Frank McCormick points out this recent collection of short pieces in the summer issue of Regulation.
Ideas to Increase Transplant Organ Donation, edited by Ike Brannon, in Regulation / SUMMER 2022
Introduction BY IKE BRANNON
Emulate Israel’s Program of Covering Donors’ Expenses BY JOSH MORRISON AND SAMMY BEYDA
Give Donors a Tax Credit BY SALLY SATEL AND ALAN D. VIARD
Expose OPOs to Competition BY ABE SUTTON
Help People Understand the Benefits of Donation BY MARIO MACIS
A discussion of kidney exchange in Brazil began with this letter to the editor, describing how kidney exchange (aka kidney paired donation) could increase transplantation in Brazil:
Bastos, J., Mankowski, M., Gentry, S., Massie, A., Levan, M., Bisi, C., Stopato,C., Freesz, T., Colares, V., Segev, D. and Ferreira, G., 2021. Kidney paired donation in Brazil-A single center perspective. Transplant International: Official Journal of the European Society for Organ Transplantation.
"Kidney paired donation (KPD) represents a strategy for increasing the number of LDKT, offering an incompatible donor/recipient pair, the chance to exchange with another pair in the same situation [4]. In Brazil, KPD is still prohibited by law. We designed a study to show mathematically how KPD could increase LDKT in a single center in Brazil.
Several comments followed in a forum.. The name of the forum is ""Kidney Paired Donation is necessary in Brazil." But not everyone agrees with that headline.
In particular, a letter to the editor from Mario Abbud-Filho & Valter Duro Garcia concludes that there are too many poor people in Brazil to allow kidney exchange:
"We do not condemn the KPD strategy, but we disagree that it should be proposed in the actual Latin American context, where such great socioeconomic disparities do exist and could fuel organ trafficking and commerce."
That letter drew this rejoinder, in favor of kidney exchange by Marcelo Perosa:
"We do not understand the rationale behind the claim that KPD could stimulate organ trafficking and trade if the LD of an eventual KPD swap would be submitted to the same steps and rigor currently used for unrelated LDKT to be approved.
"The acceptance of KPD is growing around the world. It brings a potential technological development with advanced algorithms and softwares, unites clinicians, surgeons, immunologists in fruitful discussions and analysis of match runs, expanding and exchanging knowledge among multidisciplinary teams that currently work separately. KPD still has the beauty of not dividing, but joining efforts among different centers since the more groups participating, the more patients in the database and more matches are found.
"The main goal of KPD was to increase the chance of KT among highly sensitized (HS) patients, preventing the onerous treatment of desensitization. For a country with more limited economic resources like Brazil, KPD makes perfect sense for always contemplating compatible, cheaper, and more successful transplants."
And a final summation from two of the authors of the original paper:
Bastos, Juliana, and Gustavo Ferreira. "Kidney Paired Donation in Brazil-It is time to talk about it." Transplant International: Official Journal of the European Society for Organ Transplantation (2021), 01 Oct 2021, 34(10):1757-1758 DOI: 10.1111/tri.14025 PMID: 34431143
"The history of kidney transplantation in Brazil began in 1965 when the first related living donor transplant. Since then, Brazil has established a public programme and now has the most extensive public kidney transplantation system in the world. Brazil has established a regulated, standardized and ethical organ procurement system, created awareness of transplantation in physicians and the public, upgraded facilities and standardized medical care, and enforced legislation for transplantation.
"The Aguascalientes document establishes that KPD and altruistic donation are acceptable. Its final recommendations also say that the country must provide access to transplantation based on ethical considerations and protect the most vulnerable population for a healthy transplant system [4]. We are failing to do that when we have a system that does not contemplate highly sensitized recipients, as shown by a recent Brazilian analysis: highly sensitized patients (PRA > 98%) had lower transplant rates (3.7% vs. 31.2%) and higher mortality (HR: 1.09, P = 0.05) in the waitlist when compared to nonsensitized patients [1]."
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Earlier related posts:
I recently blogged about a paper by Robertson and Lavee in the American Journal of Transplantation, looking at surgeries conducted in China before 2015, a period in which China acknowledged that most transplants there were conducted with organs from executed prisoners. Now they summarize their report in a column in the WSJ.
In China, New Evidence That Surgeons Became Executioners. Clinical reports recount scores of cases in which organ donors were alive when operations began. By Jacob Lavee and Matthew P. Robertson
"The Wuhan doctors write: “When the chest of the donor was opened, the chest wall incision was pale and bloodless, and the heart was purple and beating weakly. But the heartbeat became strong immediately after tracheal intubation and oxygenation. The donor heart was extracted with an incision from the 4th intercostal sternum into the chest. . . . This incision is a good choice for field operation where the sternum cannot be sawed open without power.”
"By casually noting that the donor was connected to a ventilator (“tracheal intubation”) only at midsurgery, the physicians inadvertently reveal that the donor was alive when the operation began.
...
"Our findings end in 2015, but we think the abuse likely continues. Medical papers like those we studied were first unearthed by Chinese grass-roots investigators in late 2014, and it would have been simple to command journals to stop publishing the incriminating details after that. While China claims to have stopped using prisoners in 2015, our previous research raises doubts. In a 2019 paper in the journal BMC Medical Ethics, we used statistical forensics to show that the official voluntary-organ donation numbers were falsified, inflating the success of a modest voluntary organ-donation reform program used to buttress the reform narrative.
"Global medical leaders have largely dismissed such concerns. The World Health Organization took advice from Chinese transplant surgeons in the establishment of its anti-organ-trafficking task force—and then installed them on the membership committee. In 2020, WHO officials joined long-time apologists for China’s transplant system, attacking our previous research showing falsified numbers."
...
"Dr. Lavee is the director of the Heart Transplantation Unit at Tel Aviv’s Sheba Medical Center and a professor of surgery at Tel Aviv University. Mr. Robertson is a research fellow with the Victims of Communism Memorial Foundation and a doctoral candidate in political science at the Australian National University."
Medpage Today warns us not to take credit for increases in organ donation that are due to rising numbers of opioid overdose deaths.
'Shocking Mismanagement' in Our Organ Donation System Is Causing Needless Death— OPTN and OPOs are mischaracterizing organ donation data to block system reform by DJ Patil, PhD, Greg Segal, Ebony Hilton, MD, and Lachlan Forrow, MD
"The magnitude of the opioid crisis shows no signs of peaking. New data from the CDC's National Center for Health Statistics show that deaths from the opioid epidemic soared by 50% from October 2019 to October 2021, some of which reflected second-order effects of the COVID-19 pandemic. Similarly, alcohol-related deaths, according to recent CDC reports, were also up by a shocking 25% in 2020, from an average increase of 3.6% per year from 1999-2019.
"What does this have to do with organ donation? Drug overdoses and alcohol-related deaths fall into the subset of deaths that allow for organ donation to occur, so this sharp rise in opioid deaths has driven record-breaking organ donation numbers. That might sound like a silver lining to a very dark cloud, but as is often the case with public health data, the picture is much more complex.
"The government contractors in charge of organ donation -- both organ procurement organizations (OPOs), which oversee local organ recovery, and the organ procurement transplantation network (OPTN), which manages the system -- are hiding behind increases in these deaths of despair to deflect criticism from what the House Oversight Committee has characterized as "shocking mismanagement" in organ procurement.
"In fact, HHS has deemed the majority of OPOs to be failing key performance metrics, contributing to 33 Americans dying every day for lack of an organ transplant. And the Senate Finance Committee is investigating the United Network for Organ Sharing (UNOS), the OPTN contractor, over "serious concerns related to [its] role in overseeing our nation's OPOs, which have been severely underperforming for decades."
...
"We have more organ donors in America not because we have a strong -- or even remotely adequate -- organ procurement system, but because on a per capita basis among wealthy nations, we have many times more deaths in those subsets of deaths that allow for organ donation to occur. This includes 20 to 30 times more opioid deaths, 25 times as many gun deaths, the highest suicides rates, and more than twice as many fatal car accidents -- a number that spiked again precipitously last year."
Here's a collection of events in which people interested in kidney transplantation can participate. I'll give a short talk on kidney exchange in the May 7 event. There are also events tomorrow, April 23, and June 12, as well as ways to help particular transplant candidates who you know.
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Here's a recent report in the American Journal of Transplantation:
OPTN/SRTR 2020 Annual Data Report: Kidney
K. L. Lentine,J. M. Smith,A. Hart,J. Miller,M. A. Skeans,L. Larkin,A Robinson,K. Gauntt,A. K. Israni,R. Hirose,J. J. Snyder First published: 10 March 2022 https://doi.org/10.1111/ajt.16982
Abstract: "The year 2020 presented significant challenges to the field of kidney transplantation. After increasing each year since 2015 and reaching the highest annual count to date in 2019, the total number of kidney trans- plants decreased slightly, to 23642, in 2020. The decrease in total kidney transplants was due to a decrease in living donor transplants; the number of deceased donor transplants rose in 2020. The number of patients waiting for a kidney transplant in the United States declined slightly in 2020, driven by a slight drop in the number of new candidates added in 2020 and an increase in patients removed from the waiting list owing to death-important patterns that correlated with the COVID-19 pandemic. The complexities of the pandemic were accompanied by other ongoing challenges. Nationwide, only about a quarter of waitlisted patients receive a deceased donor kidney transplant within 5 years, a proportion that varies dramatically by donation service area, from 14.8% to 73.0%. The nonutilization (discard) rate of recovered organs rose to its highest value, at 21.3%, despite a dramatic decline in the discard of organs from hepatitis C-positive donors. Nonutilization rates remain particularly high for Kidney Donor Profile Index ≥85% kidneys and kidneys from which a biopsy specimen was obtained. Due to pandemic-related disruption of living donation in spring 2020, the number of living donor transplants in 2020 declined below annual counts over the last decade. In this context, only a small proportion of the waiting list receives living donor transplants each year, and racial disparities in living donor transplant access persist. As both graft and patient survival continue to improve incrementally, the total number of living kidney transplant recipients with a functioning graft exceeded 250,000 in 2020. Pediatric transplant numbers seem to have been impacted by the COVID-19 pandemic. The total number of pediatric kidney transplants performed decreased to 715 in 2020, from a peak of 872 in 2009. Despite numerous efforts, living donor kidney transplant remains low among pediatric recipients, with continued racial disparities among recipients. Of concern, the rate of deceased donor transplant among pediatric waitlisted candidates continued to decrease, reaching its lowest point in 2020. While this may be partly explained by the COVID-19 pandemic, close attention to this trend is critically important. Congenital anomalies of the kidney and urinary tract remain the leading cause of kidney disease in the pediatric population. While most pediatric de- ceased donor recipients receive a kidney from a donor with KDPI less than 35%, most pediatric deceased donor recipients had four or more HLA mis- matches. Graft survival continues to improve, with superior survival for living donor recipients versus deceased donor recipients."
The Covid pandemic reduced transplants, more in some countries than in others. Here's a survey from the Lancet, covering 22 countries (with more authors than countries):
COVID-19 pandemic and worldwide organ transplantation: a population-based study by Olivier Aubert, MD Daniel Yoo, MPH Dina Zielinski, PhD Emanuele Cozzi, MD Massimo Cardillo, MD Michael Dürr, MD Beatriz DomÃnguez-Gil, MD Elisabeth Coll, MD Margarida Ivo Da Silva, MD Ville Sallinen, MD Karl Lemström, MD Karsten Midtvedt, MD Camilo Ulloa, MD Franz Immer, MD Annemarie Weissenbacher, MD Natalie Vallant, MD Nikolina Basic-Jukic, MD Kazunari Tanabe, MD Georgios Papatheodoridis, PhD Georgia Menoudakou, MSc Martin Torres, MD Carlos Soratti, MD Daniela Hansen Krogh Carmen Lefaucheur, MD Gustavo Ferreira, MD Helio Tedesco Silva Jr, MD David Hartell, MA John Forsythe, MD Lisa Mumford, MSc Peter P Reese, MD François Kerbaul, MD Christian Jacquelinet, MD Serge Vogelaar, MD Vassilios Papalois, MD Alexandre Loupy, MD
"In this population-based, observational, before-and-after study, we collected and validated nationwide cohorts of consecutive kidney, liver, lung, and heart transplants from 22 countries. Data were collected from Jan 1 to Dec 31, 2020, along with data from the same period in 2019. The analysis was done from the onset of the 100th cumulative COVID-19 case through to Dec 31, 2020. We assessed the effect of the pandemic on the worldwide organ transplantation rate and the disparity in transplant numbers within each country.
...
"Transplant activity in all countries studied showed an overall decrease during the pandemic. Kidney transplantation was the most affected, followed by lung, liver, and heart."
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Here's a figure of percentage reduction in transplants, overall and by organ, for each country. The U.S. performance was relatively good.
Dr Arthur Matas, the distinguished surgeon who directs the renal transplant program at the University of Minnesota, is tired of seeing his patients die for lack of an organ transplant. Here's his latest plea to the profession.
A Regulated System of Incentives for Kidney Donation—Time for a Trial!, by Arthur J. Matas, MD, JAMA Surg. Published online June 2, 2021. doi:10.1001/jamasurg.2021.1435
"In the past 2 decades, numerous attempts have been made to increase the number of both living donors (eg, nondirected donors, paired exchange) and deceased donors (eg, donation after circulatory death), yet there has been little change in the number of donated kidneys. With increasing need but limited supply, the waiting list for a transplant has grown and waiting times have increased, with substantial negative consequences for patients in the US. In the last 20 years, more than 89 000 candidates in the US died while waiting for a kidney. An additional 54 838 were removed from the waiting list because of becoming too sick to undergo a transplant.1
"A regulated system of incentives for donation could provide a sizable increase in the number of kidneys available for transplant. Yet incentives for kidney donation are illegal in the US. Proposals for a regulated system have existed since the 1980s. But, in addition to other objections to changing the law (discussed later in this article), the constant refrain has been “let’s see if this next innovation works first.” Although the previously described innovations have been important advances, none have significantly reduced the waiting list. Given the ongoing failure to provide the best treatment option for a large segment of the patient population, it is time to move forward with trials of incentives.
...
"Trials of incentives for kidney donation may not be successful. Yet while trials have been prohibited, donation rates have been stagnant and wait-listed patients are dying or becoming too sick to undergo a transplant. The American Society of Transplantation and the American Society of Transplant Surgeons have endorsed moving toward pilot projects of incentives.3 The US government, recognizing the benefits of transplant, recently initiated incentivization of providers for directing kidney failure patients to transplantation9 and provided lifetime coverage for immunosuppressive drugs.10
"It is time to move past the feelings that incentives are wrong to the reality that as a result of a potentially preventable shortage of organs, patients on the waiting list are dying or becoming too sick to transplant. We need to act to determine if we can improve outcomes for these patients while providing benefit to, and not harming, incentivized donors. It is time for professional societies and patient groups to advocate for changing the law to allow trials of incentives for donation."
Philosophers argue differently than economists do, but can sometimes reach similar conclusions. And (like economists) philosophers can sometimes reach very different conclusions from one another. Here's a philosopher who comes out in favor of allowing governments to pay for kidneys, to be allocated to transplant recipients without requiring any payment from them. Among the philosophical counterarguments to a market that must be dealt with along the way are those such as "it is unjust to be paid to do one's duty" (i.e. since the healthy may be argued to have a duty to the ill, we shouldn't try to reduce the shortage of organs by compensating donors because they have a duty to be altruistic...). I don't think this is a line of argument that an economist would feel compelled to respond to.
Why States Should Buy Kidneys, by Aksel Braanen Sterri, Journal of Applied Philosophy, First published: 02 June 2021 https://doi.org/10.1111/japp.12523
ABSTRACT: In this article, I argue we have collective duties to people who suffer from kidney failure and these duties are best fulfilled through a government-monopsony market in kidneys. A government-monopsony market is a model where the government is the sole buyer, and kidneys are distributed according to need, not ability to pay. The framework of collective duties enables us to respond to several of the most pressing ethical and practical objections to kidney markets, including Cécile Fabre's objection that it is unjust to be paid to do one's duty, Simon Rippon's objections that it is harmful to be pressured to sell a kidney and that a market is unfair, Richard Titmuss's crowding out objection, and Ronald Dworkin's objection that body parts should not be among the goods we owe each other.
"By prohibiting monetary compensation, it has been objected that the government takes advantage of people who feel compelled to save someone close to them. Receiving a kidney may also come with a price, a price compounded by how kidney donations are framed within the current system: as priceless gifts and extraordinary acts of sacrifice. When kidney donations are seen in this way, they may impose a burden of gratitude on the recipient; recipients may feel they can never repay such priceless gifts. ‘The tyranny of the gift’ challenges the donor and recipient's equal standing.
...
"Several authors, most notably Charles Erin and John Harris, have defended a government-monopsony model. My primary contribution is to present a novel defence of this model. I argue we have collective duties to provide the sick with kidneys and derivative duties to pay donors. This view provides us with resources to respond to many of the most compelling ethical objections to kidney markets."
During the pandemic, Canadian kidney exchange was suspended, and organ donation was sharply reduced.
The ChronicleHerald has the story:
Organ donations down sharply during pandemic by Andrew Duffy
"Organ donations in Canada have dropped significantly during the pandemic even though COVID-19 has raised the country’s annual death toll.
"Medical officials say organ donations are down 20 to 30 per cent from pre-pandemic levels.
...
"Living donations, including kidney and liver donations, are down 30 per cent, Shemie said, while organ donations from deceased patients have dropped 21 per cent.
"There are a variety of reasons for those declines, he said, starting with the impact of the pandemic on intensive care units (ICUs). Organ donors are identified and managed in ICUs, but those units have been swamped with COVID-19 cases at various times during the past 10 months, he said. Transplant recipients also need to spend time in ICUs recovering from their surgeries.
...
"What’s more, he said, the pandemic has reduced the pool of potential organ donors because the number of people suffering devastating brain injuries has gone down. Lockdown restrictions mean fewer people are driving cars or playing sports with a resultant drop in serious injuries.
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"More than 20,000 Canadians have died from COVID-19 during the past year, but the disease makes them unsuitable as organ donors. “There are a substantial number of people who are dying, tragically, of COVID, but because they have COVID, they can’t become donors,” Shemie said.
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"In Italy, transplant doctors have made limited use of donated organs from COVID-19 patients. In that country, people on the transplant wait list who have survived COVID-19 are eligible to receive organs donated by people who have died with the disease, Shemie said.
...
"Canadian Blood Services recently announced that its Kidney Paired Donation program, an inter-provincial organ sharing effort, is back up and running after a temporary pause. "
The NY Times reports today on an Afghan hospital at which people in need of a transplant can buy a kidney. The report focuses on apparently poor after-care for donors, who are interviewed recovering in nearby apartments. It would be interesting to know more about how that compares to the situation in neighboring Iran, where there is a legal monetary market for kidneys for transplant.
In Afghanistan, a Booming Kidney Trade Preys on the Poor. Widespread poverty and an ambitious private hospital are helping to fuel an illegal market — a portal to new misery for the country’s most vulnerable. By Adam Nossiter and Najim Rahim
"The illegal kidney business is booming in the western city of Herat, fueled by sprawling slums, the surrounding land’s poverty and unending war, an entrepreneurial hospital that advertises itself as the country’s first kidney transplantation center, and officials and doctors who turn a blind eye to organ trafficking.
...
"For the impoverished kidney sellers who recover in frigid, unlit Herat apartments of peeling paint and concrete floors, temporarily delivered from crushing debt but too weak to work, in pain and unable to afford medication, the deal is a portal to new misery. In one such dwelling, a half-sack of flour and a modest container of rice was the only food last week for a family with eight children.
"For Loqman Hakim Hospital, transplants are big business. Officials boast it has performed more than 1,000 kidney transplants in five years, drawing in patients from all over Afghanistan and the global Afghan diaspora. It offers them bargain-basement operations at one-twentieth the cost of such procedures in the United States, in a city with a seemingly unending supply of fresh organs.
...
"On the fourth floor of the hospital, three out of four patients in recovery said they had bought their kidneys.
“I feel fine now,” said Gulabuddin, a 36-year-old imam and kidney recipient from Kabul. “No pain at all.” He said he had paid about $3,500 for his kidney, bought from a “complete stranger,” with an $80 commission to the broker."
...
"“My father would have died if we had not sold,” said Jamila Jamshidi, 25, sitting on the floor across from her brother, Omid, 18, in a frigid apartment near the city’s edge. Both had sold their kidneys — she, five years ago, and he, one year ago — and both were weak and in pain."
This won't be the most memorable thing about the Congress that adjourned in 2020, but it's something positive: up through the end of 2020, inexplicably, Medicare covered only 3 years of immunosuppressive drugs for kidney transplant recipients. This meant that a few hundred patients a year who had no other medical insurance would lose their drugs, and their kidneys, after which Medicare (having refused to pay for the drugs that would have kept the transplanted kidneys working), cheerfully resumes paying for dialysis, which is vastly more expensive (and far less good for the patients). It looks like Medicare is now going to be the insurer of last resort for such patients, and so they will be both healthier and less expensive.
H.R.5534 - Comprehensive Immunosuppressive Drug Coverage for Kidney Transplant Patients Act of 2020 116th Congress (2019-2020)
"To amend title XVIII of the Social Security Act to provide for extended months of Medicare coverage of immunosuppressive drugs for kidney transplant patients, and for other purposes."
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Here's an earlier post, about the previous situation:
The Evening Standard has the story:
Organ transplant waiting list jumps to five-year high due to pandemic, new NHS figures show
by Naomi Ackerman
"The number people waiting for an organ transplant has soared to five-year high as a result of the coronavirus pandemic, new NHS figures have shown.
"NHS Blood and Transplant (NHSBT) said this week that an estimated 6,700 people are currently in need of a transplant across the UK - up from 6,138 prior to the start of the pandemic.
"The health body has estimated that the increase in patients waiting - expected to be the highest since 2015-16 - comes after services were impacted by the effects of the pandemic.
...
"It is hoped that the waiting list can be shortened going forward following the introduction of a new law in May, making organ donation "opt-out" rather than an active choice.
...
"The law will see that families are still consulted before organ donation goes ahead - the reason is why health officials have implored people to make their wishes about donation known to their families.
"NHSBT has said that thousands of "transplant opportunities" have been missed in recent years. In 2018-19, it reported that 835 families declined to support organ donation - with many families saying they did not know what their relative would have wanted."
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HT: Alex Chan
Alex Chan draws my attention to this paper on airline transport of kidneys for transplant:
38 Pages Posted: 6 May 2020
Nearly 5,000 patients die every year while waiting for kidney transplants, and an estimated 18% of procured kidneys are discarded. Such a polarized co-existence of dire scarcity and massive wastefulness has been mainly driven by insufficient pooling of cadaveric kidneys across geographic regions. Although numerous policy initiatives are aimed at broadening organ pooling, they rarely account for a key friction — efficient airline transportation, ideally direct flights, is necessary for long-distance sharing due to the time-sensitive nature of kidney transplantation. Conceivably, transplant centers may be reluctant to accept kidney offers from far-off locations without direct flights. In this paper, we estimate the effect of the introduction of new airline routes on broader kidney sharing. By merging the U.S. airline transportation and kidney transplantation datasets, we create a unique sample tracking (1) the evolution of airline routes connecting all the U.S. airports and (2) kidney transplants between donors and recipients connected by these airports. We estimate the introduction of a new airline route increases the number of shared kidneys by 7.3%. We also find a net increase in the total number of kidney transplants with the introduction of new routes. Notably, the post-transplant survival rate remains largely unchanged, though average travel distance increases after the introduction of new airline routes. Our results are robust to alternative empirical specifications and have important implications for improving access to the U.S. organ transplantation system.
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