Germany legalizes kidney exchange !!

 Axel Ockenfels forwards the good news. He writes: "It passed! The Bundestag voted today to permit kidney exchange in Germany. The CDU/CSU, SPD, and Greens voted in favor." 

 (More steps will have to be taken before kidney exchanges occur regularly in Germany, but this is a giant step forward.) 

 Here's the official announcement:

Parlament weitet Regeln zur Lebendorganspende aus  

Parliament expands rules on living organ donation 

"On Thursday, March 26, 2026, the Bundestag expanded the possibility of living kidney donations to increase the circle of possible organ donors and organ recipients. A corresponding bill of the Federal Government "to amend the Transplantation Act – Amendment of the regulations on living organ donation and further amendments" (21/3619) in the version amended by the Health Committee was adopted by the majority of the CDU/CSU, SPD and Bündnis 90/Die Grünen against the votes of the parliamentary group Die Linke, with the AfD abstaining. In the future, this will also enable so-called cross-over living kidney donations between different couples. 

...

"Despite numerous initiatives to promote organ donation, there has been no trend reversal so far. At the end of 2024, around 6,400 people were waiting for a donor kidney, according to the information. At the same time, the number of kidney transplants fell to 2,075. A total of 253 patients died in 2024 who were on the waiting list for a kidney.

"Opening up further therapy options
"Therefore, it is important to open up further therapy options that have long been established internationally. The goal of countering the danger of organ trafficking remains decisive in the amendment of the regulations, according to the draft.

"In the future, living kidney donations will be possible "crosswise" by another organ donor partner in the case of immunologically incompatible organ donor couples. The organ donor couples do not have to know each other. However, the so-called close relationship of the respective incompatible partners should remain mandatory. 

"Principle of subsidiarity is repealed
"The so-called principle of subsidiarity, according to which organ removal from living persons is only permitted if no suitable organ from a deceased donor is available, will be repealed. Non-directed anonymous kidney donation, i.e. a donation to an unknown person, is also made possible. The donor should have no influence on the recipient.

"The plan is to establish a program for the mediation and implementation of crossover living kidney donation, including anonymous kidney donation. A center for the placement of kidneys is to be established. The conciliation procedure is laid down by law.

"Care in the transplant center mandatory
"Mandatory independent psychosocial counselling and evaluation of donors before a donation will be introduced. In addition, care in the transplant center will be mandatory throughout the entire donation process.

"If a living kidney donor later falls ill himself and needs a kidney transplant, this should be taken into account when arranging kidneys donated postmortem. Institutions that remove tissue postmortem should be able to be connected to the Register for Declarations of Organ and Tissue Donation (OGR) so that they can clarify for themselves whether there is a willingness to donate tissue in a potential donation case." 

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It's been a long campaign, and Axel and a number of others played a critical, tireless role, both in public and in private consultation with lawmakers and interested parties. It's notable that the legislation looks forward to allowing nondirected donors (not every European kidney exchange program does.) It's also notable that the current bill expects that compatible pairs will not be eligible to participate in kidney exchange to seek a better match. That's a battle that hasn't yet been won, despite the fact that compatible pairs are important in a number of ways in U.S. kidney exchange.

Still, this is a significant victory in a campaign that has been going on for at least a decade. I may have written the first German newspaper editorial on the need to legalize kidney exchange in Germany, almost exactly ten years ago:

Thursday, March 17, 2016  German organ transplant law should be amended or reinterpreted to allow kidney exchange: my op-ed in Der Tagesspiegel

 

Here's one of the more recent editorials, which I was privileged to coauthor with Ockenfels and two other heroes (or in this case heroines) of this struggle, Agnes Cseh and Christine Kurschat:

Monday, September 9, 2024  Anticipating kidney exchange in Germany in the Frankfurter Allgemeine Zeitung

 Der Volkswirt Hoffnung durch Tausch  by Ágnes Cseh, Christine Kurschat, Axel Ockenfels und Alvin E. Roth

 

 There will be more steps to take to establish effective regulations and institutions to make kidney exchange readily available in Germany, but this is a big step in that direction.

Abundant, the movie about nondirected kidney donors, is now available for streaming.

 Abundant, the movie about (mostly) non-directed (mostly) kidney donors (but also some livers), is now available for streaming.

You can get it at https://abundantmovie.com/ 

You can see all my posts about the movie Abundant here. 

Kidney exchange now has a broad literature across multiple disciplines

 One pleasure of following an area of research for a long time is getting to see how its academic literature becomes both deeper and broader.  That's certainly been the case with kidney exchange, which now has (of course) a big medical literature, but has also spurred research in the economics and operations research communities.  Here's a recent survey of the OR literature:

Barkel, M., Colley, R., Delorme, M., Manlove, D., & Pettersson, W. (2025). Operational research approaches and mathematical models for kidney exchange: A literature survey and empirical evaluation. European Journal of Operational Research. 

Abstract: "Kidney exchange is a transplant modality that has provided new opportunities for living kidney donation in many countries around the world since 1991. It has been extensively studied from an Operational Research (OR) perspective since 2004. This article provides a comprehensive literature survey on OR approaches to fundamental computational problems associated with kidney exchange over the last two decades. We also summarise the key integer linear programming (ILP) models for kidney exchange, showing how to model optimisation problems involving only cycles and chains separately. This allows new combined ILP models, not previously presented, to be obtained by amalgamating cycle and chain models. We present a comprehensive empirical evaluation involving all combined models from this paper in addition to bespoke software packages from the literature involving advanced techniques. This focuses primarily on computation times for 49 methods applied to 4320 problem instances of varying sizes that reflect the characteristics of real kidney exchange datasets, corresponding to over 200,000 algorithm executions. We have made our implementations of all cycle and chain models described in this paper, together with all instances used for the experiments, and a web application to visualise our experimental results, publicly available. "

 

"The first papers to study algorithms or mechanisms for KE-Opt were the landmark papers of Roth et al., 2004, Roth et al., 2005. When the objective is to maximise the number of transplants, KE-Opt is 
-hard in general (Abraham et al., 2007).

... 

 

"The main contributions of this survey paper are as follows:
 

•A detailed literature survey (with over 210 references) of OR approaches to KE-Opt, covering the following topics: algorithms and complexity for KE-Opt; hierarchical optimisation in KE-Opt; enabling equal access to transplantation; dynamic KEPs; uncertainty and robustness in KEPs; multi-hospital and international KEPs; recipients’ preferences; dataset generators and software tools; emerging topics; and other related surveys.
•A systematic exposition of all the key existing ILP approaches for KE-Opt, describing separately models for representing optimal solutions comprising only cycles from those comprising only chains. As a consequence, combined ILP models for KE-Opt can be obtained by mixing a cycle model with a chain model. We also use a running example (appearing in the Supplementary Material) to illustrate all models for the benefit of the reader. 

•A comprehensive empirical evaluation of all combined ILP models for KE-Opt that are described in this paper, together with “off-the-shelf” approaches involving advanced techniques such as column generation and branch-and-price, where we have been able to obtain and execute the third-party software. The main aim is to compare execution times of the different approaches considered on randomly generated datasets that reflect the characteristics of real data from the UK’s KEP. In particular, we tested 49 methods on 4320 instances, corresponding to over 200,000 algorithm executions, and amounting to over 10 years of computational processing time in total, across multiple cores running in parallel.
•An interactive tool to allow the reader to analyse the data resulting from our experiments that is publicly available at https://optimalmatching.com/kep-survey-2025, allowing custom heatmaps to be created by varying instance sets, models to be considered and measures of performance.
•All of the implementations of the combined cycle and chain ILP models presented in this paper are available for the reader to access at https://doi.org/10.5281/zenodo.14905243, and the benchmark instances used for the experiments are available for download at https://doi.org/10.5525/gla.researchdata.1878." 

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 "

 ##########

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.

##########

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. "

########

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. "

 

Ed Peskowitz (1944-2026)

 After an eventful life, with major accomplishments in business and philanthropy, Ed Peskowitz succumbed to kidney failure this week.  I met him only after he had turned to philanthropy, and after he had received a kidney transplant.

Here's his obit in the Washington Jewish Week: 

Edwin Peskowitz 

"Ed was an extremely generous man who touched the lives of many. Over the course of his life, he and his wife supported local educational initiatives, such as the I Have a Dream Foundation and the SEED Public Charter School. Ed was passionate about promoting Middle Eastern peace and supported numerous causes in the region aimed at building understanding between various cultures and religions and he created the Friendship Games to encourage this among young athletes. He was a supporter of the Anti-Defamation League, the United States Holocaust Memorial Museum and the University of Maryland.

Ed suffered from renal disease and was given the gift of life by an altruistic kidney donation in 2019. Ed devoted the last years of his life to creating and supporting philanthropic efforts, such as the Alliance for Paired Kidney Donation, Kidney Transplant Collaborative and Kidneys for Communities, to encourage living kidney donation and improve matches between potential donors and recipients." 

 

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 comes to Hungary

Péter Biró  writes with good news about kidney exchange in Hungary.

 Here's the announcement from the  University of Pécs, of the first kidney exchange performed in Hungary, following the first legislation passed to legalize kidney exchange in 2014. (And more details follow from a second announcement below.)

The first cross-donation kidney transplant was performed in Hungary at the University of Pécs Clinical Center  2026.01.29

"The first cross-donation kidney transplant performed in Hungary a few days ago can be considered a new milestone in the history of organ transplantation in Hungary. Within the framework of the living donor kidney exchange program, two women received new kidneys at the Department of Surgery of the University of Pécs Clinical Center (PTE KK), which gives them the opportunity for a better quality of life. It is particularly interesting that in both cases the organ donor was a male member of the other couple.

...

"In his speech, Dr. Péter Szakály, Head of Department of the Department of Surgery of the University of Pécs, emphasized that: The establishment of a national pool was of fundamental importance in this program, and this program will be able to operate successfully in the future as well if there are as many such couples as possible. He also added that compared to traditional kidney transplantation, living donor transplantation is always a much greater challenge (...) Transplantation with a living donor comes with increased responsibility, as it involves a healthy donor. In this case, two surgeries were performed at the same time: Ádám Varga, assistant professor, and I simultaneously removed and replaced the organs between the two pairs from the adjacent operating room. 

"Since 2014, the law allows this type of transplant, but no specific surgeries have been performed so far. Recognizing this shortcoming, at the initiative of the National Hospital Administration, the four kidney transplant centers in Hungary and the Regional Kidney Transplant Committees operating there, in cooperation with the National Blood Transfusion Service, have developed a nationally uniform program in accordance with the legislation in force, which ensures equal opportunities for all patients who voluntarily enter the program. This became the living donor kidney transplant exchange program, which was launched in Hungary on June 21, 2024. The search for optimally compatible pairings between the pairs applying for the program is carried out with the help of a software developed for this purpose." 

#########

And here is the emailed announcement forwarded by Peter Biro, who has been a champion of kidney exchange in Europe for many years now:

Dear EURO-KEP Colleagues,

 

We are pleased to inform you that we have reached a significant milestone within the Hungarian Kidney Paired Kidney Exchange Program (HKEP), in line with the objectives of the EURO-KEP initiative.

 

On January 20, 2026, the first two kidney transplants were successfully performed in Hungary within the national living donor kidney exchange program. The surgeries took place at the University of Pécs Clinical Centre, marking the first realization of kidney cross-over donation in the country.

We believe that this milestone, supported by a well-structured professional and patient information campaign lasting more than a year and a half, will contribute to increasing the number of living donor kidney transplants and encourage more patients and voluntary donors to join kidney exchange programs. This, in turn, will support further kidney exchanges and improve equal access to transplantation.

 

Chronology and key developments of the Hungarian KEP

• June 2024 – With the support and authorization of the National Directorate General for Hospitals (OKFŐ), a nationally unified kidney paired exchange program was launched, coordinated by the National Blood Transfusion Service, with the participation of all four Hungarian kidney transplant centers and regional waiting list committees.
• Since the launch – The matching algorithm has been run every three months; to date, six matching runs have been completed, involving 57 donors and 44 recipients. The seventh run is scheduled for tomorrow.
• July 2025 – A key legislative amendment entered into force, allowing:
• simultaneous transplants among more than two donor–recipient pairs in a closed chain,
• transplant surgeries to be performed in different centers, enabling patients to remain at their original listing centers and
• not only incompatible pairs can join the program, but compatible pairs in the hope of better matching.
• Following the legal amendment, an updated and detailed printed patient information package was distributed nationwide, with the involvement of all dialysis units and transplant centers.
• During the optimization process, a clinically acceptable match was identified between two married couples. In both cases, the male partner donated a kidney to the female recipient of the other couple. The transplant surgeries were performed on 20 January 2026 at the Surgical Clinic of the University of Pécs Clinical Centre. In both cases, graft function started immediately. The recipients and donors are in good condition and both patients were discharged home on Friday.

We consider this achievement a significant milestone in Hungarian transplantation and a meaningful contribution to the shared European objectives of the EURO-KEP project. We remain committed to continuing this work in the service of saving lives.

 

Best regards,

 

Dr. Sándor Mihály, Ph.D  
Director of transplantation

Honorary College Associate Professor at Semmelweis University

General Secretary of the Hungarian Transplant Society

EDTCO Past-Chair 2023-2025

 

 

Organ Coordination Office

Central Waiting List Office

National Organ and Tissue Donation Opting-out Registry

Hungarian Stem Cell Donor Registry

 

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)

 

 

History of the U.S. National Science Foundation (NSF)

 The NSF has played a key role in American science, and risks being collateral damage in the war against science.

Here is a their history web page:

History of the U.S. National Science Foundation 

Like many scientists, I'm deeply grateful for their support, particularly their early support. 

 The section "NSF's history and impacts: A brief timeline" mentions some accomplishments decade by decade, including this for the 2010's

    2010

"NSF-supported researchers use economic matching theory to develop a kidney exchange program that dramatically improves efficiency and doctors' ability to match organs. For his work in this area, Alvin Roth shares the 2012 Nobel Memorial Prize in Economic Sciences."

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All my posts on NSF.  

Four international kidney exchange programs: 3 achieve substantial success

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

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

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

 ...

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

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

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

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

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

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

 ########

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

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

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*Notes on population:

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

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

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

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

NKR in the NYT

 Today's NYT has a story on the country's largest kidney exchange network, a private company with opaque finances called National Kidney Registry (NKR). The story also raises questions about some of the promises NKR makes through a voucher program.

 How One Father Created an Organ Empire.  The National Kidney Registry has matched thousands of kidney donors with recipients. It has also paid millions of dollars to a company owned by its founder.    By  Danielle Ivory, Grace Ashford and Robert Gebeloff 

 "Since its founding, N.K.R. has enabled nearly 12,000 such swaps, called paired donations, far more than any other public or private program. The organization’s focus on technology and efficiency has jolted a sluggish system, many health experts said.

But at the same time, N.K.R. has created a multimillion-dollar business with considerable power over the flow of thousands of organs, according to interviews with more than 100 people in transplant medicine and a review of business records. Many doctors told The Times the stakes of these lifesaving exchanges were too high to be managed by a private company with little government oversight.

...

"The organization was a nonprofit for more than a decade, but during that period paid at least $39 million for technology and other services to a company owned by Mr. Hil, charity filings show. In 2023, N.K.R.’s commercial operations were sold to a new for-profit company owned by Mr. Hil, making its finances much more opaque. 

...

“It’s basically a money transfer,” said Dr. Lloyd Ratner, a surgeon at Columbia University who performed the second-ever paired transplant in the country. He said the hospital had parted ways with N.K.R.

...

"One of N.K.R.’s most innovative policies, many doctors said, is known as voucher donation: Donors can choose to give their kidneys immediately, in exchange for organ vouchers their loved ones redeem later.

"This arrangement has helped N.K.R. expand its pool. But vouchers add risk for donors giving on behalf of hard-to-match patients. They might go through surgery months or even years before their loved ones get a match. Matches are especially unlikely, doctors said, for “very highly sensitized” patients who carry antibodies likely to reject a transplant.

...

" Doctors told The Times that they knew of some patients who became too sick or died before they redeemed their vouchers."

####### 

 

Not mentioned in the article is the Alliance for Paired Kidney Donation (APKD) a smaller, older, highly ethical non-profit kidney exchange network founded by the transplant surgeon Mike Rees (with whom I often work). 

Kidney exchange updates

 Here are three kidney papers and proposals that I've noted recently,  which will have implications for the growing interest in international kidney exchange on a global scale:

Klaassen MF., de Klerk M, Dor FJ.M.F., Heidt S, van de Laar SC., Minnee RC., van de Wetering J, Pengel LH.M. and de Weerd AE. (2025) Navigating a Quandary in Kidney Exchange Programs: A Review of Donor Travel versus Organ Shipment. Transpl. Int. 38:14804. doi: 10.3389/ti.2025.14804

Abstract:  In multicenter kidney exchange programs (KEPs), either the explanted kidney must be shipped, or the donor must travel to the transplanting center. This review describes the available data on these two approaches and formulates recommendations for practice. We searched for studies addressing organ shipment or donor travel in KEPs. Data were categorized into four domains: cold ischemia time (CIT), logistics, donor/recipient perspectives and professional perspectives. From 547 articles screened, 105 were included. Kidneys are shipped in most countries. Prolonged CIT due to shipment may increase the risk of delayed graft function, but does not seem to impact graft survival. Planning the shipment requires a robust logistical framework with guaranteed operating room availability. Donor travel is reported to be both emotionally and financially distressing for donors and exposes them to inconsistencies in donor evaluation and counseling across centers. Reduced willingness to participate in KEP when travelling was reported by 36%–51% of donors. Professionals generally support offering organ shipment to donors not willing to travel. In conclusion, the decision between donor travel or organ shipment should be tailored to local circumstances. Healthcare professionals should prioritize minimizing barriers to KEP participation, either by facilitating organ shipment or reducing the burden of donor travel. 

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Neetika Garg, Joe Habbouche, Elisa J. Gordon, AnnMarie Liapakis, Michelle T. Jesse, Krista L. Lentine,
Practical and ethical considerations in kidney paired donation and emerging liver paired exchange,
American Journal of Transplantation,
Volume 25, Issue 11,  2025, Pages 2292-2302,
ISSN 1600-6135,  https://doi.org/10.1016/j.ajt.2025.07.2459.
(https://www.sciencedirect.com/science/article/pii/S1600613525028382)
 

Abstract: Since the first kidney paired donation (KPD) transplant in the United States in 1999, the volume and scope of KPD has expanded substantially, accounting for nearly 20% of living donor kidney transplants in 2021-2022. This review article discusses the practical and ethical issues specific to paired donor exchange that patients, transplant centers, and exchange programs commonly encounter. Access to paired donor exchange and education of candidates regarding the potential benefits, risks, and logistics of KPD are important considerations. Transplant centers and patients must consider practical issues including wait times, allocation and matching strategies, assessment of organ quality, complex donors, cold ischemia time, and risks of broken chains. Protections available to donors from current KPD programs, the potential psychosocial effects, and the ethical concerns related to variable access and the proprietary nature of private exchange programs are also discussed. More detailed, timely data collection at a national level, and ability to merge national data with individual donor exchange registries will enable the analysis of the impact and outcomes of future trends in paired donation. KPD experience and key concepts may inform liver paired exchange, which has been used internationally to expand living donor liver transplantation and is emerging in the United States.

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Alliance for Paired Kidney Donation (APKD) Launches Wish Upon a Donor: A Hope-Focused Advocacy Program Helping Kids Who Need Kidneys Find Living Donors

"TOLEDO, OHIO / ACCESS Newswire / December 9, 2025 / The Alliance for Paired Kidney Donation (APKD) is proud to announce Wish Upon a Donor, a groundbreaking program that amplifies the voices of families fighting for a better and brighter future for their child. While pediatric kidney patients cannot advocate for themselves, their parents can - and too often, they face this battle alone. Wish Upon a Donor helps families share their child's story, shining a light on their hopes, dreams, and urgent need for a living kidney donor.

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"The onboarding process is fast and simple, taking just 10-15 minutes to complete, and finalized videos are sent to patients in just one to three days. Participation is free, and patients retain full control over how and where their stories are shared.

Wish Upon a Donor offers a range of support for families as they seek living donors, including:

Production of a personalized, high-quality video designed to reflect the patient's wishes, personality, and future - not just their disease

Dedicated campaign webpage to make it easy to convert interest into action

QR-coded postcards and magnets for sharing in local communities

Social media guidance to help families and supporters spread the word

Spanish- and English-language outreach materials for broader access

A living donor mentor to answer any non-medical questions about the process

"Wish buddy" volunteers to assist with video narration and/or sharing patient videos with a broader audience

When interest is generated through the Wish Upon a Donor campaign, APKD ensures both patients and transplant centers are effectively supported with guidance grounded in real-life experience from a dedicated living donor mentor. The organization manages all incoming donor inquiries, educates potential donors on the process, protections, and realities of living donations, and then refers qualified donors to an appropriate transplant center partner. APKD maintains communication and support throughout the evaluation and donation process. This approach empowers potential donors with education while easing the burden on transplant centers."