Are vouchers appropriate for hard-to-match patient-donor kidney exchange pairs?

 A recent letter from Mayo Clinic transplant providers raises concerns related to bad outcomes when some patient-donor pairs are separated (the donor donates before the intended recipient is matched to a donor), but the intended recipient is hard to match.

Donor Mentoring in Private Kidney Paired Donation Programs: The Need for Transparency and Accountability by Tayyab S. Diwan, Pooja Bhudiraja, Shennen Mao, and Carrie Schinstock, Transplantation 110(7):p e1555-e1556, July 2026. | DOI: 10.1097/TP.0000000000005764 

"it is important to recognize that some KPD organizations, such as the National Kidney Registry, operate as private organizations (POs) with distinct governance structures, priorities, and commercial interests. These objectives may not always fully align with those of transplant centers or the broader transplant community, potentially creating gaps in transparency and accountability within a process that directly affects donors and recipients.

"We recently encountered a concerning example that illustrates the ethical tensions inherent when donor mentors are employed by private KPD organizations. ... During a routine text message check-in, the mentor initiated a discussion promoting voucher donation, emphasizing that voucher donors receive priority within the system.  

...
"The donor described the interaction as uncomfortable and “pushy,” and subsequently contacted our transplant center for guidance. Notably, the communication focused on system-level benefits and prioritization metrics but did not explore critical clinical and ethical considerations specific to this donor-recipient pair.

"The discussion was insufficiently individualized and appeared framed toward a preferred outcome. The donor’s preferences and the potential downsides of voucher donation were not explored. The mentor did not ask how the donor would feel if they proceeded with voucher donation and their intended recipient never received a transplant. The discussion lacked any reference to recipient factors that could influence the advisability of voucher donation, including sensitization or recipient comorbid conditions. There was also no discussion about why KPD was being used. Often the donor can donate directly to a recipient (eg, compatible pair), but may decide to enter a KPD pool temporarily to see whether the recipient could receive a transplant with improved size or HLA matching. Finally, the average wait times for a recipient to receive a transplant after voucher donation were not mentioned.

"This interaction raises concern about whether the mentor’s guidance was fully centered on the donor-recipient pair or instead influenced, even indirectly, by organizational incentives to increase voucher participation. When donor mentors are employed by entities that operationally benefit from particular forms of donation, even well-intentioned communication can create perceived or actual conflicts of interest. Transparency regarding these structural incentives, along with a clear commitment to individualized donor-centered mentoring, is essential to maintaining ethical integrity in these situations.

...

"As stewards of living donor trust, the transplant community must ensure that innovation proceeds with appropriate oversight. Any perception that donor education or support is influenced by business interests risks eroding public confidence in living donation programs, with potentially far-reaching consequences that could discourage future donors." 

#########

 Here's an article on NKR from the NYT that discusses its particular voucher program (and also its finances):

How One Father Created an Organ Empire: The National Kidney Registry has matched thousands of kidney donors with recipients. It has also paid millions of dollars to a company owned by its founder.
By Danielle IvoryGrace Ashford and Robert Gebeloff
Dec. 27, 2025 

 "One of N.K.R.’s most innovative policies, many doctors said, is known as voucher donation: Donors can choose to give their kidneys immediately, in exchange for organ vouchers their loved ones redeem later.

"This arrangement has helped N.K.R. expand its pool. But vouchers add risk for donors giving on behalf of hard-to-match patients. They might go through surgery months or even years before their loved ones get a match. Matches are especially unlikely, doctors said, for “very highly sensitized” patients who carry antibodies likely to reject a transplant.

...

" many doctors said that given N.K.R.’s relatively small size, these rare patients would be better served waiting for a match before their loved ones donate.

"“We definitely recommend that they not go with a voucher,” said Dr. Miklos Molnar, the medical director of the kidney transplantation program at the University of Utah, which works with N.K.R.

"Dozens of highly sensitized patients who are also on kidney dialysis have waited a year or more after their loved ones donated, according to N.K.R. quarterly reports since 2022. At least three waited more than four years, and one for seven years.

"Doctors told The Times that they knew of some patients who became too sick or died before they redeemed their vouchers."

######## 

Here's a a discussion of the earliest exploration of unpaired donation that I know of:

Sunday, September 13, 2020

A proposal for non-simultaneous kidney exchange in pairs and chains and with deceased donors...