Transplants dropped as Covid-19 rose, in France and the U.S.

In France, even more than in the U.S., kidney transplants were considered elective surgery.

In the Lancet:

Organ procurement and transplantation during the COVID-19 pandemic
Alexandre Loupy, Olivier Aubert, Peter P Reese, Olivier Bastien, Florian Bayer, Christian Jacquelinet
Published:May 11, 2020

Here is a set of figures showing "Trends in COVID-19 spread over time in France and the USA and recovery of organs and solid-organ transplantation procedures from deceased donors" (The top two figures are France, the bottom two US)

Here's an updated snapshot of American transplants from UNOS, for all organs:

and for kidneys:

Transplants under lockdown (but beginning to pick up)

Since the beginning of pandemic lockdowns, living donor kidney surgeries in the U.S. have almost ceased (partly because living donor surgeries aren't emergency surgeries, and were being cancelled with all elective surgeries as hospitals readied themselves for covid-19 patients, who materialized in large numbers in some places but not others). Deceased donor transplants have also been down, for a variety of corona-related reasons, which means that donor organs are going to waste.

Here's an aggregate graph from https://unos.org/covid/

And here's a story from Statnews.com

Transplants plummet as overwhelmed hospitals focus on the coronavirus
By ELIZABETH COONEY

"Organ transplant medicine is always a high-wire act, balancing too many people’s needs with too few matches. The coronavirus epidemic has only heightened the significant risks and hoped-for benefits of transplant surgery. Organ donations are down by a third and the health care system itself is in full-blown scarcity, triaging elective surgeries to some unknown future date so only emergency cases find their way into precious operating rooms and intensive care beds. As life-saving as they are, even many transplants are being put off.

"For people who need a transplant, their fate depends on the organ and how sick they are. Pancreas transplants are on hold indefinitely, classified as “life-enhancing,” not life-saving because patients can survive on insulin. Kidney patients who can continue to function on dialysis have been taken off waiting lists while still accruing waiting time for the day when non-urgent transplants resume. Heart patients who are not already in the hospital on mechanical heart-assist devices and who may be able to wait a few weeks will do so.
...
"Prospective transplant recipients can’t have Covid-19, either. The immune-suppression drugs they must take to prevent organ rejection would prevent them from fighting off the virus and make them super-shedders of the virus, placing those around them at hugely increased risk of being infected.

Transplant emergencies mean people who can’t wait another week or even another day. But these patients are also balancing on a knife’s edge: They have to be sick enough to be near death but well enough not to need long ICU stays in hospitals overwhelmed by coronavirus patients who need weeks on ventilators so they can breathe.

“Our ability to do a liver transplant is not always just about the [risk of Covid-19] exposure to the patient,” said David Mulligan, chief of transplantation surgery and immunology at Yale. “It’s also, do we have a bed? Do we have a ventilator to take care of the patient? Can we isolate the patient from other Covid-infected patients? Do we have enough time to do this operation, get them through it, keep them away from Covid, and then get them out of the hospital safely? That’s what we’re shooting for.”
...
"The widespread delays in testing people for the coronavirus have also meant delays in testing organs, said Gabriel Danovitch, medical director of UCLA’s kidney and pancreas transplant program. “When the virus was first detected, we didn’t have the capacity to test all potential donor organs. And a lot of organs were wasted because of concern of possible infection.”

Good things to do after a kidney transplant: save an NHL game as an Emergency Backup Goalie (EBUG)

It turns out that in the NHL there is an Emergency Backup Goalie (EBUG) who is available to either team should the need arise. In this case, the Toronto EBUG saved the game for the visiting (opposing) team.

Emergency goalie completes journey from kidney transplant to NHL game
"Fifteen years ago, the aspiring NHL goalie had a kidney transplant with his mom Mary as his donor. His career was secondary. He was just glad to be alive.

"I never thought I'd play hockey again at that moment," Ayres said Saturday. "To go from that to what happened tonight is just unbelievable, unreal."

"Not only did Ayres play hockey Saturday, he was the winning goalie for the Carolina Hurricanes in a 6-3 victory against the Toronto Maple Leafs at Scotiabank Arena."
*************

42-year-old pulled out of crowd to make NHL debut ... and wins game
"David Ayres was sitting in the stands with his wife at Scotiabank Arena when Carolina Hurricanes goalie James Reimer went down with an injury. Ayers, the on-call emergency netminder in Toronto, left his seat and got half dressed into his gear on the off-chance something might happen to Carolina’s second option, Petr Mrazek.
...
"The next thing the 42-year-old Zamboni driver knew, he was walking down the tunnel and into the spotlight. And not long after, he had an improbable first NHL win. He is the oldest goalie in NHL history to win his regular-season debut.
...
"Ayres has been the emergency goalie in Toronto for about half the games this season and is available to either team. “You kind of think, ‘Oh well how’s this gonna end up?’” said Hurricanes head coach Rod Brind’Amour said. “That’s incredible. That’s why you do this.”

"Ayres was asked what he’ll remember most from the game. “These guys,” he said. “How great they were to me. The crowd in Toronto was unreal. Even though I was on the other team they were so receptive. Every time I made a save I could hear them cheering for me."


HT: Alex Chan

Repeal of motorcycle helmet laws increases deceased donor transplants: Dickert-Conlin, Elder and Teltser in AEJ:Applied

I imagine that a law that anyone who dies while riding a motorcycle without a helmet is automatically considered to be registered as a willing deceased organ donor would increase the voluntary use of helmets.  Here's a paper that investigates the relationship between helmet laws and transplants under current laws, which vary by state and over time.

Allocating Scarce Organs: How a Change in Supply Affects Transplant Waiting Lists and Transplant Recipients
By Stacy  Dickert-Conlin, Todd Elder, and Keith Teltser
American Economic Journal: Applied Economics 2019, 11(4): 210–239 https://doi.org/10.1257/app.20170476

Abstract: "Vast  organ  shortages  motivated  recent  efforts  to  increase  the  sup-ply  of  transplantable  organs,  but  we  know  little  about  the  demand  side  of  the  market.  We  test  the  implications  of  a  model  of  organ  demand using the universe of US transplant data from 1987 to 2013. Exploiting variation in supply induced by state-level motorcycle helmet  laws,  we  demonstrate  that  each  organ  that  becomes  available  from a deceased donor in a particular region induces five transplant candidates to join that region’s transplant wait list, while crowding out    living-donor  transplants.  Even  with  the  corresponding  demand  increase,  positive  supply  shocks  increase    post-transplant  survival  rates."


"We find that transplant candidates respond strongly to local supply shocks, along two  dimensions.  First,  for  each  new  organ  that  becomes  available  in  a  market,  roughly five new candidates join the local wait list. With detailed zip code data, we demonstrate that candidates listed in multiple locations and candidates living out-side of the local market disproportionately drive demand responses. Second, kidney transplant recipients substitute away from  living-donor transplants. We estimate the largest crowd out of potential transplants from living donors who are neither blood relatives  nor  spouses,  suggesting  that  these  are  the  marginal  cases  in  which  the  relative  costs  of  living-donor  and    deceased-donor  transplants  are  most  influential.  Taken together, these findings show that increases in the supply of organs generate demand behavior that at least partially offsets a shock’s direct effects. Presumably as  a  result  of  this  offset,  the  average  waiting  time  for  an  organ  does  not  measurably  decrease  in  response  to  a  positive  supply  shock.  However,  for  livers,  hearts,  lungs, and pancreases, we find evidence that an increase in the supply of deceased organs increases the probability that a transplant is successful, defined as graft survival. Among kidney transplant recipients, we hypothesize that living donor crowd out mitigates any health outcome gains resulting from increases in  deceased-donor transplants.
...
"The  SRTR  data  show  that  multi-listing  is  not  common,  with  only  6  percent  of  all  candidates  choosing  to  do  so  at  a  point  in  time  (online Appendix A describes how we identify multi-listed candidates and spells in the data). However, those who multi-list are systematically different from those who do not, with higher probabili-ties of having attended some college (46 percent versus 36 percent), higher rates of employment (44 percent versus 33 percent), and lower rates of insurance coverage via Medicaid (5 percent versus 11.5 percent). Not surprisingly, they are also more likely to register outside their own or a bordering DSA (12 percent) than candidates with a single listing (4 percent).
...
"the  percentage  of  liver candidates who receive a transplant within 5 years of listing ranged from 30.5 percent in New York to 86.1 percent in Arkansas (Israni, et al. 2012, 70). Similarly, “a striking (but not new) observation is the tremendous difference ... in the percent-age  of    wait-listed  patients  who  undergo  deceased  donor  kidney  transplant  within  5  years,”  varying  from  roughly  25  percent  in  California  DSAs  to  67  percent  in  Wisconsin (Israni, et al. 2012, 13).
...
"in  the  early  1970s  most  states  had  universal  helmet  laws  because  the  federal  government  tied  state  highway  construction  funds  to  such  laws  (Insurance Institute for Highway Safety (IIHS) 2018). By the  mid-1970s, states successfully lob-bied  Congress  to  break  that  link,  and  states  began  repealing  their  universal  helmet  laws (IIHS 2018).
...
"Using    state-level  OPTN  data  from  1994  to  2007,    Dickert-Conlin,  Elder  and  Moore (2011)—henceforth, DCEM—uses 6  state-level repeals and 1 enactment of a universal helmet law to estimate that repealing universal helmet laws increases the supply of organ donors who die in motor vehicle accidents by roughly 10 percent."
*********
This paper is part of an exciting line of work that I've blogged about earlier:

Thursday, August 1, 2019  How much do Kidney Exchanges Improve Patient Outcomes? Keith Teltser in AEJ-Policy

More on the shortage of transplantable kidneys

Here are some snips from the transcript of the Undark podcast,
Solving the Deadly Transplantable Kidney Shortage
This month: A penetrating look at the trials of patients with kidney failure, and the doctors working to make more lifesaving transplants possible.

In the U.S., there are 58 local organ procurement organizations, more commonly known as OPOs. When someone is dying in the hospital with no chance of recovery, doctors will call their local OPO and set the organ procurement process into motion. The donor will go into surgery, their organs will be collected and the OPO will work to distribute the organs to people on the local waitlist. But for years, journalists and independent researchers have said these OPOs are not getting as many organs as they should be. Numerous studies and investigations have claimed OPOS could be recovering more than twice as many organs as they do now, if they were to opt for organs that were less-than-perfect, but likely still good enough.

Just a few weeks ago, a study published in the journal JAMA Internal Medicine looked at discard rates in France and in the United States. It found that OPOS in the U.S. discard at least 3,500 kidneys a year, nearly 20 percent of all deceased donor kidneys, as compared to 9 percent in France. These discarded kidneys are often from donors over 50 years old, or with curable diseases. But it’s hard to tell just how many organs we are missing out on because OPOS self-report their own numbers. And, according to a 2017 study published by the American Society of Transplantation and the American Society of Transplant Surgeons, some OPOS have even manipulated their numbers to appear better than they are.

In July, President Trump signed an executive order to launch an initiative called “Advancing American Kidney Health.” One of the plans is to order Secretary of Health and Human Services Alex Azar to reform the organ procurement process to increase the supply of transplantable kidneys

...

Kaitlin Benz: Highly complex because the transplant surgeons who decide whether or not to accept a less-than-perfect kidney have a lot to consider. The government evaluates the 261 transplant centers in the U.S. by their one-year post-op success rate, which generally ranges between 90 to 95 percent. Ideally, all of a program’s transplanted patients are still alive and well after a year, but that’s just not always going to happen. For their program to be considered successful, doctors need to have a high success rate, which means they have to closely consider how much risk they’re able to take on donor organs. What if they accept a less-than-perfect kidney and the patient dies six months later? Here’s Ron Gill.

Ron Gill: And so, ok, if I’m being measured on a one-year survival, I don’t want to take a kidney that has a greater risk of not working in a year. However, what’s dawning on us all is the comparator can’t be them not working as well. The comparator is the waiting list.

Kaitlin Benz: He says measuring success by one-year survival rates can disincentivize surgeons from even trying on those borderline, suboptimal kidneys that may not be perfect, but might give their patient a few more years of health and freedom than dialysis would.

Ron Gill: It kind of puts a stranglehold on innovation in my view. And many of us in the field feel that if you’re going to hold people to a very high standard and we keep losing so many people on the waiting list every year, what is it going to take to make that change? There are groups that are probably being punished for some of their lesser outcomes because they’ve taken greater risks. And again, we all probably made a mistake if we’re comparing their outcomes with other centers rather than comparing their outcomes with the waiting list.

Alex Azar (Secretary of HH&S) writes about possible new kidney policies

In the New Hampshire Business Review, the Secretary of the U.S. Department of Health and Human Services writes about the recent executive order* concerning caring for kidney patients:

President is providing hope for kidney patients
August 29, 2019  Alex M. Azar

"To prevent kidney disease and provide more treatment options, we’re launching new ways for Medicare to pay for kidney care. For example, nephrologists will soon be able to receive bonuses for preventing the progress of kidney disease in their patients. We’ll give providers a financial stake in getting their patients healthy, as opposed to just paying them for performing more procedures.

"We have also proposed a Medicare initiative to give about half of America’s dialysis providers new incentives to provide patients with dialysis at home or even in their beds at night, rather than having them travel to dialysis centers. Today, only 6.1% of kidney patients in New Hampshire receive dialysis at home, an option that’s much more common in other countries.
...
"To provide more kidney transplants, we will be revising how kidneys are obtained from deceased organ donors, allowing better identification of kidneys for transplant. The executive order also calls for us to expand support for the generous living donors who choose to donate organs. Changing how we identify transplantable kidneys from deceased donors, by itself, could produce life-saving organs for an additional 17,000 Americans each year — including some of the 87 individuals currently waiting for a kidney in New Hampshire.
**************

*See earlier post:

Tuesday, July 16, 2019

President Trump's Executive Order on kidney care

HT: Frank McCormick

Transplantation in China: update

I returned Sunday from a busy and potentially productive trip to China.

Since 2015 it has been illegal in China to use organs from executed prisoners for transplants. The passage of that law was the result of a long struggle between an opaque, often black market system of transplantation, and an emerging transparent system based on voluntary donation.  The transparent system has made, and is continuing to make, enormous strides.

In Shenzhen I visited the China Organ and Transplant Response System (COTRS), run by Dr. Haibo Wang, which organizes and records the data of transplant patients and donors. 

It also collects large amounts of data on all hospital stays at China’s largest hospitals. Together with the National Institute of Health Data Science at Peking University, run by Dr. Luxian Zhang, they are assembling a vast data resource that will have many uses.

In Beijing I also visited the China Organ Transplant Development Foundation, run by Dr. Jeifu Huang, which plays a role in guiding the emerging body of legislation through which transplants are being organized in China with increased transparency.

I also spoke at the Beijing Summit on Health Data Science.

It was a busy week that left me optimistic that we'll see continued big progress in healthcare delivery in China, including but not limited to transplantation.

Some photos were taken...

President Trump's Executive Order on kidney care

On July 10, while I was in China, President Trump issued an executive order touching on all aspects of care for kidney patients, including dialysis and transplantation from both deceased and living donors.

Here's the text of that executive order:
Executive Order on Advancing American Kidney Health
 Issued on: July 10, 2019

Because I anticipated being potentially incommunicado when the executive order was announced, I had filed an op-ed article (giving my proxy to my coauthor Greg Segal for any necessary last-minute edits) to be published on CNN's web site, applauding the order:
The Trump administration's organ donation efforts will save lives
By Alvin E. Roth and Greg Segal
Updated 1:20 PM ET, Wed July 10, 2019

As it happens, a reporter for PBS news hour reached me by phone in China, and so I got to chime in in person:
Trump’s plan to combat kidney disease aims to save money and lives. Can it?
Health Jul 10, 2019 4:39 PM EDT


The part of the executive order that touches most closely on my work on kidney exchange is Section 8:

"Sec. 8.  Supporting Living Organ Donors.  Within 90 days of the date of this order, the Secretary shall propose a regulation to remove financial barriers to living organ donation.  The regulation should expand the definition of allowable costs that can be reimbursed under the Reimbursement of Travel and Subsistence Expenses Incurred Toward Living Organ Donation program, raise the limit on the income of donors eligible for reimbursement under the program, allow reimbursement for lost-wage expenses, and provide for reimbursement of child-care and elder-care expenses."

Regarding deceased donor transplants, Section 7 says

"Sec. 7.  Increasing Utilization of Available Organs.  (a)  Within 90 days of the date of this order, the Secretary shall propose a regulation to enhance the procurement and utilization of organs available through deceased donation by revising Organ Procurement Organization (OPO) rules and evaluation metrics to establish more transparent, reliable, and enforceable objective metrics for evaluating an OPO’s performance.

(b)  Within 180 days of the date of this order, the Secretary shall streamline and expedite the process of kidney matching and delivery to reduce the discard rate.  Removing process inefficiencies in matching and delivery that result in delayed acceptance by transplant centers will reduce the detrimental effects on organ quality of prolonged time with reduced or cut-off blood supply."

***************

Here is some of the news coverage:

Trump signs executive order revamping kidney care, organ transplantation By Lenny Bernstein July 10 (Washington Post);
Trump signs executive order to transform kidney care, increase transplants 
By Jen Christensen and Betsy Klein, CNN Updated 4:21 PM ET, Wed July 10, 2019

This executive order is well worth supporting, and it will need support to achieve the goals it outlines.  The Secretary of Health and Human Services has been directed to do things in fairly broad terms, and we'll have to watch carefully to see the results, which will be interpreted, contested, and implemented through multiple political/regulatory processess

*************

Regarding removing financial disincentives for kidney (and liver) donors, I'm on the advisory board of the federally funded National Living Donor Assistance Center (NLDAC), which has been able, under very tight constraints, to reimburse some donors for some travel expenses (see related posts here).  A minimalist interpretation/implementation of the Executive Order would be to relax some of the constraints on whose expenses and which expenses can be reimbursed, and to increase NLDAC's budget accordingly.  A more expansive interpretation would be to remove some of those constraints so that no donor would have to pay to rescue someone with kidney failure by donating a kidney.

Transplant statistics (through 2016) from the 2018 USRDS annual data report

The United States Renal Data System. 2018 USRDS annual data report  has come out. It seems to cover data through 2016.  Here are the bullet points on transplantation.

Chapter 6: Transplantation

• In 2016, 20,161 kidney transplants were performed in the United States (19,301 were kidney-alone; Figure 6.6).
• Fewer than a third (28%) of kidneys transplanted in 2016 were from living donors (Figure 6.6).
• From 2015 to 2016, the cumulative number of recipients with a functioning kidney transplant increased by 3.4%, from 208,032 to a total of 215,061 (Figure 6.7).
• On December 31, 2016, the kidney transplant waiting list had 81,418 candidates on dialysis, 51,238 (62.9%) of whom were active. Eighty-five percent of all candidates were awaiting their first transplant (Figure 6.1).
• Among Candidates newly wait-listed for either a first or repeat kidney-alone transplant (living or deceased-donor) during 2011, the median waiting time to transplant was 4.0 years (Figure 6.4). This waiting time varied greatly by region of the country, from a low of 1.4 years in Nebraska to a high of 5.1 years in Georgia (Reference Table E.2.2).
• Unadjusted rates of kidney transplantation among dialysis patients had been declining since at least 2006 for candidates for both living and deceased donors. These appear to have stabilized as of 2013, at about 2.5 per 100 dialysis patient-years for recipients from deceased donors and about 1.0 per 100 dialysis patient-years for recipients from living donors (Figure 6.8).
• The number of deceased kidney donors, aged 1-74 years, with at least one kidney retrieved increased by 62.7%, from 5,981 in 2001 to 9,732 in 2016 (Figure 6.19.a).
• The rate of kidney donation from deceased Blacks/African Americans nearly doubled from 2002 to 2016, from 4.5 to 7.9 donations per 1,000 deaths (Figure 6.21.b). This rate overtook that of Whites in 2009. Asians consistently had the highest rate of deceased kidney donation during this time, at about 9 per 1,000 deaths.
• Since 1999, Whites have had the highest rate of living kidney donation, although this has been in decline along with all other races except Asians, who as of 2016 showed rates of living donation essentially equivalent to Whites (Figure 6.16.b).
• Eighteen percent of kidneys recovered from deceased donors were discarded in 2016; this rate has increased slightly since 2010.
• The number of kidney paired donation transplants has risen sharply since 2005, with 642 performed in 2016, which represented 11% of living-donor transplants that year. The rate plateaued during 2012-2014 but increased again in 2016 (Figure 6.18).*
• Since 1999, the probabilities of graft survival have improved among recipients of both living and deceased-donor kidney transplants, over both the short-term (one-year survival) and long-term (five and ten-year survival) (Figure 6.25).
• In 2015, the probabilities of one-year graft survival were 93% for deceased and 98% for living-donor kidney transplant recipients (Figure 6.25).
• In 2015, the probabilities of patient survival within one-year post-transplant were 96% and 99% of deceased- and living-donor kidney transplant recipients (Figure 2.6).
• The one-year graft-survival and patient-survival advantages experienced by living-donor transplant recipients persisted at five and ten years post-transplant (Figures 6.25 and 6.26).

*

Transplantation is one of the casualties of Venezuela's economic crisis

The Pulitzer Center reports:

The Waiting List: Organ Transplants in Venezuela

"The government-managed organ procurement system that facilitated organ donations for transplant patients stopped working in 2017, leaving thousands of patients with no option to receive a transplant.

"The country has seen the number of kidney transplants from deceased donors performed every year drop from a record of 240 in 2012,to only nine in 2017. Government funding for transplant activity has also been curtailed, making it harder for low-income patients to obtain a transplant. This procedure has now become a luxury only the wealthiest patients can afford. "

Kidney donor/sellers in Iran face social stigma--2 papers

The first of these two recently published papers is a report compiling interviews taken some time ago:

Coercion, dissatisfaction, and social stigma: an ethnographic study of compensated living kidney donation in Iran
Sigrid Fry‑Revere,  Deborah Chen,  Bahar Bastani,  Simin Golestani,  Rachana Agarwal, Howsikan Kugathasan, and Melissa Le
International Urology and Nephrology, https://doi.org/10.1007/s11255-018-1824-y, Online, February 2018

Abstract: "This article updates the qualitative research on Iran reported in the 2012 article by Tong et al. “The experiences of commercial kidney donors: thematic synthesis of qualitative research” (Tong et al. in Transpl Int 25:1138–1149, 2012). The basic approach used in the Tong et al. article is applied to a more recent and more comprehensive study of Iranian living organ donors, providing a clearer picture of what compensated organ donation is like in Iran since the national government began regulating compensated donation. Iran is the only country in the world where kidney selling is legal, regulated, and subsidized by the national government. This article focuses on three themes: (1) coercion and other pressures to donate, (2) donor satisfaction with their donation experience, and (3) whether donors fear social stigma. We found no evidence of coercion, but 68% of the paid living organ donors interviewed felt pressure to donate due to extreme poverty or other family pressures. Even though 27% of the living kidney donors interviewed said they were satisfied with their donation experience, 74% had complaints about the donation process or its results, including some of the donors who said they were satisfied. In addition, 84% of donors indicated they feared experiencing social stigma because of their kidney donation."

Here's an excerpt from the discussion of social stigma:  

"Some donors had a general sense that people had negative impressions of donors. One donor pointed out, “When people find out that you have donated, they start looking at you in a different way. They start keeping their distance.” Another donor explained what he thought was going through
people’s heads: “Oh, he sold his kidney, he’s not a good person.”
***********
and here's a paper with reports from an internet survey:

The Social Stigma of Selling Kidneys in Iran as a Barrier to Entry: A Social Determinant of Health
Mohammad Mehdi Nayebpour  Naoru Koizumi
World Medical and Health Policy, Volume10, Issue1, March 2018,
Pages 55-64
"Abstract
Iran is the only country in the world currently with a legalized compensated kidney donation system, in which kidney sellers are matched with end‐stage renal disease patients through a regulated process. From a practical point of view, this model provides an abundance of kidneys for transplantation as opposed to the American model that relies on altruistic donation. The major concern about adopting the Iranian model is the possibility of exploitation. A large body of literature exists on this topic, but few have focused on its cultural aspects. This paper sheds light on the cultural implications of the Iranian model by providing empirical evidence on the social stigmas against kidney sale in Iran. We claim that these stigmas act as barriers to entry to the supply market of kidneys. Due to the conditions created by social stigmas, kidney sellers are forced to consider not only monetary rewards but also cultural factors. Thus, they tend to be more cautious and try to avoid impulsive decisions. Such social stigmas act as unofficial regulatory forces to keep kidney sale as the last resort for the poor, to diversify the supply market by age, and to stretch the decision‐making process in the absence of a mandatory waiting period for transplantation."

from the discussion:
"Our survey demonstrated that an immense amount of negative stigma is directed toward kidney sellers in Iran from society. Comparison of our findings to those reported by Ghods et al. (2001), who studied the actual characteristics of kidney sellers, reveals stark differences between perception and reality. Ghods et al. interviewed 500 kidney sellers in Iran in 2001 (Ghods et al., 2001). The study reports that only 6 percent of them were actually illiterate (while 71 percent of our respondents thought kidney sellers are illiterate), 88 percent had elementary to high school degree (while only 22 percent of our respondents thought kidney sellers have a high school education), and 6 percent had university degrees and above (6 percent of our respondents thought kidney sellers have above high school education). This gap between the actual profile and the perception of kidney sellers indicates that while Iranians benefit from the current policy, they have a grave stigma against it. The other important gap between perception and reality appears in question 5. About 15 percent of people consider that kidney sellers are drug addicts and 56 percent are not sure whether kidney sellers are drug addicts or not. This particular perception is stunning, since by law kidney sellers undergo a series of strict medical tests before becoming eligible for selling. "

Organ donation and transplantation data from around the world

The International Registry in Organ Donation and Transplantation  maintains an informative international database.
Here's a list of the files they show...

WORLDWIDE ACTUAL DECEASED DONORS (PMP) 2013

WORLDWIDE LIVING DONORS (PMP) 2013

WORLDWIDE DCD DONORS (PMP) 2013

WORLDWIDE KIDNEY TRANSPLANT FROM DECEASED DONORS (PMP) 2013

WORLDWIDE KIDNEY TRANSPLANT FROM LIVING DONORS (PMP) 2013

WORLDWIDE LIVER TRANSPLANT FROM DECEASED DONORS (PMP) 2013

WORLDWIDE LIVER TRANSPLANT FROM LIVING DONORS (PMP) 2013

WORLDWIDE HEART TRANSPLANT (PMP) 2013

WORLDWIDE LUNG TRANSPLANT (PMP) 2013

WORLDWIDE PANCREAS TRANSPLANT (PMP) 2013

EUROPE ACTUAL DECEASED ORGAN DONORS (PMP) 2013

EUROPE LIVING ORGAN DONORS (PMP) 2013

AMERICA ACTUAL DECEASED ORGAN DONORS (PMP) 2013

AMERICA LIVING ORGAN DONORS (PMP) 2013

ASIA - OCEANIA ACTUAL DECEASED ORGAN DONORS (PMP) 2013

ASIA - OCEANIA LIVING ORGAN DONORS (PMP) 2013

AFRICA - MIDDLE EAST ACTUAL DECEASED ORGAN DONORS (PMP) 2013

AFRICA - MIDDLE EAST LIVING ORGAN DONORS (PMP) 2013

Transplant surgeons meet in Hong Kong amid questions about China's continued use of organs from executed prisoners

The NY Times has the story: Debate Flares on China’s Use of Prisoners’ Organs as Experts Meet in Hong Kong

It discusses a recent article in the American Journal of Transplantation:
Transplant Medicine in China: Need for Transparency and International Scrutiny Remains by T. Trey, A. Sharif, A. Schwarz, M. Fiatarone Singh, and J. Lavee

Here's the abstract of the article:
"Previous publications have described unethical organ procurement procedures in the People's Republic of China. International awareness and condemnation contributed to the announcement abolishing the procurement of organs from executed prisoners starting from January 2015. Eighteen months after the announcement, and aligned with the upcoming International Congress of the Transplantation Society in Hong Kong, this paper revisits the topic and discusses whether the declared reform has indeed been implemented. It is noticeable that China has neither addressed nor included in the reform a pledge to end the procurement of organs from prisoners of conscience, nor have they initiated any legislative amendments. Recent reports have discussed an implausible discrepancy of officially reported steady annual transplant numbers and a steep expansion of the transplant infrastructure in China. This paper expresses the viewpoint that, in the current context, it is not possible to verify the veracity of the announced changes and it thus remains premature to include China as an ethical partner in the international transplant community. Until we have independent and objective evidence of a complete cessation of unethical organ procurement from prisoners, the medical community has a professional responsibility to maintain the academic embargo on Chinese transplant professionals."
************

The NY Times story includes this:
"In an interview conducted on the messaging app WeChat, Huang Jiefu, a senior Chinese transplant official and a former deputy minister of health, appeared to defend the changes but simultaneously acknowledge they were far from perfect.

“We have finished walking the first step of a long march of 10,000 li, the task is heavy and the road far, but we are walking on a path of light,” he wrote. "

Desensitization prior to kidney transplantation

From the American Journal of Transportation, some discussion of desensitizing patients to get around blood type barriers to kidney transplant:

Economic Impacts of ABO-Incompatible Live Donor Kidney Transplantation: A National Study of Medicare-Insured Recipients
Axelrod et al

ABO-Incompatible Kidney Transplants: Twice as Expensive, Half as Good
Held and McCormick

The black market for kidneys in South Asia

It sounds like you can buy a kidney in India, and have it transplanted in Sri Lanka. But it isn't clear how large the market is compared to the vast worldwide demand or even to the number of legal kidney  transplants around the world (in the US we have about 17,000) a year). When I say it isn't clear, I mean that the story is based mostly on anecdotal information from market participants...
However I can supply an additional anecdote about social media: almost every morning as I get ready to publish my blog post for the day, I delete spam "comments" on previous posts about kidneys, offering phone numbers to call if you want to sell yours...

Al Jazeera has the story:
Need a kidney? Inside the world’s biggest organ market
The illicit kidney trade in South Asia has exploded as brokers use social media to find donors.

""If you have the money and want it fast, you come here. I will find you a donor and you can go home with a new kidney in a month," Vikas told Al Jazeera, speaking on the condition that his real name not be published.

"According to the World Health Organisation (WHO), South Asia is now the leading transplant tourism hub globally, with India among the top kidney exporters. Each year more than 2,000 Indians sell their kidneys, with many of them going to foreigners.

"This gaping hole between demand and the legal supply of kidneys is being filled by what may be the world's biggest black market for organs, which criss-crosses India, Nepal, Bangladesh, Pakistan, Sri Lanka and Iran.

"However, in recent years, Sri Lanka's capital Colombo has become the new nerve centre of this network, where most transplant operations are carried out. In recent years, Sri Lanka has attracted kidney buyers from as far afield as Israel and the United States.

"This development came after India tightened its rules on organ exchanges in 2008, following the arrest of a "kidney kingpin" running one of the world's largest kidney trafficking rings. Many donors are also taken to Iran, the only country in the world where selling kidneys is legal, though not to foreigners.

"Anurag, one of the top names in brokering circles, told Al Jazeera that many agents in India and Bangladesh were working at the behest of individual doctors or hospitals based in Colombo who offered "complete packages" to foreign recipients, with prices ranging from $53,000 to $122,000.

"It covers everything - hospital bill, doctor's fee, payment to the donor, his travel and accommodation cost, and, of course, broker's commission. This is the best way because it saves everybody time and hassle," Anurag - who also wanted his real name withheld to avoid trouble - told Al Jazeera from Sri Lanka.

"Although the illicit racket has flourished since the 1990s, social media has catapulted the trade into a new dimension. Brokers like Vikas and Aadarsh are openly lurking on dozens of Facebook pages fashioned as kidney and transplant support groups.

HT: Mohammad Akbarpour

Organjet versus regional transplant lists

Forbes discusses the unequal waiting times for deceased donor organs caused by the fact that transplant waiting lists are organized regionally.

Your New Liver Is Only A Learjet Away: First Of Three Parts

"Tayur’s initial business model for OrganJet was quite simple. OrganJet would charge a modest fee to help clients figure out which transplant programs would be likely to shorten their waiting time for an organ. Clients could then sign up to have access to an on-demand flight, in case one of those transplant programs called up with an available donor. Having a flight at ready disposal is critical because many transplant programs require patients to arrive within six hours after an organ becomes available, or they pass the organ on to the next person on the list. The six hour requirement exists because in organ transplantation, donor organs need to be placed into recipients in a timely manner or the organs accumulate irreversible damage. Thus, if a patient on the transplant waiting list in, say, Pittsburgh cannot make it there in time, the transplant team will call another candidate until it finds one that can make use of the organ.

Excited about his chance to address an important social problem, Tayur began working through the details of his business plan, issues such as how many jet companies he would need to contract with and how much money he would need to charge customers for a given flight. “I envisioned OrganJet as an opportunity to make some money and save some lives at the same time,” Tayur told me, words not that different from what honest medical school applicants would tell interviewers about their career choice. The fees he charged customers for these flights would not only cover the charge of paying for the pilots and the fuel, but would include a surcharge that would be the source of OrganJet’s profits.

Tayur was excited about his idea, but the more people he bounced his business plan off, the more pushback he received. In particular, many people told Tayur his idea would only promote greater unfairness in the transplant system, by further disadvantaging people who lacked the financial resources to pay for OrganJet’s services. Tayur thought he could minimize this problem by convincing health insurance companies to pay for the flights, but his critics pointed out that many low-income patients wouldn’t be able to afford such generous insurance.

Tayur realized his new company needed to become two new companies. He had already incorporated OrganJet as a nonprofit entity in May 2011. So in July of 2012 he started a second company, GuardianWings, a tax-exempt nonprofit that raises funds to cover flight costs for low-income patients. His vision was now clear – he would work to overcome geographic inequities in transplantation one patient at a time, giving everyone a fair shake at life-saving treatments even if they were not wealthy CEOs."
...
"Neither Medicare nor Medicaid currently pays for OrganJet’s services, and it is too early to tell whether private insurers will embrace OrganJet’s prices. Tayur, the CEO of OrganJet, is still negotiating with insurance companies on a case-by-case basis. He is also negotiating with large companies that self-insure their employees, presenting them with results of statistical analyses he has conducted which demonstrate that OrganJet’s services could save them money: “It would get their employees off dialysis sooner, not only improving their quality of life in the process, but also allowing them to return to work sooner, with greater productivity.”"

Compensating donors for a different kind of transplant

You Can Sell Your Poop For $13k Per Year And Help Science

"In the spirit of one man’s trash being another man’s treasure, the non-profit companyOpenBiome is actually paying for stool samples in order to create lifesaving fecal transplant treatments for those infected with Clostridium difficile, a bacteria which is highly resistant to antibiotics.

Infections of C. difficile result in severe diarrhea, hospitalizing 250,000 Americans each year and causing about 14,000 deaths. It can actually come about after using antibiotics for too long, which ties into what makes it exceptionally difficult to treat. The patient’s gut microbiota is nearly wiped out, and conventional probiotics are not sufficient to replace them. 

The best treatment for C. difficile infections is a fecal transplant, and yes, it has traditionally been as horrible as it sounds. Doctors have relied on highly invasive nasogastric tubes (NG tubes) or colonoscopies to put donor fecal matter into the gut of their infected patients. As difficult as the process may be, it is highly successful. A new method uses capsules of frozen fecal matter, which thaw out in the body and release the contents in the small intestines. The success rates of the capsules is comparable to traditional treatments, around 90 percent. 

These frozen fecal capsules are OpenBiome’s wheelhouse, as they collect and screen stool samples, and turn them into the ready-to-administer treatments for hospitals. Of course, the feces needs to be sourced from somewhere. OpenBiome pays donors who are committed to providing multiple samples per week.

Though everybody may do it, not everyone is an ideal candidate to get paid to do it. First and foremost, OpenBiome needs donors to be near their lab in Medford, Massachusetts to join the registry to donate. Candidates who meet the requirements for age, BMI, and health pre-screening questions are then invited to get blood and stool testing. Donations are then made at least four times per week for 60 days, when each donor is re-evaluated. Once the next round of blood and stool tests come back clear, the previous samples are then converted into capsules and sent to patients across the country.

The going rate is $40 per donation, with a $50 kicker for those who come five days a week. This translates into $250 per week, or $13,000 per year. OpenBiome tries to make the experience as fun as they can by offering prizes to donors who make the most donations, provide the biggest sample, etc. However, there’s no word on if OpenBiome offers a fun sticker to show off your donation to friends and family, such as the “Be nice to me, I gave blood today” badge handed out by the Red Cross. "

Deceased donor waiting times, and OrganJet

Here's an article by Daniela Lamas in the Atlantic on waiting times by region, and how to register at a transplant center outside of your home region:

A Private Jet Is Waiting to Take You to Your Kidney Transplant
"Waiting lists for donations can vary dramatically between cities--so OrganJet provides planes to fly patients to their new organs."

The article focuses on Sridhar Tayur, and OrganJet: my previous posts on OrganJet are here.

How to arrange an organ transplant in China

It appears that you can buy one here: Omar Healthcare Service, Tianjin, China

New transplant statistics from Israel

The Jerusalem Post has the story: Israel Transplant Center reaches all-time high in number of transplants, potential donors

"Last year brought good news to the Israel Transplant Center and to 392 people whose lives were saved by deceased and live donors.

There was an increase by 24 percent of live kidney donors; 56% of family members of deceased agreed to donate organs; 90,000 more people signed donor cards; and almost half of those who received organs from deceased donors were advanced in the queue because they had signed a donor card.

In addition, the first transplant of a small intestine was successfully performed and 637 corneas were also transplanted in 769 patients (some were split into parts), giving recipients the gift of sight, the center announced on Sunday.

Of the 143 requests to families whose loved ones suffered lower-brain death, 80 of them consented to give one or more organs. The families said it was important to save the lives of others, while the most common reason for refusal were “religious” – even though modern Orthodox clergymen say donating fulfills a very important positive commandment – and the concern that the body to be buried would “not be whole.”

The figure of 392 donated organs was the highest ever.

Of these, 104 of the donors were from live relatives (who gave a kidney or liver lobe), and the rest were from altruistic families who gave their loves ones’ organs.

Of 248 organs from deceased donors, 109 of the recipients had to wait less because they had previously signed up as potential donors. The number of patients waiting to receive a lifesaving organ dropped from 1,114 in 2012 to 1,075 in 2013.

Of the 109 recipients who were advanced in the queue, four received hearts, 25 received lungs, 13 received livers and 67 received kidneys.

Of the deceased donors, 112 were donors of kidneys, 10 of kidney-pancreases, 5 double kidneys (usually from elderly donors), 57 of livers, one liver and kidney, 13 hearts, 24 double lungs, 25 single lungs and one “domino” donation of a liver (when an organ or part of one is removed for the primary purpose of a person’s medical treatment and may prove suitable for transplant into another person)."

HT: Jay Lavee