Kidney exchange in Germany can draw on the experience in other countries

 Here's an editorial arguing that as the recently legalized kidney exchange in Germany is implemented, attention should be paid to the controversies that have been encountered and addressed elsewhere, including those about non-directed donors, and the governance and transparency of transplant decisions.

 Benning L, Lu W, Budde K , Josephson, M.  Germany’s move toward kidney paired exchange and non-directed donation: governance lessons from abroad, Kidney International Reports, 2026 

"In 1986 F.T. Rapaport outlined a core idea behind kidney paired exchange: that a registry can coordinate incompatible donor-recipient pairs so that incompatibility becomes a solvable matching problem rather than a barrier to transplantation1. Today, forty years later, Germany is on the verge of making that coordination legally possible. In October 2025, the German federal cabinet approved a draft amendment to the Transplantation Act that would enable kidney paired exchange and non-directed anonymous living kidney donation, while strengthening donor protection and establishing the legal basis for a national program with a central matching function. If operationalized, Germany would move from a restrictive framework for living kidney donation, historically tied to a strict requirement of a close relationship between donor and recipient, toward a governance model that supports kidney exchange and donor chains at scale.

"This moment is internationally relevant because Germany now faces the same policy questions that have shaped kidney paired exchange implementation elsewhere. The impending change creates an opportunity to learn from other countries on key issues, including who should govern a registry, which safeguards ensure legitimacy, how to balance privacy and transparency regarding organ quality, and how to promote access without risking commercialization. Rather than being mere technical considerations, these questions are constitutive for the legitimacy and public trust required for kidney paired exchange to function as a public good. 

"Early debates about living kidney donation repeatedly straddled suspicion and admiration. In the 1970s, living non-related and particularly non-directed donors were sometimes portrayed in medical discourse as psychologically unstable or even pathological, raising concerns about whether such donors should be permitted to proceed2,3. 

...

" History offers two more lessons: (i) Donor protection and respecting donor agency are not mutually exclusive: psychosocial assessment, independent counseling, and rigorous consent procedures can reduce coercion and misunderstanding while still recognizing donors as autonomous agents making a deliberate moral choice. (ii) Public legitimacy is fragile and easily lost: If suspicion dominates, programs risk being viewed as illegitimate or unfair. If, on the other hand, enthusiasm and implementation moves faster than safeguards, programs risk scandal, backlash and, ultimately, lose public support. Germany’s 2012 transplant scandal, involving the manipulation of patient data to improve waiting-list positions, offers a cautionary example of how deficits in transparency and accountability can erode trust in transplantation more broadly and disrupt an entire program4."

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 There are many reviews of the international experience.  Below is a recent one from physicians at Erasmus University in the Netherlands:

Stijn C. van de Laar, Hidde A. de Heus, Annelies E. de Weerd, Matthijs F. Klaassen, Robert J. Porte, Robert C. Minnee Frank J.M.F. Dor, A Comprehensive Review of Strategies to Advance Kidney Exchange Programs and Optimize Effectiveness and Outcomes, Kidney International Reports, Volume 11, Issue 7, July 2026, 106539

"Living donor kidney transplantation (LDKT) offers superior graft survival and cost-effectiveness compared with deceased donor transplantation (DDKT), yet the availability of immunologically compatible living donors limits its reach. Kidney exchange programs (KEPs) can overcome these barriers by matching incompatible pairs through paired exchanges, domino chains, and nonsimultaneous extended altruistic donor (NEAD) chains. This review summarizes the evolution and current landscape of national and international KEPs. We examine operational challenges (cold ischemia time [CIT], logistical coordination, algorithmic fairness, and ethical and regulatory heterogeneity) and explore innovations in matching algorithms, international kidney exchange debates, and machine perfusion technologies. We conclude by proposing strategic priorities to optimize capacity, equity, and outcomes in future kidney exchange efforts. " 

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Earlier: 

Friday, March 27, 2026 Germany legalizes kidney exchange !!

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...

  

Deceased-donor-initiated kidney-exchange chains are performing well in Italy

 Here's a new report from Italy on initiating kidney exchange chains with a deceased donor.*  In Italy to date, 34 deceased donor initiated chains generated 84 transplants (34 from deceased donors  and 50 from living donors), including 56 among incompatible pairs and 28 to candidates on the waitlist.

Furian L., Di Bella C., Maggiore U., Fiaschetti P., Partelli S., Feltrin G. Integrating Deceased and Living Donation: Long-Term Outcomes of the Italian Deceased-Donor-Initiated Kidney Exchange (DEC-K) Program AJT_ 26/7S1, Volume 26, Issue 7, S1. The cover date will be July 2026. 

"Integrating deceased and living donation through deceased-donor (DD)-initiated chains can expand kidney transplant access in small paired exchange pools. The Italian DEC-K program allocates a DD kidney to initiate a chain (chain-initiating kidney, CIK) among incompatible living-donor (LD) pairs, ultimately returning a LD kidney to the national waiting list (WL). We report the first long-term national results of this donor organ allocation model.
 

"Methods: All DEC-K chains performed in Italy (2018-2025) were retrospectively analyzed. Recipients were stratified by kidney source (CIK vs LD).

...
"Results: Thirty-four DEC-K chains generated 84 transplants (34 DD and 50 LD), including 56 among incompatible pairs and 28 to candidates on the WL. Donor withdrawal occurred once. Four chains were terminated early after CIK transplantation due to newly developed contraindications to donation. At a median follow-up of 60 months, 1- and 3-year graft survival was 100% in both groups, while patient survival was 97.1% for CIK and 98.0% for LD. Three CIK and one LD recipients died with functioning graft (suicide, sepsis, urothelial carcinoma, and acute myocardial infarction, respectively). One CIK recipient experienced graft loss after 40 months due to chronic rejection. Adjusted eGFR trajectories were comparable between CIK and LD (P = 0.48). Chain-ending kidney recipients, with 4 graft loss overall (1 antibody-mediated rejection and 3 vascular thrombosis), showed outcomes comparable to LD (P = 0.64 for eGFR; P = 0.57 for graft survival).
 

"Conclusions: The DEC-K program proved feasible, safe, and effective in expanding transplant opportunities for incompatible and hard-to-match patients."

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* Some earlier posts on deceased donor initiated chains:

Sunday, April 3, 2022

Kidney Paired Donation Chains Initiated by Deceased Donors

Monday, November 22, 2021

A naturally occurring deceased-donor-initiated kidney exchange chain, by Maghen and Veale

Sunday, August 23, 2020

More on Deceased donors as non‐directed donors in kidney exchange chains

Tuesday, August 7, 2018

Deceased donor chains: Market design language is entering transplantation

Monday, April 11, 2016

Using deceased donor kidneys to start living donor kidney exchange chains

 

It’s time to carefully but urgently rethink payments to kidney donors. My op-ed in the Washington Post

 This morning the Washington Post published my op-ed online (which is scheduled to appear in the print edition on Sunday). 800 words is hardly enough to explain why I think what I do...I could write a whole book about that.

But here's the op-ed: 

Why paying people to donate kidneys is a good idea

With 90,000 patients waiting for a kidney, compensating living donors would save lives.

May 8, 2026 at 6:30 a.m. EDT

 

By Alvin E. Roth

Alvin E. Roth is an economics professor at Stanford University and co-recipient, with Lloyd Shapley, of the 2012 Nobel Prize in economics. This article was adapted from his new book, "Moral Economics: From Prostitution to Organ Sales, What Controversial Transactions Reveal About How Markets Work."

It’s time to carefully but urgently rethink payments to kidney donors.

There are approximately 130,000 new cases of kidney failure annually in the United States. It is disproportionately a disease of the poor, and is four times as likely to affect Black people as White people. Kidney failure costs Medicare alone more than $55 billion per year, mostly for dialysis. More than 500,000 people are presently on dialysis, about half of whom will die within five years of beginning treatment. The best treatment for kidney failure is transplantation, but in 2025 fewer than 30,000 people in the United States received kidney transplants. So most people who could benefit from a lifesaving transplant will die without one.

 About 90,000 people are registered on the national waiting list to receive a deceased-donor kidney, and many more would be, if there were enough transplants for all who need them. Thousands die each year while waiting, and thousands more are removed from the waiting list when they become too sick to undergo transplant surgery.

The law in the U.S. and most of the world says kidneys must be gifts; their price must be zero. So, any attempt to raise the supply of kidneys by compensating donors would have to overcome the almost worldwide repugnance for payment.

About three-quarters of kidneys transplanted in the U.S. come from deceased donors, and the rest come from living donors: Healthy people have two kidneys and can remain healthy with one. But sometimes potential donors can’t donate to the person they love, because kidneys have to be medically compatible with the recipient. It’s a challenge even within families. For example, often a mother can’t receive a kidney from her spouse or children because during pregnancy, her immune system developed antibodies to some of their proteins.

 

 For the last quarter-century, living-donor transplants have also been arranged through kidney exchange, in which each patient receives a compatible kidney from another patient’s intended donor. Some of these transplants take place in long chains initiated by a nondirected donor, who donates a kidney, anonymously, to anyone who needs one. That begins a chain of donations in which each recipient’s intended donor passes the gift forward. Kidney exchange has made possible thousands of additional transplants, without payments to donors.  

Nevertheless, kidneys for transplant remain in tragically short supply. So it is past time to consider amending the 1984 law that prohibits giving “valuable consideration” for a kidney for transplant.

This would have to be done with care, because there are good reasons that the phrase “payments for kidneys” arouses repugnance. We wouldn’t want inappropriate donors to be unduly influenced to give up a kidney. (This is something already considered when screening the thousands of people who donate one of their kidneys each year without payment.) Another concern is that we wouldn’t want to live in a world in which only rich people could get kidneys, by buying them from poor people.

In the United States, we might think about letting individual states experiment with different regulations. Or we could explore a national system in which only the federal government could buy kidneys — from carefully qualified donors, after a significant period devoted to medical and psychological screening, and having obtained carefully informed consent. Those kidneys could then be allocated without regard to patients’ income, much as we presently allocate deceased-donor kidneys, which are treated as a national resource. 

 

It would be financially feasible to pay donors quite generously without requiring recipients to pay anything at all. Donors could be paid entirely from the savings to the health care system by taking patients off dialysis.

There is a long history of thoughtful arguments in favor of allowing kidney donors to be legally paid or compensated in some way, with carefully considered precautions. These include a current proposal called the End Kidney Deaths Act, which would establish a limited pilot program for a tax credit to nondirected kidney donors.

To be clear, we should keep trying for big long-term goals, such as vastly reducing the incidence of kidney disease by preventing or curing diabetes, hypertension and other causes. We should keep trying to expand deceased donation (perhaps by offering funeral benefits in gratitude to the next of kin who allow it). We should keep exploring cures that don’t require transplants of human organs. But we can save many lives now by being more generous to living donors, and it makes sense to start experimenting with ways to do this legally, ethically and equitably."

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And here's the picture they chose to accompany the op-ed.

 

 

 

 

 

 

 

A rare -directed- deceased donor kidney transplant

 Most organ transplants come from deceased donors, and the vast majority of these deceased donor organs are allocated by a regulated system of national waiting lists. That is, the organs of a deceased donor go to strangers in need. In contrast, most transplants from living donors (of kidneys and livers) are direct donations from someone healthy enough to donate to someone who they know.*  Living donations are also different in that they can be planned well in advance, while deceased donations have to be hastily arranged following a death.

But it is legal, and sometimes possible, for the next of kin of a deceased potential donor to direct an organ donation to someone they know who needs a transplant.  This will only take place if the potential recipient is available on short notice, and if the donor organ is compatible with the recipient.  So it's a rare event: the next of kin need to know someone in need, and the transplant has to turn out to be feasible.

But rare events happen, and the NYT reports on just such a story:

A Man Who Shunned Cheap Sentiment Left a Gift for Others: Life  By Dan Barry

"Informed that her 55-year-old brother would never regain consciousness, Darlene Costello made the heartbreaking decision to have him removed from his ventilator — only to learn, seconds before it was time, that Brendan was a registered organ donor.

"Once Ms. Costello calmed down — why wasn’t this known before? — she came to embrace the news of her brother’s final selfless act. She also knew someone who desperately needed a kidney. Calls were made, tests done, overwhelming odds overcome."

...

" His lungs went to a woman in Tennessee, his right kidney to a man in Pennsylvania. And his left kidney was received by Ms. Costello’s mentor and employer, Dr. Sylvio Burcescu, 62, whose ability to run his Westchester County clinic had been hampered by a rare kidney disease requiring dialysis."

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*Nondirected living donors can also start chains of kidney exchange. 

Are transplants too scarce, or not scarce enough? A surprising debate about India

 India, now the most populous country in the world, does the third highest number of kidney transplants in the world (although their rate of transplantation per million population is quite low).  So transplants are nevertheless very scarce in India compared to the need, which is the situation worldwide.

Earlier this year, however, a paper by three veteran (non-Indian) transplant professionals who have headed large organizations expressed repugnance for the volume of transplants in India, and the fact that it depends mostly on living donor transplantation (LDT), suggesting it can be viewed as "both alarming and reprehensible."  Their paper's title makes it clear how they view it. 

Domínguez-Gil, Beatriz, Francis L. Delmonico, and Jeremy R. Chapman. "Organ transplantation in India: NOT for the common good." Transplantation 109, no. 2, February, 2025: 240-242. 

"The field of organ transplantation has evolved very differently across the world under the influence of different national healthcare financing systems. Healthcare is, in most countries, financed by taxation and thus through governmental budgets, in combination with private funds, mostly through contributory health insurance systems (eg, Australia, Canada, Europe, New Zealand, South America, and the United States). But across much of Asia, tertiary healthcare services, such as transplantation, are almost entirely dependent on the private finances of individuals. The impressive growth in Indian organ transplantation has been accomplished in for-profit hospitals, which have expanded Indian transplantation into 807 facilities, mostly associated with the major corporate hospital chains.6 Organ transplantation, in a part of the world where one-fifth of all people live, is thus largely not for the common good, but a treatment available for those with ample monetary resources." 

########## 

 This was followed by a firm rebuttal by distinguished Indian transplant professionals.  Their title makes their view equally clear:

Rela, Mohamed, Ashwin Rammohan, Vivek Kute, Manish R. Balwani, and Arpita Ray Chaudhury. "Organ Transplantation in India: INDEED, for the Common Good!." Transplantation 109, no. 6 (2025): e340-e342. 

 "We were deeply concerned by the article “Organ Transplantation in India: NOT for the Common Good” by Domínguez-Gil et al,  which we felt provided an unfairly critical view of the current state of organ transplantation in India. We aim to provide a point-by-point rebuttal based on actual figures and ground-reality rather than tabloid-press articles as cited by the authors.
 

"It is true that in the past 5 y, there has been an extraordinary growth in the number of transplantations in India (more than those achieved over several decades by European countries). While it is natural to be wary of this astronomical increase in transplant numbers, the authors’ assumption that this growth is likely nefarious reflects an outdated western mindset, rather than a true understanding of over 2 decades of massively coordinated effort by the Government of India, transplant professionals and all other stakeholders in the country. 

...

" The development of LDT has been presented with a negative connotation. This shows a scant understanding of the geo-socio-political idiosyncrasies prevalent in the Asian region, and unlike the west, its conventional dependence on LDT.

 ...

"The authors have further confused LDT and deceased donor transplantation with regards to foreigners having access to organs in India. The authors’ accusation of deceased donor organs being preferentially allocated to foreigner is presumptuous at best. The current organ allocation system under the aegis of the Government of India and state-wise organ transplant governing bodies is a very transparent process—and is reserved for Indian nationals.

...

" Transplant tourism being equated with organ commerce is erroneous, the authors’ fail to understand that many poor countries find India a more financially viable destination to get a transplant than countries in the west. Even affordable Governments in the middle east are moving to the east for transplantation, where the ministries have a direct tie-up with transplant units. 

"While it should be conceded that transplantation in India may not be available to all, true social upliftment necessitates broader initiatives beyond just immediate transplant availability: that of addressing poverty. Nonetheless, access to transplants for the underprivileged has greatly improved over the past decade. There are several public sector hospitals in the country that routinely provide transplantation services. In 2023, in the state of Tamil Nadu, 35.1% of all deceased donor renal transplants were performed for free in public sector hospitals (Table 1). 5 While traditionally, the private pay-from-pocket healthcare has been only for those with the resources, the central and several state governments (Tamil Nadu, Andhra Pradesh, Gujarat, etc) sponsor an all-inclusive healthcare state insurance for the poor, which includes transplantation at any approved private hospital in the state; which includes LDT.

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I'm on my way to a conference in Cairo that is motivated in part by concern that healthcare in low and middle income countries has been impeded by some of the international healthcare organizations' lack of understanding or empathy for their situations. 

Stanford kidney conference, recap

 Stanford Impact Labs (SIL) reports on our recent kidney exchange conference

Global Solutions-focused Summit on Expanding Access to Kidney Transplantation held at Stanford. Physicians, scholars, healthcare practitioners, and policymakers gathered to explore research advances underway in India, Brazil, and the U.S.   by Kate Green Tripp and Marina Kaneko

 "Earlier this month, the Alliance for Paired Kidney Donation (APKD), Stanford economist Alvin E. Roth, and Stanford Impact Labs hosted the Palo Alto Summit, a two-day global convening at Stanford University dedicated to exploring challenges and advances in kidney transplantation around the world.

"On the heels of the 2025 World Transplant Congress in San Francisco, more than 30 physicians, scholars, transplant coordinators, and government officials from the U.S., India, Brazil, Italy, the United Arab Emirates, Qatar, and South Africa gathered to share key learnings, challenges, and advances in the field.

...

" APKD and Roth, the Craig and Susan McCaw Professor of Economics at Stanford’s School of Humanities and Sciences, have teamed up with transplant specialists in India, Brazil, and the United States to form the Extending Kidney Exchange project. 

...

"The summit’s sessions were designed to advance national efforts in KPD in India and Brazil, and deceased donor-initiated chains (DDIC); foster collaboration among leading clinical, policy, and academic partners; and identify actionable steps and shared milestones for KPD in India and Brazil, paired liver exchange in India, and DDIC in the United States. As a transplant strategy, DDIC utilizes kidneys from deceased donors to create a chain of transplants so as to maximize the use of available organs and to connect multiple recipients, especially when there are mismatches or compatibility issues.

...

"“When the very first [nonsimultaneous] chain of kidney transplants took place in 2006, it was not necessarily welcomed as an innovation,” recalls Michael Rees, a transplant surgeon at the University of Toledo and founder of the Alliance for Paired Kidney Donation (APKD). “It is incredibly exciting to reflect on the progress we’ve been able to make across the transplant community since that time, to increase the utility of a single kidney from either a living or deceased donor.”

 

 

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Earlier:

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

 

Also of note:

Matthew Gentzkow Named Director of Stanford Impact Labs

"The economist will lead a community of social scientists who want their scholarship to improve people’s lives."
 

 

More on non-anonymous kidney exchange in India

 Here's some further description of how kidney exchange is conducted in India without authorization* to use nondirected donors (so that all exchanges are conducted in cycles, i.e. in the absence of chains of exchange).

Vivek B. Kute, Himanshu V Patel, Subho Banerjee,Divyesh P Engineer, Ruchir B Dave, Nauka Shah, Sanshriti Chauhan ,Harishankar Meshram , Priyash Tambi  , Akash Shah, Khushboo Saxena,Manish Balwani , Vishal Parmar, Shivam Shah, Ved Prakash ,Sudeep Patel, Dev Patel, Sudeep Desai, Jamal Rizvi , Harsh Patel, Beena Parikh, Kamal Kanodia, Shruti Gandhi, Michael A Rees,  Alvin E Roth,  Pranjal Modi “Impact of single centre kidney-exchange transplantation to increase living donor pool in India: A cohort study involving non-anonymous allocation,”Nephrology, September 2024, https://onlinelibrary.wiley.com/doi/10.1111/nep.14380  

"In India, 85% of organ donations are from living donors and 15% are from deceased donors. One-third of living donors were rejected because of ABO or HLA incompatibility. Kidney exchange transplantation (KET) is a cost-effective and legal strategy to increase living donor kidney transplantation (LDKT) by 25%–35%.

"3.3 Non-anonymous allocation

"The THOA*, which regulates KET in India, is silent on the need for anonymity, so there is no legal requirement for anonymity in India, as compared with other countries, such as the Netherlands and Sweden. Our experience was that 90% of iDRP [incompatible Donor-Recipient Pairs] requested the opportunity to meet their matched donor and recipient pair (mDRP) and 10% asked the treating physician to decide if they should meet. None of the iDRP requested anonymity. Therefore, we have practiced absolute non-anonymity, meaning that all mDRPs meet and share medical reports after a potential exchange is identified, but before the formal allocation of pairs. If an iDRP requests anonymity, we would be willing to accommodate them, but to date, none have done so.

"Upon meeting with their mDRP, the iDRP can refuse the proposed exchange option without reason and continue to be on the waitlist and active in the KET pool. iDRPs must complete transplant fitness and legal documents required for transplant permission from the health authority before they are given the opportunity to meet their mDRP. A meeting between mDRPs occurs in the presence of a transplant physician, who can help solve any query before the proposed match is accepted by the involved pairs. iDRP are introduced to their mDRP prior to scheduling transplants to avoid chain collapse due to iDRP refusal of the mDRP. The mDRP shares medical reports of donors with each other, can also discuss with their other family members, and consults with their family physician/nephrologist before deciding whether to proceed. Living kidney donors are fully informed of perioperative and long-term risks before making their decision to donate. In India, donor age group matching is most commonly expected for all iDRP in the KAS."

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Earlier:

Monday, September 18, 2023

Kidney Paired Donation in Developing Countries: a Global Perspective

*Here's the THOA, THE TRANSPLANTATION OF HUMAN ORGANS AND TISSUES ACT, 1994

Kidney Exchange among Austria, Czech Republic, and Israel

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

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

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

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

...

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

Recent kidney transplant papers

 Here are two new papers on kidney exchange that caught my eye, and one on incentivizing deceased donation by prioritizing registered donors on the deceased donor waiting list.

This one concerns organizing international kidney exchanges between countries while making sure that each one gets their fair share. (All exchanges are between 2 pairs.)

Benedek, Márton, Péter Biró, Daniel Paulusma, and Xin Ye. "Computing balanced solutions for large international kidney exchange schemes." Autonomous Agents and Multi-Agent Systems 38, no. 1 (2024): 1-41.

Abstract: To overcome incompatibility issues, kidney patients may swap their donors. In international kidney exchange programmes (IKEPs), countries merge their national patient–donor pools. We consider a recently introduced credit system. In each round, countries are given an initial “fair” allocation of the total number of kidney transplants. This allocation is adjusted by a credit function yielding a target allocation. The goal is to find a solution that approaches the target allocation as closely as possible, to ensure long-term stability of the international pool. As solutions, we use maximum matchings that lexicographically minimize the country deviations from the target allocation. We perform, for the first time, a computational study for a large number of countries. For the initial allocations we use two easy-to-compute solution concepts, the benefit value and the contribution value, and four classical but hard-to-compute concepts, the Shapley value, nucleolus, Banzhaf value and tau value. By using state-of-the-art software we show that the latter four concepts are now within reach for IKEPs of up to fifteen countries. Our experiments show that using lexicographically minimal maximum matchings instead of ones that only minimize the largest deviation from the target allocation (as previously done) may make an IKEP up to 54% more balanced.

"We consider IKEPs in the setting of European KEPs which are scheduled in rounds, typically once in every three months.

...

"We first note that the search for an optimal exchange scheme can be done in polynomial time for 2-way exchanges (matchings) but becomes NP-hard as soon as 3-way exchanges are permitted."

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Here's a paper that reports simulations on Using deceased donor kidneys to start living donor kidney exchange chains

Verma, Utkarsh, Nayaran Rangaraj, Viswanath Billa, and Deepa Usulumarty. "Long term simulation analysis of deceased donor initiated chains in kidney exchange programs." Health Systems (2023): 1-12.

ABSTRACT: Kidney exchange programs (KEPs) aim to find compatible kidneys for recipients with incompatible donors. Patients without a living donor depend upon deceased donor (DD) donations to get a kidney transplant. In India, a DD donates kidneys directly to a DD wait-list. The idea of initiating an exchange chain starting from a DD kidney is proposed in a few articles (and executed in Italy in 2018), but no mathematical formulation has been given for this merger. We have introduced an integer programming formulation that creates DD-initiated chains, considering both paired exchange registry and DD allocations simultaneously and addressing the overlap issue between the exchange registry and DD wait-list as recipients can register for both registries independently. A long-term simulation study is done to analyse the gain of these DD-initiated chains over time. It suggests that even with small numbers of DDs, these chains can significantly increase potential transplants.

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And here's the paper on incentivizing registration to be a deceased donor.

Li, Mengling, and Yohanes E. Riyanto. "Incentivizing Organ Donation Under Different Priority Rules: The Role of Information." Management Science (2024).

Abstract: This paper examines the incentive to register for deceased organ donation under alternative organ allocation priority rules, which may prioritize registered donors and/or patients with higher valuations for organ transplantation. Specifically, the donor priority rule grants higher priority on the organ waiting list to those who have previously registered as donors. The dual-incentive priority rules allocate organs based on donor status, followed by individual valuations within the same donor status, or vice versa. Both theoretical and experimental results suggest that the efficacy of the donor priority rule and the dual-incentive priority rules critically depends on the information environment. When organ transplantation valuations are unobservable prior to making donation decisions, the hybrid dual-incentive rules generate higher donation rates. In contrast, if valuations are observable, the dual-incentive priority rules create unbalanced incentives between high- and low-value agents, potentially undermining the efficacy of the hybrid dual-incentive rules in increasing overall donation rates.

Kidney Exchange in Latin America and the Caribbean

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

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

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

  

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

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

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

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

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

...

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

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

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

 Stanford Impact Labs has announced an investment designed to help the Alliance for Paired Kidney Donation (APKD) increase access to kidney exchange in Brazil, India, and the U.S.  Here are three related web pages...

1. Stanford Impact Labs Invests in Global Collaboration to Increase Access to Kidney Transplants.  $1.5 million over three years will support solutions-focused project led by Stanford’s Dr. Alvin Roth and the Alliance for Paired Kidney Donation (APKD)  by Kate Green Tripp

"Stanford Impact Labs (SIL) is delighted to announce a $1.5 million Stage 3: Amplify Impact investment to support Extending Kidney Exchange, a solutions-focused project established to increase access to lifesaving kidney transplants.

"The team, led by Stanford’s Dr. Alvin (Al) Roth, who shared the 2012 Nobel Prize in Economics for his work on market design, and the Alliance for Paired Kidney Donation (APKD) is working in close partnership with organ transplant specialists and medical centers in Brazil, India, and the U.S., including Santa Casa de Misericórdia de Juiz de Fora, the Institute of Kidney Diseases and Research Center and Dr. H L Trivedi Institute of Transplantation Sciences (IKDRC-ITS), and Walter Reed National Military Medical Center.

"Over the course of the next three years, the team aims to increase the number of transplant opportunities available to patients who need them by creating and growing kidney exchange programs in Brazil and India, where millions of people suffer from kidney disease yet exchange is minimal; and explore the effects of initiating donor chains with a deceased donor kidney (DDIC) in the U.S., an approach which could unlock hundreds more transplants each year.

..."

2. How Does Applied Economics Maximize Kidney Transplants? A project aimed at expanding kidney exchange and saving lives puts Nobel Prize-winning matching theory into practice.  by Jenn Brown   (including a video...)

"APKD uses open source software developed by Itai Ashlagi, Professor of Management Science and Engineering at Stanford University, to facilitate the matching process for its NEAD chains, and they currently average 5 non-simultaneous transplants per chain.

3. Extending Kidney Exchange

"In Brazil, our team has launched a kidney exchange program within Santa Casa de Misericórdia de Juiz de Fora and Hospital Clínicas FMUSP in São Paulo and aims to expand to facilitating exchanges between these centers and others with the ultimate goal of kidney exchange transitioning from a research project to an officially approved practice in Brazil.

"In India, our team has deployed kidney matching software and resources for growth to the Institute of Kidney Diseases and Research Center and Dr. HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS) to support kidney exchange programs. We aim to develop an evidence base for potential updates to organ transplantation laws that expand criteria for who can give and receive lifesaving kidneys.

"In the U.S., we are working with Walter Reed National Military Medical Center to test the use of deceased donor-initiated chains (DDIC) so as to generate hundreds of additional life-saving transplants each year that are not currently supported by today's practice of utilizing a deceased donor kidney to save the life of a single person on a transplant waitlist. "

 

Kidney exchange in the U.S. from 2006-2021

 Here's an interesting look at the (ongoing) development of kidney exchange in the U.S

Temporal trends in kidney paired donation in the United States: 2006-2021 UNOS/OPTN database analysis, by Neetika Garg, Carrie Thiessen, Peter P. Reese, Matthew Cooper, Ruthanne Leishman, John Friedewald, Asif A. Sharfuddin, Angie G. Nishio Lucar, Darshana M. Dadhania, Vineeta Kumar, Amy D. Waterman, and Didier A. Mandelbrot, American Journal of Transplantation,  24, 1, P46-56, JANUARY 2024.

Abstract: Kidney paired donation (KPD) is a major innovation that is changing the landscape of kidney transplantation in the United States. We used the 2006-2021 United Network for Organ Sharing data to examine trends over time. KPD is increasing, with 1 in 5 living donor kidney transplants (LDKTs) in 2021 facilitated by KPD. The proportion of LDKT performed via KPD was comparable for non-Whites and Whites. An increasing proportion of KPD transplants are going to non-Whites. End-chain recipients are not identified in the database. To what extent these trends reflect how end-chain kidneys are allocated, as opposed to increase in living donation among minorities, remains unclear. Half the LDKT in 2021 in sensitized (panel reactive antibody ≥ 80%) and highly sensitized (panel reactive antibody ≥ 98%) groups occurred via KPD. Yet, the proportion of KPD transplants performed in sensitized recipients has declined since 2013, likely due to changes in the deceased donor allocation policies and newer KPD strategies such as compatible KPD. In 2021, 40% of the programs reported not performing any KPD transplants. Our study highlights the need for understanding barriers to pursuing and expanding KPD at the center level and the need for more detailed and accurate data collection at the national level.

"Kidney paired donation (KPD) is rapidly evolving and reshaping the landscape of living donor kidney transplantation (LDKT). Since the initial KPD transplants performed in the United States in 1999,1 the scope of KPD has expanded substantially. With the inclusion of nondirected donor,2 it has progressed from simple 2-way or multiple-way exchanges to nonsimultaneous kidney donor chains3 and, more recently, to advanced and voucher donations.4 Downstream from nondirected donors, chains often conclude with end-chain kidneys allocated to candidates on the deceased kidney donor waitlist without a living donor (LD).5 Historically used to overcome the barrier of ABO/human leukocyte antigens (HLA) incompatibility, KPD is being increasingly used by compatible donor-recipient pairs to obtain more suitable kidneys for the respective recipients.6 KPD programs can be single center or internal, regional, or national.7,8 The largest multicenter or national KPD programs in the United States are the National Kidney Registry,9 the Alliance for Paired Donation,10 the MatchGrid/Medsleuth program,11 and the program operated by the Organ Procurement and Transplantation Network (OPTN).12 While multicenter KPD often expands the pool of candidates to improve match possibilities, there are examples of very successful single-center programs."

Coalition to Modify NOTA (the National Organ Transplant Act of 1984)

 Elaine Perlman forwards the following discussion points:

Coalition to Modify NOTA Talking Points

modifyNOTA.org

What is the Coalition to Modify NOTA proposing? The Coalition to Modify NOTA proposes providing a $50,000 refundable tax credit to remove all disincentives for American non-directed kidney donors who donate their kidney to a stranger at the top of the kidney waitlist in order to greatly increase the supply of living kidney transplants, the gold standard for patients with kidney failure.

What is the value of a new kidney? The value of a new kidney, in terms of quality of life and future earnings potential, is between $1.1 million and $1.5 million.

What is the American kidney crisis? Fourteen Americans on the waiting list for a kidney transplant die each day. That number does not include the many kidney failure patients who are not placed on the waiting list but would have benefited from a kidney transplant if we had no shortage. The total number of Americans with kidney failure will likely exceed one million by 2030. 

Why not rely on deceased donor kidneys to end the shortage? A living kidney transplant lasts on average twice as long as a deceased donor kidney. Fewer than 1 in 100 Americans die in a way that their kidneys can be procured. Currently, the 60% of Americans who are registered as deceased donors provide kidneys for 18,000 Americans annually. Even if 100% of Americans agreed to become organ donors, this would raise donations by only about 12,000 per year. In the USA, 93,000 Americans are on the kidney waitlist. A total of 25,000 people are transplanted annually, two-thirds from deceased donors and one-third from living donors. The size of the waitlist has nearly doubled in the past 20 years, while the number of living donors has not increased.

What is the extra value that non-directed kidney donors provide? Non-directed kidney donors often launch kidney chains that can result in a multitude of Americans receiving kidneys. Fewer than 5% of all living kidney donations are from non-directed kidney donors who are an excellent source of organs for transplantation because they are healthier than the general population. 

 

How much does the taxpayer currently spend on dialysis? Kidney transplantation not only saves lives; it also saves money for the taxpayer. The United States government spends nearly $50 billion dollars per year (1% of all $5 trillion collected in annual taxes) to pay for 550,000 Americans to have dialysis, a cost of approximately $100,000 per year per patient, a treatment that is far more expensive than transplantation.

 

How many more lives will be saved with the refundable tax credit for non-directed donors? The number of non-directed donors increased from 18 in 2000 to around 300 each year. After our Act becomes law, we estimate that we will add approximately 7,000 non-directed donor kidneys annually. That is around 70,000 new transplanted Americans by year ten. 

 

How much tax money will be saved once the Act is passed? The refundable tax credit will greatly increase the number of living donors who generously donate their kidneys to strangers. We estimate that in year ten after the Act is passed, the taxpayers will have saved $12 billion. 

 

What is a refundable tax credit? A refundable tax credit can be accessed by both those who do and those who do not pay federal taxes. 

 

What do Americans think about compensating living kidney donors? Most Americans favor compensation for living kidney donors  to increase donation rates. 

 

Who is able to donate their kidneys?  Donation requires potential organ donors to undergo a comprehensive physical and psychological evaluation, and each transplant center has its own rigorous criteria. Only around 5% of those who pursue evaluation actually end up donating, and only about one-third of Americans are healthy enough to be donors. Providing financial incentives will encourage more Americans to donate their kidneys to help those with kidney failure.

 Do kidney donors currently have expenses that result from their donation? The medical costs of donation are covered by the recipients' insurance, but donors are responsible for providing for the costs of their own travel, out-of-pocket expenses, and lost wages. Programs like the federal NLDAC and NKR's Donor Shield can help offset these costs, making donation less expensive.

Is it moral to compensate kidney donors? Compensation for kidney donors can be viewed as a way to address the current kidney shortage and save lives. Americans are compensated for various forms of donation such as sperm, eggs, plasma, and surrogacy, all of which involve giving life. 

How long do we need to compensate living kidney donors? Compensation should continue until a xenotransplant or advanced kidney replacement technology becomes available. In the meantime, it's crucial to prevent further loss of lives due to the shortage.

 Will incentivizing donors undermine altruism?  Financial compensation for donors can coexist with altruism. Donors can opt out of the funds from the tax credit or choose to donate those funds to charity. The majority of donors support financial compensation, and relying solely on altruism has led to preventable deaths.

 In addition to ending the kidney shortage, what are other benefits of the Act? The Act can help combat the black market for kidneys and reduce human trafficking because we will have an increased number of transplantable kidneys. It can also motivate individuals to become healthier to pass donor screening, potentially further reducing overall healthcare costs.

 Why provide non-directed donors with a refundable tax credit of $50,000? The compensation is designed to attract those who are both healthy and willing to donate. Given the commitment, time, and effort involved in the donation process, this compensation recognizes the value of those who save lives and taxpayer funds.

 When more donors step forward, can transplant centers increase the number of surgeries?  There is considerable unused capacity at most U.S. transplant centers, and increasing the number of donors is likely to lead to more surgeries. The goal is to perform more kidney transplants and reduce the waitlist, benefiting patients in need.

 In what way does the Act uphold The Declaration of Istanbul?  While the Act deviates from one principle of the Declaration of Istanbul by offering compensation, it aligns with the other principles and is expected to standardize compensation and reduce worldwide organ trafficking.

 What about dialysis as an alternative to transplant?  Dialysis, while a treatment option, can be a challenging and uncomfortable process for patients. For those who could have been transplanted if there were no kidney shortage, dialysis can result in needless suffering and an untimely death.

 Why not compensate living liver donors? Liver donation is riskier and not as cost-effective as kidney donation. While the Act currently focuses on kidney donors, it's possible that compensation for liver donors could be considered in the future.

 What about the argument that providing an incentive to donate will exploit the donors, especially low income donors? 

Primarily middle and low income kidney failure patients are dying due to the kidney shortage. People with lower incomes tend to have social networks with fewer healthy people because health is related to income level. In addition, being placed on a waitlist often costs money. Kidney donation also costs money, an estimated 10% of annual income. The refundable tax credit will help low income donors and recipients the most by making donation affordable and increasing the number of kidneys for those waiting the longest on the waitlist, frequently middle and low income Americans. The tax credit aims to help those most affected by the kidney shortage, as poorer and middle-income individuals often bear the brunt of the kidney crisis’s consequences. The Act will level the playing field, making it easier for those at all income levels to receive a life-saving kidney. 

Please examine this chart: