Deceased-donor-initiated kidney-exchange chains are performing well in Italy

 Here's a new report from Italy on initiating kidney exchange chains with a deceased donor.*  In Italy to date, 34 deceased donor initiated chains generated 84 transplants (34 from deceased donors  and 50 from living donors), including 56 among incompatible pairs and 28 to candidates on the waitlist.

Furian L., Di Bella C., Maggiore U., Fiaschetti P., Partelli S., Feltrin G. Integrating Deceased and Living Donation: Long-Term Outcomes of the Italian Deceased-Donor-Initiated Kidney Exchange (DEC-K) Program AJT_ 26/7S1, Volume 26, Issue 7, S1. The cover date will be July 2026. 

"Integrating deceased and living donation through deceased-donor (DD)-initiated chains can expand kidney transplant access in small paired exchange pools. The Italian DEC-K program allocates a DD kidney to initiate a chain (chain-initiating kidney, CIK) among incompatible living-donor (LD) pairs, ultimately returning a LD kidney to the national waiting list (WL). We report the first long-term national results of this donor organ allocation model.
 

"Methods: All DEC-K chains performed in Italy (2018-2025) were retrospectively analyzed. Recipients were stratified by kidney source (CIK vs LD).

...
"Results: Thirty-four DEC-K chains generated 84 transplants (34 DD and 50 LD), including 56 among incompatible pairs and 28 to candidates on the WL. Donor withdrawal occurred once. Four chains were terminated early after CIK transplantation due to newly developed contraindications to donation. At a median follow-up of 60 months, 1- and 3-year graft survival was 100% in both groups, while patient survival was 97.1% for CIK and 98.0% for LD. Three CIK and one LD recipients died with functioning graft (suicide, sepsis, urothelial carcinoma, and acute myocardial infarction, respectively). One CIK recipient experienced graft loss after 40 months due to chronic rejection. Adjusted eGFR trajectories were comparable between CIK and LD (P = 0.48). Chain-ending kidney recipients, with 4 graft loss overall (1 antibody-mediated rejection and 3 vascular thrombosis), showed outcomes comparable to LD (P = 0.64 for eGFR; P = 0.57 for graft survival).
 

"Conclusions: The DEC-K program proved feasible, safe, and effective in expanding transplant opportunities for incompatible and hard-to-match patients."

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* Some earlier posts on deceased donor initiated chains:

Sunday, April 3, 2022

Kidney Paired Donation Chains Initiated by Deceased Donors

Monday, November 22, 2021

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

Sunday, August 23, 2020

More on Deceased donors as non‐directed donors in kidney exchange chains

Tuesday, August 7, 2018

Deceased donor chains: Market design language is entering transplantation

Monday, April 11, 2016

Using deceased donor kidneys to start living donor kidney exchange chains

 

Starzl Lecture: "The Economics of Kidney Exchange," Sunday at the American Transplant Congress in Boston

 I'll be speaking Sunday at the American Transplant Congress, on kidney exchange.  It will be hard to squeeze in all the recent developments in my half hour, including current controversies.

State-of-the-Art Speakers:  Transplantation’s leading luminaries and innovative thinkers will share inspiring research and insights at ATC 2026.  
 
Alvin E. Roth, PhD: 
Thomas E. Starzl State-of-the-Art Lecture: The Economics of Kidney Exchange

Sunday, June 21: 11:00 AM ET 

 

 

 

Horsemeat, Prostitution and Kidney Sales, interview by Peter Coy

 Peter Coy interviewed me about Moral Economics for his substack Economics for Everyone.

You can find the video and the transcript at this link: 

Horsemeat, Prostitution and Kidney Sales  by Peter Coy 
"Nobel laureate Al Roth tackles them all in a fine new book. I interviewed him."

"I asked Roth if he’s a libertarian, since libertarians say people should be free to do what they want as long as it doesn’t hurt others. No, Roth told me.

“People who call themselves libertarians often don’t like market regulation of any sort, but I’m a market designer,” Roth said. “I think that good regulations help markets work well.”

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 Peter C. interviewd me once before:

Tuesday, February 6, 2024

Kidney exchange (and other bits of market design) in the New York Times

" Peter Coy, the veteran New York Times economics columnist, writes about kidney exchange, after an interview/conversation sparked by a recent working paper of mine, Market Design and Maintenance. (He's a rare economic journalist who reads economists' papers.)

Here's his column, published yesterday afternoon:

The Economist Who Helped Patients Get New Kidneys, Feb. 5, 2024, 3:00 p.m. ET, By Peter Coy

He's also a rare interviewer: his column includes the names of more of my coauthors than I can recall in any other interview. In order of appearance: Tayfun Sonmez and Utku Unver, Frank Delmonico, Susan Saidman, Mike Rees (implicitly) when he names Mike's nonprofit Alliance for Paired Kidney Donation, and Elliott Peranson.  Market design is, after all, a team sport."

 

Organ Allocation and Transplantation, by Ashlagi and Roth, forthcoming in Annual Review of Economics 2026

 Here's a  forthcoming review paper on organ allocation and transplantation that focuses on the allocation of deceased-donor organs, particularly kidneys, and goes through the whole supply chain, from donor registration and family consent after death, to patient prioritization, and organ allocation. We also discuss the regulatory and political practices and ethical concerns that keep the availability of transplants far short of their need.

Organ Allocation and Transplantation
by Itai Ashlagi and Alvin E. Roth, Annual Review of Economics   
Vol. 18 https://doi.org/10.1146/annurev-economics-092425-123425
Review in Advance first posted online on June 08, 2026. (Changes may still occur before final publication.)
 
Abstract: There is a large shortage of solid organs for transplants. This survey reviews the allocation of organs (particularly kidneys), with an emphasis on how deceased donor organs are obtained and allocated in the United States but with pointers to related issues involving living donors and transplantation around the world. We review some of the key institutional details and theoretical and empirical studies and describe some open questions that we hope will continue to attract attention from researchers interested in the economic and operational aspects of organ allocation. 

 

The paper ends with a set of open questions and research directions, followed by these concluding paragraphs about the future:

 "THE DAY AFTER TOMORROW

"Efforts to quickly improve the availability of transplants include recovering more transplantable organs from deceased donors, successfully transplanting more of those recovered organs, and facilitating more living donor organ transplants of kidneys and livers. In the longer term, efforts are under way to reduce the need for human organ transplants by reducing the need for re-transplantation (after graft failure) and by preventing organ failure or curing it by other means. 

"It is common to hear that xenotransplantation is tomorrow’s cure for organ failure, and always will be. However, recent developments in transplanting organs from genetically modified pigs into primates and humans suggest that the future possibilities are real, even though (as of this writing) no pig organ transplant to a human has yet survived for as much as a year (although there have now been some pig kidney and heart transplants that worked for months; Tector 2025). Another somewhat related approach involves trying to bioengineer an artificial kidney by removing from a pig kidney the pig cells that would be attacked by the human immune system, leaving a scaffold that could be populated with human kidney cells (Lo et al. 2024). Less developed so far is the hope of regrowing kidneys through some kind of stem cell manipulation, although some kidney cell growth in mice has been achieved (Araoka et al. 2025).
 

"Each of these lines of research offers the possibility of reducing or ending the need for, and hence the scarcity of, human organs for transplantation. That scarcity would also be reduced by medical progress in reducing the incidence and progression of kidney disease and its precursors and of other kinds of organ failure that now require transplantation.  Yet it remains likely that almost everyone whose life could be extended by a human organ transplant today will die without one, and so our attention to the shortage of transplants is still needed." 

Survey of economists, concerning Living-Donor Kidney Transplants

Romesh Vaitilingam writes to draw my attention to the recent survey of economists, concerning Living-Donor Kidney Transplants, conducted by the Clark Center for Global Markets at Chicago Booth.

He says 

" I’m writing now as I thought you might be interested in the results of this survey, which was inspired by reading your recent Wash Post column."*

Below are the three questions they asked, and the results to each one. At the survey link above you can find the responses of the individual economists surveyed.

 

 

 Only one economist appeared to be skeptical about kidney exchange, and I was surprised at who it was (respondents may answer these questions very quickly...).

 

The next question concerns the End Kidney Deaths Act, which was introduced to the respondents at these links:

"There is draft legislation in Congress to increase the supply of human kidneys by encouraging donations to strangers: https://www.congress.gov/bill/119th-congress/house-bill/2687

"It is summarized here: https://www.hawaiibusiness.com/bipartisan-bill-aims-to-prevent-kidney-deaths-by-compensating-donors/ "

 

 

 The End Kidney Deaths Act gets a good deal of support (above) while an unspecified decentralized market gets considerably less support, below.

 

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*Earlier posts

Friday, May 8, 2026 It’s time to carefully but urgently rethink payments to kidney donors. My op-ed in the Washington Post

 

Neale Mahoney interviews me abut Moral Economics on Econ to Go

 Neale Mahoney interviews me on Econ to go (with a transcript of our half hour conversation).

 "Neale Mahoney: Markets are often treated like natural objects, things that simply exist. But economist Al Roth sees them differently. To him, markets are human inventions, systems we design, shape, and sometimes struggle to agree on. Because when money and morality collide, things can get complicated. Who should be allowed to buy and sell? What should they be allowed to transact? and what happens when people want to trade things that others find morally unacceptable.

Alvin Roth: I think that one of the things we need to do is experiment on what we're morally obliged to do and reflect on it in connection with what we're actually able to do. 

Neale Mahoney: I'm Neale Mahoney, Economist and Director of the Stanford Institute for Economic Policy Research. On this episode of "Econ To Go," I catch up with Stanford Economist and Nobel Laureate Al Roth over coffee on campus. We talk about what he calls moral economics, the study of markets where society struggles to agree on what should be bought and sold. From kidney exchange to commercial surrogacy, from prostitution laws to the surprising economics of matchmaking, Al shows us that markets don't just allocate goods. They also reflect our values. You've said that markets and marketplaces are human artifacts. They are not just features of the natural environment. Why is that a good starting place when we think about the study of economics?

Alvin Roth: Well, for a long time, economists sort of thought that markets were things that we just had to take as given. You know, we speak of economists thinking of people as price takers, but in fact, they also thought of us as market takers. There are these markets. But of course, markets are human artifacts. To a great extent they're collective human artifacts, but marketplaces are often artifacts of individual companies or designers, or small groups of participants who modify the marketplace to fit their needs over time, just in the way that Uber is a marketplace designed by the company Uber. But I think there's a good analogy, which is that languages are also human artifacts, and they're collective human artifacts. You and I can speak to each other in English because we both learned English in a conventional way, but there are lots of words in our English that weren't in the language 100 years ago, words like computer and internet and AI. So, we're constantly modifying the language to better suit our needs."

Here is the whole half hour interview on YouTube:

 

There's also a Stanford news story:

Sex, drugs & surrogacy: When morality and markets clash
Stanford’s Alvin Roth won the Nobel Prize for improving how markets work. In a new book, he introduces a new way of thinking about society’s most controversial transactions, from sex work to drugs to assisted dying.  byKrysten Crawford
 

Felix Salmon, at Bloomberg, reviews Moral Economics

  Felix Salmon, at Bloomberg, reviews Moral Economics, which starting today is now sold in stores (at least in the U.S.):

An Economist’s Case for Selling a Kidney.  In a new book, Nobel laureate Alvin Roth argues that decriminalizing taboo markets can save lives.  

He tells this story from the book:

"Roth gave a talk in 2017 at the Organ Donation Congress in Geneva about one such chain that started in 2015. A woman from the Philippines, known in the literature as FW, was willing to give up one of her kidneys to save the life of her husband, FM. The two flew to the US, where FM received a kidney from an altruistic donor in Georgia, and FW’s kidney was transplanted into a man in Minnesota. A friend of the Minnesota man, who had been willing to give up one of her kidneys to save his life, instead gave one to a man in Washington, whose father-in-law gave a kidney to a woman in Georgia, and so on. By the end of the year there had been 11 successful transplants, and the chain was still continuing.

" After his talk, Roth was confronted by a Spanish doctor who was deeply concerned about the potentially problematic implications of the economic inequality between the Philippines and the US. Roth pointed out that without the transplant, the patient would surely have died. Replied the Spanish nephrologist: “He should be dead!” Spain’s National Transplant Organization later denounced Roth as an organ trafficker.

"Roth tells this story in his most recent book, Moral Economics (Basic Venture, May 12), which, at least in part, is an attempt to apply the empiricism of economics to domains that are often resistant to such analysis. The opposition to the 2015 kidney chain, for instance, comes from nephrologists who have no problem with chains but who draw the line at international chains, or at least chains linking poor and rich countries."

######

Much of the objection to cross-border kidney exchange appears to be fading, some of it was based on the idea that countries should be self-sufficient in transplants.

See earlier posts:

Friday, January 9, 2026  WHO Says Countries Should Be Self-Sufficient In (Unremunerated) Organs And Blood by Krawiec and Roth (now open source)

 

Friday, September 11, 2020  Global Kidney Exchange supported by the European Society of Transplantation's committee on Ethical, Legal, and Psychosocial Aspects of Transplantation .

It’s time to carefully but urgently rethink payments to kidney donors. My op-ed in the Washington Post

 This morning the Washington Post published my op-ed online (which is scheduled to appear in the print edition on Sunday). 800 words is hardly enough to explain why I think what I do...I could write a whole book about that.

But here's the op-ed: 

Why paying people to donate kidneys is a good idea

With 90,000 patients waiting for a kidney, compensating living donors would save lives.

May 8, 2026 at 6:30 a.m. EDT

 

By Alvin E. Roth

Alvin E. Roth is an economics professor at Stanford University and co-recipient, with Lloyd Shapley, of the 2012 Nobel Prize in economics. This article was adapted from his new book, "Moral Economics: From Prostitution to Organ Sales, What Controversial Transactions Reveal About How Markets Work."

It’s time to carefully but urgently rethink payments to kidney donors.

There are approximately 130,000 new cases of kidney failure annually in the United States. It is disproportionately a disease of the poor, and is four times as likely to affect Black people as White people. Kidney failure costs Medicare alone more than $55 billion per year, mostly for dialysis. More than 500,000 people are presently on dialysis, about half of whom will die within five years of beginning treatment. The best treatment for kidney failure is transplantation, but in 2025 fewer than 30,000 people in the United States received kidney transplants. So most people who could benefit from a lifesaving transplant will die without one.

 About 90,000 people are registered on the national waiting list to receive a deceased-donor kidney, and many more would be, if there were enough transplants for all who need them. Thousands die each year while waiting, and thousands more are removed from the waiting list when they become too sick to undergo transplant surgery.

The law in the U.S. and most of the world says kidneys must be gifts; their price must be zero. So, any attempt to raise the supply of kidneys by compensating donors would have to overcome the almost worldwide repugnance for payment.

About three-quarters of kidneys transplanted in the U.S. come from deceased donors, and the rest come from living donors: Healthy people have two kidneys and can remain healthy with one. But sometimes potential donors can’t donate to the person they love, because kidneys have to be medically compatible with the recipient. It’s a challenge even within families. For example, often a mother can’t receive a kidney from her spouse or children because during pregnancy, her immune system developed antibodies to some of their proteins.

 

 For the last quarter-century, living-donor transplants have also been arranged through kidney exchange, in which each patient receives a compatible kidney from another patient’s intended donor. Some of these transplants take place in long chains initiated by a nondirected donor, who donates a kidney, anonymously, to anyone who needs one. That begins a chain of donations in which each recipient’s intended donor passes the gift forward. Kidney exchange has made possible thousands of additional transplants, without payments to donors.  

Nevertheless, kidneys for transplant remain in tragically short supply. So it is past time to consider amending the 1984 law that prohibits giving “valuable consideration” for a kidney for transplant.

This would have to be done with care, because there are good reasons that the phrase “payments for kidneys” arouses repugnance. We wouldn’t want inappropriate donors to be unduly influenced to give up a kidney. (This is something already considered when screening the thousands of people who donate one of their kidneys each year without payment.) Another concern is that we wouldn’t want to live in a world in which only rich people could get kidneys, by buying them from poor people.

In the United States, we might think about letting individual states experiment with different regulations. Or we could explore a national system in which only the federal government could buy kidneys — from carefully qualified donors, after a significant period devoted to medical and psychological screening, and having obtained carefully informed consent. Those kidneys could then be allocated without regard to patients’ income, much as we presently allocate deceased-donor kidneys, which are treated as a national resource. 

 

It would be financially feasible to pay donors quite generously without requiring recipients to pay anything at all. Donors could be paid entirely from the savings to the health care system by taking patients off dialysis.

There is a long history of thoughtful arguments in favor of allowing kidney donors to be legally paid or compensated in some way, with carefully considered precautions. These include a current proposal called the End Kidney Deaths Act, which would establish a limited pilot program for a tax credit to nondirected kidney donors.

To be clear, we should keep trying for big long-term goals, such as vastly reducing the incidence of kidney disease by preventing or curing diabetes, hypertension and other causes. We should keep trying to expand deceased donation (perhaps by offering funeral benefits in gratitude to the next of kin who allow it). We should keep exploring cures that don’t require transplants of human organs. But we can save many lives now by being more generous to living donors, and it makes sense to start experimenting with ways to do this legally, ethically and equitably."

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And here's the picture they chose to accompany the op-ed.

 

 

 

 

 

 

 

Introduction to market design and medicine: video of my public lecture in Taiwan

 Here's a video of the talk I gave in Taiwan on Markets, marketplaces and medicine. My talk begins at around minute 9:35, after introductions and photographs, and the camera focuses on me rather than on my slides, but I think you can follow the talk well even without seeing the slides.  A Q&A session begins at around minute 59:45, with the first question being about marriage (in which I get to quote Claudia Goldin on dads versus duds:)*

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* See, earlier

Tuesday, September 23, 2025  The Downside of Fertility by Claudia Goldin---Dads versus duds

 

Thumbs-up pictures in Taiwan, and kidney notes

 Photographers in Taiwan often ask their subjects to raise their thumbs (see all our thumbs below), just as American photographers ask for smiles.  One of the hosts in our recent visit suggested that this custom may have become solidified during Covid, when everyone wore masks, so that smiles couldn't be seen.

 

 

 I came away from Taiwan thinking that kidney exchange (which is now legal there) does not seem to be occurring with any regularity. This is a missed opportunity so far, since Taiwan has a very high incidence of kidney failure and dialysis. And (like everywhere else) there's a dire shortage of transplants: around 8500 people are on the waiting list, but the total annual number of transplants is below 500.

 But there's certainly hope for the future: as the I Ching says,* the universe progresses persistently:) 

 

*"Heaven keeps moving forward vigorously" (天行健, tiān xíng jiàn) is a foundational tenet from the I Ching (Book of Changes), specifically the Daxiang Zhuan (Commentary on the Images) regarding the Qian (Creative) hexagram. It signifies that the universe is robust and unceasing in its operation, urging humans to model this by constantly striving for self-improvement and diligence"

 (A friend, seeing this photo, says "Whoa, super deep life lessons, and yummy snacks in the background...)

Market Design and Kidney Exchange at NTHU: Public Lecture in Taiwan (video)

 Here is a video of a public lecture I gave at National Tsing Hua University (NTHU) in Taiwan.

It begins at around 13:40 (and if I've done it right, the version below should start around there), and the Q&A starts around 1:15:00 

 

Lund University anticipates EU-wide kidney exchange, and celebrates Tommy Andersson

European kidney exchange is making progress:)

 Kidney Transplants Save Lives, Cut Taxpayer Costs   Lund University
Sweden's kidney exchange programme has been operational since 2018 and will soon be expanded to include the entire EU. The programme has meant that patients' previous waiting times of up to two years have been reduced to just six months.

"Tommy Andersson, Professor of Economics at Lund University School of Economics and Management, never imagined his research would one day lead to this-but his joy, pride, and commitment are unmistakable.

"Thirteen years ago, we began the planning phase in Sweden, and in 2019 we expanded to Denmark, and later to Finland, Iceland, and Norway. The programme is called STEP (Scandiatransplant Exchange Programme). Now, in 2026, there is a consensus on how kidney exchanges should be conducted across the entire EU, and almost all the pieces of the puzzle are in place for us to launch the pilot project during 2026," says Tommy Andersson.

WATCH FILM (in Swedish): "The Economist Saving Lives" -  

Tommy Andersson was involved from the start, developing the algorithms that make the kidney exchange programme in Sweden possible. In cases where a family member can donate a kidney, the transplant can occur directly. However, if the donor's kidney does not match the patient, the exchange programme becomes vital. The programme enables matching across Scandinavia and soon across the entire EU." 

Market Design and Medicine, in Taiwan (public lectures at National Tsing Hua University)

I'll be in Taiwan for some talks on Monday and Tuesday at National Tsing Hua University

NTHU Nobel Laureate Lecture Series: Prof. Alvin E. Roth & Prof. Brian K. Kobilka (April 20–21, 2026)
 

"National Tsing Hua University is honored to host two Nobel Laureates on April 20 (Mon) and April 21 (Tue), 2026. We cordially invite you to join this series of prestigious lectures, forums, and academic exchanges.

Distinguished Speakers:

• Prof. Alvin E. Roth (Economics, 2012) – Speaker Bio
• Prof. Brian K. Kobilka (Chemistry, 2012) – Speaker Bio

Event Schedule & Registration

1. Public Lecture by Prof. Alvin E. Roth

• Topic: Markets, Market Design and Medicine
• Time: April 20 (Mon), 14:00 – 16:00
• Venue: Sun Yun-suan Lecture Hall, 1F, TSMC Building
• Register: Click Here to Register

2. Industry Forum (Prof. Roth & Prof. Kobilka)

• Topic: Navigating the Future: AI, Health, and Society
• Time: April 21 (Tue), 10:00 – 12:00
• Venue: Sun Yun-suan Lecture Hall, 1F, TSMC Building
• Register: Click Here to Register

3. Discussion Session: Prof. Roth with CTM & TSE Faculty/Students

• Time: April 21 (Tue), 14:30 – 16:00
• Venue: Room 901 (AUO Auditorium), 9F, TSMC Building
• Register: Click Here to Register

 

We look forward to your participation in these insightful academic sessions."