessing surrogacy in other countries where it is legal.  It will be interesting to see how they enforce this. (But of course gay couples will have fewer opportunities to skirt the law than couples who could pretend to have had a pregnancy..)

The NYT has the story:

Italy Criminalizes Surrogacy From Abroad, a Blow to Gay and Infertile Couples. The new law was pushed by the party of Giorgia Meloni, Italy’s conservative prime minister. by Emma Bubola

"Italy passed a law on Wednesday that criminalizes seeking surrogacy abroad, a move the country’s conservative government said would protect women’s dignity, while critics see it as yet another crackdown by the government on L.G.B.T. families, as the law will make it virtually impossible for gay fathers to have children.

"Surrogacy is already illegal in Italy. But the government of Prime Minister Giorgia Meloni has vowed to broaden the ban to punish Italians who seek it in countries where it is legal, like in parts of the United States."

###########

Earlier:

Thursday, August 22, 2024  Surrogacy under continued attack in Italy

Surrogacy under continued attack in Italy

The language of repugnance is strong in these latest developments.

The NYT has the story:

Has Power Moderated Italy’s Leader? Not to Same-Sex Parents.  Prime Minister Giorgia Meloni has mostly shown a pragmatic streak abroad. But at home, her government is plunging many gay families into panic. 

"Surrogacy is already illegal if conducted in Italy. But the government of Prime Minister Giorgia Meloni wants to expand the prohibition. It has promoted a bill that would also punish Italians who make use of surrogacy even in places abroad where it is legal, like in parts of the United States. Those Italians who do could face up to two years in prison and be fined the equivalent of about a million dollars.

"Italy’s lower chamber of Parliament approved the bill last summer, and the Senate’s justice committee greenlighted it last month. The Senate is expected to vote on it as soon as the fall.

...

"No one can convince me that it is an act of freedom to rent one’s womb,”  [Prime Minister Meloni] said in the spring at an event in Rome. “No one can convince me that it is an act of love to consider children as an over-the-counter product in a supermarket.”

“Uterus renting is a shameful, inhuman practice,” she said. “It will become a universal crime.”

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

Earlier

Wednesday, April 5, 2023

Surrogacy under siege in Italy

Talks to doctors and students in Italy

 I just returned from a busy trip to Italy, that began with a talk to physicians in Rome about kidney exchange, after which I moved on to talk to students in Padua.

Both were fun in different ways.  Here are some of the students gathered for a spritz after one of my talks in Padua.

The design of markets, in Padua (video)

Yesterday I had the pleasure of speaking about market design in the Aula Magna of the University of Padua, where Galileo lectured.  Below is a video. I start to speak around minute 14:20.

Update: here's a post-talk photo:

Kidney exchange in Italy, Europe and the U.S.: video of my talk in Rome

 Here is a video recording of my talk in Rome yesterday at the  Istituto Superiore di Sanità. There are some introductions by people with vast accomplishments in Italian transplantation and kidney exchange, Giuseppe Feltrin (director of the National Transplant Center), Antonio Nicolò (professor of Economic Theory at the University of Padua) and Lucrezia Furian (Kidney and Pancreas Transplant Surgery Unit - Department of Surgical, Oncological and Gastroenterological Sciences of the University Hospital of Padua)*. 

My talk begins at 27:55.

x

*Although her web page didn't yet reflect this, Dr. Furian was very recently promoted to the rank of Full Professor of Surgery.  Congratulations Lucrezia!

The Design of Markets. Una Nobel Lecture (Two talks in Padua, on Tuesday and Wednesday)

 Following my talk in Rome today, I'll be speaking in Padua tomorrow and Wednesday, first giving a seminar on controversial markets, and then a public lecture on market design.

The Design of Markets. Una Nobel Lecture di Alvin Eliot Roth

"On Wednesday 8 May the University of Padua hosts the  Nobel Lecture

...

"The meeting opens with greetings from the vice-rector Antonio Parbonetti  and the director of the Galilean School of Higher Studies,  Gianguido Dall'Agata . The guest is introduced by Antonio Nicolò , coordinator of the Social Sciences Class of the Galilean School.

...

"The Nobel Lecture, which is held in English , is  open to the public . To participate, reservations are required 

You can also follow the meeting via  live streaming on YouTube .

---

The Padua Nobel Lecture by Alvin Eliot Roth is preceded, on Tuesday 7 May at 3pm, by a seminar aimed exclusively at professors, researchers, fellows of the Department of Economic Sciences of the University of Padua - dSEA .
The Economics Seminar  is entitled " Controversial markets and repugnant transactions " and is held at the department headquarters in via del Santo 33 in Padua.

Matching markets and organ transplantation at the Istituto Superiore di Sanità in Rome on Monday

 I'm traveling this weekend to help inaugurate  the celebration of the 90th anniversary of Italy's Istituto Superiore di Sanità (Higher Institute of Health).  Below is their press release, which also notes that my talk will mark the 20th anniversary of the publication of my paper with Tayfun Sonmez and Utku Unver:

Roth, Alvin E., Tayfun Sonmez, and M. Utku Unver, "Kidney Exchange," Quarterly Journal of Economics, 119, 2, May, 2004, 457-488

Nobel Prize winner Alvin Roth opens the series of conferences dedicated to the 90th anniversary of the ISS

"Thanks to his work, 'crossover' kidney transplants are possible; next May 6th lectio magistralis in person and streaming.

"The cycle of scientific conferences that the Istituto Superiore di Sanità dedicates to the 90th anniversary of its foundation begins with a lectio magistralis by the Nobel Prize winner for economics Alvin Roth. On May 6th at 12.30 pm, Professor Roth, whose work has paved the way for the possibility of carrying out crossed kidney transplants between incompatible couples, will hold a keynote address entitled "Matching markets and organ transplantation".

"Exactly 20 years ago, in May 2004, Roth published "Kidney Exchange" in the Quarterly Journal of Economics (the oldest economic studies journal in the United States), the article in which the scholar exposed his "matching theory" by applying it to problem of compatibility between donor and recipient in living kidney transplantation and the need to find a sufficient number of donors for patients waiting for an organ. Roth demonstrated mathematically that, by cross-referencing the immunological data of all couples in which a healthy person wants to donate a kidney to a sick family member but cannot do so due to lack of compatibility, all patients could receive the organ they need. For his studies on stable allocations, defined by the Royal Swedish Academy as "a masterpiece of economic engineering", Roth was awarded the Nobel Prize in 2012.

"Starting from that first algorithm developed by Roth, today cross-kidney transplant programs between incompatible couples (called "crossover") have become a reality in many countries around the world: in Italy 132 transplants of this type have been carried out so far thanks to crossing of 85 pairs of donors and recipients, as part of a complex clinical and logistical program managed by the National Transplant Center which has so far involved 20 different hospitals. In 2023 alone there were 17 crossover transplants, of which 2 were carried out thanks to international exchange programmes: the first, last June, performed in Padua thanks to the crossing with two other Spanish couples, one in Bilbao and one in Barcelona, and the second in Vicenza, with an exchange organized with the Porto hospital.

"Professor Roth will hold his dissertation at the invitation of the National Transplant Center, the Galilean School of Higher Studies and the Department of Economic and Business Sciences of the University of Padua, the university at which the Stanford University economist will continue his series of conferences in Italy. The event, which will be held in the Pocchiari Hall of the Higher Institute of Health starting from 12.30, will be attended by Rocco Bellantone (president of the ISS), Giuseppe Feltrin (director of the National Transplant Center), Antonio Nicolò (professor of Economic Theory at the University of Padua) and Lucrezia Furian ( responsible for the Kidney and Pancreas Transplant Surgery Unit - Department of Surgical, Oncological and Gastroenterological Sciences of the University Hospital of Padua).

"It will be possible to follow the event in person (the request for accreditation can be made to ufficio.stampa@iss.it) and in streaming on the Institute's home page."

Kidney exchange between Portugal and Italy

 Italy-Portugal cross transplants. that click that saved two

"Thanks to a complex work of intervention planning and logistics, managed by the National Transplant Center, the Veneto Regional Transplant Center and the Portuguese institutions, the kidney of the Italian donor was removed in Vicenza and transplanted in Porto in a 41-year-old man while the Italian patient was transplanted with a kidney donated by a 36-year-old woman. The organs were harvested in the two centers simultaneously on the morning of 20 July. The Portuguese kidney arrived at Treviso airport at 2.10 pm on board a Lusitanian Air Force flight: the military delivered the organ to the regional transplant coordinator of the Veneto, Dr. Giuseppe Feltrin, receiving the Italian kidney in exchange. The 118 of Vicenza immediately transported the organ to San Bortolo where the transplantation began immediately. Both surgeries were successful and all recipients and donors went home in excellent condition."

Surrogacy under siege in Italy

 Opposition to surrogacy in Italy has taken aim at the babies of same sex couples.

The NYT has the story:

Surrogacy Emerges as the Wedge Issue for Italy’s Hard Right. Prime Minister Giorgia Meloni has ordered municipalities to stop certifying foreign birth certificates for same-sex couples who used surrogacy, leaving some babies in a legal limbo.  By Jason Horowitz

"the government of Prime Minister Giorgia Meloni ordered municipalities to obey a court ruling made in December and stop certifying foreign birth certificates of children born to Italian same-sex couples through surrogacy, which is illegal in Italy.

"The decision has left Martino Libero and several other children suspended in a legal limbo, depriving them of automatic Italian citizenship and residency rights like access to the country’s free health care system and nursery school.

...

"Milan, a city that has long served as a cosmopolitan haven for same-sex couples in Italy, has for now complied with the Meloni government order and suspended issuing Italian birth certificates.

"Without official recognition, Libero Martino, 2 months old this month, will have to leave and re-enter the country every few months to remain legal. A court could eventually recognize one of the men as the biological father — they decline to say which one is the sperm donor — and then they could start a separate adoption process for the other.

...

"Ms. Meloni’s government has sought to shift the issue away from the status of the children to the practice of surrogacy, which, while legal in the United States and Canada, is illegal or restricted in much of Europe outside of Greece, Ukraine and a few other countries. In Italy, home of the Vatican, it is not only illegal, but it is also widely opposed, including among Catholic corners of the center-left opposition.

...

"Prominent members of Ms. Meloni’s Brothers of Italy party have called surrogacy a crime “even worse than pedophilia,” in which gay couples, one of whom is usually the biological father, seek to “pass off” children as their own and mistake “children for Smurfs,” saying gay couples can uniquely afford surrogacy, even though it is overwhelmingly used more by heterosexual couples.

"The party is floating a proposal, made by Ms. Meloni when she was a member of Parliament, to make Italians’ seeking of surrogate births abroad — what she had called “procreative tourism” — illegal and “punishable with three months to two years of prison and a fine of 600,000 to a million euros.”

...

"In an interview shortly before her election, as her young daughter ran around her in a Sardinia courtyard, Ms. Meloni said she opposed gay marriage, not because she was homophobic — “I’ve got many, many homosexual friends” — but because she saw it as a step to same-sex adoption, which she opposed, and which the Roman Catholic Church successfully lobbied to exclude from a civil unions law passed in 2016.

********

Earlier:

Monday, February 20, 2023

Will Italy criminalize foreign surrogacy?

Will Italy criminalize foreign surrogacy?

 It's hard to ban something that people want and need and is legally available in other jurisdictions, but it looks like Italy might try it regarding surrogacy.  Here's a story from Britain's Sunday Times:

Italian families seeking surrogates abroad could face jail or €1 million fines by Tom Kington

"Italians travelling abroad to seek surrogate mothers to start families could face jail time and a million euro fine thanks to a new bill introduced by senators close to Giorgia Meloni, the Italian prime minister.

"The proposed law, which must be approved by the Italian parliament, describes surrogacy as “an execrable example of the commercialisation of the female body and the treatment of babies as merchandise”.

...

"An Italian law passed in 2004 banned surrogate pregnancies in Italy, forcing couples to travel to countries such as the United States and Canada to find surrogate mothers."

Kidney exchange launched between the U.S. and Italy

 Here's the announcement from Italy (in Italian), on the site of the Centro Nazionale Trapianti, the National Transplant Center: 

Al via programma di trapianti incrociati di rene tra Italia e Usa, firmato l'accordo, 

Google translate: "The pilot phase will cover the first three cases and will be limited to  three hospitals : for Italy, the kidney transplant center of the  Agostino Gemelli Polyclinic in Rome will participate, directed by Professor Franco Citterio, present at the signing of the agreement, while for the USA the  University of Toledo Medical Center  and the hospitals of  Thomas Jefferson University in Philadelphia will be involved . Once the operational and management experimentation has been completed, the program will be re-evaluated for a possible consolidation of the protocol and for the progressive expansion to other living kidney transplant centers of the Italian network. 

"The one with the United States is  the second international exchange protocol  activated by our country: since 2018 an agreement has been in force involving France, Portugal and  Spain  and which has resulted in three cross transplants with the latter nation. From 2015 to date, the Italian national crossover kidney transplant program has allowed  77 interventions to be carried out . Overall, 2,043 kidney transplants were performed in Italy in 2021, of which 341 from living donors: of these, 5 were carried out through an exchange between donor and recipient pairs. "

*******

Here's the announcement from the Alliance for Paired Kidney donation, the U.S. partner (in English):

PILOT KIDNEY EXCHANGE TRANSPLANT PROGRAM LAUNCHED BETWEEN US, ITALY

""The goal of the memorandum of understanding, which was signed at the Ministry of Health in Rome, is to provide for the possible treatment of thousands of patients awaiting kidney transplants in both the U.S. and Italy. The agreement was signed on behalf of CNT by its director, Massimo Cardillo, and by Michael A. Rees, MD, PhD, the CEO of APKD and the surgical director of kidney transplantation at the University of Toledo Medical Center in Ohio.

"The new US-Italy program concerns kidney exchange transplantation, in which incompatible living donor and recipient pairs are matched with other incompatible pairs for kidney transplants. Thanks to the agreement between APKD and CNT, incompatible American and Italian donor-recipient pairs will be able to exchange with each other based on a shared algorithm that will verify the level of compatibility between those on the countries’ transplant waiting lists. In this way, patients with kidney failure, who also have an incompatible volunteer donor, will have a greater chance of receiving the transplant they need.

"In addition to the technical-operational aspects – such as the requirements of the participating hospitals, matching algorithm and overall governance of the transplant process – the agreement provides that the costs related to the transplant procedure are borne by the U.S. insurance coverage for the U.S. recipient and the Italian donor, while the Italian National Health Service will cover the expenses for the Italian recipient and the American donor. Transplant surgeries will take place in the country where the recipient is located.

********

A critical role was played by Dr. Ignacio Marino, the transplant surgeon who took time off to be the mayor of Rome and is now at Jefferson Hospital in Philadelphia.

His facebook post yesterday describes some details of the proceedings (first in Italian and then in English:

"The agreement was signed by the Italian National Transplant Centre (NTC), represented by director Massimo Cardillo, and the Alliance for Paired Kidney Donation (APKD), a non-profit organisation that runs one of the largest living kidney exchange programmes in the United States, represented by its CEO, Professor Michael A. Rees, MD PhD, director of the Kidney Transplant Centre at the University of Toledo Medical Center, Ohio. The signing of the protocol was attended by the Italian Deputy Minister for Health Pierpaolo Sileri, who has wholeheartedly supported this innovative project from the outlet."

Drs. Mike Rees and Ignazio Marino

**********

 ******** 

Update, October 3:

Here's an Italian news article from Sanita24 taking note of the agreement.

Trapianti di rene: attese più brevi grazie all'algoritmo del premio Nobel Alvin Roth  di Paolo Castiglia

G translate of first paragraph: "In no country in the world is there a sufficient number of donors to cover the transplant needs of all patients suffering from end-stage renal failure and who therefore have to resort to dialysis. To address this need, a memorandum of understanding was signed for the launch of an organ donation program in a “cross” mode between different continents, to offer a new possibility of treatment to patients on dialysis."

************

Related earlier posts

Tuesday, September 4, 2018

Ignazio Marino on global kidney exchange

Sunday, December 20, 2020

Jefferson University celebrates Dr. Ignazio Marino

Medical aid in dying in Italy--a first

 The NYT has the story:

Man Paralyzed 12 Years Ago Becomes Italy’s First Assisted Suicide  By Elisabetta Povoledo

"Paralyzed 12 years ago in a traffic accident, “Mario” faced a series of legal, bureaucratic and financial hurdles in his pursuit of death

"On Thursday, “Mario,” identified for the first time by his real name, Federico Carboni, ended his life, becoming Italy’s first legal assisted suicide, in his home in the central Italian port town of Senigallia.

"Mr. Carboni, an unmarried truck driver, was surrounded by his family, friends, and people who had helped him to achieve his goal, including officials with the Luca Coscioni Association, a right-to-die advocacy group that assisted Mr. Carboni during the past 18 months and announced his death.

...

"An Italian court ruling has declared assisted suicide permissible in Italy under certain limited circumstances, but there is no legislation enshrining the practice, which for Mr. Carboni, led to delays.

...

"In a landmark ruling in 2019, Italy’s Constitutional Court said that assisted suicide could not be considered a crime as long as certain conditions were met.

...

"The Constitutional Court ruled that in some cases assisting someone could not be considered a crime as long as the person requesting aid met certain conditions: they had to have full mental capacity and suffer from an incurable disease that caused severe and intolerable physical or psychological distress. They also had to be kept alive by life-sustaining treatments.

...

"The Roman Catholic Church is firmly opposed to assisted suicide and euthanasia, which it has called “intrinsically evil” acts “in every situation or circumstance.” 

More on Deceased donors as non‐directed donors in kidney exchange chains

I anticipate that we  will be reading more in the future about kidney exchange chains started by a deceased donor kidney.  In the meantime, here are two recent papers:

From the American Journal of Transplantation:

Deceased donors as non‐directed donors in kidney paired donation

W. Wang 

 

M.A. Rees 

 

A.B. Leichtman 

 

P. X‐K. Song 

 

M. Bray 

 

V.B. Ashby 

 

T. Shearon 

 

A Whiteman 

 

J.D. Kalbfleisch

First published: 16 August 2020

 

https://doi.org/10.1111/ajt.16268

This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi:10.1111/ajt.16268

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Abstract

As proof of concept, we simulate a revised kidney allocation system that includes deceased donor (DD) kidneys as chain‐initiating kidneys (DD‐CIK) in a kidney paired donation pool (KPDP), and estimate potential increases in number of transplants. We consider chains of length 2 in which the DD‐CIK gives to a candidate in the KPDP, and that candidate’s incompatible donor donates to the deceased donor (DD) waitlist. In simulations, we vary initial pool size, arrival rates of candidate/donor pairs and (living) non‐directed donors (NDDs), and delay time from entry to the KPDP until a candidate is eligible to receive a DD‐CIK. Using data on candidate/donor pairs and NDDs from the Alliance for Paired Kidney Donation, and the actual DDs from the Scientific Registry of Transplant Recipients (SRTR) data, simulations extend over two years. With an initial pool of 400, respective candidate and NDD arrival rates of two per day and 3 per month, and delay times for access to DD‐CIK of 6 months or less, including DD‐CIKs increases the number of transplants by at least 447 over two years, and greatly reduces waiting times of KPDP candidates. Potential effects on waitlist candidates are discussed as are policy and ethical issues.

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And from Transplant International: 

Kidney exchange strategies: New aspects and applications with a focus on deceased‐donor‐initiated chains

Lucrezia Furian  Antonio Nicolò  Caterina Di Bella  Massimo Cardillo  Emanuele Cozzi  Paolo Rigotti

First published: 09 August 2020 https://doi.org/10.1111/tri.13712

This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi:10.1111/tri.13712

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Abstract: "Kidney paired donation (KPD) is a valuable way to overcome immunological incompatibility in the context of living donation, and several strategies have been implemented to boost its development. In this article, we reviewed the current state of the art in this field, with a particular focus on advanced KPD strategies, including the most recent idea of initiating living donor (LD) transplantation chains with a deceased‐donor (DD) kidney, first applied successfully in 2018. Since then, Italy has been running a national program in which a chain‐initiating kidney is selected from a DD pool and allocated to a recipient with an incompatible LD, and the LD’s kidney is transplanted into a patient on the waiting list (WL).

"At this stage, since the ethical and logistic issues have been managed appropriately, KPD starting with a DD has proved to be a feasible strategy. It enables transplants in recipients of incompatible pairs without the need for desensitizing and also benefits patients on the WL who are allocated chain‐ending kidneys from LDs (prioritizing sensitized patients and those on the WL for longer)."

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Previous posts:

Monday, October 14, 2019  A kidney exchange chain initiated by a deceased donor, in Italy

Tuesday, September 5, 2017 UNOS proposal: Allowing Deceased Donor-Initiated Kidney Paired Donation (KPD) Chains

Monday, April 11, 2016 Using deceased donor kidneys to start living donor kidney exchange chains

 

Utilization of Deceased Donor Kidneys to Initiate Living Donor Chains

1. M. L. Melcher¹, 
 
2. J. P. Roberts^2,*, 
 
3. A. B. Leichtman³, 
 
4. A. E. Roth⁴ and
 
5. M. A. Rees

 

Social distancing during the plague

 The Washington Post has the story (as a tourist destination...)

Restaurants in Italy are reopening ancient ‘wine windows’ used during the plague

The coronavirus pandemic has inspired a comeback for the socially distant invention.

By Natalie B. Compton Add to list

"In the 1300s, Europeans lived in fear of the plague claiming lives across the continent. In 2020, Europeans face the threat of the coronavirus, a pandemic that has killed more than 728,000 worldwide.

..."Between the wrath of the Black Death in the 1300s and the Italian Plague in the 1600s, wine merchants in the Italian region of Tuscany built “wine windows” to protect buyers and sellers from coming into close contact."

"The socially distant precaution was ahead of its time."

City of Science museum in Naples

Last June I gave some talks in Italy (back when there were airplanes, and in-person talks--remember?) One side trip took me to the City of Science museum in Naples.  I've just now come across a web page that memorialized that visit, with some pictures that reminded me of what a fine science museum it is.  (I still enjoy science museums, even though I'm temporarily out of kids to bring with me...)

Il Premio Nobel per l’Economia 2012 Alvin Eliot Roth in visita a Città della Scienza
19 giugno 2019

A kidney exchange chain initiated by a deceased donor, in Italy

 Deceased Donor–initiated Chains
First Report of a Successful Deliberate Case and Its Ethical Implications
Furian, Lucrezia MD1; Cornelio, Cristina PhD2; Silvestre, Cristina MD, PhD1; Neri, Flavia MD1; Rossi, Francesca PhD2,3; Rigotti, Paolo MD1; Cozzi, Emanuele MD, PhD4; Nicolò, Antonio PhD

Transplantation: October 2019 - Volume 103 - Issue 10 - p 2196–2200
doi: 10.1097/TP.0000000000002645

Background. It has been suggested that deceased donor kidneys could be used to initiate chains of living donor kidney paired donation, but the potential gains of this practice need to be quantified and the ethical implications must be addressed before it can be implemented.

Methods. The gain of implementing deceased donor–initiated chains was measured with an algorithm, using retrospective data on the pool of incompatible donor/recipient pairs, at a single center. The allocation rules for chain-ending kidneys and the characteristics and quality of the chain-initiating kidney are described.

Results. The benefit quantification process showed that, with a pool of 69 kidneys from deceased donors and 16 pairs enrolled in the kidney paired donation program, it was possible to transplant 8 of 16 recipients (50%) over a period of 3 years. After obtaining the approval of the Veneto Regional Authority’s Bioethical Committee and the revision of the Italian National Transplant Center’s allocation policies, the first successful case was completed. For the recipient (male, aged 53 y), who entered the program for a chain-initiating kidney with a Kidney Donor Risk Index of 0.61 and a Kidney Donor Profile Index of 3%, the waiting time was 4 days. His willing donor (female, aged 53 y) with a Living Kidney Donor Profile Index of 2, donated 2 days later to a chain-ending recipient (male, aged 47 y) who had been on dialysis for 5 years.

Conclusions. This is the first report of a successfully completed, deliberate deceased donor–initiated chain, which was made possible after a thorough assessment of the ethical issues and the impact of allocation policies. This article includes a preliminary efficacy assessment and describes the development of a dedicated algorithm.
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See earlier post:

Monday, April 11, 2016

Using deceased donor kidneys to start living donor kidney exchange chains