A decade of progress in kidney exchange in India

 This morning I zoomed in to the tail end of a quiet celebration in India of a decade of collaboration between the Alliance for Paired Kidney Donation  (APKD) and our Indian medical colleagues..

Mike Rees and I both had sent messages of support, and during the call I spoke about my hope that India, which already does the third most kidney transplants in the world, will in the coming decade come to be the country that does the most kidney exchange transplants. That in turn could lead to India eventually becoming a global attractor for patient-donor pairs from countries that don't have lots of transplants or exchanges, to come to India to participate in kidney exchange there.

There remain many obstacles to be overcome before that can happen, but there's been so much progress in India already that those are real possibilities.

Here's the message I emailed to the founding team yesterday:

"Dear Vivek, Pranjal, Mike, Atul  and Colleagues: It’s amazing that the collaboration  between the Institute of Kidney Diseases and Research Center at the Dr. H L Trivedi Institute of Transplantation Sciences, and the Alliance for Paired Donation is entering its second decade.  It’s been thrilling for me to observe the progress that you have made.  I recall vividly meeting Dr. Trivedi in 2019 in his hospital room, and I was later deeply honored to deliver The Dr H.L. Trivedi Oration at the ISOT Meeting  in 2022.  I’ve learned so much from Vivek, and I will never forget watching Pranjal perform a robotic surgery.  And it was memorable that you both were able to visit us at Stanford for the kidney summit organized by APKD and Stanford Impact Labs.
 

"Seeing what you have accomplished has been one of the highlights of my career in market design. It’s good that we’re all still young, since I’m looking forward to the next decade of accomplishment in India." 
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Here's Mike's message:

"Mike Rees on the 10-year anniversary of IKDRC and APKD working together

"I remember the first time I met Vivek in 2016 at the TTS meeting in Hong Kong. Vivek received the “International Transplantation Science Mentee-Mentor” Award at the TTS 2016 Congress in Hong Kong. The award recognized his work on "Impact of Single Center Kidney Paired Donation Transplantation to Increase Donor Pool in India," completed under the mentorship of Prof. H.L. Trivedi and Prof. P.R. Shah. I remember meeting Vivek, Dr. PR Shah and Pranjal at the award ceremony and thinking about how wonderful it would be if we could work together. I imagined harnessing their great passion of helping patients through kidney transplantation and paired exchange and combining that with the APKD’s powerful software employing Al Roth’s Nobel Prize winning algorithm. While in Hong Kong, Vivek and I went to dinner at my first vegetarian restaurant and there we agreed to work together to try to help expand kidney exchange in India. 
 

"Three years later I travelled to Ahmedabad in May of 2019 with Alvin Roth for the ISOT Mid-term meeting. During that trip, Al and I watched Pranjal do a retroperitoneal donor nephrectomy and a robotic kidney transplantation. It was my first time seeing a robotic kidney transplant and it was so amazing. I met Dr. Himanshu Patel on that trip and I also had the honor of visiting Dr. HL Trivedi and his wife with Vivek. What a legacy Dr. Trivedi has left and I am so proud that APKD has been able to work together with Vivek, Himanshu, Pranjal and all the members of the IKDRC team to extend his wonderful vision.
 

"Since that meeting in Hong Kong, I have now made 12 trips to India and have become a big fan of Indian food and diversity of Indian culture. I have been so impressed with the passion and commitment of doctors across India, but none more so than at IKDRC. Along the way I have been fortunate to have been joined by Atul Agnihotri, Shridhar Hanchinal, and Trilly Mathew to expand our work in India. We are so grateful for the amazing example the IKDRC team has demonstrated in terms of what is possible when hard work and technology come together to saves the lives of patients with kidney disease. It is truly a joy to celebrate today with you our tenth anniversary of the work between IKDRC and APKD as we commemorate all that we have accomplished together!"

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 Over the last decade I've blogged many times in connection with transplant progress in India.  Here's a selection related to this ten-year anniversary:

Wednesday, January 13, 2016  77 Kidney Exchange transplants in 2015 at one transplant center in India

Friday, April 14, 2017  A transplant center in India has done 300 kidney exchange transplants

Wednesday, May 3, 2017 Mike Rees in India to help remove obstacles to kidney exchange

Tuesday, May 21, 2019 Robot-assisted kidney transplantation in Ahmedabad, India.

 

Wednesday, February 3, 2021 Non-Simultaneous Kidney Exchange Cycles in India: new design, in Transplant International by Kute and Rees et al.

Thursday, October 13, 2022 The Dr H.L. Trivedi Oration at the Indian Society of Transplantation (ISOT) Meeting 2022

Tuesday, February 27, 2024  Stanford Impact Labs announces support for kidney exchange in Brazil, India, and the U.S.

Saturday, April 19, 2025 One Nation One Swap: National kidney exchange in India

 Thursday, August 7, 2025 Stanford conference on extending kidney exchange

 

WHO Says Countries Should Be Self-Sufficient In (Unremunerated) Organs And Blood by Krawiec and Roth (now open source)

The published version of our paper is now widely available:

Kimberly D. Krawiec and Alvin E. Roth, “WHO Says Countries Should Be Self-Sufficient In (Unremunerated) Organs And Blood,” in James Stacey Taylor and Mark J. Cherry, eds., Markets in Human Organs for Transplantation: Controversy and Contention., Routledge, November 2025 (open source) https://www.taylorfrancis.com/reader/download/5885e1ba-c9af-4547-941c-821a2afaa7ee/chapter/pdf?context=ubx  

From the introduction:

[The nonremuneration principle] is only half of a WHO policy, broadly accepted around the world, that mandates both national (or sometimes only regional) self-sufficiency and an absence of remuneration for both blood products and transplantable organs (hereafter, the “twin principles”) (WHO 2009, 2023). This self-
sufficiency mandate, though less examined than the ban on  remuneration, presents a real hurdle to progress in transplantation, especially for smaller and low and middle income (LMIC) countries. 

"WHO’s insistence on self-sufficiency inhibits cooperative kidney
exchange efforts (as well as other innovations) among countries that
would benefit all concerned, especially the LMIC that the policy is purportedly designed to help. As will be discussed, the policy’s effect on blood products, especially when combined with the no remuneration rule, is even more stark – no country that fails to compensate donors is self-sufficient in plasma collection and few LMIC collect sufficient supplies of whole blood.
 

"This chapter critiques these twin principles, making several central points. In Section 2.2, we discuss the twin principles as applied to blood products, noting the particularly pernicious effects on plasma supply and availability, especially in poorer nations. In Section 2.3, we turn to transplantation, emphasizing the numerous benefits of international cooperation and cross-border transplantation – benefits that would be undermined by self-sufficiency, especially in smaller countries and those without well-developed domestic exchange programs. We illustrate this point with examples drawn from several noteworthy instances of cross-border kidney exchange.
 

"In Section 2.4, we argue that the current discourse around remuneration and organ donation is frequently overdramatic and unhelpful. Although nearly every effort to increase organ donation and transplantation presents ethical challenges, not every such effort amounts to “trafficking” or “a crime against humanity.” These labels stifle helpful deliberation, progress, and consensus. Section 2.5 concludes with recommendations for a saner approach to the scarce resources of blood products and transplantable organs – one that is focused on international cooperation, rather than self-sufficiency; evidence-based policies, rather than a reliance on decades-old
assumptions and understandings; and the use of pilot studies and trials to test the ethics, safety, and efficacy of incentives in various settings."

######

Here's the book:

 

Four international kidney exchange programs: 3 achieve substantial success

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

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

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

 ...

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

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

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

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

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

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

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

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

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*Notes on population:

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

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

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

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

Interview about the new edition of the Chinese translation of Who Gets What and Why

 Last month I was interviewed in connection with the new edition of the Chinese translation of my 2015 book Who Gets What and Why.  

Here is the interview in Chinese, and translated back to English. (You can also click "translate to English" from the Chinese version, to get a more creative translation that among other things renders my name as variations on "Erwin Ross.")

 Below are some excerpts from the better back-translation (from interview in English translated into Chinese, and then back to English):

"In November 2025, LatePost conducted a video interview with Roth. The interview began at 7 a.m. local time, and the 74-year-old had already arrived at his office, walking on a treadmill desk while conversing with us. A white beard, furrowed brow when deep in thought, a smiling expression, and concise communication—these are the impressions Roth gave during the conversation.

'Market design is economics confronting the external world,' Roth told us. A month earlier, his popular book on market design, Who Gets What―and Why, was republished in Chinese under the title Matching. Designing, improving, and maintaining well-functioning matching mechanisms is the work of market design. In Matching, Roth demonstrated how market design could be applied in practice to change people's destinies and the way societies operate. 

...

"Alvin Roth: Significant changes have occurred in both kidney transplantation and kidney exchange. By the way, since 2015, there has been a major transformation in the approach to transplant surgeries in China. Prior to that, most organs used in transplants came from executed prisoners; now, China is developing a voluntary organ donation program, which represents a significant shift. However, China has yet to initiate kidney exchange programs.

"A new global trend is that we are beginning to experiment with cross-border kidney exchanges. This is particularly crucial for smaller countries or regions with limited numbers of kidney transplants, where some patients struggle to find compatible donors. 

...

"Q: In your "Market Design" blog, you previewed a new book to be published next year titled Moral Economics: From Prostitution to Organ Sales, What Controversial Transactions Reveal About How Markets Work. Why did you write this book? What issues do you discuss and how do you address them?

"Alvin Roth: One issue that economists have yet to fully understand is which markets gain societal support and which ones do not. For instance, I have explored the surrogacy market. Surrogacy is legal in the United States but illegal in China. After the Chinese government relaxed its one-child policy, many people desired to have a second child, but age became an obstacle. In California, where I reside, there are agencies offering surrogacy services where Mandarin is spoken, and many clients come from China.

"This is one of the core questions I attempt to address: why are certain genuinely beneficial practices legal in some places but illegal in others? "

#######

When I search for the new edition on Google I get the following AI overview:

Alvin Roth's book, originally titled

Who Gets What―and Why: The New Economics of Matchmaking and Market Design, has been published in Chinese under two different titles. 

The two Chinese titles are:

• 《共享经济：市场设计及其应用》 (Simplified Chinese: Gòngxiǎng jīngjì: Shìchǎng shèjì jí qí yìngyòng, meaning "Sharing Economy: Market Design and Its Application").
• 《配对：诺奖得主艾文・罗斯教你赢得博弈，突破市场经济赛局的思维》 (Traditional Chinese: Pèiduì: Nuò jiǎng dé zhǔ Ài wén luō sī jiào nǐ yíng dé bó yì, tū pò shìchǎng jīngjì sài jú de sī wéi, meaning "Matching: Nobel Laureate Alvin Roth Teaches You to Win the Game and Break Through Market Economy Game Thinking"). 

The simplified Chinese characters edition was published by Machinery Industry Press in 2015. 

 

Earlier: 

Thursday, January 28, 2016  Who Gets What and Why in Chinese

 

 

"Better to exchange kidneys than bombs."

 Some coffee cups  should naturally come in pairs, so that you have one for a friend in need. (These recently arrived in the mail, from Laurie Lee)

Better to exchange kidneys than bombs

I was quoted as having said that to Marco della Cava, the USA Today reporter who wrote about the first kidney exchange between Israel and the UAE.

“Better to exchange kidneys than bombs,” says Roth, adding that using computers to search the world for medical solutions radically increases the chances of patients getting help. “International boundaries are artificial markers. Kidney disease doesn’t care about that.”

Thursday, September 30, 2021 Kidney Exchange between Israel and the UAE (in USA Today, yesterday)

How three Jewish and Arab families swapped kidneys, saved their mothers and made history by Marco della Cava, USA TODAY, Wed, September 29, 2021 AM