Operational experience of kidney exchange with the Alliance for Paired Donation (APD)

Like having children, the hard work of market design doesn't end at conception, or even at birth, it's an ongoing process, particularly when it has to interact with the day to day operating procedures (excuse the double entendre) of the participants.

Here's a paper that reports results of some of that experience with the innovative kidney exchange network that began life as the Alliance for Paired Donation (APD), and is now called the Alliance for Paired Kidney Donation (APKD):

The 6‐year clinical outcomes for patients registered in a multiregional United States Kidney Paired Donation program ‐ a retrospective study
Stanislaw M. Stepkowski  Beata Mierzejewska  David Fumo  Dulat Bekbolsynov Sadik Khuder  Caitlin E. Baum  Robert J. Brunner  Jonathan E. Kopke  Susan E. Rees Connie Smith  Itai Ashlagi  Alvin E. Roth  Michael A. Rees
Transplant International, 2019, Volume 32, Issue 8, 839-853.

"Summary

We examined what happened during a 6‐year period to 1121 end‐stage renal disease patients who registered with their willing/incompatible living donors for kidney exchanges with the Alliance for Paired Donation (APD). Of all patients, 65% were transplanted: 37% in kidney paired donation (APD‐KPD, APD‐other‐KPD); 10% with compatible live donors (APD‐LD); and 18% with deceased donors (APD‐DD). The remaining patients were withdrawn (sick/died/others; 15%), or were still waiting (20%). For those patients with a cPRA 0–94%, 72% received a transplant. In contrast, only 49% of very highly sensitized (VHS; cPRA 95–100%) were transplanted. Of the VHS patients, 50% were transplanted by KPD/APD‐LD while 50% benefited through prioritization of deceased donors in the modified kidney allocation system (KAS introduced in 2014). All APD transplanted groups had similar death‐censored 4‐year graft survivals as their relevant Organ Procurement and Transplantation Network (OPTN) groups. It is noteworthy that VHS graft and patient survival results were comparable to less sensitized and nonsensitized patients. All patients should be encouraged to search for compatible donors through different options. Expanding the donor pool through KPD and the new KAS of the OPTN increases the likelihood of transplantation for VHS patients.

Sperm selection

I've blogged before about selection of sperm donors, but here's a story from the NY Times about the selection of sperm itself:

Tinder for Sperm: Even in the Petri Dish, Looks and Athleticism Are Prized
What makes one sperm cell — a blob of DNA with a tail — stand out? The selection process is like a microscopic Mr. America contest.
By Randi Hutter Epstein

“Not that one with the droopy head,” Lo said, pointing to a sperm that looked like a deflated balloon sagging over its string. He rejected a sperm with a thickened midpiece that he described as a “turtleneck,” and said he also avoids sperm with curlicue tails or an extra tail. Slow pokes and non-swimmers are spurned as well.

...
"When a sperm cell reaches the egg, it releases hyaluronidase, an enzyme that dissolves the cumulus, a layer of cells surrounding the egg. Next, the acrosome, a vesicle inside the sperm cell’s head, fuses with the outer layer of the egg, igniting the release of enzymes that ease the route inside. The sperm’s vigorously waving tail provides an extra push to help it through. Once inside, proteins within the sperm cell’s head prompt the oocyte to finish maturing and to release chemicals that harden the outer shell of the egg, preventing other sperm from barging in.

"These days, many leading fertility centers use techniques that allow them to bypass all these steps. Instead, they pick a single sperm and inject it into the egg, a technique called intracytoplasmic sperm injection or ICSI (pronounced ICK-see). ICSI was designed to help men with few or defective sperm, but has become so common that it’s used in more than half* of all I.V.F. procedures.
...
"In addition to having a keen eye for promising sperm, an embryologist must have excellent hand-eye coordination. Even then, learning to identify and successfully catch a single sperm before it swims away can take months of practice, said Lo. “I told my parents those years of video game playing, they’ve really paid off.”

* From The Lancet: "Globally, between 2008 and 2010, more than 4·7 million treatment cycles of assisted reproduction techniques were performed, of which around half involved intracytoplasmic sperm injection (ICSI), leading to the birth of 1·14 million babies.

Compensation of kidney donors in Chile: an estimate of benefits

A look into a possible future, from the December 2019 issue of the Latin American Economic Review:

An analysis of economic incentives to encourage organ donation: evidence from Chile
Parada-Contzen, M. & Vásquez-Lavín, F. Lat Am Econ Rev (2019) 28: 6. https://doi.org/10.1186/s40503-019-0068-2

Abstract
We perform a cost–benefit analysis on the introduction of monetary incentives for living kidney donations by estimating the compensation that would make an individual indifferent between donating and not donating a kidney while alive using Chilean data. We find that monetary incentives of US$12,000 save US$38,000 to health care system per donor and up to US$169,871 when we consider the gains in quality of life of receiving an organ. As one allows the incentives to vary depending on the individual position on the wage distribution, the compensation ranges from US$4214 to US$83,953. Importantly, introducing payments to living donors payable by a third party helps patients who currently may not have access to necessary medical treatment. Therefore, exclusions in access for organs due to the monetary constraints can be prevented.

Removing disincentives to kidney donation, by McCormick et al. in J.Am.Soc.Nephrology

Here's the latest paper in an illuminating series on the costs and consequences of kidney donation and transplantation:

McCormick F, Held PJ, Chertow G, Peters T, and Roberts J.  Removing Disincentives to Kidney Donation: A Quantitative Analysis.  J Am Soc Nephrol 30: ccc–ccc, 2019. doi: https://doi.org/10.1681/ASN.2019030242 is:

https://jasn.asnjournals.org/content/jnephrol/early/2019/07/23/ASN.2019030242.full.pdf

I'm fortunate to be on McCormick's distribution list for email updates on matters related to kidney transplantation, and here's how he introduced and summarized this paper (the table of cost estimates is at the very bottom):

"Friends,

About two years ago, Economics Nobel Laureate Alvin Roth observed that since no-one in the transplant community seemed to be opposed to removing disincentives to kidney donation, the community should unite behind accomplishing that goal.  Our just-published article -- “Removing Disincentives to Kidney Donation: A Quantitative Analysis” -- lays out the consequences of pursuing that consensus objective.  It identifies seven disincentives facing living kidney donors and a single disincentive facing the families of deceased donors. 

The seven disincentives to living donors are listed in column 1 of the table below.  Columns 2 - 5 show estimates of the magnitudes of some of these disincentives made by earlier researchers.  Column 6 indicates our own best estimates of all of the disincentives, and Column 7 specifies the government actions needed to remove these disincentives without violating the National Organ Transplant Act.

Note that the disincentives to living donors total almost $38,000, which is much larger than generally assumed.  This is a substantial deterrent to kidney donation by living donors and goes a long way toward explaining why, even though about 125,400 patients were diagnosed with kidney failure in the U.S. in 2017, most of whom could have benefited from a kidney transplant, only 5,811 patients (4.6%) received a kidney from a living donor.

It follows that if the government could remove all of these disincentives by compensating donors, it could substantially boost kidney donations.  We estimate total donations from both living and deceased donors would increase by about 12,500 per year (63%).  That would cut the waiting list for transplant kidneys (currently numbering about 93,000 patients) in half in about four years.

We estimate removing all the disincentives would require an initial government outlay of only about $0.5 billion per year.  But this investment would quickly be recovered because (a) the long-run cost of transplantation is much less than for dialysis and (b) the government pays most of the costs of both.  So taxpayers would wind up saving a net $1.3 billion each year.  Much more importantly, society would enjoy a net welfare gain of about $14 billion per year, reflecting the great value of the additional donated kidneys to recipients and the savings from these recipients no longer needing expensive dialysis therapy. 

The timing of this article is fortuitous because there is currently great interest in Washington in proposals to remove disincentives to organ donation.  Indeed, on July 10, President Trump issued an executive order stating: “Within 90 days of the date of this order, the Secretary [of the Department of Health and Human Services] shall propose a regulation to remove financial barriers to living organ donation.”

               

Frank

The URL for the just published article: McCormick F, Held PJ, Chertow G, Peters T, and Roberts J.  Removing Disincentives to Kidney Donation: A Quantitative Analysis.  J Am Soc Nephrol 30: ccc–ccc, 2019. doi: https://doi.org/10.1681/ASN.2019030242 is:

https://jasn.asnjournals.org/content/jnephrol/early/2019/07/23/ASN.2019030242.full.pdf

This is the fourth in a series of articles aimed at reducing the kidney shortage and thereby saving tens of thousands of lives each year.  The previous three were:

1.             Held PJ, McCormick F, Ojo A, Roberts JP.  A cost-benefit analysis of government compensation of kidney donors.  Am J Transplant 16: 877–885, 2016.         

This article laid out in great detail (13 Supplements) all of the costs and benefits of compensating kidney donors, showing it would confer a net benefit on society of about $46 billion per year and would save taxpayers about $12 billion per year.

https://onlinelibrary.wiley.com/doi/full/10.1111/ajt.13490

2.       Held PJ, McCormick F, Chertow GM, Peters TG, Roberts JP.  Would government compensation of living kidney donors exploit the poor? An empirical analysis.  PLOS ONE, November 28, 2018. 

This article presented evidence that the poor would not be exploited by government compensation of kidney donors.  Indeed, the aggregate net benefit to the poor would increase to $12 billion per year from only $1 billion per year currently.

https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0205655&type=printable

 

 

3.       McCormick F, Held PJ, Chertow GM.  The Terrible Toll of the Kidney Shortage.   J Am Soc Nephrol 29: 2775–2776, 2018.

This editorial argued that the shortage of transplant kidneys is causing the needless premature deaths of about 43,000 Americans each year (118 per day), the same death toll as from 85 fully loaded 747s crashing each year.  This is a much larger number than had previously been assumed. 

 https://jasn.asnjournals.org/content/jnephrol/29/12/2775.full.pdf

Table 1 Disincentives to Kidney Donation Facing Living Donors
(1) Disincentive		Estimated Magnitudes of Disincentives (Adjusted to U.S. prices and standard of living in 2017)					(7) Proposed Government Action To Remove  the Disincentive
		(2) Gaston          et al.      (2006)	(3) Becker – Elías  (2007)	(4) Rodrigue  et al.    (2016)	(5) Przech  et al.    (2018)	(6) McCormick – Held  et al.  (this study)
1	Travel to, and lodging near, a transplant center	$4,313	--	$1,945	$1,653	$3,122	Expand current NLDAC program to include donors of all income levels
2	Loss of income while recovering from surgery		$3,631	$5,118	$4,368	$5,118	Expand current NLDAC pilot program to include donors of all income levels, providing donors with a tax credit of $5,000
3	Cost of home/ dependent care	--	--	--	$5,592	$5,592	Include cost of home/ dependent care in NLDAC program, providing donors with a tax credit of $6,000
4	Risk of dying during kidney removal	$2,951	$6,723	--	--	$1,860	Provide donors with a $5 million short-term life insurance policy
5	Pain and discomfort of kidney removal	$6,414	--	--	--	$6,414	Provide donors with a tax credit of $6,500
6	Decrease in the long-term quality of life	$23,250	$10,085	--	--	$7,910	Provide donors with an insurance policy covering death, disability, and long-term health problems due to donation
7	Concern that a relative or close friend may need a kidney in the future	--	--	--	--	$7,728	Promise to provide a kidney in the future for a specific person in exchange for a donation now
Total		$36,928	$20,439	--	--	$37,745

Elephant tusks and pangolin scales

Singapore has just seized a big load of contraband materials from endangered species. I had been aware of the black market in elephant ivory, but pangolin scales are new to me.

Singapore seizes record haul of smuggled elephant ivory

"Singapore has made its largest ever seizure of smuggled ivory, impounding a haul of nearly nine tonnes of contraband tusks from an estimated 300 elephants, according to authorities.

"The illegal cargo, discovered on Sunday in a container from the Democratic Republic of the Congo also included a huge stash of pangolin scales – the third such seizure in as many months.

Officials said both the ivory and pangolin scales were in a container declared to be loaded with timber destined for Vietnam and passing through Singapore, a major transhipment hub for global trade."
...

"Pangolins, also known as scaly anteaters, are critically endangered. They are the world’s most trafficked mammals because of their meat, which is considered a delicacy, and their scales, which some believe to have medicinal qualities.

"Elephant ivory is coveted because it can be fashioned into items like combs, pendants and other exotic jewellery.

"The global trade in elephant ivory, with rare exceptions, has been outlawed since 1989 after the population of the African animals dropped from millions in the mid-20th century to about 600,000 by the end of the 1980s."

Will we learn to handle immigration by the time sea levels rise?

Below is a link to a 3-minute video of an interview (in English with Portuguese subtitles) that I gave some time ago on Portuguese TV, but just saw recently...  We talked about populism, immigration, and how we're going to have to learn from our failures today to prepare for future mass movements of people. (It starts with an advertisement, before the interview begins:(


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."

Black markets in organs in Egypt and Bangladesh

Dr.  Frederike Ambagtsheer  points me to the following papers. She is one of the coordinators of the HOTT project, Combating trafficking in persons for the purpose of organ removal.

Disqualified Bodies: A Sociolegal Analysis of the Organ Trade in Cairo, Egypt,  Law & Society Review, Volume 51, Number 2 (2017), by Seán Columb

Abstract: Legislative and policy interventions in response to the organ trade have centered on the introduction of criminal sanctions in an effort to deter organ sales
and/or “trafficking.” Yet, such measures fail to take account of the social and
political processes that facilitate the exploitation of individuals in organ markets
in different contexts. Informed by empirical data, gathered via a series of
in-depth interviews with Sudanese migrants who have sold a kidney, this
paper examines the link between increased urbanization, migration patterns,
informalization, and the emergence of organ markets in the Egyptian-
Sudanese context. The findings illustrate how processes of legal marginalization
and social exclusion leave people vulnerable to exploitation in organ markets.
The prevailing law enforcement response does not capture or respond
to the empirical reality. Accordingly, this paper shifts the emphasis away from
criminalization toward an analysis of the legal barriers and policy decisions
that shape the poor bargaining position of organ sellers. In doing so, it opens
up discussion of the organ trade onto wider critiques that disrupt boundaries
between formality and informality in labor markets and trouble dominant
modes of criminalization.
**********

EXCAVATING THE ORGAN TRADE: AN EMPIRICAL STUDY OF
ORGAN TRADING NETWORKS IN CAIRO, EGYPT, British Journal of Criminology, 2016, doi:10.1093/bjc/azw068
Seán Columb

Abstract
Legislative action in response to the organ trade has centred on the prohibition of organ sales and the enforcement of criminal sanctions targeting ‘trafficking’ offences. This paper argues that the existing law enforcement response is not only inadequate but harmful. The analysis is based on empirical data gathered in Cairo, Egypt, among members of the Sudanese population who have either sold or arranged for the sale of kidneys. The data suggest that prohibition has pushed the organ trade further underground increasing the role of organ brokers and reducing the bargaining position of organ sellers, leaving them exposed to greater levels of exploitation.
**********

And an opposite conclusion:

Against a Regulated Market in Human Organs: Ethical Arguments and EthnographicInsights from the Organ Trade in Bangladesh, Human Organization, Vol. 77, No. 4, 2018
Monir Moniruzzaman

Abstract: While organ transplantation is often highly successful in saving lives, it has created an illicit, but thriving, trade in human organs, including kidneys, livers, and corneas sourced from living bodies of the desperate poor. Based on challenging ethnographic fieldwork with seventy organ sellers, along with a group of recipients, brokers, and doctors, this article explains how organ trade results in violence, exploitation, and suffering against the vulnerable, who sell their live organs on the black market of Bangladesh. In opposition to allowing a “regulated organ market,” I argue that such a market is not a magic bullet that by itself would eliminate deception, coercion, and corruption that exist in the illegal trade of vital organs, nor would it ensure equity, rights, and justice to organ sellers. Instead, a regulated market would exacerbate, institutionalize, and normalize violence, exploitation, and suffering against impoverished populations. I, therefore, conclude that organ trade needs to be condemned, as there are alternative ways to resolve organ shortages. I suggest that government authorities must enact stringent laws, ensure ethical transparency, and encourage cadaveric donations to combat organ trafficking worldwide
********

Here are the earlier reports of the HOTT project.

Kidney exchange needs to be conducted at scale, in the AER by Agarwal, Ashlagi, Azevedo, Featherstone and Karaduman

Market Failure in Kidney Exchange

• Nikhil Agarwal
• Itai Ashlagi
• Eduardo Azevedo
• Clayton R. Featherstone
• Ömer Karaduman


AMERICAN ECONOMIC REVIEW (FORTHCOMING)


Abstract
We show that kidney exchange markets suffer from market failures whose remedy could increase transplants by 30%–63%. First, we document that the market is fragmented and inefficient: most transplants are arranged by hospitals instead of national platforms. Second, we propose a model to show two sources of inefficiency: hospitals only partly internalize their patients' benefits from exchange, and current platforms suboptimally reward hospitals for submitting patients and donors. Third, we calibrate a production function and show that individual hospitals operate below efficient scale. Eliminating this inefficiency requires either a mandate or a combination of new mechanisms and reimbursement reforms.
Forthcoming Article Downloads
• Preview (AEA members only) (966.12 KB)

Celebrating Christos Papadimitriou at 70 at Columbia: September 6-8, 2019.

Christos Papadimitriou, the computer scientist who intersects with market design trhough his big contributions to algorithmic game theory, is being celebrated at Columbia in September:
70 Years Papadimitriou. 
A beautiful journey to the Theory of Computation.