Monthly Archives: October 2017

GKE Debate in The Latest Issue of the American Journal of Transplantation

I’ve blogged a few times before about Global Kidney Exchange (GKE, formerly called Reverse Transplant Tourism). See, for example here, here, and here. The October issue of the American Journal of Transplantation (AJT) contains a news report and six letters to the editor about GKE (3 are replies by us to pushback on our original article in the March 2017 issue). You can see Al Roth’s discussion of the issue here.

The report, written by Lara Pullen, is very well done and worth reading in full here to get a sense of the debate.

As noted in the Report:

In a recently published paper, Dr. Rees and his colleagues stressed the financial inaccessibility of dialysis for most low-income individuals.[1] With the GKE, recipients from developing countries not only receive a kidney, but also financial support to help them pay for the medical costs of maintaining their organ after they return to their home country. “Because the GKE involves exchange, it benefits both the foreign pairs and the domestic pairs. It’s a win for patients and the donors who love them in both countries,” says Alvin Roth, PhD, professor of economics at Stanford University in Palo Alto, California, and co-developer of the GKE.. . .

In an editorial and series of letters, transplantation surgeons throughout North America have raised objections to GKE.[2-4] Among the concerns is that staggering numbers of financially incompatible yet biologically compatible pairs would desire entrance into the program, and would likely overwhelm it. Opponents also contend that cultural differences in developing countries will make it difficult to definitively determine potential donors’ motivations. The risk, then, is one of exploiting individual citizens in developing countries, as well as undermining national KEs that may be in their early stages in these countries.

Some have also raised concerns that kidney paired donation (KPD) transplants would violate the current U.S. law that limits paired donation transplants to biologically incompatible donors, as opposed to financially incompatible donors. Dr. Rees and colleagues voiced their opinion on this in a recent paper.[5] [KDK-Mike Rees and I address the legality of GKE at great length here]

Thus GKE remains the subject of very strongly held opposing points of view.

As I’ve already noted in a prior post, some of these concerns are valid, but addressable by proceeding carefully with GKE. Others are simply, in my opinion, ridiculous. In any event, we respond to these criticisms in our responses and I plan to say more on this in further posts.

My co-author (not on GKE, but on another paper concerning Advanced Donation – see here), Marc Melcher, is quoted in the Report and is characteristically thoughtful:

Dr. Melcher acknowledges the importance of cultural differences and corruption. He also suggests that these factors are not unique to transplantation, and that any time a non-governmental organization (NGO) enters a developing country to provide aid, there is risk of corruption and unintended consequences. This risk, however, does not stop NGOs from stepping in and trying to provide aid in a developing country. Dr. Melcher feels that Dr. Rees and the GKE should be viewed within the context of NGOs.. . .

Perhaps Dr. Melcher best articulates the middle-of-the-road response. Noting that there are always unintended consequences in any such venture, he suggests a deliberate approach. “On a case-by-case basis it certainly seems like a win-win situation,” he says. “My bias would be to lead with ‘yes’ and go slowly.”

The Report and Letters to the Editor are all free and available from the links below:


The AJT Report

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

Lara C. Pullen

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.


Letters to the Editor

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

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


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

  1. S. Baines and R. M. Jindal


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

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


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

Francis L. Delmonico and Nancy L. Ascher


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


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


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