Category Archives: Global Kidney Exchange

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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GKE Debate in Current Issue of The American Journal of Transplantation

Figure showing the first GKE (to date)

Both Al Roth at his Market Design blog and Timothy Taylor on his blog, the Conversable Economist, have discussions today about our paper reporting the first Global Kidney Exchange (GKE) and the pushback it has received in the current issue of the American Journal of Transplantation. I’ve blogged about GKE (which Mike Rees and I previously referred to as Reverse Transplant Tourism or “RTT) before (see, e.g. here).

As Al says:

I’ve written earlier about the possibility of Global Kidney Exchange (GKE), in which foreign patient-donor pairs who cannot afford transplantation are invited to join American kidney exchange chains. The idea is that the cost of the foreign pair’s surgeries and postoperative care can be paid for by the savings that result whenever an American is transplanted (because transplantation is so much cheaper than dialysis).

The March issue of the American Journal of Transplantation  contains a report of the first foreign pair, and the chain of exchanges that included them.

Curiously, the issue also contains an editorial that is profoundly ambivalent about GKE, in a way that makes clear that the issues of repugnance that surround organ donation, and incentives, and equity, and patients and donors from developing countries, are not vanishing in the face of the benefits that GKE provides to patient-donor pairs from developing countries. (emphasis mine)

Taylor also has a nice summary of our paper:

Basically, the notion is to involve pairs of people from low-income countries–one needing a kidney, one offering to donate a kidney–in these interlocking chains of kidney donation. For those in high-income countries, the advantage is potentially a lot more compatible kidney donors. Because getting a kidney donation saves money on dialysis, it is possible to use that saved money and provide the kidney donation for free to recipients from the low-income country. The result is healthier people, and overall cost savings.

And of the accompanying editorial:

The same issue of the journal includes a short editorial called “Financial Incompatibility and Paired Kidney Exchange: Walking a Tightrope or Blazing a Trail?” by A. C. Wiseman and J. S. Gill (pp. 597-98). As they write, “there are numerous considerations that require equipoise …” They point out issues that could arise in how donors in other countries are identified, whether the benefits are equitably distributed, whether consent is freely given, how this might affect providers of transplant services in low-income countries, and more. All fair enough, and I suppose only a benighted economist could bristle against their request for “sensitivity to the ethical pitfalls.” I would only point out that while we are being sensitive to ethical pitfalls of global kidney exchange, 2-7 million people are dying every year without access to treatment for their kidney disease, and we should spare a little sensitivity for them, too. (emphasis mine)

I would go even further than Taylor or Roth. The editorial is very thoughtful and worth reading in its entirety, here. It also raises some important ethical issues that have to be considered as GKE goes forward and I am grateful to the authors for having so carefully engaged our paper. At the same time, though, the argument that GKE may be ethically problematic because the benefits are unequally distributed between the US and developing world patients is, for me, just a nonstarter (and, to be clear, I speak for myself here and not for any of my coauthors).

As Roth says:

Here’s one sentence that illustrates the power of repugnance (it suggests that maybe the Filipino pair who joined the kidney exchange were really being exploited…):

“At a societal level, American patients received a disproportionate share of the societal benefit enabled by the participation of the compatible Filipino pair in KPE, which may not be adequately remedied by the payment for transplantation and posttransplant care.”

Given the Filipino patient’s lack of access to transplantation (and possibly even dialysis – we discuss this in the paper) GKE almost certainly saved his life. To paraphrase Taylor, perhaps only a benighted lawyer could question how this life saving transaction is exploitative of a Filipino patient, just because some Americans also benefit from the trade. The Filipino patient doesn’t care whether one or one hundred Americans were transplanted because of the chain he enabled – only that he received a healthy, compatible kidney that he otherwise could not have.

Here’s our full abstract:

Kidney Exchange to Overcome Financial Barriers to Kidney Transplantation

by M. A. Rees, T. B. Dunn, C. S. Kuhr, C. L. Marsh, J. Rogers, S. E. Rees, A. Cicero, L. J. Reece, A. E. Roth, O. Ekwenna, D. E. Fumo, K. D. Krawiec, J. E. Kopke, S. Jain, M. Tan, S. R. Paloyo

American Journal of Transplantation, Volume 17, Issue 3 March 2017, Pages 782–790

Abstract: Organ shortage is the major limitation to kidney transplantation in the developed world. Conversely, millions of patients in the developing world with end-stage renal disease die because they cannot afford renal replacement therapy—even when willing living kidney donors exist. This juxtaposition between countries with funds but no available kidneys and those with available kidneys but no funds prompts us to propose an exchange program using each nation’s unique assets. Our proposal leverages the cost savings achieved through earlier transplantation over dialysis to fund the cost of kidney exchange between developed-world patient–donor pairs with immunological barriers and developing-world patient–donor pairs with financial barriers. By making developed-world health care available to impoverished patients in the developing world, we replace unethical transplant tourism with global kidney exchange—a modality equally benefitting rich and poor. We report the 1-year experience of an initial Filipino pair, whose recipient was transplanted in the United states with an American donor’s kidney at no cost to him. The Filipino donor donated to an American in the United States through a kidney exchange chain. Follow-up care and medications in the Philippines were supported by funds from the United States. We show that the logistical obstacles in this approach, although considerable, are surmountable.

And here’s the accompanying editorial:

Walking a Tightrope or Blazing a Trail?

by A. C. Wiseman, J. S. Gill

Abstract: Engaging compatible kidney donor–recipient pairs from other countries for participation in a paired kidney exchange program in the United States poses a number of ethical challenges that deserve close scrutiny. Rees et al’s article is on page 782.

Related posts:

Global Kidney Exchange (GKE) to Overcome Financial Barriers to Kidney Transplantation

Reverse Transplant Tourism

Reverse Transplant Tourism (cont.)

RTT Conclusion

Reverse Transplant Tourism Goes Live!!

More News Coverage Of Reverse Transplant Tourism

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Global Kidney Exchange (GKE) to Overcome Financial Barriers to Kidney Transplantation

Over at his Market Design blog, Al Roth has posted about our new article, forthcoming in the American Journal of Transplantation. From his post:

Kidney Exchange to Overcome Financial Barriers to Kidney Transplantation

by

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, Siegfredo R. Paloyo

Accepted manuscript online: 7 November 2016

“This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/ajt.14106”

Abstract:

Organ shortage is the major limitation to kidney transplantation in the developed world. Conversely, millions of end-stage renal disease patients in the developing world die because they cannot afford renal replacement therapy—even when willing living kidney donors exist. This juxtaposition between countries with funds but no available kidneys and those with available kidneys but no funds, prompts us to propose an exchange program utilizing each nation’s unique assets. Our proposal leverages the cost savings achieved through earlier transplantation over dialysis to fund the cost of kidney exchange between developed-world patient/donor pairs with immunological barriers and developing-world patient/donor pairs with financial barriers. By making developed-world healthcare available to impoverished patients in the developing world, we replace unethical transplant tourism with global kidney exchange—a modality equally benefitting rich and poor. We report the one-year experience of an initial Filipino pair, whose recipient was transplanted in the US with an American donor’s kidney at no cost to him. The Filipino donor donated to an American in the US through a kidney exchange chain. Follow-up care and medications in the Philippines were supported by funds from the US. We show that the logistical obstacles in this approach, although considerable, are surmountable.

*******************

And here’s that first GKE chain to date: it started with an American non-directed donor (blood type A) donating to the Filipino patient, and this chart shows the first 11 transplants that resulted.

1st GKE

 

I blogged about GKE before (back when we were calling it Reverse Transplant Tourism – admittedly a less palatable name than Global Kidney Exchange).  Mike Rees and I floated the idea as a hypothetical in Reverse Transplant Tourism, part of the Law & Contemporary Problems volume, Organs & Inducements. Back then, we proposed that a simple 2-way swap could help US incompatible pairs and developing world pairs (whether biologically incompatible or not), while also saving money, by leveraging the cost savings of transplantation over dialysis.  In practice, though, and as shown by the figure posted by Al, the first GKE helped a Filipino patient unable to afford transplantation on his own, while also facilitating a chain that has transplanted 11 US patients so far.

 

This video of the first GKE transplant is both informative and uplifting.

 

 

 

Related posts:

Reverse Transplant Tourism

Reverse Transplant Tourism (cont.)

RTT Conclusion

Reverse Transplant Tourism Goes Live!!

More News Coverage Of Reverse Transplant Tourism

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