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.

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."

Harm reduction is not a panacea: drug use and drug policy in Portugal, and San Francisco

 The Washington Post has a story about Portugal, and the SF Chronicle has one as well. Both stories touch on the tensions between treating drug addicts with respect, and assuring that cities remain safe and livable.  

Here's the Washington Post:

Once hailed for decriminalizing drugs, Portugal is now having doubts  By Anthony Faiola and Catarina Fernandes Martins

"Portugal decriminalized all drug use, including marijuana, cocaine and heroin, in an experiment that inspired similar efforts elsewhere, but now police are blaming a spike in the number of people who use drugs for a rise in crime. In one neighborhood, state-issued paraphernalia — powder-blue syringe caps, packets of citric acid for diluting heroin — litters sidewalks outside an elementary school.

"Porto’s police have increased patrols to drug-plagued neighborhoods. But given existing laws, there’s only so much they can do. 

...

"Portugal became a model for progressive jurisdictions around the world embracing drug decriminalization, such as the state of Oregon, but now there is talk of fatigue. Police are less motivated to register people who misuse drugs and there are year-long waits for state-funded rehabilitation treatment even as the number of people seeking help has fallen dramatically. The return in force of visible urban drug use, meanwhile, is leading the mayor and others here to ask an explosive question: Is it time to reconsider this country’s globally hailed drug model?

“These days in Portugal, it is forbidden to smoke tobacco outside a school or a hospital. It is forbidden to advertise ice cream and sugar candies. And yet, it is allowed for [people] to be there, injecting drugs,” said Rui Moreira, Porto’s mayor. “We’ve normalized it.”

...

" In the United States alone, overdose deaths, fueled by opioids and deadly synthetic fentanyl, topped 100,000 in both 2021 and 2022 — or double what it was in 2015. According to the National Institutes of Health, 85 percent of the U.S. prison population has an active substance use disorder or was jailed for a crime involving drugs or drug use.

"Across the Atlantic in Europe, tiny Portugal appeared to harbor an answer. In 2001, it threw out years of punishment-driven policies in favor of harm reduction by decriminalizing consumption of all drugs for personal use, including the purchase and possession of 10-day supplies. Consumption remains technically against the law, but instead of jail, people who misuse drugs are registered by police and referred to “dissuasion commissions.” 

...Other countries have moved to channel drug offenses out of the penal system too. But none in Europe institutionalized that route more than Portugal. Within a few years, HIV transmission rates via syringes — one the biggest arguments for decriminalization — had plummeted. From 2000 to 2008, prison populations fell by 16.5 percent. Overdose rates dropped as public funds flowed from jails to rehabilitation. There was no evidence of a feared surge in use.

...

"But in the first substantial way since decriminalization passed, some Portuguese voices are now calling for a rethink of a policy that was long a proud point of national consensus. Urban visibility of the drug problem, police say, is at its worst point in decades

...

"A newly released national survey suggests the percent of adults who have used illicit drugs increased to 12.8 percent in 2022, up from 7.8 in 2001, though still below European averages.

...

"Porto’s mayor and other critics, including neighborhood activist groups, are not calling for a wholesale repeal of decriminalization — but rather, a limited re-criminalization in urban areas and near schools and hospitals to address rising numbers of people misusing drugs."

...

"After years of economic crisis, Portugal decentralized its drug oversight operation in 2012. A funding drop from 76 million euros ($82.7 million) to 16 million euros ($17.4 million) forced Portugal’s main institution to outsource work previously done by the state to nonprofit groups,

...

"Twenty years ago, “we were quite successful in dealing with the big problem, the epidemic of heroin use and all the related effects,” Goulão said in an interview with The Washington Post. “But we have had a kind of disinvestment, a freezing in our response … and we lost some efficacy.”

*******

And here are some related paragraphs about San Francisco, in a story in the San Francisco Chronicle about a concentration of drug dealers from Honduras:

THIS IS THE HOMETOWN OF SAN FRANCISCO’S DRUG DEALERS By Megan Cassidy and Gabrielle Lurie |  July 10, 2023

"Like many other U.S. cities, San Francisco shifted years ago to treating drug use more like a disease than a crime. The heavy policing approach of the War on Drugs era failed to slow dealers or decrease demand while overcrowding jails and disproportionately punishing people of color, studies show.

"Now one of the most progressive cities in the nation is fracturing over concerns that it has become too permissive. What to do about the Honduran dealers is a key political issue as a major citywide election approaches in 2024.

"On a weekday afternoon in June, a man in his early 30s lay motionless on a SoMa sidewalk outside the Federal Building. On his right, a dozen users smoked fentanyl and crack cocaine or hung bent at the waist, heads suspended at their knees. To his left, a handful of dealers, cloaked in black but for the space around their eyes, continued selling while a passerby revived the man with Narcan, the nasal-spray antidote to opioid overdoses, and as paramedics arrived to treat him a few minutes later.

“I’m so mad at them for ruining my neighborhood,” said Kevin DeMattia, who owns Emperor Norton’s bar and has lived in the Tenderloin for the past 25 years. “Businesses are dying because people don’t want to come to the Tenderloin.  They’re ruining the neighborhood in so many ways. They’re poisoning people. … They’re this cancer, this aggressive, metastasizing cancer on the Tenderloin — the dealers and the addicts.”

Some Portuguese press on kidney exchange and market design

When I was in Lisbon I gave two talks, and some interviews.  Here's a nice story written after both my talks:
O que tem a economia a ver com transplantes de rins? Tudo [What Does The Economy Have To Do With Kidney Transplants? Everything.]
by SÓNIA M. LOURENÇO (whose sister once took my experimental economics class at Harvard)

Here's a story that followed the first talk, which was part of an honorary degree ceremony.
A ciência económica ao serviço do amor, saúde e felicidade
by Sandra Maximiano
[G translate: Economic science at the service of love, health and happiness]
Here's a video and some photos of the whole event...

And I gave a tv interview in which the interviewer wished to ignore my pre-interview insistence to talk about game theory and market design and the conference in Portugal as opposed to the recession and recovery, and Italy...(but we reached a sort of compromise...)*

Nobel da Economia em entrevista à TVI critica populismos e alerta para mais migração
Alvin Roth referiu ainda que o fenómeno do aquecimento global vai aumentar a migração.
[G translate: Nobel la Economía in interview with TVI criticizes populism and alert for more migration

Alvin Roth also noted that the phenomenon of global warming will increase migration.]
*************

Decriminalization of narcotics in Portugal, an update

Kristof in the NYT on narcotics policy and outcomes in Portugal:
How to Win a War on Drugs: Portugal treats addiction as a disease, not a

"Decades ago, the United States and Portugal both struggled with illicit drugs and took decisive action — in diametrically opposite directions. The U.S. cracked down vigorously, spending billions of dollars incarcerating drug users. In contrast, Portugal undertook a monumental experiment: It decriminalized the use of all drugs in 2001, even heroin and cocaine, and unleashed a major public health campaign to tackle addiction. Ever since in Portugal, drug addiction has been treated more as a medical challenge than as a criminal justice issue.

"After more than 15 years, it’s clear which approach worked better. The United States drug policy failed spectacularly, with about as many Americans dying last year of overdoses — around 64,000 — as were killed in the Vietnam, Afghanistan and Iraq Wars combined.
...
"The number of Portuguese dying from overdoses plunged more than 85 percent before rising a bit in the aftermath of the European economic crisis of recent years. Even so, Portugal’s drug mortality rate is the lowest in Western Europe — one-tenth the rate of Britain or Denmark — and about one-fiftieth the latest number for the U.S."

First Kidney Exchange in Portugal:

Ana Viana writes from Portugal about the first kidney exchange there, which she and other Operations Researchers helped bring about with some integer programming formulations that they've also written about:

"I am happy to inform you that the first successful kidney exchange in Portugal took place in April.
This was performed under the "Program Nacional para Doação Renal Cruzada" (National Program for Kidney Paired Exchanges), supervised by the Portuguese Institute for Blood and Transplantation ( http://ipsangue.org/).

Below you can find a partial translation of news on the subject that I took from Internet.

To help the decision process the program is using a MIP model developed by myself and my colleagues. It's just the beginning but we are very excited with it!

Best regards,

Ana


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"The two patients who received in April the kidneys from two living donors in the first kidney exchange transplant in Portugal crossover are well, said to LUSA the doctor responsible for the double intervention.

Five additional pairs are currently under study and it is possible that very soon additional transplants can be done, said surgeon Alfredo Mota from Centro Hospitalar da Universidade de Coimbra(CHUC).

(...)

The people involved in the first transplant of its kind in Portugal are a brother (donor) and a sister (patient) and husband (donor) and wife (patient).

(…)

The intervention took more than six hours and involved 12 surgeons, 4 anesthesiologists, 12 nurses and 4 technicians, using four operating rooms at the same time.

This type of intervention is "a breakthrough for the country, placing it at the forefront internationally and with greater opportunity to increase kidney transplants," said the same official.

in http://www.tvi24.iol.pt/503/sociedade/transplante-rins-coimbra-transplantes-cirurgia-tvi24/1454468-4071.html

A video can also be found in http://sicnoticias.sapo.pt/pais/2013/04/19/primeiro-duplo-transplante-cruzado-com-dadores-vivos-realizado-em-coimbra "
**************
The video is just over two minutes, and it is in Portuguese, with some good shots of both a nephrectomy and a transplant.

Here is a paper by Ana and her colleagues, which is already available online and is listed as (forthcoming) in November 2013 in the European Journal of Operational Research, Volume 231, Issue 1, 16 November 2013, Pages 57–68:

New insights on integer-programming models for the kidney exchange problem
by Miguel Constantino,  Xenia Klimentova, Ana Viana, Abdur Rais,

Abstract
In recent years several countries have set up policies that allow exchange of kidneys between two or more incompatible patient–donor pairs. These policies lead to what is commonly known as kidney exchange programs.

The underlying optimization problems can be formulated as integer programming models. Previously proposed models for kidney exchange programs have exponential numbers of constraints or variables, which makes them fairly difficult to solve when the problem size is large. In this work we propose two compact formulations for the problem, explain how these formulations can be adapted to address some problem variants, and provide results on the dominance of some models over others. Finally we present a systematic comparison between our models and two previously proposed ones via thorough computational analysis. Results show that compact formulations have advantages over non-compact ones when the problem size is large.

Same sex marriage; recent developments

Same sex marriage continues to provide a window on repugnant transactions, i.e. transactions some people think other people shouldn't engage in.

January 5: New Jersey makes last-minute bid for gay marriage "New Jersey's state Senate will vote on legalizing same-sex marriage this week, officials announced on Tuesday, in a race against the clock before a new governor who opposes the measure takes office."
January 9: Gay marriage in New Jersey, once a sure thing, became tracked for defeat "Thursday’s state Senate defeat of the controversial bill, considered a "slam dunk" to pass just a few months ago, also was a simple case of what happens in the bare-knuckle world of New Jersey politics."

January 8: Same-sex marriage law backed in Portugal's parliament "Portugal's parliament has passed a law to legalise same-sex marriage, but rejected proposals to allow homosexual couples to adopt.
The bill was approved with the support of the governing Socialist Party and other parties further to the left.
...The law has been fiercely opposed by conservatives in the Catholic country."

January 11: Pope says gay marriage threat to creation "Pope Benedict on Tuesday linked the Church's opposition to gay marriage to concern about the environment, suggesting that laws undermining "the differences between the sexes" were threats to creation."

January 12: Historic court battle decides legality of 'gay marriage' in America "Americans could be forced to accept the legality of “gay marriage” in all 50 states of the union, depending on the outcome of an historic federal court battle that began in California yesterday.
The hearing in San Francisco — which was supposed to have been shown on YouTube before a decision by the Supreme Court to block the video feed — comes after 52 per cent of Californians voted to ban same-sex unions in 2008 with a ballot named Proposition 8. "