Revisiting the Israel-UAE kidney exchange

 I spoke in Jerusalem yesterday about kidney exchange, and one of the things I talked about is the kidney exchange between Israel and the UAE.  At the time (summer 2021) I was careful not to blog about anything beforehand, because there were delicate political issues, and so I didn't start to tell the story until I returned from the UAE, and I waited until the story appeared in a U.S. newspaper.

I never got around to linking to the stories in the Israeli press, so here are two. via Google translate.

From ynet:

Historical transplant: Shani's kidney will be transplanted into an Abu Dhabi resident, her mother will receive a kidney in Israel  Shani Markowitz of Nesher is expected to go down in history this week as the first Israeli to have her kidney transplanted into the body of a resident of Abu Dhabi. The transplant will be carried out as part of an international crossover program in which an Israeli citizen will also receive a kidney from a resident of the United Arab Emirates. Markowitz: "My goal is for my mother to receive a kidney in exchange." Prof. Eitan Mor, Director of the Sheba Transplantation Center: "It is possible that after the Corona we will meet face to face"  by Adir Yanko, 24.07.21 

and from Mednews Israel

Israel Kidney Crossing Abu Dhabi

"Medical fruits of the peace agreement with the United Arab Emirates: a kidney, donated at the Sheba Hospital, was flown and transplanted in Abu Dhabi, in exchange for a kidney donated in Abu Dhabi and transplanted at the Rambam Hospital

"July 28, 2021 was a historic day for the State of Israel, the Ministry of Health, the National Center for Transplantation and the kidney patients and their families: thanks to the transfer of a kidney in a crossover, from Israel to Abu Dhabi and from Abu Dhabi to Israel, three transplants were performed on this day, two of them in Israel

...

"Dr. Tamar Ashkenazi, director of the National Center for Transplantation and the initiative  [said]of the cooperation: "The program was theoretically born from the moment the Abraham Agreement was signed in September 2020, and from the day the agreement between the Ministries of Health was signed on April 21, 2021, we began to move rapidly towards the agreement on the crossbreeding program. An American company assisted in the agreement which accompanies the program in the Emirates, APKD, along with laboratory data provided to us by the company. The matches were found by Prof. Itai Ashlagi, an Israeli researcher at Stanford, with the help of software he developed and even donated to us. Prof. Ashlagi accompaDr. Tamar Ashkenazi, director of the National Center for Transplantation and the initiativenies us in all the international crosses together with Rona Simon from the transplant center. A great feeling of satisfaction accompanies us. We turned to the next crossovers and to find more matches"

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Here are all my posts on that and related kidney exchanges

Kidney brouhaha in Israel: is a good deed still good when performed by a shmuck?

 Recently a three way kidney exchange was performed in Israel. This would have been unremarkable under most circumstances: Israel has an active kidney exchange system.  But it caused a strong reaction in the Israeli press, because one of the donors, a  well-known rightwing activist who wanted to donate a kidney so that his brother could receive one, announced that he wanted his kidney to go only to a Jew.

Here's the Ynet story (you can click to render it in English):

 kidney in a transplant marathon: "The condition was - only for a Jew

Here's the Times of Israel (already in English):

Right-wing journalist causes stir by announcing his kidney would go only to a Jew

There were many more, but you get the idea.  Some of the stories point out that the Israeli National Transplantation Center uses an algorithm* that doesn't see the religion of the recipient, so it's not clear that this was a declaration with consequences.  It was meant to provoke, and it did.

But it's a complicated issue.  In the U.S. (and in Israel), donations can be made to a specific individual, but not to a class of individuals.  With living donation, it means that the donor can choose a specific person to donate to, and it isn't an issue how they choose: no one has to donate an organ to anyone, and every donation saves a life (and maybe more than one, particularly since  living donation reduces competition for scarce deceased-donor kidneys). So if this donor had been able to donate to his brother, no one would have thought twice that he was glad to be donating to a fellow Jew.  What made his announcement provocative was that his kidney wasn't going to his brother: his brother was getting a kidney from an anonymous other donor. [Update clarification/correction: this donation was apparently an undirected (except for the 'only' condition) altruistic donation, not part of an exchange involving the donor's brother.]

Among the people I corresponded with about this is Martha Gershun, a kidney donor who thinks and writes clearly, and has given me permission to quote some of what she said.

"I’m wondering if we find the presentation of the story troubling:  “Right-wing journalist and Temple Mount activist causes stir by announcing his kidney would go only to a Jew.”  We would react badly to a story that said:  “Right-wing Trump supporter says he will only give his kidney to a white man.”

"What if instead the stories were:  “Observant Jewish father of 8 wants to donate to a fellow Jew” and “Rural man from West Virginia seeks to help another in his community”?  Would we find those stories more acceptable?"

Part of the feeling that this is a bit complicated has to do with the fact that we don't (and maybe shouldn't) look gift horses in the mouth, i.e. we don't and maybe shouldn't delve deeply into the motivation of altruistic acts that do a lot of good. We should applaud good deeds even if they aren't performed by saints. (I blogged yesterday, about paying it forward, an umbrella term for doing good deeds in a spirit of gratitude for having ourselves benefited  from past good deeds performed by others. We generally don't find it necessary to condition our approval on precisely who receives the forward-paid gifts.)

So, while I'm not sorry to see that this statement by a kidney donor is a much discussed provocation, I'm inclined to think that a good deed remains a mitzvah even if not performed by a tzadik, as we might have said in our New York English when I was growing up.

I'll give the last word to a Haaretz op-ed, also in English:

 Is It Kosher to Donate Kidneys Only to Other Jews?  A well-known religious journalist in Israel declared the " -only" donation of his kidney. His act is imperfect, but not immoral by Robby Berman

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*On the algorithm used in Israel and elsewhere, see e.g.

Wednesday, January 15, 2020 Kidney Exchange in Israel (supported by Itai Ashlagi)

and

Friday, October 1, 2021 Stanford celebrates Itai Ashlagi and the UAE-Israel kidney exchange

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Update: related subsequent post 

Monday, July 31, 2023

Altruistic kidney donors in Israel

First kidney exchange between Cyprus and Israel

 The Cyprus Mail has the story

First exchange kidney transplant between Cyprus and Israel, By Jonathan Shkurko, March 1, 2023

"The first ever crossover organ transplant involving Cyprus and Israel took place on Wednesday after two kidneys were exchanged at the old Larnaca airport in the morning.

"The effort follows an exchange agreement signed between the two countries.

"The agreement stipulates that organs belonging to donors in Cyprus that are incompatible with the recipients, will be exchanged with compatible organs arriving from Israel.

"The kidney received from Israel was transported to the new transplant clinic at Nicosia general, whereas the one donated by Cyprus was flown to Tel Aviv.

...

"During the organs’ exchange at Larnaca airport, the director of Israel Transplant Organisation Tamar Ashkenazi said she was very happy to see the results of the transnational agreement.

“I hope we will continue with more organs exchanges in the future, as we are already doing with Austria, Czech Republic and United Arab Emirates,” Ashkenazi said. 

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Earlier:

Thursday, December 19, 2019

International kidney exchange between Israel and Czech Republic

Monday, October 4, 2021

More on the UAE-Israel kidney exchange

Itai Ashlagi's kidney exchange software has played a role in all these exchanges.

More on the UAE-Israel kidney exchange

If you're just tuning in, you can follow the story of the kidney exchange between the UAE and Israel here. The pairs who exchanged kidneys were an Israeli Arab husband and wife, a Jewish Israeli mother and daughter, and a mother and daughter who wish to be identified only as Arab residents of the United Arab Emirates.  (I joined their family at their home for a meal when I was in Abu Dhabi, but won't say more about them.)

It isn't a surprise that the donor in each pair couldn't donate to the intended recipient, because in each pair the recipient was a highly sensitized mother ( i.e. for whom it was hard to find a compatible kidney, because she had many antibodies against human proteins). During childbirth, mothers can develop such antibodies to the father's proteins that the children inherited. So the father and the daughters were incompatible donors, since the mother had antibodies against the paternal proteins (human leukocyte antigens) in their kidneys. Together with the fact that the mothers were quite hard to match, and that Israel and the UAE are both small, each with populations of around ten million, they had to look across national borders.

Cross border kidney exchange requires some diplomacy, particularly when the countries involved are getting together for the first time (and don't necessarily have a long history of cooperation). The key medical diplomats were Dr. Tamar Ashkenazi* the director of Israel Transplant and Dr Ali Abdulkareem Al Obaidli, Chairman of the UAE National Transplant Committee.  (Other key collaborators in the complicated logistics were Itai Ashlagi at Stanford and Atul Agnihotri and Mike Rees of the Alliance for Paired Kidney Donation.)  

So this was the plan:

And here's a picture of the Abu Dhabi kidney packed for shipping (masked in the picture are Sue and Mike Rees, who have a lot of experience with packing and shipping kidneys, another nurse whose name I don't know, and Dr. Muhammad Badar Zaman the UAE transplant surgeon who transplanted the  kidney that was on the way.

The little box taped to the top of the shipping container allows the kidney to be tracked in transit, via an app that gives you a picture of where it is at it travels:

And here's the swap of the two kidneys in shipping containers in the airport in Abu Dhabi (Tamar Ashkenazi and Dr. Ali are in the center, Atul and Mike are at the two ends...). Dr Ashkenazi was on both legs of the flight above--she flew in with the Israeli kidney and flew out with the UAE kidney.

On my last night in Abu Dhabi I had dinner with a lot of the docs. Across from me in the picture below are the two surgeons most actively involved in this exchange on the UAE side, transplant surgeon Dr. Zaman and the nephrectomy surgeon Dr. Hamid Reza Toussi.  Next to me is the nephrologist Dr. Mohamed Yahya Seiari.

Below is that whole dinner party. If you've been following these posts up til now, you've met all of them except the gentleman second from the left, Dr. Gehad ElGhazali, who is the head of the HLA lab, which is responsible for the data that allows the matching algorithm to predict which kidneys are compatible, and is responsible for the final 'crossmatch' tests that verify compatibility. Like all the other docs I encountered, he has a multi-international background. This reflects the UAE's very international population, which is why it seems a natural global hub for kidney exchange.

I only met the Israel participants in the exchange later, by Zoom: Shani Markowitz is the donor from the Jewish pair, and Walaa Azaiza is the recipient from the Israeli Arab pair.

The Israeli transplant surgeons are Dr Tony Karam at Rambam Hospital and Dr. Eitan Mor at Sheba Medical Center.

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*As it happens, I've twice had the privilege of  being Dr. Ashkenazi's coauthor (concerning deceased organ donation):

1. Stoler, Avraham,  Judd B. Kessler, Tamar Ashkenazi, Alvin E. Roth, Jacob Lavee, “Incentivizing Authorization for Deceased Organ Donation with Organ Allocation Priority: the First Five Years,” American Journal of Transplantation, Volume 16, Issue 9, September 2016,  2639–2645. http://onlinelibrary.wiley.com/doi/10.1111/ajt.13802/full 

2. Stoler, Avraham, Judd B. Kessler, Tamar Ashkenazi, Alvin E. Roth, Jacob Lavee, “Incentivizing Organ Donor Registrations with Organ Allocation Priority,”, Health Economics, April 2016 online http://onlinelibrary.wiley.com/doi/10.1002/hec.3328/full ; doi: 10.1002/hec.3328. In print: Volume: 26   Issue: 4   Pages: 500-510   APR 2017

UAE as a natural hub for international/global kidney exchange

 There are excellent hospitals in the United Arab Emirates that can perform kidney transplants, and they are prepared to do kidney exchange, both domestically and internationally.  My post today is about why the UAE would be a natural international center for kidney exchange. 

International hubs for kidney exchange are needed because hard-to-match patient-donor pairs may need to find compatible exchanges outside the borders of their own countries. This is particularly true for citizens of countries with relatively small populations of potential compatible donors, and of countries that don't yet have widespread kidney exchange. But even a big country like the U.S., in which kidney exchange is a standard mode of transplantation, can sometimes be too small to find compatible kidneys for the hardest to match  patients. (The U.S. itself is a natural hub for global kidney exchange, about which I've written elsewhere. But so far, bureaucratic obstacles have prevented us from integrating kidney exchange even with Canada...)

The UAE itself is already quite international, as only about 10% of its approximately 10 million residents are Emirati citizens; the rest, largely foreign workers and their families, are citizens of other countries. The biggest of the Emirates, Abu Dhabi, provides medical care for its residents that includes dialysis and transplantation for kidney failure, which is prevalent there (perhaps due in part to the very hot weather and the perils of frequent dehydration in outdoor work). Most of those patients are on dialysis, although the national health insurance will pay for transplants for those who have willing donors either in the Emirates or in their home country. The UAE is wealthy, and many of the home countries are not, so my understanding is that the UAE is prepared to assume the costs of bringing family members to the UAE and providing the necessary medical care. This is cost effective as well as good for the patient, because in the UAE as elsewhere, transplantation is much cheaper than dialysis, as well as being the best treatment. So taking a UAE resident off dialysis via transplant saves a life and pays for itself.

Of course, sometimes the UAE resident's family member who is willing to donate a kidney isn't compatible with the UAE resident. So kidney exchange makes a lot of sense in this case. But with a resident population of only 10 million, there are severe limits on how much kidney exchange can do for hard-to-match patients. So international, global kidney exchange makes sense, in which patient-donor pairs from other countries could also be transplanted in the UAE through kidney exchange with UAE residents (or, eventually, with other international pairs).

It helps a lot that the UAE is also an air transit hub, with two international airlines. Emirates has a hub in the Emirate of Dubai, and Etihad has a hub in Abu Dhabi. So a big portion of the world's population is within a few hours of direct air travel to the UAE.  (When I went to the UAE this summer in connection with the UAE-Israel kidney exchange, I took a direct flight from San Francisco to Dubai, but that takes sixteen hours...)

My main goal in the UAE was to meet with various mostly government bodies engaged in an effort, in collaboration with the Alliance for Paired Kidney Donation, to make domestic and international kidney exchange a regular part of medical care there. To that end, we met with the Ministries of Health in Dubai and in Abu Dhabi, with the national health insurance, with the Red Crescent (which is able to get involved in care of patients and donors after they return home), and others.

The key player in organizing this collaboration, and in transplantation generally in the UAE is  Dr Ali Abdulkareem Al Obaidli, transplant nephrologist and Chairman of the UAE National Transplant Committee. Two other key figures from the APKD are Mike Rees and Atul Agnihotri. Many of our meetings ended in photos, and I'm with those three in all pictures below. 

I expect to write some more about this. In the meantime, here are related posts.

Thursday, September 30, 2021

Kidney Exchange between Israel and the UAE (in USA Today, yesterday)

Friday, October 1, 2021

Stanford celebrates Itai Ashlagi and the UAE-Israel kidney exchange

And this older one:

Friday, August 7, 2020

Global kidney exchange between Abu Dhabi and Kerala (India)

Here's a slide from a talk I'll be giving shortly at the annual conference of the Indian Society of Transplantation (ISOT) that provides some more information about this UAE-India exchange

Stanford celebrates Itai Ashlagi and the UAE-Israel kidney exchange

Here's a Stanford story celebrating Itai Ashlagi's role in this summer's UAE-Israel kidney exchange. (His matching software is embedded in the software suite of the Alliance for Paired Kidney Exchange (AKPD) which is a partner with a remarkable Abu Dhabi effort to further kidney exchange.)

Stanford engineers develop algorithm to aid kidney transplant exchanges. A historic and complex kidney exchange between Israel and Abu Dhabi put a spotlight on the Stanford algorithm that made it all possible. BY ANDREW MYERS.  AUGUST 12, 2021

"A historic kidney transplant exchange recently took place in the Middle East, but it might never have transpired without an algorithm developed at Stanford by Itai Ashlagi, a Stanford associate professor of management science and engineering, and his graduate student Sukolsak Sakshuwong. In all, three ailing recipients received life-sustaining transplants while three healthy donors gave kidneys.

...

"“One of the nice things in the software we developed is the user interface. We collect all the relevant patient data, but then we let the user play with the various thresholds that determine successful matches to see what works for them,” Ashlagi said as he explained the team’s game-like approach to matching. The software acts as a platform and allows different organizations to easily collaborate and create more possibilities for exchanges. “Just a few days ago, I was looking for matches and found an unexpected exchange between pairs from Israel and other European countries. Hopefully, this will lead to new collaborations.”

“Itai’s software was used on both sides of that historic exchange between Abu Dhabi and Israel,” said Alvin Roth, Nobel Laureate and Ashlagi’s mentor and frequent collaborator, who was in Abu Dhabi in connection with the exchange.

"Roth says Ashlagi exemplifies the concept of scientist-engineer and is now a driving force in contemporary kidney exchange through both his deep understanding of the immunological issues of matching kidneys to patients and his intimate appreciation of the needs of transplant centers.

“He’s turned those practical theoretical insights into widely deployed digital tools with the power to change lives,” Roth added. “Having the chance to collaborate with him has been among the best experiences of my intellectual career.”

Kidney Exchange between Israel and the UAE (in USA Today, yesterday)

 I spent a week in the UAE this summer, in connection with a three-pair kidney exchange between the UAE and Israel.  (The UAE is a natural hub for kidney exchange, something I'll say more about in subsequent posts.) Because there were some sensitivities about how it would be publicized, I've  refrained from blogging about it until now, but yesterday's front page story in USA Today met with just about everyone's approval, and so over the next few days I'll post some observations. Today I'll start with the USA Today story, which is gated, but can also be found ungated on Yahoo, here:

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

"At a time when the world seems rife with division and discord, what happened on July 28 reminds how mutual survival often depends on shared humanity triumphing over historical differences.

"In this case, with the assistance of organ transplant experts in the United States, Israel and the United Arab Emirates, three pairs of kidney donors and recipients in Israel and the UAE saved each other in a series of choreographed, pay-it-forward surgeries known as a cyclic exchange.

...

"Just consider the logistics involved in the UAE-Israel exchange. A UAE daughter who was not a match for her mother volunteered to give her kidney to a stranger. An Israeli Arab woman was a match for that kidney, so her husband agreed to donate his kidney to save an Israeli Jewish mother – whose daughter in turn gave her kidney to the sick mother in UAE.

"“The reason we are excited about this is simply because the bigger the pool, the more likely you are to find matches,” says Dr. Michael Rees, a surgeon and founder of the Alliance for Paired Kidney Donation, a Toledo, Ohio-based nonprofit instrumental in making this politically groundbreaking kidney transplant chain a reality.

...

"Those communications, however, remain politically sensitive. When asked for comment, officials in the UAE focused less on the partnership with Israel and more on a general need for international cooperation.

"We are pleased that our innovative partnership with the Alliance for Paired Kidney Donation has allowed us to help our patients,” says Dr. Ali Al Obaidli, chairman of the UAE National Transplant Committee. He added that a collaborative spirit between countries can be used to “close the gap” for those in need of kidneys.

"The UAE donor daughter and recipient mother asked not to be identified by name or religion. Conversations with those involved in the cyclic exchange say kidneys donated outside the UAE generate negative reactions among some Emirati.

...

"This unique transplant chain began when the 60-something mother in the UAE found out in fall 2020 that she had kidney failure and would soon need to start dialysis or find a new kidney.

"Because her family members were not matches, Rees and his Alliance for Paired Kidney Donation team got to work finding a match, which also involved seeing where her daughter’s donor kidney might go.

"The first step was to plug all the relevant medical details into an algorithm ...

"Also crucial to the process was Roth's Israeli colleague Itai Ashlagi, who had developed software that could instantly mine his native country’s kidney database. While Israel had started to develop transplant relationships with Austria and the Czech Republic, he was excited about this new involvement with 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.”

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Here's the picture on the USA TODAY front page: Tamar Ashkenazi flew from Israel to UAE with an Israeli kidney, and flew back with the UAE kidney...

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Here's a USA Today 1-minute video collage of pictures and video accompanying the story:

Daughters from the UAE and Israel put differences aside to save lives in kidney exchange. Three pairs of kidney donors and recipients in Israel and the UAE saved each other in a series of pay-it-forward surgeries known as a cyclic exchange. by Harrison Hill, USA TODAY

I'll have more to say soon, and will link back and forth between posts to make the whole story accessible.