Kidney exchange developments in India, Brazil, Saudi Arabia and Germany

 Here are recent reports on kidney exchange from  India, Brazil, Saudi Arabia and Germany.

 Atul Agnihotri: SOMETHING REMARKABLE IS HAPPENING IN KIDNEY TRANSPLANTATION IN INDIA.

"Through collaboration with 63 transplant centers, APKD India enabled 130 kidney swap transplants in 2025, quietly becoming ONE OF THE LARGEST KIDNEY SWAP PROGRAMS outside the U.S.

And the momentum continues — January has already kicked off with 22 swap transplants.

A powerful reminder that when hospitals collaborate, more patients receive the gift of life.

"One Nation, One Swap."

https://lnkd.in/gZD6Q-md "

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Here's an article on the clinical trials of kidney exchange in Brazil, in preparation for a possible change in the transplant law to make it standard practice. 

Doação Renal Pareada (DRP) no Brasil: relato do primeiro caso envolvendo três duplas    Kidney Paired Donation (KPD) in Brazil: first 3-way case report   by Juliana Bastos, Glaucio Silva de Souza, Marcio Luiz de Sousa, Pedro Bastos Guimarães de
Almeida, Thais Freesz, David Jose de Barros
Machado, Elias David-Neto, Gustavo Fernandes Ferreira   https://doi.org/10.1590/2175-8239-JBN-2025-0177pt

 Abstract: Kidney Paired Donation (KPD) is a transformative strategy in living kidney donor transplantation (LDKT), particularly for overcoming immunological barriers that preclude direct donation. In 2021, KPD accounted for one-fifth of adult LDKT and for half of LDKT for sensitized recipients in the United States. In Brazil, with a high prevalence of chronic kidney disease (CKD) and over 30,000 patients on transplant waiting lists, the demand for compatible donors far exceeds supply. This article presents a case report of KPD in the Brazilian context, illustrating its feasibility and highlighting challenges and considerations for broader implementation. The case demonstrates KPD’s potential to increase transplant rates, improve outcomes, and reduce dialysis costs. Nevertheless, structural, ethical, and regulatory challenges remain. This report emphasizes the implications of expanding KPD as a sustainable, life-saving strategy in Brazil.

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Here's a report from  King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia: 

Almeshari, K.A., Broering, D.C., Obeid, D.A., Alali, A.N., Algharabli, A.N., Pana, N.L. and ALI, T.Z., Innovative Strategies in Kidney Paired Donation: Single-Center Experience Achieving the Highest Annual Transplant Volume Globally. Frontiers in Immunology, 17, p.1623684. 

"Methods: We analyzed all kidney transplants performed through our KPD program between January and December 2024. The program aimed to achieve full HLA and ABO compatibility for incompatible pairs, while also incorporating additional strategies: inclusion of compatible pairs to improve HLA matching, acceptance of ABO quasi-compatible matches (e.g., A2 donors to O or B recipients), low-risk HLA-incompatible matching for HLA-incompatible candidates with cPRA >80%, and ABO-incompatible matching for those with cPRA >95%.

Results: A total of 135 patients (121 adults, 14 pediatrics) underwent KPD-facilitated transplantation, including 69 HLA-incompatible (51.1%), 37 ABO-incompatible (27.4%), and 29 compatible (21.5%) pairs. Females comprised 60.7% of the cohort, with a significantly higher proportion in the HLA-incompatible group (p < 0.001). HLA-incompatible recipients were older than others (mean age 42.5 years, p < 0.001). Most transplants (93.3%) occurred through 2- to 5-way closed chains, with the remainder via domino chains (6.7%). 

...

Conclusion: Our single-center experience demonstrates the feasibility and effectiveness of a high-volume KPD program in overcoming immunologic barriers to kidney transplantation. Strategic inclusion of compatible pairs, ABO quasi-compatible matching, low-risk HLA-incompatible, and ABO-incompatible matchings significantly increased access for difficult-to-match recipients. This model may serve as a replicable framework for other high-capacity transplant centers seeking to expand transplant access and improve outcomes for complex patient populations. "

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And here's a report on proposed German legislation to (finally) make kidney exchange legal in Germany: 

Biró, P., Budde, K., Burnapp, L., Cseh, Á., Kurschat, C., Manlove, D., & Ockenfels, A. (2026). Germany's Path to a National Kidney Exchange Program: An Assessment of the 2024 Legislative Proposal. Health Policy, 166, 105578. 

"Highlights

The German Federal Parliament plans to amend the Transplantation Act (1997).
•
The main goal of the reform is to establish a national kidney exchange program.
•
The draft law follows European best practices in many respects.
•
However, the law prohibits the participation of compatible donor–recipient pairs, contrary to international evidence.
•
Germany may join cross-border kidney exchange programs in the future. "

 

Big drop in international students coming to US (particularly from India)

 The Chronicle of Higher Ed has the story:

The Drop in International Students Last Year Was Worse Than We Thought  By Karin Fischer 

  

 

 

Kidney exchange in India (one minute video)

In India, which already does the third most kidney transplants in the world (after the US and China), physicians and surgeons are making great progress on kidney exchange.

  Some of this progress is with the help of the Alliance for Paired Kidney Exchange (APKD), supported by a grant from Stanford Impact Labs (SIL)

 Here's a short video about that collaboration, narrated by Mike Rees, the founder and guiding light of the APKD.

 The picture below was taken just after Mike Rees (on the left) and I observed a robotic kidney transplant surgery performed by  Dr. Pranjal Modi (on the right), in Ahmedabad 

 

  

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Earlier:

Thursday, January 22, 2026  Kidney exchange in Brazil (a clinical trial)

 

Tobacco banned in Indian state of Odisha

 Here's the story from the Times of India, Govt notifies ban on all chewable tobacco, nicotine products | Bhubaneswar News - The Times of India.  It remains to be seen how enforceable a statewide ban will be. (Local bans on something as addictive as nicotine are likely to face black markets sourced from neighboring jurisdictions without a ban.)

 

  

 

Are transplants too scarce, or not scarce enough? A surprising debate about India

 India, now the most populous country in the world, does the third highest number of kidney transplants in the world (although their rate of transplantation per million population is quite low).  So transplants are nevertheless very scarce in India compared to the need, which is the situation worldwide.

Earlier this year, however, a paper by three veteran (non-Indian) transplant professionals who have headed large organizations expressed repugnance for the volume of transplants in India, and the fact that it depends mostly on living donor transplantation (LDT), suggesting it can be viewed as "both alarming and reprehensible."  Their paper's title makes it clear how they view it. 

Domínguez-Gil, Beatriz, Francis L. Delmonico, and Jeremy R. Chapman. "Organ transplantation in India: NOT for the common good." Transplantation 109, no. 2, February, 2025: 240-242. 

"The field of organ transplantation has evolved very differently across the world under the influence of different national healthcare financing systems. Healthcare is, in most countries, financed by taxation and thus through governmental budgets, in combination with private funds, mostly through contributory health insurance systems (eg, Australia, Canada, Europe, New Zealand, South America, and the United States). But across much of Asia, tertiary healthcare services, such as transplantation, are almost entirely dependent on the private finances of individuals. The impressive growth in Indian organ transplantation has been accomplished in for-profit hospitals, which have expanded Indian transplantation into 807 facilities, mostly associated with the major corporate hospital chains.6 Organ transplantation, in a part of the world where one-fifth of all people live, is thus largely not for the common good, but a treatment available for those with ample monetary resources." 

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 This was followed by a firm rebuttal by distinguished Indian transplant professionals.  Their title makes their view equally clear:

Rela, Mohamed, Ashwin Rammohan, Vivek Kute, Manish R. Balwani, and Arpita Ray Chaudhury. "Organ Transplantation in India: INDEED, for the Common Good!." Transplantation 109, no. 6 (2025): e340-e342. 

 "We were deeply concerned by the article “Organ Transplantation in India: NOT for the Common Good” by Domínguez-Gil et al,  which we felt provided an unfairly critical view of the current state of organ transplantation in India. We aim to provide a point-by-point rebuttal based on actual figures and ground-reality rather than tabloid-press articles as cited by the authors.
 

"It is true that in the past 5 y, there has been an extraordinary growth in the number of transplantations in India (more than those achieved over several decades by European countries). While it is natural to be wary of this astronomical increase in transplant numbers, the authors’ assumption that this growth is likely nefarious reflects an outdated western mindset, rather than a true understanding of over 2 decades of massively coordinated effort by the Government of India, transplant professionals and all other stakeholders in the country. 

...

" The development of LDT has been presented with a negative connotation. This shows a scant understanding of the geo-socio-political idiosyncrasies prevalent in the Asian region, and unlike the west, its conventional dependence on LDT.

 ...

"The authors have further confused LDT and deceased donor transplantation with regards to foreigners having access to organs in India. The authors’ accusation of deceased donor organs being preferentially allocated to foreigner is presumptuous at best. The current organ allocation system under the aegis of the Government of India and state-wise organ transplant governing bodies is a very transparent process—and is reserved for Indian nationals.

...

" Transplant tourism being equated with organ commerce is erroneous, the authors’ fail to understand that many poor countries find India a more financially viable destination to get a transplant than countries in the west. Even affordable Governments in the middle east are moving to the east for transplantation, where the ministries have a direct tie-up with transplant units. 

"While it should be conceded that transplantation in India may not be available to all, true social upliftment necessitates broader initiatives beyond just immediate transplant availability: that of addressing poverty. Nonetheless, access to transplants for the underprivileged has greatly improved over the past decade. There are several public sector hospitals in the country that routinely provide transplantation services. In 2023, in the state of Tamil Nadu, 35.1% of all deceased donor renal transplants were performed for free in public sector hospitals (Table 1). 5 While traditionally, the private pay-from-pocket healthcare has been only for those with the resources, the central and several state governments (Tamil Nadu, Andhra Pradesh, Gujarat, etc) sponsor an all-inclusive healthcare state insurance for the poor, which includes transplantation at any approved private hospital in the state; which includes LDT.

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I'm on my way to a conference in Cairo that is motivated in part by concern that healthcare in low and middle income countries has been impeded by some of the international healthcare organizations' lack of understanding or empathy for their situations. 

Abhijit Banerjee's column on food and economics, in The Times of India

 Abhijit Banerjee writes a monthly column on food (cooking it and eating it) and economics, in The Times of India

You can see them all at the link, but here's a recent example:

Trade wars and chocolate bars, what India of the 1970s can teach Trump  May 31, 2025,  Abhijit Banerjee in Tasting Economics

"One advantage/disadvantage of being old is that I lived through what is history to so many others. President Trump adores William McKinley, the 25th US president, for his tariffs, but at 78, he is way too young to have lived behind a properly high tariff wall. I, on the other hand, lived in the India of the 1970s, when we had managed to kill almost all international trade through a combination of tariffs and other rules for importing (non-tariff barriers in trade parlance).

I mostly experienced trade barriers through the important lens of chocolate."

Kidney and liver exchange in India

 Here's an update from Dr. Vivek Kute and his colleagues on kidney and liver exchange in India.

Kute, V. B., Patel, H. V., Banerjee, S., Aziz, F., Godara, S. M., Bansal, S. B., ... & Srivastava, A. (2025). Analysis of kidney and liver exchange transplantation in India (2000–2025): a multicentre, retrospective cohort study. The Lancet Regional Health-Southeast Asia, Volume 37, June 2025, 100597. 

One Nation One Swap: National kidney exchange in India

 In India, the National Organ and Tissue Transplant Organization (NOTTO) wrote this week to all the State organizations (the SOTTOs) announcing the plan to form a nationwide kidney exchange program, called the "Uniform One Nation One Swap Transplant Program."

This has been the work of many people for a long time.  Of particular importance has been and will continue to be Dr. Vivek Kute from IKDRC Ahmedabad

 Here's the story in the Hindustan Times.

 NOTTO writes to states, UTs to implement swap organ transplant

Here's the letter itself:

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Earlier post:

Tuesday, February 27, 2024  Stanford Impact Labs announces support for kidney exchange in Brazil, India, and the U.S.

Kidney transplant black market in Myanmar

 BBC Burma has the story (I guess they haven't updated their country name...no doubt they still refer to the Gulf of Mexico, too:) 

The story is about Burmese people purchasing a kidney from other Burmese people, after which they both travel to India for the surgeries, which involves pretending to be relatives.

Myanmar villagers reveal 'desperate' illegal kidney sales, BBC Burmese 

"Zeya, whose name has been changed to conceal his identity, knew of local people who had sold one of their kidneys. "They looked healthy to me," he says. So he started asking around.

"He is one of eight people in the area who told BBC Burmese they had sold a kidney by travelling to India.

...

"Buying or selling human organs is illegal in both Myanmar and India, but Zeya says he soon found a man he describes as a "broker".

"He says the man arranged medical tests and, a few weeks later, told him a potential recipient - a Burmese woman - had been found, and that both of them could travel to India for the surgery.

"In India, if the donor and recipient are not close relatives, they must demonstrate that the motive is altruistic and explain the relationship between them.

...

"He says the broker made it appear as if he was donating to someone he was related to by marriage: "Someone who is not a blood relative, but a distant relative".

...

Zeya says he was told he would receive 7.5m Myanmar kyats. This has been worth somewhere between $1,700 and $2,700 over the past couple of years

...

" he flew to northern India for the operation and it took place in a large hospital. ... he stayed in hospital for a week afterwards.

...

"The BBC last heard from Zeya several months after his surgery.

"I was able to settle my debts and bought a plot of land," he said.

But he said he couldn't afford to build a house and had not been able to construct one while recovering from the surgery. He said he had been suffering from back pain.

"I have to restart working soon. If the side effects strike again, I have to deal with it. I have no regrets about it," he added.

He said he stayed in touch with the recipient for a while, and she had told him she was in good health with his kidney.

Speaking on condition of anonymity, she told the BBC she paid 100m kyats (between around $22,000 and $35,000 in recent years) in total. She denied that documents were forged, maintaining that Zeya was her relative."

 

HT: Colin Rowat

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Earlier, also on the Myanmar/India black market

Thursday, December 21, 2023

Cash for kidneys report in the Telegraph

Cheating on exams in India , and exam design suggestions from Spain

 India, where government jobs are allocated based on scores on a variety of national exams, cheating is a big business. One form it takes is sale of upcoming exam questions. 

An experiment conducted in Spain by Klijn, Alaoui, and Vorsatz, which introduced multiple versions of an online exam, suggests that this may reduce cheating by people who take the exam after others have already taken it.

 From the NYT:

These Exams Mean Everything in India. Thieves See a Gold Mine.
In a country where government jobs are highly coveted, the tests that govern hiring are a lucrative target for criminal gangs. By Mujib Mashal and Hari Kumar

 "Allotting jobs on the basis of exam results conveys a sense of fairness. But with competition so fierce, the temptation to seek shortcuts can be strong.

"Some aspirants, while spending long hours in study groups, also keep an eye out for shadowy figures offering access to exams.

 

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From the Indian Express

Bill in Lok Sabha to check paper leaks, use of unfair means in govt recruitment exams
At present, there is no specific substantive law to deal with unfair means adopted or offences committed by various entities involved in the conduct of public examinations by the central government and its agencies. 

"The Public Examinations (Prevention of Unfair Means) Bill, 2024, introduced by Union Minister of State for Personnel Jitendra Singh, mentions “leakage of question paper or answer key”, “directly or indirectly assisting the candidate in any manner unauthorisedly in the public examination” and “tampering with the computer network or a computer resource or a computer system” as offences done by a person, group of persons or institutions."

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 And here's an experiment with exam design, involving a Spanish exam:

Online Academic Exams: Does Multiplicity of Exam Versions Mitigate Cheating?  by Flip Klijn,  Mehdi Mdaghri Alaoui, and Marc Vorsatz

Abstract: We study academic integrity in a final exam of a game theory course with 463 undergraduate students at a major Spanish university. The exam is an unproctored online multiple-choice exam without backtracking. A key characteristic is that for each (type of) problem, groups of students receive different versions. Moreover, each problem version is assigned to one subgroup during one stage of the exam and to another subgroup during an immediately consecutive later stage. Thus, we can exploit grade points and timestamps to study students’ academic integrity. We observe a significant decrease in completion time at each later stage; however, surprisingly, there is no corresponding impact on average grade points. The precise number of different versions does not seem to have an effect on either variable. Our findings thus suggest that employing a limited number of distinct problem versions (as few as two) can diminish cheating effectiveness in online exams."

More on non-anonymous kidney exchange in India

 Here's some further description of how kidney exchange is conducted in India without authorization* to use nondirected donors (so that all exchanges are conducted in cycles, i.e. in the absence of chains of exchange).

Vivek B. Kute, Himanshu V Patel, Subho Banerjee,Divyesh P Engineer, Ruchir B Dave, Nauka Shah, Sanshriti Chauhan ,Harishankar Meshram , Priyash Tambi  , Akash Shah, Khushboo Saxena,Manish Balwani , Vishal Parmar, Shivam Shah, Ved Prakash ,Sudeep Patel, Dev Patel, Sudeep Desai, Jamal Rizvi , Harsh Patel, Beena Parikh, Kamal Kanodia, Shruti Gandhi, Michael A Rees,  Alvin E Roth,  Pranjal Modi “Impact of single centre kidney-exchange transplantation to increase living donor pool in India: A cohort study involving non-anonymous allocation,”Nephrology, September 2024, https://onlinelibrary.wiley.com/doi/10.1111/nep.14380  

"In India, 85% of organ donations are from living donors and 15% are from deceased donors. One-third of living donors were rejected because of ABO or HLA incompatibility. Kidney exchange transplantation (KET) is a cost-effective and legal strategy to increase living donor kidney transplantation (LDKT) by 25%–35%.

"3.3 Non-anonymous allocation

"The THOA*, which regulates KET in India, is silent on the need for anonymity, so there is no legal requirement for anonymity in India, as compared with other countries, such as the Netherlands and Sweden. Our experience was that 90% of iDRP [incompatible Donor-Recipient Pairs] requested the opportunity to meet their matched donor and recipient pair (mDRP) and 10% asked the treating physician to decide if they should meet. None of the iDRP requested anonymity. Therefore, we have practiced absolute non-anonymity, meaning that all mDRPs meet and share medical reports after a potential exchange is identified, but before the formal allocation of pairs. If an iDRP requests anonymity, we would be willing to accommodate them, but to date, none have done so.

"Upon meeting with their mDRP, the iDRP can refuse the proposed exchange option without reason and continue to be on the waitlist and active in the KET pool. iDRPs must complete transplant fitness and legal documents required for transplant permission from the health authority before they are given the opportunity to meet their mDRP. A meeting between mDRPs occurs in the presence of a transplant physician, who can help solve any query before the proposed match is accepted by the involved pairs. iDRP are introduced to their mDRP prior to scheduling transplants to avoid chain collapse due to iDRP refusal of the mDRP. The mDRP shares medical reports of donors with each other, can also discuss with their other family members, and consults with their family physician/nephrologist before deciding whether to proceed. Living kidney donors are fully informed of perioperative and long-term risks before making their decision to donate. In India, donor age group matching is most commonly expected for all iDRP in the KAS."

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Earlier:

Monday, September 18, 2023

Kidney Paired Donation in Developing Countries: a Global Perspective

*Here's the THOA, THE TRANSPLANTATION OF HUMAN ORGANS AND TISSUES ACT, 1994

Blood donation by family members in India: LGBT donors still banned

 In India, where the shortage of blood supplies is addressed by having family members donate, the ban on donation by LGBT people is a serious constraint.

The BBC has the story:

LGBT Indians demand end to 'discriminatory' ban on blood donation  by Umang Poddar

"In 2018, India's top court legalised gay sex in a landmark ruling - but the country still doesn't allow transgender people and gay and bisexual men to donate blood.

"People from the LGBT community say the decades-old ban is "discriminatory" and have gone to court to challenge it.

...

"Activists argue that apart from it being discriminatory, the ban is also irrational because of the high demand for blood transfusions in the country.

"A study published by the Public Library of Science in 2022 estimated that India faced an annual deficit of around one million units of blood."

HT: Vincent Jappah

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Earlier:

Tuesday, November 28, 2023

"Professional blood donors" in India (where paying blood donors is illegal)

Expanding kidney exchange in India

 The Ahmedabad Mirror reports on the success of kidney exchange at the Trivedi Institute in that City, and on discussions underway to build a national kidney exchange infrastructure in India.

City Tops In India. City’s IKDRC Accounts For 539 Swap Transplants Out Of 1,808 Such Surgeries In India Till Date

"Ahmedabad leads India in the number of Kidney Paired Donations (KPD) or ‘kidney swap transplants’ carried out till date, having conducted 539 such surgeries out of 1,808 in 65 hospitals in India, shows data from the registry made by the Indian Society of Organ Transplantation (ISOT). These include two pairs of surgeries conducted in 2024 so far.

"Gujarat accounted for 565 such transplants of which 539 were conducted at the state-run Institute of Kidney Diseases and Research Centre (IKDRC) in Ahmedabad.

"In fact, in 2013, doctors and staff at IKDRC conducted 10 kidney swap transplants in a day, operating on 10 donors and 10 recipients in a 24-hour period.

"One Nation, One Swap?

"Mirror has now learnt that a consultation on whether a national Kidney Paired Donation programme should be instituted or not, and what should be its guidelines. 

"This is currently under deliberation between stakeholders at the National Organ and Tissue Transplant Organisation (NOTTO).  

"Its director, Dr Anil Kumar, told Mirror, “It is currently at the conceptual stage and in-principle discussions are underway for a swap organ transplant programme and guidelines are yet to be framed on this issue.”

"If implemented, the biggest benefit will be decrease in waiting period for those on dialysis and waiting list due to an incompatible donor if they match with a swap pair. This will also decrease the number of patients on the transplant waitlist.

"However, there are many challenges to this. Apart from the safeguards regarding consent and transparency, other problems include the lack of a nationwide guideline on documentation and approval of swap transplants and a national swap allocation system. The logistics of long-distance organ transport also needs attention.

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Earlier:

Wednesday, May 22, 2019

Kidney exchange in India: the legal framework

Tuesday, February 27, 2024

Stanford Impact Labs announces support for kidney exchange in Brazil, India, and the U.S.

Stanford Impact Labs announces support for kidney exchange in Brazil, India, and the U.S.

 Stanford Impact Labs has announced an investment designed to help the Alliance for Paired Kidney Donation (APKD) increase access to kidney exchange in Brazil, India, and the U.S.  Here are three related web pages...

1. Stanford Impact Labs Invests in Global Collaboration to Increase Access to Kidney Transplants.  $1.5 million over three years will support solutions-focused project led by Stanford’s Dr. Alvin Roth and the Alliance for Paired Kidney Donation (APKD)  by Kate Green Tripp

"Stanford Impact Labs (SIL) is delighted to announce a $1.5 million Stage 3: Amplify Impact investment to support Extending Kidney Exchange, a solutions-focused project established to increase access to lifesaving kidney transplants.

"The team, led by Stanford’s Dr. Alvin (Al) Roth, who shared the 2012 Nobel Prize in Economics for his work on market design, and the Alliance for Paired Kidney Donation (APKD) is working in close partnership with organ transplant specialists and medical centers in Brazil, India, and the U.S., including Santa Casa de Misericórdia de Juiz de Fora, the Institute of Kidney Diseases and Research Center and Dr. H L Trivedi Institute of Transplantation Sciences (IKDRC-ITS), and Walter Reed National Military Medical Center.

"Over the course of the next three years, the team aims to increase the number of transplant opportunities available to patients who need them by creating and growing kidney exchange programs in Brazil and India, where millions of people suffer from kidney disease yet exchange is minimal; and explore the effects of initiating donor chains with a deceased donor kidney (DDIC) in the U.S., an approach which could unlock hundreds more transplants each year.

..."

2. How Does Applied Economics Maximize Kidney Transplants? A project aimed at expanding kidney exchange and saving lives puts Nobel Prize-winning matching theory into practice.  by Jenn Brown   (including a video...)

"APKD uses open source software developed by Itai Ashlagi, Professor of Management Science and Engineering at Stanford University, to facilitate the matching process for its NEAD chains, and they currently average 5 non-simultaneous transplants per chain.

3. Extending Kidney Exchange

"In Brazil, our team has launched a kidney exchange program within Santa Casa de Misericórdia de Juiz de Fora and Hospital Clínicas FMUSP in São Paulo and aims to expand to facilitating exchanges between these centers and others with the ultimate goal of kidney exchange transitioning from a research project to an officially approved practice in Brazil.

"In India, our team has deployed kidney matching software and resources for growth to the Institute of Kidney Diseases and Research Center and Dr. HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS) to support kidney exchange programs. We aim to develop an evidence base for potential updates to organ transplantation laws that expand criteria for who can give and receive lifesaving kidneys.

"In the U.S., we are working with Walter Reed National Military Medical Center to test the use of deceased donor-initiated chains (DDIC) so as to generate hundreds of additional life-saving transplants each year that are not currently supported by today's practice of utilizing a deceased donor kidney to save the life of a single person on a transplant waitlist. "

 

Cash for kidneys report in the Telegraph

 The Telegraph has this story, by Samuel Lovett, Nandi Theint,  and Nicola Smith. For some reason I can't copy the headline, but the URL is pretty informative: https://www.telegraph.co.uk/global-health/science-and-disease/kidney-organ-trafficking-scandal-private-healthcare-india-myanmar/   3 December 2023 • 9:00am

"One of the world’s biggest private hospital groups is embroiled in a ‘cash for kidneys’ racket in which impoverished people from Myanmar are being enticed to sell their organs for profit.

"India’s Apollo Hospitals, a multi-billion dollar company with facilities across Asia, boasts that it conducts more than 1,200 transplants a year, with wealthy patients arriving for operations from all over the world, including the UK.

"Paying for organs is illegal in India, as it is across most of the world, but a Telegraph investigation has revealed that desperate young villagers from Myanmar are being flown to Apollo’s prestigious Delhi hospital and paid to donate their kidneys to rich Burmese patients.

“It’s big business,” one of the racket’s ‘agents’ told an undercover Telegraph reporter. Those involved “work together to get around the obstacles between the two governments,” she added. The hospital “asks the official questions. And on this side they tell the official lies.”

"The scam involves the elaborate forging of identity documents and staging of ‘family’ photographs to present donors as the relatives of would-be patients. Under Indian and Burmese laws, a patient cannot receive an organ donation from a stranger in normal circumstances.

"Apollo Hospitals said it was “completely shocked” by the Telegraph’s findings and would launch an internal investigation. “Any suggestion of our wilful complicity or implicit sanctioning of any illegal activities relating to organ transplants is wholly denied,” it added.

"Professional blood donors" in India (where paying blood donors is illegal)

 India allows only unpaid blood donation, from altruistic donors or from "replacement donors" who are friends or relations of particular patients in need of blood (who must procure it before receiving it). There is a severe blood shortage, some of which is filled by black market "professional" blood donors, who are paid to pretend to be unpaid replacement donors.

Here's a story from the Indian news service Quint:

Out for Blood: Why Are Many Indians Forced To Seek 'Professional Blood Donors'? Although it is illegal, why is there a thriving market for paid blood donors in India?  by ANOUSHKA RAJESH and MAAZ HASAN

"Donating blood in exchange for money was banned in India in 1996. However, paying 'professional blood donors' to meet this requirement is still fairly common.

...

"To see how easy it would be to 'arrange' a paid blood donor, FIT went to one of the busiest government hospitals in Delhi.

...

"All leads – from vendors to patient families and bootleg pharmacists – point us to Ashok (name changed). He sits, surrounded by 4-5 men, and is guarded when we make inquiries.

"He begins with the following line of questioning: 'Where is our patient admitted?  What surgery do they need?  Why couldn't we just get friends and relatives to donate?

"Posing as a patient's friend, the FIT reporter gives him preplanned answers. In the emergency ward.  He had an accident and needs surgery on his leg.  I donated blood a month ago. He has no family here, and everyone else we reached out to has refused.

"Only when he's satisfied with the answers, he says he would be able to 'arrange boys' by the next day, and that it would cost between Rs 3,500 to Rs 4,000.

...

"According to the Ministry of Health and Family Welfare, India's annual requirement for blood is around 1.5 crore units per year, while in reality, only around 1 crore units are available.

"This gap in supply and demand of blood poses a major public health crisis in the country. For example, around 70 percent of postpartum hemorrhage (PPH)-related deaths in India are due to lack of immediate availability of blood.

...

"The paid donors are generally young boys, between the ages of 20 and 25, from very poor backgrounds," says Dr Dubey. ""This will no doubt be detrimental to their health," he adds. Moreover, if caught, they face the risk of jail time.

"The protocol is to ask every donor a set of questions before we take their blood. "If they seem suspicious, we ask them questions like, 'how are you related to the patient?', 'what is the patient's name?', and 'what surgery are they having?', to sus them out. If we get enough proof, we either defer them, or hand them over to the cops," Dr Priyansha Gupta, PG resident, Public Health, who has worked in Delhi's AIIMS blood bank in the past.

"What, then, happens to the families who desperately need blood when their donors are deferred?

"Dr Dubey says they are referred to the social workers attached to the hospital to get them help.

...

"But you have to understand, blood is a scarce commodity, and there's only so much we have."

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Here's a story from the Hindustan Times (in 2022), which begins with some relevant background (before debunking myths that lead to a shortage of voluntary donors):

Common myths on blood shortage in India  "The article is authored by Dr Parth Sharma, researcher, Ranita De, researcher in Lancet Citizen's Commission on Reimagining India’s Health System and Dr Vaikunth Ramesh."

"The shortage of blood products has been a major public health problem in India. It is estimated that nearly 12,000 people lose their lives every single day due to the lack of blood products. Supporting a population of 1.4 billion, the present blood transfusion service is fragmented with a little over 3,700 blood centres of which about 70% are located in eight states only. As of 2020, 63 districts in India do not have a blood centre. Space crunch and a burgeoning population have led to the establishment of health care facilities without blood centres on their premises, which in turn depend on nearby blood or storage centres for access to safe blood.

"Unfortunately, India has one of the largest shortages of blood supplies globally, while several diseases requiring blood transfusions are on the rise.

"A recent study by Joy Mammen, et. al. estimated the shortage to be around 2.5 donations per 1,000 eligible donors which equals a shortage of 1 million units. Blood products are required not only for surgeries but also for patients suffering from various medical conditions causing severe anaemia. At present, the source of donated blood is a combination of voluntary donors and replacement donors. Although professional donors are forbidden by law, they still continue to persist in our system under the guise of replacement donors. Voluntary non-remunerated donors, who donate based on altruism and a sense of doing greater good for the community, unfortunately, account for only 80% of the donors in India.

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HT: I was directed to the above links from the Indian posting

India Policy Watch #2: Regulating SoHO  by Pranay Kotasthane, which was in part about the recent move in the EU to further restrict payment for Substances of Human Origin (SoHO), as discussed in

Saturday, November 4, 2023

The EU proposes strengthening bans on compensating donors of Substances of Human Origin (SoHOs)--op-ed in VoxEU by Ockenfels and Roth

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

 I recently spoke at the CAST transplant conference in Hong Kong (see picture), and the underlying theme of my talk, and of many talks there, was the transition of transplantation in China, and what its future might hold.

Jie-Fu HUANG is the other speaker on Zoom (to my right and your left), and Haibo Wang is on the far left on stage.

Here are two of my opening slides (using 2021 data from the Global Observatory on Donation and Transplantation)

On the left, you see that, today, China and India already perform more kidney transplants than any country in the world except the U.S.  On the right, you see that, by virtue of their large populations, they accomplish this despite their quite low rates of transplants per million population, compared to the U.S. and countries in Europe.  So if China and India can raise their transplant rates to rates comparable to the U.S. and Europe, most of the transplants in the world will be done in Asia, and many many additional lives will be saved.

Note that China mostly transplants kidneys from deceased donors, while India mostly transplants kidneys from living donors. So they have different paths (and plenty of untapped potential) for raising donation and transplantation rates.  And their paths to their current positions have also been very different.

Here is a recent account reflecting China's recent progress:

Chen, Zhitao, Han, Ming, Dong, Yuqi, Zeng, Ping, Liao, Yuan, Wang, Tielong, et al. (2023). First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China: 5-year Experience at a High-volume Donor and Recipient Liver Transplant Center. Transplantation, 107, 1855-1859. https://doi.org/10.1097/TP.0000000000004561

" In 1972, our center performed the first living donor kidney transplantation in China. Since then, kidney and liver transplant programs have evolved. By the beginning of the 21st century, organ transplantation had advanced, and clinical liver transplants have been performed successfully at the First Affiliated Hospital of Sun Yat-sen University.1

"Organ shortage has been a prominent feature at our institution as it has been around the world. Starting in the early 1980s, many organs had been procured from inmates on death rows. This unethical approach has been rightfully criticized by the worldwide community. As a consequence, the source of organs for transplants has solely been replaced by voluntary donations from Chinese citizens since January 1, 2015.

...

"Moreover, policies and methods for humanitarian aid to donor families were established. Those policies follow WHO guidelines while recognizing specific aspects of the Chinese culture. The State Ministry of Health and the Red Cross Society of China launched a pilot project on organ donation after the death of citizens in 2010 and established the China Organ Donation Committee. The principle of this pilot project was to learn from the experiences and standards in developed countries while recognizing national conditions and the social reality in China aiming to build an ethical and effective scientific organ donation and transplantation system.2

**********

In the same issue of Transplantation as the above article is this invited commentary by Ascher and Delmonico, both former Presidents of The Transplanation Society (of which Transplantation is the official journal). They largely approve of the effort China has made in transplants, but they have a big reservation.

Ascher, Nancy, MD, PhD & Delmonico, Francis. (2023). Organ Donation and Transplantation in China. Transplantation, 107, 1880-1882. https://doi.org/10.1097/TP.0000000000004562

"The date of 2015 is important for the review of any organ transplantation report from China because of the public proclamation in the media in 2015 prohibiting the use of organs from executed prisoners. Clinical transplantation articles antecedent to 2015 have been consistently rejected by Transplantation and the international community because the source of the transplanted organs was most often an incarcerated prisoner. China took a major step to condemn this practice publicly in 2015. However, because there is no law or regulation that prohibits this unethical practice, there has been ongoing concern that this practice may be continuing. Notwithstanding such a reality, there have been regulations that are citable and may be reflective of the changing experience of organ donation and transplantation in China that are consistent with the World Health Organization (WHO) Guiding Principles.

...

"WHAT CONTINUES TO BE OBJECTIONABLE

"The Chinese Red Cross is prominent in the organ donation process and a center of support for deceased donor families designated by the Red Cross as humanitarian aid to donor families.7 However, such humanitarian aid, although not limited to China, should not be misinterpreted to be an effort because it includes payment to elicit consent for donation. The Sun Yat-sen publication suggests that the Red Cross policies follow WHO guidelines while recognizing specific aspects of Chinese culture without elaboration as to the cultural details. A payment to donor families for funeral expenses or other monetary incentives should be recognized as a form of commercialization and would not comply with WHO guidelines."

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Some background may help put this objection in perspective. Doctors Delmonico and Ascher are prominent signatories of a declaration that payments to families of organ donors are crimes against humanity (as are payments to living donors, and both are declared comparable to transplanting organs from executed prisoners, and to be organ trafficking. See my 2017 post.)

So, they raise the question of whether saving many lives by increasing deceased donation in China will be justified if it involves paying funeral expenses of donors.  

My guess is that Chinese health authorities, thinking of the many lives to be saved, will think that this act of generosity to families of deceased donors will indeed be justified, taking account of (see above) "national conditions and the social reality in China aiming to build an ethical and effective scientific organ donation and transplantation system." 

Many people in China and elsewhere might even think that little if any justification is needed for generosity, particularly generosity to families of deceased donors, that is to families who are themselves generous.

Kidney Paired Donation in Developing Countries: a Global Perspective

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

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

Abstract

...

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

Summary

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

...

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

...

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

...

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

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

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Update:

Tuesday, September 19, 2023

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

Affirmative action in India

 Here's an interesting paper by Orhan Aygün and Bertan Turhan. It comes with something of a backstory, which accounts for its quite delayed publication (delays both in initial acceptance and then in publication after acceptance*). I gather it will appear in the next issue of Management Science.

How to De-Reserve Reserves: Admissions to Technical Colleges in India by Orhan Aygün and Bertan Turhan, Management Science (forthcoming),  Published Online:11 Nov 2022 https://doi.org/10.1287/mnsc.2022.4566

Abstract: "We study the joint implementation of reservation and de-reservation policies in India that has been enforcing comprehensive affirmative action since 1950. The landmark judgment of the Supreme Court of India in 2008 mandated that whenever the OBC category (with 27% reservation) has unfilled positions, they must be reverted to general category applicants in admissions to public schools without specifying how to implement it. We disclose the drawbacks of the recently reformed allocation procedure in admissions to technical colleges and offer a solution through “de-reservation via choice rules.” We propose a novel priority design—Backward Transfers (BT) choice rule—for institutions and the deferred acceptance mechanism under these choice rules (DA-BT) for centralized clearinghouses. We show that DA-BT corrects the shortcomings of existing mechanisms. By formulating India’s legal requirements and policy goals as formal axioms, we show that the DA-BT mechanism is unique for the concurrent implementation of reservation and de-reservation policies."

*This paper spent a long time waiting to be published, because of what seems to have been a priority dispute that, after the paper was accepted for publication,  was pursued through  allegations of research misconduct. The editorial office of Management Science conducted an investigation that determined that there was no reason not to proceed with publication.

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Update: here's the citation to the published version

Orhan Aygün, Bertan Turhan (2022) How to De-Reserve Reserves: Admissions to Technical Colleges in India. Management Science 69(10):6147-6164.

https://doi.org/10.1287/mnsc.2022.4566

An upside to dowries, by Natalie Bau, Gaurav Khanna, Corinne Low & Alessandra Voena

 Dowries (like bride prices*) are often criticized, but may have indirect effects that aren't so easy to see, as in this recent NBER paper:

Traditional Institutions in Modern Times: Dowries as Pensions When Sons Migrate by Natalie Bau, Gaurav Khanna, Corinne Low & Alessandra Voena  NBER WORKING PAPER 31176, DOI 10.3386/w31176

Abstract: This paper examines whether an important cultural institution in India - dowry - can enable male migration by increasing the liquidity available to young men after marriage. We hypothesize that one cost of migration is the disruption of traditional elderly support structures, where sons live near their parents and care for them in their old age. Dowry can attenuate this cost by providing sons and parents with a liquid transfer that eases constraints on income sharing. To test this hypothesis, we collect two novel datasets on property rights over dowry among migrants and among families of migrants. Net transfers of dowry to a man's parents are common but far from universal. Consistent with using dowry for income sharing, transfers occur more when sons migrate, especially when they work in higher-earning occupations. Nationally representative data confirms that migration rates are higher in areas with stronger historical dowry traditions. Finally, exploiting a large-scale highway construction program, we show that men from areas with stronger dowry traditions have a higher migration response to reduced migration costs. Despite its potentially adverse consequences, dowry may play a role in facilitating migration and therefore, economic development.

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*Recall this earlier paper:

Ashraf, Nava, Natalie Bau, Nathan Nunn, and Alessandra Voena. "Bride price and female education." Journal of Political Economy 128, no. 2 (2020): 591-641.