Directed deceased donation of organs for transplant. (Legal in U.S. but not yet in Europe.)

 It is legal in the U.S. for a deceased donor organ for transplant to be directed to a particular recipient, if the recipient is compatible (and otherwise the organs are allocated as in the usual way for nondirected deceased donation.)  Because compatibility is tricky, directed deceased donation (DDD) is rare (but deceased donor kidneys can potentially be used to start a deceased donor initiated chain of kidney exchange).

But in most of Europe, it turns out, DDD isn't legal. (!) Here's a paper by the European Society of Transplantation's European Platform on Ethical, Legal and Psychosocial Aspects of Organ Transplantation. It cautiously argues that maybe this ban is "one thought too many," and that the ban should be lifted so that carefully regulated DDD would be allowed to increase organ donation in Europe and save more lives.

"When is directed deceased donation justified? Practical, ethical, and legal issues," by David Shaw1,2 , Dale Gardiner3, Rutger Ploeg4, Anne Floden5,6, Jessie Cooper7, Alicia Pérez-Blanco8, Tineke Wind9, Lydia Dijkhuizen10, Nichon Jansen10 and Bernadette Haase-Kromwijk10; on behalf of the ESOT ELPAT Working Group on Deceased Donation, Journal of the Intensive Care Society, 2024.

Abstract: This paper explores whether directed deceased organ donation should be permitted, and if so under which conditions. While organ donation and allocation systems must be fair and transparent, might it be “one thought too many” to prevent directed donation within families? We proceed by providing a description of the medical and legal context, followed by identification of the main ethical issues involved in directed donation, and then explore these through a series of hypothetical cases similar to those encountered in practice. Ultimately, we set certain conditions under which directed deceased donation may be ethically acceptable. We restrict our discussion to the allocation of organs to recipients already on the waiting list.

"The persistent shortage of organs available for transplantation demands fair and objective allocation of the scarce available organs, based on preset transparent and regulated criteria. In most European countries, organs from deceased donors are allocated to patients on the organ waiting list by national Competent Authorities.3 The current worldwide norm is that organs donated after death are considered as an unconditional gift to the patients on the transplant waiting list according to the allocation system. This implies that donors (prior to their death), or their family members (after it), cannot determine to whom the available organs will be assigned, nor exclude any potential recipients.

...

"In a few countries, like the United States, United Kingdom, Japan, and recently Australia, directed deceased donation is possible in restricted cases, since national legislation does not prohibit it. In living donation however, directed donation is permitted in many countries, even when there is no genetic or emotional relationship between the donor and the intended recipient. This inconsistency between the living donation- and deceased donation system has been noted.4

"This paper explores whether directed deceased donation should be allowed, and if so under which conditions.

...

"The main argument against DDD is that this violates the  basic principle of an altruistic, unconditional gift to society; allowing DDD may turn out to be a “slippery slope” in the direction of conditional donation and discrimination against particular patient groups. Conditional donation could also reduce public support for the transplantation system, since it could reduce transparency and fairness of the system.

...

"What, then, are the conditions for ethical DDD at the present time?

1. DDD under strict conditions should not be prohibited by legislation or policy.

2. There must be evidence that the donor wanted or would have been willing to direct the organ to a particular family member or close friend.

3. The donor/family should generally not be able to  insist on only donating the organ intended for DDD; where other organs are transplantable there should be a willingness to donate other organs (at least one) to patients on the waiting list to preserve the societal altruistic aspect of donation and diminish the overall effect on the waiting list.

4. DDD should proceed only if there is no patient on the waiting list in extremely urgent need of an organ transplantation to avoid imminent death.

5. DDD should proceed only if there is a reasonable chance of successful transplantation.

6. The intended recipient should be on the waiting list or be under assessment for being included.

"If these conditions are met, the medical team should do their best to facilitate the wishes of the deceased patient and his/her family by enabling DDD to take place. Letting deceased donors direct their organs to loved ones under carefully controlled conditions could further enhance trust in organ donation and transplantation systems, and hence willingness to become a donor."

Kidney Paired Donation in Developing Countries: a Global Perspective

 Vivek Kute and his colleagues argue that one of the lessons from the developing world is that kidney exchange can save many lives, but may need to be organized differently in some ways than in the developed world.

Kidney Paired Donation in Developing Countries: a Global Perspective by Vivek B. Kute, Vidya A. Fleetwood, Sanshriti Chauhan, Hari Shankar Meshram, Yasar Caliskan, Chintalapati Varma, Halil Yazıcı, Özgür Akın Oto & Krista L. Lentine, Current Transplantation Reports (2023)  (here's a link that may provide better access]

Abstract

...

"Despite the advantages of KPD programs, they remain rare among developing nations, and the programs that exist have many differences with those of in developed countries. There is a paucity of literature and lack of published data on KPD from most of the developing nations. Expanding KPD programs may require the adoption of features and innovations of successful KPD programs. Cooperation with national and international societies should be encouraged to ensure endorsement and sharing of best practices.

Summary

KPD is in the initial stages or has not yet started in the majority of the emerging nations. But the logistics and strategies required to implement KPD in developing nations differ from other parts of the world. By learning from the KPD experience in developing countries and adapting to their unique needs, it should be possible to expand access to KPD to allow more transplants to happen for patients in need worldwide."

...

" Despite the advantages of KPD programs, they remain rare in the developing world, and the programs that exist have many differences with those of developed countries. Program structure is one of these differences: multi-center, regional, and national KPD programs (Swiss, Australia, Canada, Dutch, UK, USA) are more common in the developed than the developing world, whereas single center programs are more common

...

"kidney exchanges frequently take weeks to months to obtain legal permission in India despite the fact that only closely-related family members (i.e., parents, spouse, siblings, children, and grandparents) are allowed to donate a kidney [47].

...

"Protecting the privacy of a donor, including maintaining anonymity when requested, is common practice among developed countries but uncommon in developing nations. Anonymous allocation during KPD is a standard practice in the Netherlands, Sweden, and other parts of Europe, but this is not the case in countries such as India, Korea, and Romania [14, 48, 49]. In areas where anonymity is not maintained, the intended donor/recipient pair must meet and share medical information once a potential exchange is identified, but before formal allocation of pairs occurs. The original donor/ recipient pair may refuse the proposed exchange option for any reason and continue to be on the waitlist. In India, nonanonymous KPD allocation is standard practice and has the goal of increasing trust and transparency between the transplant team and the administrative team [14, 49]. Countries differ in philosophical approaches to optimizing trust and transparency, and objective data on most effective practices would benefit the global community."

********

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

######

Update:

Tuesday, September 19, 2023

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

Kidney Exchange in Hong Kong

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

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

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

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

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

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

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

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

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

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

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

...

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

...

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

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

...

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

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

...

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

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

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

**********

Kidney Transplantation Across International Boundaries

 When global kidney exchange was first proposed it met with some hysterical reactions, equating it to organ trafficking.  It is good to see that being replaced by more sober, well informed discussion. Here's a recent paper on how data might be collected and shared.

The Role of Registries in Kidney Transplantation Across International Boundaries  by G. V. Ramesh Prasad, Manisha Sahay, and Jack Kit-Chung, Seminars in Nephrology, Available online 27 December  2022, https://doi.org/10.1016/j.semnephrol.2022.07.001 

Summary: Transplant professionals strive to improve domestic kidney transplantation rates safely, cost efficiently, and ethically, but to increase rates further may wish to allow their recipients and donors to traverse international boundaries. Travel for transplantation presents significant challenges to the practice of transplantation medicine and donor medicine, but can be enhanced if sustainable international registries develop to include low- and low-middle income countries. Robust data collection and sharing across registries, linking pretransplant information to post-transplant information, linking donor to recipient information, increasing living donor transplant activity through paired exchange, and ongoing reporting of results to permit flexibility and adaptability to changing clinical environments, will all serve to enhance kidney transplantation across international boundaries.

"Most KT activity occurs within a country's confines, but the increasing ease of worldwide travel and communication, and the ongoing organ shortage both motivate KT efforts across international boundaries.

...

"This review explores the specific role of patient-based registries in activating and viably maintaining KT activity across official international borders.

...

"Fewer than two thirds of countries have some form of a KT registry. With KT, however, unlike for many other therapies for which registries exist, there are two parties to consider; the donor and the recipient, and their two distinct phases of pre- and post-KT health.

...

"Transplant tourism remains a peril when promoting international transplantation. By contrast, an increasing number of international LDs now travel abroad to the home country of recipients for undergoing their donor nephrectomy.75 This travel for transplantation differs from transplant tourism by referring to the movement of organs, donors, recipients, or transplant professionals across jurisdictional borders in the absence of organ trafficking. Travel for transplantation may be increased through registries.

...

"The third and arguably most important pillar of increasing international transplant activity is to increase LD transplant activity. International comparisons based on donor source readily illustrate the varied relative proportion of DD and LD transplants worldwide.4 Large developed countries such as Canada, the United States, and Australia have developed registries to share LD organs across vast distances,80 with the goal to benefit highly sensitized recipients who have a medically suitable but immunologically incompatible LD, but at the same time maximizing the total number of KT procedures performed. Paired exchange programs and domino transplant chains81 triggered by altruistic nondirected donors best illustrate these accomplishments. Complicated computer algorithms are used to accomplish these two goals. It is important to remember, however, that organs such as kidneys are not to be treated merely as physical objects external to the human body.82 Organ donors are being paired, not organs. International LD transplants are best implemented through a paired exchange,83 as long as strict oversight policies have already been developed to respect human dignity, minimize financial burden, and ensure adequate follow-up care. Involving LICs and LMICs in paired exchange can reduce international access inequities immediately by overcoming both biological and economic imperfections. Linked registries will also permit the expansion of clinical expertise and ensure that donors and recipients are selected appropriately. Linked registries will facilitate regular follow-up evaluation and data sharing. Challenges to international LD transplantation that are best addressed through paired exchange programs include sharing hospital and travel costs, providing health insurance, respecting social and cultural norms, and ensuring administrative oversight including a mechanism for dispute resolution. The close administrative oversight provided by a paired exchange registry serves to ensure LD safety, which becomes especially pertinent when the donor belongs to a less developed country. Travel for transplantation can be encouraged, while morally burdensome transplant tourism and incentivized donation84 can be defeated. For all this to occur, however, an international registry must be much more than simply a clearinghouse for organs."

Australia-New Zealand kidney exchange program

New Zealand and Australia are cooperating with cross-border, international kidney exchange.

The Australian has the story:
The chain gang
By RICKY FRENCH

"Facilitated by the Organ and Tissue Authority, the Australian and New Zealand Paired Kidney Exchange (ANZKX) has now given 42 people new kidneys since that first operation late last year. While paired kidney exchange has happened in Australia since 2010, this is the first true international collaboration. Eleven chains of operations occurred before Covid-19 stalled things in March, but recruitment into the program continues and there are six surgeries planned in Australia for August.
...
"[Linda] Cantwell is the ­Australian Red Cross ANZKX tissue typing scientist. She’s gatekeeper to the matrix of matches needed to link up potential pairs. There are currently 150 donors and 128 potential recipients in the pool, but for some people only one donor in 10,000 might be suitable. A computer program called OrganMatch runs the algorithms based on each person’s unique antibody profile and tissue typing, and potential matches from up to 300,000 different chains are produced."
************

And here's a related story from Australia's Daily Telegraph:

Organ donation hit hard by COVID-19 global pandemic
by Jane Hansen

"The Australian and New Zealand Paired Kidney Exchange was suspended from March 6 and can only begin if and when travel restrictions lift.

"Deceased kidney and live kidney donor programs across Australia were also suspended from March 24 and only recommenced in May, blowing out waitlists.

"Liver, heart, lung, paediatric and multi-organ transplant programs have continued but are subject to case-by-case review by the National Transplantation and Donation Rapid Response Taskforce, which meets weekly to discuss the response to COVID-19, the Organ and Tissue Authority said.

"According to the latest figures for 2019, the families of 548 loved ones transformed the lives of 1444 Australians by agreeing to organ donation.

"In 2019, 1309 had the potential to be organ donors but just over half of those families agreed."

Australia's parliament reports on organ trafficking

Australia's parliament has published a report on organ trafficking in Australia. They didn't find much trafficking there, but recommend that data be more vigorously collected. They report that only one case of (attempted) paid organ donation has come to the attention of the authorities, but that it was successfully prevented, and the intended recipient died. The report ends with a case study of an anatomical exhibit using human cadavers.

Compassion, Not Commerce:An Inquiry into Human Organ Trafficking and Organ Transplant Tourism

Human Rights Sub-Committee, House of Representatives, Joint Standing Committee on Foreign Affairs, Defence and Trade, November 2018, Canberra

(The above link is the the 178 page pdf version, and here's a link to the table of contents and each chapter separately).

"This report examines the global prevalence of human organ trafficking and the scope of Australian participation within this illicit trade.

...

"2.5...The commercial trade in human organs is near-universally prohibited. Despite these prohibitions and restrictions, the illicit commercial trade in human organs has been estimated by the research advisory organisation Global Financial Integrity to be worth between US$840 million and $1.7 billion globally each year.4 Up to 10 per cent of kidney transplants worldwide may now involve commercially traded organs.
...
"3.15 There has been only one reported case to date of alleged organ trafficking within Australian jurisdiction,
 Alleged case of organ trafficking in Australia
"In 2011, an Australian couple were alleged to have brought a woman from the Philippines to Australia, promising her monetary compensation and a working visa in exchange for a kidney donation.
The woman changed her mind upon arriving in Australia. Medical transplant integrity procedures – a pre-operative counselling session at a Sydney hospital –ensured that the situation was discovered before the removal of the organ.
The potential donor was identified as an alleged victim of organ trafficking, resulting in referral to the Australian Federal Police. Due to the death of the prospective recipient, and limitations of the legislation as then in force, the matter did not progress to prosecution."
...
"3.20 International studies have observed the tendency of patients born in a country where organ trafficking may occur, but living outside of that country, to be at a substantially higher risk of participation in transplant tourism.31 This would appear to be equally true in Australia, as Dr Campbell Fraser observed: "...less than five per cent of Australians who are waiting on organs are likely to even consider going overseas. ...most of the Australians who have purchased an organ overseas have ethnic family connections to the countries or regions where they buy their organs—Pakistani Australians tended to go to Pakistan, Egyptian Australians travel to Egypt, and so on."
...
"Mandatory reporting by medical practitioners
3.41 A large number of submissions and witnesses argued in favour of the establishment of a nationwide mandatory reporting scheme for commercial transplants. A Bill before the Parliament of New South Wales, Human Tissue Amendment (Trafficking in Human Organs) Bill 2016, introduced by Mr David Shoebridge MP, seeks to amend the Human Tissue Act 1983 (NSW). The amendment would, inter alia, require medical professionals to report to the NSW Secretary of Health any reasonable belief that a patient has received a commercial transplant or one sourced from a non-consenting donor.
...
"Case study on alleged human tissue trafficking 
‘Real Bodies’
6.1 The Real Bodies commercial anatomical exhibition, on display in Australia during the course of this inquiry, was brought to the attention of the  Sub-Committee by a number of witnesses and is illustrative of an apparent gap in the current legislation. The Real Bodies exhibition involves the commercial display of 20 plastinated human cadavers, and ‘over 200’ plastinated organs, embryos and foetuses.1
Allegations of the trafficking of organs and other human tissue
6.2Mr David Shoebridge MP of the New South Wales Parliament informed the Sub-Committee as to the nature of the exhibition:...
"[they] are real bodies ... they are displayed in quite grotesque circumstances—some of them literally sawn down the middle and presented as a human standing and divided in two so that you can look into the internal parts of them. There are pregnant women. There are multiple fetuses ... put on display for commercial gain ... it is a grossly exploitative process. The proprietors ... have been asked about the circumstances in which these bodies came into their possession, and they have been unable and unwilling to prove that any of the persons on display ever gave their consent."
**********

Here's an earlier post on repugnance to anatomical exhibits using cadavers:

Saturday, March 28, 2009, Markets for (viewing) bodies

Kidney exchange job opportunity in Australia

If you're a transplant professional following this blog from Australia, maybe this could be of interest:

Australian Kidney Exchange (AKX) Coordinator

"Australian Kidney Exchange (AKX) Coordinator

The Royal Melbourne Hospital - City Campus, Parkville

Full Time Fixed Term

Full time, 3 year fixed term contract

Join an award winning health service

Opportunity to manage a national program

An exciting and unique opportunity is available at the Royal Melbourne Hospital for a Program Coordinator to manage the Australian Paired Kidney Exchange program (AKX) in conjunction with the recently appointed AKX Clinical Director.

 The role is supported by the Organ and Tissue Authority (OTA) and the Transplant Society of Australia and New Zealand (TSANZ) and will be based at the Royal Melbourne Hospital in Parkville.  We are seeking a Registered Nurse from the Renal Transplant sector with exceptional clinical, communication and organisational skills. The applicant shall have a demonstrated high level of experience with the AKX program and the capability to work across a broad range of jurisdictions and organisations"

Kidney exchange in Australia--update

A report from The West Australian on a four-pair exchange includes some stats on kidney exchange in Australia:  Amazing kidney swap surgery saves four lives
Cathy O’Leary, Medical Editor - The West Australian on June 1, 2016

"Since the first kidney exchange in WA in 2007 involving two pairs of matched donor-recipients, more than 150 kidney transplants have taken place in the exchange program.

Every three months, a computer program searches the national database to look for combinations that will allow an exchange to occur.

Sir Charles Gairdner Hospital surgeon Bulang He, from the WA Liver and Kidney Surgical Transplant Service, said the biggest exchange had involved six pairs of donor recipients.

There was strict criteria for the donors and recipients to give the best possible success rates.

“It is more complicated the more pairs that are involved, and how many you use depends on the match results and what will give the best outcomes,” Dr He said.

Dr He said transplants were cost-effective because they could prevent years of dialysis.

For details on becoming a donor, visit donatelife.gov.au"

A non-directed donor kidney exchange chain in Australia

Here's a heartwarming longish story about a longish kidney exchange chain in Australia:
7 kidney donors, 7 recipients, 6 hospitals, 3 cities. What could possibly go wrong?  Medical ingenuity and the kindness of a stranger brought together 14 people in a life-changing event.

February 20, 2016

A logistically complicated 14-person kidney exchange chain in Australia--with an aircraft failure--but a happy ending

There was an aircraft failure while one of the kidneys was being shipped:

One altruistic donor, six hospitals hundreds of specialists and seven transplant patient lives saved

"All 14 patients involved in Australia’s first seven-way paired kidney swap have ­recovered well after the transplants at Victoria’s Monash Medical Centre and Royal Melbourne and Austin hos­pitals, in co-ordination with NSW’s Westmead, Prince of Wales and John Hunter ­hospitals.

For five anxious hours, the team battled to overcome a “hiccup” when a malfunctioning aircraft was forced to return to Sydney mid-flight with a Melbourne-bound kidney, but still managed to complete the operations safely on ­November 19.

After three months’ planning, Australian Paired Kidney Exchange Program director Professor Paolo Ferrari said the transplants were “an amazing team effort”.

“It is always an effort when you have two, three, four or, in this case, seven,” Prof Ferrari said.

“Although this ­occurred recently, the actual match-up that told us there was a possibility for these ­patients to have a kidney transplant first came in ­August. Because of the excitement on that day — mostly ­because of the complexity of having all the centres involved and the little hiccup — there was a lot of tension.
...
"At 8am, simultaneous operations began in seven operating theatres in the three Melbourne and three Sydney hospitals, as the first stage to remove the kidneys from the donors.

The second-stage ­operations began at a Melbourne hospital at 12.23pm when an organ couriered across town was taken off the ice and implanted into a lucky recipient.

Five other synchronised transplants occurred progressively across the two cities over the afternoon as the kidneys arrived via Qantas flights and StarTrack couriers.

But a problem with an ­anaesthetic machine delayed one Sydney retrieval and the kidney had to be placed on a flight 30 minutes later than planned.

The problem was compounded when the aircraft developed its own issues mid-flight and had to return to Sydney with its precious cargo.

Five hours later, the kidney finally arrived in Melbourne still in good health, where the Austin Hospital team led by Associate Professor Frank Ierino was able to begin the final transplant at 9.30pm."

Kidney exchange in Australia: steady progress

Here's a cheerful story about a 3-way kidney exchange in Australia,
Paired kidney exchange program gives patients waiting for organ donation new chance at life.

The Australian Paired Kidney Exchange Programme, run by Paolo Ferrari, seems to be making steady progress.

Here's the Australian Paired Kidney Exchange (AKX) programme Biannual Report #5 as of 30 June 2015
"To date the AKX programme has facilitated 121 live donor kidney transplants...
"Several innovations have been introduced or are under way this year. The NOMS-PKE platform has
undergone significant system revision and improvement, increasing its stability and performance; a
clearly defined process for enrolment of altruistic donors was made available to interested participating units and a pathway for hepatitis B core antibody positive donors as well as the corresponding matching option in NOMS have been developed and will be available from the next
match cycle in August 2015. A working party of Australian and New Zealand delegates is exploring
process and policies that may enable collaboration between the two countries with the AKX programme. This is a very exciting prospect that will benefit both Australian and New Zealand
incompatible pairs."
*********

Incidentally, in the  Queen's Birthday 2015 Honours List, Professor Ferrari was made an Officer of the Order of Australia (AO) in recognition of his work in establishing kidney exchange in Australia.

Review of living kidney donor outcomes, in The Lancet

In The Lancet
Volume 385, Issue 9981, 16–22 May 2015, Pages 2003–2013

Living kidney donation: outcomes, ethics, and uncertainty
Dr Peter P Reese, MD,  Prof Neil Boudville, MD, Prof Amit X Garg, MD

Here's the summary:
"Since the first living-donor kidney transplantation in 1954, more than half a million living kidney donations have occurred and research has advanced knowledge about long-term donor outcomes. Donors in developed countries have a similar life expectancy and quality of life as healthy non-donors. Living kidney donation is associated with an increased risk of end-stage renal disease, although this outcome is uncommon  (less than .5 percent increase in incidence at 15 years). Kidney donation seems to elevate the risks of gestational hypertension and pre-eclampsia. Many donors incur financial expenses due to factors such as lost wages, need for sick days, and travel expenses. Yet, most donors have no regrets about donation. Living kidney donation is practised ethically when informed consent incorporates information about risks, uncertainty about outcomes is acknowledged when it exists, and a donor's risks are proportional to benefits for the donor and recipient. Future research should determine whether outcomes are similar for donors from developing countries and donors with pre-existing conditions such as obesity."


And this...
"In many countries, living kidney donation is the only affordable treatment for kidney failure. This is evident across large regions of India and Pakistan, for example, where chronic dialysis is rationed in units supported by government or community donations, or is only available with payments that are prohibitive for most patients. In this respect, chronic dialysis is viewed as a bridge to a life-saving kidney transplant from a living donor. In many developing countries, the infrastructure to procure deceased-donor organs does not exist.

"Unrelated and incompatible donors
Living kidney donation in unrelated donors (eg, friends, spouses, or distant relatives of the recipient) are becoming more common. In the USA, the proportion of living kidney donations from unrelated donors increased from 30% to 57% between 1999 and 2013. Similar trends are evident in Europe, Australia, and New Zealand.

"This rise in unrelated living kidney donation is largely associated with a declining emphasis on close HLA matches between donor–recipient pairs. With advances in immunosuppressive therapy, the longevity and function of the transplanted organ is now less dependent on the genetic donor–recipient relationship than in the past. The rise in unrelated donors has also been helped by so-called kidney paired donation, a strategy used to overcome donor–recipient incompatibility if the transplant candidate has antibodies to the donor's blood or HLA type. Such antibodies greatly increase the risk of donated-organ rejection and, in the case of anti-HLA antibodies, might develop because of previous pregnancies, blood transfusions, or transplants. As shown in figure 2, registries of incompatible donor–recipient pairs have enabled transplantation to proceed through paired exchanges, or donation chains in which each donor provides a kidney to an unrelated compatible recipient. Paired exchange has been helped by the transportation of living-donor kidneys between centres and by non-synchronous transplants, in which one or more donors wait to donate until new pairs enter the chain. In some cases, a transplantation chain begins when an individual with no relationship to any recipient donates a kidney (termed non-directed donation). In 2012, this type of altruistic donation enabled a 30-transplant chain to proceed."

Kidney exchange in Switzerland

Here's a paper reviewing kidney exchange around the world, from an Australian perspective (Paolo Ferrari has been one of the Australian pioneers), and advocating for a national kidney exchange program in Switzerland...

Kidney paired donation: a plea for a Swiss National Programme

Karine Hadayaa,b, Thomas Fehrc, Barbara Rüsic, Sylvie Ferrari-Lacrazd, Jean Villardd, Paolo Ferrarie,f

a Service of Nephrology. Geneva University Hospital, Geneva, Switzerland
b Service of Transplantation, Geneva University Hospital, Geneva, Switzerland
c Service of Nephrology and Histocompatibility laboratory, Zurich University Hospital, Switzerland
d Transplant Immunology Unit and National Reference Laboratory for Histocompatibility (LNRH), Division of Immunology, Allergy and Laboratory Medicine, Geneva, Switzerland
e Department of Nephrology, Prince of Wales Hospital and Clincal School, University of New South Wales, Randwick, Sydney, Australia
f Organ and Tissue Authority, Australia

Summary

Growing incidence of end-stage renal disease, shortage of kidneys from deceased donors and a better outcome for recipients of kidneys from living donor have led many centres worldwide to favour living donor kidney transplantation programmes. Although criteria for living donation have greatly evolved in recent years with acceptance of related and unrelated donors, an immunological incompatibility, either due to ABO incompatibility and/or to positive cross-match, between a living donor and the intended recipient, could impede up to 40% of such procedures. To avoid refusal of willing and healthy living donors, a number of strategies have emerged to overcome immunological incompatibilities. Kidney paired donation is the safest way for such patients to undergo kidney transplantation. Implemented with success in many countries either as national or multiple regional independent programmes, it could include simple exchanges between any number of incompatible pairs, incorporate compatible pairs and non-directed donors (NDDs) to start a chain of compatible transplantations, lead to acceptance of ABO-incompatible matching, and integrate desensitising protocols. Incorporating all variations of kidney paired donation, the Australian programme has been able to facilitate kidney transplantation in 49% of registered incompatible pairs. This review is a plea for implementing a national kidney paired donation programme in Switzerland.

Swiss Med Wkly. 2015;145:w14083

Kidney exchange in Australia passes the 100 transplant mark

"In September the Paired Kidney Exchange Program reached the milestone of 100 transplants."

Here's the story, focused on a six-way chain:
Six-way kidney transplant boosts altruistic donor rates
by Lucie Van Den Berg, Herald Sun, November 22, 2014

Kidney exchange in Spain: now more than 100 transplants

Here's some good news about kidney exchange, from Spain.

The programme was launched in 2009

First 100 cross-over kidney transplants performed in Spain, now becomes standard practice in the country

Wednesday 29 October 2014

Live-donor cross-over kidney transplants, which basically comprise an exchange of kidney donors between two or more donor-recipient couples, are gaining popularity and becoming standard practice in Spain.

​Spain recently performed its 100th cross-over kidney transplant, the acceptance of which in society is increasing every day. According to data from the ONT, a total of 101 cross-over kidney transplants had been performed in Spain at 1 October 2014, 35 of them this year.
54 of the transplant recipients were women and 47 were men.
This type of transplant has increased five-fold in the last four years and now accounts for 11% of all live-donor kidney transplants.
In Spain, the most recent cross-over kidney transplant was performed at the end of September and comprised an exchange between three donor-recipient couples undergoing surgery in Malaga and Zaragoza.
A few days earlier, a transplant chain involving a 'good samaritan' donor had taken place during a complicated process that involved medical teams, donors and recipients from Murcia, Andalusia and Catalonia.
Spain is also seeing an increase in the number of effective 'good samaritan' donors. To date, this type of donor has enabled five cross-over kidney transplant chains to be initiated, involving a total of 17 transplant recipients.

Living-donor kidney transplantation

Cross-over kidney transplants basically comprise an exchange of live kidney donors between two or more donor-recipient couples. The goal is to offer patients with chronic renal failure the chance to receive an organ from a living donor, even when their partner or family members are incompatible. This is a highly developed form of treatment in countries with a high living-donor kidney transplantation rate. This is the case in South Korea, the Netherlands, the United Kingdom, Australia, Canada and the United States, where this type of transplant has been performed for over a decade with excellent results.
The use of increasingly less invasive surgical techniques and the study and care of donors (before, during and after the operation) have enabled this type of transplant to become more common, given that the possible complications for the donor have been reduced considerably and kidney extraction from live donors is now considered a low-risk procedure.
This type of transplant involves a complicated logistics process that requires full cooperation between the central ONT office, the regional transplant coordinators, the hospitals and the medical teams taking part in the operation.
The first cross-over kidney transplant in Spain was performed in July 2009. For this milestone to be achieved, the ONT first worked with a multidisciplinary task force on developing a joint protocol that carefully examines every aspect of a cross-over live kidney transplant.

Register of donor-recipient couples

One fundamental aspect of this programme is the National Register of Donor-Recipient Couples and a computer application that enables possible exchanges between couples on the register to be quickly identified. It should be noted that those patients who register with this programme still remain on the waiting list for a deceased donor.
Since 2009, a total of 340 patients and their respective donors have been registered on this system at one time or another. 114 of those were active at 1 October, which means that possible combinations involving the various couples are currently being assessed. This latest crossover will enable the number of transplants to be increased by the end of the year.
23 hospitals throughout Spain and 16 histocompatibility laboratories are involved in the cross-over kidney transplant programme.

Ranking by hospital

The top hospitals in terms of the number of cross-over kidney transplants performed are as follows: Fundación Puigvert in Barcelona (17); Hospital Clínic i Provincial in Barcelona (15); Hospital Carlos Haya in Malaga (11); Hospital de Cruces in Bilbao ( 9); and Hospital Puerta del Mar in Cadiz (9).
The cross-over kidney transplant is one of the living-donor kidney transplantation methods being promoted by the ONT as part of its Donation 40 strategic plan.
Last year, 382 live-donor kidney transplants were performed in Spain, representing 15% of the total target set by the Spanish National Transplant Organisation.

Recent articles on kidney exchange

On my reading list...

Kidney paired donation: principles, protocols and programs

1. Paolo Ferrari1,2,3,*, 
2. Willem Weimar4,5, 
3. Rachel J. Johnson6, 
4. Wai H. Lim2,7and 
5. Kathryn J. Tinckam8,9
6. 1. Nephrol. Dial. Transplant.(2014)doi: 10.1093/ndt/gfu309First published online:October 7, 2014

-Author Affiliations

1. ¹Department of Nephrology, Fremantle Hospital, Fremantle, WA, Australia
2. ²School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
3. ³Organ and Tissue Authority, Canberra, ACT, Australia
4. ⁴Department of Internal Medicine and Transplantation, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
5. ⁵Dutch Transplant Foundation, Leiden, The Netherlands
6. ⁶NHS Blood and Transplant, NHS, Bristol, UK
7. ⁷Department of Nephrology, Sir Charles Gairdner Hospital, Perth, Australia
8. ⁸Division of Nephrology, Department of Medicine and HLA Laboratory, Laboratory Medicine Program, University Health Network, Toronto, ON, Canada
9. ⁹Canadian Blood Services, Organ Donation and Transplantation,Toronto, ON, Canada

*****

Kidney exchange: Further utilization of donors via listed exchange

• Özgür Yılmaz^, 

College of Administrative Science and Economics, Koç University, Sarıyer, İstanbul, 34450, Turkey

Journal of Mathematical Economics

Volume 51, March 2014, Pages 178–186

---

Abstract

There is a set of incompatible patient–donor pairs and these pairs are matched pairwise. A match between two pairs corresponds to a paired kidney donation, where pairs exchange donated kidneys, or a paired listed exchange, where the first donor donates a kidney to the deceased donor wait-list, the first patient receives the kidney of the second donor, and the second patient receives a priority on the wait-list. We characterize the set of exchanges with the maximum number of transplants from the set of pairs. This characterization generalizes the well-known Gallai–Edmonds Decomposition Theorem.