Deceased-donor initiated kidney exchange chaiins in Italy, after six years

 Kidney exchange in Italy is now making good use of deceased-donor initiated chains.

 

American Journal of Transplantation

Available online 10 August 2026

In Press, Journal Pre-proof

Original Article

Integrating Deceased and Living Donation: Six-Year Outcomes of the Italian Deceased-Donor–Initiated Kidney Paired Exchange (DEC-K) Program

Author links open overlay panel, , , , , , , , , , , , , , , , , , , …

 ABSTRACT
Using a deceased donor (DD) to initiate living-donor (LD) exchange chains can expand access to kidney transplantation in recipients with an HLA or ABO incompatible living donor. The Italian DD-initiated Kidney Paired Exchange (DEC-K) program uses a DD kidney to start a chain among incompatible pairs, ultimately returning a LD kidney to the waiting list. We report the first long-term analysis of this approach worldwide. All DEC-K chains performed in Italy between March 2018 and May 2025 were analyzed. Thirty-four chains generated 84 transplants (34 chain initiating kidneys CIK, 22 from LD, 28 chain-ending kidneys CEK) versus 17 transplants from conventional Kidney Paired Donation (KPD) program in the same period. Five-year outcomes were similar between CIK and LD recipients (eGFR slope: −2.0 mL/min/1.73m2/year, P=0.37; graft survival: log-rank P=0.28). While this approach diverts blood-group O DD kidneys from the general waiting list, potentially affecting non-sensitized candidates, it was designed to address the unmet needs of highly sensitized patients facing years of waiting. In the Italian setting, the DEC-K program successfully initiates LD chains from DD kidneys with outcomes equivalent to LD transplant; implementation should include monitoring of blood-group-specific outcomes and flexible design to accommodate healthcare system priorities.

... 

 "DISCUSSION
The six-year DEC-K experience demonstrates that DD-initiated KPD chains are highly effective in small national pools such as Italy’s, which include about 70 incompatible pairs at a time. Because closed-loop exchanges rarely provide enough matches, especially for blood group O or highly sensitized recipients, open chains initiated by DDs can convert a single graft into multiple sequential transplants without simultaneous multi-center surgery. In our program, 34 DDs generated 84 transplants, corresponding to a threefold increase compared to conventional loops in the Italian KPD. Broader enrollment could further enhance impact, although participation remains limited by concerns about receiving a DD kidney while the paired LD proceeds, underscoring the need for transparent counseling and clear communication about outcomes and equity.
The rationale for DEC-K aligns with models proposed by Melcher and later implemented by Furian, in which a SCD kidney is allocated to an incompatible pair whose LD subsequently donates to another recipient, propagating the chain21, 23, 29. Similar donor-driven chains were pioneered in the United States, where Rees demonstrated that a single altruistic donor could initiate a ten-transplant sequence14. Mathematical modeling by Wang et al.23 supports this approach, showing that allocating just 2-3% of DD to initiate KPD chains could generate several hundred additional transplants annually, with maximum benefit for highly sensitized and blood-group O candidates23. In countries with rare or restricted altruistic donation and small KPD pools, such as Italy, DD initiation is the only practical way to generate compatible matches. Over the past decade, only ten non-directed donors enabled 30 transplants and unlocked 21 incompatible pairs, substantially fewer than DEC-K.

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Earlier: 

Monday, April 11, 2016  Using deceased donor kidneys to start living donor kidney exchange chains

 

Public attitudes towards deceased organ donation and allocation in china

 Deceased  organ donation in China does not  yet have overwhelming public support although receiving a deceased donor organ transplant does:

Hu, D., Wang, Y., Hu, Q. et al. Public attitudes and preferences on organ donation and allocation in china: a cross-sectional study. Sci Rep 16, 24995 (2026). https://doi.org/10.1038/s41598-026-54903-4 

 

 

 

Bra doping at the women’s Tour de France

 I follow the Tour de France, partly out of an interest in performance enhancing drugs.  But from time to time other strategic kinds of doping are also discussed, as in altering the bikes rather than the bike riders.

In this connection, The Tour de France Femmes, the women's Tour, now has a discussion of bra doping, for better aerodynamics:

Bra doping at the women’s Tour de France 

"This year’s Tour de France Femmes has been rocked by allegations that some riders are artificially exaggerating their bust size to gain an aerodynamic advantage.

Several women’s World Tour teams have raised concerns that cyclists on rival teams are padding their sports bras to give them a boost in time trials, according to leading Dutch cycling news site, WielerFlits.

"The practice of “chest fairing” – also known as “bra boosting” or “bra doping” – involves increasing the surface area of the chest to change the airflow around the torso. Other forms of chest fairing include placing a water bottle or radio receiver under your cycling jersey. This can reduce drag, potentially saving valuable seconds in a time trial, where aerodynamics are crucial.

An optimised chest fairing can reduce drag by as much as 3.6%, which could gain a time-trial cyclist at least 0.78 seconds every kilometre, according to research published in the Journal of Wind Engineering and Industrial Aerodynamics in 2024. “You won’t gain tens of seconds,” said study lead Bert Blocken, an aerodynamics expert at Heriot-Watt University in Scotland. But over a 20- to 30-km time trial, “it could save enough seconds to make the difference”.

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Earlier posts:

Friday, July 25, 2025  Tour de France competitions: conditioning, bikes, and drugs?

 Agence France Presse (AFP) reports on the bike race, and speculates on the historical competition between drug takers and drug testers.

 

Tuesday, July 8, 2025 Doping in the Tour de France: new dimensions

 There was a time when only riders had to be tested for doping, but advances in electric motors and batteries mean that bikes too can be suspect.  However it's the riders who get the most, increasingly sophisticated scrutiny.

Moral Economics: read the first 30 pages, open access on Google books

 I know you have been just about to buy my book Moral Economics, ever since it came out in May.  But you don't need to charge blindly ahead, you can gather evidence first (something the book strongly suggests is a good general practice:).  You can read the introduction and part of the first chapter (which happens to be on Sex), for free, on google books: https://www.google.com/books/edition/Moral_Economics/rb2CEQAAQBAJ?hl=en&gbpv=1

 And here is the table of contents (which, despite the alluring blue colors doesn't in fact contain any links:(

 

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And here's an Amazon link, where they stoop to actual commerce: Moral Economics: From Prostitution to Organ Sales, What Controversial Transactions Reveal About How Markets Work  

Controversial markets in Canada

 I talk with Gemma Boothroyd, about Moral Economics and controversial markets in Canada, including medical aid in dying, about which she has a story of her own.

 CANADALAND #1414 Repugnant Markets: Where Blood is Sold and Kidneys Swapped
“Sometimes the transplants weren't done in a sterile environment. They weren't done in a hospital. They were done in an apartment somewhere. There are some very bad black markets.” - Nobel Laureate economist Alvin Roth 

 Gemma Boothroyd Reporter

"They’re shamed, banned, or driven underground but “repugnant markets” have a way of surviving. Organ sales, MAID, even blood sales fall into the category. Nobel Prize-winning economist Alvin Roth comes to Canadaland to discuss his latest book, Moral Economics: From Prostitution to Organ Sales, What Controversial Transactions Reveal about How Markets Work.

 You can listen here. (but you have to listen to some ads too:(

Further Reading:

• The Nobel Prize – Alvin E. Roth
• Can economics save lives? –  Alvin E. Roth
• Repugnance as a Constraint on Markets – Alvin E. Roth
• A Conversation with Alvin Roth – The Conversation
• Kidney Paired Donation Program – Canadian Blood Services

 

Host: Gemma Boothroyd

 

True Crime: Illegal markets have great variety (PNAS)

 The forthcoming issue of PNAS (August 18, 2026 | vol. 123 | no. 33) has a big set of papers on illegal markets, with the goal of searching for common features, which turn out to be somewhat elusive.

Research ArticleAugust 10, 2026

A budding science of illegal markets

Illegal markets create untold societal and environmental harm, but they have attracted surprisingly little scholarly attention. This paper explores illegal markets as a class of objects. It considers similarities and differences across markets, with ...

• Jonathan P. Caulkins

"The raw material for these comparisons mostly comes from the February 2025 Policy and Research on Illegal Markets (PRIM) workshop held at RAND in Santa Monica. The workshop convened 17 experts on nine specific markets, or types of markets. They wrote the market-specific papers contained within this volume."  

Research ArticleAugust 10, 2026

Stability and turbulence in illegal drug markets

This article provides a primer on illegal drug markets, with a focus on the structure and nature of these markets and the enterprises involved. The markets for illegal drugs are large, with annual retail expenditures likely exceeding $100 billion in the ...

• Beau Kilmer
• 
  

IntroductionAugust 10, 2026

Illegal markets: An important domain for applied science

• Jonathan P. Caulkins,
• Beau Kilmer and
• Peter Reuter

"One premise of this special issue is that illegal markets and the supply chains that support them are a worthy topic of scientific inquiry. That turns out to be a novel claim. Illegal markets have simply not been a major topic of interest to economists, the discipline that would most plausibly study them. For example, Nobel laureate Alvin Roth, in his magisterial review of markets and market design, describes illegal markets but offers no specific analytic insights about them (2[A. E. Roth, Marketplaces, markets, and market design. Am. Econ. Rev. 108, 1609–1658 (2018).]). Gary Becker, one of the giants of microeconomics, wrote occasionally about drug markets but forced on them the presumption that they were analytically no different than legal markets (e.g., ref. 3). 

Research ArticleAugust 10, 2026

How illegal wildlife trade adheres to and defies conventional market behavior

Illegal wildlife markets comprise a complex global economy generating criminal profits while harming biodiversity and livelihoods. The negative externalities from biodiversity loss, ecosystem destabilization, and zoonotic disease risk may be orders of ...

• Greg Midgette and
• Meredith L. Gore

"At least since the third century BCE, when the Edicts of Ashoka prohibited the killing of animals with aesthetic value on the Indian subcontinent, wildlife has been trapped, harvested, and sold in contravention of laws (1). " 

PerspectiveAugust 10, 2026

Illegal firearms markets: Transaction patterns, evolving sources, and importance in criminal misuse

In the United States, the legal status of the 30 to 40 million annual firearms transactions is defined by state and federal regulations. These regulations primarily aim to reduce criminal misuse while preserving access for the large majority of adults who ...

• Philip J. Cook and
• Rosanna Smart

"Illegal transactions in firearms are often embedded in the much larger formal and informal markets, simply because sellers cannot easily distinguish between legal and illegal buyers even if they are motivated to do so. As one analogy, illegal firearms transactions look less like the market for heroin, where everyone involved knows the illegality of their transaction, than that for diverted pharmaceuticals." 

PerspectiveAugust 10, 2026

The market for human smuggling: Structure, mechanisms, and paradoxes

Human smuggling is the facilitation of unlawful cross-border movement. It is primarily a commercial activity, offered as a service to willing, paying customers, and a large-scale market catering to millions seeking to circumvent mobility restrictions. ...

• Paolo Campana

"The terms human smuggling and human trafficking are often confused, but they represent two very different phenomena, albeit potentially occurring in the same places and populations. While a victim of trafficking and a genuine client of a smuggler might find themselves shoulder-to-shoulder in the same inflatable boat, thus sharing the same means to cross the same border, smuggling and trafficking remain distinct—both analytically and legally. In the case of smuggling, the service provided is the illegal entry into a country—and a migrant enters into the transaction with a smuggler voluntarily (1). Some may have few options other than to migrate, and in that sense be forced to migrate, but they are not forced into that action by an individual or organization selling them the smuggling service. The relationship between a migrant and a smuggler terminates when the former has reached the agreed destination and paid the latter the agreed sum. On the other hand, the purpose of trafficking is obtaining control over a person for exploitation, including sexual exploitation, labor exploitation, or domestic servitude (2).† Victims of human trafficking may enter a country through legal channels, and in some cases, trafficking takes place wholly within national borders." 

PerspectiveAugust 10, 2026

The money laundering market: An economic analysis

Criminals launder their proceeds from crime, either themselves or by paying a professional, to disguise the link between the criminal, the crime, and the proceeds. This allows the criminal to spend the proceeds more freely and lowers the chance of ...

• Joras Ferwerda

"Since the goal of money laundering is to go unnoticed or to be seen as some other form of legitimate transaction, it is, by nature, difficult to provide credible estimates of how big the problem is. Moreover, the purchase of laundering services is generally a consensual crime: Both parties voluntarily enter into the transaction. Consensual crimes lack a direct victim to report the crime, which means the crime is revealed only when it is actively investigated.
There are a number of estimates of the volume of money laundering. These range in credibility; some lack empirical backup altogether [e.g., the widely quoted International Monetary Fund estimate of 2 to 5% of global GDP (3)]..." 

PerspectiveAugust 10, 2026

Casting light on the workings of illegal fishing markets

About 3.5 million fishing vessels ply the world’s oceans, providing livelihoods and food for millions of people. Sound management is key to fisheries’ sustainability, but illegal fishing, along with fishing overcapacity generally and environmental change, ...

• Philippe Le Billon,
• Zelda Ladefoged and
• U. Rashid Sumaila

 

PerspectiveAugust 10, 2026

Illegal markets for cigarettes and e-cigarettes

This paper discusses the long-standing illegal markets for cigarettes and the more recently emerged illegal markets for e-cigarettes. We identify three distinctive market fundamentals that help explain many features of the illegal markets. First, in ...

• Donald Kenkel and
• Grace Phillips

"In 2024, tobacco products generated almost $1 trillion in revenues, mainly from cigarette sales; e-cigarettes generated $26 billion dollars (1–3). While the share of the illegal markets varies by country, it is estimated that illegal markets account for about 10 percent of global cigarette consumption (4). Second, the illegal markets have arisen to evade high excise taxes that increase prices and regulations that restrict the availability of desirable features of legal products.  "

PerspectiveAugust 10, 2026

The illegal market for sex in the United States: Insights from economic research

The illegal market for sex in the United States generates significant economic activity yet remains understudied due to its illegality and clandestine nature. This paper synthesizes existing empirical evidence documenting aspects of market structure, ...

• Manisha Shah

"Although sex work is often perceived as predominantly occurring in marginalized urban areas or among underprivileged cultural groups, sex work is pervasive at all echelons of society. Media portrayals often emphasize street-based sex work, presenting it as the predominant form of prostitution; however, street-based sex work has been estimated to account for approximately 10 to 15% of total sex work participation (2). In the United States and in many other countries, the majority of the sex market has moved “indoors,” whether that be through massage parlors or brothels and/or online encounters." 

PerspectiveAugust 10, 2026

The policy construction of illegal markets: Exploring variation, success, failure, and unintended consequences

Illegal markets, broadly defined to include markets where only specific transactions are illegal, are the consequence of policy, either a prohibition or highly restrictive regulation. They are generated by a variety of concerns, some moral, some ...

• Letizia Paoli and
• Peter Reuter

"Drugs that are now prohibited were perfectly legal in most countries until the early 20th century. Famously, the British fought two “Opium Wars” with China (1839–1842 and 1856–1858) to open up that nation to opium exports from India (8). Cannabis, the most popular plant-based illegal drug, was cultivated—and also grew wildly—in at least four continents and until the 1920s “the large majority of countries did not have any controls at all” (9). However, the 1961 UN Single Convention on Narcotics Drugs virtually prohibited all production and distribution of many prominent psychoactive substances, including heroin, cocaine, and cannabis; it also prohibited possession. Since then, drug transactions have grown to form what is generally believed to be the largest illegal market globally. For the United States (US), an estimate for 2016, the latest available, was over $150 billion (10)." 

PerspectiveAugust 10, 2026

A descriptive analysis for the markets for counterfeit products

Product counterfeiting is a pervasive crime that involves the unauthorized use of a legitimate trademark, a violation of intellectual property rights. Counterfeiting is also one of many forms of global illicit trade, mirroring legitimate markets in ...

• Jay P. Kennedy

"US Customs and Border Protection reports (2) regarding intellectual property rights violations state that the most commonly seized counterfeit products at US ports of entry in 2024 were handbags/wallets (36% of all seizures), pharmaceuticals (27%), and apparel (7.4%). Other products seized included footwear, automotive parts, health and beauty products, and electronics like cell phones, computers, microprocessors, and circuit boards. While Customs seizure reports give an indication of the types of products identified and interdicted by law enforcement agencies, many more counterfeit products slip past customs agents and enter the market, including items like counterfeit aircraft parts, military equipment, weapons systems components, and even parts for nuclear reactors. "

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Some of these markets are also discussed in my recent book, 

Moral Economics: From Prostitution to Organ Sales, What Controversial Transactions Reveal About How Markets Work