Showing posts with label chains. Show all posts
Showing posts with label chains. Show all posts

Tuesday, January 18, 2022

Evictions and coalitions in the housing market of hermit crabs--shell trafficking in the wild

 I've previously blogged about the observation that hermit crabs, who live in the shells of other animals and have to get new shells as they grow, sometimes engage in chains of exchange, that resemble kidney exchange chains, or vacancy chains in labor markets.

In particular, they resemble kidney exchange chains initiated by a deceased donor, in this case initiated by an empty shell.

 Here's a new article about hermit crabs which reports that they also engage in something that looks like organ trafficking, with a hermit crab being forcibly removed from its shell by two smaller crabs acting in concert, so that one of them may occupy the now vacant shell while the other moves into the shell of its partner in crime.

Laidre, Mark E. "The Architecture of Cooperation Among Non-kin: Coalitions to Move Up in Nature’s Housing Market." Frontiers in Ecology and Evolution (2021): 928.

"Coalitions typically involve two individuals (a pair), with a third individual being the target that the two-member coalition seeks to evict from its shell (Figure 1). Both members of the coalition have shells of their own, but these individuals and their shells are virtually always smaller than that of the target individual and its shell. Sometimes, based on the commotion and struggle generated during an attempted eviction, additional individuals—beyond the target and the core two-member coalition—are attracted to the area. These additional individuals—referred to as “third parties” or “bystanders”—are not part of the actual coalition, since they do not help at all to evict the target. Generally, third parties simply wait in the vicinity and sometimes position themselves in a social chain, which emanates from the back of the shell of one or both of the coalition members (Figure 2). This positioning in a social chain enables third parties to indirectly benefit, since in the event an eviction succeeds, it can catalyze a succession of back-to-back shell swaps (see Laidre, 2019a). Third parties are thus, in effect, “free riders” (Sigmund, 2010), since their positioning around the coalition offers no advantage whatsoever to the coalition itself as it works to evict the target. Indeed, whether third parties are positioned in a chain or not, they merely wait, performing no pulling actions and never adding any strength or providing any help to the two-member coalition. Interestingly, based on precisely where third parties position themselves, some may potentially even undermine the coalition (see below), effectively acting not merely as “free riders” but as “cheaters” (Sigmund, 2010). Finally, if too many bystanders accumulate, it can lead to chaotic jockeying and repositioning, with the original coalition separating.

"Whether with third parties present or not, the two members of the coalition attempt to physically evict the target. The target remains flipped on its back (i.e., with the dorsal side of its shell on the ground) and the opening of the target’s shell faces upward, allowing both coalition members to use their claws and legs to grab at and pull the anterior portion of the target’s body. As the coalition forcibly pulls, the target attempts to resist by clinging inside its shell. Typically, the two coalition members both pull simultaneously; though at times the two may alternate attempts at pulling, each doing so sequentially as one or the other member briefly rests. Both members of a coalition appear strongly involved, in terms of time and effort. Yet coalitions are not always successful. In some cases, one or both coalition members may give up; or the target individual may manage to flip itself over, escape from being pinned down, and run away. If a coalition is successful at evicting the target, the time till eviction occurs can vary widely, from just minutes up to hours (Laidre, personal observation). Once a coalition is successful and the target individual is evicted from its shell, then the evictee is pushed to the side and remains naked and shell-less as one of the coalition members moves into its now empty shell."

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

Earlier:

Saturday, July 21, 2012

Monday, November 22, 2021

A naturally occurring deceased-donor-initiated kidney exchange chain, by Maghen and Veale

 Here's an interesting case report, from the innovative UCLA transplant center, about a kidney exchange chain actually, if not officially, initiated by a deceased donor.

With “reverse engineering” were some living donor kidney chains in actuality triggered by deceased donors?  by Ariella Maghen and Jeffrey Veale, Clinical Transplantation, First published: 21 September 2021 https://doi.org/10.1111/ctr.14491

"Mr. M is a 58-year-old polycystic kidney disease patient waiting for a kidney transplant in the United States (US). Although his wife Mrs. M offered to donate her kidney to him, they were not a compatible match. While waiting to be “exchanged or swapped” with another donor/recipient pair facilitated by the National Kidney Registry (NKR), Mr. M received a rare offer for a “perfectly-matched” (zero-mismatch) deceased donor (DD) kidney. Only 5% of candidates receive a perfectly matched kidney from a DD; Mr. M accepted the offer and underwent transplantation in February 2020. Currently, his allograft is functioning beautifully, and he states never feeling better. 

"One may think Mrs. M feels relief now and that she is “off-the-hook” to donate. But au contraire as she has completed the extensive donor evaluation and remains in the mindset to donate. Mrs. M's gratitude towards the DD family's gift to her husband motivated her to “pay-their-generosity-forward” and now donate her kidney.

"Mrs. M's donation performed on October 21, 2020, brings greater awareness to the concept of a DD triggered kidney chain, a relatively novel phenomenon in the United States.

...

"This case elucidates how transplant chains, believed to be initiated by non-directed living donors, when reverse-engineered may in actuality have been triggered by DDs who were at the pole position. Although this may be one of the first reported cases, it is possible that other transplant centers have been encouraging the allocation of donors in this fashion. There are likely more living donors who may still want to donate their kidney even after their intended recipient received a DD transplant via “zero-mismatch” or “high-PRA” offers."

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

Italy seems to be among the first places to formally follow up on the idea of deceased donor chains. See:

Transplant InternationalVolume 33, Issue 10 p. 1177-1184, Kidney exchange strategies: new aspects and applications with a focus on deceased donor-initiated chains, by 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

Summary: 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 programme 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).

...

"Melcher et al. [10] suggested merging DD programmes with KPD programmes in 2016, an idea explored more recently in a concept paper issued by the Organ Procurement and Transplantation Network (OPTN) [11]. 

...

10 M. L. Melcher, J. P. Roberts, A. B. Leichtman, A. E. Roth, M. A. Rees Utilization of deceased donor kidneys to initiate living donor chains. Am J Transplant 2016; 16: 1367.

11Rock Haynes C, Leishman R. Allowing deceased donor-initiated kidney paired donation (KPD) chains. OPTN/UNOS Kidney Transplantation Committee. Concept Paper; July 31–October 2, 2017.

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

Earlier:

Tuesday, August 7, 2018

Wednesday, October 13, 2021

Kidney donation and the strange, viral story of the "Bad Art Friend"

 A short story about a kidney donor prompted a long article in the NY Times Magazine last week, and that article has gone viral. Here's the article:

Who Is the Bad Art Friend? Art often draws inspiration from life — but what happens when it’s your life? Inside the curious case of Dawn Dorland v. Sonya Larson.   By Robert Kolker

Here are some paragraphs that set the stage for the drama described in the article.

"On June 24, 2015, a year after completing her M.F.A. in creative writing, Dorland did perhaps the kindest, most consequential thing she might ever do in her life. She donated one of her kidneys, and elected to do it in a slightly unusual and particularly altruistic way. As a so-called nondirected donation, her kidney was not meant for anyone in particular but instead was part of a donation chain, coordinated by surgeons to provide a kidney to a recipient who may otherwise have no other living donor. 

...

"Several weeks before the surgery, Dorland decided to share her truth with others. She started a private Facebook group, inviting family and friends, including some fellow writers from GrubStreet, the Boston writing center where Dorland had spent many years learning her craft. After her surgery, she posted something to her group: a heartfelt letter she’d written to the final recipient of the surgical chain, whoever they may be."

***********

The NYT article goes on to tell a sad story about how some of the "fellow writers" took a dislike to the kidney donor, feeling that her good deed was inspired by nothing more than attention seeking.  One of them published a short fiction called "The Kindest," about just such a supposed donor (depicted as a racist or at least racially insensitive "white savior").  It contained a letter vey much like the one the real kidney donor shared.  Some but not all of the dispute that followed involves the question about whether this met the legal definition of plagiarism.

********

This is a good place to (re)state my own view, as someone with a long interest in kidney exchange, that kidney donors, especially nondirected donors, are heroes whose donation does a world of good.  Thousands of kidney transplants have been facilitated by kidney exchange chains begun by nondirected donors.  I've met a number of such donors, and they seem to me to be by and large selfless people who did something wonderful that became a significant part of their lives, even though they don't generally regard themselves as heroes.

Listen to some of their stories here, in interviews of donors by a donor: Donor Diaries Podcast

Of course, they probably have to be a bit careful telling their stories, and discussions among donors might be safe spaces where they won't be misunderstood.  That's surely an experience that donors have in common with other people who have done or experienced something remarkable, such as military veterans who are Medal of Honor winners, and who give each other needed support when recognized as such.

********

But how about art?

Here's a story in the New Yorker reviewing the short story described in the NY Times Magazine article. It asks whether the short story in question qualifies as the kind of art that might justify the liberties the author took.

The Short Story at the Center of the “Bad Art Friend” Saga.  A Times Magazine feature has prompted feverish discourse about the ethics of artistic appropriation. Is the art in question any good?  By Katy Waldman

"This raises the question of whether Larson did any better of a job exploiting Dorland’s kidney donation for personal gain, insofar as exploiting existing material for personal gain is a pretty good working definition of being a writer.

"By my reading, she did not. Larson lifted an extremely potent premise—the needy organ donor, seeking connection and validation—and crafted a story that manages to diminish its built-in intrigue. In fact, “The Kindest” falls short in precisely the ways the saga laid out in the Times Magazine piece might lead us to expect: it makes a cartoon of the donor character, and it over-relies on identity-inflected hand-waving. Also, the prose is bad."

***********

I don't know how much of a larger lesson is contained in all this, aside from the observation that even acts of great generosity can be viewed with suspicion, by those who are so inclined.  This may have something to do with why the efforts against black markets in kidneys have turned into an obsessive campaign against compensation for donors and  repugnance to any transactions that resemble rewarding donors for their generosity.

I think this is a shame. To put it another way, even if some donors were to be motivated by attention seeking, isn't it better for society if they seek attention by behaving heroically in such beneficial ways? (Just think about all the wasteful or destructive ways that attention seekers sometimes seek attention...)

I'm sticking to my view of donors as heroes. 

(I even have a paper about heroism and kidney donation:

Niederle, Muriel and Alvin E. Roth, “Philanthropically Funded Heroism Awards for Kidney Donors?, Law & Contemporary Problems, 77:3, 2014, 131-144.  )

Sunday, September 12, 2021

A living kidney donor podcast by Ned Brooks

 Here's a link at which you can hear Ned Brooks, on the latest episode of Donor Diaries

"Ned is a high-profile activist for living kidney donation and the founder of The National Kidney Donors Organization.  Ned’s appearance on Freakonomics podcast and his TEDx Talk on living kidney donation are often mentioned by living kidney donors as an early inspiration for their donation."  

https://www.donordiaries.com/episodes

Saturday, July 10, 2021

Vouchers in kidney exchange chains: a report of initial experience at NKR

 Here's a report of the experience with kidney vouchers, pioneered at UCLA and the National Kidney Registry. That's a policy that has now spread more widely, in the U.S.  This paper reports data from the NKR for 2014 through January 2021, during which time 250 donors were given vouchers, 6 of which have so far been redeemed. Voucher donors start kidney exchange chains (like non-directed donors) that can later be redeemed by (e.g.) their family members.

Voucher-Based Kidney Donation and Redemption for Future Transplant, by Jeffrey L. Veale, MD1; Nima Nassiri, MD2; Alexander M. Capron, JD2,3; Gabriel M. Danovitch, MD1; H. Albin Gritsch, MD1; Matthew Cooper, MD4,5; Robert R. Redfield, MD6; Peter T. Kennealey, MD7; Sandip Kapur, MD8

JAMA Surg. Published online June 23, 2021. doi:10.1001/jamasurg.2021.2375

"Abstract:

Importance  Policy makers, transplant professionals, and patient organizations agree that there is a need to increase the number of kidney transplants by facilitating living donation. Vouchers for future transplant provide a means of overcoming the chronological incompatibility that occurs when the ideal time for living donation differs from the time at which the intended recipient actually needs a transplant. However, uncertainty remains regarding the actual change in the number of living kidney donors associated with voucher programs and the capability of voucher redemptions to produce timely transplants.

...

Design, Setting, and Participants  This multicenter cohort study of 79 transplant centers across the US used data from the National Kidney Registry from January 1, 2014, to January 31, 2021, to identify all family vouchers and patterns in downstream kidney-paired donations. The analysis included living kidney donors and recipients participating in the National Kidney Registry family voucher program.

Exposures  A voucher was provided to the intended recipient at the time of donation. Vouchers had no cash value and could not be sold, bartered, or transferred to another person. When a voucher was redeemed, a living donation chain was used to return a kidney to the voucher holder.

Main Outcomes and Measures  Deidentified demographic and clinical data from each kidney donation were evaluated, including the downstream patterns in kidney-paired donation. Voucher redemptions were separately evaluated and analyzed.

Results  Between 2014 and 2021, 250 family voucher–based donations were facilitated. Each donation precipitated a transplant chain with a mean (SD) length of 2.3 (1.6) downstream kidney transplants, facilitating 573 total transplants. Of those, 111 transplants (19.4%) were performed in highly sensitized recipients. Among 250 voucher donors, the median age was 46 years (range, 19-78 years), and 157 donors (62.8%) were female, 241 (96.4%) were White, and 104 (41.6%) had blood type O. Over a 7-year period, the waiting time for those in the National Kidney Registry exchange pool decreased by more than 3 months. Six vouchers were redeemed, and 3 of those redemptions were among individuals with blood type O. The time from voucher redemption to kidney transplant ranged from 36 to 155 days.

Conclusions and Relevance  In this study, the family voucher program appeared to mitigate a major disincentive to living kidney donation, namely the reluctance to donate a kidney in the present that could be redeemed in the future if needed. The program facilitated kidney donations that may not otherwise have occurred. All 6 of the redeemed vouchers produced timely kidney transplants, indicating the capability of the voucher program."

***********

I haven't managed to sign a data use agreement with NKR, because Stanford's policies don't allow researchers to cede editorial control of the final paper to the data owners, which NKR's agreement requires.  See earlier post:

Thursday, March 18, 2021

Monday, June 28, 2021

Kidney exchange (including global kidney exchange), discussed at the European Society of Organ Transplantation meeting in Milan, Tuesday 29 June

 ESOT: The 20th Congress of the European Society of Organ Transplantation, meeting (by Zoom) in Milan, Italy (so the talks start at 9am pacific time, noon Eastern time in U.S., tomorrow)

Models of kidney exchange and chains

Tuesday 29 June 18:00 (CEST) 

18:00 – 18:12 Kidney exchange in UK Lisa Burnapp 

18:12 – 18:24 Kidney exchange in EU: where we are? Peter Biro

 18:24 – 18:36 Kidney exchange in US Michael Rees 

18:36 – 18:48 Ethical and legal issue in kidney exchange Frederike Ambagtsheer 

18:48– 19:00 Discussion Panellists 

19:00 Conclusions Nizam Mamode

Registration is free via https://us02web.zoom.us/webinar/register/WN_3sfBEFxnQleNoYezQvyjbg.


Sunday, June 6, 2021

Global kidney exchange with Denmark, in the U.S.

A Danish citizen with a willing but incompatible living donor, received a kidney exchange transplant in the U.S., through the Alliance for Paired Kidney Donation (APKD).

Denmark is a wealthy country that has good health care for its citizens. ScandiaTransplant has recently started kidney exchange.  But there wasn't a match there for this incompatible pair. Fortunately for them they encountered Susan and Mike Rees, who were in Copenhagen for a transplant conference.

But Danish health insurance couldn't find a will and a way to pay for the transplant in the U.S., so there were still financial barriers that had to be overcome. About two thirds of the needed funds were raised from private donations in Denmark, and about a third was covered by the AKPD.


ABC news first reported the story:
Chance meeting at bus stop in Denmark saves many lives 

"Natacha Kragesteen, 28, was born with a genetic defect that eventually led to her need for a life-saving kidney transplant. She lives in Denmark with her two young daughters and her boyfriend Louis Plesner.

"Louis wanted to donate a kidney to Natacha, but he was not a match. That left her on the kidney transplant waiting list for the last few years and undergoing kidney dialysis three times a week for four hours a day.
...
"The couple connected with Susan, who is a registered nurse, and Mike, who is a kidney transplant surgeon, and came to the conclusion that they would be helped in Toledo in the paired kidney exchange.
...
"The life-saving chain wouldn't just help the young couple. Louis's kidney would be flown down to Wake Forest University in North Carolina to help someone there, and the donor from Wake Forest donated a kidney to someone at Duke University. The Duke donor's kidney came to Toledo to save Natacha's life.

"In addition to this life-saving chain, the Minister of Health from Denmark is now considering opening that country to the paired kidney exchange program so that other people waiting for kidney transplants have a greater chance of getting one.

"So a chance meeting at a bus stop has the potential to save thousands of lives."
***********
And here's an article from the Danish press (and Google Translate):

"After almost three years in treatment, the miracle happened. Louis was on a trip to Copenhagen and was waiting for a bus when he fell into conversation with two Americans at the stop.

"It turned out that they were researchers from Johns Hopkins Hospital in the USA, and that they had just been to a kidney conference in the Danish capital. 

"Louis told them about his girlfriend's situation, and they immediately offered their help. The two researchers knew the renowned kidney surgeon Michael Rees, who is behind a successful kidney exchange program in the United States.
...
" It was completely surreal when he showed up at the hospital. He explained to us about his kidney exchange program, where a kidney patient and a willing donor who unfortunately do not fit together are matched with other couples in the same situation. That way Louis could donate his kidney to a foreign patient who would then have his own donor ready who could donate a kidney to me. Several pairs could also be included in such a kidney exchange chain so that all kidney patients would get a kidney that fit them perfectly.

"A similar kidney exchange program exists in Scandinavia, but it would not have been possible for Natacha to find a kidney through this system due to the relatively small pool of donor pairs and Natacha's many antibodies.

" So I decided to give the American program a try, and Michael Rees took blood samples from both me and Louis home to the United States and ran them through his system. A few hours later, he had found six potential donors for me. I felt it was almost too good to be true.

"Maybe it was too. The operation cost 800,000 kroner, and like most others, Natacha and her family were nowhere near being able to pay the amount out of their own pocket. When they applied for financial help from the Danish state, they were rejected.
...
"Natacha refused to give up, however, and with the help of the businessman Claus Walther Jensen, who himself has kidney disease in the family and therefore has also had contact with Michael Rees, she started a fundraising campaign, where she via Facebook posts, newspaper articles and the website savenatacha.dk explained his situation and appealed to the support of the people. 
...
"On February 2, Natacha and Louis left for the United States to undergo their kidney surgery, which was to take place 11 days later at Toledo University in Ohio and performed by Michael Rees. Meanwhile, their two daughters were cared for by their grandparents back home in Denmark.
...
"Louis' operation did not go exactly as planned. During the operation, a vein ruptured and he was about to bleed on the operating table.

"The doctors therefore had to open him up completely to stop the bleeding, so he ended up getting a giant scar on his stomach instead of the expected three small scars where the kidney was taken out. 
...
"Nor did Natacha's operation go exactly as hoped. Shortly after the transplant, it turned out that the new kidney was not getting enough blood, so the doctors had to take it out again and try to angle it differently. It helped with the blood flow, but when Natacha subsequently started bleeding inside, she had to have surgery for the third time in  a few days.
...
"Today, Natacha is feeling better than she has been for many years. She takes immunosuppressive medication so that her body does not attack the new kidney, and is monitored regularly by the Danish healthcare system. But the time of countless hospitalizations and dialysis treatments is over.
...
"Natacha hopes that her story can raise awareness of the benefits of a kidney exchange program, and that in the future it will be easier for Danish kidney patients to have surgery abroad."
************
A Danish television broadcast in two parts is here (in Danish):
 

***********
One of the issues in Global Kidney Exchange is covering not only the initial costs of patients and donors who aren't insured in the U.S., but also arranging for insurance in case of complications.  This story gives some insight into the kinds of complications that can arise, even if only rarely.  Part of the market design issue is how to cover these costs in a systematic rather than an ad hoc way.  In the present case, the costs of caring for the donor and recipient when they returned home was taken care of by the Danish healthcare system, even though  it had declined to help with the transplant in the U.S.

Friday, March 12, 2021

Kidneys for Communities

 A new organization, Kidneys for Communities, plans to advocate for living kidney donation by seeking donors who identify with a particular community.  Their come-on is "Put your kidney where your heart is.  Share your spare with someone in your community"

They say "Kidneys for Communities was founded on the idea that communities inherently take care of each other. If we can save a life, we can save the world.

"When we tap in to the compassion and connection of communities, we can radically increase the number of living kidney donors around the world and save tens of thousands of lives every year. By enlisting one community after another to join our mission, more donors will choose to give, more lives will be saved and more communities will be strengthened."

**********

Here's their press release, which includes the idea of a community member starting a kidney exchange chain that would end with a donation to a community member:

Kidneys for Communities' new program aims to increase living kidney donations impacted by COVID. New national community-directed donation program takes center stage for National Kidney Month

"Tackling the living kidney-donor shortage, Kidneys for Communities, a nonprofit, has launched the first-ever national community-directed donation program to increase the pool of living kidney donors in the United States.

"The pandemic has impacted living kidney donations across the U.S. According to the U.S. Organ Procurement and Transplantation Network (OPTN), living kidney donations in 2020 dropped to just 5,237, the lowest number in just over two decades. 

...

"The Kidneys for Communities model addresses the significant shortage of living kidney donations in the U.S., where more than 100,000 people are in immediate need of a kidney transplant, according to the OPTN. Based on OPTN data, of those who receive kidneys from living donors, approximately 95 percent know or are associated with the donor through their community network.

"The community-directed donation model increases living kidney donations by allowing potential donors who belong to membership-based associations to direct their lifesaving donation to someone—even a potential stranger—based on a community they want to support.

...

"To further increase living donor and recipient matches, Kidneys for Communities partners with leaders in the renal transplantation field, including Alliance for Paired Kidney Donation, which matches willing but incompatible kidney donor and recipient pairs through paired donations.

"Through Kidneys for Communities and Alliance for Paired Kidney Donation, a person can donate their kidney on a community member's behalf, similar to a voucher concept; the member in need is then entered into a pool, where they're matched with a viable donor. This creates a chain that allows for at least two people in need to receive a kidney: the member of the respective community and another recipient in need.

**********

The program is loosely motivated by some of the faith-based organiztions that have been so successful in recruiting living donors in the U.S. and Israel.

Related posts

Friday, February 9, 2018

Tuesday, February 23, 2021

A non-simultaneous liver exchange chain at UCSF, and a brief history of liver exchange

 Living donor liver transplants are relatively uncommon in North America compared to Asia.  Liver exchange might help change that. Here are some reports of recent and not so recent liver exchanges, including a non-simultaneous exchange chain  at UCSF, and a simultaneous chain in Canada.  Expect more in the near future.

 (Non-simultaneous chains have become the backbone of kidney exchange in the U.S., so we may start to see longer chains of liver exchange as well.)

Here's the most recent report of a short non-directed donor chain:

Expanding living donor liver transplantation: Report of first US living donor liver transplant chain  by Hillary J. Braun  Ana M. Torres  Finesse Louie  Sandra D. Weinberg  Sang‐Mo Kang  Nancy L. Ascher  John P. Roberts, American Journal of Transplantation, First published: 10 November 2020 https://doi.org/10.1111/ajt.16396

Abstract: "Living donor liver transplantation (LDLT) enjoys widespread use in Asia, but remains limited to a handful of centers in North America and comprises only 5% of liver transplants performed in the United States. In contrast, living donor kidney transplantation is used frequently in the United States, and has evolved to commonly include paired exchanges, particularly for ABO‐incompatible pairs. Liver paired exchange (LPE) has been utilized in Asia, and was recently reported in Canada; here we report the first LPE performed in the United States, and the first LPE to be performed on consecutive days. The LPE performed at our institution was initiated by a nondirected donor who enabled the exchange for an ABO‐incompatible pair, and the final recipient was selected from our deceased donor waitlist. The exchange was performed over the course of 2 consecutive days, and relied on the use and compliance of a bridge donor. Here, we show that LPE is feasible at centers with significant LDLT experience and affords an opportunity to expand LDLT in cases of ABO incompatibility or when nondirected donors arise. To our knowledge, this represents the first exchange of its kind in the United States."

The paper says this about the timing of the surgeries:

"Other centers reporting LPE have performed the donor and recipient operations in four operating rooms simultaneously4, 5 which can be logistically challenging, but addresses concerns regarding simultaneity and equalizing risk. In our case, we performed the operations on sequential days. In doing so, we accepted the risk that, given a good outcome in Recipient 1 on the first day, Donor 2 (the “bridge” donor) might opt out of living donation at the last moment. Reappropriating terminology from the kidney paired exchange (KPE) literature, a bridge donor is defined as someone who donates more than 1 day after their intended recipient received a transplant.12 A recent paper discussing the feasibility of LPE in the United States emphasized that, in the early days of KPE, there was concern that the bridge donor might back out at the last minute and break the chain.13 As a result, kidney donor operations were initially attempted simultaneously. However, a 2018 review of 344 KPE chains between 2008 and 2016 revealed that only 5.6% of bridge donors broke the chain and the majority of these donors developed a medical issue during their time as a bridge donor that prohibited them from completing donation.12 Ultimately, because this occurrence was so infrequent, the authors concluded that simultaneous donor operating rooms for chains are unnecessary and may actually deter potential donors based on logistical issues. "

***********

And here's a report from Canada of a non-directed donor chain of liver exchange with all surgeries conducted simultaneously (also with the NDD donating to an incompatible patient-donor pair whose donor donated to a patient on the deceased donor waiting list).

Living donor liver paired exchange: A North American first  by Madhukar S. Patel  Zubaida Mohamed  Anand Ghanekar  Gonzalo Sapisochin  Ian McGilvray  Blayne A. Sayed  Trevor Reichman  Markus Selzner  Jed A. Gross  Zita Galvin  Mamatha Bhat  Les Lilly  Mark Cattral  Nazia Selzner, American Journal of Transplantation, First published: 10 June 2020 https://doi.org/10.1111/ajt.16137 

Abstract: Paired organ exchange can be used to circumvent living donor‐recipient ABO incompatibilities. Herein, we present the first case of successful liver paired exchange in North America. This 2‐way swap required 4 simultaneous operations: 2 living donor hepatectomies and 2 living donor liver transplants. A nondirected anonymous living donor gift initiated this domino exchange, alleviating an ABO incompatibility in the other donor‐recipient pair. With careful attention to ethical and logistical issues, paired liver exchange is a feasible option to expand the donor pool for incompatible living liver donor‐recipient pairs.

*******

Here's a 2014 report from S. Korea:

Section 16. Update on Experience in Paired-Exchange Donors in Living Donor Liver Transplantation For Adult Patients at ASAN Medical Center by  Jung, Dong-Hwan1; Hwang, Shin1; Ahn, Chul-Soo1; Kim, Ki-Hun1; Moon, Deok-Bog1; Ha, Tae-Yong1; Song, Gi-Won1; Park, Gil-Chun1; Lee, Sung-Gyu, Transplantation: April 27, 2014 - Volume 97 - Issue - p S66-S69, doi: 10.1097/01.tp.0000446280.81922.bb

"Between January 2003 and December 2011, approximately 2,182 adult LDLT cases were included in this study. During this period, 26 paired-exchange donor LDLT cases were performed (1.2%).

"Results: Of the 26 paired-exchange donor LDLT cases, 22 pairs were matched due to ABO-incompatibility, and 4 pairs were matched because of cascade allocation of unrelated donors or relatively small graft volume to the recipients. A total of 28 living donors were included in the 26 paired-exchange donor LDLT cases because of inclusion of two dual-graft transplants. Elective surgery was performed in 22 cases, and urgent operation was performed in 4 cases. The overall 1-year and 5-year patient and graft survivals were both 96.2% and 90.1%, respectively.

"Conclusions : Our experience suggests that the paired-exchange donor program for adult LDLT seems to be a feasible modality to overcome donor ABO incompatibility."

**********

Here's a story of a liver exchange in Texas, between an incompatible pair and a compatible pair.

Saturday, December 28, 2019 A liver exchange in San Antonio, Texas

***********
Here's a liver exchange in Hong Kong between an incompatible pair and a compatible pair.

Friday, April 4, 2014 An unusual liver exchange in Hong Kong

***********
Here's a report from two major liver transplant centers in Hong Kong and S. Korea. The Korean team reported 16 donor exchanges conducted over a 6-year period.

Friday, April 9, 2010 Liver exchange



Friday, February 19, 2021

The 1% Steps for Health Care Reform Project (including kidney exchange)

 The goal of the 1% Steps for Health Care Reform Project is to shift the way we think about health care spending in the US and offer a roadmap to policy makers of tangible steps we as a country can take to lower the cost of health care in the US. We want to leverage leading scholars’ work to identify discrete problems in the US health system and offer evidence-based steps for reform. We will continually update the project with new proposals that are based on the latest academic research.

Here is their full list of Policy Briefs.

Here's one on kidney exchange:

Expanding Kidney Exchange

Authors: Nikhil Agarwal, Massachusetts Institute of Technology; Itai Ashlagi, Stanford University; Michael Rees, The University of Toledo Medical Center; Alvin Roth, Stanford University

Here's one paragraph:

"Policy Proposal: This brief discusses three specific proposals for expanding kidney exchange. First, policy makers should eliminate financial disincentives for participating in kidney exchange platforms by including medical and administrative costs specific to kidney exchange in reimbursements from the Medicare program. Second, policy makers should direct the federal contractor UNOS (United Network for Organ Sharing) to allow kidney exchange chains to be initiated by deceased donors. Third, Medicare should pay for the costs of a global kidney exchange that allows exchanges involving patients in different nations."

And here's some discussion by Nikhil Agarwal with Zack Cooper:

Wednesday, February 3, 2021

Non-Simultaneous Kidney Exchange Cycles in India: new design, in Transplant International by Kute and Rees et al.

 Perhaps the biggest part of the ongoing design of kidney exchange around the world involves adapting to constantly changing local conditions in patient and donor populations, and the prevailing laws, regulations and medical situation.  In India, where non-directed donation is illegal (except in Kerala), this means that some patients can be transplanted only if long exchange cycles are possible.  In most of the world, the requirement that the surgeries in a cycle be performed simultaneously has prevented this.

The paper below, organized by two of the world's most innovative transplant doctors, Vivek Kute and Mike Rees (first and last authors, in the medical manner), demonstrates a path forward in India. The paper reports 17 very carefully arranged and conducted non-simultaneous (and non-anonymous) kidney exchange cycles, accomplishing 67 transplants. These were performed at the  Trivedi Institute of Transplantation Sciences  (using our software:).

Vivek B. Kute, Himanshu V. Patel, Pranjal R. Modi, Sayyad J. Rizvi, Pankaj R. Shah, Divyesh P Engineer, Subho Banerjee, Hari Shankar Meshram, Bina P. Butala, Manisha P. Modi, Shruti Gandhi, Ansy H. Patel, Vineet V. Mishra, Alvin E. Roth, Jonathan E. Kopke, Michael A. Rees, “Non-simultaneous kidney exchange cycles in resource-restricted countries without non-directed donation,” Transplant International, February 2021.


Abstract: Recent reports suggest that bridge-donor reneging is rare (1.5%) in non-simultaneous kidney exchange chains. However, in developing countries, the non-directed donors who would be needed to initiate chains are unavailable, and furthermore, limited surgical space and resources restrain the feasibility of simultaneous kidney exchange cycles. Therefore, the aim of this study was to evaluate the bridge-donor reneging rate during non-simultaneous kidney exchange cycles (NSKEC) in a prospective single-center cohort study (n=67). We describe the protocol used to prepare co-registered donor-recipient pairs for non-simultaneous surgeries, in an effort to minimize the reneging rate. In addition, in order to protect any recipients who might be left vulnerable by this arrangement, we proposed the use of standard criteria deceased-donor kidneys to rectify the injustice in the event of any bridge-donor reneging.  We report 17 successful NSKEC resulting in 67 living-donor kidney transplants (LDKT) using  23 bridge-donors without donor renege  and  no intervening pairs became unavailable. We propose that NSKEC could increase LDKT, especially for difficult-to-match sensitized pairs (25 of our 67 pairs) in countries with limited transplantation resources. Our study confirms that NSKEC can be safely performed with careful patient-donor selection and non-anonymous kidney exchanges.



**************
Some previous posts:

Sunday, January 24, 2021

Mike Rees wins transplant surgeon excellence award for innovations in kidney exchange

Mike Rees, who founded the Alliance for Paired Kidney Donation (APKD), received The American Association of Kidney Patients (AAKP)  2021 MEDAL OF EXCELLENCE AWARD at the American Society of Transplant Surgeons Winter Symposium (January 16),  during the ASTS Awards Ceremony.  In the two-minute video below, he accepts the award for his introduction of Nonsimultaneous Extended Altruistic Donor Chains, Standard Acquisition Charges, and Global Kidney Exchange (GKE).


Friday, December 25, 2020

A chain of 900 strangers...

 When I talk about chains on this blog, I'm almost always talking about kidney exchange.  But there are other kinds of gift giving chains. The Washington Post has this cheerful story:

A chain of 900 strangers bought one another’s meals at a Dairy Queen drive-through  By Cathy Free

"It started with an older gentleman who pulled up to the Dairy Queen Grill & Chill drive-through window in Brainerd, Minn., at the height of the lunch hour on a Thursday.

“I’d also like to pay for the car behind me,” cashier Darla Anderson said the customer told her on Dec. 3. “Whatever they’ve ordered, I’ll cover it.”

...

"two days and hundreds of cars later, she and the rest of the crew were still ringing up “pay it forward” orders as each person who came to the drive-through offered to pay for the car behind them.

“I’ve seen ‘pay it forward’ chains that went on for about 20 cars, but never anything like this,” said general manager Tina Jensen, 43.

"In the end, it spanned more than 900 cars over 2½ days.

"On the first day, Jensen watched as hour after hour customers paid for the ice cream and hamburgers of the strangers behind them. So she decided to write a quick post on the Dairy Queen Facebook page.

...

"People who saw the post wanted to join in, and a long line of cars was soon snaking along the drive-through lane.

...

"The first two evenings of the pay-it-forward chain, before Dairy Queen closed for the night, Jensen gave the last person at the drive-through the option to leave a few dollars to pay it forward for the first customer the next day.

...

"The chain was finally broken early in the evening Dec. 5, she said, when a customer said he didn’t have enough money to pay for the order behind him, which cost more than his. The restaurant was out of carry-over funds left by other customers."


Wednesday, October 21, 2020

National Kidney Donor Advocate Conference, on YouTube

 Here's an announcement I received from Ned Brooks, the founder of  NKDO, National Kidney Donation Organization (formerly Donor to Donor).  If I understand correctly, the different talks and interviews will be available at the link after first streaming in conference style, starting at 9am Pacific time. It includes a video of Ned interviewing me.

I'll update this post as necessary. 


"This Wednesday, October 21st, NKDO, National Kidney Donation Organization (formerly Donor to Donor) will release the virtual National Kidney Donor Advocate Conference. This event is designed to give volunteer living donor advocates the information they need to be more effective advocates for living donation. Transplant industry experts across the country will be presenting to you and delivering invaluable advice about their area of expertise.

The conference will stream on our YouTube channel beginning at 12:00 noon Eastern this Wednesday. The conference will be in segments and accessed through the “playlist”, either streaming as one event or accessed at different points in the conference. The link is  https://www.youtube.com/channel/UCsoS-yavRQCVl7bwcjT2iCA , which will go live at noon Eastern on Wednesday.


- Have you ever wondered about the transplant surgeons who do the surgery? What they are thinking and what they would like you to know? Dr. Joshua Mezrich, transplant surgeon at UWMadison and author of “When Death Becomes Life: Notes from a Transplant Surgeon” talks about his experience with organ donors and recipients.


- Are you a living donor or a transplant recipient, or expecting to be one? Do you remember the experience of being evaluated at the transplant center and listening to all the information, and maybe feeling a little overwhelmed? Living Donor Coordinator Marian Charlton and Patient Coordinator Janet Hiller are two of the most respected voices in transplant, and they will tell you what they want you to know to better understand the process. Anyone who goes through this experience or has a loved one in transplant will want to see these segments.


- Living kidney donors deserve all protections available, from reimbursement for out-of-pocket costs and lost wages to medical coverage for medical issues that may arise months or years after donation. Garet Hil, founder and CEO of the National Kidney Registry, talks about the suite of protections available to living donors through Donor Shield.


-  Are you a kidney patient in need of a donor? Harvey Mysel, a two-time kidney recipient and founder and CEO of the Living Kidney Donor Network, talks about how to have your kidney donor find you.


- Professor Alvin Roth won the Nobel Prize in Economics for his work creating the algorithms that contributed to the creation of the “kidney chain”, a development that transformed kidney transplant procedures. Prof. Roth discusseshis work and the business known by the intriguing moniker of “repugnanttransactions.”


- All kidney patients will benefit by watching nephrologist Dr. David Serur talk about kidney disease and what every kidney patient and advocate needs to know to be properly informed about how to deal with renal disease. 


- Non-directed, or altruistic, donors are a rare breed, though we are trying to change that. No one knows the brain of the non-directed donor better than Professor Abigail Marsh, who has been studying non-directed donors for years. If you want to better understand why someone will happily donate a kidney to a stranger, this presentation will help answer that question.  Prof. Marsh is the author of “The Fear Factor: How One Emotion Connects Altruists, Psychopaths, and Everyone In-Between.”


- If you listen to podcasts, you are probably familiar with “Freakonomics” and its creator, Stephen Dubner. It was the Freakonomics interview with Prof. Roth that set Donor to Donor and NKDO into motion, and our interview with Mr. Dubner will interest anyone who understands “the power of the pod”.


- Jim Gleason is a heart transplant recipient and the president of TRIO, Transplant Recipients International Organization. Mr. Gleason is a motivational speaker who asks the question, “Are you a cookie monster?”



Here's the video of my video

Sunday, August 23, 2020

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

First published: 16 August 2020
 

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

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.

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

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

PDFPDFTOOLS SHARE

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)."

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

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

 

  1. M. L. Melcher1
  2.  
  3. J. P. Roberts2,*
  4.  
  5. A. B. Leichtman3
  6.  
  7. A. E. Roth4 and
  8.  
  9. M. A. Rees