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

 

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)

 

Kidney exchange in Brazil (a clinical trial)

Here's a video in which Mike Rees, the founder of the Alliance for Paired Kidney Donation (APKD) describes how (with the help of a grant from Stanford Impact Labs) the APKD is helping Brazilian transplant docs get kidney exchange going there. 

 

Earlier:

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

 

Thursday, October 10, 2024  Kidney exchange in Brazil, continued (with pictures)

 

 

Stanford kidney conference, recap

 Stanford Impact Labs (SIL) reports on our recent kidney exchange conference

Global Solutions-focused Summit on Expanding Access to Kidney Transplantation held at Stanford. Physicians, scholars, healthcare practitioners, and policymakers gathered to explore research advances underway in India, Brazil, and the U.S.   by Kate Green Tripp and Marina Kaneko

 "Earlier this month, the Alliance for Paired Kidney Donation (APKD), Stanford economist Alvin E. Roth, and Stanford Impact Labs hosted the Palo Alto Summit, a two-day global convening at Stanford University dedicated to exploring challenges and advances in kidney transplantation around the world.

"On the heels of the 2025 World Transplant Congress in San Francisco, more than 30 physicians, scholars, transplant coordinators, and government officials from the U.S., India, Brazil, Italy, the United Arab Emirates, Qatar, and South Africa gathered to share key learnings, challenges, and advances in the field.

...

" APKD and Roth, the Craig and Susan McCaw Professor of Economics at Stanford’s School of Humanities and Sciences, have teamed up with transplant specialists in India, Brazil, and the United States to form the Extending Kidney Exchange project. 

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"The summit’s sessions were designed to advance national efforts in KPD in India and Brazil, and deceased donor-initiated chains (DDIC); foster collaboration among leading clinical, policy, and academic partners; and identify actionable steps and shared milestones for KPD in India and Brazil, paired liver exchange in India, and DDIC in the United States. As a transplant strategy, DDIC utilizes kidneys from deceased donors to create a chain of transplants so as to maximize the use of available organs and to connect multiple recipients, especially when there are mismatches or compatibility issues.

...

"“When the very first [nonsimultaneous] chain of kidney transplants took place in 2006, it was not necessarily welcomed as an innovation,” recalls Michael Rees, a transplant surgeon at the University of Toledo and founder of the Alliance for Paired Kidney Donation (APKD). “It is incredibly exciting to reflect on the progress we’ve been able to make across the transplant community since that time, to increase the utility of a single kidney from either a living or deceased donor.”

 

 

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Earlier:

Thursday, August 7, 2025 Stanford conference on extending kidney exchange

 

Also of note:

Matthew Gentzkow Named Director of Stanford Impact Labs

"The economist will lead a community of social scientists who want their scholarship to improve people’s lives."
 

 

Kidney exchange in Brazil, continued (with pictures)

 In August I posted about a trip to Brazil with Mike Rees where we traveled with Dr. Gustavo Ferreira, the director of transplantation at the hospital Santa Casa de Misericórdia de Juiz de Fora

Part of our trip was spent in the capital, Brasilia, talking to the government about extending Brazilian transplant law to allow kidney exchange, after which we went to Juiz de Fora.  Here's my blog post about that trip:  Kidney exchange in Brazil: prelude. 

That post concluded by saying "On Saturday we had an exciting finish to the trip, but it's not my story to tell yet, so I'll blog again after there is an official announcement."

Now Brazil's first three-way kidney exchange has been announced, as part of a clinical trial that I hope will help change Brazilian law to allow kidney exchange as a regular medical procedure.  The three donors and three recipients all did well, and left the hospital very shortly after the actual surgeries, but came back to tell their stories to the Brazilian news show Profissão Repórter (Professional Reporter). You can see the video here  https://globoplay.globo.com/v/12997336/

It's in Portuguese but you will quickly get the idea, presented even more briefly on Instagram by the transplant nephrologist Dr. Juliana Bastos here: https://www.instagram.com/reel/DA4JBVIsFta/?igsh=d2hnb3hoNjJxN2I4     where you can see the three incompatible patient-donor pairs rearrange themselves for the camera into the three-way exchange in which each patient received an organ from a compatible donor. (Dr. Bastos recently added a PhD to her MD, with a dissertation on kidney exchange.)

Here's another Instagram link to the video.

I had the privilege of observing parts of five of the six surgeries (three nephrectomies and three transplants), and some pictures are below.  

If someone directs a movie about this kind of transplant surgery, there will be two dramatic scenes, one in which the donated kidney is carried across the hall to the transplant operating room, and the second showing the moment the clamps are removed from the blood vessels of the transplanted kidney, so that it turns from grey to pink as blood returns to it. 

But here's a photo I took at  the start of what I think is the most dramatic moment of the surgery, as the artery from the kidney is just about to be connected to the artery of the recipient.

The artery from the donated kidney is the small white tube being pointed to by the instrument held in the fingers at the top right of the picture. Immediately in front of it--the long red tube--is the artery of the recipient, to which it must be connected so that blood can again flow to the kidney.  Notice that a small incision has already been made in the recipient's artery--this is where the two will be attached. The connection has to be perfect, so that the blood can flow without obstruction that could cause a clot.

The surgeon who first figured out how to do this kind of vascular surgery, Dr. Alexis Carrel, won the 1912 The Nobel Prize in Physiology or Medicine

I was able to follow the proceedings thanks to the running commentary offered to me by the Brazilian surgeons and by Mike Rees (who wasn't busy doing surgery). That wasn't the only kind of support Mike offered me in the OR (as I balanced on a pair of stools to better appreciate the commentary):

And here's a post-op picture of most of the big team that made it happen:

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Parabéns ao Gustavo e à Juliana! Congratulations. Your work and leadership can make a big difference not just to your patients, but to people all over Brazil.

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Earlier:

Monday, August 12, 2024

Kidney exchange in Brazil: prelude

Kidney exchange in Brazil: prelude

 Yesterday I flew home from a busy visit to Brazil, with Mike Rees and Dr. Gustavo Ferreira.  

On Wednesday we all traveled to the capital, Brasilia, meeting with government ministries and agencies about how to move kidney exchange forward there.

Our most promising meeting on Wednesday was with the company that organizes the hospitals associated with Brazil's Federal universities. We talked about research possibilities

Wednesday Aug 7: Brazilian Hospital Services Company

Our most important meeting was on Thursday with the Ministry of Health  We talked about how clinical trials of kidney exchange in Brazil could help guide changes in Brazil's organ transplant laws and regulations.

Thursday: Brazil Ministry of Health, August 8 2024

On Friday we traveled to Juiz de Fora where we participated in a transplant symposium at the Santa Casa hospital there

On Saturday we had an exciting finish to the trip, but it's not my story to tell yet, so I'll blog again after there is an official announcement.

Earlier:

Tuesday, February 27, 2024

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