Australia-New Zealand kidney exchange program

New Zealand and Australia are cooperating with cross-border, international kidney exchange.

The Australian has the story:
The chain gang
By RICKY FRENCH

"Facilitated by the Organ and Tissue Authority, the Australian and New Zealand Paired Kidney Exchange (ANZKX) has now given 42 people new kidneys since that first operation late last year. While paired kidney exchange has happened in Australia since 2010, this is the first true international collaboration. Eleven chains of operations occurred before Covid-19 stalled things in March, but recruitment into the program continues and there are six surgeries planned in Australia for August.
...
"[Linda] Cantwell is the ­Australian Red Cross ANZKX tissue typing scientist. She’s gatekeeper to the matrix of matches needed to link up potential pairs. There are currently 150 donors and 128 potential recipients in the pool, but for some people only one donor in 10,000 might be suitable. A computer program called OrganMatch runs the algorithms based on each person’s unique antibody profile and tissue typing, and potential matches from up to 300,000 different chains are produced."
************

And here's a related story from Australia's Daily Telegraph:

Organ donation hit hard by COVID-19 global pandemic
by Jane Hansen

"The Australian and New Zealand Paired Kidney Exchange was suspended from March 6 and can only begin if and when travel restrictions lift.

"Deceased kidney and live kidney donor programs across Australia were also suspended from March 24 and only recommenced in May, blowing out waitlists.

"Liver, heart, lung, paediatric and multi-organ transplant programs have continued but are subject to case-by-case review by the National Transplantation and Donation Rapid Response Taskforce, which meets weekly to discuss the response to COVID-19, the Organ and Tissue Authority said.

"According to the latest figures for 2019, the families of 548 loved ones transformed the lives of 1444 Australians by agreeing to organ donation.

"In 2019, 1309 had the potential to be organ donors but just over half of those families agreed."

Patricia Kravey on non-directed organ donation

From my recent email, a nuanced yet inspiring story from non-directed donor Patricia Kravey.

"I’ve been meaning to write you for five years so it’s time I finally got around to it, but I’ll try to keep it short.

I’d been thinking about being an altruistic for many years without people being able to understand why. When my husband heard your interview on Freakonomics he finally got it and shared the podcast with me.

Your chapter on Kidney Chains has changed my life and the five people who received kidneys in the chain I was a part of. Without the power of knowledge from your book I would not have understood why my hospital was resistant to creating a national chain that went outside their hospital system. From your chapter I called the National Kidney Registry and UNOS to ask how they formed chains, how many people could receive kidneys in their chains and the barriers hospitals encounter in joining their programs. On the phone I was thrilled to speak to Ruthanne Leishman, she was in your book, she was famous!

After learning the cost for hospital to join NKR even though they have lengthy donor chains; I told my hospital, where I was also an employee, that I would only be donating through them if they participated in a chain through UNOS. Despite my request to wait the hospital ran their program and matched me internally. So I had this heavy weight of decision to give to the highly sensitized person my hospital matched me with or to pursue a donor chain. After sleepless nights I came up with what I thought was the perfect solution. I would agree to give to the recipient within the hospital and their mismatched donor would be the person officially enrolled in the UNOS program.

The surgery to my anonymous recipient went smoothly. I cried when the doctors told me he was doing well.

Months later I bumped into my transplant coordinator in the hallway at the hospital and she excitedly told me a news story was being released tonight. The mismatched donor of the person I had given to had completed her surgery and the kidney chain and continued on in the mad rush of 24 hours across the country. The news story was going to be about the hospital’s first national donor chain and the person who started it.

Since my donation wasn’t within the exciting 24 hours my hospital had decided I wasn’t part of the chain. I wasn’t included in the news story or even formally told about it. The story showed my recipient who I hadn’t decided if I was going to meet yet. My colleagues saw the story that night and could tell it was my story that didn’t include me.

Your book helped me understand why the hospital and the media would do that as well.

I did meet my recipient in person later. He was a lovely man. Charming, appreciative and so full of energy. He visited me at my office at the hospital several times and he sent a gift for my baby shower. I felt very lucky and grateful to have met him.

Four years after the transplant he died. Skin cancer got him. His wife told me the doctors had led him to believe that the kidney he’d received from me could be passed on. Of course it couldn’t be since it could contain cancer cells.

I have mixed feelings about being an altruist donor. It wasn’t perfect. It wasn’t the story or the fulfilling experience I had hoped it would be. But it was better and it benefited more people because of you. I hope people tell you everyday that your work has changed lives.

Thank you.

Best regards,

Patricia Kravey (Harvey)

https://komonews.com/news/healthworks/seattle-kidney-chain-changes-8-lives-its-the-gift-of-life

https://blog.swedish.org/swedish-blog/how-donating-a-kidney-gave-me-joy-and-someone-else-his-life-back

(in rereading my interview in Swedish Medical Center's blog, I’m embarrassed that I didn’t cite you!)"

Sam Trejo on non-directed kidney donation (in the LA Times)

It's always good to hear from former students.

Sam Trejo writes:

"Hi Dr. Roth,

I'm PhD student in the GSE who took your Behavioral class a couple years back; you probably don't remember me, I didn't talk very much. Anyways, I donated my kidney last month to start a chain and wrote about it here. Just wanted to let you know of a concrete way that your market design work is making an impact!

Best,

Sam"

The op-ed he linked to in the LA Times is called:

I donated my kidney to a stranger — and more of us should

By SAM TREJO, JAN. 19, 2020 

KIDNEY EXCHANGE AND THE ETHICS OF GIVING by Philippe van Basshuysen

 Philippe van Basshuysen considers various forms of kidney exchange, including non-directed (altruistic) donor chains, but not global kidney exchange (GKE), which he defers for future consideration. His work is motivated by the effective ban on kidney exchange in Germany, and, he writes, in " Bulgaria, Estonia, Finland and Hungary, among others." He also notes that non-directed donors are excluded in " Belgium, France, Greece, Poland and Switzerland..."

KIDNEY EXCHANGE AND THE ETHICS OF GIVING
Philippe van Basshuysen,  December 2019
Forthcoming in Journal of Ethics and Social Philosophy

"The arguments given here are not wedded to a specific moral theory. They will appeal to effective altruists, but because of their weak, conditional premises, many people who are not committed effective altruists will welcome them as well. They are also consistent with conservative views on donor protection and allocative justice concerning patients on waiting lists. I hope that these arguments will lead to a clarification of the debates about the ethics underlying KE programmes, particularly in countries that have hitherto banned these programmes."

Effective altruism and (non-directed) kidney donation

In their Christmas day discussion, the podcast Here Be Monsters considers the Quality Adjusted Life Years (QALYS) that can result from non-directed kidney donation, and how that qualifies it as a form of effective altruism.

December 25, 2019 Here Be Monsters HBM127: QALYs

"In 2014, a post showed up on effectivealtruism.org’s forum, written by Thomas Kelly and Josh Morrison.  The title sums up their argument well: Kidney donation is a reasonable choice for effective altruists and more should consider it. 

They lay out the case for helping others through kidney donation.  Kidney disease is a huge killer in the United States, with an estimated one in seven adults having the disease (though many are undiagnosed).  And those with failing kidneys have generally bad health outcomes, with many dying on the waitlist for an organ they never receive.  There’s currently about 100,000 people in the country on the kidney donation waitlist.  An editorial recently published in the Journal of the American Society of Nephrology estimated that 40,000 Americans die annually waiting for a kidney. 

The previously mentioned post on the EA forums attempts to calculate all the goods that kidney donation can do, namely adding between six and twenty good years to someone’s life.  Quantifying the “goodness” of a year is tricky, so EAs (and others) use a metric called “Quality Adjusted Life Years” or QALYs. 

The post also attempts to calculate the downsides to the donor, namely potential lost wages, potential surgery complications, and a bit of a decrease in total kidney function.  

The post concludes that kidney donation is a “reasonable” choice.  By the EA standards, “reasonable” is pretty high praise; a month or so of suffering to give about a decade of good life to someone else, all with little long term risk to the donor.  

On this episode, Jeff interviews Dylan Matthews, who donated his kidney back in 2016.  His donation was non-directed, meaning he didn’t specify a desired recipient.  This kind of donation is somewhat rare, comprising only about 3% of all kidney donations.  However, non-directed donations are incredibly useful due to the difficulty of matching donors to recipients..."
*********
The discussion of kidneys and effective altruism starts about minute 7 in the podcast:

International kidney exchange between Israel and Czech Republic

The news embargo is over for last week's kidney exchange chain between Israel and the Czech Republic. (On the Israeli side, the necessary software was supplied by Itai Ashlagi, here at Stanford.)

Itai writes:
"Some background: in August 2019 there was an agreement between Israel and Czech republic to check the possibility of kidney exchanges. This was initiated by Prof. Eitan Mor from Israel  and Dr. Proniak from the Czech Republic and the whole operation was conducted by the national Israeli center for transplantation led by Dr. Tamar Askenazi and their counterpart in Czech republic."

The Israeli database contains a list of all pairs, and uses kidney exchange software donated to Israel by Itai Ashlagi and Sukolsak Sakshuwong.   Czech software was used in Prague to identify the chain.

Here's the story from News1 in Israel:

6 transplants thanks to the exchange of kidney donations between Israel and the Czech Republic

"At 5 a.m., two kidneys from two donors were removed from Beilinson Hospital. One kidney was packed in ice cooler and transported by ambulance to Ben Gurion Airport.

"About an hour after taking off from Israel, an operation to remove a Czech donor kidney was started at the Prague Hospital. At the same time, Bilinson's second kidney was transplanted, and surgery was performed to remove a kidney at Hadassah Hospital – which was transported by ambulance to Bilinson's transplant.

"At 12:30 the kidney cooler from Israel landed at the Prague airport. A vehicle was waiting by the plane and moved to the mirroring spot. At this point, Dr. Jiri Froniac, director of the Prague Transplant Program and Dr. Ashkenazi from Israel, met and exchanged documents while the coolers were [scanned].

"At the same time, the kidney from Hadassah Hospital was transferred to Beilinson for a transplant. An hour later, the Israeli plane took off from Prague back to Israel with a cooler containing the kidney from the Czech donor. The kidney came to the operating room in Hadassah and before the evening was transplanted in a patient.
**********

Diagram of the exchange between IKEM in the Czech Republic and Hadassah and Beilinson Hospitals in Israel

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

Here's the story in the Jerusalem Post (I don't have a link yet, this is a picture):

And see this related older story about Itai Ashlagi's software:

New software to help increase kidney matches for transplants

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

And here is the story in the Czech news, forwarded by Pavel Chromy.

Čeští lékaři poprvé provedli párovou výměnu ledvin s Izraelem
[Google translate: Czech doctors first performed paired kidney replacement with Israel]
"In the first half of December, doctors from the Prague Institute of Clinical and Experimental Medicine (IKEM) and two Israeli hospitals performed their first paired kidney exchange between the two countries. Three beneficiaries from the Czech Republic and three from Israel received the new authority. This is the first time a pair exchange has taken place with a non-European country, said IKEM director Michal Stiborek at a press conference."

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.
**********

See earlier post:

Monday, April 11, 2016

Using deceased donor kidneys to start living donor kidney exchange chains

Podcast on non-directed kidney donation as an act of effective altruism

Here's a very personal discussion  about becoming a non-directed donor.

The Neoliberal Podcast

Donating a Kidney with Dylan Matthews

"Jeremiah sits down with Dylan Matthews of Vox.com to discuss his decision to donate a kidney to a stranger, and Jeremiah's plans to do the same.  While our previous episode with Nobel prize winner Alvin Roth explored the economics of kidney markets and the details of kidney policy, this episode dives more deeply into the medical and personal side of deciding to donate a kidney."
***********

Dylan Matthews has his own podcast, called Future Perfect.

Followup on the latest Freakonomics kidney exchange chain

Earlier this month I blogged about a kidney exchange chain at Virginia Mason Hospital, in Seattle, initiated by a non-directed donor who had heard an interview about kidney exchange on Freakonomics.  Subsequently, my colleague Elena Cryst, whose dad is a transplant nephrologist at that hospital, sent her the email below about a short talk he'd prepared, which they have given me permission to reproduce with minor edits. (They also note that "the participants OK’d sharing this so no HIPA violations.")

Dr. Cryst writes:

"I’m a transplant nephrologist, and  I’m  sharing this story on the insistence of these four patients who want to get their story out and encourage others to participate in organ donation and increase the options for kidney transplants in our country”

This is a photo of 4 people – I hope you can see them as you read this.

Three out of four of these folks in the picture just so happened to have appointments in my Monday AM clinic.  I’ve been taking care of kidney transplant patients for thirty years, but by the end of clinic, I was astounded by seeing how much this meant for each one of them and the different reasons why.  As this morning went on I heard this story from three of the four points of view.  It very much took me by surprise how much had changed for all four.…  It was just another day in the office, but this story is striking and they all wanted to share it with everyone in hopes more people can receive transplants.

THE PHOTO: 

THE STORIES:  First with hat on backwards is DC my patient.  A naturally shy and private person.   Happiest I’ve seen him in three years but has had many disappointments.   It has been an emotional roller coaster, as three years ago he thought he was passing a kidney stone- only to learn he had an advanced kidney disorder and soon would either need to get a transplant  or start on dialysis.  There had been lots of struggles to get to the point of transplant…. one by one, donors came forward but were disqualified due to minor health issues.  Finally one did  get through testing and qualify to donate, only to find out she was not a match.  He was devastated again.  After working with our program, we were poised for a paired donor exchange but with time running out…we needed a non-directed donor to step forward.  If someone could donate for DC, his donor would give a kidney for the next person on our waiting list and he would not have to start the process of dialysis. 

Next to DC’s left is Steve, healthy tugboat pilot who commutes to his home inland and on the way listens to lots of podcasts.  Freakonomics Radio had one about Al Roth, a Nobel prize winning economist at Stanford who researches how to create markets for things that don’t have a price.  He was the economist who worked to redesign the resident matching program to accommodate couples in the 1990’s and was fascinated by the challenge of how to allocate kidneys from live donors.  This is another problem of how to make a market for something that could not be exchanged for cash.  He and colleagues designed the system and did the math.  And won the Nobel prize!  Steve caught on to a few facts in the story – like the huge number of potential living donors in this country, and the benefit that could be afforded to those waiting for a kidney from a deceased donor.  The fact that the number of such paired donor exchange transplants has grown from only 2  in 2000 to 1000 in 2018, and said sign me up.  His generosity and courage started this chain of events.  Al Roth’s work is changing the way we are doing kidney transplants at my hospital and bringing in more and more living donors together with recipients they don’t know. The process was hugely important to Steve and it was icing on the cake that he was able to meet DC after it was done.  They all mutually agreed to make the process open rather than confidential which was their personal choice.

Next is Debbie from Ukqiagvik Alaska (formally Barrow)  – the literal ‘end of the earth’ the northern most point in the USA above the arctic circle in Alaska.   Debbie is an Alaska native who toughed it out with barely enough renal function for many  years but time was running out for her as well.  She was at the very top of the waiting list and she was waiting for a deceased donor kidney at our far away transplant center. The logistics of urgent travel to a faraway city fast enough to get a kidney transplant from a deceased donor -- while the clock was ticking -- made it much more better for her to have a living donor transplant that could be scheduled.  As you can tell Debbie has been delighted with her new kidney.  She is a long way from home for a few months, but enjoying the challenges of being in the city, even trying foods not part of her diet - like cucumbers (“not my favorite” she says) - not often available above the arctic circle!  She is here with family for a few months recovering and adapting to having normal kidney function again.

Next is Wendy – Journalist, community organizer and friend of DC.  She did gently insist that he let her get tested to donate.  He was apprehensive and certainly did not want to ask her.  But, as usual, Wendy prevailed.   In exchange her kidney went to Debbie who now feels better than she has in years.  Wendy is being ‘adopted’ by the women in Ukqiagvik and in clinic that morning, she was wearing the traditional hoodie blouse with big pockets that Debbie’s sisters back home had specially made for Wendy.  She is thinking about how to make the trip up north to see her new family of friends.  It was Wendy who also gently admonished me for not doing a better job of telling our story to others.  She strongly felt that we need to point out that her life and Steve’s are forever changed for the better - -  as well as the obvious benefit for DC and Debby. 

Although this is the kind of work we do every day, we would like to do many more living donor transplants for people and take more people off the waiting lists and out of the dialysis units.  There are a lot of moving parts and a lot of people who contribute, but we can scale it up.  The more scheduled procedures we do, opposed to deceased donor surgeries which are by necessity emergency surgeries, the greater our impact  can be. Each living kidney transplant also frees the deceased donor kidney to go to someone else - in effect doubling the benefit.  Thanks to Al Roth, there is now a new market for getting our willing donors together with recipients they do not know.  We always respect privacy and our default is to keep this process of ‘entering the market’ safe and anonymous.  But, as in this case, the participants can decide to share their experience, meet each other and . . . as Wendy said, “get the word out.”   In fact this photo captured the moment after surgery where this group organized a first meeting on their own and went off for lunch.  As a kidney transplant physician, I know we have the systems in place to grow this work.  Facilitating living kidney donation benefits not only more recipients, but it positively  changes lives of these donors.  It really positively affects lives of everyone involved. . .even the doctors like me…and I bet even the economists! 

Cyrus Cryst MD FASN

First-person account of a four-way kidney exchange in Houston, in the WSJ

Here's a moving first-person account by journalist Yogita Patel in the Wall Street Journal, about her decision to donate a kidney to her brother, through kidney exchange.

I Gave My Kidney to a Stranger to Save My Brother’s Life
By Yogita Patel, March 9, 2019

It's full of interesting introspection. Here's one bit:
"As I expressed my growing concerns, my brother quietly acknowledged to other family members some of his own doubts. “I wasn’t sure if it would always be something you’d hold over me,” he recently admitted. I wasn’t sure, either."

I was also interested in a technical part of the story about the lengths that Houston Methodist Hospital goes to try to perform all the kidney exchange transplants they do internally, i.e. at their own hospital.  In this case, a four-pair exchange was assembled over a period of months, that included at least one non-directed donor who participated in the exchanges, which all took place on the same day.

"Houston Methodist first aims to create a donor chain without other hospitals—its longest involved 12 people. If appropriate matches fail to come together, the hospital expands the search regionally, then ultimately to a national registry that helped create a 30-pair swap the hospital took part in eight years ago.
...
"As months went by, our small network continued to come together behind the scenes.
...
"Twice, Pesh got word from his coordinator that it was nearly go time in what turned out to be false alarms.As the wait dragged on, he made two trips to the ICU because of complications tied to dialysis. Each episode left him fearing that the prospect of a donation was fading.

"Finally in June, we got word that they had found matches for both of us. Our four-pair exchange took place on the same day, Aug. 7, with everyone having surgery at Houston Methodist."

Another kidney donor from the Freakonomics interview

Yesterday I got this cheerful email from Harry Huggins at Freakonomics, about another nondirected donor motivated to start a kidney exchange chain, after learning about them on Freakonomics:

"Hello Professor Roth,

I'm a producer at Freakonomics Radio. I just wanted to let you know that we've published a post on our blog about another listener inspired by your episode to donate a kidney. You can find it (the blog post, not the kidney) here: 

Another Kidney-Donation Story to Make You Smile

Hope all is well,

Harry Huggins
Managing Producer
Freakonomics Radio"

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

I now know of several donors who heard the original 2015 Freakonomics story on kidney exchane (Make Me a Match (Ep. 209)). The first was Ned Brooks (who writes about it at the link), and whose web page/organization Donor to Donor speaks about others.

And here are all my posts that mention Freakonomics, many of them (but not all) related to kidney exchange.

Kidney exchange chains and altruistic kidney donation on PBS newshour

PBS economics correspondent Paul Solman interviews non-directed kidney donors, and kidney exchange patients, and me, in yesterday's PBS newshour.

Here's a link to video of the 10 minute segment on kidneys, including a transcript.
How an economist’s idea to create kidney transplant chains has saved lives

and here's the video itself:

The show talks about how a single altruistic donor can initiate a long chain of kidney transplants that helps many people.

The kidney exchange organization that started non-simultaneous non-directed donor chains is the Alliance for Paired Donation, run by Mike Rees, and I think that they still organize the longest chains, i.e. the ones with the highest average number of transplants.  

The very first long chain was reported in this article in the New England Journal of Medicine:

Rees, Michael A., Jonathan E. Kopke, Ronald P. Pelletier, Dorry L. Segev, Matthew E. Rutter, Alfredo J. Fabrega, Jeffrey Rogers, Oleh G. Pankewycz, Janet Hiller, Alvin E. Roth, Tuomas Sandholm, Utku Ünver, and Robert A. Montgomery, “A Non-Simultaneous Extended Altruistic Donor Chain,” New England Journal of Medicine, 360;11, March 12, 2009

Here's the full hour-long newshour: kidneys are from about minute 34:46 to minute 44:38 on the video below.

The first global kidney exchange: temporarily ungated link

Here's a shareable link to the paper below, which I blogged about earlier without having an ungated link. This link is good til October 27. [Update: here's a possibly longer lasting ungated link.}
Along with the medical details of this successful kidney exchange chain, the paper shares some of the arguments we've heard suggesting that Global Kidney Exchange might be objectionable, and our replies, in considerable detail:)

Complete Chain of the First Global Kidney Exchange Transplant and 3-yr Follow-up

Author links open overlay panelDanielle N.BozekabTy B.DunncChristian S.KuhrdChristopher L.MarsheJeffreyRogersfSusan E.ReesbLauraBasagoitiagRobert J.BrunneraAlvin E.RothhObiEkwennaabDavid E.FumoabKimberly D.KrawieciJonathan E.KopkebPuneetSindhwaniaJorgeOrtizaMiguelTanjSiegfredo R.PaloyoklJeffrey D.PunchmMichael A.Reesab

https://doi.org/10.1016/j.euf.2018.07.021Get rights and content

Abstract

Background

Global Kidney Exchange (GKE) offers an opportunity to expand living renal transplantation internationally to patients without financial means. These international pairs are entered into a US kidney exchange program that provides long-term financial support in an effort to identify opportunities for suitable exchanges for both these international pairs and US citizens.

Objective

While the promise of GKE is significant, it has been met with ethical criticism since its inception in 2015. This paper aims to demonstrate the selection process and provide >3 yr of follow-up on the first GKE donor and recipient from the Philippines.

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

About the link, Elsevier writes: 

To help you and the other authors access and share this work, we have created a Share Link – a personalized URL providing 50 days' free access to the article. Anyone clicking on this link before October 27, 2018 will be taken directly to the final version of your article on ScienceDirect, which they are welcome to read or download. No sign up, registration or fees are required.

Your personalized Share Link:
https://authors.elsevier.com/c/1XhNI8Yy0L8qol

Deceased donor chains: Market design language is entering transplantation

Here's some more argument in favor of starting kidney chains with deceased donors, from the journal
Clinical Transplantation Volume 32, Issue 7:

Lessons from Uber and Airbnb: Why we should link the deceased and living donor pools

by Avi Baskin  Ariella Maghen  Tom Mone  Jeffrey Veale

"Deceased donor organs are currently underutilized and undervalued, particularly in kidney chains, similar to how parked cars and vacant homes were before Uber and Airbnb. The ride‐sharing company Uber has been hailed for allowing people to drive their cars to generate more benefit from this underutilized resource. Similarly, Airbnb enables people to rent out their unused property, increasing the potential of an otherwise missed opportunity. Together, Uber and Airbnb represent a new era, amplifying the benefit of cars and property that would be otherwise underused.

"Likewise, the world of transplantation should take note as software programs and mathematical algorithms could also be applied to maximize the benefits of available kidneys for transplant."
*********

The authors are all transplant professionals, not an economist among them. We've come a long way from the days when it was hard to convince the transplant community that kidney transplantation, and kidney exchange in particular, could be usefully thought about in connection with markets, marketplaces, and market design.

Religiosity of non-directed kidney donors

Here's an online early view of a paper from the Journal of Clinical Nursing (and see some related blog posts at the end of this post):

Spirituality and religiosity of non‐directed (altruistic) living kidney donors
Ariella Maghen BA  Grecia B Vargas MSPH  Sarah E Connor MPH, CHES Sima Nassiri BS  Elisabeth M Hicks MA  Lorna Kwan MPH  ... See all authors
First published: 5 March 2018 https://doi.org/10.1111/jocn.14223

Abstract
Aims and objectives
To describe the spirituality and religiosity of 30 non‐directed (altruistic) living kidney donors in the USA and explore how they may have affected their motivations to donate and donation process experiences.

Background
The rise in non‐directed donors and their ability to initiate kidney chains offer a novel approach to help alleviate the overextended kidney transplant wait list in the USA. However, little is known about the non‐directed donors’ motivations, characteristics and experiences.

Design
We conducted a qualitative‐dominant study and used a grounded theory approach to analyse data.

Methods
Thirty participants completed in‐depth interviews between April 2013–April 2015. Three analysts independently read and coded interview transcripts. Grounded theory techniques were used to develop descriptive categories and identify topics related to the non‐directed donors donation experience.

Results
Sixteen of the 30 non‐directed donorss discussed the topic of spirituality and religiosity when describing their donation experiences, regardless of whether they were actively practising a religion at the time of donation. Specifically, three themes were identified within spirituality and religiosity: motivation to donate, support in the process, and justification of their donation decisions postdonation.

Conclusions
Findings from this study are the first to describe how spirituality and religiosity influenced the experiences of U.S. non‐directed donorss and may help improve non‐directed donors educational resources for future spiritual or religious non‐directed donors, and the overall non‐directed donors donation experience in efforts to increase the living donor pool.

Relevance to clinical practice
Spirituality and religiosity are often overlooked yet potentially influential factors in Western medicine, as demonstrated through the experiences of Jehovah's Witnesses and their religious restrictions while undergoing surgery and the beliefs of Christian Scientists against taking medications and receiving medical procedures. Understanding needs of non‐directed donors specifically with spirituality and religiosity can better position kidney transplant centres and teams to improve predonation screening of non‐directed donor candidates and provide support services during the donation process.
************

Here are some earlier posts about religion and living kidney donation:

Thursday, September 5, 2013

Project Renewal: Kidney donation in faith-based communities

Tuesday, April 21, 2015

Expanding non-directed kidney donation: the Renewal model

Friday, February 9, 2018

Altruistic kidney donation in Israel: Matnat Chaim (gift of life)

Deceased donor kidney exchange chain in Italy (and some Italian kidney politics)

First, some excellent transplant news from Italy: A deceased donor kidney exchange transplant chain has been conducted there. Here's some of the (English language) press release.

PRESS RELEASE

ITALIAN NATIONAL TRANSPLANT CENTRE

THE FIRST CROSSOVER TRANSPLANT CHAIN TRIGGERED BY A CADAVERIC DONOR WAS LAUNCHED YESTERDAY IN ITALY

"On March 14th, for the first time in the world, the first live kidney transplantation chain between incompatible donor-recipient pairs (the so-called "cross over" program) triggered by a deceased donor was successfully launched in Italy.

 ....

The complex study phase for implementing the program, presented by Dr. Lucrezia Furian, member of the kidney transplant team of Padua University hospital, during the General Meeting of the Transplant Network, requested a careful retrospective evaluation of the data related to incompatible donors-recipient couples, a scrupulous analysis of the aspects related to efficacy, ethical and logistical problems and the development of algorithms for optimization of crossover chains. This study was conducted as part of an interdisciplinary research project funded by the University of Padua which involved, together with the transplant center team, researchers from the Department of Economics and Business Sciences and the Padua University Mathematics Department, led by Prof. Antonio Nicolò, scientific director of the research project. "

**********

Antonio Nicolò, Professor of Economics at the University of Padua, has written about kidney exchange.

**********

Here are some of my earlier posts about starting kidney exchange chains with deceased donors:

Tuesday, June 14, 2016

White House Organ Summit--video and links. Deceased donor chains planned at Walter Reed

Thursday, February 11, 2016

Using deceased donor kidneys to start some kidney exchange chains

**********

The announcement also drew from the depths some curious parts of transplant politics in Italy (and in Europe more generally), where Global Kidney Exchange (GKE) has received both strong support, and organized opposition.
Here's an article from Corriere Della Sera (MARCH 16, 2018), which quotes the director of the Italian National Transplant Center as celebrating that the chain did not benefit any patient-donor pairs from poor countries, as in the proposal for GKE, which he condemns. In particular, he attacks one of the transplant surgeons involved in GKE, Ignazio Marino, a former Mayor of Rome.

This led to the following reply (in Italian, of which I am a coauthor:)

Here's the google translate of our letter:
"On 16/3 the Corriere described the transplant a Padova of a kidney taken from one deceased person for a patient who he had the wife's willingness to donate the organ but could not do it being incompatible from the immune point of view.
The lady then donated one kidney to another patient, thus helping another person. Congratulations to the living donor and to the family of the deceased donor: they are the real heroes of transplant surgery. They go also praised the doctors who performed the interventions. We must however rectify several incorrect information. It is important that the team by Paolo Rigotti has turned into reality an idea, but it is not true what the Corriere and, apparently also the Head of the National Transplant Center, that "so far nobody had thought of it". The concept was known to the whole scientific world since 2016 because published, by two signatories of this letter, on the American Journal of Transplantation. It is not even true that there are no algorithms or studies.
They have existed for years and on their basis one of the signatories of this letter received in 2012 the Nobel Prize. It is also false as written that "in the US the hypothesis among the polemics is the recourse to living Filipino donors who in exchange could take advantage of a transplant free for the sick relative ». And then defamatory to affirm that "ours surgeon Ignazio Marino "(our of whom?) would support this practice. It is true instead that there is a project (Global Kidney Exchange) that in the US has not seen any conflict, but the endorsement, in 2017, of the American Society for Transplant Surgeons, the society which brings together all the transplant surgeons. Furthermore, on January 22, 2018, the President of the Istituto Superiore di Sanità, Prof. Walter Ricciardi, in his role as a member of the Executive Board of the Organization World Health Organization has promoted this idea which has since been viewed on the WHO website. Is an idea born from the desire to help the the largest possible number of patients. In practice, if one of us wanted to give a kidney a a loved one, but can not because he has a blood group B, and the person who loves needs a kidney from a donor with a blood group A, that transplant impossible can be achieved because in there are two others in the world people who love each other and have groups opposing blood. Making them meet yes they can transplant patients otherwise they will not transplantable. This is what we illustrated in Rome, in a conference promoted by the Italian NIH, January 15, 2018. Yes it is a revolutionary project if one thinks that only in sub-Saharan Africa every year about 5 million people die because they have no access to hemodialysis or to kidney transplantation.
Ignazio R. Marino Professor of Surgery,
Jefferson University
Cataldo Doria Professor of Surgery,
Jefferson University
Michael Rees, Professor of Urology,
University of Toledo
Alvin E. Roth Professor of Economics, University
of Stanford and Harvard, Nobel Economics 2012
**************
And here are some previous blog posts relating to kidney exchange politics in Italy, as discussed in the letter.

Monday, January 29, 2018

Italy recommends Global Kidney Exchange to the World Health Organization

Monday, January 22, 2018

Pursuing Global Kidney Exchange in Rome: photos