Peter Singer interview in the NYT

 The NYT interviews the eminent philosopher:

Peter Singer Wants to Shatter Your Moral Complacency  By David Marchese

Q. "I think of you as being best known for your work on animals and ethics, which flows out of utilitarian principles — that the right action is the one that produces the most good. But you’re also seen as one of the godfathers of effective altruism. Can you explain what effective altruism is and how it builds on utilitarianism?

A. "Sure. Effective altruism is the view that firstly, we ought to try to make the world a better place. Doesn’t mean that we all have to become saints, but it should be an important goal for people to think, What can I do to make the world better? And to think about that in a global way, not just for me and my family and those close to me but for people anywhere in the world and, indeed, for beings capable of suffering who are not of our species. Effective altruism developed into a kind of a social movement to encourage people to do that, and effective altruists have done a lot of research to try to find which are the most effective charities in different areas. What is the connection with utilitarianism? I think if you are a utilitarian, you ought to be an effective altruist. Because if you’re a utilitarian you ought to want to reduce suffering and increase happiness, and given that we all have limited resources, surely we should be using those resources as effectively as possible to do as much good as we can."

######

Earlier: Singer is one of the founding editors of the Journal of controversial ideas (which has a large, diverse and distinguished editorial board):

Friday, May 21, 2021  Journal of controversial ideas

and he defends sensible views on kidney exchange:

Saturday, November 2, 2019

Video Interview: Peter Singer on Global Kidney Exchange

Peter Singer discusses Global Kidney Exchange, and his recent article in the Lancet, in this interview on the Practical Ethics blog at Oxford.

Kidney exchange chains between Israel and Cyprus

 Israel Hayom has the story. (Itai Ashalgi's software gets a shout-out):

Unprecedented Israel-Cyprus kidney exchange saves 8 lives. Cross-border medical collaboration showcases the power of organ donation and transplant innovation.    By  Eleanor Favriker/Makor Rishon

"In a remarkable display of international medical cooperation, eight kidney transplants have been performed across Israel and Cyprus as part of a pioneering cross-border organ exchange program. The intricate operation, involving multiple hospitals and a meticulously coordinated logistics effort, was made possible by two altruistic donors who approached the National Transplant Center, initiating a "transplant chain."

"The joint operation, conducted on Monday, saw five procedures taking place in Israel and three in Cyprus. The National Transplant Center matched the pairs using specialized computer software, drawing from an international database containing incompatible family member pairs.

"Starting at 5:00 a.m., kidneys harvested at Hadassah and Soroka hospitals were transported by ambulance to the airport and flown to Cyprus. Concurrently, another kidney from Hadassah was transferred to Soroka, while one from Beilinson was sent to Hadassah. At 2:00 p.m., two kidneys arrived from Cyprus, destined for Beilinson and Hadassah. By 6:00 p.m., all transplants were completed in both countries, with recipients in good condition and new kidneys functioning.

"In Israel, three transplants occurred at Hadassah, one at Beilinson, and one at Soroka, with an additional Hadassah transplant performed a day earlier. In total, Israel saw 10 surgeries: five kidney removals and five transplants.

"Professor Shlomo Mor Yosef, chairman of the Steering Committee, said, "I commend the cooperation between Israel and Cyprus. These exchanges provide solutions for patients with antibodies. I urge every family with a patient needing a kidney transplant to join the exchange database if no match is found among them."

"Dr. Tamar Ashkenazi commented, "This marks our first two-way kidney exchange with Cyprus. Their single transplant center in Nicosia performed six surgeries in one day, supported by a surgeon from England. I'd like to thank Ms. Rona Simon, who manages our exchange database, facilitating over 60 successful cross-transplants annually. Israel maintains similar programs with the Czech Republic, Austria, and the United Arab Emirates."

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

 Requiring national self sufficiency in blood and plasma supplies is particularly hard on low and middle income countries, as is limiting the possibility of participating in active kidney exchange programs.

WHO Says Countries Should Be Self-Sufficient In (Unremunerated) Organs And Blood by Kimberly D. Krawiec and Alvin E. Roth : August 24, 2024,   Available at SSRN: https://ssrn.com/abstract=4935827

Abstract: This chapter critiques the twin World Health Organization (WHO) principles of self-sufficiency and nonremuneration in organs and blood, urging a more sensible approach to the scarce resources of blood products and transplantable organs. WHO and other experts have failed to acknowledge the tension between self-sufficiency and nonremuneration in blood products--no country that fails to pay plasma donors is self-sufficient. Furthermore, international cooperation and cross-border transplantation provide numerous benefits, especially in smaller countries and those without well-developed domestic exchange programs. The combination of these twin principles denies to health care many of the benefits that trade has brought to so many other human endeavors and the effects are particularly damaging to low and middle income countries. Substances of human origin are special, but not so special that we prohibit plasma or organ donation. We should be open to exploring and experimenting with ways to bring to health care some of the benefits that trade has brought to so many other human endeavors, such as the production and distribution of food and lifesaving vaccines and other medicines.

Here's the concluding paragraph:

"We close by noting that the combination of the nonremuneration principle and the self-sufficiency principle deny to health care many of the benefits that trade has brought to so many other human endeavors. Substances of human origin are special, but not so special that we prohibit plasma or organ donation. So we should be open to exploring and experimenting with ways to bring to health care some of the benefits that trade has brought to so many other human endeavors, such as the production and distribution of food and lifesaving vaccines and other medicines."

Kidney Exchange in Latin America and the Caribbean

 Kidney exchange isn't yet thriving in Latin America, but the basic infrastructure is in place. It would make a lot of sense to jumpstart kidney exchange by allowing cross border exchange, so that there would be a large enough pool of patient-donor pairs to make finding a match easy. Here's an article surveying the member countries of the Latin America and Caribbean Transplant Society.

Bastos, Juliana, David José de Barros Machado, Raquel Megale Moreira, Gustavo Fernandes Ferreira, and Elias David-Neto. "Kidney Paired Donation in Latin America and the Caribbean: An Update." Transplantation 108, no. 6 (2024): 1257-1258.

"we assess the situation of KPD in the countries affiliated with the Latin America and Caribbean Transplant Society (STALYC).

  

"Guatemala was the first country to publish a scientific report on KPD in 2018,8 with 4 kidney paired transplants performed between 2010 and 2017.

"Two reports from Argentina on local news websites reported 2-way exchanges involving 2 pairs in 20159 and 2018.10

"Costa Rica published a 2-way exchange on the hospital’s social media page in 2016,11 whereas a 2-way exchange transplantation was performed in Brazil in 2020.12

"Mexico is leading the reported KPD activity with a first experience involving 4 pairs in a chain beginning with an altruistic donor13 reported in 2019. A more recent publication reported on 22 pairs transplanted with longer chains and excellent results.14

"It is interesting to note that there are 6 countries—Panama, Ecuador, Venezuela, Peru, Chile, and Paraguay—with laws explicitly permitting KPD. Thus far, there has not been a report on KPD in those countries, which is likely due to the relatively recent publication of these legislations, all of which occurred after 2010.

...

"A recent publication has shed light on the potential of KPD in low-to-middle income countries (LMICs), strongly advocating for the promotion and encouragement of KPD programs, including considerations of cost advantages.17 Of additional relevance, valuable recommendations on initiating KPD programs in LMICs include starting with smaller chains, considering simultaneous surgeries, and implementing effective organ transport strategies.17 By adopting these strategies, LMICs can address compatibility issues and enhance their organ transplantation capabilities.

"Considering that KT is the superior and more cost-effective treatment option for patients with CKD, it is puzzling that the initiation of KPD programs remains limited in a region primarily composed of LMICs. Although some countries may have implemented KPD programs without publication, genuinely active programs beyond Mexico remain missing. It is crucial to emphasize that in most of these countries, deceased donor transplantation also falls significantly short of estimated needs.3,7 The entire infrastructure surrounding transplantation, including both living and deceased donors, continues to require substantial improvements. Particularly for KPD, initiatives such as educational campaigns for physicians, recipients, and donors, as well as investments in logistics and software in addition to a legal framework, need to be encouraged. Similar to KPD programs in Europe,5,18 collaborative efforts across countries could benefit smaller countries. Transplant societies, including STALYC, could play a vital role in supporting the advancement of paired donation, ensuring improved access to transplantation for their populations, especially with living donors."

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

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

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

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

...

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

...

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

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

---

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

Call for kidney exchange in Jordan

 Here's a paper by Jordanian transplant docs, pointing out that kidney exchange (and perhaps cross border kidney exchange) would be useful for Jordan, a small country with little deceased donation.

Al-Thnaibat, Mohammad H., Mohammad K. Balaw, Mohammed K. Al-Aquily, Reem A. Ghannam, Omar B. Mohd, Firas Alabidi, Suzan Alabidi, Fadi Hussein, and Badi Rawashdeh. "Addressing Kidney Transplant Shortage: The Potential of Kidney Paired Exchanges in Jordan." Journal of Transplantation 2024 (2024).

Abstract

Jordan performed the Middle East’s first living-donor kidney transplant in 1972. In 1977, the country became one of the first Arab countries to regulate organ donation and transplantation. Despite these early advances in living donor transplantation, Jordan’s organ donation after brain death program remains inactive, making it challenging to meet organ demand and placing many patients on long transplant waiting lists. As of 2020, only 14.2% of the patients with end-stage kidney disease have access to a living donor. The scarcity of compatible living donors exacerbates Jordan’s organ shortage, leaving patients with extended waits and uncertain transplant prospects. Due to the lack of living donors and the inactive brain death donation program, additional options are needed to meet organ demand. Kidney paired exchange (KPE), emerges as a potential solution to the problem of donor shortage and donor-recipient incompatibility. By allowing living donors to direct their donated organs to different compatible recipients, KPE offers the promise of expanding transplant opportunities for patients without suitable living donors. However, the current Jordanian law restricting living kidney donation to fifth-degree relatives further limits the pool of potential donors, aggravating the organ shortage situation. This article explores the feasibility of implementing KPE in Jordan and proposes an approach to implementing KPE in Jordan, considering ethical and legal aspects to substantially increase kidney transplants.

Kidney exchange between Portugal and Spain, and prospects for global kidney exchange

 Here's an article from a Portuguese hospital that has engaged in kidney exchanges with Spanish hospitals that have resulted in three transplants for Portuguese patients since the program was initiated in 2017.  The paper considers how international kidney exchange can be expanded globally, so as to have significant effects on the health of Portuguese and other patients.  

The concluding  two paragraphs of the paper speak about global kidney exchange, and the controversy that it has aroused, particularly in Spain, where there has been opposition to significant cross-border kidney exchange.

Francisco, José Teixeira, Renata Carvalho, Joana Freitas, Miguel Trigo Coimbra, Sara Vilela, Manuela Almeida, Sandra Tafulo et al. "International Crossed Renal Donation – The Experience of a Single Center," Brazilian Journal of Transplantation, v. 26 (2023)

"Introduction: Kidney transplantation is the preferred treatment for end-stage chronic kidney disease, however, the shortage of organs can result in long waiting times. Living donor kidney transplantation offers an alternative to cadaver donor, but HLA or AB0 incompatibility can represent a significant obstacle. This study aimed to show the results achieved by a Portuguese hospital since its integration into an international cross-donation program, the South Alliance for Transplants (SAT). 

"Methods: The SAT program was founded in 2017 and is made up of ten Spanish hospitals, three Italian hospitals and one Portuguese hospital. The program takes place every 4 months and only enrolls pairs who are incompatible. Organ transport is carried out in partnership with the Portuguese Air Force. 

"Results: Three different crosses were carried out in partnership with three Spanish hospitals, culminating in the transplantation of three Portuguese patients out of a total of seven patients. The first crossing was carried out in March 2020, at the beginning of the COVID-19 pandemic, with the partnership of two Portuguese hospitals and a Spanish hospital, involving 1 donor/recipient pair from each country,... The second occurred in December 2021 with 3 donor/recipient pairs (1 Portuguese in which the recipient had anti-donor antibodies and positive crossmatch with the potential donor; and 2 from two Spanish hospitals),... The third crossing also took place in December 2021 with 2 donor/recipient pairs (1 Portuguese and 1 Spanish)

...

"A Global Kidney Exchange Program (GKEP), an idea initiated by Rees et al.,16 which involves kidney paired donation between high-income and low-income and medium-income countries (LMICs). Beyond the potential benefits associated with this type of transplantation, similar to those already addressed for international programs, there are concerns about the ethical implications of  such  programs.  They  may  perpetuate  existing  inequalities  between  high  and  low-income  countries,  which  has  motivated  a  statement  from  the  Declaration  of  Istanbul  Custodian  Group.17  Some  critics  argue  that  the  practices  of  most  PRMBs  lack  transparency, leaving room for exploitation and corruption,18 or raise ethical concerns regarding the commodification of organs.19On the other hand, proponents of the idea argue that a GKEP could help address the global shortage of donor organs and provide lifesaving  opportunities  for  patients  in  need.  They  also  note  that  such  programs  could  foster  collaboration  and  information-sharing between countries and institutions, potentially leading to improvements in transplant practices worldwide.16,20 Despite the controversy surrounding the proposal, the idea of a GKEP remains an intriguing possibility for advancing kidney transplantation on a global scale.

"CONCLUSION: Our experience and that of other locations show that programs like these offer numerous benefits, such as expanding the pool of available donors, improving compatibility between donors and recipients, and avoiding the costs and risks associated with desensitization therapies for ABO or HLA incompatible transplantations. These programs represent a valuable option for individuals who require a kidney transplant and can be an effective means of increasing transplant success rates and improving quality of life for patients. However, the success of these programs depends on the number of pairs enrolled. To ensure the success of these programs, there is a need for greater awareness, education, and promotion of their benefits and outcomes among the public, healthcare providers, and policymakers alike.

Global disparities in kidney disease and care

 Here's a report on the availability of treatment of kidney disease around the world.  If you are unlucky enough to have kidney failure (which is a top 10 cause of death), it's good to be in North America or Western Europe. Most countries (70%) have at least a minimal capacity to perform transplants. But if I read the map correctly, preemptive kidney transplants (i.e. transplants before dialysis, in map D below) are relatively common only in the U.S., Britain, and Norway. (And worldwide, a transplant costs less than two years of dialysis...)

Bello, A.K., Okpechi, I.G., Levin, A., Ye, F., Damster, S., Arruebo, S., Donner, J.A., Caskey, F.J., Cho, Y., Davids, M.R. and Davison, S.N., 2024. An update on the global disparities in kidney disease burden and care across world countries and regions. The Lancet Global Health, 12(3), pp.e382-e395.

"Background

"Since 2015, the International Society of Nephrology (ISN) Global Kidney Health Atlas (ISN-GKHA) has spearheaded multinational efforts to understand the status and capacity of countries to provide optimal kidney care, particularly in low-resource settings. In this iteration of the ISN-GKHA, we sought to extend previous findings by assessing availability, accessibility, quality, and affordability of medicines, kidney replacement therapy (KRT), and conservative kidney management (CKM).

...

"Findings

The literature review used information on prevalence of chronic kidney disease from 161 countries. The global median prevalence of chronic kidney disease was 9·5% (IQR 5·9–11·7) with the highest prevalence in Eastern and Central Europe (12·8%, 11·9–14·1). For the survey analysis, responses received covered 167 (87%) of 191 countries, representing 97·4% (7·700 billion of 7·903 billion) of the world population. Chronic haemodialysis was available in 162 (98%) of 165 countries, chronic peritoneal dialysis in 130 (79%), and kidney transplantation in 116 (70%). However, 121 (74%) of 164 countries were able to provide KRT to more than 50% of people with kidney failure. Children did not have access to haemodialysis in 12 (19%) of 62 countries, peritoneal dialysis in three (6%) countries, or kidney transplantation in three (6%) countries. CKM (non-dialysis management of people with kidney failure chosen through shared decision making) was available in 87 (53%) of 165 countries. The annual median costs of KRT were: US$19 380 per person for haemodialysis, $18 959 for peritoneal dialysis, and $26 903 for the first year of kidney transplantation. Overall, 74 (45%) of 166 countries allocated public funding to provide free haemodialysis at the point of delivery; use of this funding scheme increased with country income level. The median global prevalence of nephrologists was 11·8 per million population (IQR 1·8–24·8) with an 80-fold difference between low-income and high-income countries. Differing degrees of health workforce shortages were reported across regions and country income levels. A quarter of countries had a national chronic kidney disease-specific strategy (41 [25%] of 162) and chronic kidney disease was recognised as a health priority in 78 (48%) of 162 countries.

Figure 3 Worldwide incidence of general, deceased-donor, living-donor, and pre-emptive kidney transplantations (cases pmp per year) (A) Incidence of kidney transplantation. (B) Incidence of deceased-donor kidney transplantation. (C) Incidence of living-donor kidney transplantation. (D) Incidence of pre-emptive kidney transplantation. pmp=per million population

Even in the U.S., we aren't able to supply enough transplantable kidneys for everyone who needs one. Domestic kidney exchange helps fill some of the gap, but the gap, and the resulting number of premature deaths, is still huge.  It's enough to make you think about global kidney exchange...

Global pacemaker retransplantation

 There are innovative approaches to global health care.  Here is one, that involves reusing pacemakers recovered from deceased donors and refurbished for use in countries where pacemakers are too expensive for wide use.  Unlike some of what we encounter in kidney transplants across borders, the legal bans that have to be overcome may not come from the war against the poor.  A careful clinical trial is underway. There is also an unregulated black market...

Here's the encouraging story from Helio.com:

After death, a new life for refurbished pacemakers in low-, middle-income countries, February 23, 2024

"Lack of access to pacemakers is a major challenge to the provision of CV health care in low- and middle-income countries; however, postmortem pacemaker utilization could offer an opportunity to deliver this needed care, according to Thomas Crawford, MD, an electrophysiologist and associate professor of internal medicine at University of Michigan Health and the medical director of My Heart Your Heart, a cardiac pacemaker reuse initiative at the University of Michigan Cardiovascular Center

...

"Crawford: The need is great. Each year, somewhere between 1 million and 2 million people worldwide die due to a lack of access to pacemakers and defibrillators. There is literature reflecting this. When you query pacemaker implantation data for the United States, it is roughly 800 pacemakers per 1 million population. When you query countries like, for example, Nigeria, it says four pacemakers per million. Quite a difference.

"Per capita gross domestic product is such that, in many countries, a pacemaker costs more than a person’s annual income.

...

"Healio: What are the regulations around using a refurbished pacemaker?

"Crawford: Pacemaker reuse is illegal in all jurisdictions. The FDA states that pacemaker reuse is an “objectionable practice.” We know we can do it, but we need to develop partnerships with other entities to give us credibility. One of those methods to do this is by engaging the government. FDA issues export permits for this type of activity. We created a protocol where we reprocess the device, working with Northeast Scientific, which provides the pacemaker cleaning and sterilization. We have received permission from the FDA to export them. We have to put a sticker on them saying “not for use in the United States.” We are doing this in countries in which governments will allow it. One of the limitations is needing a government letter from each of the recipient countries. We have about 12 countries now, and the collection of countries we are working with is purely accidental. It is not a normal methodological process. A lot of it is through contact with individuals and opportunities that arise.

...

"Healio: You are leading a randomized controlled trial called Project My Heart Your Heart: Pacemaker Reuse. What is the study design, and what do you and your colleagues hope to learn?

"Crawford: The objective of the clinical trial is to determine if pacemaker reutilization can be shown to be a safe means of delivering pacemakers to patients in low- and middle-income countries without resources. The target enrollment is 270 patients, all from outside the United States, who each have a class I indication for pacing and who attest that they do not have the ability to purchase a device on their own. They must consent to be randomly assigned to receive either a brand-new pacemaker, which we purchase, or a reprocessed pacemaker, for which we provide the leads and accessories. Donated devices are inspected according to specific protocols that evaluate physical and electrical suitability, including battery longevity, for future use. Devices deemed to be acceptable are shipped to a third-party vendor, Northeast Scientific, for disassembly, cleaning and re-sterilization. There will be about 130 participants in each arm. We will follow those patients and report any adverse events. The countries that have contributed patients include Kenya, Nigeria, Paraguay, Sierra Leone and Venezuela. We hope to soon begin enrolling patients in Mexico and Mozambique.

"I have had clinicians outside the U.S. who tell me they removed a pacemaker device, cleaned it, reprocessed it and then implanted it in someone else — but the government does not know about it. This practice does happen and it is not regulated in any way; patients and physicians know about it and keep it quiet. The difference with what we are doing and these other efforts is we bring it to a much higher level, because that is what the FDA requires. "

Global kidney exchange between Denmark and U.S.

 Here's a news story from North Carolina, home of one of the patient-donor pairs in the U.S.-Denmark kidney exchange, organized by the Alliance for Paired Kidney Donation (APKD).

Worldwide kidney transplant chain saves lives in Raleigh, Denmark, Colorado. by: Maggie Newland

"RALEIGH, N.C. (WNCN) — When a Raleigh musician needed a kidney, a friend of a friend offered to donate hers. The offer led to a kidney transplant chain stretching from the Triangle all the way to Denmark.

...

"Meanwhile, across the ocean, in Denmark, friends Peter Wichmann and Morton Berktoft were dealing with a similar issue. Wichmann wanted to donate his kidney to Berktoft, but they didn’t match either.

"Then something called a paired kidney exchange ended up helping all of them.  

"“It’s actually a Nobel prize-winning algorithm,” explained Krista Sweeney with AKPD. “They put these pairs into our system… We’re able to identify the best matches for each pair.”

"In this case, Kovacic donated her kidney to someone in Colorado. Their loved one donated a kidney to Berktoft, who flew to the U.S. for the surgery along with Wichmann, who donated a kidney to Adamo.

...

"Three months after the surgeries the donors and recipients are all doing well and got a chance to talk to each other in a virtual meeting.

...

“Even though the paired exchange wasn’t our initial plan it worked out so great for six people,” said Kovacic. “And three people’s lives to be saved.”

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Earlier posts on Denmark-US exchange:

Monday, June 7, 2021

Help for Danish kidney-exchange pairs, from a private foundation (while waiting for the health care system to cover international exchange)

Sunday, June 6, 2021

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

Kidney Exchange: Within and Across Borders (video lecture).

 Below is a video of my 40 minute talk at Berkeley on Monday, on Kidney Exchange: Within and Across Borders, at the final workshop on Mathematics and Computer Science of Market and Mechanism Design,  at the Simons Laufer Mathematical Sciences Institute (SLMath). (But we warned or reassured, this isn't a mathematical lecture...)

Here's another link to the video if you have trouble connecting:  https://www.slmath.org/workshops/1082/schedules/34227

Kidney Paired Donation in Developing Countries: a Global Perspective

 Vivek Kute and his colleagues argue that one of the lessons from the developing world is that kidney exchange can save many lives, but may need to be organized differently in some ways than in the developed world.

Kidney Paired Donation in Developing Countries: a Global Perspective by Vivek B. Kute, Vidya A. Fleetwood, Sanshriti Chauhan, Hari Shankar Meshram, Yasar Caliskan, Chintalapati Varma, Halil Yazıcı, Özgür Akın Oto & Krista L. Lentine, Current Transplantation Reports (2023)  (here's a link that may provide better access]

Abstract

...

"Despite the advantages of KPD programs, they remain rare among developing nations, and the programs that exist have many differences with those of in developed countries. There is a paucity of literature and lack of published data on KPD from most of the developing nations. Expanding KPD programs may require the adoption of features and innovations of successful KPD programs. Cooperation with national and international societies should be encouraged to ensure endorsement and sharing of best practices.

Summary

KPD is in the initial stages or has not yet started in the majority of the emerging nations. But the logistics and strategies required to implement KPD in developing nations differ from other parts of the world. By learning from the KPD experience in developing countries and adapting to their unique needs, it should be possible to expand access to KPD to allow more transplants to happen for patients in need worldwide."

...

" Despite the advantages of KPD programs, they remain rare in the developing world, and the programs that exist have many differences with those of developed countries. Program structure is one of these differences: multi-center, regional, and national KPD programs (Swiss, Australia, Canada, Dutch, UK, USA) are more common in the developed than the developing world, whereas single center programs are more common

...

"kidney exchanges frequently take weeks to months to obtain legal permission in India despite the fact that only closely-related family members (i.e., parents, spouse, siblings, children, and grandparents) are allowed to donate a kidney [47].

...

"Protecting the privacy of a donor, including maintaining anonymity when requested, is common practice among developed countries but uncommon in developing nations. Anonymous allocation during KPD is a standard practice in the Netherlands, Sweden, and other parts of Europe, but this is not the case in countries such as India, Korea, and Romania [14, 48, 49]. In areas where anonymity is not maintained, the intended donor/recipient pair must meet and share medical information once a potential exchange is identified, but before formal allocation of pairs occurs. The original donor/ recipient pair may refuse the proposed exchange option for any reason and continue to be on the waitlist. In India, nonanonymous KPD allocation is standard practice and has the goal of increasing trust and transparency between the transplant team and the administrative team [14, 49]. Countries differ in philosophical approaches to optimizing trust and transparency, and objective data on most effective practices would benefit the global community."

********

Tomorrow I hope to have a few words to say about the equally unique situation in China.

######

Update:

Tuesday, September 19, 2023

Organ transplantation in China: in transition--and controversy about paying funeral costs

First kidney exchange between Cyprus and Israel

 The Cyprus Mail has the story

First exchange kidney transplant between Cyprus and Israel, By Jonathan Shkurko, March 1, 2023

"The first ever crossover organ transplant involving Cyprus and Israel took place on Wednesday after two kidneys were exchanged at the old Larnaca airport in the morning.

"The effort follows an exchange agreement signed between the two countries.

"The agreement stipulates that organs belonging to donors in Cyprus that are incompatible with the recipients, will be exchanged with compatible organs arriving from Israel.

"The kidney received from Israel was transported to the new transplant clinic at Nicosia general, whereas the one donated by Cyprus was flown to Tel Aviv.

...

"During the organs’ exchange at Larnaca airport, the director of Israel Transplant Organisation Tamar Ashkenazi said she was very happy to see the results of the transnational agreement.

“I hope we will continue with more organs exchanges in the future, as we are already doing with Austria, Czech Republic and United Arab Emirates,” Ashkenazi said. 

*********

Earlier:

Thursday, December 19, 2019

International kidney exchange between Israel and Czech Republic

Monday, October 4, 2021

More on the UAE-Israel kidney exchange

Itai Ashlagi's kidney exchange software has played a role in all these exchanges.

Kidney Transplantation Across International Boundaries

 When global kidney exchange was first proposed it met with some hysterical reactions, equating it to organ trafficking.  It is good to see that being replaced by more sober, well informed discussion. Here's a recent paper on how data might be collected and shared.

The Role of Registries in Kidney Transplantation Across International Boundaries  by G. V. Ramesh Prasad, Manisha Sahay, and Jack Kit-Chung, Seminars in Nephrology, Available online 27 December  2022, https://doi.org/10.1016/j.semnephrol.2022.07.001 

Summary: Transplant professionals strive to improve domestic kidney transplantation rates safely, cost efficiently, and ethically, but to increase rates further may wish to allow their recipients and donors to traverse international boundaries. Travel for transplantation presents significant challenges to the practice of transplantation medicine and donor medicine, but can be enhanced if sustainable international registries develop to include low- and low-middle income countries. Robust data collection and sharing across registries, linking pretransplant information to post-transplant information, linking donor to recipient information, increasing living donor transplant activity through paired exchange, and ongoing reporting of results to permit flexibility and adaptability to changing clinical environments, will all serve to enhance kidney transplantation across international boundaries.

"Most KT activity occurs within a country's confines, but the increasing ease of worldwide travel and communication, and the ongoing organ shortage both motivate KT efforts across international boundaries.

...

"This review explores the specific role of patient-based registries in activating and viably maintaining KT activity across official international borders.

...

"Fewer than two thirds of countries have some form of a KT registry. With KT, however, unlike for many other therapies for which registries exist, there are two parties to consider; the donor and the recipient, and their two distinct phases of pre- and post-KT health.

...

"Transplant tourism remains a peril when promoting international transplantation. By contrast, an increasing number of international LDs now travel abroad to the home country of recipients for undergoing their donor nephrectomy.75 This travel for transplantation differs from transplant tourism by referring to the movement of organs, donors, recipients, or transplant professionals across jurisdictional borders in the absence of organ trafficking. Travel for transplantation may be increased through registries.

...

"The third and arguably most important pillar of increasing international transplant activity is to increase LD transplant activity. International comparisons based on donor source readily illustrate the varied relative proportion of DD and LD transplants worldwide.4 Large developed countries such as Canada, the United States, and Australia have developed registries to share LD organs across vast distances,80 with the goal to benefit highly sensitized recipients who have a medically suitable but immunologically incompatible LD, but at the same time maximizing the total number of KT procedures performed. Paired exchange programs and domino transplant chains81 triggered by altruistic nondirected donors best illustrate these accomplishments. Complicated computer algorithms are used to accomplish these two goals. It is important to remember, however, that organs such as kidneys are not to be treated merely as physical objects external to the human body.82 Organ donors are being paired, not organs. International LD transplants are best implemented through a paired exchange,83 as long as strict oversight policies have already been developed to respect human dignity, minimize financial burden, and ensure adequate follow-up care. Involving LICs and LMICs in paired exchange can reduce international access inequities immediately by overcoming both biological and economic imperfections. Linked registries will also permit the expansion of clinical expertise and ensure that donors and recipients are selected appropriately. Linked registries will facilitate regular follow-up evaluation and data sharing. Challenges to international LD transplantation that are best addressed through paired exchange programs include sharing hospital and travel costs, providing health insurance, respecting social and cultural norms, and ensuring administrative oversight including a mechanism for dispute resolution. The close administrative oversight provided by a paired exchange registry serves to ensure LD safety, which becomes especially pertinent when the donor belongs to a less developed country. Travel for transplantation can be encouraged, while morally burdensome transplant tourism and incentivized donation84 can be defeated. For all this to occur, however, an international registry must be much more than simply a clearinghouse for organs."

Kidney exchange collaboration between Stanford and APKD

 I recently had occasion to review the long collaboration between my Stanford colleagues and Mike Rees and the Alliance for Paired Kidney Donation. It turns out that, together with other coauthors, Mike and his APKD colleagues have written well over a dozen papers with me and my colleagues at Stanford.  (My own collaboration with Mike and APKD goes back to when Itai Ashlagi and I were still in Boston, where my earliest papers on kidney exchange were with  Tayfun Sönmez and Utku Ünver, and with Frank Delmonico and his colleagues at the New England Program for Kidney Exchange.)

Here's the list I came up with, probably not exhaustive:

Mike Rees/APKD collaborations with Stanford scholars (Ashlagi, Melcher, Roth, Somaini)

 1. 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, 1096-1101. https://www.nejm.org/doi/full/10.1056/NEJMoa0803645

2.     Ashlagi, Itai, Duncan S. Gilchrist, Alvin E. Roth, and Michael A. Rees, “Nonsimultaneous Chains and Dominos in Kidney Paired Donation – Revisited,” American Journal of Transplantation, 11, 5, May 2011, 984-994 http://www.stanford.edu/~alroth/papers/Nonsimultaneous%20Chains%20AJT%202011.pdf

3.     Ashlagi, Itai, Duncan S. Gilchrist, Alvin E. Roth, and Michael A. Rees, “NEAD Chains in Transplantation,” American Journal of Transplantation, December 2011; 11: 2780–2781. http://web.stanford.edu/~iashlagi/papers/NeadChains2.pdf

4.     Wallis, C. Bradley, Kannan P. Samy, Alvin E. Roth, and Michael A. Rees, “Kidney Paired Donation,” Nephrology Dialysis Transplantation, July 2011, 26 (7): 2091-2099 (published online March 31, 2011; doi: 10.1093/ndt/gfr155, https://academic.oup.com/ndt/article/26/7/2091/1896342/Kidney-paired-donation

5.     Rees, Michael A.,  Mark A. Schnitzler, Edward Zavala, James A. Cutler,  Alvin E. Roth, F. Dennis Irwin, Stephen W. Crawford,and Alan B.  Leichtman, “Call to Develop a Standard Acquisition Charge Model for Kidney Paired Donation,” American Journal of Transplantation, 2012, 12, 6 (June), 1392-1397. (published online 9 April 2012 http://onlinelibrary.wiley.com/doi/10.1111/j.1600-6143.2012.04034.x/abstract )

6.     Anderson, Ross, Itai Ashlagi, David Gamarnik, Michael Rees, Alvin E. Roth, Tayfun Sönmez and M. Utku Ünver, " Kidney Exchange and the Alliance for Paired Donation: Operations Research Changes the Way Kidneys are Transplanted," Edelman Award Competition, Interfaces, 2015, 45(1), pp. 26–42. http://pubsonline.informs.org/doi/pdf/10.1287/inte.2014.0766

7.     Fumo, D.E., V. Kapoor, L.J. Reece, S.M. Stepkowski,J.E. Kopke, S.E. Rees, C. Smith, A.E. Roth, A.B. Leichtman, M.A. Rees, “Improving matching strategies in kidney paired donation: the 7-year evolution of a web based virtual matching system,” American Journal of Transplantation, October 2015, 15(10), 2646-2654 http://onlinelibrary.wiley.com/enhanced/doi/10.1111/ajt.13337/ (designated one of 10 “best of AJT 2015”)

8.     Melcher, Marc L., John P. Roberts, Alan B. Leichtman, Alvin E. Roth, and Michael A. Rees, “Utilization of Deceased Donor Kidneys to Initiate Living Donor Chains,” American Journal of Transplantation, 16, 5, May 2016, 1367–1370. http://onlinelibrary.wiley.com/doi/10.1111/ajt.13740/full

9.     Michael A. Rees, Ty B. Dunn, Christian S. Kuhr, Christopher L. Marsh, Jeffrey Rogers, Susan E. Rees, Alejandra Cicero, Laurie J. Reece, Alvin E. Roth, Obi Ekwenna, David E. Fumo, Kimberly D. Krawiec, Jonathan E. Kopke, Samay Jain, Miguel Tan and Siegfredo R. Paloyo, “Kidney Exchange to Overcome Financial Barriers to Kidney Transplantation,” American Journal of Transplantation, 17, 3, March 2017, 782–790. http://onlinelibrary.wiley.com/doi/10.1111/ajt.14106/full  

a.     M. A. Rees, S. R. Paloyo, A. E. Roth, K. D. Krawiec, O. Ekwenna, C. L. Marsh, A. J. Wenig, T. B. Dunn, “Global Kidney Exchange: Financially Incompatible Pairs Are Not Transplantable Compatible Pairs,” American Journal of Transplantation, 17, 10, October 2017, 2743–2744. http://onlinelibrary.wiley.com/doi/10.1111/ajt.14451/full

b.     A. E. Roth, K. D. Krawiec, S. Paloyo, O. Ekwenna, C. L. Marsh, A. J. Wenig, T. B. Dunn, and M. A. Rees, “People should not be banned from transplantation only because of their country of origin,” American Journal of Transplantation, 17, 10, October 2017, 2747-2748. http://onlinelibrary.wiley.com/doi/10.1111/ajt.14485/full

c.      Ignazio R. Marino, Alvin E. Roth, Michael A. Rees; Cataldo Doria, “Open dialogue between professionals with different opinions builds the best policy, American Journal of Transplantation, 17, 10, October 2017, 2749. http://onlinelibrary.wiley.com/doi/10.1111/ajt.14484/full

10.  Danielle Bozek, Ty B. Dunn, Christian S. Kuhr, Christopher L. Marsh, Jeffrey Rogers, Susan E. Rees, Laura Basagoitia, Robert J. Brunner, Alvin E. Roth, Obi Ekwenna, David E. Fumo, Kimberly D. Krawiec, Jonathan E. Kopke, Puneet Sindhwani, Jorge Ortiz, Miguel Tan, and Siegfredo R. Paloyo, Michael A. Rees, “The Complete Chain of the First Global Kidney Exchange Transplant and 3-yr Follow-up,” European Urology Focus, 4, 2, March 2018, 190-197. https://www.sciencedirect.com/science/article/pii/S2405456918301871

11.  Itai Ashlagi, Adam Bingaman, Maximilien Burq, Vahideh Manshadi, David Gamarnik, Cathi Murphey, Alvin E. Roth,  Marc L. Melcher, Michael A. Rees, ”The effect of match-run frequencies on the number of transplants and waiting times in kidney exchange,” American Journal of Transplantation, 18, 5, May 2018,  1177-1186, https://onlinelibrary.wiley.com/doi/full/10.1111/ajt.14566

12.   Stepkowski, S. M., Mierzejewska, B., Fumo, D., Bekbolsynov, D., Khuder, S., Baum, C. E., Brunner, R. J., Kopke, J. E., Rees, S. E., Smith, C. E., Ashlagi, I., Roth, A. E., Rees, M. A., “The 6-year clinical outcomes for patients registered in a multiregional United States Kidney Paired Donation program- a retrospective study,” Transplant international 32: 839-853. 2019. https://onlinelibrary.wiley.com/doi/10.1111/tri.13423

13.   Roth, Alvin E., Ignazio R. Marino, Obi Ekwenna, Ty B. Dunn, Siegfredo R. Paloyo, Miguel Tan, Ricardo Correa-Rotter, Christian S. Kuhr, Christopher L. Marsh, Jorge Ortiz, Giuliano Testa, Puneet Sindhwani, Dorry L. Segev, Jeffrey Rogers, Jeffrey D. Punch, Rachel C. Forbes, Michael A. Zimmerman, Matthew J. Ellis, Aparna Rege, Laura Basagoitia, Kimberly D. Krawiec, and Michael A. Rees, “Global Kidney Exchange Should Expand Wisely, Transplant International, September 2020, 33, 9,  985-988. https://onlinelibrary.wiley.com/doi/full/10.1111/tri.13656

14.  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,  Volume 34, Issue 4, April 2021,  669-680  https://doi.org/10.1111/tri.13833

15.   Afshin Nikzad, Mohammad Akbarpour, Michael A. Rees, and Alvin E. Roth “Global Kidney Chains,” Proceedings of the National Academy of Sciences, September 7, 2021 118 (36) e2106652118; https://doi.org/10.1073/pnas.2106652118 .

16.    Alvin E. Roth, Ignazio R. Marino, Kimberly D. Krawiec, and Michael A. Rees, “Criminal, Legal, and Ethical Kidney Donation and Transplantation: A Conceptual Framework to Enable Innovation,” Transplant International  (2022), 35: doi: 10.3389/ti.2022.10551, https://www.frontierspartnerships.org/articles/10.3389/ti.2022.10551/full

17.   Ignazio R. Marino, Alvin E. Roth, and Michael A. Rees, “Living Kidney Donor Transplantation and Global Kidney Exchange,” Experimental and Clinical Transplantation (2022), Suppl. 4, 5-9. http://www.ectrx.org/class/pdfPreview.php?year=2022&volume=20&issue=8&supplement=4&spage_number=5&makale_no=0

18.  Agarwal, Nikhil, Itai Ashlagi, Michael A. Rees, Paulo Somaini, and Daniel Waldinger. "Equilibrium allocations under alternative waitlist designs: Evidence from deceased donor kidneys." Econometrica 89, no. 1 (2021): 37-76.

And here’s a report of work in progress:

The First 52 Global Kidney Exchange Transplants: overcoming multiple barriers to transplantation by MA Rees, AE Roth , IR Marino, K Krawiec, A Agnihotri, S Rees, K Sweeney, S Paloyo, T Dunn, M Zimmerman, J Punch, R Sung, J Leventhal, A Alobaidli, F Aziz, E Mor, T Ashkenazi, I Ashlagi, M Ellis, A Rege, V Whittaker, R Forbes, C Marsh, C Kuhr, J Rogers, M Tan, L Basagoitia, R Correa-Rotter, S Anwar, F Citterio, J Romagnoli, and O Ekwenna.  Transplantation: September 2022 - Volume 106 - Issue 9S - p S469 doi: 10.1097/01.tp.0000887972.53388.77  https://journals.lww.com/transplantjournal/Fulltext/2022/09001/423_9__The_First_52_Global_Kidney_Exchange.697.aspx

The First 52 Global Kidney Exchange Transplants: today at TTS2022 in Buenos Aires

 Tomorrow at TTS2022 in Buenos Aires, Mike Rees will present

The First 52 Global Kidney Exchange Transplants: overcoming multiple barriers to transplantation by MA Rees, AE Roth , IR Marino, K Krawiec, A Agnihotri, S Rees, K Sweeney, S Paloyo, T Dunn, M Zimmerman, J Punch, R Sung, J Leventhal, A Alobaidli, F Aziz, E Mor, T Ashkenazi, I Ashlagi, M Ellis, A Rege, V Whittaker, R Forbes, C Marsh, C Kuhr, J Rogers, M Tan, L Basagoitia, R Correa-Rotter, S Anwar, F Citterio, J Romagnoli, and O Ekwenna.  

Introduction: Many barriers currently stand in the way of achieving international kidney exchange including: financial, regulatory, logistical, cultural, immunological and legal barriers. 

Methods: The Alliance for Paired Kidney Donation serves patients in 15 countries. Ten of these countries have participated in Global Kidney Exchange (GKE) transplants in which either living donors, their kidneys or recipients have traveled internationally to achieve successful living donor kidney transplantation (LDKT). In all cases, barriers were present that prevented LKDT in the donor or recipient country of origin.

Results: Between January of 2015 and February of 2022, GKE has produced 11 chains and 4 cycles that has provided LDKT for 17 international patients from 10 countries to be transplanted, as well as 35 LDKT for patients in the United States (US). GKE chains lengths have ranged from 1 to 11; cycles were length 2 or 3. Eight GKE transplants overcame immunologic barriers, 4 financial barriers, and 5 both immunologic and financial barriers. GKE has involved 19 US transplant centers across 18 states and 38% of recipients were minorities. For US recipients 11% had blood type (BT)-A, 57% BT-0, 17% BT-B, and 14% BT-AB; for international recipients 41% had BT-A, 53% BT-O and 6% BT-B. The PRA was 0-20% for 23 patients, 21-79% for 14 and > 80% for 15 (10 international). International pairs were funded by a combination of self-pay, insurance and philanthropy. Transplanting 35 US patients saved US healthcare payers $7-10M vs. dialysis. International recipients have 100% 3-year patient and graft survival and all international donors are alive and have normal creatinine and blood pressure.

Conclusion: GKE overcomes financial and immunological barriers to transplantation. Savings from avoided dialysis offers scalability. Our program ensures transparency of international pair selection, emphasis on donor safety, and assurance of longterm immunosuppression for recipients as prerequisites for sustainability.

Access to transplantation around the world, at the International Congress of The Transplantation Society (TTS 2022) in Buenos Aires

I'm attending the 29th International Congress of The Transplantation Society (TTS 2022) | Buenos Aires - Argentina, and will speak in the first plenary session, on Access and Transparency in transplantation around the world.  I'll be the third of three speakers:

Plenary on access and transparency

 Monday, September 12, 2022 – 09:40 to 11:10

Transplantation in a moving world: Migrants, refugees & organ trafficking

Dominique Martin, Australia

Short Biography

Steps towards increasing deceased donation worldwide

Beatriz Dominguez-Gil, Spain

Short Biography

Transplant sufficiency in an unequal world

Alvin E. Roth, United States

Short Biography