Revisiting the Israel-UAE kidney exchange

 I spoke in Jerusalem yesterday about kidney exchange, and one of the things I talked about is the kidney exchange between Israel and the UAE.  At the time (summer 2021) I was careful not to blog about anything beforehand, because there were delicate political issues, and so I didn't start to tell the story until I returned from the UAE, and I waited until the story appeared in a U.S. newspaper.

I never got around to linking to the stories in the Israeli press, so here are two. via Google translate.

From ynet:

Historical transplant: Shani's kidney will be transplanted into an Abu Dhabi resident, her mother will receive a kidney in Israel  Shani Markowitz of Nesher is expected to go down in history this week as the first Israeli to have her kidney transplanted into the body of a resident of Abu Dhabi. The transplant will be carried out as part of an international crossover program in which an Israeli citizen will also receive a kidney from a resident of the United Arab Emirates. Markowitz: "My goal is for my mother to receive a kidney in exchange." Prof. Eitan Mor, Director of the Sheba Transplantation Center: "It is possible that after the Corona we will meet face to face"  by Adir Yanko, 24.07.21 

and from Mednews Israel

Israel Kidney Crossing Abu Dhabi

"Medical fruits of the peace agreement with the United Arab Emirates: a kidney, donated at the Sheba Hospital, was flown and transplanted in Abu Dhabi, in exchange for a kidney donated in Abu Dhabi and transplanted at the Rambam Hospital

"July 28, 2021 was a historic day for the State of Israel, the Ministry of Health, the National Center for Transplantation and the kidney patients and their families: thanks to the transfer of a kidney in a crossover, from Israel to Abu Dhabi and from Abu Dhabi to Israel, three transplants were performed on this day, two of them in Israel

...

"Dr. Tamar Ashkenazi, director of the National Center for Transplantation and the initiative  [said]of the cooperation: "The program was theoretically born from the moment the Abraham Agreement was signed in September 2020, and from the day the agreement between the Ministries of Health was signed on April 21, 2021, we began to move rapidly towards the agreement on the crossbreeding program. An American company assisted in the agreement which accompanies the program in the Emirates, APKD, along with laboratory data provided to us by the company. The matches were found by Prof. Itai Ashlagi, an Israeli researcher at Stanford, with the help of software he developed and even donated to us. Prof. Ashlagi accompaDr. Tamar Ashkenazi, director of the National Center for Transplantation and the initiativenies us in all the international crosses together with Rona Simon from the transplant center. A great feeling of satisfaction accompanies us. We turned to the next crossovers and to find more matches"

 #########

Here are all my posts on that and related kidney exchanges

Bring Them Home

 I'm in Israel this week, where there are constant reminders of the hostages

at Ben Gurion airport

at Symphony hall

The Impact of prioritization on kidney and liver allocation in Israel

   Israel's  Organ Transplantation Law grants some priority on waiting lists for transplants to candidates who are first-degree relatives of deceased organ donors (i.e. whose family has given permission for someone's deceased organ donation) or who previously registered as organ donors themselves. (There's also a tiny priority for relatives of people who signed organ donor cards...)  Here are two papers that looks at the effect of those priorities on kidney and liver transplants, and how they interact with other priorities on waiting lists for Israeli organs.  

The first paper, on kidneys, concludes that the priorities are effective in reducing waiting time to transplant, and suggests that perhaps these priorities should not be so large compared to other existing priorities (e.g. for time on dialysis), or for priorities that could be established, e.g. for highly sensitized patients (who get high priority in the U.S., for example.)

Mor, Eytan, Meitar Bloom, Ronen Ghinea, Roi Anteby, Ronit Pasvolsky-Gutman, Ron Loewenthal, Ido Nachmani, and Tammy Hod. "The Impact of the Donor Card Holder Prioritization Program on Kidney Allocation in Israel." Transplantation (2024): 10-1097.

Abstract

Background: Since 2014, as part of a priority program within the Israeli Transplant Law, additional points were given to waitlisted candidates with donor cards. We assessed the impact on deceased donor kidney allocation.

Methods: This study enrolled all patients older than 18 y who underwent deceased donor kidney transplantation (January 2016–December 2019). Data were obtained from the National HLA Tissue Laboratory registry at the Sheba Medical Center. Patients were grouped by donor card status (ADI group) (not signed, 0 points; relative signed, 0.1 points; patient signed, 2 points; and relative donated, 9 points). The primary outcome was waiting time until kidney transplantation with and without the additional score.

Results: Four hundred forty-four patients underwent kidney transplantation during the study period: 281 (63%) were donor card holders (DCH) and 163 (37%) were not DCH. DCH with extra points waited 68.0 (±47.0) mo on average, compared with 94.6 (±47.3) mo for not DCH (P < 0.001). Donor card signers had a shorter time until transplant in a multivariable model. Without extra points, 145 recipients (32.6%) would have missed organs allocated to higher-scored candidates. Allocation changes occurred in 1 patient because of an additional 0.1 points, in 103 candidates because of an additional 2 points, and in 41 candidates because of an additional 9 points.

Conclusions: Additional DCH scores improved allocation and reduced waiting time for donor card signers and those with donating relatives. To enhance fairness, consideration should be given to reducing the score weight of this social criterion and raising scores for other factors, especially dialysis duration.

##########

There are many fewer liver transplants than kidney transplants, and the effect of priority is less clear:

Ashkenazi, Tamar, Avraham Stoler, and Eytan Mor. "The effect of priority given to donor card holders on the allocation of livers for transplant—evidence from 7 years of the Israeli priority program." Transplantation 106, no. 2 (2022): 299-307.

Abstract

Background. The Israeli Transplant Law grants priority in organ allocation to patients signing a donor card. Liver transplant candidates get additional 2 points on their Model for End Stage Liver Disease score for signing a donor card, 0.1 points for a relative holding a card, and 5 points if a relative donated an organ. We studied the effect of the priority program on waiting list mortality and allocation changes due to priority.

Methods. Using Israeli Transplant data of 531 adult liver transplant candidates with chronic liver disease listed between 2012 and 2018 we compared waitlist mortality and transplant rate of candidates with and without priority. Then we analyzed liver allocations resulting from additional priority points and followed outcome of patients who were skipped in line.

Results. Of the 519 candidates, 294 did not sign a donor card, 82 signed, 140 had a relative sign, and for 3, a relative donated an organ. The rates of waitlist mortality in these 4 groups were 22.4%, 0%, 21.4%, and 0%, respectively, and the transplant rates were 50%, 59.8%, 49.3%, and 100%, respectively. Of the 30 patients who were skipped because of priority, 24 subsequently underwent transplant, 2 are on the waiting list, and 4 died within 0.75, 1.75, 7, and 17 mo.

Conclusions. The 2 points added to the Model for End Stage Liver Disease score were associated with lower waitlist mortality and higher transplant rate for candidates signing a donor card without significantly affecting access to transplant during allocation. Further research and consideration of optimal policy when granting priority for candidates signing a donor card should continue.

###########

Earlier:

Stoler, Avraham,  Judd B. Kessler, Tamar Ashkenazi, Alvin E. Roth, Jacob Lavee, “Incentivizing Authorization for Deceased Organ Donation with Organ Allocation Priority: the First Five Years,” American Journal of Transplantation, Volume 16, Issue 9, September 2016,  2639–2645. 

 Stoler, Avraham, Judd B. Kessler, Tamar Ashkenazi, Alvin E. Roth, Jacob Lavee, “Incentivizing Organ Donor Registrations with Organ Allocation Priority,”, Health Economics, April 2016 Volume: 26   Issue: 4   Pages: 500-510   APR 2017

Eyal Winter's historical novel "Anna's Children"

 Eyal Winter, the eminent Israeli economist (who was a postdoc of mine a lifetime ago, in Pittsburgh), has published a novel called Anna's Children, about his aunt, who tried to rescue 22 orphans after Kristallnacht. It's discussed in this interview in Haaretz (and there is another link to the article here if the one below doesn't work).

'The Idea That Who You Are Is Only Genetics Is the Essence of Evil' A new book by Prof. Eyal Winter, an economist and games theory researcher, tells the story of his aunt, a woman of high society in pre-Nazi Germany, who tried to rescue 22 orphans from the Holocaust.  by Gili Izikovich

"Winter, 64, is no stranger to writing, but "Anna's Children" is his first novel. He was born and raised in Jerusalem and now lives in a bright, beautiful stone house in the suburb of Mevasseret Zion.

...

"Is this a good time to publish a book about the Holocaust?

"I pondered a lot about the link between the Holocaust and what happened in October," says Winter. "I considered delaying the book. It's a difficult story with a bad ending, but it also has elements of comfort given what is happening with us. It's possible to understand our reactions to the contemporary situation and maybe make it easier somehow."

#######

Here's his related post on Linkedin: Eyal Winter’s Post

Privacy while driving

 Internet connected cars collect lots of data on driving behavior, which can be sold to insurance companies and used to change drivers' insurance rates.

The NYT has the story:

Automakers Are Sharing Consumers’ Driving Behavior With Insurance Companies . LexisNexis, which generates consumer risk profiles for the insurers, knew about every trip G.M. drivers had taken in their cars, including when they sped, braked too hard or accelerated rapidly.   By Kashmir Hill

"LexisNexis is a New York-based global data broker with a “Risk Solutions” division that caters to the auto insurance industry and has traditionally kept tabs on car accidents and tickets. 

...

"In recent years, insurance companies have offered incentives to people who install dongles in their cars or download smartphone apps that monitor their driving, including how much they drive, how fast they take corners, how hard they hit the brakes and whether they speed. But “drivers are historically reluctant to participate in these programs,” as Ford Motor put it in a patent application that describes what is happening instead: Car companies are collecting information directly from internet-connected vehicles for use by the insurance industry.

"Sometimes this is happening with a driver’s awareness and consent. Car companies have established relationships with insurance companies, so that if drivers want to sign up for what’s called usage-based insurance — where rates are set based on monitoring of their driving habits — it’s easy to collect that data wirelessly from their cars.

But in other instances, something much sneakier has happened. Modern cars are internet-enabled, allowing access to services like navigation, roadside assistance and car apps that drivers can connect to their vehicles to locate them or unlock them remotely. In recent years, automakers, including G.M., Honda, Kia and Hyundai, have started offering optional features in their connected-car apps that rate people’s driving. Some drivers may not realize that, if they turn on these features, the car companies then give information about how they drive to data brokers like LexisNexis.

"Automakers and data brokers that have partnered to collect detailed driving data from millions of Americans say they have drivers’ permission to do so. But the existence of these partnerships is nearly invisible to drivers, whose consent is obtained in fine print and murky privacy policies that few read.

"Especially troubling is that some drivers with vehicles made by G.M. say they were tracked even when they did not turn on the feature — called OnStar Smart Driver — and that their insurance rates went up as a result."

Match Day for new doctors

 The 2024 Match for new American doctors was announced yesterday by the NRMP, the National Resident Matching Program. Congratulations to all!

Here are some links:

Advance Data Tables
Match By the Numbers
Press Release

Plasma in Canada: payments and protests

 The local newspaper in Niagara on the Lake, a town in Ontario, Canada, covers the proposed opening next year of plasma collection centers that will pay for plasma.

Pay-for-plasma centre draws criticism from Health Coalition. The centre, which will pay residents to donate their blood plasma, is scheduled to open on Hespeler Road by early 2025, by Matt Betts

"The chair of the Waterloo Region Health Coalition is raising concerns about a pay-for-plasma centre slated to open on Hespeler Road in Cambridge by early 2025.

"Just as it sounds, residents can be compensated for donating their blood plasma.

"It's all part of an agreement between Spanish global healthcare company, Grifols, and the Canadian Blood Services.

"In September 2022, Canadian Blood Services announced our action plan in response to a global shortage of medications called immunoglobulins and plasma needed to make them," CBS said in an email to CambridgeToday.

"With funding from governments, Canadian Blood Services is opening 11 plasma donor centres in Canada and collecting more plasma ourselves. Our agreement with Grifols, a global healthcare company and leader in producing plasma medicines, is another part of that plan."

...

"paying for donations is banned in Ontario, Quebec and British Columbia. 

"However, CBS said its been in close discussions with the government and has an exemption.

...

"The agreement also complies with Ontario’s Voluntary Blood Donations Act, which has always contained an exemption for Canadian Blood Services, with implicit consideration of our agents, given our role as the national blood operator and supplier of blood products in Canada. Through our agreement, Grifols will operate under the Act as an agent of Canadian Blood Services."

"Per the agreement, Grifols must use plasma they collect in Canada to make immunoglobulins exclusively for patients in Canada, which reduces reliance on the global market, CBS said.

"But the whole operation doesn't sit right with Waterloo Region Health Coalition chair, Jim Stewart.

"It's a repugnant example of profit driven healthcare," Stewart said, questioning who's profiting in the end.

"What's next, paying people for their organs or embryos? This is just another example of Premier Doug Ford’s drive to privatize our healthcare system."

...

""These pay-for-donations centres really impact the homeless, people with low incomes and those with high levels of unemployment. This is going to dismantle the voluntary donor base and the sustainability of blood supply could be in jeopardy."

...

"While not confirmed by Grifols, Canadian Blood Resources and giveplasma.ca states qualified donors can earn up to $70 per donation and can donate twice in a seven day period."

#####

HT: Frank McCormick

Earlier:

Sunday, September 18, 2022

Canadian Blood Services to start paying Canadian plasma donors

New Zealand repeals anti-smoking law that would have prevented tobacco sales to anyone born after 2008

 In an earlier blog post, I wrote about a New Zealand anti-smoking law, saying "And now there's a law that cuts nicotine content of cigarettes, and (get this) "bans the next generation of New Zealanders — anyone born after 2008 or currently 14 years old or younger — from ever buying cigarettes in the country. " (That's going to be a complicated age restriction to administer in, say, 10 years from now...)  

Well, people born in 2008 are turning 16 this year, and New Zealand just repealed that law, for reasons that New Zealand's prime minister Christopher Luxon says include concerns about black markets.

Here's an article from Medpage today, reporting on the change in the law. However the article takes the point of view that black markets are just a smokescreen thrown up by tobacco companies.

Up in Smoke: What Happened to New Zealand's Tobacco Ban Plan?— It appears the new government is making an embarrassing attempt to fend off a budget shortfall. by Eric Trump, March 6, 2024

"As part of the newly elected coalition government's rush to tick 49 "actions"  off its 100-day list by March 8, it has repealed  the Smokefree Environments and Regulated Products Amendment Act of 2022. This act, passed by the previous Labour government, would have banned selling tobacco products to those born on or after January 1, 2009, reduced the nicotine in tobacco products to non-addictive levels, and slashed the number of outlets allowed to sell tobacco by 90%, from 6,000 to 600. Overall tobacco use was predicted to drop from the current 8% to lower than 5% by 2025, and the act was expected to create a tobacco-free generation.

...

"Why would New Zealand's new coalition government, an alliance opens in a new tab or window

of the conservative National Party along with the libertarian ACT and populist New Zealand First parties, repeal data-driven and life- and money-saving legislation? Without a shred of evidence, Prime Minister Christopher Luxon and his coalition partners have repeatedly claimed restricting tobacco and reducing nicotine levels is experimental (as though that were a bad thing), leading to black marketsopens in a new tab or window and a proliferation of crimeopens in a new tab or window. ACT's health spokesperson Todd Stephenson, for example, said thatopens in a new tab or window the "radical prohibitionism" of creating a smoke-free generation would "push smokers into the arms of gang members."

"This rhetoric uncannily echoes the tobacco lobby. Public health experts at the University of Otago recently released a damning reportopens in a new tab or window showing that the coalition government's arguments in favor of a repeal closely mirror the tobacco industry's own narratives on this subject.

"So suspicious are the similarities between the flimsy remarks of coalition partners and tobacco companies' talking points that the report's authors are calling on all members of parliament to declare any past associations with tobacco companies.

######

 

Here's the story about the Prime Minister's concerns, from Radio New Zealand (RNZ):

Smokefree legislation would have driven cigarette black market - Christopher Luxon

SITE 2024 Conference: Call For Papers for Summer 2024

 Now is the time to be thinking of submitting papers for the summer sessions at Stanford. (Some deadlines are in April.)

Here's the call for papers:

SITE 2024 Conference: Call For Papers

Stanford Economics is proud to host its annual Stanford Institute for Theoretical Economics (SITE) Conference from July 1 to September 11 2024. SITE sponsors sessions that encompass both economic theory and empirical work and cover a broad range of topics. It brings together established and emerging scholars to present leading-edge economic research, to educate, and to collaborate.

These sessions are scheduled:

1. Gender  Monday, July 1, 2024, 8:00am - Tuesday, July 2, 2024, 5:00pm
2. Empirical Implementation of Theoretical Models of Strategic Interaction and Dynamic Behavior  Thursday, July 11, 2024, 8:00am - Friday, July 12, 2024, 5:00pm
3. Trade and Finance  Thursday, July 25, 2024, 8:00am - Friday, July 26, 2024, 5:00pm
4. Fiscal Sustainability  Thursday, August 1, 2024, 8:00am - Friday, August 2, 2024, 5:00pm
5. Dynamic Games, Contracts, and Markets  Monday, August 5, 2024, 8:00am - Wednesday, August 7, 2024, 5:00pm
6. The Micro and Macro of Labor Markets  Tuesday, August 6, 2024, 8:00am - Wednesday, August 7, 2024, 5:00pm
7. Political Economic Theory  Thursday, August 8, 2024, 8:00am - Friday, August 9, 2024, 5:00pm
8. Market Design  Thursday, August 8, 2024, 8:00am - Friday, August 9, 2024, 5:00pm
9. Market Failures and Public Policy  Wednesday, August 14, 2024, 8:00am - Thursday, August 15, 2024, 5:00pm
10. Empirical Market Design  Thursday, August 15, 2024, 8:00am - Friday, August 16, 2024, 5:00pm
11. Climate Finance and Banking  Monday, August 19, 2024, 8:00am - Tuesday, August 20, 2024, 8:00am
12. Frontiers of Macroeconomic Research Wednesday, August 21, 2024, 8:00am - Friday, August 23, 2024, 5:00pm
13. Experimental Economics  Thursday, August 22, 2024, 8:00am - Friday, August 23, 2024, 5:00pm
14. Psychology and Economics Monday, August 26, 2024, 8:00am - Tuesday, August 27, 2024, 9:00pm
15. The Labor Market Experience of Vulnerable Populations of Workers  Monday, August 26, 2024, 8:00am - 5:00pm
16. Housing and Urban Economics  Wednesday, August 28, 2024, 8:00am - Friday, August 30, 2024, 5:00pm
17. The Macroeconomics of Uncertainty and Volatility  Wednesday, September 4, 2024, 8:00am - Friday, September 6, 2024, 5:00pm
18. New Research in Asset Pricing  Wednesday, September 4, 2024, 8:00am - Friday, September 6, 2024, 5:00pm
19. The Economics of Transparency  Thursday, September 5, 2024, 8:00am - Friday, September 6, 2024, 5:00pm
20. Financial Regulation  Monday, September 9, 2024, 8:00am - Wednesday, September 11, 2024, 5:00pm

Kidney exchange between Portugal and Spain, and prospects for global kidney exchange

 Here's an article from a Portuguese hospital that has engaged in kidney exchanges with Spanish hospitals that have resulted in three transplants for Portuguese patients since the program was initiated in 2017.  The paper considers how international kidney exchange can be expanded globally, so as to have significant effects on the health of Portuguese and other patients.  

The concluding  two paragraphs of the paper speak about global kidney exchange, and the controversy that it has aroused, particularly in Spain, where there has been opposition to significant cross-border kidney exchange.

Francisco, José Teixeira, Renata Carvalho, Joana Freitas, Miguel Trigo Coimbra, Sara Vilela, Manuela Almeida, Sandra Tafulo et al. "International Crossed Renal Donation – The Experience of a Single Center," Brazilian Journal of Transplantation, v. 26 (2023)

"Introduction: Kidney transplantation is the preferred treatment for end-stage chronic kidney disease, however, the shortage of organs can result in long waiting times. Living donor kidney transplantation offers an alternative to cadaver donor, but HLA or AB0 incompatibility can represent a significant obstacle. This study aimed to show the results achieved by a Portuguese hospital since its integration into an international cross-donation program, the South Alliance for Transplants (SAT). 

"Methods: The SAT program was founded in 2017 and is made up of ten Spanish hospitals, three Italian hospitals and one Portuguese hospital. The program takes place every 4 months and only enrolls pairs who are incompatible. Organ transport is carried out in partnership with the Portuguese Air Force. 

"Results: Three different crosses were carried out in partnership with three Spanish hospitals, culminating in the transplantation of three Portuguese patients out of a total of seven patients. The first crossing was carried out in March 2020, at the beginning of the COVID-19 pandemic, with the partnership of two Portuguese hospitals and a Spanish hospital, involving 1 donor/recipient pair from each country,... The second occurred in December 2021 with 3 donor/recipient pairs (1 Portuguese in which the recipient had anti-donor antibodies and positive crossmatch with the potential donor; and 2 from two Spanish hospitals),... The third crossing also took place in December 2021 with 2 donor/recipient pairs (1 Portuguese and 1 Spanish)

...

"A Global Kidney Exchange Program (GKEP), an idea initiated by Rees et al.,16 which involves kidney paired donation between high-income and low-income and medium-income countries (LMICs). Beyond the potential benefits associated with this type of transplantation, similar to those already addressed for international programs, there are concerns about the ethical implications of  such  programs.  They  may  perpetuate  existing  inequalities  between  high  and  low-income  countries,  which  has  motivated  a  statement  from  the  Declaration  of  Istanbul  Custodian  Group.17  Some  critics  argue  that  the  practices  of  most  PRMBs  lack  transparency, leaving room for exploitation and corruption,18 or raise ethical concerns regarding the commodification of organs.19On the other hand, proponents of the idea argue that a GKEP could help address the global shortage of donor organs and provide lifesaving  opportunities  for  patients  in  need.  They  also  note  that  such  programs  could  foster  collaboration  and  information-sharing between countries and institutions, potentially leading to improvements in transplant practices worldwide.16,20 Despite the controversy surrounding the proposal, the idea of a GKEP remains an intriguing possibility for advancing kidney transplantation on a global scale.

"CONCLUSION: Our experience and that of other locations show that programs like these offer numerous benefits, such as expanding the pool of available donors, improving compatibility between donors and recipients, and avoiding the costs and risks associated with desensitization therapies for ABO or HLA incompatible transplantations. These programs represent a valuable option for individuals who require a kidney transplant and can be an effective means of increasing transplant success rates and improving quality of life for patients. However, the success of these programs depends on the number of pairs enrolled. To ensure the success of these programs, there is a need for greater awareness, education, and promotion of their benefits and outcomes among the public, healthcare providers, and policymakers alike.

Global disparities in kidney disease and care

 Here's a report on the availability of treatment of kidney disease around the world.  If you are unlucky enough to have kidney failure (which is a top 10 cause of death), it's good to be in North America or Western Europe. Most countries (70%) have at least a minimal capacity to perform transplants. But if I read the map correctly, preemptive kidney transplants (i.e. transplants before dialysis, in map D below) are relatively common only in the U.S., Britain, and Norway. (And worldwide, a transplant costs less than two years of dialysis...)

Bello, A.K., Okpechi, I.G., Levin, A., Ye, F., Damster, S., Arruebo, S., Donner, J.A., Caskey, F.J., Cho, Y., Davids, M.R. and Davison, S.N., 2024. An update on the global disparities in kidney disease burden and care across world countries and regions. The Lancet Global Health, 12(3), pp.e382-e395.

"Background

"Since 2015, the International Society of Nephrology (ISN) Global Kidney Health Atlas (ISN-GKHA) has spearheaded multinational efforts to understand the status and capacity of countries to provide optimal kidney care, particularly in low-resource settings. In this iteration of the ISN-GKHA, we sought to extend previous findings by assessing availability, accessibility, quality, and affordability of medicines, kidney replacement therapy (KRT), and conservative kidney management (CKM).

...

"Findings

The literature review used information on prevalence of chronic kidney disease from 161 countries. The global median prevalence of chronic kidney disease was 9·5% (IQR 5·9–11·7) with the highest prevalence in Eastern and Central Europe (12·8%, 11·9–14·1). For the survey analysis, responses received covered 167 (87%) of 191 countries, representing 97·4% (7·700 billion of 7·903 billion) of the world population. Chronic haemodialysis was available in 162 (98%) of 165 countries, chronic peritoneal dialysis in 130 (79%), and kidney transplantation in 116 (70%). However, 121 (74%) of 164 countries were able to provide KRT to more than 50% of people with kidney failure. Children did not have access to haemodialysis in 12 (19%) of 62 countries, peritoneal dialysis in three (6%) countries, or kidney transplantation in three (6%) countries. CKM (non-dialysis management of people with kidney failure chosen through shared decision making) was available in 87 (53%) of 165 countries. The annual median costs of KRT were: US$19 380 per person for haemodialysis, $18 959 for peritoneal dialysis, and $26 903 for the first year of kidney transplantation. Overall, 74 (45%) of 166 countries allocated public funding to provide free haemodialysis at the point of delivery; use of this funding scheme increased with country income level. The median global prevalence of nephrologists was 11·8 per million population (IQR 1·8–24·8) with an 80-fold difference between low-income and high-income countries. Differing degrees of health workforce shortages were reported across regions and country income levels. A quarter of countries had a national chronic kidney disease-specific strategy (41 [25%] of 162) and chronic kidney disease was recognised as a health priority in 78 (48%) of 162 countries.

Figure 3 Worldwide incidence of general, deceased-donor, living-donor, and pre-emptive kidney transplantations (cases pmp per year) (A) Incidence of kidney transplantation. (B) Incidence of deceased-donor kidney transplantation. (C) Incidence of living-donor kidney transplantation. (D) Incidence of pre-emptive kidney transplantation. pmp=per million population

Even in the U.S., we aren't able to supply enough transplantable kidneys for everyone who needs one. Domestic kidney exchange helps fill some of the gap, but the gap, and the resulting number of premature deaths, is still huge.  It's enough to make you think about global kidney exchange...

Does high pay equal "undue inducement"? An experiment by Sandro Ambuehl

 Here's an experiment about repugnant transactions, by Sandro Ambuehl.

Ambuehl, Sandro, "An experimental test of whether financial incentives constitute undue inducement in decision-making." Nature Human Behavior (2024). https://doi.org/10.1038/s41562-024-01817-8

Abstract: Around the world, laws limit the incentives that can be paid for transactions such as human research participation, egg donation or gestational surrogacy. A key reason is concerns about ‘undue inducement’—the influential but empirically untested hypothesis that incentives can cause harm by distorting individual decision-making. Here I present two experiments (n = 671 and n = 406), including one based on a highly visceral transaction (eating insects). Incentives caused biased information search—participants offered a higher incentive to comply more often sought encouragement to do so. However, I demonstrate theoretically that such behaviour does not prove that incentives have harmful effects; it is consistent with Bayesian rationality. Empirically, although a substantial minority of participants made bad decisions, incentives did not magnify them in a way that would suggest allowing a transaction but capping incentives. Under the conditions of this experiment, there was no evidence that higher incentives could undermine welfare for transactions that are permissible at low incentives.

From the conclusions:

"Given the potentially high costs of preventing voluntary transactions, experiments paralleling those reported here should be conducted in the field. Unless their results differ drastically from the current ones, the rules and guidelines restricting incentives due to undue inducement concerns should be reconsidered."

Michael Kremer on market design by economists (and other essays on developments in economics)

 The March issue of the IMF publication Finance and Development (F&D) contains this essay by Michael Kremer.

ECONOMICS AND INNOVATION by MICHAEL KREMER, MARCH 2024

Here are his concluding paragraphs:

"Economists as innovators

"In addition to shedding light on the design of policies and institutions for innovation, economists can also participate directly in the innovation process. For example, economic theorists have used market design principles to design kidney transplant matching systems, and development economists are using experimental methods not just to test innovations, but also to help develop them. An analysis of Development Innovation Ventures (DIV)—the US Agency for International Development’s tiered evidence-based social innovation fund—found that 36 percent of awards went to innovations developed by teams including development economists, scaled to reach over 1 million users, compared with just 6 percent of awards to innovations without such involvement.

"Furthermore, 63 percent of DIV-supported innovations that had previously been tested in randomized controlled trials reached more than 1 million people, compared with only 12 percent of those without such trials. For example, economists helped develop a credit-scoring approach using psychometrics (psychological testing) to assess default risk for potential borrowers without credit histories, which scaled through adoption by commercial lenders.

"Just as biochemists and computer scientists often develop practical innovations in their fields, economists are increasingly developing social innovations in ours."

#########

The March issue also includes

NEW LESSONS FROM BEHAVIORAL ECONOMICS, by ULRIKE MALMENDIER  and CLINT HAMILTON

and

RETHINKING MY ECONOMICS  by ANGUS DEATON

Dr. Guy Alexandre (1934-2024), gave birth to brain death in deceased organ transplantation

 The father of brain death has died.

Here's the NYT obit.

Guy Alexandre, Transplant Surgeon Who Redefined Death, Dies at 89. His willingness to remove kidneys from brain-dead patients increased the organs’ viability while challenging the line between living and dead.  By Clay Risen

"Guy Alexandre, a Belgian transplant surgeon who in the 1960s risked professional censure by removing kidneys from brain-dead patients whose hearts were still beating — a procedure that greatly improved organ viability while challenging the medical definition of death itself — died on Feb. 14 at his home in Brussels. He was 89.

...

"Dr. Alexandre was just 29 and fresh off a yearlong fellowship at Harvard Medical School when, in June 1963, a young patient was wheeled into the hospital where he worked in Louvain, Belgium. She had sustained a traumatic head injury in a traffic accident, and despite extensive neurosurgery, doctors pronounced her brain dead, though her heart continued to beat.

"He knew that in another part of the hospital, a patient was suffering from renal failure. He had assisted on kidney transplants at Harvard, and he understood that the organs began to lose viability soon after the heart stops beating.

"Dr. Alexandre pulled the chief surgeon, Jean Morelle, aside and made his case. Brain death, he said, is death. Machines can keep a heart beating for a long time with no hope of reviving a patient. His argument went against centuries of assumptions about the line between life and death, but Dr. Morelle was persuaded.

...

"Over the next two years, Dr. Alexandre and Dr. Morelle quietly performed several more kidney transplants using the same procedure. Finally, at a medical conference in London in 1965, Dr. Alexandre announced what he had been doing.

...

"In 1968, the Harvard Ad Hoc Committee, a group of medical experts, largely adopted Dr. Alexandre’s criteria when it declared that an irreversible coma should be understood as the equivalent of death, whether the heart continues to beat or not.

"Today, Dr. Alexandre’s perspective is widely shared in the medical community, and removing organs from brain-dead patients has become an accepted practice.

“The greatness of Alexandre’s insight was that he was able to see the insignificance of the beating heart,” Robert Berman, an organ-donation activist and journalist, wrote in Tablet magazine in 2019.

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And here's the story from Tablet magazine, interesting in a number of respects:

The Man Who Remade Death. Guy Alexandre was the first surgeon to remove organs from a patient with a beating heart. His colleagues thought him a murderer; Alexandre disagreed and revolutionized our understanding of death.  BY ROBBY BERMAN, Feb 4, 2019

"I met Alexandre a few months ago in his home in an upscale suburb of Brussels. The octogenarian is charming, affable and avuncular but he does not mince words: The physicians who accused him of murder “were hypocrites. They viewed their brain dead patients as alive yet they had no qualms about turning off the ventilator to get the heart to stop beating before they removed kidneys. In addition to ‘killing’ the patient, they were giving the recipients damaged kidneys that suffered ischemia … oxygen deprivation. The kidneys did not work well; they did not last long.”

"Given that brain death was not well known by the public in 1963, I asked Alexandre how he succeeded in getting consent from families to donate the organs. “It was simple. I didn’t ask. I told the families the situation was grim and I removed the organs in the middle of the night. When the family returned the next morning I told them their loved one had died during the night.”

"In 1961, Alexandre was in his third year of surgical training. He left Brussels for Boston to attend Harvard Medical School where he studied under professor Joseph Murray, the surgeon famous for performing the first successful kidney transplant between twins in 1954. After Alexandre successfully executed a number of kidney transplants between dogs in the laboratory, he was invited by Murray to join him in the operating room to operate on humans. It was there that Alexandre noticed a curious phenomenon.

"Murray turned off the ventilator in order to cause the heart to stop beating and only then did he extract the organs. Alexandre felt there was no need to damage the kidneys by depriving them of oxygen. He believed when looking at a human body with a dead brain that he was looking at a corpse that was suffering from a bizarre medical condition: a beating heart. In other words, the organism was dead but the organs remained alive."

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Earlier:

Friday, January 18, 2019

Fifty years of "brain death"

Increasing kidney transplants by reducing discards of risky kidneys

 Kidneys from deceased donors are too often discarded. Dr. Joshua Mezrich, a transplant surgeon at U. Wisconsin, writes in Stat about how to reduce the rate at which high risk kidneys are discarded (after being on ice for a long time while being rejected by many patients). He proposes that kidneys that can be identified as high risk even before being recovered from the deceased donor  be offered promptly to patients/transplant centers that have indicated a willingness to take them. It would require transplant centers to keep current blood tests available for patients who are candidates for high risk kidneys (who may be candidates in part because they are far from the front of the waiting list...)

Too many donor organs go to waste. Here’s how to get them into the patients who need them  By Joshua Mezrich, Stat, March 2, 2024 

"So here is the fix. High-risk kidneys should immediately be offered to transplant centers that opt into a high-risk program as an open offer to their wait list rather than to a specific patient, on a rotating schedule with weight put on proximity to the donor hospital. Ideally the offer should be made prior to procurement of the organ, with final acceptance once it is removed and anatomy and biopsy results can be reviewed by the accepting surgeon.

"If the biopsies show significant disease and the function of the kidney would be inadequate for a recipient, the receiving center can request both kidneys for a single patient, termed a dual transplant (which has been shown to have good outcomes). If a center accepts a kidney, it can then choose the patient who will benefit the most from the transplant and has a long predicted wait time for a low-risk transplant, with informed consent. That would entail a discussion with the patient about expectations regarding the quality of the kidney, how long and how well it might work, and how much longer they might need to wait for a lower-risk kidney. The ability to match the kidney to a recipient is important, as high-risk kidneys need to go into patients who can tolerate the slow initial function. Centers that opt into the high-risk program will need to maintain an updated list of informed patients who are predicted to benefit from these kidneys, who can be called in as soon an offer becomes available. For them, taking a chance beats remaining on dialysis.

France amends its constitution to protect access to abortion

 The decision of the U.S. Supreme Court to overturn Roe v.Wade and end a constitutional right to abortion in the U.S. prompted France to amend its constitution to guarantee access to abortion.

Here's the WSJ story:

France becomes first country to explicitly enshrine abortion rights in constitution  By Karla Adam

"With the endorsement of a specially convened session of lawmakers at the Palace of Versailles, France on Monday became the first country in the world to explicitly enshrine abortion rights in its constitution — an effort galvanized by the rollback of protections in the United States.

"The amendment referring to abortion as a “guaranteed freedom” passed by a vote of 780 in favor and 72 against, far above the required threshold of support from three-fifths of lawmakers, or 512 votes.

"French President Emmanuel Macron announced that a “sealing ceremony,” a tradition reserved for the most significant laws, would take place Friday, coinciding with International Women’s Day.

“We’re sending a message to all women: Your body belongs to you, and no one can decide for you,” Prime Minister Gabriel Attal told lawmakers assembled in Versailles."*

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Le Monde has the story, in an editorial supporting the amendment:

Enshrining abortion access in the French Constitution is a win for feminism and democracy, EDITORIAL, Le Monde, March 4

"The joint session of both houses of Parliament convened in Versailles on Monday, March 4, to enshrine access to abortion in the French Constitution, marks an important moment in the life of the nation. And a proud moment, too. A few days before International Women's Rights Day on March 8, women's freedom to control their own bodies should be anchored in French law. It also comes at a time when abortion, once thought to be a widely accepted procedure, is being undermined in a number of democracies, most notably the United States.

...

"The three-fifths majority required in Parliament means that a consensus has been reached, despite the fact that abortion still disgusts some on the right and far right. It's a sign that democracy works, despite the distress signals it is sending out.

"At every stage of the lengthy procedure initiated in November 2022, the drafting of the Constitutional reform constantly required perseverance and tact. First in the Assemblée Nationale, where, in response to the shockwave caused in June 2022 by the US Supreme Court's decision to revoke the federal right to abortion, the radical-left La France Insoumise party and the center-right presidential majority agreed to work together on a common cause.

"Then the fight continued in the Sénat, where, in loyalty to Simone Veil's 1975 battle to decriminalize abortion, a number of right-wing Les Républicains elected representatives fought hard to ensure that the debate, which they had reframed, could continue against the advice of their group's president, Bruno Retailleau, and Sénat President Gérard Larcher. Finally, in the government, Justice Minister Eric Dupond-Moretti facilitated the drafting and adoption of the final text. The compromise consists of enshrining the notion of "guaranteed freedom" for women to have access to abortion, without introducing an enforceable "right" to abortion as demanded by the left."

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*Regarding the Prime Minister's remark to women that "no one can decide for you" I note that surrogacy remains illegal in France.

Friday, October 18, 2019

Will IVF become more widely legal in France?

Oregon is re-criminalizing drugs

 The war on drugs is unforgiving, and neither criminalization nor decriminalization seems to be a winning strategy.  The NYT has the latest from Oregon, where there were high hopes for decriminalization and harm reduction, and where there are now second thoughts. 

Oregon Is Recriminalizing Drugs, Dealing Setback to Reform Movement. Oregon removed criminal penalties for possessing street drugs in 2020. But amid soaring overdose deaths, state lawmakers have voted to bring back some restrictions.  By Mike Baker

"Three years ago, when Oregon voters approved a pioneering plan to decriminalize hard drugs, advocates looking to halt the jailing of drug users believed they were on the edge of a revolution that would soon sweep across the country.

"But even as the state’s landmark law took effect in 2021, the scourge of fentanyl was taking hold. Overdoses soared as the state stumbled in its efforts to fund enhanced treatment programs. And while many other downtowns emerged from the dark days of the pandemic, Portland continued to struggle, with scenes of drugs and despair.

"Lately, even some of the liberal politicians who had embraced a new approach to drugs have supported an end to the experiment. On Friday, a bill that will reimpose criminal penalties for possession of some drugs won final passage in the State Legislature and was headed next to Gov. Tina Kotek, who has expressed alarm about open drug use and helped broker a plan to ban such activity.

“It’s clear that we must do something to try and adjust what’s going on out in our communities,” State Senator Chris Gorsek, a Democrat who had supported decriminalization, said in an interview. Soon after, senators took the floor, with some sharing stories of how addictions and overdoses had impacted their own loved ones. They passed the measure by a 21-8 margin."

50th anniversary of Shapley and Scarf (1974), and of the Journal of Mathematical Economics

Now available online is the first in what I understand will be a series of papers commemorating the 50th anniversary of the Journal of Mathematical Economics.  The paper by Shapley and Scarf appeared in volume 1, number 1. (Thayer Morrill and I will have a paper surveying the literature on the Top Trading Cycle (TTC) algorithm, which was introduced in that first paper.)

Housing markets since Shapley and Scarf by Mustafa Oğuz Afacan, Gaoji Hu, and Jiangtao Li, Journal of Mathematical Economics, Available online 1 March 2024, In Press, Journal Pre-proof, https://doi.org/10.1016/j.jmateco.2024.102967

Abstract: Shapley and Scarf (1974) appeared in the first issue of the Journal of Mathematical Economics, and is one of the journal’s most impactful publications. As we approach the remarkable milestone of the journal’s 50th anniversary (1974–2024), this article serves as a commemorative exploration of Shapley and Scarf (1974) and the extensive body of literature that follows it.

Telephones and telephone operators, as telephone exchanges became automated

 Earlier experiences in automation may be helpful in thinking about current technologies. Here's a paper about automation that replaced telephone operators, largely in the early 20th Century.  (But in 1980, when I lived in Farmer City Illinois, our telephone provider was GTE (General Telephone & Electronics Corporation), not AT&T, and they still relied in part on human operators.)

Answering the Call of Automation: How the Labor Market Adjusted to Mechanizing Telephone Operation by James Feigenbaum and Daniel P Gross, The Quarterly Journal of Economics, forthcoming

Abstract: In the early 1900s, telephone operation was among the most common jobs for American women, and telephone operators were ubiquitous. Between 1920 and 1940, AT&T undertook one of the largest automation investments in modern history, replacing operators with mechanical switching technology in over half of the U.S. telephone network. Using variation across U.S. cities in the timing of adoption, we study how this wave of automation affected the labor market for young women. Although automation eliminated most of these jobs, it did not reduce future cohorts’ overall employment: the decline in operators was counteracted by employment growth in middle-skill clerical jobs and lower-skill service jobs, including in new categories of work. Using a new genealogy-based census-linking method, we show that incumbent telephone operators were most impacted, and a decade later more likely to be in lower-paying occupations or no longer working.

Planet money plus-- interview on repugnant transactions

 Behind a paywall :(, but here's some more of the interview that I did with Planet Money last month:

Extended Play: Al Roth on money and 'repugnant markets' (Planet Money+)Planet Money

• • Business

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Repugnant markets. We heard about them from economist Al Roth in a recent Planet Money episode. These are markets that aren't allowed because people feel icky about putting a price on something. For example, it's basically illegal to buy and sell kidneys in much of the world. In today's bonus episode, Mary Childs talks with Al about other repugnant markets that didn't make it into the original show, like surrogacy and blood plasma. They also discuss how money can change relationships.You can hear that original Planet Money episode here: https://www.npr.org/1197956769 Show your support for Planet Money and the reporting we do by subscribing to Planet Money+ in Apple Podcasts or at plus.npr.org. You'll be able to unlock this episode and other great bonus content. Regular episodes remain free to listen! Email the show at planetmoney@npr.org.

Earlier:

hursday, February 8, 2024

Morally contested markets on NPR's Planet Money (including kidneys, revenge and insider trading)