Market Design and Kidney Exchange at NTHU: Public Lecture in Taiwan (video)

 Here is a video of a public lecture I gave at National Tsing Hua University (NTHU) in Taiwan.

It begins at around 13:40 (and if I've done it right, the version below should start around there), and the Q&A starts around 1:15:00 

 

Lund University anticipates EU-wide kidney exchange, and celebrates Tommy Andersson

European kidney exchange is making progress:)

 Kidney Transplants Save Lives, Cut Taxpayer Costs   Lund University
Sweden's kidney exchange programme has been operational since 2018 and will soon be expanded to include the entire EU. The programme has meant that patients' previous waiting times of up to two years have been reduced to just six months.

"Tommy Andersson, Professor of Economics at Lund University School of Economics and Management, never imagined his research would one day lead to this-but his joy, pride, and commitment are unmistakable.

"Thirteen years ago, we began the planning phase in Sweden, and in 2019 we expanded to Denmark, and later to Finland, Iceland, and Norway. The programme is called STEP (Scandiatransplant Exchange Programme). Now, in 2026, there is a consensus on how kidney exchanges should be conducted across the entire EU, and almost all the pieces of the puzzle are in place for us to launch the pilot project during 2026," says Tommy Andersson.

WATCH FILM (in Swedish): "The Economist Saving Lives" -  

Tommy Andersson was involved from the start, developing the algorithms that make the kidney exchange programme in Sweden possible. In cases where a family member can donate a kidney, the transplant can occur directly. However, if the donor's kidney does not match the patient, the exchange programme becomes vital. The programme enables matching across Scandinavia and soon across the entire EU." 

A decade of progress in kidney exchange in India

 This morning I zoomed in to the tail end of a quiet celebration in India of a decade of collaboration between the Alliance for Paired Kidney Donation  (APKD) and our Indian medical colleagues..

Mike Rees and I both had sent messages of support, and during the call I spoke about my hope that India, which already does the third most kidney transplants in the world, will in the coming decade come to be the country that does the most kidney exchange transplants. That in turn could lead to India eventually becoming a global attractor for patient-donor pairs from countries that don't have lots of transplants or exchanges, to come to India to participate in kidney exchange there.

There remain many obstacles to be overcome before that can happen, but there's been so much progress in India already that those are real possibilities.

Here's the message I emailed to the founding team yesterday:

"Dear Vivek, Pranjal, Mike, Atul  and Colleagues: It’s amazing that the collaboration  between the Institute of Kidney Diseases and Research Center at the Dr. H L Trivedi Institute of Transplantation Sciences, and the Alliance for Paired Donation is entering its second decade.  It’s been thrilling for me to observe the progress that you have made.  I recall vividly meeting Dr. Trivedi in 2019 in his hospital room, and I was later deeply honored to deliver The Dr H.L. Trivedi Oration at the ISOT Meeting  in 2022.  I’ve learned so much from Vivek, and I will never forget watching Pranjal perform a robotic surgery.  And it was memorable that you both were able to visit us at Stanford for the kidney summit organized by APKD and Stanford Impact Labs.
 

"Seeing what you have accomplished has been one of the highlights of my career in market design. It’s good that we’re all still young, since I’m looking forward to the next decade of accomplishment in India." 
 #########

Here's Mike's message:

"Mike Rees on the 10-year anniversary of IKDRC and APKD working together

"I remember the first time I met Vivek in 2016 at the TTS meeting in Hong Kong. Vivek received the “International Transplantation Science Mentee-Mentor” Award at the TTS 2016 Congress in Hong Kong. The award recognized his work on "Impact of Single Center Kidney Paired Donation Transplantation to Increase Donor Pool in India," completed under the mentorship of Prof. H.L. Trivedi and Prof. P.R. Shah. I remember meeting Vivek, Dr. PR Shah and Pranjal at the award ceremony and thinking about how wonderful it would be if we could work together. I imagined harnessing their great passion of helping patients through kidney transplantation and paired exchange and combining that with the APKD’s powerful software employing Al Roth’s Nobel Prize winning algorithm. While in Hong Kong, Vivek and I went to dinner at my first vegetarian restaurant and there we agreed to work together to try to help expand kidney exchange in India. 
 

"Three years later I travelled to Ahmedabad in May of 2019 with Alvin Roth for the ISOT Mid-term meeting. During that trip, Al and I watched Pranjal do a retroperitoneal donor nephrectomy and a robotic kidney transplantation. It was my first time seeing a robotic kidney transplant and it was so amazing. I met Dr. Himanshu Patel on that trip and I also had the honor of visiting Dr. HL Trivedi and his wife with Vivek. What a legacy Dr. Trivedi has left and I am so proud that APKD has been able to work together with Vivek, Himanshu, Pranjal and all the members of the IKDRC team to extend his wonderful vision.
 

"Since that meeting in Hong Kong, I have now made 12 trips to India and have become a big fan of Indian food and diversity of Indian culture. I have been so impressed with the passion and commitment of doctors across India, but none more so than at IKDRC. Along the way I have been fortunate to have been joined by Atul Agnihotri, Shridhar Hanchinal, and Trilly Mathew to expand our work in India. We are so grateful for the amazing example the IKDRC team has demonstrated in terms of what is possible when hard work and technology come together to saves the lives of patients with kidney disease. It is truly a joy to celebrate today with you our tenth anniversary of the work between IKDRC and APKD as we commemorate all that we have accomplished together!"

 ########

 Over the last decade I've blogged many times in connection with transplant progress in India.  Here's a selection related to this ten-year anniversary:

Wednesday, January 13, 2016  77 Kidney Exchange transplants in 2015 at one transplant center in India

Friday, April 14, 2017  A transplant center in India has done 300 kidney exchange transplants

Wednesday, May 3, 2017 Mike Rees in India to help remove obstacles to kidney exchange

Tuesday, May 21, 2019 Robot-assisted kidney transplantation in Ahmedabad, India.

 

Wednesday, February 3, 2021 Non-Simultaneous Kidney Exchange Cycles in India: new design, in Transplant International by Kute and Rees et al.

Thursday, October 13, 2022 The Dr H.L. Trivedi Oration at the Indian Society of Transplantation (ISOT) Meeting 2022

Tuesday, February 27, 2024  Stanford Impact Labs announces support for kidney exchange in Brazil, India, and the U.S.

Saturday, April 19, 2025 One Nation One Swap: National kidney exchange in India

 Thursday, August 7, 2025 Stanford conference on extending kidney exchange

 

Multi-pair kidney exchange comes to Karnataka

 Sophisticated kidney exchange is coming to more Indian States.

The Indian Express has the story from Karnataka:

Kidney donation to become easier as Karnataka okays multi-pair exchange
Until now, swap kidney donations were limited to two incompatible donor-recipient pairs. 

"In a significant move that could help patients awaiting a kidney transplant, the Karnataka Government has issued guidelines permitting multi-pair kidney paired swap transplantation. This will expand the scope of organ donation beyond the traditional two-way system.

The Karnataka Multi-Pair Kidney Exchange Transplantation Guidelines 2026 were issued via a government order on April 4.

“A significant number of donor-recipient pairs in Karnataka are unable to undergo transplantation on account of biological incompatibility… Applications have been received from registered transplant hospitals in Karnataka seeking approval for multi-pair Kidney Paired Exchange Transplantation involving three or more donor-recipient pairs,” the order said."

Alex Chan on deceased organ donation

 The Harvard Gazette points to this interview with HBS professor Alex Chan:

Designing Incentives That Matter—Even After Death: Interview with Alex Chan By Avery Forman 

"In “Reimagining Transplant Center Incentives Beyond the CMS IOTA Model,” published in January in the Journal of the American Medical Association, Chan explores a government experiment that pays kidney centers for volume and efficiency—not just outcomes—which could increase transplant numbers. Chan cowrote the article with Alvin E. Roth, the George Gund Professor of Economics and Business Administration, Emeritus, at HBS.

In addition, covering funeral costs for organ donors could increase donation rates by up to 35%, and save up to 419,000 life years and as much as $800 million in Medicare expenses, Chan and coauthor Kurt Sweat of the University of Texas Southwestern Medical Center write in “Funeral Expense Reimbursement as a Strategy to Enhance Organ Donation and Transplantation Access,” published in October in NPJ Health Systems.

 ...

"Why Chan felt compelled to study the organ market

“Two things pulled me in. First, this is a market where the stakes are brutally clear. Organ transplantation is one of the few places where inefficiency shows up not as a deadweight loss in a textbook, but as people dying on a waiting list. When a market fails here, it fails loudly.

Second, the level of inefficiency is staggering. Each year, more than 5,000 organs are recovered and then discarded, while roughly the same number of people die waiting for an organ. These are million-dollar transactions once you account for surgery, lifelong care, and avoided dialysis. So even small improvements in incentives can save lives directly and save the healthcare system billions of dollars.

For an economist or market designer, that’s a rare alignment: moral urgency and economic leverage pointing in the same direction.”

Incentives must consider what’s socially acceptable

“Incentive design is much harder than we like to admit. Organ transplantation is a supply chain. You have procurement organizations, hospitals, surgeons, patients, regulators, all responding to different incentives.

Designing a good incentive for one actor is already difficult. Designing incentives so that the entire chain works well is not just adding up the optimal incentives for each link. Sometimes improving one part of the system quietly breaks another.

The choice isn't between market and no market. It’s between a system we design on purpose and a system that fails by accident.

This is a market with moral and political constraints embedded in it. In healthcare, and frankly now in most markets, the incentives that are economically sensible also need to be socially legitimate.

Incentives don’t just change behavior; they express values. In markets that touch life, death, or dignity, people react not only to what the incentive does, but to what it seems to say. That makes incentive design less like tuning a machine and more like negotiating a fragile social contract.

 ...

"The ‘ick factor’ might prevent progress

“Very often people do not want to use the right incentives because they have this concept of it being repugnant.

[For instance], we would pay for the funeral of someone who gives their life for their country when they serve in the military. We will pay for the funeral of someone who donated their body for scientific research to advance society. But if people want to donate an organ to save another person's life? If [that donor’s] family would very much welcome some support at a moment of crisis, we are not going to pay for the funeral. Even a very sensible incentive sometimes is bound by social norms, or even what we call the ‘ick factor,’ and we have a less effective system at the end.

People worry that incentives will corrupt the gift of life. But the truth is that we already have incentives; they’re just accidental and poorly distributed. The choice isn't between market and no market. It’s between a system we design on purpose and a system that fails by accident. Ignorance of incentives doesn't make a system moral; it just makes it inefficient.”

 

Tim O'Reilly on market design in the age of A.I.

 Tim O'Reilly, one of the OG commentators/facilitators/cheerleaders of the internet revolution, has some thoughts on the infrastructure  of the various marketplaces for AI.

The Missing Mechanisms of the Agentic Economy: From disclosures to protocols to markets By Tim O’Reilly
 

"For the past two years, I’ve been working with economist Ilan Strauss at the AI Disclosures Project. We started out by asking what regulators would need to know to ensure the safety of AI products that touch hundreds of millions of people. We are now exploring the missing mechanisms that are needed to enable the agentic economy.

"This essay traces our path from disclosures through protocols to markets and mechanism design. Rather than simply stating our conclusions, I’m sharing our thought process and some of the conversations and historical examples that have shaped it. 

...

"Economists use the term “mechanism design” to describe the engineering of rules and incentive structures that lead self-interested actors to produce outcomes that are good for everyone. It’s sometimes called “reverse game theory.” Rather than analyzing the equilibria that emerge from a given set of rules, you start with the outcome you want and work backward to design the rules that will get you there.

"Mechanism design theory got its start in the 1960s when Leonid Hurwicz took up the problem of how a planner can make good decisions when the information needed to make them is scattered among many different people, each of whom has their own interests. His key insight was that people won’t reliably reveal what they know unless it’s in their interest to do so. So how do you design a system that aligns their incentives?

"The field that Hurwicz founded and that Eric Maskin and Roger Myerson developed through the 1970s and 80s earned all three the Nobel Prize in Economics in 2007.

"I first encountered the field when Jonathan Hall, at the time the Chief Economist at Uber, waved Al Roth’s book Who Gets What — and Why at me and said “This is my Bible.” In it, Roth describes his own work on mechanism design, which won him the 2012 Nobel Prize in Economics along with Lloyd Shapley. Roth applied mechanism design to kidney matching markets, markets for college admissions, for law clerks and judges, and for hospitals and medical residents. When I first talked to Jonathan and then Al Roth, my layman’s takeaway about mechanism design was that it was simply the application of economic theory to design better markets.

"And I’ve since come to think even more broadly about what mechanism design might mean in a technology context. In my broader framing, packet switching was a breakthrough in mechanism design. So for that matter was TCP/IP, the World Wide Web, and the protocol-centric architecture of Unix/Linux, which enabled open source and the distributed, cooperative software development environment we take for granted today. PageRank and the rest of Google’s organic search system also seems to me to be a kind of mechanism design. So do Pay Per Click advertising and the Google ad auction. All of them are ways of aligning incentives such that self-interested actors produce outcomes that are good for others as well. "

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." 

########## 

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." 

The States as the laboratory of democracy: helping organ donors

News from the States:

Pa. senators mull inheritance tax cut, deductions for organ donors 

"While employers across the state are allowed to claim tax deductions for time off offered to living organ donors, donors themselves receive no such benefits.

That would change if lawmakers pass a bill sponsored by Sens. Lindsey Williams (D-Allegheny) and Lynda Schlegel Culver (R-Northumberland), who testified to members of the Senate Finance Committee almost five years to the date after receiving her sister’s kidney.
...
“I’ve seen firsthand the gift of donation and what it means,” Culver told lawmakers. “It has allowed me and so many others the opportunity to have a full life.”

According to the University of Pennsylvania Health System, more than 6,000 Pennsylvanians were on the transplant waiting list in 2025.

Culver and Williams’ proposal would allow living organ donors to deduct up to $10,000 in unreimbursed expenses related to the donation from their taxable income. That would include costs like travel, lodging, lost wages and medical expenses.

According to Culver, studies show the average living organ donor faces roughly $5,000 in expenses, which includes things like travel, lost wages and child care during recovery.
...
The measure was passed unanimously by members of the Senate Finance Committee." 

PS 205: A brief address to my elementary school alma mater, about science in grade school

 A few weeks ago I was surprised to receive this email from a teacher at the elementary school that I attended, PS 205, in the New York City borough of Queens:

"Dear Mr. Roth,

I am a teacher at The Alexander Graham Bell School, PS 205 in Bayside, NY.

This is my 29th year teaching at this school and it is still an amazing school where children acquire the skills to blossom as adults!

It is my understanding that you are a graduate of this school.

We are holding a Career Day on Friday, March 6, 2026.

It would be wonderful if you could participate in some way, whether in person, zoom pre-recorded video or by another method.

As a Nobel Prize winner, this would be very inspiring for our students.

Please let me know if you would like to be part of this awesome event."

 

After some further correspondence, I sent a video greeting of a bit over a minute.  Here's the transcript:
 

 Transcript:

"Hi PS 205!  I hear that you’re having career day today.

  Mr Blum asked me to say a few words about how my career began to take shape when I was a student at PS 205, way back before your parents were born. I was a PS 205 student from 1957 to 1962, and it was in those years that I started to think about becoming a scientist.

In 1957, when I started school, the Sputnik satellite was launched by Russia, and in 1961 the first American astronaut, Allan Shepherd, rocketed into space. So science was in the news.  My big brother Ted (who was also a PS 205 student, four years older than me) was excited by the idea of becoming a scientist, and that made me excited too. And pretty soon I was entering the school’s annual science fairs, with demonstrations of scientific things.

When I grew up I did become a scientist, a social scientist.  I’m  an economist, which allows me to study how we humans coordinate and cooperate and compete with each other, in ways that have made us, on average, live longer and healthier lives. In fact one of the things I have worked on is to help doctors organize how more people can get kidney transplants if they need them, which helps them live longer and healthier lives.

Science can be a lot of fun.  In 2012 I won the Nobel Prize in Economics, which means I got to go to a big celebration of science and literature in Sweden, which almost everyone in that country watches on television. It’s sort of like their Super Bowl.

I can only imagine the things that you will do as you grow up. It will be an adventure."

Pre-publication review of Moral Economics from Publisher's Weekly

Another small adventure in publishing:) 

Here's the pre-publication review of Moral Economics from Publisher's Weekly. "

TL;DR "Bringing balanced, evidence-based analyses to emotionally fraught debates, Roth reveals the power of markets to inspire solutions. This is trailblazing"

 

Moral Economics: From Prostitution to Organ Sales, What Controversial Transactions Reveal About How Markets Work

Alvin E. Roth. Basic Venture, $35 (368p) ISBN 978-1-5417-0201-1

"Nobel Prize–winning economist Roth (Who Gets What—and Why) delivers a stimulating study of morally contested products and services, such as abortion, assisted suicide, and marijuana. He refers to these as “repugnant transactions,” as they spark objections primarily on religious or moral grounds but don’t cause easily measurable harms to those seeking to ban them. Viewing these transactions as markets, or systems that can be designed to “allocate scarce resources efficiently and equitably,” can help people make progress on challenging topics, he argues. For example, analyses of legal prostiution show it can increase the market for paid sex but can also reduce rape and the spread of sexually transmitted disease. Another topic discussed is kidney donation. There is a nearly universal ban on compensating donors based on the concern that payments might lead to poor or vulnerable people being coerced into selling their organs. Meanwhile, there is an extreme shortage of donors, and loved ones are often incompatible with those they want to help (kidney disease runs in families). Roth and his colleagues designed a kidney exchange, in which incompatible patient-donor pairs exchange kidneys with other such pairs. Because no money changes hands, the problem of paying donors can be avoided. Bringing balanced, evidence-based analyses to emotionally fraught debates, Roth reveals the power of markets to inspire solutions. This is trailblazing. (May) 

 

 

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.
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The draft law follows European best practices in many respects.
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However, the law prohibits the participation of compatible donor–recipient pairs, contrary to international evidence.
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Germany may join cross-border kidney exchange programs in the future. "