Are vouchers appropriate for hard-to-match patient-donor kidney exchange pairs?

 A recent letter from Mayo Clinic transplant providers raises concerns related to bad outcomes when some patient-donor pairs are separated (the donor donates before the intended recipient is matched to a donor), but the intended recipient is hard to match.

Donor Mentoring in Private Kidney Paired Donation Programs: The Need for Transparency and Accountability by Tayyab S. Diwan, Pooja Bhudiraja, Shennen Mao, and Carrie Schinstock, Transplantation 110(7):p e1555-e1556, July 2026. | DOI: 10.1097/TP.0000000000005764 

"it is important to recognize that some KPD organizations, such as the National Kidney Registry, operate as private organizations (POs) with distinct governance structures, priorities, and commercial interests. These objectives may not always fully align with those of transplant centers or the broader transplant community, potentially creating gaps in transparency and accountability within a process that directly affects donors and recipients.

"We recently encountered a concerning example that illustrates the ethical tensions inherent when donor mentors are employed by private KPD organizations. ... During a routine text message check-in, the mentor initiated a discussion promoting voucher donation, emphasizing that voucher donors receive priority within the system.  

...
"The donor described the interaction as uncomfortable and “pushy,” and subsequently contacted our transplant center for guidance. Notably, the communication focused on system-level benefits and prioritization metrics but did not explore critical clinical and ethical considerations specific to this donor-recipient pair.

"The discussion was insufficiently individualized and appeared framed toward a preferred outcome. The donor’s preferences and the potential downsides of voucher donation were not explored. The mentor did not ask how the donor would feel if they proceeded with voucher donation and their intended recipient never received a transplant. The discussion lacked any reference to recipient factors that could influence the advisability of voucher donation, including sensitization or recipient comorbid conditions. There was also no discussion about why KPD was being used. Often the donor can donate directly to a recipient (eg, compatible pair), but may decide to enter a KPD pool temporarily to see whether the recipient could receive a transplant with improved size or HLA matching. Finally, the average wait times for a recipient to receive a transplant after voucher donation were not mentioned.

"This interaction raises concern about whether the mentor’s guidance was fully centered on the donor-recipient pair or instead influenced, even indirectly, by organizational incentives to increase voucher participation. When donor mentors are employed by entities that operationally benefit from particular forms of donation, even well-intentioned communication can create perceived or actual conflicts of interest. Transparency regarding these structural incentives, along with a clear commitment to individualized donor-centered mentoring, is essential to maintaining ethical integrity in these situations.

...

"As stewards of living donor trust, the transplant community must ensure that innovation proceeds with appropriate oversight. Any perception that donor education or support is influenced by business interests risks eroding public confidence in living donation programs, with potentially far-reaching consequences that could discourage future donors." 

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 Here's an article on NKR from the NYT that discusses its particular voucher program (and also its finances):

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 IvoryGrace Ashford and Robert Gebeloff
Dec. 27, 2025 

 "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.

...

" many doctors said that given N.K.R.’s relatively small size, these rare patients would be better served waiting for a match before their loved ones donate.

"“We definitely recommend that they not go with a voucher,” said Dr. Miklos Molnar, the medical director of the kidney transplantation program at the University of Utah, which works with N.K.R.

"Dozens of highly sensitized patients who are also on kidney dialysis have waited a year or more after their loved ones donated, according to N.K.R. quarterly reports since 2022. At least three waited more than four years, and one for seven years.

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

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Here's a a discussion of the earliest exploration of unpaired donation that I know of:

Sunday, September 13, 2020

A proposal for non-simultaneous kidney exchange in pairs and chains and with deceased donors...

  

Choosing between public and private schools: vouchers in Arizona

There's a fight over public versus private school funding in Arizona. Here's the background:

Arizona OKs Biggest US School Voucher Plan, Faces Challenge. Republican Gov. Doug Ducey has signed a massive expansion of Arizona’s private school voucher system.  AP, July 7, 2022

"Republican Gov. Doug Ducey on Thursday signed a massive expansion of the state’s private school voucher system, even as he faced a promised effort by public school advocates to block the bill and ask voters to erase it during November’s election.

"The expansion Ducey signed will let every parent in Arizona take public money now sent to the K-12 public school system and use it to pay for their children’s private school tuition or other education costs.

...

"Ducey has championed “school choice” during his eight years in office. He signed a universal voucher expansion in 2017 with enrollment caps that was referred to the ballot by a grassroots group called Save Our Schools Arizona.

"Voters soundly rejected the expansion by a 2-to-1 vote in the 2018 election, but advocates of what are formally called “Empowerment Scholarship Accounts” pushed ahead with new expansions anyway. The universal voucher bill passed with only support from majority Republican lawmakers in the legislative session that ended early on June 25."

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And Salon brings us up to date:

Arizona's school privatization battle heats up: Will the voters get to decide?  Republicans' massive school voucher plan may yet be defeated (again) — but the challenge is stiffer this time By KATHRYN JOYCE, SEPTEMBER 20

"A fight over the future of the most sweeping school voucher program in the country has heated up in Arizona over the last few weeks, as public school advocates race to gather enough signatures to trigger a ballot referendum aimed at overturning a voucher law recently passed by the state's Republican-dominated legislature. The referendum campaign, which faces a crucial deadline this Friday, has drawn intense opposition from Arizona conservatives. This has included funding for multiple anti-referendum websites, roadside protests starring Republican legislators and, over the last two weeks, conflicts between activists both on social media and in the streets. 

...

"Under the new law, any Arizona parent who opts their children out of public school will receive a debit card with an average balance of just under $7,000, which they can use to spend on almost any educational needs they choose, from private school tuition to homeschooling expenses to buying computers to hiring private teachers for "microschools." Public education advocates immediately warned that such a huge transfer of public funds to private hands could be the death knell for public schools, which would likely have to make untenable cuts to teaching staff and school programs.

...

"From the inception of Arizona's ESAs, critics have charged that they're little more than a workaround to funnel public tax dollars to private schools. The idea was born after a court found in 2009 that two earlier Arizona school voucher programs were unconstitutional, violating the state's prohibition on using public money for private education. In 2011, under the guidance of the Goldwater Institute, a conservative think tank, the state launched an ingenious alternative: sending state funds directly to parents, who spend the money as they see fit. The ESA option then became a nationwide model, copied in numerous other states and increasingly seen by conservative education reform activists as "the purest form of school choice." 

HT: Bertan Turhan

Vouchers in kidney exchange chains: a report of initial experience at NKR

 Here's a report of the experience with kidney vouchers, pioneered at UCLA and the National Kidney Registry. That's a policy that has now spread more widely, in the U.S.  This paper reports data from the NKR for 2014 through January 2021, during which time 250 donors were given vouchers, 6 of which have so far been redeemed. Voucher donors start kidney exchange chains (like non-directed donors) that can later be redeemed by (e.g.) their family members.

Voucher-Based Kidney Donation and Redemption for Future Transplant, by Jeffrey L. Veale, MD1; Nima Nassiri, MD2; Alexander M. Capron, JD2,3; Gabriel M. Danovitch, MD1; H. Albin Gritsch, MD1; Matthew Cooper, MD4,5; Robert R. Redfield, MD6; Peter T. Kennealey, MD7; Sandip Kapur, MD8

JAMA Surg. Published online June 23, 2021. doi:10.1001/jamasurg.2021.2375

"Abstract:

Importance  Policy makers, transplant professionals, and patient organizations agree that there is a need to increase the number of kidney transplants by facilitating living donation. Vouchers for future transplant provide a means of overcoming the chronological incompatibility that occurs when the ideal time for living donation differs from the time at which the intended recipient actually needs a transplant. However, uncertainty remains regarding the actual change in the number of living kidney donors associated with voucher programs and the capability of voucher redemptions to produce timely transplants.

...

Design, Setting, and Participants  This multicenter cohort study of 79 transplant centers across the US used data from the National Kidney Registry from January 1, 2014, to January 31, 2021, to identify all family vouchers and patterns in downstream kidney-paired donations. The analysis included living kidney donors and recipients participating in the National Kidney Registry family voucher program.

Exposures  A voucher was provided to the intended recipient at the time of donation. Vouchers had no cash value and could not be sold, bartered, or transferred to another person. When a voucher was redeemed, a living donation chain was used to return a kidney to the voucher holder.

Main Outcomes and Measures  Deidentified demographic and clinical data from each kidney donation were evaluated, including the downstream patterns in kidney-paired donation. Voucher redemptions were separately evaluated and analyzed.

Results  Between 2014 and 2021, 250 family voucher–based donations were facilitated. Each donation precipitated a transplant chain with a mean (SD) length of 2.3 (1.6) downstream kidney transplants, facilitating 573 total transplants. Of those, 111 transplants (19.4%) were performed in highly sensitized recipients. Among 250 voucher donors, the median age was 46 years (range, 19-78 years), and 157 donors (62.8%) were female, 241 (96.4%) were White, and 104 (41.6%) had blood type O. Over a 7-year period, the waiting time for those in the National Kidney Registry exchange pool decreased by more than 3 months. Six vouchers were redeemed, and 3 of those redemptions were among individuals with blood type O. The time from voucher redemption to kidney transplant ranged from 36 to 155 days.

Conclusions and Relevance  In this study, the family voucher program appeared to mitigate a major disincentive to living kidney donation, namely the reluctance to donate a kidney in the present that could be redeemed in the future if needed. The program facilitated kidney donations that may not otherwise have occurred. All 6 of the redeemed vouchers produced timely kidney transplants, indicating the capability of the voucher program."

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I haven't managed to sign a data use agreement with NKR, because Stanford's policies don't allow researchers to cede editorial control of the final paper to the data owners, which NKR's agreement requires.  See earlier post:

Thursday, March 18, 2021

Data use agreements, and university research policies regarding restrictions on publication