Long kidney exchange in Ahmedabad, India

Vivek Kute writes with the news:
IKDRC completes India’s longest cross-transplant chain

"Institute of Kidney Diseases and Research Center, Institute of Transplantation Sciences (IKDRC-ITS) Ahmedabad, India is pleased to share the news of an exciting milestone for the patients with end stage renal disease with incompatible living kidney donors. Our transplant team has completed longest Kidney Exchange transplant chain in India as well as Asia involving 10 donor-recipients pairs over 5 days in January 2020. Two kidney transplant surgeries were performed each on 4, 6 and 7 January, 3 transplants on 8 January and last kidney transplant was completed on 22 January 2020.
...
". The success of this program can be attributed to the selflessness of the more than 500 family members who have stepped forward to be living organ donors. Dr Vivek Kute Professor of Nephrology maintains the single center registry of incompatible pairs. Dr Vivek Kute  and his team is greatful to Prof. Michael Rees and Prof. Alvin Roth for providing the Alliance for Paired Donations software for computer allocation at free of cost. Transplant team members are Dr Vineet Mishra, Dr Pranjal Modi, Dr Himanshu Patel, Dr Jamal Rizvi, Dr Vivek Kute, Dr Bina Butala and others."

A transplant center in India has done 300 kidney exchange transplants

Here's the article, whose first author is Dr. Vivek Kute, of the Faculty of Nephrology and Transplantation, Institute of Kidney Diseases and Research Center and Dr. H L Trivedi Institute of Transplantation Sciences ,
(IKDRC-ITS) Ahmedabad , India

Transpl Int. 2017 Mar 20. doi: 10.1111/tri.12956. [Epub ahead of print]

Impact of Single-Centre Kidney Paired Donation Transplantation to Increase the Donor Pool in India.

Kute VB1, Patel HV1, Shah PR1, Modi PR2, Shah VR3, Rizvi SJ2, Pal BC2, Shah PS1, Modi MP3, Butala BP3, Wakhare PS1, Varyani UT1, Shinde SG1, Ghodela VA1, Kasat GS1, Patil MV1, Patel JC1, Kumar DP1, Trivedi VB4, Patel MH4, Trivedi HL1.

Author information

Abstract

In a living donor kidney transplantation (LDKT) dominated transplant programme, kidney paired donation (KPD) may be a cost-effective and valid alternative strategy to increase LDKT in countries with limited resources where deceased donation kidney transplantation (DDKT) is in the initial stages. Here, we report our experience of 300 single-centre KPD transplantations to increase LDKT in India. Between January 2000 and July 2016, 3616 LDKT and 561 DDKT were performed at our transplantation centre, 300 (8.3%) using KPD. The reasons for joining KPD among transplanted patients were ABO incompatibility (n=222), positive cross match (n=59) and better matching (n=19). A total of 124 two-way (n=248), 14 three-way (n=42), one 4-way (n=4) and one 6-way exchange (n=6) yielded 300 KPD transplants. Death-censored graft and patient survival were 96% (n=288) and 83.3% (n=250), respectively. The mean serum creatinine was 1.3 mg/dl at a follow-up of 3±3 years. We credit the success of our KPD programme to maintaining a registry of incompatible pairs, counselling on KPD, a high-volume LDKT programme and teamwork. KPD is legal, cost effective and rapidly growing for facilitating LDKT with incompatible donors. This study provides large-scale evidence for the expansion of single-centre LDKT via KPD when national programmes do not exist. This article is protected by copyright. All rights reserved.

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Here's a related recent article by Dr. Kute:

World J Transplant. 2017 Feb 24;7(1):64-69. doi: 10.5500/wjt.v7.i1.64.

International kidney paired donation transplantations to increase kidney transplant of O group and highly sensitized patient: First report from India.

Kute VB1, Patel HV1, Shah PR1, Modi PR1, Shah VR1, Rizvi SJ1, Pal BC1, Shah PS1, Wakhare PS1, Shinde SG1, Ghodela VA1, Varyani UT1, Patel MH1, Trivedi VB1, Trivedi HL1.

Author information

Abstract

AIM:

To report the first international living related two way kidney paired donation (KPD) transplantation from India which occurred on 17th February 2015 after legal permission from authorization committee.

METHODS:

Donor recipient pairs were from Portugal and India who were highly sensitized and ABO incompatible with their spouse respectively. The two donor recipient pairs had negative lymphocyte cross-matching, flow cross-match and donor specific antibody in two way kidney exchange with the intended KPD donor. Local KPD options were fully explored for Indian patient prior to embarking on international KPD.

RESULTS:

Both pairs underwent simultaneous uneventful kidney transplant surgeries and creatinine was 1 mg/dL on tacrolimus based immunosuppression at 11 mo follow up. The uniqueness of these transplantations was that they are first international KPD transplantations in our center.

CONCLUSION:

International KPD will increases quality and quantity of living donor kidney transplantation. This could be an important step to solving the kidney shortage with additional benefit of reduced costs, improved quality and increased access for difficult to match incompatible pairs like O blood group patient with non-O donor and sensitized patient. To the best of our knowledge this is first international KPD transplantation from India.

77 Kidney Exchange transplants in 2015 at one transplant center in India

I received the following cheerful news from Dr. Vivek Kute at the Institute of Kidney Diseases and Research Center and Dr. H L Trivedi Institute of Transplantation Sciences ,
(IKDRC-ITS) Ahmedabad , India

 Kidney Paired Donation (KPD) Transplantation Activity At Single Center In Institute Of Kidney Diseases And Research Center And Dr. H L Trivedi Institute Of Transplantation Sciences , (IKDRC-ITS) Ahmedabad , India

Kute VB , Patel HV, Shah PR, Vanikar AV, Modi PR, Shah VR , Varyani UT, Wakhare PS ,  Shinde  SG,  Godhela VA, Shah PS , MK Shah , Gattani VS ,Shah JH, Wadhai KG , Trivedi VB, Patel MH, Trivedi HL.

1) We have performed the largest number of KPD Transplantations (77 patients from 1 Jan 2015 to 1 Jan 2016) in our single center and to the best of our knowledge this is largest number for KPD transplants in single center in one year in the World. KPD constitutes 25% of living donor kidney transplant (LDKT) in 2015.

2) We have performed 274 KPD Transplantations in Our Single Center from Year 2000- 2015 and total 231 KPD Transplantations from Year 2011-2015

3) We Have Performed First Non-Simultaneous Domino Chain Transplant of 6 ESRD Patients and 6 Donors in Single Center in August 2015.

4) We Have Performed First International KPD Transplant on 17 Feb 2015.

5) In The Year 2013, we have performed 56 Kidney Paired Donation Transplantations in our single center. KPD constitutes 15.8% of LDKT in 2013.

6) In The Year 2014, we have performed 56 Kidney Paired Donation Transplantations in our single center. KPD constitutes 18.1% of LDKT in 2014.

7) We Have Performed Ten KPD Transplantations on World Kidney Day 2013 in Single Day in Our Single Center on 14 March 2013.

8) We Have Performed Successful Three-Way KPD Transplantation: First Time in India on 13 February 2013.

9) We Have Performed Successful Three-Way KPD Transplantation in Combination with Desensitization Protocol: First Time in India on 6 May 2014.

Under Mentorship of Prof. HL Trivedi, Vivek Kute is mainly focused on expanding donor pool and kidney-paired donation (KPD) transplantation. 

Correspondence Address

Dr.Vivek Kute. 

MBBS, MD, FCPS, DM Nephrology (Gold Medalist), FASN

Associate Professor , Nephrology and Transplantation, Institute of Kidney Diseases and Research Center and Dr. H L Trivedi Institute of Transplantation Sciences , (IKDRC-ITS) Ahmedabad , India

(M) : +919099927543  

Email: drvivekkute@rediffmail.com  

Website : www.ikdrc-its.org

Kidney exchange in India: progress, then Covid

 Here's a paper reporting, among other things, a long kidney exchange cycle in India.  But Covid has put a temporary halt to all that.

Paired Kidney Exchange in India: Future Potential and Challenges Based on the Experience at a Single Center  by Kute, Vivek B. MD, DM, FASN, FRCP1; Patel, Himanshu V. MD, DNB1; Modi, Pranjal R. MS, DNB2; Rizvi, Syed J. MS, MCh2; Engineer, Divyesh P. MD, DM1; Banerjee, Subho MD, DM1; Butala, Bina P. MD3; Gandhi, Shruti MD4; Patel, Ansy H. MBBS5; Mishra, Vineet V. MS  Transplantation: May 2021 - Volume 105 - Issue 5 - p 929-932  doi: 10.1097/TP.0000000000003421

But now Covid is taking a toll. Dr. Kute writes in an email that transplantation has been on hold in Gujarat since April. He says "we had cumulative 225 kidney transplant recipients with PCR confirmed COVID-19 in our single center. Over all mortality in transplants population 10% and much higher in dialysis."

Here's hoping that vaccine production ramps up and Covid falls away in India and the rest of the world soon.

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I have quite a number of posts following the work of Dr. Kute and his colleagues in Ahmedabad.

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

 Perhaps the biggest part of the ongoing design of kidney exchange around the world involves adapting to constantly changing local conditions in patient and donor populations, and the prevailing laws, regulations and medical situation.  In India, where non-directed donation is illegal (except in Kerala), this means that some patients can be transplanted only if long exchange cycles are possible.  In most of the world, the requirement that the surgeries in a cycle be performed simultaneously has prevented this.

The paper below, organized by two of the world's most innovative transplant doctors, Vivek Kute and Mike Rees (first and last authors, in the medical manner), demonstrates a path forward in India. The paper reports 17 very carefully arranged and conducted non-simultaneous (and non-anonymous) kidney exchange cycles, accomplishing 67 transplants. These were performed at the  Trivedi Institute of Transplantation Sciences  (using our software:).

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, February 2021.

Abstract: Recent reports suggest that bridge-donor reneging is rare (1.5%) in non-simultaneous kidney exchange chains. However, in developing countries, the non-directed donors who would be needed to initiate chains are unavailable, and furthermore, limited surgical space and resources restrain the feasibility of simultaneous kidney exchange cycles. Therefore, the aim of this study was to evaluate the bridge-donor reneging rate during non-simultaneous kidney exchange cycles (NSKEC) in a prospective single-center cohort study (n=67). We describe the protocol used to prepare co-registered donor-recipient pairs for non-simultaneous surgeries, in an effort to minimize the reneging rate. In addition, in order to protect any recipients who might be left vulnerable by this arrangement, we proposed the use of standard criteria deceased-donor kidneys to rectify the injustice in the event of any bridge-donor reneging.  We report 17 successful NSKEC resulting in 67 living-donor kidney transplants (LDKT) using  23 bridge-donors without donor renege  and  no intervening pairs became unavailable. We propose that NSKEC could increase LDKT, especially for difficult-to-match sensitized pairs (25 of our 67 pairs) in countries with limited transplantation resources. Our study confirms that NSKEC can be safely performed with careful patient-donor selection and non-anonymous kidney exchanges.

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Some previous posts:

Saturday, February 1, 2020

Long kidney exchange in Ahmedabad, India

Wednesday, May 22, 2019

Kidney exchange in India: the legal framework

Tuesday, May 21, 2019

Robot-assisted kidney transplantation in Ahmedabad, India.

Ten kidney exchange transplants on World Kidney Day in Ahmedabad, India

Here's the link:

Clinical Studies

Ten kidney paired donation transplantation on World Kidney Day 2013: raising awareness and time to take action to increase donor pool

Posted online on August 12, 2013. (doi:10.3109/0886022X.2013.823997)

Vivek B. Kute¹, Aruna V. Vanikar², Pankaj R. Shah¹, Manoj R. Gumber¹, Himanshu V. Patel¹, Divyesh P. Engineer¹, Pranjal R. Modi³, S.J. Rizvi³, Veena R. Shah⁴, Manisha P. Modi⁴, Kamal V. Kanodia², and Hargovind L. Trivedi¹

¹Department of Nephrology and Clinical Transplantation,

²Department of Pathology, Laboratory Medicine, Transfusion Services and Immunohematology,

³Department of Urology and Transplantation, and

⁴Anesthesia and Critical Care, Institute of Kidney Diseases and Research Center, Dr. HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS),

Ahmedabad

, India

Address correspondence to

Dr. Vivek Kute

, Department of Nephrology and Clinical Transplantation, Institute of Kidney Diseases & Research Centre, Dr. HL Trivedi Institute of Transplantation Sciences (IKDRC- ITS), Civil Hospital Campus,

Ahmedabad 380016, Gujarat

, India. Tel.: +91 79 22687000; Fax: +91 79 2268 5454; E-mail: drvivekkute@rediffmail.com

Abstract

Background: Kidney paired donation (KPD) is feasible for any center that performs living related donor renal transplantation (LRDRTx). Lack of awareness, counseling and participation are important hurdles in KPD patients with incompatible donors. Materials and methods: This is an institutional review board approved study of 10 ESRD patients who consented to participate in the KPD transplantation at our center. All the surgeries were carried out on the same day at the same center on the occasion of World Kidney Day (WKD) (14 March 2013). All recipients had anatomic, functional and immunological similar donors. Results: KPD were performed to avoid blood group incompatibility (n = 8) or to avoid a positive crossmatch (n = 2). None of the patients experienced delayed graft function and surgical complications. At 3 month follow-up, median serum creatinine was 1 (range 0.6 to 1.25) mg/dL and two patients developed allograft biopsy-proven acute rejection and responded to antirejection therapy. Due to impact of our awareness activity, 20 more KPD patients are medically fit for transplantation and waiting for permission from the authorization committee before transplantation. Conclusion: This is a report of 10 simultaneous KPD transplantations in a single day in a single centre on WKD raising awareness of KPD. KPD is viable, legal and rapidly growing modality for facilitating LRDRTx for patients who are incompatible with their healthy, willing LRD.

Read More: http://informahealthcare.com/doi/abs/10.3109/0886022X.2013.823997

Kidney Paired Donation in Developing Countries: a Global Perspective

 Vivek Kute and his colleagues argue that one of the lessons from the developing world is that kidney exchange can save many lives, but may need to be organized differently in some ways than in the developed world.

Kidney Paired Donation in Developing Countries: a Global Perspective by Vivek B. Kute, Vidya A. Fleetwood, Sanshriti Chauhan, Hari Shankar Meshram, Yasar Caliskan, Chintalapati Varma, Halil Yazıcı, Özgür Akın Oto & Krista L. Lentine, Current Transplantation Reports (2023)  (here's a link that may provide better access]

Abstract

...

"Despite the advantages of KPD programs, they remain rare among developing nations, and the programs that exist have many differences with those of in developed countries. There is a paucity of literature and lack of published data on KPD from most of the developing nations. Expanding KPD programs may require the adoption of features and innovations of successful KPD programs. Cooperation with national and international societies should be encouraged to ensure endorsement and sharing of best practices.

Summary

KPD is in the initial stages or has not yet started in the majority of the emerging nations. But the logistics and strategies required to implement KPD in developing nations differ from other parts of the world. By learning from the KPD experience in developing countries and adapting to their unique needs, it should be possible to expand access to KPD to allow more transplants to happen for patients in need worldwide."

...

" Despite the advantages of KPD programs, they remain rare in the developing world, and the programs that exist have many differences with those of developed countries. Program structure is one of these differences: multi-center, regional, and national KPD programs (Swiss, Australia, Canada, Dutch, UK, USA) are more common in the developed than the developing world, whereas single center programs are more common

...

"kidney exchanges frequently take weeks to months to obtain legal permission in India despite the fact that only closely-related family members (i.e., parents, spouse, siblings, children, and grandparents) are allowed to donate a kidney [47].

...

"Protecting the privacy of a donor, including maintaining anonymity when requested, is common practice among developed countries but uncommon in developing nations. Anonymous allocation during KPD is a standard practice in the Netherlands, Sweden, and other parts of Europe, but this is not the case in countries such as India, Korea, and Romania [14, 48, 49]. In areas where anonymity is not maintained, the intended donor/recipient pair must meet and share medical information once a potential exchange is identified, but before formal allocation of pairs occurs. The original donor/ recipient pair may refuse the proposed exchange option for any reason and continue to be on the waitlist. In India, nonanonymous KPD allocation is standard practice and has the goal of increasing trust and transparency between the transplant team and the administrative team [14, 49]. Countries differ in philosophical approaches to optimizing trust and transparency, and objective data on most effective practices would benefit the global community."

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Tomorrow I hope to have a few words to say about the equally unique situation in China.

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Update:

Tuesday, September 19, 2023

Organ transplantation in China: in transition--and controversy about paying funeral costs

Kidney exchange in all its aspects: a view from India

Here's a survey that sees kidney exchange, and all the advances that have been made in how to use it to facilitate more transplants, as a force for making medicine more inclusive around the world.

Kidney exchange transplantation current status, an update and future perspectives
Vivek B Kute, Narayan Prasad, Pankaj R Shah, Pranjal R Modi
World J Transplant. Jun 28, 2018; 8(3): 52-60
Published online Jun 28, 2018. doi: 10.5500/wjt.v8.i3.52

Abstract: "Kidney exchange transplantation is well established modality to increase living donor kidney transplantation. Reasons for joining kidney exchange programs are ABO blood group incompatibility, immunological incompatibility (positive cross match or donor specific antibody), human leukocyte antigen (HLA) incompatibility (poor HLA matching), chronological incompatibility and financial incompatibility. Kidney exchange transplantation has evolved from the traditional simultaneous anonymous 2-way kidney exchange to more complex ways such as 3-way exchange, 4-way exchange, n-way exchange,compatible pair, non-simultaneous kidney exchange,non-simultaneous extended altruistic donor, never ending altruistic donor, kidney exchange combined with desensitization, kidney exchange combined with ABO incompatible kidney transplantation, acceptable mismatch transplant, use of A2 donor to O patients, living donor-deceased donor list exchange, domino chain, non-anonymous kidney exchange, single center, multicenter, regional, National, International and Global kidney exchange. Here we discuss recent advances in kidney exchanges such as International kidney exchange transplantation in a global environment, three categories of advanced donation program, deceased donors as a source of chain initiating kidneys, donor renege myth or reality, pros and cons of anonymity in developed world and (non-) anonymity in developing world, pros and cons of donor travel vs kidney transport, algorithm for management of incompatible donor-recipient pairs and pros and cons of Global kidney exchange. The participating transplant teams and donor-recipient pairs should make the decision by consensus about kidney donor travel vs kidney transport and anonymity vs non-anonymity in allocation as per local resources and logistics. Future of organ transplantation in resource-limited setting will be liver vs kidney exchange, a legitimate hope or utopia?"

An interesting section of the paper discusses different practices regarding anonymity in kidney exchange centers in different countries:

"PROS AND CONS OF ANONYMITY IN DEVELOPED WORLD AND (NON-) ANONYMITY IN DEVELOPING WORLD

There is disparity on standard practice of kidney exchange in developed and developing World in term of (non-) anonymity. There is variable practice on anonymity before and after surgery in different countries.

Conditional approach[38]: When the donor-recipient pairs give consent for meeting after surgery, they are allowed to meet each other after surgery in some countries such as the United States of America[39] and the United Kingdom[40]. In other countries, such as the Netherlands and Sweden[41], anonymity is absolute. Anonymity protects patients, donors and transplant hospital/ administration against the risks of revoking anonymity and prevents further commercialization of organs, and breach of patient donor privacy. An Ethical, Legal and Psychosocial Aspects of Organ Transplantation (ELPAT), a subsection of the European Society for Organ Transplantation reported that a conditional approach to anonymity should be possible after surgery[42]. Pronk et al[38] showed that most donor-recipient pairs who participated in anonymous donation process are in favour of a conditional approach to anonymity. Guidelines on how to revoke anonymity if both parties agree are needed and should include education about pros and cons of (non-) anonymity and a logistical plan on how, when, where, and by whom anonymity should be revoked.

Non-anonymous allocation[11,12]: Donor-recipient pairs are allowed to meet each other before allocation of donor for surgery and even after surgery. They can share medical reports of exchange donors before surgery and kidney transplant and donor surgery outcome after surgery. Donor-recipient pairs do not choose their match but donor-recipient pairs may decline a match or can withdraw from participation in the kidney exchange program at any time, for any reason. Non-anonymous allocation has the potential of commercialization of organs in case of compatible donor-recipient pairs along with breach in privacy of donor-recipient pairs. Kute et al[11,12] reported that donor-recipient pairs are willing for non-anonymous allocation process in single center study of 300 kidney exchange transplants in India. They reported that non-anonymity is more helpful in manual allocation in absence of computer software allocation which also increases trust between patients, donors and transplant hospital/administration and legal team. More long term prospective studies are required to explore the donor and recipient perspective on anonymity in living kidney donation in different socio-economic regions and countries."

Regarding Global Kidney Exchange they conclude:

"Global kidney exchange appears to provide life-saving kidney transplantation to poor donor-recipient pairs from developing countries that otherwise could die due to economic constrain[50-53]."

And here's their conclusion:

CONCLUSION

"Kidney exchange transplantation has increased living donor kidney transplantation for end stage renal disease patients with chronological incompatibility and financial incompatibility. The participating transplant teams and donor-recipient pairs should make the decision by consensus about kidney donor travel vs kidney transport and anonymity vs non-anonymity in allocation as per local resources and logistics. There is need of uniform algorithm for management of incompatible donor-recipient pairs."

TTS2022 Awards--Congratulations

 Today at TTS2022, prizes will be awarded.  One that I know is very well deserved, is to Dr. Vivek Kute, for his extraordinary achievements in kidney transplantation in India. Congratulations to all the prize winners.

I've followed Dr. Kute's work over the years in multiple posts.

Kidney exchange in India

Outcome of kidney paired donation transplantation to increase donor pool and to prevent commercial transplantation: a single-center experience from a developing country.

Kute VB, Gumber MR, Patel HV, Shah PR, Vanikar AV, Modi PR, Shah VR, Patel MP, Trivedi HL.

Source

Department of Nephrology and Clinical Transplantation, Institute of Kidney Diseases and Research Center, Dr. HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Civil Hospital Campus, Asarwa, Ahmedabad, 380016, Gujarat, India, drvivekkute@rediffmail.com.

Abstract

BACKGROUND:

Economic constraints in operating an effective maintenance dialysis program leaves renal transplantation as the only viable option for end-stage renal disease patients in India. Kidney paired donation (KPD) is a rapidly growing modality for facilitating living donor (LD) transplantation for patients who are incompatible with their healthy, willing LD.

MATERIALS AND METHODS:

The aim of our study was to report a single-center feasibilities and outcomes of KPD transplantation between 2000 and 2012. We performed KPD transplants in 70 recipients to avoid blood group incompatibility (n = 56) or to avoid a positive crossmatch (n = 14).

RESULTS:

Over a mean follow-up of 2.72 ± 2.96 years, one-, five- and ten-year patient survival were 94.6, 81, 81 %, and death-censored graft survival was 96.4, 90.2, 90.2 %, respectively. Ten percent of patients were lost, mainly due to infections (n = 4). There was 14.2 % biopsy-proven acute rejection, and 5.7 % interstitial fibrosis with tubular atrophy eventually leading to graft loss.

CONCLUSION:

The incidences of acute rejection, patient/graft survival rates were acceptable in our KPD program and, therefore, we believe it should be encouraged. These findings are valuable for encouraging participation of KPD pairs and transplant centers in national KPD program. It should be promoted in centers with low-deceased donor transplantation. Our study findings are relevant in the context of Indian government amending the Transplantation of Human Organs Act to encourage national KPD program. To our knowledge, it is largest single-center report from India.

More on starting kidney exchange chains with deceased donor kidneys

Here's a forthcoming letter to the editor in the American Journal of Transplantation: We need to take the next step, by Marc L. Melcher, John P. Roberts, Alan B. Leichtman, Alvin E. Roth, and Michael A. Rees

It replies to another letter: A potential solution to make best use of living donor- deceased donor list exchange by VB Kute, HV Patel, PR Shah, PR Modi, VR Shah, HL Trivedi

which was prompted by our earlier article: 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.


Here's a post about that earlier article:

Using deceased donor kidneys to start living donor kidney exchange chains

and here's a post about the followup we hope to do:

White House Organ Summit--video and links. Deceased donor chains planned at Walter Reed

Kidney exchange in India

Right now, kidney exchange in India is all done in single transplant center programs. Here's an article advocating inter-hospital exchange to increase accesss to transplantation.

Kidney-paired donation to increase living donor kidney transplantation in India: Guidelines of Indian Society of Organ Transplantation – 2017
Kute VB, Agarwal SK, Sahay M, Kumar A, Rathi M, Prasad N, Sharma RK, Gupta KL, Shroff S, Saxena SK, Shah PR, Modi PR, Billa V, Tripathi LK, Raju S, Bhadauria DS, Jeloka TK, Agarwal D, Krishna A, Perumalla R, Jain M, Guleria S, Rees MA
Indian Journal of Nephrology, 2018  |  Volume : 28  |  Issue : 1  |  Page : 1-9

"Conclusion: KPD transplant is legal, cost-effective, rapidly expanding modality with good long-term outcome, and being implemented in several centers in India with the potential to increase LDKT by 25%. KPD transplant should be encouraged over ABOiKT and desensitization protocol. The quality of matching and number of KPD will be superior in national program versus single-center program due to large donor pool. Transplant team members, stakeholder, and policy-makers should work together to expand KPD.

...
These are recommendation on KPD transplantation after the Indian Society of Organ Transplantation (ISOT) midterm meeting organized at Chennai on March 18, 2017, and 1-day Workshop organized at Hotel Pullman, Aerocity, New Delhi, on April 29, 2017, under the Aegis of ISOT and participation of NOTT organization to discuss various issues related to expanding KPD and starting the National KPD program. Transplant surgeons, physicians, and other stakeholders from major centers across the country participated and had a robust discussion on the related issues."

Kidney exchange in India: the legal framework

Last week in Ahmedabad I had a chance to interact with Dr. Vivek Kute and his colleagues at the Trivedi Institute, to better understand the setting of their innovative kidney exchange program.  The legal framework is of course a big part of that environment.

Here's India's Transplantation of Human Organs and Tissues Act (THOA), 2014 (scroll down for the English language version).

As in other places, much of the law is shaped by  repugnance towards kidney sales. To this end, the law requires that an Authorisation Committee approve donation from someone who is not a "near relative," in the immediate nuclear family.

"Authorisation Committee.
(3) When the proposed donor and the recipient are not near relatives, the Authorisation Committee shall,- 
(i)evaluate that there is no commercial transaction between the recipient and the donor and that no payment has been made to the donor or promised to be made to the donor or any other person; 
(ii)prepare an explanation of the link between them and the circumstances which led to the offer being made;"

In the case of kidney exchange, only a near relative may serve as the intended donor (i.e. no uncles, aunts, cousins, etc.).

"(4)Cases of swap donation referred to under subsection (3A) of section 9 of the Act shall be approved by Authorisation Committee of hospital or district or State in which transplantation is proposed to be done and the donation of organs shall be permissible only from near relatives of the swap recipients."

The present law also does not allow nondirected donors.
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Here are some related earlier posts:

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

Monday, July 2, 2018

Kidney exchange in all its aspects: a view from India

Monday, May 14, 2018

Kidney Exchange in India: current conditions and recommendations for the future

Kidney Exchange in India: current conditions and recommendations for the future

The Indian Society of Organ Transplantation has published guidelines for expanding kidney exchange in India:

Kute VB, Agarwal SK, Sahay M, Kumar A, Rathi M, Prasad N, Sharma RK, Gupta KL, Shroff S, Saxena SK, Shah PR, Modi PR, Billa V, Tripathi LK, Raju S, Bhadauria DS, Jeloka TK, Agarwal D, Krishna A, Perumalla R, Jain M, Guleria S, Rees MA. Kidney-paired donation to increase living donor kidney transplantation in India: Guidelines of Indian Society of Organ Transplantation – 2017. Indian J Nephrol 2018;28:1-9

Here's the summary of their recommendations:

"Evidence-based recommendations, suggestions, and expert consensus statements in this document aim to expand KPD and may serve as a model for other developing countries. For these guidelines, all reference articles in the English literature related to KPD transplantation in India from MEDLINE (PubMed from 2000 to 2017) database were included and reviewed.

We recommend that each potential DRP should be educated, encouraged, and counseled about KPD transplant in an easy-to-understand format as early as possible in the process of chronic kidney disease (CKD) care.

We recommend that all the transplant team members including transplant coordinator in addition to other regular training should also be trained for counseling about risk, benefits of KPD, nonexchange options, consent process, financial screening of DRP, data entry-related issues of KPD, and overall support for KPD.

We recommend that a standard written informed consent should be obtained from each DRP. We suggest that DRP should be given information about expected waiting time before transplantation, and every attempt should be made to reduce waiting time, particularly for hard-to-match pairs with the innovative ways in KPD matching.

We suggest that easy-to-match pairs (A donor and B recipient and vice versa) and sensitized pairs should be encouraged for KPD over ABO-incompatible kidney transplantation (ABOiKT) and desensitization protocol.

We recommend that all types of KPD should be practiced only after legal permission as per the existing transplant law.

We suggest that three-way exchange has optimum quality and quantity of matching.

We suggest that potential KPD transplant centers should study the key elements of success of other successful KPD program.

We suggest that computerized algorithms should be encouraged over manual allocation.

We recommend that all patients should be screened for pretransplant immunological risk, occult infections, and other risk factors to prevent and reduce posttransplant unequal outcome due to patient-related factors.

We suggest that the age difference between KPD donors should not be the key issue in allocation and better immunological match may counteract the effect of higher donor–recipient age difference.

We recommend that participating transplant teams should make the decision by consensus about kidney donor travel versus kidney transport as per local resources and logistics, though donor travel rather than kidney transport is likely to be simple.

We suggest that transplant surgery should be performed at the place where patient is evaluated, admitted, and willing to do posttransplant follow-up and simultaneous rather than sequential surgery should be preferred.

We recommend that the formation of KPD registry is one of the principal strategies to improve the quality of matching and number of KPD.

We suggest that DRP needs to be cognizant of transcultural, language, and legal barriers in national program when patients and their donors may belong to different regions or states of India."


And here's the introductory summary of the background in India:

The Indian CKD registry in 2010 reported that at the time of enrolment in registry, 61% of end-stage renal disease (ESRD) patients were not on any form of renal replacement therapy (RRT), while 32% were on hemodialysis, 5% on peritoneal dialysis, and only 2% were being worked up for kidney transplantation.^[1] There is a gross disparity between supply and demand of the transplant organs across the world, including India. All efforts are to be made to increase the supply of quality organs to the waiting transplant recipients. KPD is one such process for increasing supply of organs to patients waiting for transplant. ABO-compatible living donor kidney transplant (LDKT) is the ideal and cost-effective RRT modality for ESRD patients in resource-limited developing country such as India, where morbidity and mortality on long-term dialysis is unacceptably high. Access to RRT is mainly prevented by paucity of facilities and affordability. Up to 80% of kidney donors are living donors, while DDKT programs are still evolving in most parts of India.

KPD transplant enables two incompatible DRP to receive more compatible kidneys. In this, a living kidney donor who is otherwise incompatible with the recipient exchanges kidneys with another DRP. KPD can be performed at any transplant center that is doing kidney transplantation without the need of extra facilities as required for ABOiKT and transplant with desensitization protocol.

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