Ethical considerations and global cooperaton in transplantation, Wednesday in Cairo

It's Wednesday morning in Cairo, and here's today's conference schedule, which will include discussion of (and voting on) global cooperation in transplantation. (See my earlier post for context.) 

 

8:00 AM 08:30 AM	Opening Session of Ethical Consensus Global Consensus on Emerging Ethical Frontiers in Transplantation: Innovations & Global Collaboration	HALL A
Strategic Co-Leaders (Alphabetical)	Alvin E. Roth (Stanford University, USA) John Fung (University of Chicago, USA) Mark Ghobrial (Methodist Hospital, Houston, USA) Osama A Gaber (Methodist Hospital, Houston, USA) Sandy Feng (UCSF, USA) Valeria Mas (University of Maryland, USA)
Chairs (Alphabetical)	Ahmed Elsabbagh (University of Pittsburgh, USA) Medhat Askar (Baylor University, USA) Mohamed Ghaly (Hamad Bin Khalifa University, Qatar) Mohamed Hussein (National Guard Hospital, KSA)
Scientific Committee (Alphabetical)	Abdul Rahman Hakeem (King’s College Hospital, UK) Dieter Broering (KFSHRC, KSA) Hermien Hartog (Groningen, the Netherlands) Hosam Hamed (Mansoura University, Egypt) Manuel Rodriguez (Universidad Nacional Autónoma de México, Mexico) Matthew Liao (Center for Bioethics, New York University, USA) Nadey Hakim (King’s College, Dubai, UAE) Stefan Tullius (Harvard Medical School, USA) Varia Kirchner (Stanford University, USA) Wojciech Polak (Erasmus Medical Center, Rotterdam, the Netherlands)
Leadership of Jury Committee (Alphabetical)	Chair: John Fung (University of Chicago, USA) Vice-Chairs Hatem Amer (Mayo Clinic, Rochester, USA) Lloyd Ratner (Columbia University, USA) Maye Hassaballa (Cairo University, Egypt)
08:30 AM 09:30 AM	State of Art Lecture (1, 2)	HALL A
Chairpersons (Alphabetical)	Mahmoud El-Meteini (Ain Shams University, Egypt) Mehmet Haberal (Baskent University, Turkey) Sandy Feng (UCSF, USA)
08:30 AM 09:00 AM	From Dr. Starzl to the Future: The Evolution of Transplantation and the Call to Continue the Journey John Fung (University of Chicago, USA)
09:00 AM 09:30 AM	Organ Transplant Ethics: How Technoscientific Developments Challenge Us to Reaffirm the Status of the Human Body so as to Navigate Innovation in a Responsible Manner Hub A.E. Zwart (Erasmus University Rotterdam, Netherlands)
09:30 AM 11:00 AM	Working Group 1:	HALL A
Chairpersons (Alphabetical)	Ali Alobaidli (Chairman of UAE National transplant committee) Hermien Hartog (Groningen, The Netherlands) Khalid Amer (Military Medical Academy, Egypt) Lloyd Ratner (Columbia University, NY, USA) Thomas Müller (University Hospital Zurich, Switzerland)
09:30 AM 09:50 AM	Keynote Lecture: Xenotransplantation: Scientific Milestones, Clinical Trials, Risks, and Opportunities Jay Fishman (MGH, USA)
09:50 AM 11:00 AM	WG1 Presentation & Panel Voting Matthew Liao (Center for Bioethics, New York University, USA) Hosam Hamed (Mansoura University, Egypt) Daniel fogal (New York University, USA)
11:00 AM 11:30 AM	Coffee Break
11:30 AM 01:00 PM	Working Group 2:	HALL A
Chairpersons (Alphabetical)	Daniel Maluf (University of Maryland, USA) Karim Soliman (University of Pittsburgh, USA) Marleen Eijkholt (Leiden University Medical Centre, Netherlands) Refaat Kamel (Ain Shams University, Egypt) Varia Krichner (Stanford University, USA)
11:30 AM 11:50 AM	Keynote Lecture: Smart Transplant: How AI & Machine Learning Are Shaping the Future Dorry Segev (NYU Langone, USA)
11:50 AM 01:00 PM	WG2 Presentation & Panel Voting Hub A.E. Zwart (Erasmus University Rotterdam, Netherlands) Varia Krichner (Stanford University, USA) Eman Elsabbagh (Duke University, USA) Mohammad Alexanderani (University of Pittsburgh, USA)
01:00 PM 02:30 PM	Working Group 3:	HALL A
Chairpersons (Alphabetical)	Ahmed Marwan (Mansoura University, Egypt) Ashraf S Abou El Ela (Michigan, USA) Mostafa El Shazly (Cairo University, Egypt) Peter Abt (UPenn, USA) Philipp Dutkowski (University Hospital Basel, Switzerland)
01:00 PM 01:20 PM	Keynote Lecture: Ischemia-Free Transplantation: A New Paradigm in Organ Preservation and Transplant Medicine Zhiyong Guo (The First Affiliated Hospital of Sun Yat-sen University, China)
01:20 PM 02:30 PM	WG3 Presentation & Panel Voting Jeffrey Pannekoek (Center for Bioethics, Cleveland Clinic, USA) Abdul Rahman Hakeem (King’s College Hospital, UK) Georgina Morley (Center for Bioethics, Cleveland Clinic, USA)
02:30 PM 03:30 PM	Lunch Symposium	HALL B
03:30 PM 05:00 PM	Working Group 4:	HALL A
Chairpersons (Alphabetical)	David Thomson (Cape Town University, South Africa) Lucrezia Furian (University Hospital of Padova, Italy) May Hassaballa (Cairo University, Egypt) Abidemi Omonisi (Ekiti State University, Nigeri) Vivek Kute (IKDRC-ITS, Ahmedabad, India)
03:30 PM 03:50 PM	Keynote Lecture: Framing the Conversation: Ethical considerations at the foundation for global transplant collaboration Marleen Eijkholt (Leiden University Medical Centre, Netherlands)
03:50 PM 05:00 PM	WG4 Presentation & Panel Voting Alvin Roth (Stanford University, USA) Marleen Eijkholt (Leiden University Medical Centre, Netherlands) Michael Rees (University of Toledo, USA) Ahmed Elsabbagh (University of Pittsburgh, USA) Nikolas Stratopoulos (Leiden University Medical Centre, Netherlands)
05:00 PM 05:30 PM	Closing Session of Ethical Consensus Global Consensus on Emerging Ethical Frontiers in Transplantation: Innovations & Global Collaboration	HALL A
Strategic Co-Leaders (Alphabetical)	Alvin E. Roth (Stanford University, USA) John Fung (University of Chicago, USA) Mark Ghobrial (Methodist Hospital, Houston, USA) Osama A Gaber (Methodist Hospital, Houston, USA) Sandy Feng (UCSF, USA) Valeria Mas (University of Maryland, USA)
Chairs (Alphabetical)	Ahmed Elsabbagh (University of Pittsburgh, USA) Medhat Askar (Baylor University, USA) Mohamed Ghaly (Hamad Bin Khalifa University, Qatar)
05:10 PM 05:30 PM	State of Art Lecture (3): Reflections from a Transplant Pioneer: Ethics, Policy, and the Future of Global Collaboration Ignazio R. Marino (Thomas Jefferson University, Italy/USA)

 

"Better to exchange kidneys than bombs."

 Some coffee cups  should naturally come in pairs, so that you have one for a friend in need. (These recently arrived in the mail, from Laurie Lee)

Better to exchange kidneys than bombs

I was quoted as having said that to Marco della Cava, the USA Today reporter who wrote about the first kidney exchange between Israel and the UAE.

“Better to exchange kidneys than bombs,” says Roth, adding that using computers to search the world for medical solutions radically increases the chances of patients getting help. “International boundaries are artificial markers. Kidney disease doesn’t care about that.”

Thursday, September 30, 2021 Kidney Exchange between Israel and the UAE (in USA Today, yesterday)

How three Jewish and Arab families swapped kidneys, saved their mothers and made history by Marco della Cava, USA TODAY, Wed, September 29, 2021 AM 

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

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

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

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

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

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

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

Simulating kidney exchange policies in Germany

 Here are a set of simulations designed to help Germany establish a national (rather than a fragmented) kidney exchange system.

Itai Ashlagi, Ágnes Cseh, David Manlove, Axel Ockenfels & William Pettersson,  Designing a kidney exchange program in Germany: simulations and recommendations. Central European Journal of Operations Research  (2024). https://doi.org/10.1007/s10100-024-00933-0

"Abstract: We examine some of the opportunities and challenges concerned with establishing a centralized national kidney exchange program in Germany. Despite the many advantages of a national program, without deliberate design and policy intervention, a fragmented kidney exchange program may emerge. We study a number of collaboration strategies, and resulting simulations suggest that transplant centers may find it advantageous not to fully participate, resulting in a net reduction in the number of transplants. These results also suggest that allowing more forms of kidney exchange, such as three-way exchanges and non-directed donations, can significantly increase the number of transplants while making participation in a national program more attractive and thus national coordination and cooperation more robust. We propose a multi-level policy approach that is easy to implement and would promote an efficient German kidney exchange program that benefits recipients, donors and hospitals."

...

The concluding sentence of the paper is:

"Germany should establish a robust, well-functioning national KEP that can be easily and straightforwardly integrated into an international KEP."

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Background:

Thursday, July 18, 2024

Kidney exchange in Germany: draft of a proposed law

WHO Says Countries Should Be Self-Sufficient In (Unremunerated) Organs And Blood, by Krawiec and Roth

 Requiring national self sufficiency in blood and plasma supplies is particularly hard on low and middle income countries, as is limiting the possibility of participating in active kidney exchange programs.

WHO Says Countries Should Be Self-Sufficient In (Unremunerated) Organs And Blood by Kimberly D. Krawiec and Alvin E. Roth : August 24, 2024,   Available at SSRN: https://ssrn.com/abstract=4935827

Abstract: This chapter critiques the twin World Health Organization (WHO) principles of self-sufficiency and nonremuneration in organs and blood, urging a more sensible approach to the scarce resources of blood products and transplantable organs. WHO and other experts have failed to acknowledge the tension between self-sufficiency and nonremuneration in blood products--no country that fails to pay plasma donors is self-sufficient. Furthermore, international cooperation and cross-border transplantation provide numerous benefits, especially in smaller countries and those without well-developed domestic exchange programs. The combination of these twin principles denies to health care many of the benefits that trade has brought to so many other human endeavors and the effects are particularly damaging to low and middle income countries. Substances of human origin are special, but not so special that we prohibit plasma or organ donation. We should be open to exploring and experimenting with ways to bring to health care some of the benefits that trade has brought to so many other human endeavors, such as the production and distribution of food and lifesaving vaccines and other medicines.

Here's the concluding paragraph:

"We close by noting that the combination of the nonremuneration principle and the self-sufficiency principle deny to health care many of the benefits that trade has brought to so many other human endeavors. Substances of human origin are special, but not so special that we prohibit plasma or organ donation. So we should be open to exploring and experimenting with ways to bring to health care some of the benefits that trade has brought to so many other human endeavors, such as the production and distribution of food and lifesaving vaccines and other medicines."

Kidney Exchange among Austria, Czech Republic, and Israel

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

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

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

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

...

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

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.

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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.

Kidney exchange between Israel and the Czech Republic

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

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

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

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

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

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

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

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

Kidney Exchange in Latin America and the Caribbean

 Kidney exchange isn't yet thriving in Latin America, but the basic infrastructure is in place. It would make a lot of sense to jumpstart kidney exchange by allowing cross border exchange, so that there would be a large enough pool of patient-donor pairs to make finding a match easy. Here's an article surveying the member countries of the Latin America and Caribbean Transplant Society.

Bastos, Juliana, David José de Barros Machado, Raquel Megale Moreira, Gustavo Fernandes Ferreira, and Elias David-Neto. "Kidney Paired Donation in Latin America and the Caribbean: An Update." Transplantation 108, no. 6 (2024): 1257-1258.

"we assess the situation of KPD in the countries affiliated with the Latin America and Caribbean Transplant Society (STALYC).

  

"Guatemala was the first country to publish a scientific report on KPD in 2018,8 with 4 kidney paired transplants performed between 2010 and 2017.

"Two reports from Argentina on local news websites reported 2-way exchanges involving 2 pairs in 20159 and 2018.10

"Costa Rica published a 2-way exchange on the hospital’s social media page in 2016,11 whereas a 2-way exchange transplantation was performed in Brazil in 2020.12

"Mexico is leading the reported KPD activity with a first experience involving 4 pairs in a chain beginning with an altruistic donor13 reported in 2019. A more recent publication reported on 22 pairs transplanted with longer chains and excellent results.14

"It is interesting to note that there are 6 countries—Panama, Ecuador, Venezuela, Peru, Chile, and Paraguay—with laws explicitly permitting KPD. Thus far, there has not been a report on KPD in those countries, which is likely due to the relatively recent publication of these legislations, all of which occurred after 2010.

...

"A recent publication has shed light on the potential of KPD in low-to-middle income countries (LMICs), strongly advocating for the promotion and encouragement of KPD programs, including considerations of cost advantages.17 Of additional relevance, valuable recommendations on initiating KPD programs in LMICs include starting with smaller chains, considering simultaneous surgeries, and implementing effective organ transport strategies.17 By adopting these strategies, LMICs can address compatibility issues and enhance their organ transplantation capabilities.

"Considering that KT is the superior and more cost-effective treatment option for patients with CKD, it is puzzling that the initiation of KPD programs remains limited in a region primarily composed of LMICs. Although some countries may have implemented KPD programs without publication, genuinely active programs beyond Mexico remain missing. It is crucial to emphasize that in most of these countries, deceased donor transplantation also falls significantly short of estimated needs.3,7 The entire infrastructure surrounding transplantation, including both living and deceased donors, continues to require substantial improvements. Particularly for KPD, initiatives such as educational campaigns for physicians, recipients, and donors, as well as investments in logistics and software in addition to a legal framework, need to be encouraged. Similar to KPD programs in Europe,5,18 collaborative efforts across countries could benefit smaller countries. Transplant societies, including STALYC, could play a vital role in supporting the advancement of paired donation, ensuring improved access to transplantation for their populations, especially with living donors."

Simulating European kidney exchange, by Druzsin, Biró, Klimentova, and Fleiner

There are a big variety of procedures used for kidney exchange in Europe.  Here are a set of simulations meant to explore their effects.

Druzsin, Kristóf, Péter Biró, Xenia Klimentova, and Rita Fleiner. "Performance evaluation of national and international kidney exchange programmes with the ENCKEP simulator." Central European Journal of Operations Research (2024): 1-21.

"we are aware of four international KEPs running worldwide:

• Czech-Austrian-Israeli collaboration,

• KEPSAT involving Italy, Portugal, Spain,

• STEP, run by Scandiatransplant,

• NZKX by Australia and New Zealand.

One of the main aspects that can differ in between international KEPs is collaboration polices. In KEPSAT each of the three countries conducts a national matching run first, and only after that they seek for international cycles in the remaining pools. The other three international KEPs merge their pools and conduct one single matching run."

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Not surprisingly, maximizing domestic kidney exchange first leaves only hard to match pairs, which limits the effectiveness of international cooperation.  A 2023 paper from Portugal reports that, since 2017, only three Portuguese pairs were matched in the KEPSAT program with Spain and Italy.

Tuesday, March 12, 2024

Kidney exchange between Portugal and Spain, and prospects for global kidney exchange

Kidney exchange in Italy, Europe and the U.S.: video of my talk in Rome

 Here is a video recording of my talk in Rome yesterday at the  Istituto Superiore di Sanità. There are some introductions by people with vast accomplishments in Italian transplantation and kidney exchange, Giuseppe Feltrin (director of the National Transplant Center), Antonio Nicolò (professor of Economic Theory at the University of Padua) and Lucrezia Furian (Kidney and Pancreas Transplant Surgery Unit - Department of Surgical, Oncological and Gastroenterological Sciences of the University Hospital of Padua)*. 

My talk begins at 27:55.

x

*Although her web page didn't yet reflect this, Dr. Furian was very recently promoted to the rank of Full Professor of Surgery.  Congratulations Lucrezia!

Call for kidney exchange in Jordan

 Here's a paper by Jordanian transplant docs, pointing out that kidney exchange (and perhaps cross border kidney exchange) would be useful for Jordan, a small country with little deceased donation.

Al-Thnaibat, Mohammad H., Mohammad K. Balaw, Mohammed K. Al-Aquily, Reem A. Ghannam, Omar B. Mohd, Firas Alabidi, Suzan Alabidi, Fadi Hussein, and Badi Rawashdeh. "Addressing Kidney Transplant Shortage: The Potential of Kidney Paired Exchanges in Jordan." Journal of Transplantation 2024 (2024).

Abstract

Jordan performed the Middle East’s first living-donor kidney transplant in 1972. In 1977, the country became one of the first Arab countries to regulate organ donation and transplantation. Despite these early advances in living donor transplantation, Jordan’s organ donation after brain death program remains inactive, making it challenging to meet organ demand and placing many patients on long transplant waiting lists. As of 2020, only 14.2% of the patients with end-stage kidney disease have access to a living donor. The scarcity of compatible living donors exacerbates Jordan’s organ shortage, leaving patients with extended waits and uncertain transplant prospects. Due to the lack of living donors and the inactive brain death donation program, additional options are needed to meet organ demand. Kidney paired exchange (KPE), emerges as a potential solution to the problem of donor shortage and donor-recipient incompatibility. By allowing living donors to direct their donated organs to different compatible recipients, KPE offers the promise of expanding transplant opportunities for patients without suitable living donors. However, the current Jordanian law restricting living kidney donation to fifth-degree relatives further limits the pool of potential donors, aggravating the organ shortage situation. This article explores the feasibility of implementing KPE in Jordan and proposes an approach to implementing KPE in Jordan, considering ethical and legal aspects to substantially increase kidney transplants.

Kidney exchange between Portugal and Spain, and prospects for global kidney exchange

 Here's an article from a Portuguese hospital that has engaged in kidney exchanges with Spanish hospitals that have resulted in three transplants for Portuguese patients since the program was initiated in 2017.  The paper considers how international kidney exchange can be expanded globally, so as to have significant effects on the health of Portuguese and other patients.  

The concluding  two paragraphs of the paper speak about global kidney exchange, and the controversy that it has aroused, particularly in Spain, where there has been opposition to significant cross-border kidney exchange.

Francisco, José Teixeira, Renata Carvalho, Joana Freitas, Miguel Trigo Coimbra, Sara Vilela, Manuela Almeida, Sandra Tafulo et al. "International Crossed Renal Donation – The Experience of a Single Center," Brazilian Journal of Transplantation, v. 26 (2023)

"Introduction: Kidney transplantation is the preferred treatment for end-stage chronic kidney disease, however, the shortage of organs can result in long waiting times. Living donor kidney transplantation offers an alternative to cadaver donor, but HLA or AB0 incompatibility can represent a significant obstacle. This study aimed to show the results achieved by a Portuguese hospital since its integration into an international cross-donation program, the South Alliance for Transplants (SAT). 

"Methods: The SAT program was founded in 2017 and is made up of ten Spanish hospitals, three Italian hospitals and one Portuguese hospital. The program takes place every 4 months and only enrolls pairs who are incompatible. Organ transport is carried out in partnership with the Portuguese Air Force. 

"Results: Three different crosses were carried out in partnership with three Spanish hospitals, culminating in the transplantation of three Portuguese patients out of a total of seven patients. The first crossing was carried out in March 2020, at the beginning of the COVID-19 pandemic, with the partnership of two Portuguese hospitals and a Spanish hospital, involving 1 donor/recipient pair from each country,... The second occurred in December 2021 with 3 donor/recipient pairs (1 Portuguese in which the recipient had anti-donor antibodies and positive crossmatch with the potential donor; and 2 from two Spanish hospitals),... The third crossing also took place in December 2021 with 2 donor/recipient pairs (1 Portuguese and 1 Spanish)

...

"A Global Kidney Exchange Program (GKEP), an idea initiated by Rees et al.,16 which involves kidney paired donation between high-income and low-income and medium-income countries (LMICs). Beyond the potential benefits associated with this type of transplantation, similar to those already addressed for international programs, there are concerns about the ethical implications of  such  programs.  They  may  perpetuate  existing  inequalities  between  high  and  low-income  countries,  which  has  motivated  a  statement  from  the  Declaration  of  Istanbul  Custodian  Group.17  Some  critics  argue  that  the  practices  of  most  PRMBs  lack  transparency, leaving room for exploitation and corruption,18 or raise ethical concerns regarding the commodification of organs.19On the other hand, proponents of the idea argue that a GKEP could help address the global shortage of donor organs and provide lifesaving  opportunities  for  patients  in  need.  They  also  note  that  such  programs  could  foster  collaboration  and  information-sharing between countries and institutions, potentially leading to improvements in transplant practices worldwide.16,20 Despite the controversy surrounding the proposal, the idea of a GKEP remains an intriguing possibility for advancing kidney transplantation on a global scale.

"CONCLUSION: Our experience and that of other locations show that programs like these offer numerous benefits, such as expanding the pool of available donors, improving compatibility between donors and recipients, and avoiding the costs and risks associated with desensitization therapies for ABO or HLA incompatible transplantations. These programs represent a valuable option for individuals who require a kidney transplant and can be an effective means of increasing transplant success rates and improving quality of life for patients. However, the success of these programs depends on the number of pairs enrolled. To ensure the success of these programs, there is a need for greater awareness, education, and promotion of their benefits and outcomes among the public, healthcare providers, and policymakers alike.

Design of (international) kidney exchange: ex-post rejection versus ex-ante withholding

 Here's a paper by several Dutch computer scientists, which seems to be motivated by the problem of international kidney exchange within the EU, in which there are lots of concerns about fairness between countries.  But (as the paper notes) these could also apply to individual transplant centers, in the U.S. context.  The thrust of the paper is that looking for exchanges that won't be rejected ex post in a full information environment may be more productive than looking for ways to incentivize countries or transplant centers to reveal their full sets of patient donor pairs in an incomplete information environment.

Blom, Danny, Bart Smeulders, and Frits Spieksma. "Rejection-Proof Mechanisms for Multi-Agent Kidney Exchange." Games and Economic Behavior (2023).

Abstract: Kidney exchange programs (KEPs) increase kidney transplantation by facilitating the exchange of incompatible donors. Increasing the scale of KEPs leads to more opportunities for transplants. Collaboration between transplant organizations (agents) is thus desirable. As agents are primarily interested in providing transplants for their own patients, collaboration requires balancing individual and common objectives. In this paper, we consider ex-post strategic behavior, where agents can modify a proposed set of kidney exchanges. We introduce the class of rejection-proof mechanisms, which propose a set of exchanges such that agents have no incentive to reject them. We provide an exact mechanism and establish that the underlying optimization problem is 

we also describe computationally less demanding heuristic mechanisms. We show rejection-proofness can be achieved at a limited cost for typical instances. Furthermore, our experiments show that the proposed rejection-proof mechanisms also remove incentives for strategic behavior in the ex-ante setting, where agents withhold information.