Pakistan police bust organ trafficking ring --transplants were carried out in private homes

 Outlawing compensation for donors doesn't end black markets for kidneys from living donors, but may succeed in driving them out of hospitals, and making them increasingly dangerous and black.

The BBC has the story:

Pakistan police bust organ trafficking ring that took kidneys from hundreds By Rachel Russell

"Eight members of an organ trafficking ring in north-east Pakistan have been arrested, police say.

"The ring's alleged leader, Fawad Mukhtar, is accused of extracting the kidneys of more than 300 people and transplanting them into rich clients.

...

"At least three people died from having their organs harvested in this way, authorities said.

...

"The transplants were carried out in private homes - often without the patient knowing, the chief minister of Punjab province Mohsin Naqvi said.

"A car mechanic is said to have worked as Mr Mukhtar's surgical assistant and helped lure vulnerable patients from hospitals.

"The kidneys were then sold for up to 10 million rupees (£99,000; $120,000) each, Mr Naqvi added.

...

"The commercial trade of human organs was made illegal in Pakistan in 2010.

"The punishment for those caught includes a decade-long jail term and huge fines in the hope that this will stop sales to overseas clients by exploitative doctors, middlemen, recipients and donors.

"However, there has been a rise in organ trafficking in the country as people struggle with low wages and a poor enforcement of the law."

HT: Jlateh Vincent Jappah

Blasphemy in Pakistan

 How to strengthen a ban that already allows the death penalty for repugnant speech?  The NYT has the story:

Pakistan Strengthens Already Harsh Laws Against Blasphemy. Insulting Islam or its founder is already a capital offense, but now those who insult people connected to the Prophet Muhammad could get prison time. By Salman Masood

"Pakistan’s blasphemy laws, which can already mean death for those deemed to have insulted Islam or the Prophet Muhammad, can now also be used to punish anyone convicted of insulting people who were connected to him.

"The move this week by Parliament to further strengthen the nation’s strict blasphemy laws, which are often used to settle personal scores or persecute minorities, has raised concerns among rights activists about the prospect of an increase in such persecution, particularly of religious minorities, including Christians.

...

"Those convicted of insulting the Prophet Muhammad’s wives, companions or close relatives will now face 10 years in prison, a sentence that can be extended to life, along with a fine of 1 million rupees, roughly $4,500. It also makes the charge of blasphemy an offense for which bail is not possible.

...

"Taking a stand on the issue can also be dangerous, as the assassination of two senior politicians more than a decade ago made clear. In 2011, Salmaan Taseer, the governor of Punjab Province, was fatally shot by one of his own bodyguards. Mr. Taseer had been an outspoken opponent of the blasphemy laws and had campaigned for the release of Asia Bibi, a Christian convicted of insulting the Prophet Muhammad. Shahbaz Bhatti, a federal minister and a Christian who had also opposed the death sentence imposed on Ms. Bibi, was fatally shot the same year."

Three way liver exchange in Pakistan, reported in JAMA Surgery by Salman, Arsalan, and Dar, in collaboration with economist Alex Chan

 Here's an exciting account, just published in JAMA Surgery, of a three way liver exchange in Pakistan, achieved in part by collaboration with economist and market designer Alex Chan (who is on the job market this year).

Launching Liver Exchange and the First 3-Way Liver Paired Donation by Saad Salman, MD, MPH1; Muhammad Arsalan, MBBS2; Faisal Saud Dar, MBBS2, JAMA Surg. Published online December 7, 2022. doi:10.1001/jamasurg.2022.5440 (pdf)

Here are the first paragraphs:

"There is a shortage of transplantable organs almost everywhere in the world. In the US, about 6000 transplant candidates die waiting each year.1 In Pakistan, 30% to 50% of patients who needed a liver transplant are unable to secure a compatible donor, and about 10 000 people die each year waiting for a liver.2 Kidney paired donations, supported by Nobel Prize–winning kidney exchange (KE) algorithms,3 have enabled living donor kidneys to become an important source of kidneys. Exchanges supported by algorithms that systematically identify the optimal set of paired donations has yet to take hold for liver transplant.

"The innovation reported here is the successful implementation of a liver exchange mechanism4 that also led to 3 liver allotransplants and 3 hepatectomies between 3 incompatible patient-donor pairs with living donor–patient ABO/size incompatibilities. These were facilitated by one of the world’s first documented 3-way liver paired donations (LPD) between patient-donor pairs.

"Since 2018 and 2019, we have explored LPD as a strategy to overcome barriers for liver failure patients in Pakistan in collaboration with economist Alex Chan, MPH.2 With LPD, the incompatibility issues with relative donors can be solved by exchanging donors. The Pakistan Kidney and Liver Institute (PKLI) adopted a liver exchange algorithm developed by Chan4 to evaluate LPD opportunities that prioritizes clinical urgency (Model for End-stage Liver Disease [MELD] scores) while maximizing transplant-enabling 2-way or 3-way swaps that ensures that hepatectomies for every donor within each swap has comparable ex ante risk (to ensure fairness). As of March 2022, 20 PKLI liver transplant candidates had actively coregistered living and related but incompatible liver donors. Evaluating these 20 incompatible patient-donor pairs with the algorithm,4 we found 7 potential transplants by two 2-way swaps and the 3-way swap reported. In contrast to ad hoc manual identification of organ exchange opportunities, the hallmark of a scalable organ exchange program is the regular deployment of algorithms to systematically identify possible exchanges. Regular deployment of LPD algorithms is novel.

"A total of 6 procedures took place on March 17, 2022. Patient 1, a 57-year-old man, received a right liver lobe from donor 2, a 28-year-old coregistered donor of patient 2 (56-year-old man), who in turn received a right liver lobe from donor 3, a 35-year-old woman who was a coregistered donor of patient 3. Patient 3, a 46-year-old man, received a right liver lobe from donor 1, a 22-year-old woman who was a coregistered donor of patient 1, completing the cycle (Figure). Five PKLI consultant surgeons and 7 senior registrars led the hepatectomies and liver allotransplants; 6 operating rooms were used simultaneously. One month postsurgery, all patients and donors are robust with no graft rejection. All the donors are doing well in the follow-up visits and have shown no psychological issues."

Here's a sentence in the acknowledgements:

"We thank Alex Chan, MPH (Stanford University, Palo Alto, California), whose initiative and expertise in economics were the key driving forces for launching liver exchange."

*********

NB: this is a "Surgical Innovation" article, for which the journal requires that there be no more than three authors.

And here are the references cited:

1.

Chan  A, Roth  AE. Regulation of organ transplantation and procurement: a market design lab experiment. Accessed April 28, 2022. https://www.alexchan.net/_files/ugd/a47645_99b1d4843f2f42beb95b94e43547083b.pdf

2.

Salman  S, Gurev  S, Arsalan  M, Dar  F, Chan  A. Liver exchange: a pathway to increase access to transplantation. Accessed April 1, 2022. http://www.hhpronline.org/articles/2021/1/14/liver-exchange-a-pathway-to-increase-access-to-transplantation

3.

Henderson  D. On marriage, kidneys and the Economics Nobel. Wall Street Journal. October 15, 2012. Accessed March 5, 2022. https://www.wsj.com/articles/SB10000872396390443675404578058773182478536

4.

Chan  A. Optimal liver exchange with equipoise. Accessed April 23, 2022. https://www.alexchan.net/_files/ugd/a47645_36e252f4df0c4707b6431b0559b03143.pdf

5.

Hwang  S, Lee  SG, Moon  DB,  et al.  Exchange living donor liver transplantation to overcome ABO incompatibility in adult patients.   Liver Transpl. 2010;16(4):482-490. doi:10.1002/lt.22017PubMedGoogle ScholarCrossref

6.

Patel  MS, Mohamed  Z, Ghanekar  A,  et al.  Living donor liver paired exchange: a North American first.   Am J Transplant. 2021;21(1):400-404. doi:10.1111/ajt.16137PubMedGoogle ScholarCrossref

7.

Braun  HJ, Torres  AM, Louie  F,  et al.  Expanding living donor liver transplantation: report of first US living donor liver transplant chain.   Am J Transplant. 2021;21(4):1633-1636. doi:10.1111/ajt.16396

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Here's a Stanford story on this collaboration:

Stanford student devises liver exchange, easing shortage of organs. A rare three-way exchange of liver transplants in Pakistan was made possible with a new algorithm developed by a Stanford Medicine student.  by Nina Bai

"The liver exchange idea actually came out of a term paper in a first-year market design class at Stanford," Chan said.

"As he learned more about liver transplants, Chan realized there were important biological and ethical differences from kidney transplants. 

...

"Instead of just finding compatible swaps, we want to find swaps that prioitize the most urgent patients first in order to prevent the most deaths," Chan said.

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Here are some contemporaneous stories from March in the newspaper Dawn (now that the JAMA embargo on the story is lifted):

Liver transplants at PKLI under 'swap' plan - Newspaper - Dawn

Mar 18, 2022 — A highly-trained team of the surgeons headed by PKLI Dean Prof Faisal Dar had performed liver transplants at the institute and other members ...

• First swap liver transplant surgeries at PKLI today - Dawn

  
  

  Mar 17, 2022 — An official told Dawn on Wednesday the treating doctors had recommended liver transplant of all the three patients due to their end-stage ...

Kidney transplant controversies on World Kidney Day

 Yesterday, March 10 was World Kidney Day, whose theme was "Kidney health for all."

I couldn't help noticing that reports in honor of WKD reflect some of the considerable controversy that exists about kidney transplants.

Here are two with opposite points of view on increasing access to kidney transplants, with special attention to kidney exchange.

First, from Abu Dhabi:

World Kidney Day: SEHA Kidney Care leads the way in ensuring kidney health for all

"A key area that SKC is spearheading is investing in opportunities to increase transplant activities, for patients locally and further afield.  SEHA’s recent collaborations with international organizations and the Department of Health – Abu Dhabi have ensured that it is prepared for an influx in transplant volumes, with an increased deceased donor activity from 3 donors in 2017 to 39 donors in 2021, and more opportunities for live donation with the start of a paired kidney exchange program in partnership with Alliance for Paired Kidney Donation. Through these partnerships, kidney transplants, often resulting in enhanced quality of life, are now a viable option for many patients here in the UAE. SEHA’s Transplant Program has performed more than 52 pediatric kidney transplants and almost 393 transplants in total since its inception.

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

And here, from the Pakistani newspaper Dawn, is an editorial that bemoans the prevalence of black market kidney transplants in Pakistan, and worries that increasing access to  kidney exchange will only increase the black market (as opposed to giving patients a safe and legal alternative to the black market). This is an opinion that seems to underlie the policies of a number of international transplant organizations.

Swap Transplants

"IRONICALLY, the Punjab government’s recent step in the effort to stop organ trafficking may well end up providing a shot in the arm to the illegal transplant racket. At a meeting chaired by the Punjab health minister, the provincial government has given its approval to a swap transplant plan which expands the living donor pool beyond immediate family members.

...

"Organ swap transplants, or paired exchanges, work by matching a recipient-donor pair that is medically incompatible, with another pair in a similar predicament. An organ ‘swap’ can then take place between the two pairs. However, these are only the bare bones of the procedure. It must be carried out according to strict ethical and clinical guidelines if it is not to open the floodgates for illegal transplants. Among these is the requirement that each recipient-donor pair must meet the eligibility criteria laid out in the law.

...

"Thus, while paired exchanges are an accepted method of addressing donor-recipient incompatibility, the level of oversight mechanisms needed to prevent abuse are daunting — even more so in an unequal society riddled with corruption. The first paired kidney exchange in Pakistan was performed in 2015 at the Sindh Institute of Urology and Transplantation in Karachi; only seven more have taken place since then — all at SIUT — partly because of the extreme diligence that the process calls for. The troubling fact is that most illegal transplants take place in Punjab; some were found to have been carried out surreptitiously in KP and Azad Kashmir by doctors from Punjab. The situation in recent years had improved considerably after several organ trafficking gangs were busted, again mostly in Punjab. Does the province have a system in place to ensure that unethical individuals do not use the organ swap programme as a cover for illegal transplants?"

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And here's a recent BBC video, "Kidneys for Sale?" on the controversy about compensation for donors. I just saw it yesterday (HT David Klinowski) but was produced earlier this year. A number of people are interviewed, and Sally Satel makes the point that increasing access to legal, safe kidney transplants is a way of competing with and reducing the prevalence of black markets.

Payments for Covid vaccine

 The NY Times has the story:

Pakistan’s Private Vaccine Sales Highlight Rich-Poor Divide.  An inoculation push, plagued with limited supplies and red tape, makes doses available to those who can pay for them. In a country with a struggling economy, most can’t.  By Salman Masood

"Access to the coronavirus vaccine has thrown a stark light on global inequality. The United States and other rich countries have bought up most of the world’s vaccine supplies to protect their own people, leaving millions of doses stockpiled and in some places unused. Less developed countries scramble over what’s left.

"To speed up vaccinations, some countries have allowed doses to be sold privately. But those campaigns have been troubled by supply issues and by complaints that they simply reflect the global disparities.

...

"“The Pakistani example is a microcosm of what has gone wrong with the global response — where wealth alone has primarily shaped who gets access,” Zain Rizvi, an expert on medicine access at Public Citizen, a Washington, D.C., advocacy group, said in an email.

...

India sells vaccines to private hospitals, though they are scrambling to find supplies now that the pandemic there is so serious. Kenya authorized private sales, then blocked them over fears that counterfeit vaccines would be sold. In the United States, some well-connected companies, like Bloomberg, have secured doses for employees.

...

"Pakistan says the private program could make more free shots available to low-income people. By purchasing doses of the Russian-made Sputnik 5 vaccine, the country’s wealthy wouldn’t need to get the free doses, which are made by Sinopharm of China. Some people would prefer to get inoculated at a private hospital because they are widely believed to be comparatively better organized and more efficient than overwhelmed government facilities.