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 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: 

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: 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.

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."

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 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."

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 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."

Global kidney exchange debated in the October issue of American Journal of Transplantation

The October issue of the AJT starts off with a news report, and ends with six letters to the editor (3 of which are replies by us to the letters and to the editorial that was published along with our original article in the March 2017 issue).

The AJT Report

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Global Kidney Exchange: Overcoming the Barrier of Poverty (pages 2499–2500)

Lara C. Pullen

Version of Record online: 28 SEP 2017 | DOI: 10.1111/ajt.14469

This month's installment of “The AJT Report” debates the benefits, ethics and sustainability of Global Kidney Exchange. We also look at efforts to shore kidney paired donation implementation in the United States.

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Letters to the Editor

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Kidney Paired-Donation Program Versus Global Kidney Exchange in India (pages 2740–2741)

V. Kute, R. M. Jindal and N. Prasad

Version of Record online: 22 MAY 2017 | DOI: 10.1111/ajt.14324

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Comment: Kidney Exchange to Overcome Financial Barriers to Kidney Transplantation (page 2742)

L. S. Baines and R. M. Jindal

Version of Record online: 15 MAY 2017 | DOI: 10.1111/ajt.14325

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Global kidney exchange: Financially incompatible pairs are not transplantable compatible pairs (pages 2743–2744)

M. A. Rees, S. R. Paloyo, A. E. Roth, K. D. Krawiec, O. Ekwenna, C. L. Marsh, A. J. Wenig and T. B. Dunn

Version of Record online: 1 SEP 2017 | DOI: 10.1111/ajt.14451

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Opposition to irresponsible global kidney exchange (pages 2745–2746)

Francis L. Delmonico and Nancy L. Ascher

Version of Record online: 2 SEP 2017 | DOI: 10.1111/ajt.14473

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People should not be banned from transplantation only because of their country of origin (pages 2747–2748)

Alvin E. Roth, Kimberly D. Krawiec, Siegfredo Paloyo, Obi Ekwenna, Christopher L. Marsh, Alexandra J. Wenig, Ty B. Dunn and Michael A. Rees

Version of Record online: 13 SEP 2017 | DOI: 10.1111/ajt.14485

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Open dialogue between professionals with different opinions builds the best policy (page 2749)

Ignazio R. Marino, Alvin E. Roth, Michael A. Rees and Cataldo Doria

Version of Record online: 11 SEP 2017 | DOI: 10.1111/ajt.14484

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