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."

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

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Update:

Tuesday, September 19, 2023

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

THE 18TH CONGRESS OF ASIAN SOCIETY OF TRANSPLANTATION (CAST) 25 -28 August 2023 • Hong Kong

Tonight, Sunday, at 5:30pm California time, I'll be opening the Monday morning session in Hong Kong of the THE 18TH CONGRESS OF ASIAN SOCIETY OF TRANSPLANTATION 25 -28 August 2023.

Keynote Lecture

28 Aug 0815-0915 Theatre 1 Keynote Lecture III

Chairs : Albert CY CHAN, Hong Kong, China

Hai-Bo WANG, Mainland China

Topic 1. Transplant economics Alvin ROTH USA

Topic 2. Organ transplantation reform in China: The synergy of Chinese cultural traditions and WHO guiding principle  Jie-Fu HUANG Mainland China

Kidney exchange between Portugal and Italy

 Italy-Portugal cross transplants. that click that saved two

"Thanks to a complex work of intervention planning and logistics, managed by the National Transplant Center, the Veneto Regional Transplant Center and the Portuguese institutions, the kidney of the Italian donor was removed in Vicenza and transplanted in Porto in a 41-year-old man while the Italian patient was transplanted with a kidney donated by a 36-year-old woman. The organs were harvested in the two centers simultaneously on the morning of 20 July. The Portuguese kidney arrived at Treviso airport at 2.10 pm on board a Lusitanian Air Force flight: the military delivered the organ to the regional transplant coordinator of the Veneto, Dr. Giuseppe Feltrin, receiving the Italian kidney in exchange. The 118 of Vicenza immediately transported the organ to San Bortolo where the transplantation began immediately. Both surgeries were successful and all recipients and donors went home in excellent condition."

Kidney brouhaha in Israel: is a good deed still good when performed by a shmuck?

 Recently a three way kidney exchange was performed in Israel. This would have been unremarkable under most circumstances: Israel has an active kidney exchange system.  But it caused a strong reaction in the Israeli press, because one of the donors, a  well-known rightwing activist who wanted to donate a kidney so that his brother could receive one, announced that he wanted his kidney to go only to a Jew.

Here's the Ynet story (you can click to render it in English):

 kidney in a transplant marathon: "The condition was - only for a Jew

Here's the Times of Israel (already in English):

Right-wing journalist causes stir by announcing his kidney would go only to a Jew

There were many more, but you get the idea.  Some of the stories point out that the Israeli National Transplantation Center uses an algorithm* that doesn't see the religion of the recipient, so it's not clear that this was a declaration with consequences.  It was meant to provoke, and it did.

But it's a complicated issue.  In the U.S. (and in Israel), donations can be made to a specific individual, but not to a class of individuals.  With living donation, it means that the donor can choose a specific person to donate to, and it isn't an issue how they choose: no one has to donate an organ to anyone, and every donation saves a life (and maybe more than one, particularly since  living donation reduces competition for scarce deceased-donor kidneys). So if this donor had been able to donate to his brother, no one would have thought twice that he was glad to be donating to a fellow Jew.  What made his announcement provocative was that his kidney wasn't going to his brother: his brother was getting a kidney from an anonymous other donor. [Update clarification/correction: this donation was apparently an undirected (except for the 'only' condition) altruistic donation, not part of an exchange involving the donor's brother.]

Among the people I corresponded with about this is Martha Gershun, a kidney donor who thinks and writes clearly, and has given me permission to quote some of what she said.

"I’m wondering if we find the presentation of the story troubling:  “Right-wing journalist and Temple Mount activist causes stir by announcing his kidney would go only to a Jew.”  We would react badly to a story that said:  “Right-wing Trump supporter says he will only give his kidney to a white man.”

"What if instead the stories were:  “Observant Jewish father of 8 wants to donate to a fellow Jew” and “Rural man from West Virginia seeks to help another in his community”?  Would we find those stories more acceptable?"

Part of the feeling that this is a bit complicated has to do with the fact that we don't (and maybe shouldn't) look gift horses in the mouth, i.e. we don't and maybe shouldn't delve deeply into the motivation of altruistic acts that do a lot of good. We should applaud good deeds even if they aren't performed by saints. (I blogged yesterday, about paying it forward, an umbrella term for doing good deeds in a spirit of gratitude for having ourselves benefited  from past good deeds performed by others. We generally don't find it necessary to condition our approval on precisely who receives the forward-paid gifts.)

So, while I'm not sorry to see that this statement by a kidney donor is a much discussed provocation, I'm inclined to think that a good deed remains a mitzvah even if not performed by a tzadik, as we might have said in our New York English when I was growing up.

I'll give the last word to a Haaretz op-ed, also in English:

 Is It Kosher to Donate Kidneys Only to Other Jews?  A well-known religious journalist in Israel declared the " -only" donation of his kidney. His act is imperfect, but not immoral by Robby Berman

+++++++++++++++

*On the algorithm used in Israel and elsewhere, see e.g.

Wednesday, January 15, 2020 Kidney Exchange in Israel (supported by Itai Ashlagi)

and

Friday, October 1, 2021 Stanford celebrates Itai Ashlagi and the UAE-Israel kidney exchange

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Update: related subsequent post 

Monday, July 31, 2023

Altruistic kidney donors in Israel

Paying it forward

 Scott Cunningham, an economist who devotes a lot of his efforts to providing public goods, recently had a post on the phrase "paying it forward." He writes that he connected it with a movie with a similar name, but has recently come to view it differently (for reasons I find too embarrassing to quote, but related to the fact that I use the phrase now and then.)

Wikipedia says "Pay it forward is an expression for describing the beneficiary of a good deed repaying the kindness to others instead of to the original benefactor."  It goes on to say "Robert Heinlein's 1951 novel Between Planets helped popularize the phrase."  I could have first seen it there, as I read much of Heinlein's science fiction when I was a boy.

My associations with the phrase now mostly come from the motivations and actions of some living kidney donors, particularly in kidney exchange chains.

The phrase is certainly is evocative of what we do so much of in academia (when we're doing academia well): it describes the relationship between studying and teaching, and between teachers and students.

********

Scott's post announced that, as part of paying things forward, he's funding a prize for young economists.

Laurie Lee interviews me about kidney exchange, repugnance, and more (podcast)

 Laurie Lee interviews me in her podcast Donor Diaries.

Donor Diaries

Coffee and Kidneys with Al Roth

https://www.buzzsprout.com/1748941/13094958?t=35 (You don’t have to log in; just click on “Listen Now”.)

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Here is her written description:

"Exchanging kidneys is a complicated process that involves multiple collaborations between kidney patients, living donors, transplant centers, insurance companies, airlines and more.  It’s truly remarkable if you stop to think about the number of people and organizations that need to come together to make 1 paired exchange possible.  We only started exchanging kidneys between non-compatible pairs a little over 20 years ago, so it’s a somewhat new process.  Have you ever wondered how this was made possible?

"Meet Nobel Laureate Al Roth who is an economist and Stanford University professor.  Al designs markets.  He’s one of the prominent players who has made kidney exchange possible.  In a nutshell, his work has revolutionized kidney exchange around the world by using economic theory to make kidneys more available.

"In October 2012, Al was the co-recipient of the 2012 Nobel Memorial Prize in Economic Sciences, together with Lloyd S. Shapley, for “ the theory of stable allocations and the practice of market design."

"Al Roth is well known for his application of economics to real world problems.  In this podcast episode we touch a wide range of topics ranging from paired exchanges, prostitution, surrogacy, and more.  All of these markets are examples of repugnant markets.  Kidney Donation can be characterized as a repugnant market, and Al will tell us all about it! 

Links:

Abundant/ CrowdSource for Life Film
Al Roth’s Blog
Al Roth’s Website
Freakonomics Make Me a Match Episode with Al Roth

Donor Diaries Website
Donor Diaries on Facebook
Crowd Source for Life

Kidney Exchange in Hong Kong

While liver exchanges have been done for some time in Hong Kong, possibly the first kidney exchange  has recently been reported by China Daily:

Exchanging the hope of life By Li Bingcun | HK EDITION |  2023-06-16 

"It was the first time that paired kidney transplants had been carried out in the city. Following a pilot program launched in 2018, if a patient's family member is willing to donate a kidney to the patient but their conditions do not match, the family is allowed to make a cross-donation with another family in the same situation. Previously, organ donations from living donors could be made only by close blood relatives and spouses.

"In addition to kidney transfers, Hong Kong has accomplished several cross-family liver transplants since 2009 with special approvals made by the Human Organ Transplant Board on a case-by-case basis. Facing a severe shortage of organ donations, Hong Kong is drawing on overseas experiences to widen the scope of donations from living donors by trying to overcome restrictions concerning blood type and marriage, seeking greater matching possibilities to achieve more life-saving miracles.

"These attempts involve considerable efforts to update traditional mindsets, address the accompanying ethical and legal issues, and protect the safety and interests of donors and recipients to the fullest extent.

However, because of risks to donors, medical experts suggest that organ donations from living people should never be the first choice, and that the priority should be boosting people's willingness to register as organ donors, allowing organs to be reused after registered people die.

"Globally, such kidney exchange programs have been introduced in South Korea, the United States, the United Kingdom, Australia and Canada, with surgeries performed two decades ago.

"Besides paired donations, the US also allows "nondirected donations", which means a donor can donate his or her kidney to any compatible patient. The largest kidney swaps were completed in 2014, involving 70 participants. Some global exchange programs have also carried out transnational kidney donations.

"With Hong Kong's relatively low organ-donation rate, more than 2,000 local residents are awaiting kidney transplants each year, with an average waiting time of about five years, and the longest 29 years. The number of kidney donations from living family members is less than 20 annually, while the number of cadaveric donations declined from 84 in 2012 to 45 in 2022.

"Although renal-failure patients can receive dialysis to sustain their lives, organ transplantation is still the best option. Moreover, the quality of organs of living donors is considered better than that of cadaveric organs.

"To offer patients another option, Hong Kong had been preparing to introduce the paired kidney donation (PKD) program since 2012, according to Chau Ka-foon, former co-chairperson of the Hospital Authority's Paired Kidney Donation Working Group. After extensive discussions, the city revised the law in 2018 and officially launched the program.

...

"two families that were successfully matched in 2020 canceled their planned surgeries due to personal concerns. Chau explains that the families might have worried that the organ received was of lower quality than the one they donated. It would also be a heavy blow if a family donating a kidney were unable to receive one if an operation were to fail.

...

"Attempts to swap organs among strangers have also encountered complex legal and technical problems.

"In Hong Kong's first-ever cross-family transplant in 2009, the medical team made a lot of efforts explaining to the Human Organ Transplant Board that the operation wasn't a transaction. "We repeatedly emphasized that the two families did not intend to exchange organs. It was simply the medical workers' proposal to raise the success rate of organ transplants," says Lo Chung-mau, chief surgeon of the operation and also director of the liver transplantation center at Queen Mary Hospital at that time.

...

"The 2019 social unrest and the following COVID-19 pandemic presented even greater challenges for Hong Kong's PKD program. In 2021, there were 26 eligible families in the city's organ matching pool.

"The Hospital Authority expects the number of participating families to climb to 50 to 100 in a few years. It will consider expanding the program to liver donations and collaborating with overseas matching pools. Chau hopes that kidney swaps will not be limited to just two families, and that multiple swaps among several families will be allowed to increase the chances of matching.

...

"Wang Haibo, a member of China's National Organ Donation and Transplantation Committee, says the pair-donation program is worth looking into and being discussed. The mainland is also conducting clinical research on paired-kidney donations. Alvin Roth, who won the 2012 Nobel Memorial Prize in Economic Sciences and developed a global kidney-exchange program, visited China before the COVID-19 pandemic to seek collaboration in this area, he recalls.

"Wang says both Hong Kong's and the mainland's organ donation rates still lag far behind those of developed economies. "They have reached a plateau and have made relatively adequate utilization of organ donations from the deceased. We have much room to develop in this regard."

"He says that while officials explore innovative approaches concerning living-organ donations, the priority should still focus on how to boost people's willingness to register as organ donors and better utilize the organs. "These are the so-called 'low hanging fruit'. It would be wise to concentrate our limited resources on the most rewarded option."

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More kidney exchange in the UAE--

 Kidney exchange in the UAE, with the assistance of the Alliance for Paired Kidney Donation (AKPD), took another step forward, with a three way exchange.

Here is the press release fron the Cleveland Clinic Abu Dhabi:

Cleveland Clinic Abu Dhabi supports Abu Dhabi’s Paired Kidney Donation Program by successfully completing a triple swap kidney transplant 

"Cleveland Clinic Abu Dhabi, a Mubadala Health partner, played a major role in a groundbreaking triple ‘kidney swap’ transplant case in the UAE where three patients received life-saving organs under Abu Dhabi’s Paired Kidney Donation Program."

Interview in the Brazil Journal

 I was interviewed for the Brazil Journal by Giuliano Guandalini. The interview was conducted in English, but appears in Portuguese. We discussed controversial markets generally, including kidney exchange, which is not legal yet in Brazil.

Troca de rins. Drogas. Barriga de aluguel. Este Nobel sugere liberar tudo  (Kidney exchange. Drugs. Surrogacy...)

 Here's a snippet that comes through pretty clearly in retranslation back into English by Google Translate:

"In the US and many other countries, his work and that of other researchers has contributed to improving the waiting list for kidney transplants. In Brazil, we continue with the traditional system, with a long wait for donors. Why is it so difficult to make reforms of this kind in public services based on the teachings of modern economics?  

"A transplant always depends on an organ donation, whether from a dead person or a living individual. It is natural that family members and society in general are concerned about how this will be done in an ethical and careful manner. 

"Brazil does a lot of transplants. So there is no restriction on the medical capacity side so that more transplants can be done. But when we look at total kidney transplants in relation to population size, the number is not that big. 

"Meanwhile, there are thousands of people on dialysis because transplants have not been enough. The issue, therefore, is to allow more donations to occur in life, and changing kidneys is a way for people to help save someone they love. 

"Brazil may be one of the next countries to carry out the exchange of kidneys. Some experimental surgeries have already been performed, with legal authorization. Researchers will be able to gain support to perform more operations of this type and then, perhaps, society will be able to convince itself of the importance of changing kidneys. 

"What are the obstacles that prevent the adoption of organ exchange? Are they ethical, moral, religious issues? 

"A little bit of all those things. There are those concerned that poor and vulnerable people may have their organs stolen. Evidently, there must be complete assurance that this will not happen. But of course the poor would also like to save the lives of loved ones by giving them a kidney. "

Canadian kidney exchange reaches 1000 transplants

 The May 2023 update from Canadian Blood Services shows that Canada's kidney paired donation program recently performed its 1,000th transplant.

Earlier:

Wednesday, December 8, 2010

National kidney exchange in Canada

Here's a recent announcement from Canadian Blood Services: Kidney Exchange Registry Goes National, Living Donor Paired Exchange becomes first Canada-wide organ donation registry

Kidney exchange progress in Europe

 The program on European Cooperation in Science and Technology  (COST) has just published an update on steps being taken to advance kidney exchange in Europe, including the goal of more cross-border exchange.

The crucial role of Kidney Exchange Programmes and the ENCKEP and KEP-SOFT innovations making it possible

"Setting up KEPs is difficult due to the ethical, legal, practical, and logistical considerations that must be faced. These include ratifying policy decisions, establishing a software infrastructure, and satisfying clinical requirements. Additionally, KEPs vary across European countries in terms of policy, clinical practice, and optimisation methods. For instance, the maximum number of recipients allowed to exchange donors in a single “cycle” differs between the Netherlands and the UK. Furthermore, some countries allow non-directed donation while others prohibit it. Crossmatching** processes also vary. The ENCKEP and KEP-SOFT network has proved instrumental in meeting many of these challenges. And its associated software addresses many of these variations.

...

"On 15 June 2023, EU4Health will publish a call for proposals to implement an EU-wide KEP. On page 65, the announcement makes specific reference to the KEP-SOFT software. This presents an exciting potential future opportunity to influence further developments in KEPs in the European context and to widen the user-base of the KEP-SOFT software"

HT: David Manlove

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When I first read the last paragraph above I thought that "KEP"  probably stood for "Kidney Exchange Program," and that the proposal was to make that EU-wide rather than country by country. But it turns out that "KEP" stands for Knowledge Exchange Platform (KEP), so the progress is a bit less specific than I had hoped. But on page 65 it does include a "Call for proposals: action grants on facilitating organ paired exchange." It states that "In view of the scarcity of organs available for transplantation, there is a need to strengthen the exchange schemes among Member States, with a clear added value for European patients, as such exchange schemes can save the life of patients."

Kidney exchange, around the world and in Germany? German Health Economics Association (DGGÖ) webinar tomorrow

Tomorrow  I'll be giving a talk in Germany (8am California time, 17:00 in Germany), hosted by the German Health Economics Association (DGGÖ).  (Bob Slonim will be giving a talk in this series in the summer.)

My title will be Kidney Exchange to increase transplantation: around the world, and in Germany?

(One big issue is that kidney exchange isn't yet supported in Germany.) 

There is a webinar address at the above link for those who might like to listen.

Freakonomics replay and update on kidney exchange and organ donation

 Freakonomics Radio yesterday revisited some of their old podcasts about kidney exchange. In one, they interview me, and in another, they interview Ned Brooks, who listened to that interview and went on to become a non-directed kidney donor and to found an organization to support other kidney donors, the NKDO, National Kidney Donation Organization.  You can listen and/or read the transcript at this link:

EPISODE 209

Make Me a Match (Update)

"Sure, markets work well in general. But for some transactions — like school admissions and organ transplants — money alone can’t solve the problem. That’s when you need a market-design wizard like Al Roth. Plus: We hear from a listener who, inspired by this episode, made a remarkable decision.

"Last month, the federal government announced plans to modernize the U.S. organ-donation system. They want to speed up the process by which organ-transplant patients are matched with donated organs, and they also want to reduce racial inequities in the system. When we saw this news, we decided to go into our archive and put together the episode you’re about to hear. It’s a mashup of a 2015 episode, No. 209, called “Make Me a Match,” and a portion of a 2016 episode, No. 237, which includes a personal story from a listener who was inspired by that earlier episode to make a remarkable decision. All the relevant facts and figures have been updated. As always, thanks for listening."

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Here are my previous posts on Freakonomics episodes.

How much compensation for U.S. kidney donors would end the kidney transplant shortage?

 Here's a paper with a forbidding title but an important message (and an eye-catching first paragraph...:)

McCormick, Frank, Philip J. Held, Glenn M. Chertow, Thomas G. Peters, and John P. Roberts. "Projecting the economic impact of compensating living kidney donors in the United States: cost-benefit analysis demonstrates substantial patient and societal gains." Value in Health Volume 25, Issue 12, December 2022, Pages 2028-2033

"Abstract:

Objectives: The aim of this study was to show how the US government could save approximately 47 000 patients with chronic kidney failure each year from suffering on dialysis and premature death by compensating living kidney donors enough to completely end the kidney shortage.

Methods: Supply and demand analysis was used to estimate the number of donated kidneys needed to end the kidney shortage and the level of compensation required to encourage this number of donations. These results were then input into a detailed cost-benefit analysis to estimate the economic value of kidney transplantation to (1) the average kidney recipient and their caregiver, (2) taxpayers, and (3) society in general.

Results: We estimate half of patients diagnosed with kidney failure each year—approximately 62 000 patients—could be saved from suffering on dialysis and premature death if they could receive an average of 1½ kidney transplants. However, currently there are only enough donated kidneys to save approximately 15 000 patients. To encourage sufficient donations to save the other 47 000 patients, the government would have to compensate living kidney donors approximately $77 000 (±50%) per donor. The value of transplantation to an average kidney recipient (and caregiver) would be approximately $1.5 million, and the savings from the recipient not needing expensive dialysis treatments would be approximately $1.2 million.

Conclusions: This analysis reveals the huge benefit that compensating living kidney donors would provide to patients with kidney failure and their caregivers and, conversely, the huge cost that is being imposed on these patients and their families by the current legal prohibition against such compensation."

and here's the first paragraph:

"Economics Nobel Laureate Alvin Roth has played a crucial role in developing paired kidney donation, which is currently saving >1100 US patients with kidney failure per year from suffering on dialysis and dying prematurely. Nevertheless, Professor Roth often points out that this is a victory in a war that we are losing.1 The number of patients diagnosed with kidney failure each year in the United States is not only much greater than the number who receive kidney transplants; it is rising at a faster rate.2,3 Thus, the number of patients diagnosed with kidney failure who are fated to suffer on dialysis for an average of 4 to 5 years while their health steadily deteriorates until they die prematurely has trended upward and is now >100 000 per year."

Kidney exchange in Turkey: a decade of experience at a hospital in Istanbul

 Here's a recent article, from Bahcesehir University Goztepe Medicalpark Hospital Transplant Center,  in Istanbul which has a decade of experience in kidney exchange. It's main point is that Turkey needs more kidney exchange, organized on a larger scale, because the deceased donor system there is very limited, so transplants primarily involve living donors. 

Long-Term Outcomes of Kidney Paired Donation Transplantation: A Single Center Retrospective Cohort Study, by Eda Altun and Melike Yavuz  In Transplantation Proceedings. Elsevier, 2023.

"In this single-center, retrospective, cohort study, we analyzed 141 KPD transplant patients from July 2011 to June 2020 at Bahcesehir University Goztepe Medicalpark Hospital Transplant Center, Istanbul, Turkey.

...

"Although the current study is based on a single-center's records, the findings suggest that the long-term outcomes of the KPD program were similar to conventional LDKT. These results demonstrate that KPD is practicable, thriving, and successful if performed to a more extensive donor list. Efforts should be made to expand the KPD program in countries such as Turkey, where cadaveric transplantation is insufficient. "

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Earlier:

Friday, July 24, 2015

Kidney exchange in Turkey, and the state of Turkish transplantation

Tuesday, February 3, 2015

Organ donation in Turkey

Wednesday, November 21, 2018

Kidney exchange in Turkey, some recent reports

Kidney exchange in Mexico

 Here's a report from the journal Cirugia y Cirujanos  (Surgery and Surgeons) on the experience with kidney exchange (aka kidney paired donation) at the Central Military Hospital in Mexico City, where 

Donación renal pareada: beneficio de este programa en la tasa de trasplantes y sobrevida del injerto

Kidney paired donation: benefit of this program on the transplant rate and graft survival  by Lucino Bahena-Carrera, Héctor F. Noyola-Villalobos, Edgar E. Ramos-Díaz, Marco A. Loera-Torres, Ricardo Mendiola-Fernández y Mónica L. Razo-Padilla, Cirugia y Cirujanos 91, no. 1 (2023): 50-57.

 Abstract: 

"Objective: To demonstrate the experience since the transplant program under paired kidney donation implementation; program that increases the donation rate by 25-30% in hospitals with no inferior graft survival compared to directed living donor kidney transplantation. 

"Method: Observational, analytical, longitudinal and prospective study from December 2018 to July 2021. All G5 KDIGO chronic kidney patients who were HLA or ABO incompatible with their original donors in the pretransplant protocol and who were transplanted under the paired kidney donation program, were included. 

"Results: 22 kidney transplants were performed under this program. Survival of the graft and the patient 1 year after transplantation was 100%. The post-transplant glomerular filtration rate was 72.5 ± 17 ml/min/1.73 m2  body surface. 36.3% of hypersensitized patients were successfully transplanted. The in-hospital donation rate increased by 33.33%. 

"Conclusions: Transplantation under the kidney paired donation program constitutes a real modality of successful transplantation when there is incompatibility with the original donor. The greater use and socialization of this program can increase the country kidney transplantation rate, reducing the waiting list. Our hospital represents the largest experience published in Mexico with this transplant program

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. 

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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.

Obstacles facing liver exchange

 Liver exchange is different than kidney exchange in a number of important dimensions, some of which will present obstacles that need to be overcome in different ways. (Although it looks like in liver exchange the donors will travel to the recipients instead of having the organs shipped, as is now mostly done in U.S. kidney exchange.  That's actually how kidney exchange worked when it began) Here's a recent article from Medscape:

Can a Nationwide Liver Paired Donation Program Work?  by Lucy Hicks

"To expand the number of living liver donations in the United States, the United Network for Organ Sharing (UNOS) has launched the first national paired liver donation pilot program in the United States.

...

"In 2020, 1095 people died while waiting for a liver transplant

...

"Paired kidney donation programs have been running since 2002, but paired liver donation is relatively new. Since the first US living-donor liver transplant in 1989, the procedure has become safer and is a viable alternative to deceased liver donation. A growing number of living donor programs are popping up at transplant centers across the country.

"Still, living-donor liver donation makes up a small percentage of the liver transplants that are performed every year. In 2022, 603 living-donor liver transplants were performed in the United States, compared to 8925 liver transplants from deceased donors

...

"There are several notable differences between living donor kidney transplants and living donor liver transplants. For example, living donor liver transplant is a more complicated surgery and poses greater risk to the donor. According to the OPTN 2020 Annual Report, from 2015–2019, the rehospitalization rate for living liver donors was twice that of living kidney donors up to 6 weeks after transplant (4.7% vs 2.4%). One year post transplant, the cumulative rehospitalization rate was 11.0% for living liver donors and 4.8% for living kidney donors.

"The risk of dying because of living donation is also higher for liver donors compared to kidney donors. The National Kidney Association states that the odds of dying during kidney donation are about 3 in 100,000, while estimates for risk of death for living liver donors range from 1 in 500 to 1 in 1000. But some of these estimates are from 10 or more years ago, and outcomes have likely improved

...

"In addition to a more complex surgery, surgeons also have a smaller time window in which to transplant a liver than than they do to transplant a kidney. A kidney can remain viable in cold storage for 24–36 hours, and it can be transported via commercial airlines cross country. Livers have to be transplanted within 8–12 hours, according to the OPTN website. For living donation, the graft needs to be transplanted within about 4 hours, Samstein noted; this poses a logistical challenge for a national organ paired donation program.

"We worked around that with the idea that we would move the donor rather than the organ," he said. The program will require a donor (and a support person) to travel to the recipient's transplant center where the surgery will be performed. While 3 of the 15 pilot paired donation transplant centers are in New York City, the other programs are scattered across the country, meaning a donor may have to fly to a different city to undergo surgery.

"Including the preoperative evaluation, meeting the surgical team, the surgery itself, and follow-up, the donor could stay for about a month. The program offers up to $10,000 of financial assistance for travel expenses (for both the donor and support person), as well as lost wages and dependent care (for the donor only). Health insurance coverage will also be provided by the pilot program, in partnership with the American Foundation for Donation and Transplant.

...

"The 1-year pilot program is set to begin when the program conducts its first match run — an algorithm will help match pairs who are enrolled in the program. About five to seven enrolled pairs would be ideal for the first match run, a UNOS spokesperson said. It is possible that the 1-year pilot program could run without performing any paired transplants, but that's unlikely if multiple pairs are enrolled in the system, the spokesperson said. At the time of this story's publication, the one enrolled pair are a mother and daughter who are registered at the UCHealth Transplant Center in Colorado."

Liver exchange pilot program at UNOS

 In another step for liver exchange, here's the announcement from UNOS, which recently registered its first patient-donor pair:

UNOS launches first national liver paired donation pilot program

"An innovative approach to matching livers to patients in need aims to increase lifesaving transplants by expanding the number of living liver donations. United Network for Organ Sharing (UNOS) has launched the UNOS Liver Paired Donation (LPD) pilot program, the first nation-wide initiative facilitating liver paired donation matches; the project is led by UNOS Labs in collaboration with transplant and donation professionals from across the country.

"More than 10,000 people are currently waiting for a liver transplant, and increasing paired donation can make a difference. “The community recognized a critical need,” said Ruthanne Leishman, who manages UNOS paired donation programs. “While the idea of swapping livers is new, transplant programs have successfully been swapping kidneys since 2002.” Leishman was part of the UNOS team that initiated the Organ Procurement and Transplantation Network (OPTN) Kidney Paired Donation (KPD) pilot program in 2010, at a time when there were fewer living liver donor transplants. Since that time, living liver donations have become safer and more viable, contributing to the development of living liver donation programs throughout the country. There were 603 living liver donor transplants in the United States in 2022.

"The UNOS LPD pilot program includes 15 experienced transplant programs across the country who have together performed hundreds of living liver transplants over the years. “UNOS Labs has collaborated with a team of some of the most respected transplant professionals in the country. Working with this high caliber of transplant professionals has helped UNOS build a strong program that will increase living donor transplants,” said Leishman.

"While some transplant hospitals have swapped livers within their own or neighboring hospitals, the UNOS LPD program now makes it possible to swap livers across the country. The larger pool of potential living donors means candidates can have increased access to living liver donations, and transplant hospitals have the opportunity to grow their living transplants programs through collaboration.

"The first donor and recipient pair registered in the program are at UCHealth Transplant Center in Aurora, Colo., and are waiting for a match.

“The UNOS LPD program has totally shifted our frame of mind,” says Jaime Cisek, Living Donor Coordinator at UC Health Transplant Center. “It used to be that if someone was incompatible because of their blood type, or there was a significant size discrepancy, then there was no point in working them up. Now, nobody is off the table. Now we’re able to consider that there is somebody out there who is compatible and make that swap.”

"The UNOS LPD program offers living liver donors assistance with both medical and non-medical expenses related to donation, such as travel expenses, lost wages and dependent care. This financial assistance was made possible through a partnership with the National Living Donor Assistance Center (NLDAC) and a generous gift from living liver transplant recipient and UNOS financial supporter David Landes. "

The power of kidneys, altruism, and books. (And recommendation of a doctor in the UK)

 Here's a story, about kidneys and about books, in inews.co.uk:

‘It’s a gift with no conditions attached’: Why I donated my kidney to a person I’ll never meet. 250 people die each year in the UK because there are not enough kidneys available. So when GP Richard Armitage discovered altruistic donation was possible, he gave away an organ. By Tom Ough

"Despite being a GP, Richard Armitage had spent most of his career unaware that altruistic donations were possible. In this respect, Armitage, 34, was like many of his colleagues in the medical profession. That changed in 2017. Armitage, visiting the Nobel Laureate Museum Stockholm, bought a book by Alvin Roth, an economist who won a Nobel Prize in 2012. The book was Who Gets What — and Why: The New Economics of Matchmaking and Market Design, and in it Roth wrote how we allocate things within markets that aren’t dictated by money.

"Examples include the allocation of children to schools, doctors to hospitals, and kidneys to people with end-stage renal disease. Roth discussed what is known as non-directed altruistic kidney donations – in short, kidneys donated to strangers. Sitting on the plane home, Armitage read the book with fascination. When he returned to Nottingham he checked the NHS website to see whether non-directed altruistic kidney donation was possible in the UK. It was.

...

"In 2018 altruistic donors began being routinely added to the UK Living Kidney Sharing Scheme (UKLKSS), which oversees this sharing of organs by living donors. Apparently as a result of the move, in 2019 there was a 60 per cent rise in altruistic donations – from 124 to 183. Twenty-eight per cent of kidney transplants are now from living donors.

...

"It seemed a good application of the kind of moral philosophy that Armitage had discovered the same year, 2017, when he read Famine, Affluence and Morality. It is an influential essay in which Peter Singer, an Australian philosopher, argued that the West should be donating far more resources to humanitarian causes.

...

"All of Armitage’s intellectual discovery, including his reading of Roth’s writing on kidney donation, happened in one year, 2017 – also the year that Armitage finished his GP training. It marked the end of “a 10-year head-down slog” that began with the first day of medical school. “After I passed my last exam, it felt like I finally lifted my head up and asked: ‘But why am I doing this?’”

"And so Armitage’s first conversation with his regional kidney transplant centre was followed by an appointment with a Living Donor Nurse, who explained what donation would entail: the testing, the preparation, the surgery. Armitage was invited to speak to his loved ones and consider whether he was ready; it turned out he wasn’t.

"There were several hold-ups. At first, Armitage felt the beginning of his GP career was the wrong time to take weeks off work. Then Covid stalled the NHS’s kidney-sharing scheme. Armitage still wanted to donate his kidney, and successfully underwent a battery of investigations: a renal tract ultrasound scan, an electrocardiogram, chest X-ray, various fasted blood tests, and an X-ray of his kidney. As per the requirements of the donation scheme, Armitage met a clinical psychologist to discuss his state of mind, put the psychologist in touch with a loved one in order to independently assess his state of mind, and met a representative of the Human Tissue Authority to ensure that he was not donating his kidney under duress or for financial gain.

...

"Armitage spent several weeks in Ukraine as part of his work for the charity UK-Med, which sent British medics to deliver emergency healthcare. “That obviously meant I couldn’t continue with the donation process,” he says with some understatement. But when he got home, he told the donor team he was ready. “Can we crack on?”, he asked.

"The operation was on 23 November. Everything was in place; Armitage was part of a chain on which three people with end-stage renal disease were due a kidney.

...

"And just before he was discharged – three days after surgery, having convinced the hospital staff he was ready to take care of himself – he was informed that all the recipients in the chain now had working kidneys. “That was a very meaningful moment that made it all worthwhile,” says Armitage."