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:

 

Report From a Multidisciplinary Symposium on the Future of Living Kidney Donor Transplantation

 How might we increase the number of lifesaving transplants from living kidney donors? Might we one day be able to reward donors? And what might we do until then, while we wait for something that will eventually replace human organ transplantation?  Here's the published account of last year's symposium.

Thomas G. Peters, John J. Fung, Janet Radcliffe-Richards, Sally Satel, Alvin E. Roth, Frank McCormick, Martha Gershun, Arthur J. Matas, John P. Roberts, Josh Morrison, Glenn M. Chertow, Laurie D. Lee, Philip J. Held, and Akinlolu Ojo, “Report From a Multidisciplinary Symposium on the Future of Living Kidney Donor Transplantation,” Progress in Transplantation  (forthcoming), Online first, Nov 15, 2023 https://journals.sagepub.com/doi/full/10.1177/15269248231212911  (pdf here).

Abstract: Virtually all clinicians agree that living donor renal transplantation is the optimal treatment for permanent loss of kidney function. Yet, living donor kidney transplantation has not grown in the United States for more than 2 decades. A virtual symposium gathered experts to examine this shortcoming and to stimulate and clarify issues salient to improving living donation. The ethical principles of rewarding kidney donors and the limits of altruism as the exclusive compelling stimulus for donation were emphasized. Concepts that donor incentives could save up to 40 000 lives annually and considerable taxpayer dollars were examined, and survey data confirmed voter support for donor compensation. Objections to rewarding donors were also presented. Living donor kidney exchanges and limited numbers of deceased donor kidneys were reviewed. Discussants found consensus that attempts to increase living donation should include removing artificial barriers in donor evaluation, expansion of living donor chains, affirming the safety of live kidney donation, and assurance that donors incur no expense. If the current legal and practice standards persist, living kidney donation will fail to achieve its true potential to save lives.

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Links to videos of the symposium presentations are here:

Friday, July 15, 2022

The Future of Living Donor Kidney Transplantation (videos)

Deceased organ donation in the Economist (article and letter to the editor)

 Here's a recent article on deceased organ donation, in The Economist, followed by a letter to the editor from Alex Chan and me.

In America, lots of usable organs go unrecovered or get binned. That is a missed opportunity to save thousands of lives

"More than four-fifths of all donated organs and two-thirds of kidneys come from dead people (who must die in hospital); living donors can give only a kidney or parts of a lung or liver. Whereas some countries, such as England, France and Spain, have an opt-out model, in America donors must register or their families must agree. Persuading them will always be hard: Dr Karp’s hospital gets consent from about half of potential donors.

...

"Responsibility lies partly with some of the 56 nonprofit Organ Procurement Organisations (opos), like LiveOnNY, that do the legwork. Brianna Doby, a researcher and consultant, advised Arkansas’s opo in 2021 and was astounded to learn that most calls about potential donors went unanswered outside the nine-to-five workday and at weekends. Other opos, by contrast, sent staff to hospitals within an hour of an alert about a prospective donor.

...

"Yet unrecovered organs are not the only reason America could do more transplants. A surprising number of organs from deceased donors end up in the rubbish: more than a quarter of kidneys and a tenth of livers last year.

...

"Hospitals are often risk-averse, too. Discard rates are higher for organs of lower quality.

...

"For elderly recipients, getting older or otherwise risky kidneys generally means better odds of survival than staying on dialysis. But hospitals dislike using them for two reasons. First, they can lead to more complications and thus require more resources, eating into margins. Second, if the recipient dies soon after the transplant, hospitals suffer—a key measure used to evaluate them is the survival rate of recipients a year after transplant. According to Robert Cannon, a liver-transplant surgeon at the University of Alabama at Birmingham, hospitals succeed by being excessively cautious and keeping patients with worse prospects off waiting lists."

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And here's our followup letter to the editor, published November 2:

Organ-donation economics

"More than 110,000 Americans are waiting for an organ transplant and over 5,000 died waiting for an organ in 2019. Close to 6,000 recovered organs were discarded. “Wasted organs” (September 23rd) correctly pointed out that the responsibility lies in part with non-profit Organ Procurement Organisations and in part with the excessive caution exercised by transplant centres when deciding who to conduct transplants for and which kidneys to use.

"Numerous initiatives in Congress, and more proposed by various non-governmental agencies, such as the Federation of American Scientists and the National Academies of Sciences, Engineering and Medicine, among others, have been focused on tweaking how the performance of organ procurers and transplant centres should be measured while keeping in place the system that put us in today’s quagmire. As we indicate in our recent paper (conditionally accepted at the Journal of Political Economy), such approaches that keep regulations fragmented are bound to be inefficient, given that the incentives and opportunities facing organ procurers and transplant centres are intertwined.

"We show that “holistic regulation”, which aligns the interests of organ procurers and transplant centres by rewarding them based on the health outcomes of the entire patient pool, can get at the root of the problem. This approach also leads to more organ recoveries while increasing the use of organs for sicker patients who otherwise would be left without a transplant.

"In the end increasing access to kidney transplantation will require the improvement of the entire supply chain of organs. This means boosting donor registrations and donor recoveries from the deceased. It also means increasing living donations, and co-ordinating donations through mechanisms like paired kidney donations and deceased-donor-initiated kidney- exchange chains.

Alex Chan, Assistant professor of business administration, Harvard University

Alvin E. Roth, Professor of economics, Stanford University

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And here's the paper referred to in our letter, on Alex's website:

Regulation of Organ Transplantation and Procurement: A Market Design Lab Experiment, by Alex Chan and Alvin E. Roth

Abstract: "We conduct a lab experiment that shows current rules regulating transplant centers (TCs) and organ procurement organizations (OPOs) create perverse incentives that inefficiently reduce both organ recovery and beneficial transplantations. We model the decision environment with a 2-player multi-round game between an OPO and a TC. In the condition that simulates current rules, OPOs recover only highest-quality kidneys and forgo valuable recovery opportunities, and TCs decline some beneficial transplants and perform some unnecessary transplants. Alternative regulations that reward TCs and OPOs together for health outcomes in their entire patient pool lead to behaviors that increase organ recovery and appropriate transplants."

Organ donation day in Germany

 Yesterday was organ donation day in Germany. Here's a post from the German Health Economics Association (DGGÖ): Day of Organ Donation on June 3, 2023

"In Germany, there are about 8,500 people waiting for an organ donation (www.Bundesärztekammer.de). On the Day of Organ Donation, the German Society for Health Economics (dggö) wants to emphasize the urgency of increasing organ donation rates to improve the lives of these individuals. This applies equally to deceased organ donation and living donation. An international comparison also shows that there is room for improvement in Germany: Both in terms of living and deceased donations per million population, Germany lags behind in the EU (see Figure 1).

...

"On Wednesday, May 31, 2023, Nobel laureate in economics and professor at Stanford University, Alvin Roth, spoke to a broad audience in the 6th virtual dggö Talk (see https://www.dggoe.de/aktuelles for details) about the possibilities of kidney exchange between compatible but previously unknown pairs and the implementation of cross-over donations and exchange chains in the US.

"Unlike in the US, in Germany, living donation outside of close family is only possible if a close relationship between the donor and recipient has been officially confirmed. Alvin Roth noted in the case of cross-over kidney donations, that it was very complicated for German hospitals to build up and prove a close relationship between two pairs of donors in front of a commission. This should be simplified, especially considering the overall strong support for kidney exchange among the German population. As Figure 2 from a survey conducted by Roth and Wang (2020) illustrates, 79% even agree to kidney exchange across borders and outside of family and friends, although such an exchange is currently not legally possible in Germany.

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Earlier: 

Tuesday, May 30, 2023

Kidney exchange, around the world and in Germany? German Health Economics Association (DGGÖ) webinar 

Kidney exchange collaboration between Stanford and APKD

 I recently had occasion to review the long collaboration between my Stanford colleagues and Mike Rees and the Alliance for Paired Kidney Donation. It turns out that, together with other coauthors, Mike and his APKD colleagues have written well over a dozen papers with me and my colleagues at Stanford.  (My own collaboration with Mike and APKD goes back to when Itai Ashlagi and I were still in Boston, where my earliest papers on kidney exchange were with  Tayfun Sönmez and Utku Ünver, and with Frank Delmonico and his colleagues at the New England Program for Kidney Exchange.)

Here's the list I came up with, probably not exhaustive:

Mike Rees/APKD collaborations with Stanford scholars (Ashlagi, Melcher, Roth, Somaini)

 1. Rees, Michael A., Jonathan E. Kopke, Ronald P. Pelletier, Dorry L. Segev, Matthew E. Rutter, Alfredo J. Fabrega, Jeffrey Rogers, Oleh G. Pankewycz, Janet Hiller, Alvin E. Roth, Tuomas Sandholm, Utku Ünver, and Robert A. Montgomery, “A Non-Simultaneous Extended Altruistic Donor Chain,” New England Journal of Medicine, 360;11, March 12, 2009, 1096-1101. https://www.nejm.org/doi/full/10.1056/NEJMoa0803645

2.     Ashlagi, Itai, Duncan S. Gilchrist, Alvin E. Roth, and Michael A. Rees, “Nonsimultaneous Chains and Dominos in Kidney Paired Donation – Revisited,” American Journal of Transplantation, 11, 5, May 2011, 984-994 http://www.stanford.edu/~alroth/papers/Nonsimultaneous%20Chains%20AJT%202011.pdf

3.     Ashlagi, Itai, Duncan S. Gilchrist, Alvin E. Roth, and Michael A. Rees, “NEAD Chains in Transplantation,” American Journal of Transplantation, December 2011; 11: 2780–2781. http://web.stanford.edu/~iashlagi/papers/NeadChains2.pdf

4.     Wallis, C. Bradley, Kannan P. Samy, Alvin E. Roth, and Michael A. Rees, “Kidney Paired Donation,” Nephrology Dialysis Transplantation, July 2011, 26 (7): 2091-2099 (published online March 31, 2011; doi: 10.1093/ndt/gfr155, https://academic.oup.com/ndt/article/26/7/2091/1896342/Kidney-paired-donation

5.     Rees, Michael A.,  Mark A. Schnitzler, Edward Zavala, James A. Cutler,  Alvin E. Roth, F. Dennis Irwin, Stephen W. Crawford,and Alan B.  Leichtman, “Call to Develop a Standard Acquisition Charge Model for Kidney Paired Donation,” American Journal of Transplantation, 2012, 12, 6 (June), 1392-1397. (published online 9 April 2012 http://onlinelibrary.wiley.com/doi/10.1111/j.1600-6143.2012.04034.x/abstract )

6.     Anderson, Ross, Itai Ashlagi, David Gamarnik, Michael Rees, Alvin E. Roth, Tayfun Sönmez and M. Utku Ünver, " Kidney Exchange and the Alliance for Paired Donation: Operations Research Changes the Way Kidneys are Transplanted," Edelman Award Competition, Interfaces, 2015, 45(1), pp. 26–42. http://pubsonline.informs.org/doi/pdf/10.1287/inte.2014.0766

7.     Fumo, D.E., V. Kapoor, L.J. Reece, S.M. Stepkowski,J.E. Kopke, S.E. Rees, C. Smith, A.E. Roth, A.B. Leichtman, M.A. Rees, “Improving matching strategies in kidney paired donation: the 7-year evolution of a web based virtual matching system,” American Journal of Transplantation, October 2015, 15(10), 2646-2654 http://onlinelibrary.wiley.com/enhanced/doi/10.1111/ajt.13337/ (designated one of 10 “best of AJT 2015”)

8.     Melcher, Marc L., John P. Roberts, Alan B. Leichtman, Alvin E. Roth, and Michael A. Rees, “Utilization of Deceased Donor Kidneys to Initiate Living Donor Chains,” American Journal of Transplantation, 16, 5, May 2016, 1367–1370. http://onlinelibrary.wiley.com/doi/10.1111/ajt.13740/full

9.     Michael A. Rees, Ty B. Dunn, Christian S. Kuhr, Christopher L. Marsh, Jeffrey Rogers, Susan E. Rees, Alejandra Cicero, Laurie J. Reece, Alvin E. Roth, Obi Ekwenna, David E. Fumo, Kimberly D. Krawiec, Jonathan E. Kopke, Samay Jain, Miguel Tan and Siegfredo R. Paloyo, “Kidney Exchange to Overcome Financial Barriers to Kidney Transplantation,” American Journal of Transplantation, 17, 3, March 2017, 782–790. http://onlinelibrary.wiley.com/doi/10.1111/ajt.14106/full  

a.     M. A. Rees, S. R. Paloyo, A. E. Roth, K. D. Krawiec, O. Ekwenna, C. L. Marsh, A. J. Wenig, T. B. Dunn, “Global Kidney Exchange: Financially Incompatible Pairs Are Not Transplantable Compatible Pairs,” American Journal of Transplantation, 17, 10, October 2017, 2743–2744. http://onlinelibrary.wiley.com/doi/10.1111/ajt.14451/full

b.     A. E. Roth, K. D. Krawiec, S. Paloyo, O. Ekwenna, C. L. Marsh, A. J. Wenig, T. B. Dunn, and M. A. Rees, “People should not be banned from transplantation only because of their country of origin,” American Journal of Transplantation, 17, 10, October 2017, 2747-2748. http://onlinelibrary.wiley.com/doi/10.1111/ajt.14485/full

c.      Ignazio R. Marino, Alvin E. Roth, Michael A. Rees; Cataldo Doria, “Open dialogue between professionals with different opinions builds the best policy, American Journal of Transplantation, 17, 10, October 2017, 2749. http://onlinelibrary.wiley.com/doi/10.1111/ajt.14484/full

10.  Danielle Bozek, Ty B. Dunn, Christian S. Kuhr, Christopher L. Marsh, Jeffrey Rogers, Susan E. Rees, Laura Basagoitia, Robert J. Brunner, Alvin E. Roth, Obi Ekwenna, David E. Fumo, Kimberly D. Krawiec, Jonathan E. Kopke, Puneet Sindhwani, Jorge Ortiz, Miguel Tan, and Siegfredo R. Paloyo, Michael A. Rees, “The Complete Chain of the First Global Kidney Exchange Transplant and 3-yr Follow-up,” European Urology Focus, 4, 2, March 2018, 190-197. https://www.sciencedirect.com/science/article/pii/S2405456918301871

11.  Itai Ashlagi, Adam Bingaman, Maximilien Burq, Vahideh Manshadi, David Gamarnik, Cathi Murphey, Alvin E. Roth,  Marc L. Melcher, Michael A. Rees, ”The effect of match-run frequencies on the number of transplants and waiting times in kidney exchange,” American Journal of Transplantation, 18, 5, May 2018,  1177-1186, https://onlinelibrary.wiley.com/doi/full/10.1111/ajt.14566

12.   Stepkowski, S. M., Mierzejewska, B., Fumo, D., Bekbolsynov, D., Khuder, S., Baum, C. E., Brunner, R. J., Kopke, J. E., Rees, S. E., Smith, C. E., Ashlagi, I., Roth, A. E., Rees, M. A., “The 6-year clinical outcomes for patients registered in a multiregional United States Kidney Paired Donation program- a retrospective study,” Transplant international 32: 839-853. 2019. https://onlinelibrary.wiley.com/doi/10.1111/tri.13423

13.   Roth, Alvin E., Ignazio R. Marino, Obi Ekwenna, Ty B. Dunn, Siegfredo R. Paloyo, Miguel Tan, Ricardo Correa-Rotter, Christian S. Kuhr, Christopher L. Marsh, Jorge Ortiz, Giuliano Testa, Puneet Sindhwani, Dorry L. Segev, Jeffrey Rogers, Jeffrey D. Punch, Rachel C. Forbes, Michael A. Zimmerman, Matthew J. Ellis, Aparna Rege, Laura Basagoitia, Kimberly D. Krawiec, and Michael A. Rees, “Global Kidney Exchange Should Expand Wisely, Transplant International, September 2020, 33, 9,  985-988. https://onlinelibrary.wiley.com/doi/full/10.1111/tri.13656

14.  Vivek B. Kute, Himanshu V. Patel, Pranjal R. Modi, Sayyad J. Rizvi, Pankaj R. Shah, Divyesh P Engineer, Subho Banerjee, Hari Shankar Meshram, Bina P. Butala, Manisha P. Modi, Shruti Gandhi, Ansy H. Patel, Vineet V. Mishra, Alvin E. Roth, Jonathan E. Kopke, Michael A. Rees, “Non-simultaneous kidney exchange cycles in resource-restricted countries without non-directed donation,” Transplant International,  Volume 34, Issue 4, April 2021,  669-680  https://doi.org/10.1111/tri.13833

15.   Afshin Nikzad, Mohammad Akbarpour, Michael A. Rees, and Alvin E. Roth “Global Kidney Chains,” Proceedings of the National Academy of Sciences, September 7, 2021 118 (36) e2106652118; https://doi.org/10.1073/pnas.2106652118 .

16.    Alvin E. Roth, Ignazio R. Marino, Kimberly D. Krawiec, and Michael A. Rees, “Criminal, Legal, and Ethical Kidney Donation and Transplantation: A Conceptual Framework to Enable Innovation,” Transplant International  (2022), 35: doi: 10.3389/ti.2022.10551, https://www.frontierspartnerships.org/articles/10.3389/ti.2022.10551/full

17.   Ignazio R. Marino, Alvin E. Roth, and Michael A. Rees, “Living Kidney Donor Transplantation and Global Kidney Exchange,” Experimental and Clinical Transplantation (2022), Suppl. 4, 5-9. http://www.ectrx.org/class/pdfPreview.php?year=2022&volume=20&issue=8&supplement=4&spage_number=5&makale_no=0

18.  Agarwal, Nikhil, Itai Ashlagi, Michael A. Rees, Paulo Somaini, and Daniel Waldinger. "Equilibrium allocations under alternative waitlist designs: Evidence from deceased donor kidneys." Econometrica 89, no. 1 (2021): 37-76.

And here’s a report of work in progress:

The First 52 Global Kidney Exchange Transplants: overcoming multiple barriers to transplantation by MA Rees, AE Roth , IR Marino, K Krawiec, A Agnihotri, S Rees, K Sweeney, S Paloyo, T Dunn, M Zimmerman, J Punch, R Sung, J Leventhal, A Alobaidli, F Aziz, E Mor, T Ashkenazi, I Ashlagi, M Ellis, A Rege, V Whittaker, R Forbes, C Marsh, C Kuhr, J Rogers, M Tan, L Basagoitia, R Correa-Rotter, S Anwar, F Citterio, J Romagnoli, and O Ekwenna.  Transplantation: September 2022 - Volume 106 - Issue 9S - p S469 doi: 10.1097/01.tp.0000887972.53388.77  https://journals.lww.com/transplantjournal/Fulltext/2022/09001/423_9__The_First_52_Global_Kidney_Exchange.697.aspx

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

Here's the meeting announcement:

ISOT 2022 NAGPUR

32^nd Annual Conference of The Indian Society of Organ Transplantation
2^nd Mid-term Meeting of Liver Transplantation Society of India
15^th Annual International Conference of NATCO
Dates : 12^th - 16^th October 2022 | Venue : Hotel Le Meridien, Nagpur

My talk, the Dr H.L. Trivedi Oration   is scheduled for 11:00am on Friday the 14th in Nagpur, which means I'll be giving it by zoom tonight, Thursday evening at 10:30 pm Pacific Time.

The presentation, which  will be about "Increasing the availability of transplants in India" is in honor of the late Dr. Hargovind Laxmishanker "H. L." Trivedi (August 1932 – October 2019), who I had the privilege of meeting,

Here's his obituary : 

Kute, Vivek, Himanshu Patel, Pankaj Shah, Pranjal Modi, and Vineet Mishra. "Professor Dr. HL Trivedi pioneering nephrologist and patriot who cared for his country (31-08-1932 TO 2-10-2019)." Indian Journal of Nephrology 29, no. 6 (2019): 379.

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Here's my concluding slide:

• India has enormous talent and accomplishment in living-donor transplantation
• To more nearly reach it’s potential, India needs to invest in recovering deceased donor organs.
• In the near term, it can build on it’s accomplishments in kidney transplantation, by 
• establishing national (not just regional) kidney exchange
• Continuing to explore international exchange for the hardest to match pairs
• Reducing restrictions on who can be an exchange donor
• Allowing non-directed donors and chains
• Allowing some chains to begin with a deceased-donor kidney
• Reducing financial barriers by increased investment in public hospitals and government health insurance, for organ donors as well as recipients

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Update: 

Prospects for improving kidney exchange in France

A recent article in Néphrologie & Thérapeutique simulates how kidney exchange in France could possibly be made substantially more effective, following liberalizations in the law. (The article is in French, but also has an English abstract.) A promising feature is that the article is a collaboration between physicians and market design economists.

Perspectives pour une évolution du programme de don croisé de reins en France

Perspectives for future development of the kidney paired donation programme in France by Julien Combe, Victor Hiller, Olivier Tercieux,  Benoît Audry, Jules Baudet, Géraldine   Malaquin, François Kerbaul, Corinne Antoine, Marie-Alice Macher, Christian Jacquelinet, Olivier Bastien, and Myriam Pastural

Abstract: "Almost one third of kidney donation candidates are incompatible (HLA and/or ABO) with their directed recipient. Kidney paired donation allows potential donors to be exchanged and gives access to a compatible kidney transplant. The Bioethics Law of 2011 authorised kidney paired donation in France with reciprocity between 2 incompatible “donor-recipient” pairs. A limited number of transplants have been performed due to a too restricted authorization compared to other European practices. This study presents the perspectives of the new Bioethics Law, enacted in 2021, which increases the authorised practices for kidney paired donation in France. The two simulated evolutions are the increase of the number of pairs involved in a kidney paired donation to 6 (against 2 currently) and the use of a deceased donor as a substitution to one of living donor. Different scenarios are simulated using data from the Agence de la Biomedecine; incompatible pairs registered in the kidney paired donation programme in France between December 2013 and February 2018 (78 incompatible pairs), incompatible transplants performed during the same period (476 incompatible pairs) and characteristics of deceased donors as well as proposals made over this period. Increasing the number of pairs has a limited effect on the number of transplants, which increases from 18 (23% of recipients) in the current system to 25 (32% of recipients) when 6 pairs can be involved. The use of a deceased donor significantly increases the number of transplants to 41 (52% of recipients). This study makes it possible to evaluate the increase in possibilities of kidney transplants by kidney paired donation following the new bioethics law. A working group and an information campaign for professionals and patients will be necessary for its implementation."

While the paper focuses on the situation in France, it's opening lines could have been written anywhere:

"La France, comme l’ensemble des pays du monde, souffre d’une pénurie de greffons rénaux de sorte que le nombre de malades en attente d’une greffe de rein ne cesse de croître." [France, like all countries in the world, suffers from a shortage of kidney transplants so that the number of patients waiting for a kidney transplant continues to grow."

Here's hoping that the authors will succeed in their plans to use deceased-donor initiated chains to save more lives in France.

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Earlier related posts:

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