Four international kidney exchange programs: 3 achieve substantial success

 Here's a paper reporting on the experience of four cross-border kidney exchange programs, whose experience teaches an important lesson.  In particular (see the figure below), one of  the programs is run by Spain, Italy and Portugal, whose  total population of approximately 118 million people is far larger than the combined population of the other three*, but manages to do less than 5% of the total cross-border exchanges, far fewer than any of the others.  Despite its size, the Spain-Italy-Portugal program only tries to match hard-to-match patient-donor pairs with other hard-to-match pairs, unlike the other three programs.

 International Kidney Paired Donation Programs: Evolution and Practices of 4 Large Collaborations
Klimentova, Xenia PhD1; Domínguez-Gil, Beatriz MD, PhD2; Viana, Ana PhD1,3; Manlove, David PhD4; Andersson, Tommy PhD5; Ashkenazi, Tamar RN, PhD6; Berlakovich, Gabriela MD7; Böhmig, Georg A. MD8; Burton, Jo RN, PGDip9; Coll, Elisabeth MD, PhD2; Dittmer, Ian FRACP9; Fiaschetti, Pamela MD10; Fronek, Jiri MD, PhD11; Hughes, Peter D. MBBS, PhD12,13; Ivo da Silva, Margarida MD14; Mor, Eytan MD15; Viklický, Ondřej MD, PhD16; Weinreich, Ilse Duus BMLS17; Ferrari, Paolo MD, FRACP18,19
Transplantation ():10.1097/TP.0000000000005602, December 24, 2025. | DOI: 10.1097/TP.0000000000005602

"Plain Language Summary: Kidney paired donation (KPD) programs are organized in various countries to facilitate the donation of kidneys from willing but incompatible donors by matching them with pairs in similar situations. These programs often struggle with an accumulation of difficult-to-match recipients and small pools of incompatible pairs. To address this, several international collaborations have emerged to expand the pool sizes and increase the number of transplants by “exchanging” donors’ kidneys across countries. We identified 4 established international KPD programs, each supported by protocols and agreements signed by the participating parties. Each program is presented separately, detailing its historical establishment, operational aspects, and statistics on pool characteristics and performance. Following this, we provide a comparative analysis of key aspects across the 4 programs. Each program has its unique context and specificities. Even though 3 of 4 collaborations started just before the COVID-19 pandemic, they have collectively facilitated >450 transplants. This underscores the importance of further developing these collaborations to share practices and experiences, and to facilitate more transplants, particularly for difficult-to-match recipients. Three of the 4 presented collaborations are either fully operated or led by European countries. This highlights the crucial role of ongoing international cooperation in the development of KPDs, in particular in Europe. By further promoting collaboration among countries, we can facilitate pan-European exchanges and improve access to live kidney transplants for patients in need.

 ...

"A fundamental difference between the programs is their collaboration model. STEP, ANZKX, and the Czech-Austrian-Israeli collaboration operate as “merged pool” model, where all participating pairs are combined for joint matching runs. For STEP and ANZKX, no other matching runs are conducted by partners at any level (hospital or national), whereas in the Czech-Austrian-Israeli collaboration, the Austrian and Israeli partners report performing local exchanges whenever compatible pairs are identified.
 

"In contrast, KEPSAT uses a “sequential pool” model, where national matches are attempted first, and only unmatched pairs are entered into the international pool. It is recognized that the last 2 strategy strategies may lead to a fragmented market, potentially limiting matches for highly sensitized patients, as easier-to-match pairs are removed beforehand."

 It's ironic that a program that appears to be intended primarily to help hard-to-match pairs is organized in a way that limits them in this way.

The paper concludes on an optimistic note (with which I fully agree):

"In conclusion, ongoing international cooperation is essential for advancing KPD programs globally. Expanding cross-border exchanges and improving access to kidney transplants can greatly benefit patients worldwide. Additional strategies, such as NDADs, desensitization protocols, and the inclusion of compatible pairs, can further enhance the effectiveness of both national and international programs. Oversight of these initiatives is crucial to safeguarding the welfare of both donors and recipients, as well as to maximizing the success rates of kidney transplants.
 

"Looking ahead, new initiatives, and projects, funded by international health organizations, such as the European Kidney Paired Exchange Programme project (https://www.hnbts.hu/euro-kep/project), funded by EU4Health and starting in November 2024, aim to expand global collaboration among KPD programs, building on and strengthening existing partnerships. This increased international cooperation is expected to create additional opportunities for patients in need of kidney transplants worldwide, making life-saving transplants accessible to more individuals regardless of their geographic location."

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Earlier: Portuguese transplant docs noted the problem and argued for more global kidney exchange:

Tuesday, March 12, 2024 Kidney exchange between Portugal and Spain, and prospects for global kidney exchange

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*Notes on population:

Spain: 49 million; Italy 59 million; Portugal 10 million ; KEPSAT total pop =  approx 118 million

 Australia 28 million; NZ 5 million: ANZKX total pop approx 33 million

Austria: 9 million, Czech Republic  11 million, Israel 10 million: AT-CZ-IL total 30 million

Sweden: 11 million; Norway:  6 million; Denmark 6 million; Finland  6 million: STEP total approx 29 mil

Jewish cemetery and Pinkas synagogue in Prague

 During our visit to Prague in May we visited the Old Jewish Cemetery, crowded with the dead from the historic Jewish Ghetto.

 We also visited the Pinkas synagogue, whose walls are covered with the names of those murdered in the Shoah, with their birth dates and death dates.  The birth dates reveal a vibrant community, from small children to senior citizens.  The dates of death are all from 1942 to 1944.

 

Notes from Prague (kidney exchange, market design, and progress on a new book)

I flew back to California yesterday, after spending some time in Czechia and Italy talking about kidney exchange.  Here is a video of the public talk I gave at Prague Castle.  Among other things it highlights the Czech kidney exchanges with Israel. (I had the pleasure of meeting  Prof. Jiri Fronek, the distinguished surgical pioneer who led the Czech side of that effort.)

https://youtu.be/jrrlNWMkQyE?feature=shared

I also had the privilege of visiting CERGE-EI  (Center for Economic Research and Graduate Education - Economics Institute) where my host was Prof  Štěpán Jurajda.  He and I first met when we were both at the University of Pittsburgh in the 1990s.

And here's an interview with the Economic newspaper  Hospodářské noviny  that starts off with the optimistic notion that I may have just (largely) completed the draft of a new book:)

Zkoumá trhy, kde peníze nevládnou. Ledvinu ani lásku si za ně většinou nekoupíte, říká nobelista Alvin Roth [ He explores markets where money doesn't rule. You can't usually buy a kidney or love with it, says Nobel laureate Alvin Roth]

“Before flying from the USA to Prague, economist and Nobel laureate Alvin Roth managed to send the publisher a draft of his new book, which he is currently finishing. He calls it Controversial Markets. Between an afternoon lecture for students at the CERGE-EI Institute in Prague and an evening lecture at Prague Castle, he also found time for an interview with Hospodářské noviny, in which he outlines what his new book will be about. One of the controversial markets he deals with, for example, is the organ transplant market."

Public Lecture on Market Design at Prague Castle, Wednesday, 7 May, 6 p.m

 I'll be speaking at Prague Castle: here's the official announcement:

Science at the Prague Castle: Who Gets What? The New Economics of Matching and Market Design 

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Speaker: Alvin Roth 

Al Roth is the Craig and Susan McCaw Professor of Economics at Stanford University and the George Gund Professor Emeritus of Economics and Business Administration at Harvard. He shared the 2012 Nobel memorial prize in Economics. He was President of the American Economic Association in 2017, and is a member of the National Academy of Science. He directed the redesign of the National Resident Matching Program, through which most American doctors find their first employment. He helped design the school choice systems used in several large American cities. He is one of the organizers and designers of kidney exchange in the United States, which helps incompatible patient-donor pairs find compatible kidneys for transplantation.   

*
Science-popularizing lecture from the series Science at the Prague Castle

Market design is an ancient human activity but a relatively new part of economics. It seeks to understand how the design of markets and marketplaces influences their performance, and to use this growing understanding to fix markets when they're broken, and to help establish markets where they are missing.  Many markets are matching markets, in which you can't just choose what you want, even if you can afford it: you also have to be chosen. In these markets, prices don’t do all the work. Examples of matching markets are labor markets (workers can't just choose where to work, nor can employers just choose who will work for them), school choice, and kidney exchange. I'll illustrate with examples from these. 

The lecture will be given in English.

Organized by Prague Castle Administration, Institute of Organic Chemistry and Biochemistry  of the CAS, and Charles University. Supported by IOCB Tech Foundation.

Date and place

Wednesday, 7 May, 6 p.m.
Lecture takes place in the lecture room in the Supreme Burgrave´s House
(entrance from the Golden Lane)
map

If you are interested in this lecture, please make reservation here.   Free admission

Kidney Exchange among Austria, Czech Republic, and Israel

 Here's an article that includes description of the joint Austria, Czech Republic and Israel kidney exchanges.

Böhmig, Georg A., Thomas Müller‐Sacherer, and Ondrej Viklicky. "Kidney Paired Donation—European Transnational Experience in Adults and Opportunities for Pediatric Kidney Transplantation." Pediatric Transplantation 28, no. 6 (2024): e14840.

"One approach to expanding the pool, akin to deceased donor kidney transplantation through the transnational Eurotransplant Organization, involves the establishment of cross-border KPD joint programs. In Europe, several joint programs have successfully conducted such transplants, one of which is the Scandiatransplant Exchange Program, inaugurated in 2019. As of February 2023, this program has facilitated 49 transplantations [29]. Another transnational initiative, the focus of this article, is the joint program involving Austria, the Czech Republic, and Israel. This collaboration resulted in the first transnational live donor kidney exchange in Europe, a two-way exchange between Vienna and Prague in 2017 [30].

"The Vienna and Prague Kidney Paired Donation (KPD) programs were merged in 2015 following a consensus on medical, psychological, and immunological requirements [23]. ... Both programs agreed on a binational algorithm, utilizing a computer algorithm developed in Prague. This algorithm not only facilitates the calculation of ABO-incompatible combinations but also includes the option of Non-Directed Altruistic Donor (NEAD) chains initiated by altruistic donors [23].

...

"Recent developments in the transnational program include its expansion to additional centers. Prague initiated a transnational cooperation with the national KPD program in Israel, successfully conducting the first ring exchange in 2019. In this context, transplantations cannot be realized simultaneously due to the financial burden associated with the need for two private flights. Later, this cooperation extended to the Vienna center, leading to the first exchange between Vienna and Israel in 2022, involving a simultaneous three-way chain with one Vienna and two Israel pairs. Innsbruck has also joined the international KPD program as a second Austrian center, participating in local exchanges and one 2-way exchange with Prague (2020). A good example of different approaches in timing of surgeries among Prague and Israel centers (non-simultaneous) in one hand and Vienna (simultaneous surgeries) in the other hand is Czech-Austrian-Israel international NEAD chain initiated in Prague which has lasted for several years, prioritized smaller exchanges and has not been terminated so far. Such a NEAD chain used both altruistic and bridge donors in Prague. Terminated NEAD chain may allow to prioritize patient at special need. For example, our short 3-country NEAD chain was terminated to offer transplantation to a previous kidney donor who donated 20 years ago but unfortunately developed end stage kidney disease. Such approach may have implications also in pediatrics."

Kidney exchange between Israel and the Czech Republic

 The Jerusalem Post reports another kidney exchange between Israel and the Czech Republic:

Miraculous kidney donation between friends spans continents and save lives. The complex and sensitive cross-continental operation required coordination between senior officials in both countries.   https://www.jpost.com/international/article-804396   By JERUSALEM POST STAFF  MAY 30, 2024 18:39

"it was soon discovered that Glaor was not a direct match for a transplant, and their medical details were entered into the National Transplant Center's cross-matching database. The entry resulted in an international kidney transplant exchange in which Glaor donated his kidney to a patient in the Czech Republic, and the wife of the Czech patient donated her kidney to Shitrit.

"The complex and sensitive cross-continental operation required coordination between senior officials in both countries, with an emphasis on the precise timing of operating rooms, flights, and quick security and customs arrangements.

"The operation began in the middle of the night at the Hadassah University Medical Center in Jerusalem’s Ein Kerem. It was managed and coordinated by the National Transplant Center.

"Dr. Tamar Ashkenazi, director of the National Transplant Center, was in charge of coordinating the transplant.  Alongside her on the flight to Prague were coolers containing two kidneys that were removed overnight from two Israeli donors at Hadassah Ein Kerem, which were intended for transplantation in two Czech patients. 

"In the evening, at around 10 p.m., the transplants in Israel were completed, and the Czech kidneys successfully functioned in the bodies of the Israeli recipients, as reported similarly from Prague regarding the Israeli kidneys that were transplanted in the Czech Republic.

""We planned the process precisely, and were in constant contact with our counterparts in the Czech Republic regarding the surgical issues. Every action that takes place is critical and impacts the continuation of the operation," said Dr. Ashraf Imam, a senior surgeon in the transplant unit at Hadassah, who participated in the transplant operation."

Celebrating the 30th Anniversary of CERGE-EI: Supporting Excellence in Economic Research and Education in Post-Communist Societies

In 1990, when I was on the faculty of the University of Pittsburgh (where I happily taught from 1982-1998), my colleague Jan Svenjar was instrumental in founding  a graduate program in Economics at Charles University, which soon after became  CERGE-EI, which is now about to celebrate it's 30th anniversary.  It is an appropriate time once again to be thinking about post-communist Europe.

Celebrating the 30th Anniversary of CERGE-EI: Supporting Excellence in Economic Research and Education in Post-Communist Societies

Tuesday, April 26, 2022 ● 4:00 p.m. Bohemian National Hall, 321 East 73rd Street, New York City

CERGE-EI has reached a pivotal moment of change in its history. The 30th Anniversary Celebration of CERGE-EI, hosted by the CERGE-EI U.S. Foundation in conjunction with the Consulate General of the Czech Republic in New York, will be both a reflection of CERGE-EI’s impact over the last thirty years and an opportunity to lay out our vision for the future.

The war in Ukraine and its impact on the surrounding region have established that the Cold War whose ending we celebrated more than 30 years ago has revived and is heating up. Now more than ever, initiatives to raise the standards of economics education and leadership have a critical role to play in supporting national and regional stability.

For the 30th Anniversary, we are honored to be supported by a Host Committee of Nobel Memorial Prize in Economic Sciences Laureates.

Professor
Francis Fukuyama

Professor
Deirdre McCloskey

Professor
Sir Angus Deaton

Professor
Paul Krugman

Professor
Branko Milanović

Professor
Jeffrey Sachs

Professor
Jan Švejnar

International kidney exchange between Israel and Czech Republic

The news embargo is over for last week's kidney exchange chain between Israel and the Czech Republic. (On the Israeli side, the necessary software was supplied by Itai Ashlagi, here at Stanford.)

Itai writes:
"Some background: in August 2019 there was an agreement between Israel and Czech republic to check the possibility of kidney exchanges. This was initiated by Prof. Eitan Mor from Israel  and Dr. Proniak from the Czech Republic and the whole operation was conducted by the national Israeli center for transplantation led by Dr. Tamar Askenazi and their counterpart in Czech republic."

The Israeli database contains a list of all pairs, and uses kidney exchange software donated to Israel by Itai Ashlagi and Sukolsak Sakshuwong.   Czech software was used in Prague to identify the chain.

Here's the story from News1 in Israel:

6 transplants thanks to the exchange of kidney donations between Israel and the Czech Republic

"At 5 a.m., two kidneys from two donors were removed from Beilinson Hospital. One kidney was packed in ice cooler and transported by ambulance to Ben Gurion Airport.

"About an hour after taking off from Israel, an operation to remove a Czech donor kidney was started at the Prague Hospital. At the same time, Bilinson's second kidney was transplanted, and surgery was performed to remove a kidney at Hadassah Hospital – which was transported by ambulance to Bilinson's transplant.

"At 12:30 the kidney cooler from Israel landed at the Prague airport. A vehicle was waiting by the plane and moved to the mirroring spot. At this point, Dr. Jiri Froniac, director of the Prague Transplant Program and Dr. Ashkenazi from Israel, met and exchanged documents while the coolers were [scanned].

"At the same time, the kidney from Hadassah Hospital was transferred to Beilinson for a transplant. An hour later, the Israeli plane took off from Prague back to Israel with a cooler containing the kidney from the Czech donor. The kidney came to the operating room in Hadassah and before the evening was transplanted in a patient.
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Diagram of the exchange between IKEM in the Czech Republic and Hadassah and Beilinson Hospitals in Israel

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Here's the story in the Jerusalem Post (I don't have a link yet, this is a picture):

And see this related older story about Itai Ashlagi's software:

New software to help increase kidney matches for transplants

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And here is the story in the Czech news, forwarded by Pavel Chromy.

Čeští lékaři poprvé provedli párovou výměnu ledvin s Izraelem
[Google translate: Czech doctors first performed paired kidney replacement with Israel]
"In the first half of December, doctors from the Prague Institute of Clinical and Experimental Medicine (IKEM) and two Israeli hospitals performed their first paired kidney exchange between the two countries. Three beneficiaries from the Czech Republic and three from Israel received the new authority. This is the first time a pair exchange has taken place with a non-European country, said IKEM director Michal Stiborek at a press conference."