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

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

 

American Journal of Transplantation

Available online 10 August 2026

In Press, Journal Pre-proof

Original Article

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

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

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

... 

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

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Earlier: 

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

 

Deceased organ donation by Ashlagi and Roth in the Annual Review of Economics (with open questions)

 Here's a review paper concentrating primarily on transplantation of  organs (primarily kidneys) from deceased donors. It closes with a set of open research questions.

Organ Allocation and Transplantation  by Itai Ashlagi and Alvin E. Roth,  Annual Review of Economics, Volume 18, 2026, Vol. 18:613-645, August 2026, https://doi.org/10.1146/annurev-economics-092425-123425     
 
ABSTRACT: There is a large shortage of solid organs for transplants. This survey reviews the allocation of organs (particularly kidneys), with an emphasis on how deceased donor organs are obtained and allocated in the United States but with pointers to related issues involving living donors and transplantation around the world. We review some of the key institutional details and theoretical and empirical studies and describe some open questions that we hope will continue to attract attention from researchers interested in the economic and operational aspects of organ allocation.

 
1. INTRODUCTION
 "Since at least the turn of the century, organ transplants have attracted considerable interest from economists. This is due both to their importance in modern medicine and to the fact that organ transplantation deals directly with some of the most basic questions of economics—namely, how to efficiently allocate scarce resources and how to make them less scarce. "

...

OPEN QUESTIONS AND RESEARCH DIRECTIONS
 
This section highlights research opportunities, some of which have been raised above.

1.  Can we design allocation rules free of justified envy that place hard-to-match organs quickly enough so that they remain transplantable? A large number of recovered organs that might be transplanted are discarded. How can we increase utilization of marginal-quality organs and get them accepted after fewer offers and less CIT? How can we do this in a transparent and equitable way? How can we use the information about organ quality that arrives during the offering process? 91 How can we use offer refusals in real time? How should we design allocation rules in the presence of social learning and potential information cascades (Zhang 2010, Doval et al. 2024)? How should the variability in centers’ willingness to accept marginal organs be accounted for?
2.  How to design priorities to balance efficiency and equity? How can priorities be designed to account for both longevity and urgency (Zhang et al. 2024, Lazenby et al. 2025)? How can priorities depend on patients’ treatments, taking into account that treatment decisions may in turn depend on priorities (Sweat 2023)? Countries use different priority rules, and there is a need to compare these to better understand trade-offs between these rules. The OPTN is seeking to implement continuous distribution allocation policies for hearts and kidneys, which will assign priority points smoothly across patient and match features. There are not yet studies that offer guidance to the resulting (in)efficiencies. 92
3.  How should organ quality be measured and reported? The KDPI is currently used for both acceptance decisions by surgeons and prioritization in the allocation system. As supply changes over time, percentiles correspond to different qualities. For example, a KDPI of 85% (which is the threshold for requiring patient consent to receive an offer) in 2018 corresponds to (i.e., has the same underlying nonnormalized KDRI risk measure as) a KDPI of 75% in 2024 due to the recovery of more organs and therefore the higher availability of organs of marginal quality. Would the use of the nonnormalized KDRI substantially change behavior and outcomes?
4.  How should surgeons’ and patients’ preferences be elicited? The OPTN allows transplant centers to express preferences via filters that screen organ offers. Despite this, many organs are still declined hundreds and even thousands of times (Agarwal et al. 2021, Guan et al. 2025). How can we better design these filters? Can we use AI to help recommend filters or to predict organ refusals in real time? More broadly, how should waitlist mechanisms be designed given incomplete patient and center preferences?
5.  How should transplant centers’ performance be measured? Should transplant centers be incentivized to accept marginal organs, for example, for patients facing many years of dialysis? How should we regulate transplant centers? Are new incentive schemes useful in increasing utilization? For example, how will the acceptance rate and pre-transplant mortality rate metrics impact centers’ behavior? The CMS has also launched the Increasing Organ Transplant Access model, 93 using a long-term field experiment that offers monetary incentives based on the number of transplants performed, graft survival, and percentage of accepted offers (Chan & Roth 2026.) How should we incorporate the huge role that transplant centers play in acceptance/rejection decisions when studying organ allocation mechanisms (Chan & Roth 2024, Ashlagi et al. 2025a)? There is a need for research on designing centers’ performance measures that include outcomes for patients on the waiting list.
6.  How should OPO performance be measured? OPOs vary in performance in terms of organ recovery and utilization, and incentive schemes remain controversial. How effective is the new tier system for monitoring OPOs based on donation and age-adjusted transplant rates? How should OPOs be incentivized to improve performance and transparency and to coordinate with transplant centers (see Chan & Roth 2024, Bae et al. 2026, Skowronski et al. 2026)?
7.  What should we incorporate in transplant centers’ preferences? Most theoretical models treat patients as the decision makers who accept or reject organ offers. In practice, however, transplant centers exercise substantial discretion over acceptance decisions, listing practices, and setting filters. How do equilibrium outcomes reflect centers’ preferences? There is a need for empirical and theoretical studies of how centers’ characteristics and incentives shape outcomes.
8.  Can we design simulation tools that account for equilibrium behavior? Simulations and historical data have been instrumental to the study and design of allocation policies. Existing simulations apply myopic acceptance models that are invariant to the allocation rules. There is a need for simple modern simulation tools that account for the incentives of patients and centers. 94 It would be interesting to create tools that generate not only better equilibrium predictions but also short-term equilibration effects. 95
9.  What kinds of experiments should the OPTN conduct? The OPTN conducts very few controlled experiments, despite facing ongoing allocation policy decisions. While simulation tools are useful to inform policy, field experiments offer another approach. Experiments can generate useful data to evaluate different approaches (e.g., for expediting placements). The size and heterogeneity of the United States present opportunities to test different approaches; but they also raise questions about whether different approaches would work differently in different regions, and about how to overcome the reluctance to conduct experiments.
10.  How can countries with low transplant rates be helped? Many countries have low living and/or deceased donation rates. Understanding the underlying barriers (organization structure, population preferences, etc.) would be fruitful in making progress toward increasing transplant rates (see, e.g., Okubo et al. 2026).
11.  What can be done to increase incentives for organ donation in ways that attract social support? What accounts for the widespread reluctance to increase organ donation by compensating donors? How can economists better explain the value of incentives in addressing scarcity and gather persuasive evidence to engage in a productive dialog with those who fear that this will increase rather than decrease black markets, or who feel there are fundamental religious or ethical objections to compensating organ donation? [For some thoughts on this, readers are referred to Roth (2026b)]. 

Deceased-donor-initiated kidney-exchange chains are performing well in Italy

 Here's a new report from Italy on initiating kidney exchange chains with a deceased donor.*  In Italy to date, 34 deceased donor initiated chains generated 84 transplants (34 from deceased donors  and 50 from living donors), including 56 among incompatible pairs and 28 to candidates on the waitlist.

Furian L., Di Bella C., Maggiore U., Fiaschetti P., Partelli S., Feltrin G. Integrating Deceased and Living Donation: Long-Term Outcomes of the Italian Deceased-Donor-Initiated Kidney Exchange (DEC-K) Program AJT_ 26/7S1, Volume 26, Issue 7, S1. The cover date will be July 2026. 

"Integrating deceased and living donation through deceased-donor (DD)-initiated chains can expand kidney transplant access in small paired exchange pools. The Italian DEC-K program allocates a DD kidney to initiate a chain (chain-initiating kidney, CIK) among incompatible living-donor (LD) pairs, ultimately returning a LD kidney to the national waiting list (WL). We report the first long-term national results of this donor organ allocation model.
 

"Methods: All DEC-K chains performed in Italy (2018-2025) were retrospectively analyzed. Recipients were stratified by kidney source (CIK vs LD).

...
"Results: Thirty-four DEC-K chains generated 84 transplants (34 DD and 50 LD), including 56 among incompatible pairs and 28 to candidates on the WL. Donor withdrawal occurred once. Four chains were terminated early after CIK transplantation due to newly developed contraindications to donation. At a median follow-up of 60 months, 1- and 3-year graft survival was 100% in both groups, while patient survival was 97.1% for CIK and 98.0% for LD. Three CIK and one LD recipients died with functioning graft (suicide, sepsis, urothelial carcinoma, and acute myocardial infarction, respectively). One CIK recipient experienced graft loss after 40 months due to chronic rejection. Adjusted eGFR trajectories were comparable between CIK and LD (P = 0.48). Chain-ending kidney recipients, with 4 graft loss overall (1 antibody-mediated rejection and 3 vascular thrombosis), showed outcomes comparable to LD (P = 0.64 for eGFR; P = 0.57 for graft survival).
 

"Conclusions: The DEC-K program proved feasible, safe, and effective in expanding transplant opportunities for incompatible and hard-to-match patients."

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* Some earlier posts on deceased donor initiated chains:

Sunday, April 3, 2022

Kidney Paired Donation Chains Initiated by Deceased Donors

Monday, November 22, 2021

A naturally occurring deceased-donor-initiated kidney exchange chain, by Maghen and Veale

Sunday, August 23, 2020

More on Deceased donors as non‐directed donors in kidney exchange chains

Tuesday, August 7, 2018

Deceased donor chains: Market design language is entering transplantation

Monday, April 11, 2016

Using deceased donor kidneys to start living donor kidney exchange chains

 

Kidneys and Controversies at Mt. Sinai hospital

 I gave a talk yesterday at Mt. Sinai hospital. They had encouraged me to talk about controversies, which I happily did.  They were a sympathetic audience (although the majority of their last five speakers would not have been:)

 

 

 

Recent kidney transplant papers

 Here are two new papers on kidney exchange that caught my eye, and one on incentivizing deceased donation by prioritizing registered donors on the deceased donor waiting list.

This one concerns organizing international kidney exchanges between countries while making sure that each one gets their fair share. (All exchanges are between 2 pairs.)

Benedek, Márton, Péter Biró, Daniel Paulusma, and Xin Ye. "Computing balanced solutions for large international kidney exchange schemes." Autonomous Agents and Multi-Agent Systems 38, no. 1 (2024): 1-41.

Abstract: To overcome incompatibility issues, kidney patients may swap their donors. In international kidney exchange programmes (IKEPs), countries merge their national patient–donor pools. We consider a recently introduced credit system. In each round, countries are given an initial “fair” allocation of the total number of kidney transplants. This allocation is adjusted by a credit function yielding a target allocation. The goal is to find a solution that approaches the target allocation as closely as possible, to ensure long-term stability of the international pool. As solutions, we use maximum matchings that lexicographically minimize the country deviations from the target allocation. We perform, for the first time, a computational study for a large number of countries. For the initial allocations we use two easy-to-compute solution concepts, the benefit value and the contribution value, and four classical but hard-to-compute concepts, the Shapley value, nucleolus, Banzhaf value and tau value. By using state-of-the-art software we show that the latter four concepts are now within reach for IKEPs of up to fifteen countries. Our experiments show that using lexicographically minimal maximum matchings instead of ones that only minimize the largest deviation from the target allocation (as previously done) may make an IKEP up to 54% more balanced.

"We consider IKEPs in the setting of European KEPs which are scheduled in rounds, typically once in every three months.

...

"We first note that the search for an optimal exchange scheme can be done in polynomial time for 2-way exchanges (matchings) but becomes NP-hard as soon as 3-way exchanges are permitted."

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Here's a paper that reports simulations on Using deceased donor kidneys to start living donor kidney exchange chains

Verma, Utkarsh, Nayaran Rangaraj, Viswanath Billa, and Deepa Usulumarty. "Long term simulation analysis of deceased donor initiated chains in kidney exchange programs." Health Systems (2023): 1-12.

ABSTRACT: Kidney exchange programs (KEPs) aim to find compatible kidneys for recipients with incompatible donors. Patients without a living donor depend upon deceased donor (DD) donations to get a kidney transplant. In India, a DD donates kidneys directly to a DD wait-list. The idea of initiating an exchange chain starting from a DD kidney is proposed in a few articles (and executed in Italy in 2018), but no mathematical formulation has been given for this merger. We have introduced an integer programming formulation that creates DD-initiated chains, considering both paired exchange registry and DD allocations simultaneously and addressing the overlap issue between the exchange registry and DD wait-list as recipients can register for both registries independently. A long-term simulation study is done to analyse the gain of these DD-initiated chains over time. It suggests that even with small numbers of DDs, these chains can significantly increase potential transplants.

#########

And here's the paper on incentivizing registration to be a deceased donor.

Li, Mengling, and Yohanes E. Riyanto. "Incentivizing Organ Donation Under Different Priority Rules: The Role of Information." Management Science (2024).

Abstract: This paper examines the incentive to register for deceased organ donation under alternative organ allocation priority rules, which may prioritize registered donors and/or patients with higher valuations for organ transplantation. Specifically, the donor priority rule grants higher priority on the organ waiting list to those who have previously registered as donors. The dual-incentive priority rules allocate organs based on donor status, followed by individual valuations within the same donor status, or vice versa. Both theoretical and experimental results suggest that the efficacy of the donor priority rule and the dual-incentive priority rules critically depends on the information environment. When organ transplantation valuations are unobservable prior to making donation decisions, the hybrid dual-incentive rules generate higher donation rates. In contrast, if valuations are observable, the dual-incentive priority rules create unbalanced incentives between high- and low-value agents, potentially undermining the efficacy of the hybrid dual-incentive rules in increasing overall donation rates.

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. "

 

Directed deceased donation of organs for transplant. (Legal in U.S. but not yet in Europe.)

 It is legal in the U.S. for a deceased donor organ for transplant to be directed to a particular recipient, if the recipient is compatible (and otherwise the organs are allocated as in the usual way for nondirected deceased donation.)  Because compatibility is tricky, directed deceased donation (DDD) is rare (but deceased donor kidneys can potentially be used to start a deceased donor initiated chain of kidney exchange).

But in most of Europe, it turns out, DDD isn't legal. (!) Here's a paper by the European Society of Transplantation's European Platform on Ethical, Legal and Psychosocial Aspects of Organ Transplantation. It cautiously argues that maybe this ban is "one thought too many," and that the ban should be lifted so that carefully regulated DDD would be allowed to increase organ donation in Europe and save more lives.

"When is directed deceased donation justified? Practical, ethical, and legal issues," by David Shaw1,2 , Dale Gardiner3, Rutger Ploeg4, Anne Floden5,6, Jessie Cooper7, Alicia Pérez-Blanco8, Tineke Wind9, Lydia Dijkhuizen10, Nichon Jansen10 and Bernadette Haase-Kromwijk10; on behalf of the ESOT ELPAT Working Group on Deceased Donation, Journal of the Intensive Care Society, 2024.

Abstract: This paper explores whether directed deceased organ donation should be permitted, and if so under which conditions. While organ donation and allocation systems must be fair and transparent, might it be “one thought too many” to prevent directed donation within families? We proceed by providing a description of the medical and legal context, followed by identification of the main ethical issues involved in directed donation, and then explore these through a series of hypothetical cases similar to those encountered in practice. Ultimately, we set certain conditions under which directed deceased donation may be ethically acceptable. We restrict our discussion to the allocation of organs to recipients already on the waiting list.

"The persistent shortage of organs available for transplantation demands fair and objective allocation of the scarce available organs, based on preset transparent and regulated criteria. In most European countries, organs from deceased donors are allocated to patients on the organ waiting list by national Competent Authorities.3 The current worldwide norm is that organs donated after death are considered as an unconditional gift to the patients on the transplant waiting list according to the allocation system. This implies that donors (prior to their death), or their family members (after it), cannot determine to whom the available organs will be assigned, nor exclude any potential recipients.

...

"In a few countries, like the United States, United Kingdom, Japan, and recently Australia, directed deceased donation is possible in restricted cases, since national legislation does not prohibit it. In living donation however, directed donation is permitted in many countries, even when there is no genetic or emotional relationship between the donor and the intended recipient. This inconsistency between the living donation- and deceased donation system has been noted.4

"This paper explores whether directed deceased donation should be allowed, and if so under which conditions.

...

"The main argument against DDD is that this violates the  basic principle of an altruistic, unconditional gift to society; allowing DDD may turn out to be a “slippery slope” in the direction of conditional donation and discrimination against particular patient groups. Conditional donation could also reduce public support for the transplantation system, since it could reduce transparency and fairness of the system.

...

"What, then, are the conditions for ethical DDD at the present time?

1. DDD under strict conditions should not be prohibited by legislation or policy.

2. There must be evidence that the donor wanted or would have been willing to direct the organ to a particular family member or close friend.

3. The donor/family should generally not be able to  insist on only donating the organ intended for DDD; where other organs are transplantable there should be a willingness to donate other organs (at least one) to patients on the waiting list to preserve the societal altruistic aspect of donation and diminish the overall effect on the waiting list.

4. DDD should proceed only if there is no patient on the waiting list in extremely urgent need of an organ transplantation to avoid imminent death.

5. DDD should proceed only if there is a reasonable chance of successful transplantation.

6. The intended recipient should be on the waiting list or be under assessment for being included.

"If these conditions are met, the medical team should do their best to facilitate the wishes of the deceased patient and his/her family by enabling DDD to take place. Letting deceased donors direct their organs to loved ones under carefully controlled conditions could further enhance trust in organ donation and transplantation systems, and hence willingness to become a donor."

Kidney exchange in The Times of India

 The Times of India covers my talk at the Indian Society of Transplantation meeting:

Alvin Roth for legal boost to kidney exchange pool in India by Chaitanya Deshpande, Oct 15, 2022c

 The site makes it hard to extract text, but here's a photo of some comments, which make me hope that some action may be taken:

Update: 

The Dr H.L. Trivedi Oration at the Indian Society of Transplantation (ISOT) Meeting 2022

Here's the meeting announcement:

ISOT 2022 NAGPUR

32^nd Annual Conference of The Indian Society of Organ Transplantation
2^nd Mid-term Meeting of Liver Transplantation Society of India
15^th Annual International Conference of NATCO
Dates : 12^th - 16^th October 2022 | Venue : Hotel Le Meridien, Nagpur

My talk, the Dr H.L. Trivedi Oration   is scheduled for 11:00am on Friday the 14th in Nagpur, which means I'll be giving it by zoom tonight, Thursday evening at 10:30 pm Pacific Time.

The presentation, which  will be about "Increasing the availability of transplants in India" is in honor of the late Dr. Hargovind Laxmishanker "H. L." Trivedi (August 1932 – October 2019), who I had the privilege of meeting,

Here's his obituary : 

Kute, Vivek, Himanshu Patel, Pankaj Shah, Pranjal Modi, and Vineet Mishra. "Professor Dr. HL Trivedi pioneering nephrologist and patriot who cared for his country (31-08-1932 TO 2-10-2019)." Indian Journal of Nephrology 29, no. 6 (2019): 379.

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Here's my concluding slide:

• India has enormous talent and accomplishment in living-donor transplantation
• To more nearly reach it’s potential, India needs to invest in recovering deceased donor organs.
• In the near term, it can build on it’s accomplishments in kidney transplantation, by 
• establishing national (not just regional) kidney exchange
• Continuing to explore international exchange for the hardest to match pairs
• Reducing restrictions on who can be an exchange donor
• Allowing non-directed donors and chains
• Allowing some chains to begin with a deceased-donor kidney
• Reducing financial barriers by increased investment in public hospitals and government health insurance, for organ donors as well as recipients

***********

Update: