A kidney exchange chain initiated by a deceased donor, in Italy

 Deceased Donor–initiated Chains
First Report of a Successful Deliberate Case and Its Ethical Implications
Furian, Lucrezia MD1; Cornelio, Cristina PhD2; Silvestre, Cristina MD, PhD1; Neri, Flavia MD1; Rossi, Francesca PhD2,3; Rigotti, Paolo MD1; Cozzi, Emanuele MD, PhD4; Nicolò, Antonio PhD

Transplantation: October 2019 - Volume 103 - Issue 10 - p 2196–2200
doi: 10.1097/TP.0000000000002645

Background. It has been suggested that deceased donor kidneys could be used to initiate chains of living donor kidney paired donation, but the potential gains of this practice need to be quantified and the ethical implications must be addressed before it can be implemented.

Methods. The gain of implementing deceased donor–initiated chains was measured with an algorithm, using retrospective data on the pool of incompatible donor/recipient pairs, at a single center. The allocation rules for chain-ending kidneys and the characteristics and quality of the chain-initiating kidney are described.

Results. The benefit quantification process showed that, with a pool of 69 kidneys from deceased donors and 16 pairs enrolled in the kidney paired donation program, it was possible to transplant 8 of 16 recipients (50%) over a period of 3 years. After obtaining the approval of the Veneto Regional Authority’s Bioethical Committee and the revision of the Italian National Transplant Center’s allocation policies, the first successful case was completed. For the recipient (male, aged 53 y), who entered the program for a chain-initiating kidney with a Kidney Donor Risk Index of 0.61 and a Kidney Donor Profile Index of 3%, the waiting time was 4 days. His willing donor (female, aged 53 y) with a Living Kidney Donor Profile Index of 2, donated 2 days later to a chain-ending recipient (male, aged 47 y) who had been on dialysis for 5 years.

Conclusions. This is the first report of a successfully completed, deliberate deceased donor–initiated chain, which was made possible after a thorough assessment of the ethical issues and the impact of allocation policies. This article includes a preliminary efficacy assessment and describes the development of a dedicated algorithm.
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See earlier post:

Monday, April 11, 2016

Using deceased donor kidneys to start living donor kidney exchange chains

UNOS proposal: Allowing Deceased Donor-Initiated Kidney Paired Donation (KPD) Chains

Earlier I posted about our 2016 paper proposing that some kidney exchange nondirected donor chains be started with deceased donor kidneys.

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

Now UNOS has put out a proposal for public comment.  Here's the proposal

Allowing Deceased Donor-Initiated Kidney Paired Donation (KPD) Chains

Here's the request for comments:
Deceased donor initiated KPD chains      Public Comment  

How not to assign kidneys

"That's the title of a NY Times Op-Ed by LAINIE FRIEDMAN ROSS and BENJAMIN E. HIPPEN, criticizing the recent UNOS proposals to change the deceased donor kidney allocation system (about which I recently blogged here and here). (Ross and Hippen don't always agree with each other; here they take opposite sides of the debate on whether it would be ok to compensate donors.)

In their op-ed they write:
"The proposal is supposed to provide deceased-donor kidneys of higher quality to healthier, younger patients instead of to elderly ones who presumably have fewer years to live.

"It sounds simple enough. But the strategy could result in fewer kidneys going from living donors to young candidates, and could lead to more deaths of older or sicker candidates on the waiting list. Moreover, it would do nothing to address the fundamental problem: the persistent shortage of kidneys from donors, both living and deceased.

"The proposal would set up a two-pronged strategy that is intended to increase the number of life-years gained for every donor kidney. Under the proposal, the top 20 percent of kidneys from deceased donors who had been young and healthy would be assigned to the top 20 percent of young healthy candidates. In other words, the best deceased-donor kidneys would be given to patients likeliest to have long lives ahead of them.

"The other 80 percent of deceased-donor kidneys would be allocated first to local candidates within a 15-year age range of the donor, and if no potential candidate were identified, then to the broader pool of candidates. (For example, candidates aged 25 to 55 would get priority for a kidney from a 40-year-old donor who had just died.)

"But while the goal is understandable, the proposal is flawed...

"...giving healthy young patients first dibs on kidneys from young deceased donors might reduce donation rates from living donors to the young candidates, which is at cross-purposes with the goal of extending years of life after transplant. In 2005, the network started giving pediatric transplant candidates priority for kidneys from deceased donors younger than 35. While the pediatric patients received more organs from deceased donors, they got fewer organs from living donors. The likely explanation is that the donors, including many parents, held off, figuring that they could donate later, when the deceased-donor kidney eventually failed. (Those kidneys can last up to 20 years.)

"The new proposal would effectively expand the 2005 rule to all healthier, younger candidates, potentially reducing living-donor transplantation to the very group that stands to benefit the most from it. This would only increase their need for another transplant later, since kidneys from deceased donors do not last as long as kidneys from living ones.

"Giving more organs to young recipients would also come at the expense of “older” recipients, which in this context can mean 50 to 64. (Only a tiny fraction of all kidneys go to recipients older than 70.) Since older candidates on the waiting list are less likely to live long enough to receive a kidney, making them less eligible for transplants will probably result in more deaths on the list, and more pressure on available living donors to donate to older candidates.
...
"What should be done instead?

"First, allocate kidneys on a broader basis. Under both the current and proposed systems, kidneys are allocated locally. But while a New Yorker with end-stage renal disease will typically wait at least six years for a transplant, her counterpart in Minnesota might wait just two to three. ...

"Second, the network should continue to support first-person consent legislation under which people who have properly declared their willingness to donate their organs in case of an unexpected death cannot have their wishes overruled by their bereaved families.

"But for now, the only sure way to reduce the shortage of organs is to expand transplantation from living donors...

"The network should also keep encouraging innovative efforts like “kidney swaps” or “donor chains.” Kidney swaps involve two donor-recipient pairs who are incompatible within the pair, but can donate to the other pair’s recipient. (Think of it as a square dance where the couples switch partners halfway through.)

Donor chains begin with a living donor willing to donate to anyone on the waiting list. Instead of simply giving that donor’s kidney to the next patient in line, the kidney can go to the would-be recipient in an incompatible donor-recipient pair; that donor, in turn, can then give to another recipient of an incompatible donor-recipient pair, with the chain continuing indefinitely. (Consider it the medical equivalent of “pay it forward.”)

Progress towards a sensibly organized national kidney exchange

An important story has played out one more quite positive step in the dry prose of medical bureaucracy, in the form of a report of the Policy Oversight Committee of the Organ Procurement and Transplantation Network (OPTN) of the Health Resources and Services Administration (HRSA). (All of the reports are found here.)

The report in question is this one, OPTN/UNOS Policy Oversight Committee, Report to the Board of Directors, November 16-17, 2009, and the item in question has to do with how a pilot national kidney exchange might be organized, if it overcomes some hurdles presently standing in its way. In particular, the cumbersome review process is catching up with the progress being made in regional kidney exchanges, in which chains have become important, expecially since the introduction of Non-simultaneous kidney exchange chains .

"The Committee supports the Kidney Transplantation Committee’s proposal to include living donors and donor chains in the Kidney Paired Donation Pilot Program. (Item 3, Page 6)."

Here it is:

"3. Proposal to include non-directed living donors and donor chains in the Kidney Paired Donation Pilot Program.

Currently, the Kidney Paired Donation (KPD) Pilot Program only allows living donors with incompatible potential recipients to participate. Non-directed (or altruistic) living donors (those who are not linked to an incompatible potential recipient) have no way to enter the program. Also, candidate / donor pairs can only be matched in groups of two or three, and all donor nephrectomies in the group must occur simultaneously. This proposal would allow non-directed living donors to participate in the KPD Pilot Program and add donor chains as an option in the system. A donor chain occurs when a non-directed living donor gives a kidney to a recipient whose living donor in turn gives a kidney to another recipient and continues the chain. This proposal would allow two types of donor chains: open and closed. Closed chains start with a non-directed living donor and end with a donation to a recipient on the deceased donor waiting list. Open chains start with a non-directed living donor and end with a bridge donor who will start another segment in the open chain. In open chains, the
bridge donor nephrectomy does not occur at the same time as the other living donor nephrectomies. Donor chains have the potential to increase the number of transplants in a KPD system.
The Committee used the scorecard to assess this policy, and the proposal received an overall score of 23.5. The proposal received average score of greater than 2.3 in every category except patient safety and oversight, geographical equity, and operational effectiveness.
The Committee unanimously supported this proposal by a vote of 9 in favor, 0 opposed, and 0 abstentions."

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

An economist's perspective on transplantation--in Transplantation (the journal)

I have a paper in the latest issue of the journal Transplantation, discussing some approaches to current challenges facing transplantation.

I discuss ways to extend kidney exchange by initiating nondirected donor chains with some deceased donor organs, and by developing  international kidney exchange (along the lines of what Mike Rees calls  reverse transplant tourism). Reducing barriers to participation by transplant centers would also help (e.g removing financial barriers with some kind of standard acquisition fee) and removing barriers for enrolling easy to match pairs, including compatible pairs.  I also discuss ways to increase deceased donor registration, including priorities for donors, and providing other kinds of incentive for donation.

Roth, Alvin E., “Transplantation: One Economist’s Perspective,” Transplantation, February 2015, 99, 2, 261–264

(this link will only get you to the first page; )

Here are some relevant passages from the rest of the paper:

"Extending the reach of kidney exchange

"One way to make kidney exchange accessible to more patients would be to simplify participation. Developing a standard acquisition charge for living donor kidneys  would remove some barriers that arise e.g. from different costs of nephrectomies at hospitals that may need to ship each other kidneys. And matching algorithms could be adjusted to guarantee hospitals that they and their patients won’t lose transplants or sacrifice patient care if they enroll all pairs in exchange (and not just hard-to-match pairs).17 Enrolling easy-to-match pairs, including compatible pairs, can be organized to help those pairs find better matches, and also makes it much easier to find matches for hard-to-match pairs.9, ,  Incentives for transplant centers to enroll their non-directed donors are already being implemented (a chain typically is terminated with a patient on the waiting list of a center that enrolled a non-directed donor).

"Another way to accomplish more transplants through exchange would be to allow some non-directed donor chains to be initiated with deceased donor kidneys1 which, properly organized, could facilitate more transplants and shorten the wait for deceased donor kidneys for all patients.

"Kidney exchange in the developed world could also be extended to patient-donor pairs from countries in which treatment for ESRD is essentially unavailable for large parts of the population.  Such patient-donor pairs could, for example, be invited to come to the U.S. to participate in kidney exchange , financed by the American taxpayer from the savings that result from removing an American from dialysis through receiving a transplant, which are more than sufficient to finance the additional surgeries.  (The bureaucratic obstacles to such exchanges and financial arrangements will be formidable, but the potential to aid both domestic and foreign patients is substantial.)

How else to increase donation?

"There remain many avenues other than kidney exchange through which the shortage of transplantable organs might be reduced.

"In the U.S., the scope for recovering many more transplantable organs from deceased donors seems somewhat limited for most organs, given current technology and recovery rates. But there is suggestive evidence that more frequent opportunities to register as a deceased donor would increase registration, and that the manner in which registration is solicited can influence rates of family consent for donation.

"There is growing consensus that donors should not face financial disincentives from donating, ,  and recent evidence that the costs borne by living donors are substantial enough to reduce donation in recessions. ,  There is consequently great interest in exploring ways to remove disincentives or provide inducements for donation.

"Several novel features of recent Israeli legislation are worth study.  Deceased donation is encouraged by giving registered donors and next-of-kin of deceased donors some priority to receive deceased donor organs. Living kidney donors are also reimbursed 40 days wages, at their own wage rate, to offset the costs of donation. Initial indications are that the new Israeli law is increasing donation.

"The most contentious part of the discussion of how to increase donation concerns cash compensation to donors, particularly living kidney donors. With the prominent exception of Iran, which specifically permits cash payments for kidneys , there does not appear to be a legal market for the purchase and sale of organs for transplant anywhere else, although illegal black markets are widely reported, and occasionally prosecuted.

"However the critical shortage of transplantable organs around the world prompts continual discussion of whether to relax the ban on cash compensation. For example, the March 2014 issue of the Journal of Medical Ethics devoted five articles to the subject, all by philosophers. While this discussion is too important to be left only to philosophers, neither can it be confined to the ongoing debate among transplant professionals, given the public resources devoted to transplantation and the important implications transplantation has for health policy.

"The arguments, pro and con, will already be largely familiar to those who follow this debate.  I will simply try to add some context to the discussion by noting that the ban on organ sales is not unique: other kinds of markets have also been banned in the past, and presently, and laws have changed over time.

"Of course, banning markets does not always end them: black markets for narcotics make clear that outlawing markets is simpler than abolishing them. In the United States, the manufacture and sale of alcoholic beverages was illegal from 1920 to 1933, during which time black markets for alcohol thrived. Less familiarly, an 1824 editorial in The Lancet comments on the black market in which medical schools bought cadavers for dissection from grave robbers, known as “resurrection men,” because the only cadavers that could legally be dissected were from executed murderers.  (The Anatomy Act of 1832 expanded the sources of legal cadavers for dissection in Britain.)

"Let’s call a transaction repugnant if some people want to engage in it, and others, who aren’t materially affected, don’t think they should be allowed to .

"By this definition, sales of kidneys are widely repugnant, as are (or were) the sale of narcotics, alcohol, and cadavers. But note that the ban on kidney sales is different from these other bans, since there is, or was, general disapproval of narcotics, alcohol, and dissection. But there is no similar disapproval of kidney donation and transplantation; it is only sales that are repugnant.

"This turns out not to be too unusual: a transaction that is not otherwise repugnant sometimes becomes so when money is added to the mix. For example, charging interest on loans was largely banned in medieval Europe, although loans were permitted. (The relaxation of that ban has had profound effects on the modern economy.)  Note that repugnance doesn’t only change in one direction—some transactions that used not to be repugnant are widely banned today. Indentured servitude, for example, is no longer legal in the U.S., although it was once a common way of purchasing passage across the Atlantic.41

"Some transactions are banned in some places and not others, e.g. those concerning sale of blood and blood products, and reproductive goods and services such as sperm, eggs, and surrogacy. Legal markets in some places and not others give rise to “fertility tourism,” and many countries that ban payment for blood plasma import plasma products from the U.S., where such payments are legal.

"The repugnance to kidney sales involves concerns about the identity and welfare of potential sellers. The same concerns cause many proposals for allowing some forms of compensation to address the need to avoid exploiting the poor and vulnerable, as existing black markets for kidneys are widely seen to do.  The debate on how to proceed seems likely to focus on removing disincentives to donate and providing incentives that are not seen as leading to coercive or exploitative situations. The debate can be furthered by identifying specific sources of repugnance, and considering how inducements could be structured to avoid them. , ,

"In the meantime, kidney exchange has proved to be a way of bringing some of the benefits of exchange to transplantation without running into the barrier of repugnance. So it seems promising to consider ways of extending its reach, as discussed above."

Deceased donor kidney exchange chain in Italy (and some Italian kidney politics)

First, some excellent transplant news from Italy: A deceased donor kidney exchange transplant chain has been conducted there. Here's some of the (English language) press release.

PRESS RELEASE

ITALIAN NATIONAL TRANSPLANT CENTRE

THE FIRST CROSSOVER TRANSPLANT CHAIN TRIGGERED BY A CADAVERIC DONOR WAS LAUNCHED YESTERDAY IN ITALY

"On March 14th, for the first time in the world, the first live kidney transplantation chain between incompatible donor-recipient pairs (the so-called "cross over" program) triggered by a deceased donor was successfully launched in Italy.

 ....

The complex study phase for implementing the program, presented by Dr. Lucrezia Furian, member of the kidney transplant team of Padua University hospital, during the General Meeting of the Transplant Network, requested a careful retrospective evaluation of the data related to incompatible donors-recipient couples, a scrupulous analysis of the aspects related to efficacy, ethical and logistical problems and the development of algorithms for optimization of crossover chains. This study was conducted as part of an interdisciplinary research project funded by the University of Padua which involved, together with the transplant center team, researchers from the Department of Economics and Business Sciences and the Padua University Mathematics Department, led by Prof. Antonio Nicolò, scientific director of the research project. "

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Antonio Nicolò, Professor of Economics at the University of Padua, has written about kidney exchange.

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Here are some of my earlier posts about starting kidney exchange chains with deceased donors:

Tuesday, June 14, 2016

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

Thursday, February 11, 2016

Using deceased donor kidneys to start some kidney exchange chains

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The announcement also drew from the depths some curious parts of transplant politics in Italy (and in Europe more generally), where Global Kidney Exchange (GKE) has received both strong support, and organized opposition.
Here's an article from Corriere Della Sera (MARCH 16, 2018), which quotes the director of the Italian National Transplant Center as celebrating that the chain did not benefit any patient-donor pairs from poor countries, as in the proposal for GKE, which he condemns. In particular, he attacks one of the transplant surgeons involved in GKE, Ignazio Marino, a former Mayor of Rome.

This led to the following reply (in Italian, of which I am a coauthor:)

Here's the google translate of our letter:
"On 16/3 the Corriere described the transplant a Padova of a kidney taken from one deceased person for a patient who he had the wife's willingness to donate the organ but could not do it being incompatible from the immune point of view.
The lady then donated one kidney to another patient, thus helping another person. Congratulations to the living donor and to the family of the deceased donor: they are the real heroes of transplant surgery. They go also praised the doctors who performed the interventions. We must however rectify several incorrect information. It is important that the team by Paolo Rigotti has turned into reality an idea, but it is not true what the Corriere and, apparently also the Head of the National Transplant Center, that "so far nobody had thought of it". The concept was known to the whole scientific world since 2016 because published, by two signatories of this letter, on the American Journal of Transplantation. It is not even true that there are no algorithms or studies.
They have existed for years and on their basis one of the signatories of this letter received in 2012 the Nobel Prize. It is also false as written that "in the US the hypothesis among the polemics is the recourse to living Filipino donors who in exchange could take advantage of a transplant free for the sick relative ». And then defamatory to affirm that "ours surgeon Ignazio Marino "(our of whom?) would support this practice. It is true instead that there is a project (Global Kidney Exchange) that in the US has not seen any conflict, but the endorsement, in 2017, of the American Society for Transplant Surgeons, the society which brings together all the transplant surgeons. Furthermore, on January 22, 2018, the President of the Istituto Superiore di Sanità, Prof. Walter Ricciardi, in his role as a member of the Executive Board of the Organization World Health Organization has promoted this idea which has since been viewed on the WHO website. Is an idea born from the desire to help the the largest possible number of patients. In practice, if one of us wanted to give a kidney a a loved one, but can not because he has a blood group B, and the person who loves needs a kidney from a donor with a blood group A, that transplant impossible can be achieved because in there are two others in the world people who love each other and have groups opposing blood. Making them meet yes they can transplant patients otherwise they will not transplantable. This is what we illustrated in Rome, in a conference promoted by the Italian NIH, January 15, 2018. Yes it is a revolutionary project if one thinks that only in sub-Saharan Africa every year about 5 million people die because they have no access to hemodialysis or to kidney transplantation.
Ignazio R. Marino Professor of Surgery,
Jefferson University
Cataldo Doria Professor of Surgery,
Jefferson University
Michael Rees, Professor of Urology,
University of Toledo
Alvin E. Roth Professor of Economics, University
of Stanford and Harvard, Nobel Economics 2012
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And here are some previous blog posts relating to kidney exchange politics in Italy, as discussed in the letter.

Monday, January 29, 2018

Italy recommends Global Kidney Exchange to the World Health Organization

Monday, January 22, 2018

Pursuing Global Kidney Exchange in Rome: photos

A non-simultaneous liver exchange chain at UCSF, and a brief history of liver exchange

 Living donor liver transplants are relatively uncommon in North America compared to Asia.  Liver exchange might help change that. Here are some reports of recent and not so recent liver exchanges, including a non-simultaneous exchange chain  at UCSF, and a simultaneous chain in Canada.  Expect more in the near future.

 (Non-simultaneous chains have become the backbone of kidney exchange in the U.S., so we may start to see longer chains of liver exchange as well.)

Here's the most recent report of a short non-directed donor chain:

Expanding living donor liver transplantation: Report of first US living donor liver transplant chain  by Hillary J. Braun  Ana M. Torres  Finesse Louie  Sandra D. Weinberg  Sang‐Mo Kang  Nancy L. Ascher  John P. Roberts, American Journal of Transplantation, First published: 10 November 2020 https://doi.org/10.1111/ajt.16396

Abstract: "Living donor liver transplantation (LDLT) enjoys widespread use in Asia, but remains limited to a handful of centers in North America and comprises only 5% of liver transplants performed in the United States. In contrast, living donor kidney transplantation is used frequently in the United States, and has evolved to commonly include paired exchanges, particularly for ABO‐incompatible pairs. Liver paired exchange (LPE) has been utilized in Asia, and was recently reported in Canada; here we report the first LPE performed in the United States, and the first LPE to be performed on consecutive days. The LPE performed at our institution was initiated by a nondirected donor who enabled the exchange for an ABO‐incompatible pair, and the final recipient was selected from our deceased donor waitlist. The exchange was performed over the course of 2 consecutive days, and relied on the use and compliance of a bridge donor. Here, we show that LPE is feasible at centers with significant LDLT experience and affords an opportunity to expand LDLT in cases of ABO incompatibility or when nondirected donors arise. To our knowledge, this represents the first exchange of its kind in the United States."

The paper says this about the timing of the surgeries:

"Other centers reporting LPE have performed the donor and recipient operations in four operating rooms simultaneously4, 5 which can be logistically challenging, but addresses concerns regarding simultaneity and equalizing risk. In our case, we performed the operations on sequential days. In doing so, we accepted the risk that, given a good outcome in Recipient 1 on the first day, Donor 2 (the “bridge” donor) might opt out of living donation at the last moment. Reappropriating terminology from the kidney paired exchange (KPE) literature, a bridge donor is defined as someone who donates more than 1 day after their intended recipient received a transplant.12 A recent paper discussing the feasibility of LPE in the United States emphasized that, in the early days of KPE, there was concern that the bridge donor might back out at the last minute and break the chain.13 As a result, kidney donor operations were initially attempted simultaneously. However, a 2018 review of 344 KPE chains between 2008 and 2016 revealed that only 5.6% of bridge donors broke the chain and the majority of these donors developed a medical issue during their time as a bridge donor that prohibited them from completing donation.12 Ultimately, because this occurrence was so infrequent, the authors concluded that simultaneous donor operating rooms for chains are unnecessary and may actually deter potential donors based on logistical issues. "

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And here's a report from Canada of a non-directed donor chain of liver exchange with all surgeries conducted simultaneously (also with the NDD donating to an incompatible patient-donor pair whose donor donated to a patient on the deceased donor waiting list).

Living donor liver paired exchange: A North American first  by Madhukar S. Patel  Zubaida Mohamed  Anand Ghanekar  Gonzalo Sapisochin  Ian McGilvray  Blayne A. Sayed  Trevor Reichman  Markus Selzner  Jed A. Gross  Zita Galvin  Mamatha Bhat  Les Lilly  Mark Cattral  Nazia Selzner, American Journal of Transplantation, First published: 10 June 2020 https://doi.org/10.1111/ajt.16137 

Abstract: Paired organ exchange can be used to circumvent living donor‐recipient ABO incompatibilities. Herein, we present the first case of successful liver paired exchange in North America. This 2‐way swap required 4 simultaneous operations: 2 living donor hepatectomies and 2 living donor liver transplants. A nondirected anonymous living donor gift initiated this domino exchange, alleviating an ABO incompatibility in the other donor‐recipient pair. With careful attention to ethical and logistical issues, paired liver exchange is a feasible option to expand the donor pool for incompatible living liver donor‐recipient pairs.

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Here's a 2014 report from S. Korea:

Section 16. Update on Experience in Paired-Exchange Donors in Living Donor Liver Transplantation For Adult Patients at ASAN Medical Center by  Jung, Dong-Hwan1; Hwang, Shin1; Ahn, Chul-Soo1; Kim, Ki-Hun1; Moon, Deok-Bog1; Ha, Tae-Yong1; Song, Gi-Won1; Park, Gil-Chun1; Lee, Sung-Gyu, Transplantation: April 27, 2014 - Volume 97 - Issue - p S66-S69, doi: 10.1097/01.tp.0000446280.81922.bb

"Between January 2003 and December 2011, approximately 2,182 adult LDLT cases were included in this study. During this period, 26 paired-exchange donor LDLT cases were performed (1.2%).

"Results: Of the 26 paired-exchange donor LDLT cases, 22 pairs were matched due to ABO-incompatibility, and 4 pairs were matched because of cascade allocation of unrelated donors or relatively small graft volume to the recipients. A total of 28 living donors were included in the 26 paired-exchange donor LDLT cases because of inclusion of two dual-graft transplants. Elective surgery was performed in 22 cases, and urgent operation was performed in 4 cases. The overall 1-year and 5-year patient and graft survivals were both 96.2% and 90.1%, respectively.

"Conclusions : Our experience suggests that the paired-exchange donor program for adult LDLT seems to be a feasible modality to overcome donor ABO incompatibility."

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Here's a story of a liver exchange in Texas, between an incompatible pair and a compatible pair.

Saturday, December 28, 2019 A liver exchange in San Antonio, Texas

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Here's a liver exchange in Hong Kong between an incompatible pair and a compatible pair.

Friday, April 4, 2014 An unusual liver exchange in Hong Kong

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Here's a report from two major liver transplant centers in Hong Kong and S. Korea. The Korean team reported 16 donor exchanges conducted over a 6-year period.

Friday, April 9, 2010 Liver exchange

Global Kidney Chains in PNAS by Nikzad, Akbapour, Rees and Roth

 Here's an article about extending kidney exchange globally. It's published as an open access article, so you can find the whole paper at the link.

Global kidney chains, by Afshin Nikzad, Mohammad Akbarpour, Michael A. Rees, and  Alvin E. Roth, PNAS September 7, 2021 118 (36) e2106652118; https://doi.org/10.1073/pnas.2106652118

Significance: Kidney failure is among the leading causes of death worldwide, and the best treatment is transplantation. However, transplants are in short supply because of shortfalls of transplantable organs and of finances. In the United States and some other countries, kidney exchange chains have emerged as a way to increase the number of transplants; patients who have a willing donor but cannot receive that donor’s kidney can each receive a compatible kidney from another patient’s intended donor. Such programs are much better developed within the borders of wealthy countries, which is of little help to patients in countries with limited kidney transplantation or exchange. This paper proposes and analyzes a way to extend kidney exchange chains to share the benefits globally.

Abstract: Kidney failure is a worldwide scourge, made more lethal by the shortage of transplants. We propose a way to organize kidney exchange chains internationally between middle-income countries with financial barriers to transplantation and high-income countries with many hard to match patients and patient–donor pairs facing lengthy dialysis. The proposal involves chains of exchange that begin in the middle-income country and end in the high-income country. We also propose a way of financing such chains using savings to US health care payers.

...

"Concluding Remarks: Since the beginning of the twenty-first century, kidney exchange at scale has developed from a largely academic idea initially implemented at a small scale (5, 37) to a standard mode of transplantation in the United States (with well over 1,000 exchange transplants in 2019) and in several other countries. This has been an important development, with many milestones along the way including, crucially, developments in the design and implementation of kidney exchange chains. However, these accomplishments have been victories in a war that we are losing. At the turn of the century, there were in the neighborhood of 40,000 patients on the US waitlist for deceased donor organs, and today, there are close to 100,000.‡‡ The situation is similar elsewhere in the wealthy world. Over the same period, there has been a growth of kidney disease as a cause of death around the world (as developing countries have made progress in combating infectious disease), and there have begun to be high-quality transplant centers in middle-income as well as in rich countries, which nevertheless face obstacles—including important financial obstacles—to increasing the number of transplants they are able to deliver.§§

"Before the development of kidney exchange, the organization of transplantation developed largely within the national boundaries of wealthy countries. It was primarily focused on deceased donor transplants, and the scarcity of organs meant that the concentration of effort within single countries did not have a large impact on the total number of transplants achieved. (There are well-established efforts to share deceased donor kidneys across national borders in limited circumstances.) With the growth of kidney exchange, there are now some preliminary explorations of coordinating across borders between countries with existing kidney exchange programs, primarily concentrating on looking for exchanges between hard to match pairs who have been left unmatched in the within-country kidney exchange. GKE opens up this possibility to a much larger part of the world, including countries in which unmatched patient–donor pairs may have had financial rather than immunological barriers, and so, may be easier to match with hard to match pairs. Additionally, because kidney exchange chains have amplified kidney exchange wherever they have been implemented, global exchange chains offer a way to bring these advantages to a much larger group of patients and donors.¶¶

"While Medicare aims to insure all Americans against kidney disease, the same cost savings described here could be employed to fund care for foreign patients who are uninsured, including those who are undocumented immigrants who may not have entered the country legally (but may nevertheless be long-term residents).##

"Notice that if an international exchange works perfectly—i.e., when all of the patients and donors involved have successful surgeries, have excellent follow-up care, and are restored to active, long-lasting good health—then it will be easy to see the exchange as just another example of the success of standard kidney exchange in which all patients are from the same country. However, if the pair from the developing country was to return home and have bad health outcomes, it would look a lot like badly arranged black market transactions, which are justly condemned. So, to make kidney exchange work between developed and developing countries, exceptional care will have to be delivered to the developing country donors and patients, particularly since patients in poor countries—like their compatriots who have never suffered from kidney disease—can be expected to have somewhat worse health outcomes than otherwise comparable people in rich countries, no matter what efforts are made to give them the best possible postoperative care. International exchange may also require increased vigilance, compared with domestic exchange, to ensure that donors are not coerced or otherwise exploited. Consequently, the first element of a successful design for GKC is the choice of reliable international partners able to provide excellent care for patients and donors, both prospectively and postoperatively.

"The other three design elements proposed and explored in this paper involve starting a chain in a foreign country and having a bridge donor continue it in the United States; using a LIFO queue policy on the pool of patients assembled by, for example, a coalition of self-insured companies responsible for paying for their care; and having those savings finance the otherwise unfunded additional costs (compared with an entirely domestic chain) in both countries. As we have shown, such a program could operate at a significant scale, comparable with the number of domestic patients presently beginning lengthy dialysis annually. GKCs thus appear to present a scalable approach to cross-border kidney exchange and to increasing the availability of transplantation globally. They have the potential to become at least a first step toward providing a global solution to the global problem of kidney failure."

 

Transplantation rates for patients in non-profit versus for-profit dialysis centers

From JAMA,September 10, 2019  Volume 322, Number 10:
J::AMA
September 10, 2019 Volume 322, Number 10Association Between Dialysis Facility Ownership and Accessto Kidney Transplantation

Jennifer C. Gander, PhD; Xingyu Zhang, PhD; Katherine Ross, MPH; Adam S. Wilk, PhD; Laura McPherson, MPH; Teri Browne, PhD;Stephen O. Pastan, MD; Elizabeth Walker, MS; Zhensheng Wang, PhD; Rachel E. Patzer, PhD, MPH

"MAIN OUTCOMES AND MEASURES: Access to kidney transplantation was defined as time from initiation of dialysis to placement on the deceased donor kidney transplantation waiting list,receipt of a living donor kidney transplant, or receipt of a deceased donor kidney transplant.Cumulative incidence differences and multivariable Cox models assessed the associationbetween dialysis facility ownership and each outcome.
RESULTS: Among 1 478 564 patients, the median age was 66 years (interquartile range, 55-76years), with 55.3% male, and 28.1% non-Hispanic black patients. Eighty-seven percent ofpatients received care at a for-profit dialysis facility. A total of 109 030 patients (7.4%)received care at 435 nonprofit small chain facilities; 78 287 (5.3%) at 324 nonprofitindependent facilities; 483 988 (32.7%) at 2239 facilities of large for-profit chain 1; 482 689(32.6%) at 2082 facilities of large for-profit chain 2; 225 890 (15.3%) at 997 for-profit smallchain facilities; and 98 680 (6.7%) at 434 for-profit independent facilities. During the studyperiod, 121 680 patients (8.2%) were placed on the deceased donor waiting list, 23 762 (1.6%)received a living donor kidney transplant, and 49 290 (3.3%) received a deceased donorkidney transplant. For-profit facilities had lower 5-year cumulative incidence differences foreach outcome vs nonprofit facilities (deceased donor waiting list: −13.2% [95% CI, −13.4% to−13.0%]; receipt of a living donor kidney transplant: −2.3% [95% CI, −2.4% to −2.3%]; andreceipt of a deceased donor kidney transplant: −4.3% [95% CI, −4.4% to −4.2%]). AdjustedCox analyses showed lower relative rates for each outcome among patients treated at allfor-profit vs all nonprofit dialysis facilities: deceased donor waiting list (hazard ratio [HR], 0.36[95% CI, 0.35 to 0.36]); receipt of a living donor kidney transplant (HR, 0.52 [95% CI, 0.51 to0.54]); and receipt of a deceased donor kidney transplant (HR, 0.44 [95% CI, 0.44 to 0.45]).
CONCLUSIONS AND RELEVANCE: Among US patients with end-stage kidney disease, receiving dialysis at for-profit facilities compared with nonprofit facilities was associated with a lower likelihood of accessing kidney transplantation. Further research is needed to understand the mechanisms behind this association.

Here are the figures. "For-profit large chains" seem to give the slowest access to being put on the transplant waiting list, receiving a living donation, or receiving a deceased donation.

HT: Irene Wapnir

Living Liver and Kidney Donation

The American Journal of Transplantation has assembled a "virtual issue" of articles they have published on various aspects of live donation, including kidney exchange. It seems to be ungated.

Living Liver and Kidney Donation

Guest Editor: Dr. Jonathan Bromberg
"This virtual issue of the American Journal of Transplantation is focused on living donation. For practical purposes, the articles are restricted to only liver and kidney donation. It would not be an overstatement to say that donation has probably been the number one issue to dominate the field for the last decade, as organ quality and availability determine all activities in transplantation. The breadth of importance and ramifications of donation are reflected in the wide variety of articles and topics that cover this area of interest. Novel sources of donors, such as altruistic, anonymous, and non-directed donation among others are covered in the first section. While considered even unusual a few years ago, many of these sources are now firmly partly of the mainstream of living donation. Exchanges, swaps, chains, and dominos are included in the second section, reflecting the evolution of the field as ever more complex donor and recipient algorithms are implemented, and their attendant ramifications on quality, cost, and outcomes. The third section covers organ utilization and outcomes, with an emphasis on matching the optimal donor with the correct recipient, and comparing deceased to living donor organs. The fourth section covers regulatory issues at the national and local levels, and their influence on donation and outcomes. The fifth section comprises issues relating to the donor and donor safety. The work-up process, safeguards, operative techniques, short term outcomes, and very long term outcomes are major issues the have dominated recent trends. The sixth and last section covers educational issues as they related to donor and family knowledge and attitudes toward donation, and that affects donation rates. These reports should provide the reader with a comprehensive view of issues in living liver and kidney donation, and the diverse paths taken that have moved the field forward."

Novel Donor Sources:
Twenty-Two Nondirected Kidney Donors: An Update on a Single Center's ExperienceC. L. Jacobs, D. Roman, C. Garvey, J. Kahn, A. J. Matas
Altruistic Living Donors: Evaluation for Nondirected Kidney or Liver DonationM.D. Jendrisak, B. Hong, S. Shenoy, J. Lowell, N. Desai, W. Chapman, A. Vijayan, R.D. Wetzel, M. Smith, J. Wagner, S. Brennan, D. Brockmeier, D. Kappel
Living Anonymous Liver Donation: Case Report and Ethical JustificationL. Wright, K. Ross, S. Abbey, G. Levy, D. Grant
Successful Expansion of the Living Donor Pool by Alternative Living Donation ProgramsJ. I. Roodnat, J. A. Kal-van Gestel, W. Zuidema, M. A. A. van Noord, J. van de Wetering, J. N. M. IJzermans, W. Weimar
Elective Surgical Patients as Living Organ Donors: A Clinical and Ethical InnovationG. Testa, P. Angelos, M. Crowley-Matoka, M. Siegler
Kidney Donor Exchanges, Chains, and Dominos:
A Comparison of Populations Served by Kidney Paired Donation and List Paired DonationS. E. Gentry, D. L. Segev, R. A. Montgomery
The Dutch National Living Donor Kidney Exchange ProgramM. de Klerk, K. M. Keizer, F. H. J. Claas, M. Witvliet, B. J. J. M. Haase-Kromwijk, W. Weimar
Characterization of Waiting Times in a Simulation of Kidney Paired DonationD. L. Segev, S. E. Gentry, J. K. Melancon, R. A. Montgomery
Attitudes of Minority Patients with End-Stage Renal Disease Regarding ABO-Incompatible List-Paired ExchangesP. D. Ackerman, J. R. Thistlethwaite Jr, L. F. Ross
Incompatible Kidney Donor Candidates' Willingness to Participate in Donor-Exchange and Non-directed DonationA. D. Waterman, E. A. Schenk, A. C. Barrett, B. M. Waterman, J. R. Rodrigue, E. S. Woodle, S. Shenoy, M. Jendrisak, M. Schnitzler
Utilizing List Exchange and Nondirected Donation through 'Chain' Paired Kidney DonationsA. E. Roth, T. Sönmez, M. U. Ünver, F. L. Delmonico, S. L. Saidman
Expanding Kidney Paired Donation Through Participation by Compatible PairsS. E. Gentry, D. L. Segev, M. Simmerling, R. A. Montgomery
Successful Three-Way Kidney Paired Donation with Cross-Country Live Donor Allograft TransportR. A. Montgomery, S. Katznelson, W. I. Bry, A. A. Zachary, J. Houp, J. M. Hiller, S. Shridharani, D. John, A. L. Singer, D. L. Segev
The Roles of Dominos and Nonsimultaneous Chains in Kidney Paired DonationS. E. Gentry, R. A. Montgomery, B. J. Swihart, D. L. Segev
Asynchronous, Out-of-Sequence, Transcontinental Chain Kidney Transplantation: A Novel ConceptF. K. Butt, H. A. Gritsch, P. Schulam, G. M. Danovitch, A. Wilkinson, J. Del Pizzo, S. Kapur, D. Serur, S. Katznelson, S. Busque, M. L. Melcher, S. McGuire, M. Charlton, G. Hil, J. L. Veale
Clinical Outcomes of Multicenter Domino Kidney Paired DonationY. J. Lee, S. U. Lee, S. Y. Chung, B. H. Cho, J. Y. Kwak, C. M. Kang, J. T. Park, D. J. Han, D. J. Kim
Organ Utilization and Outcomes:
Living-Donor Liver Transplantation for HepatoblastomaM. Kasahara, M. Ueda, H. Haga, H. Hiramatsu, M. Kobayashi, S. Adachi, S. Sakamoto, F. Oike, H. Egawa, Y. Takada, K. Tanaka
Living Donor Liver Transplantation for Biliary Atresia: A Single-Center Experience with First 100 CasesC.-L. Chen, A. Concejero, C.-C. Wang, S.-H. Wang, C.-C. Lin, Y.-W. Liu, C.-C. Yong, C.-H. Yang, T.-S. Lin, Y.-C. Chiang, B. Jawan, T.-L. Huang, Y.-F. Cheng, H.-L. Eng
Association Between Waiting Times for Kidney Transplantation and Rates of Live DonationD. L. Segev, S. E. Gentry, R. A. Montgomery
Regional and Racial Disparities in the Use of Live Non-Directed Kidney DonorsD. L. Segev, R. A. Montgomery
Recipient Morbidity After Living and Deceased Donor Liver Tranasplantation: Findings from the A2ALL Retrospective Cohort StudyC. E. Freise, B. W. Gillespie, A. J. Koffron, A. S. F. Lok, T. L. Pruett, J. C. Emond, J. H. Fair, R. A. Fisher, K. M. Olthoff, J. F. Trotter, R. M. Ghobrial, J. E. Everhart
Incidence and Severity of Acute Cellular Rejection in Recipients Undergoing Adult Living Donor or Deceased Donor Liver TransplantationA. Shaked, R. M. Ghobrial, R. M. Merion, T. H. Shearon, J. C. Emond, J. H. Fair, R. A. Fisher, L. M. Kulik, T. L. Pruett, N. A. Terrault
Resource Utilization of Living Donor Versus Deceased Donor Liver Transplantation Is Similar at an Experienced Transplant CenterJ. C. Lai, E. M. Pichardo, J. C. Emond, R. S. Brown Jr.
Organ Donation and Utilization in the United States: 1998–2007J. E. Tuttle-Newhall, S. M. Krishnan, M. F. Levy, V. McBride, J. P. Orlowski, R. S. Sung
Unique Early Gene Expression Patterns in Human Adult-to-Adult Living Donor Liver Grafts Compared to Deceased Donor GraftsJ. de Jonge, S. Kurian, A. Shaked, K. R. Reddy, W. Hancock, D. R. Salomon, K. M. Olthoff
Regulatory:
Incentive Models to Increase Living Kidney Donation: Encouraging Without CoercingA. K. Israni, S. D. Halpern, S. Zink, S. A. Sidhwani, A. Caplan
Limiting Financial Disincentives in Live Organ Donation: A Rational Solution to the Kidney ShortageR. S. Gaston, G. M. Danovitch, R. A. Epstein, J. P. Kahn, A. J. Matas, M. A. Schnitzler
Public Attitudes Toward Incentives for Organ Donation: A National Study of Different Racial/Ethnic and Income GroupsL. E. Boulware, M. U. Troll, N. Y. Wang, N. R. Powe
The Association of State and National Legislation with Living Kidney Donation Rates in the United States: A National StudyL. E. Boulware, M. U. Troll, L. C. Plantinga, N. R. Powe
The Evolution and Direction of OPTN Oversight of Live Organ Donation and Transplantation in the United StatesR. S. Brown, Jr, R. Higgins, T. L Pruett
Stimulus for Organ Donation: A Survey of the American Society of Transplant Surgeons MembershipJ. R. Rodrigue, K. Crist, J. P. Roberts, R. B. Freeman Jr., R. M. Merion, A. I. Reed
Donor Procedures, Outcomes and Safety:
Obesity in Living Kidney Donors: Clinical Characteristics and Outcomes in the Era of Laparoscopic Donor NephrectomyJ. K. Heimbach, S. J. Taler, M. Prieto, F. G. Cosio, S. C. Textor, Y. C. Kudva, G. K. Chow, M. B. Ishitani, T. S. Larson, M. D. Stegall
Laparoscopic Procurement of Kidneys with Multiple Renal Arteries is Associated with Increased Ureteral Complications in the RecipientJ. T. Carter, C. E. Freise, R. A. McTaggart, H. D. Mahanty, S.M. Kang, S. H. Chan, S. Feng, J. P. Roberts, A. M. Posselt
Pre-donation Assessment of Kidneys by Magnetic Resonance Angiography and Venography: Accuracy and Impact on OutcomesS. A. Ames, M. Krol, K. Nettar, J. P. Goldman, T. M. Quinn, D. M. Herron, A. Pomp, J. S. Bromberg
Long-Term Consequences of Live Kidney Donation Follow-Up in 93% of Living Kidney Donors in a Single Transplant CenterJ. Gossmann, A. Wilhelm, H.G. Kachel, J. Jordan, U. Sann, H. Geiger, W. Kramer, E.H. Scheuermann
More on Parental Living Liver Donation for Children with Fulminant Hepatic Failure: Addressing Concerns About Competing Interests, Coercion, Consent and Balancing ActsA. Spital
Predictive Capacity of Pre-Donation GFR and Renal Reserve Capacity for Donor Renal Function After Living Kidney DonationM. Rook, H. S. Hofker, W. J. van Son, J. J. Homan van der Heide, R. J. Ploeg, G. J. Navis
Laparoscopic-Assisted Right Lobe Donor HepatectomyA.J. Koffron, R. Kung, T. Baker, J. Fryer, L. Clark, M. Abecassis
Cold Ischemia Time and Allograft Outcomes in Live Donor Renal Transplantation: Is Live Donor Organ Transport Feasible?C. E. Simpkins, R. A. Montgomery, A. M. Hawxby, J. E. Locke, S. E. Gentry, D. S. Warren, D. L. Segev
Evaluating Living Kidney Donors: Relationship Types, Psychosocial Criteria, and Consent Processes at US Transplant ProgramsJ. R. Rodrigue, M. Pavlakis, G. M. Danovitch, S. R. Johnson, S. J. Karp, K. Khwaja, D. W. Hanto, D. A. Mandelbrot
The Medical Evaluation of Living Kidney Donors: A Survey of US Transplant CentersD. A. Mandelbrot, M. Pavlakis, G. M. Danovitch, S. R. Johnson, S. J. Karp, K. Khwaja, D. W. Hanto, J. R. Rodrigue
Rescue of a Living Donor with Liver TransplantationB. Ringe, G. Xiao, D. A. Sass, J. Karam, S. Shang, T. P. Maroney, A. E. Trebelev, S. Levison, A. C. Fuchs, R. Petrucci, A. Ko, M. Gonzalez, J. C. Reynolds, W. C. Meyers
Nephrectomy Elicits Impact of Age and BMI on Renal Hemodynamics: Lower Postdonation Reserve Capacity in Older or Overweight Kidney DonorsM. Rook, R. J. Bosma, W. J. van Son, H. S. Hofker, J. J. Homan van der Heide, P. M. ter Wee, R. J. Ploeg, G. J. Navis
Pregnancy and Birth After Kidney Donation: The Norwegian ExperienceA. V. Reisæter, J. Røislien, T. Henriksen, L. M. Irgens, A. Hartmann
Pregnancy Outcomes After Kidney DonationH. N. Ibrahim, S. K. Akkina, E. Leister, K. Gillingham, G. Cordner, H. Guo, R. Bailey, T. Rogers, A. J. Matas
Education:
Preferences, Knowledge, Communication and Patient-Physician Discussion of Living Kidney Transplantation in African American FamiliesL. E. Boulware, L. A. Meoni, N. E. Fink, R. S. Parekh, W. H. L. Kao, M. J. Klag, N. R. Powe
Organ Donation Decision: Comparison of Donor and Nondonor FamiliesJ. R. Rodrigue, D. L. Cornell, R. J. Howard
Increasing Live Donor Kidney Transplantation: A Randomized Controlled Trial of a Home-Based Educational InterventionJ. R. Rodrigue, D. L. Cornell, J. K. Lin, B. Kaplan, R. J. Howard
Emigration from the British Isles to Southeastern Spain: A Study of Attitudes Toward Organ DonationA. Ríos, P. Cascales, L. Martínez, J. Sánchez, N. Jarvis, P. Parrilla, P. Ramírez
Virtual Issue compiled online 2 Feb 2010

Podcast on kidney exchange at the PNAS

Science journalist Paul Gabrielsen interviews me about kidney exchange, and produced this (6 minute) podcast from our discussion.

Exchanging kidneys

Alvin Roth discusses how principles of economics can benefit people who need kidney transplants. Image ©iStockphoto/Eugene Kuklev.May 5, 2014 | Running Time: 6:10

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For those of you who prefer reading to listening, or who want to read along, here's the transcript (I always find it a little sobering to see the way I talk transcribed...):

Podcast Interview: Alvin Roth
PNAS: I’m your host, Paul Gabrielsen, and welcome to Science Sessions. Imagine that someone you love is one of the 99,000 people in the U.S. who need a potentially life-saving kidney transplant. You might gladly give them one of your kidneys to save their life, but if your kidney is incompatible with your loved one, the transplant cannot proceed. Will your loved one then have to wait for a deceased donor kidney to become available, and risk becoming one of more than
3,000 people every year who die while waiting for a transplant? Or is there another option? Alvin Roth, an economist at Stanford University, realized that many such pairs of incompatible patients and donors may exist, and that they may be able to help each other. I spoke with Roth, a member of the National Academy of Sciences, by phone to discuss how principles of economics can save the lives of people who need kidney transplants.

PNAS: So, what is the outlook like for someone who needs a kidney transplant?

Roth: Good question. So, the outlook is not so good. People live around 5 years on dialysis, I mean, there’s a lot of variance. Dialysis is no fun, and it’s not a great treatment. Over time it gets worse. So people on dialysis need transplants, and there aren’t enough organs. If you have a live donor that’s compatible with you, they might give you a kidney right away and you would be spared dialysis. So, if you didn’t have a living donor, you would just wait on the regional list for
deceased donor organs, which can be many years in length. And that’s where kidney exchange comes in. You could be in that situation, you love someone enough to give them a kidney, but they can’t take your kidney, and I’m in the same situation. But now, you could give a kidney to my patient and I can give a kidney to your patient, we’d have exchanged kidneys and arranged it so that each kidney patient could get a kidney that they were compatible with.

PNAS: And to that end, you helped found one of the first kidney exchange programs, the New England Program for Kidney Exchange, in 2004. So let's say I have a kidney that I'd like to donate and I sign up into one of these exchanges. Can you walk me through the process?

Roth: Okay, so that depends. One critical difference – when you say you have a kidney you’d like to donate, is whether or not you have an intended recipient.

PNAS: Let’s say I do.

Roth: Okay, so someone you love needs a kidney, you’re happy to give her a kidney, and you sign up together. So you guys now are an incompatible patient-donor pair, and you are entered into a database. And what the algorithm would look for, it would look for a combination of cycles and chains. So a simple cycle would just involve two pairs. But sometimes you can’t find simple pairs like that, and you might find yourself in a three-way exchange. So, you can give a kidney to someone in pair 2, the donor in pair 2 can give a kidney to someone in pair 3, and the donor in pair 3 can give a kidney to your intended recipient. That’s a three-way exchange. Now, we do those exchanges simultaneously, because you can’t write a contract on a kidney. So to do them simultaneously means that a three-way exchange requires six operating rooms and six surgical teams because there are three nephrectomies, operations to take the kidney out, and three transplants. Tha’s about as big as it’s practical to do an exchange. But there’s another way, and that’s because there are some donors who don’t have intended recipients, that’s why I asked you when you said you wanted to sign up. And they can start chains, because the exchange doesn’t have to come back to them, so they can give a kidney to someone, to some pair, and the donor in that pair can give a kidney to another pair, the donor in that pair can give a kidney to another pair. When we have one of these non-directed donor chains, we can do the exchanges non-simultaneously, and that allows the chains to become very long. So, the first non-directed donor chain had 20 people in it, because there were 10 nephrectomies and 10 transplants. Not
every chain is long. The important thing is the chains can be non-simultaneous.

PNAS: So, you’ve actually attended one of these nephrectomies in Cincinnati. Can you tell me what that experience was like and why you decided to go?

Roth: Well, so, I had gone there to give a seminar on kidney exchange, and as it happened, the day of my seminar, they were doing one of our exchanges. A surgeon named Steve Woodle said to me, why don’t you just come and watch, and I thought, what a great idea! And I was a little – I had some trepidation, I worried that I would feel ill or something, but it turns out it’s just so interesting to watch and to listen to them talk about what they’re doing that I didn’t have to worry about that. And the nephrectomy I saw is what’s called a hand-assisted laparoscopic
nephrectomy, and what that means is the surgeon is working through pretty small incisions, he’s working with a camera and a video screen, so you can watch, in detail, what he’s doing with his equipment, and he’s assisted by a surgeon who inserts his hand through a slightly larger incision, and the two of them work as a team, the surgeon doing the cutting asks the assistant to put tension on different tissues, and you see all this on a video screen. And finally, it’s like a magic trick, the kidney comes out in the surgeon’s hand.

PNAS: So, what is the future of kidney exchange?

Roth: For kidney exchange, we’re still doing lots of things on how to make the exchanges work better, and some of those have to do with how surgeries are organized, some of them have to do with how payments are organized. Eventually, I hope that in a hundred years, my grandchildren and yours will think of transplantation as an outdated barbarity, they’ll say to you, “So tell me again grandpa, you used to cut an organ out of one person and sew it into a sick person and that was modern medicine?” I hope that advances in medicine will eventually give a better solution. That doesn’t mean that we can ’t keep moving ahead now, because for the time being there are lots of people waiting on the waiting list, and many of them die while waiting.

PNAS: Thanks for listening. You can find more podcasts at pnas.org.
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This is from the collection of podcasts at the Proceeding of the National Academy of Sciences Science Sessions Podcasts

Welcome to Science Sessions, the PNAS podcast program. Listen to brief conversations with cutting-edge researchers, Academy members, and policy makers as they discuss topics relevant to today's scientific community. Learn the behind-the-scenes story of work published in PNAS, plus a broad range of scientific news about discoveries that affect the world around us.