Showing posts with label international kidney exchange. Show all posts
Showing posts with label international kidney exchange. Show all posts

Tuesday, March 12, 2024

Kidney exchange between Portugal and Spain, and prospects for global kidney exchange

 Here's an article from a Portuguese hospital that has engaged in kidney exchanges with Spanish hospitals that have resulted in three transplants for Portuguese patients since the program was initiated in 2017.  The paper considers how international kidney exchange can be expanded globally, so as to have significant effects on the health of Portuguese and other patients.  

The concluding  two paragraphs of the paper speak about global kidney exchange, and the controversy that it has aroused, particularly in Spain, where there has been opposition to significant cross-border kidney exchange.

Francisco, José Teixeira, Renata Carvalho, Joana Freitas, Miguel Trigo Coimbra, Sara Vilela, Manuela Almeida, Sandra Tafulo et al. "International Crossed Renal Donation – The Experience of a Single Center," Brazilian Journal of Transplantation, v. 26 (2023)

"Introduction: Kidney transplantation is the preferred treatment for end-stage chronic kidney disease, however, the shortage of organs can result in long waiting times. Living donor kidney transplantation offers an alternative to cadaver donor, but HLA or AB0 incompatibility can represent a significant obstacle. This study aimed to show the results achieved by a Portuguese hospital since its integration into an international cross-donation program, the South Alliance for Transplants (SAT). 

"Methods: The SAT program was founded in 2017 and is made up of ten Spanish hospitals, three Italian hospitals and one Portuguese hospital. The program takes place every 4 months and only enrolls pairs who are incompatible. Organ transport is carried out in partnership with the Portuguese Air Force. 

"Results: Three different crosses were carried out in partnership with three Spanish hospitals, culminating in the transplantation of three Portuguese patients out of a total of seven patients. The first crossing was carried out in March 2020, at the beginning of the COVID-19 pandemic, with the partnership of two Portuguese hospitals and a Spanish hospital, involving 1 donor/recipient pair from each country,... The second occurred in December 2021 with 3 donor/recipient pairs (1 Portuguese in which the recipient had anti-donor antibodies and positive crossmatch with the potential donor; and 2 from two Spanish hospitals),... The third crossing also took place in December 2021 with 2 donor/recipient pairs (1 Portuguese and 1 Spanish)

...

"A Global Kidney Exchange Program (GKEP), an idea initiated by Rees et al.,16 which involves kidney paired donation between high-income and low-income and medium-income countries (LMICs). Beyond the potential benefits associated with this type of transplantation, similar to those already addressed for international programs, there are concerns about the ethical implications of  such  programs.  They  may  perpetuate  existing  inequalities  between  high  and  low-income  countries,  which  has  motivated  a  statement  from  the  Declaration  of  Istanbul  Custodian  Group.17  Some  critics  argue  that  the  practices  of  most  PRMBs  lack  transparency, leaving room for exploitation and corruption,18 or raise ethical concerns regarding the commodification of organs.19On the other hand, proponents of the idea argue that a GKEP could help address the global shortage of donor organs and provide lifesaving  opportunities  for  patients  in  need.  They  also  note  that  such  programs  could  foster  collaboration  and  information-sharing between countries and institutions, potentially leading to improvements in transplant practices worldwide.16,20 Despite the controversy surrounding the proposal, the idea of a GKEP remains an intriguing possibility for advancing kidney transplantation on a global scale.

"CONCLUSION: Our experience and that of other locations show that programs like these offer numerous benefits, such as expanding the pool of available donors, improving compatibility between donors and recipients, and avoiding the costs and risks associated with desensitization therapies for ABO or HLA incompatible transplantations. These programs represent a valuable option for individuals who require a kidney transplant and can be an effective means of increasing transplant success rates and improving quality of life for patients. However, the success of these programs depends on the number of pairs enrolled. To ensure the success of these programs, there is a need for greater awareness, education, and promotion of their benefits and outcomes among the public, healthcare providers, and policymakers alike.

Saturday, December 2, 2023

Design of (international) kidney exchange: ex-post rejection versus ex-ante withholding

 Here's a paper by several Dutch computer scientists, which seems to be motivated by the problem of international kidney exchange within the EU, in which there are lots of concerns about fairness between countries.  But (as the paper notes) these could also apply to individual transplant centers, in the U.S. context.  The thrust of the paper is that looking for exchanges that won't be rejected ex post in a full information environment may be more productive than looking for ways to incentivize countries or transplant centers to reveal their full sets of patient donor pairs in an incomplete information environment.

Blom, Danny, Bart Smeulders, and Frits Spieksma. "Rejection-Proof Mechanisms for Multi-Agent Kidney Exchange." Games and Economic Behavior (2023).

Abstract: Kidney exchange programs (KEPs) increase kidney transplantation by facilitating the exchange of incompatible donors. Increasing the scale of KEPs leads to more opportunities for transplants. Collaboration between transplant organizations (agents) is thus desirable. As agents are primarily interested in providing transplants for their own patients, collaboration requires balancing individual and common objectives. In this paper, we consider ex-post strategic behavior, where agents can modify a proposed set of kidney exchanges. We introduce the class of rejection-proof mechanisms, which propose a set of exchanges such that agents have no incentive to reject them. We provide an exact mechanism and establish that the underlying optimization problem is 


we also describe computationally less demanding heuristic mechanisms. We show rejection-proofness can be achieved at a limited cost for typical instances. Furthermore, our experiments show that the proposed rejection-proof mechanisms also remove incentives for strategic behavior in the ex-ante setting, where agents withhold information.

Monday, November 20, 2023

Global kidney exchange between Denmark and U.S.

 Here's a news story from North Carolina, home of one of the patient-donor pairs in the U.S.-Denmark kidney exchange, organized by the Alliance for Paired Kidney Donation (APKD).

Worldwide kidney transplant chain saves lives in Raleigh, Denmark, Colorado. by: Maggie Newland

"RALEIGH, N.C. (WNCN) — When a Raleigh musician needed a kidney, a friend of a friend offered to donate hers. The offer led to a kidney transplant chain stretching from the Triangle all the way to Denmark.

...

"Meanwhile, across the ocean, in Denmark, friends Peter Wichmann and Morton Berktoft were dealing with a similar issue. Wichmann wanted to donate his kidney to Berktoft, but they didn’t match either.

"Then something called a paired kidney exchange ended up helping all of them.  

"“It’s actually a Nobel prize-winning algorithm,” explained Krista Sweeney with AKPD. “They put these pairs into our system… We’re able to identify the best matches for each pair.”

"In this case, Kovacic donated her kidney to someone in Colorado. Their loved one donated a kidney to Berktoft, who flew to the U.S. for the surgery along with Wichmann, who donated a kidney to Adamo.

...

"Three months after the surgeries the donors and recipients are all doing well and got a chance to talk to each other in a virtual meeting.

...

“Even though the paired exchange wasn’t our initial plan it worked out so great for six people,” said Kovacic. “And three people’s lives to be saved.”

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Earlier posts on Denmark-US exchange:

Monday, June 7, 2021

Friday, November 10, 2023

Kidney Exchange: Within and Across Borders (video lecture).

 Below is a video of my 40 minute talk at Berkeley on Monday, on Kidney Exchange: Within and Across Borders, at the final workshop on Mathematics and Computer Science of Market and Mechanism Design,  at the Simons Laufer Mathematical Sciences Institute (SLMath). (But we warned or reassured, this isn't a mathematical lecture...)


Here's another link to the video if you have trouble connecting:  https://www.slmath.org/workshops/1082/schedules/34227

Tuesday, October 3, 2023

Transplant grand rounds in Manitoba, tomorrow on kidney exchange

 I'll be talking tomorrow to the transplant pros in Manitoba, about kidney exchange and transplants across borders, among other things.

Wednesday, Oct 4, 2023 | 1:15 PM CST



Friday, August 18, 2023

Kidney exchange between Portugal and Italy

 Italy-Portugal cross transplants. that click that saved two

"Thanks to a complex work of intervention planning and logistics, managed by the National Transplant Center, the Veneto Regional Transplant Center and the Portuguese institutions, the kidney of the Italian donor was removed in Vicenza and transplanted in Porto in a 41-year-old man while the Italian patient was transplanted with a kidney donated by a 36-year-old woman. The organs were harvested in the two centers simultaneously on the morning of 20 July. The Portuguese kidney arrived at Treviso airport at 2.10 pm on board a Lusitanian Air Force flight: the military delivered the organ to the regional transplant coordinator of the Veneto, Dr. Giuseppe Feltrin, receiving the Italian kidney in exchange. The 118 of Vicenza immediately transported the organ to San Bortolo where the transplantation began immediately. Both surgeries were successful and all recipients and donors went home in excellent condition."

Wednesday, May 31, 2023

Kidney exchange progress in Europe

 The program on European Cooperation in Science and Technology  (COST) has just published an update on steps being taken to advance kidney exchange in Europe, including the goal of more cross-border exchange.

The crucial role of Kidney Exchange Programmes and the ENCKEP and KEP-SOFT innovations making it possible

"Setting up KEPs is difficult due to the ethical, legal, practical, and logistical considerations that must be faced. These include ratifying policy decisions, establishing a software infrastructure, and satisfying clinical requirements. Additionally, KEPs vary across European countries in terms of policy, clinical practice, and optimisation methods. For instance, the maximum number of recipients allowed to exchange donors in a single “cycle” differs between the Netherlands and the UK. Furthermore, some countries allow non-directed donation while others prohibit it. Crossmatching** processes also vary. The ENCKEP and KEP-SOFT network has proved instrumental in meeting many of these challenges. And its associated software addresses many of these variations.

...

"On 15 June 2023, EU4Health will publish a call for proposals to implement an EU-wide KEP. On page 65, the announcement makes specific reference to the KEP-SOFT software. This presents an exciting potential future opportunity to influence further developments in KEPs in the European context and to widen the user-base of the KEP-SOFT software"


HT: David Manlove

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When I first read the last paragraph above I thought that "KEP"  probably stood for "Kidney Exchange Program," and that the proposal was to make that EU-wide rather than country by country. But it turns out that "KEP" stands for Knowledge Exchange Platform (KEP), so the progress is a bit less specific than I had hoped. But on page 65 it does include a "Call for proposals: action grants on facilitating organ paired exchange." It states that "In view of the scarcity of organs available for transplantation, there is a need to strengthen the exchange schemes among Member States, with a clear added value for European patients, as such exchange schemes can save the life of patients."

Thursday, March 2, 2023

First kidney exchange between Cyprus and Israel

 The Cyprus Mail has the story

First exchange kidney transplant between Cyprus and Israel, By Jonathan Shkurko, March 1, 2023

"The first ever crossover organ transplant involving Cyprus and Israel took place on Wednesday after two kidneys were exchanged at the old Larnaca airport in the morning.

"The effort follows an exchange agreement signed between the two countries.

"The agreement stipulates that organs belonging to donors in Cyprus that are incompatible with the recipients, will be exchanged with compatible organs arriving from Israel.

"The kidney received from Israel was transported to the new transplant clinic at Nicosia general, whereas the one donated by Cyprus was flown to Tel Aviv.

...

"During the organs’ exchange at Larnaca airport, the director of Israel Transplant Organisation Tamar Ashkenazi said she was very happy to see the results of the transnational agreement.

“I hope we will continue with more organs exchanges in the future, as we are already doing with Austria, Czech Republic and United Arab Emirates,” Ashkenazi said. 


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Earlier:

Thursday, December 19, 2019

International kidney exchange between Israel and Czech Republic


Monday, October 4, 2021

More on the UAE-Israel kidney exchange


Itai Ashlagi's kidney exchange software has played a role in all these exchanges.

Wednesday, January 11, 2023

Kidney Transplantation Across International Boundaries

 When global kidney exchange was first proposed it met with some hysterical reactions, equating it to organ trafficking.  It is good to see that being replaced by more sober, well informed discussion. Here's a recent paper on how data might be collected and shared.

The Role of Registries in Kidney Transplantation Across International Boundaries  by G. V. Ramesh Prasad, Manisha Sahay, and Jack Kit-Chung, Seminars in Nephrology, Available online 27 December  2022, https://doi.org/10.1016/j.semnephrol.2022.07.001 

Summary: Transplant professionals strive to improve domestic kidney transplantation rates safely, cost efficiently, and ethically, but to increase rates further may wish to allow their recipients and donors to traverse international boundaries. Travel for transplantation presents significant challenges to the practice of transplantation medicine and donor medicine, but can be enhanced if sustainable international registries develop to include low- and low-middle income countries. Robust data collection and sharing across registries, linking pretransplant information to post-transplant information, linking donor to recipient information, increasing living donor transplant activity through paired exchange, and ongoing reporting of results to permit flexibility and adaptability to changing clinical environments, will all serve to enhance kidney transplantation across international boundaries.


"Most KT activity occurs within a country's confines, but the increasing ease of worldwide travel and communication, and the ongoing organ shortage both motivate KT efforts across international boundaries.

...

"This review explores the specific role of patient-based registries in activating and viably maintaining KT activity across official international borders.

...

"Fewer than two thirds of countries have some form of a KT registry. With KT, however, unlike for many other therapies for which registries exist, there are two parties to consider; the donor and the recipient, and their two distinct phases of pre- and post-KT health.

...

"Transplant tourism remains a peril when promoting international transplantation. By contrast, an increasing number of international LDs now travel abroad to the home country of recipients for undergoing their donor nephrectomy.75 This travel for transplantation differs from transplant tourism by referring to the movement of organs, donors, recipients, or transplant professionals across jurisdictional borders in the absence of organ trafficking. Travel for transplantation may be increased through registries.

...

"The third and arguably most important pillar of increasing international transplant activity is to increase LD transplant activity. International comparisons based on donor source readily illustrate the varied relative proportion of DD and LD transplants worldwide.4 Large developed countries such as Canada, the United States, and Australia have developed registries to share LD organs across vast distances,80 with the goal to benefit highly sensitized recipients who have a medically suitable but immunologically incompatible LD, but at the same time maximizing the total number of KT procedures performed. Paired exchange programs and domino transplant chains81 triggered by altruistic nondirected donors best illustrate these accomplishments. Complicated computer algorithms are used to accomplish these two goals. It is important to remember, however, that organs such as kidneys are not to be treated merely as physical objects external to the human body.82 Organ donors are being paired, not organs. International LD transplants are best implemented through a paired exchange,83 as long as strict oversight policies have already been developed to respect human dignity, minimize financial burden, and ensure adequate follow-up care. Involving LICs and LMICs in paired exchange can reduce international access inequities immediately by overcoming both biological and economic imperfections. Linked registries will also permit the expansion of clinical expertise and ensure that donors and recipients are selected appropriately. Linked registries will facilitate regular follow-up evaluation and data sharing. Challenges to international LD transplantation that are best addressed through paired exchange programs include sharing hospital and travel costs, providing health insurance, respecting social and cultural norms, and ensuring administrative oversight including a mechanism for dispute resolution. The close administrative oversight provided by a paired exchange registry serves to ensure LD safety, which becomes especially pertinent when the donor belongs to a less developed country. Travel for transplantation can be encouraged, while morally burdensome transplant tourism and incentivized donation84 can be defeated. For all this to occur, however, an international registry must be much more than simply a clearinghouse for organs."

Tuesday, September 13, 2022

The First 52 Global Kidney Exchange Transplants: today at TTS2022 in Buenos Aires

 Tomorrow at TTS2022 in Buenos Aires, Mike Rees will present

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.  

Introduction: Many barriers currently stand in the way of achieving international kidney exchange including: financial, regulatory, logistical, cultural, immunological and legal barriers. 

Methods: The Alliance for Paired Kidney Donation serves patients in 15 countries. Ten of these countries have participated in Global Kidney Exchange (GKE) transplants in which either living donors, their kidneys or recipients have traveled internationally to achieve successful living donor kidney transplantation (LDKT). In all cases, barriers were present that prevented LKDT in the donor or recipient country of origin.

Results: Between January of 2015 and February of 2022, GKE has produced 11 chains and 4 cycles that has provided LDKT for 17 international patients from 10 countries to be transplanted, as well as 35 LDKT for patients in the United States (US). GKE chains lengths have ranged from 1 to 11; cycles were length 2 or 3. Eight GKE transplants overcame immunologic barriers, 4 financial barriers, and 5 both immunologic and financial barriers. GKE has involved 19 US transplant centers across 18 states and 38% of recipients were minorities. For US recipients 11% had blood type (BT)-A, 57% BT-0, 17% BT-B, and 14% BT-AB; for international recipients 41% had BT-A, 53% BT-O and 6% BT-B. The PRA was 0-20% for 23 patients, 21-79% for 14 and > 80% for 15 (10 international). International pairs were funded by a combination of self-pay, insurance and philanthropy. Transplanting 35 US patients saved US healthcare payers $7-10M vs. dialysis. International recipients have 100% 3-year patient and graft survival and all international donors are alive and have normal creatinine and blood pressure.

Conclusion: GKE overcomes financial and immunological barriers to transplantation. Savings from avoided dialysis offers scalability. Our program ensures transparency of international pair selection, emphasis on donor safety, and assurance of longterm immunosuppression for recipients as prerequisites for sustainability.


Monday, September 12, 2022

Access to transplantation around the world, at the International Congress of The Transplantation Society (TTS 2022) in Buenos Aires

I'm attending the 29th International Congress of The Transplantation Society (TTS 2022) | Buenos Aires - Argentina, and will speak in the first plenary session, on Access and Transparency in transplantation around the world.  I'll be the third of three speakers:

 Monday, September 12, 2022 – 09:40 to 11:10

Transplantation in a moving world: Migrants, refugees & organ trafficking
Dominique Martin, Australia
Steps towards increasing deceased donation worldwide
Beatriz Dominguez-Gil, Spain
Transplant sufficiency in an unequal world
Alvin E. Roth, United States

Saturday, September 10, 2022

Kidney exchange launched between the U.S. and Italy

 Here's the announcement from Italy (in Italian), on the site of the Centro Nazionale Trapianti, the National Transplant Center: 

Al via programma di trapianti incrociati di rene tra Italia e Usa, firmato l'accordo

Google translate: "The pilot phase will cover the first three cases and will be limited to  three hospitals : for Italy, the kidney transplant center of the  Agostino Gemelli Polyclinic in Rome will participate, directed by Professor Franco Citterio, present at the signing of the agreement, while for the USA the  University of Toledo Medical Center  and the hospitals of  Thomas Jefferson University in Philadelphia will be involved . Once the operational and management experimentation has been completed, the program will be re-evaluated for a possible consolidation of the protocol and for the progressive expansion to other living kidney transplant centers of the Italian network. 

"The one with the United States is  the second international exchange protocol  activated by our country: since 2018 an agreement has been in force involving France, Portugal and  Spain  and which has resulted in three cross transplants with the latter nation. From 2015 to date, the Italian national crossover kidney transplant program has allowed  77 interventions to be carried out . Overall, 2,043 kidney transplants were performed in Italy in 2021, of which 341 from living donors: of these, 5 were carried out through an exchange between donor and recipient pairs. "

*******

Here's the announcement from the Alliance for Paired Kidney donation, the U.S. partner (in English):

PILOT KIDNEY EXCHANGE TRANSPLANT PROGRAM LAUNCHED BETWEEN US, ITALY

""The goal of the memorandum of understanding, which was signed at the Ministry of Health in Rome, is to provide for the possible treatment of thousands of patients awaiting kidney transplants in both the U.S. and Italy. The agreement was signed on behalf of CNT by its director, Massimo Cardillo, and by Michael A. Rees, MD, PhD, the CEO of APKD and the surgical director of kidney transplantation at the University of Toledo Medical Center in Ohio.

"The new US-Italy program concerns kidney exchange transplantation, in which incompatible living donor and recipient pairs are matched with other incompatible pairs for kidney transplants. Thanks to the agreement between APKD and CNT, incompatible American and Italian donor-recipient pairs will be able to exchange with each other based on a shared algorithm that will verify the level of compatibility between those on the countries’ transplant waiting lists. In this way, patients with kidney failure, who also have an incompatible volunteer donor, will have a greater chance of receiving the transplant they need.

"In addition to the technical-operational aspects – such as the requirements of the participating hospitals, matching algorithm and overall governance of the transplant process – the agreement provides that the costs related to the transplant procedure are borne by the U.S. insurance coverage for the U.S. recipient and the Italian donor, while the Italian National Health Service will cover the expenses for the Italian recipient and the American donor. Transplant surgeries will take place in the country where the recipient is located.

********

A critical role was played by Dr. Ignacio Marino, the transplant surgeon who took time off to be the mayor of Rome and is now at Jefferson Hospital in Philadelphia.

His facebook post yesterday describes some details of the proceedings (first in Italian and then in English:

"The agreement was signed by the Italian National Transplant Centre (NTC), represented by director Massimo Cardillo, and the Alliance for Paired Kidney Donation (APKD), a non-profit organisation that runs one of the largest living kidney exchange programmes in the United States, represented by its CEO, Professor Michael A. Rees, MD PhD, director of the Kidney Transplant Centre at the University of Toledo Medical Center, Ohio. The signing of the protocol was attended by the Italian Deputy Minister for Health Pierpaolo Sileri, who has wholeheartedly supported this innovative project from the outlet."

Drs. Mike Rees and Ignazio Marino

**********


 ******** 
Update, October 3:
Here's an Italian news article from Sanita24 taking note of the agreement.

G translate of first paragraph: "In no country in the world is there a sufficient number of donors to cover the transplant needs of all patients suffering from end-stage renal failure and who therefore have to resort to dialysis. To address this need, a memorandum of understanding was signed for the launch of an organ donation program in a “cross” mode between different continents, to offer a new possibility of treatment to patients on dialysis."

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Related earlier posts

Tuesday, September 4, 2018

Tuesday, August 23, 2022

Living Kidney Donor Transplantation and Global Kidney Exchange by Marino, Roth and Rees

 Here's a just-published article explaining global kidney exchange,  in Experimental and Clinical Transplantation (ECT), the journal of the Middle East Society for Organ Transplantation (MESOT):

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.

Update: here's a direct link to the paper.

Abstract: "Global kidney exchange offers an opportunity to expand living donor kidney transplants internationally to patients with immunologic barriers. The concept has been proven to be successful in a limited number of transplants. However, a number of misconceptions have created obstacles to its development. We suggest that a systematic application of this innovative tool would offer opportunities to treat thousands of patients worldwide who are presently denied a transplant and often even access to dialysis."

...

"The following 3 examples serve to demonstrate the financial challenges associated with GKE.

"The first GKE transplant involved an immunologically compatible husband and wife from the Philippines who were denied funding for a transplant in the Philippines by the government payer (PhilHealth). The husband-wife pair had no financial resources for travel, kidney transplant, or postoperative medications given their personal situation and the absence of a Philippine government payer for these costs (PhilHealth did not approve payment for this couple to receive a kidney transplant and also did not provide adequate payments for dialysis). The solution was a philanthropic solution whereby the APKD provided funding for travel and the transplant procedure and created an escrow account to pay for an estimated 10 years of recipient and donor follow-up care upon return to the Philippines.

"The second GKE transplant involved an immunologically incompatible donor and recipient who were cousins. They had government funding for a transplant in Mexico through the Mexican Institute of Social Security (known as IMSS by its Spanish acronym) but had not found a match from the Mexican deceased donor system in 5 years, and there was no viable kidney exchange program in Mexico.17 This pair raised sufficient financial resources to pay for travel to the United States and raised one-third of the cost of an uncomplicated kidney transplant in the United States. The IMSS agreed to provide postoperative medications and donor-recipient long-term followup care upon return to Mexico. The solution was a combination of government-financed postoperative care and private/philanthropic funding whereby the APKD partially subsidized the transplant procedures and fully managed financial aspects of potential complication costs.

"Two GKE transplants involved an immunologically incompatible pair of friends from Denmark and an immunologically incompatible mother-daughter pair from Mexico who were able to privately pay for travel, transplant, and postoperative care but were not able to manage the financial risk of a significant complication. The solution involved private/philanthropic funding whereby the patient paid for an uncomplicated kidney transplant in the United States, with APKD philanthropically fully managing the financial aspects of potential complication costs.

...

"The Philippines and Mexico do not offer kidney exchange to their citizens, so these patients had no choice but to look for an international option. In Mexico, it is possible that a living donor kidney could have been shipped from the United States to Mexico, but the patient’s transplant team in Mexico did not want to participate in the exchange. US regulations prevent a living donor kidney from being procured in Mexico, Denmark, or the Philippines and shipped to the United States. Thus, in each of these examples, the only option was for international pairs to travel to the United States and pay for transplant costs at US-based prices. Denmark offers kidney exchange through Scandiatransplant, but the program has less than 50 pairs participating, so matching for hard-to match patients is limited. For the Danish patient, who had panel reactive antibody levels greater than 90%, the only reasonable option was to look for a bigger kidney exchange pool outside of Scandiatransplant, such as the APKD pool in the United States.

...

"In conclusion, GKE provides personalized solutions by capturing relevant genetic, immunologic, physiologic, and social information to match patients with kidney failure and their willing donors to identify opportunities for living donor kidney transplant instead of dialysis or death.

"With GKE, a modality that can equally benefit rich and poor, industrialized world health care is made available to impoverished patients in less industrialized countries, while at the same time fighting unethical transplant tourism. In fact, with GKE, the exchange of a kidney for transplant is an altruistic gift and never an unethical and illegal commercial exchange. Moreover, with such a controlled system, every single donor and every single recipient of the GKE program can be scrutinized before the transplant procedure is performed and their data can be entered in a registry that can be accessed by transplant professionals to ensure ethical treatment of living donors and improved transition of care across national borders.

"Because one of the main motivations of GKE is to make transplantation more available in low- and middle-income countries, it would be helpful if the WHO revisited the ethics of GKE, ideally with an open discussion involving representatives of all WHO countries interested in this procedure."

Friday, October 22, 2021

Kidney failure is epidemic among agricultural workers in hot countries… so is likely to be exacerbated by global warming.

 When I visited the UAE this past summer, I learned that it has high rates of kidney failure, attributed to the very high temperatures that outdoor workers experience there. Here's a story that says that's a problem in other hot places, and therefore likely to get worse as the atmosphere heats up. It's a further reason why it makes sense to expand kidney exchange across borders, and not just among wealthy countries.

The Guardian has the story:

Global heating ‘may lead to epidemic of kidney disease’. Deadly side-effect of heat stress is threat to rising numbers of workers in hot climates, doctors warn  by Natalie Grover

"Chronic kidney disease linked to heat stress could become a major health epidemic for millions of workers around the world as global temperatures increase over the coming decades, doctors have warned.

"More research into the links between heat and CKDu – chronic kidney disease of uncertain cause – is urgently needed to assess the potential scale of the problem, they have said.

"Unlike the conventional form of chronic kidney disease (CKD), which is a progressive loss of kidney function largely seen among elderly people and those afflicted with other conditions such as diabetes and hypertension, epidemics of CKDu have already emerged primarily in hot, rural regions of countries such as El Salvador and Nicaragua, where abnormally high numbers of agricultural workers have begun dying from irreversible kidney failure.

"CKDu has also started to be recorded as affecting large numbers of people doing heavy manual labour in hot temperatures in other parts of Central America as well as North America, South America, the Middle East, Africa and India.

...

"Dr Ramón García Trabanino, a clinical nephrologist and medical director at El Salvador’s Centre of Hemodialysis, first noticed an unusual number of CKD patients saturating his hospital as a medical student more than two decades ago.

They were young men,” he said, “and they were dying because we didn’t have the budget or the capacity to give them dialysis treatment. We did the best we could, but they kept dying and more kept coming.”

"Since then he has started researching similar epidemics in Mexico, Nicaragua, Costa Rica and Panama."



Wednesday, October 6, 2021

Indian Society of Organ Transplantation 2021 Annual Meeting, Oct 7-10

 31st Annual Conference of The Indian Society of Organ Transplantation 7th to 10th October 2021 GRAND HYATT LULU BOLGATTY CONVENTION CENTER in Kochi (Cochin)

My talk (via Zoom) tomorrow morning in CA/evening in India will be on 

"Kidney exchange, around the world and in India"

http://www.isot2021.com/images/pop1.jpeg?refresh=210923023039

ABOUT ISOT 2021 KOCHI  Virtual Conference

"It is our pleasure to invite you to the 31st Annual Conference of the Indian Society of Organ Transplantation, ISOT 2020 Kochi a programme organized by team of Transplant Professionals of Kochi to be held at hotel Grand Hyatt, Lulu Bolgatty Convention Centre from 07th to 10th of October 2021. We are fortunate to have renowned experts across the globe as speakers. This conference will also give you an opportunity to interact with the experts in the field. Wide range of topics, venue of International standard, best hospitality in the Gods own country of Keralam will be the highlights.

"Grand Hyatt Kochi is a Luxury 5 star deluxe waterfront hotel overlooking the serene waters of Vembanad lake with a range of dining, wellness and enriching experiences.

"With a large number of advanced tertiary/quaternary care facilities, Kochi has one of the best healthcare facilities in India. It is the prime destination for people seeking advanced healthcare facilities across Kerala. In recent times, it has attracted a large number of patients from all over India, Middle East, African nations as well as from Europe and United States looking for relatively inexpensive but advanced medical care. Kochi is the only city in Kerala that have carried out successful kidney, liver, heart, pancreas and composite tissue transplantation. VPS Lakeshore Hospital, Amrita Institute of Medical Sciences and Research Centre, Medical Trust Hospital, Lisie Hospital, AsterMedicity, Lourde’s Hospital are some of the advanced tertiary/ quaternary healthcare facilities in Kochi.

"Kochi also known as Cochin is the financial and industrial capital and the biggest city of Kerala that offers excellent airline connectivity with direct flights to 22 destinations including all the major cities of the country. It is also known for its salubrious climate particularly during the month of October attracting a large number of tourists from Europe, Americas and rest of Asia as well as domestic tourists. City also flaunts one of the finest natural harbours of the world. Finest beaches, tranquil back waters, luxurious houseboats, multi-cuisine restaurants, and numerous shopping malls are other attractions."

Monday, October 4, 2021

More on the UAE-Israel kidney exchange

If you're just tuning in, you can follow the story of the kidney exchange between the UAE and Israel here. The pairs who exchanged kidneys were an Israeli Arab husband and wife, a Jewish Israeli mother and daughter, and a mother and daughter who wish to be identified only as Arab residents of the United Arab Emirates.  (I joined their family at their home for a meal when I was in Abu Dhabi, but won't say more about them.)

It isn't a surprise that the donor in each pair couldn't donate to the intended recipient, because in each pair the recipient was a highly sensitized mother ( i.e. for whom it was hard to find a compatible kidney, because she had many antibodies against human proteins). During childbirth, mothers can develop such antibodies to the father's proteins that the children inherited. So the father and the daughters were incompatible donors, since the mother had antibodies against the paternal proteins (human leukocyte antigens) in their kidneys. Together with the fact that the mothers were quite hard to match, and that Israel and the UAE are both small, each with populations of around ten million, they had to look across national borders.

Cross border kidney exchange requires some diplomacy, particularly when the countries involved are getting together for the first time (and don't necessarily have a long history of cooperation). The key medical diplomats were Dr. Tamar Ashkenazi* the director of Israel Transplant and Dr Ali Abdulkareem Al Obaidli, Chairman of the UAE National Transplant Committee.  (Other key collaborators in the complicated logistics were Itai Ashlagi at Stanford and Atul Agnihotri and Mike Rees of the Alliance for Paired Kidney Donation.)  


So this was the plan:


And here's a picture of the Abu Dhabi kidney packed for shipping (masked in the picture are Sue and Mike Rees, who have a lot of experience with packing and shipping kidneys, another nurse whose name I don't know, and Dr. Muhammad Badar Zaman the UAE transplant surgeon who transplanted the  kidney that was on the way.


The little box taped to the top of the shipping container allows the kidney to be tracked in transit, via an app that gives you a picture of where it is at it travels:


And here's the swap of the two kidneys in shipping containers in the airport in Abu Dhabi (Tamar Ashkenazi and Dr. Ali are in the center, Atul and Mike are at the two ends...). Dr Ashkenazi was on both legs of the flight above--she flew in with the Israeli kidney and flew out with the UAE kidney.



On my last night in Abu Dhabi I had dinner with a lot of the docs. Across from me in the picture below are the two surgeons most actively involved in this exchange on the UAE side, transplant surgeon Dr. Zaman and the nephrectomy surgeon Dr. Hamid Reza Toussi.  Next to me is the nephrologist Dr. Mohamed Yahya Seiari.





Below is that whole dinner party. If you've been following these posts up til now, you've met all of them except the gentleman second from the left, Dr. Gehad ElGhazali, who is the head of the HLA lab, which is responsible for the data that allows the matching algorithm to predict which kidneys are compatible, and is responsible for the final 'crossmatch' tests that verify compatibility. Like all the other docs I encountered, he has a multi-international background. This reflects the UAE's very international population, which is why it seems a natural global hub for kidney exchange.




I only met the Israel participants in the exchange later, by Zoom: Shani Markowitz is the donor from the Jewish pair, and Walaa Azaiza is the recipient from the Israeli Arab pair.






The Israeli transplant surgeons are Dr Tony Karam at Rambam Hospital and Dr. Eitan Mor at Sheba Medical Center.
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*As it happens, I've twice had the privilege of  being Dr. Ashkenazi's coauthor (concerning deceased organ donation):
1. Stoler, Avraham,  Judd B. Kessler, Tamar Ashkenazi, Alvin E. Roth, Jacob Lavee, “Incentivizing Authorization for Deceased Organ Donation with Organ Allocation Priority: the First Five Years,” American Journal of Transplantation, Volume 16, Issue 9, September 2016,  2639–2645. http://onlinelibrary.wiley.com/doi/10.1111/ajt.13802/full 

2. Stoler, Avraham, Judd B. Kessler, Tamar Ashkenazi, Alvin E. Roth, Jacob Lavee, “Incentivizing Organ Donor Registrations with Organ Allocation Priority,”, Health Economics, April 2016 online http://onlinelibrary.wiley.com/doi/10.1002/hec.3328/full ; doi: 10.1002/hec.3328. In print: Volume: 26   Issue: 4   Pages: 500-510   APR 2017



Saturday, October 2, 2021

UAE as a natural hub for international/global kidney exchange

 There are excellent hospitals in the United Arab Emirates that can perform kidney transplants, and they are prepared to do kidney exchange, both domestically and internationally.  My post today is about why the UAE would be a natural international center for kidney exchange. 

International hubs for kidney exchange are needed because hard-to-match patient-donor pairs may need to find compatible exchanges outside the borders of their own countries. This is particularly true for citizens of countries with relatively small populations of potential compatible donors, and of countries that don't yet have widespread kidney exchange. But even a big country like the U.S., in which kidney exchange is a standard mode of transplantation, can sometimes be too small to find compatible kidneys for the hardest to match  patients. (The U.S. itself is a natural hub for global kidney exchange, about which I've written elsewhere. But so far, bureaucratic obstacles have prevented us from integrating kidney exchange even with Canada...)

The UAE itself is already quite international, as only about 10% of its approximately 10 million residents are Emirati citizens; the rest, largely foreign workers and their families, are citizens of other countries. The biggest of the Emirates, Abu Dhabi, provides medical care for its residents that includes dialysis and transplantation for kidney failure, which is prevalent there (perhaps due in part to the very hot weather and the perils of frequent dehydration in outdoor work). Most of those patients are on dialysis, although the national health insurance will pay for transplants for those who have willing donors either in the Emirates or in their home country. The UAE is wealthy, and many of the home countries are not, so my understanding is that the UAE is prepared to assume the costs of bringing family members to the UAE and providing the necessary medical care. This is cost effective as well as good for the patient, because in the UAE as elsewhere, transplantation is much cheaper than dialysis, as well as being the best treatment. So taking a UAE resident off dialysis via transplant saves a life and pays for itself.

Of course, sometimes the UAE resident's family member who is willing to donate a kidney isn't compatible with the UAE resident. So kidney exchange makes a lot of sense in this case. But with a resident population of only 10 million, there are severe limits on how much kidney exchange can do for hard-to-match patients. So international, global kidney exchange makes sense, in which patient-donor pairs from other countries could also be transplanted in the UAE through kidney exchange with UAE residents (or, eventually, with other international pairs).

It helps a lot that the UAE is also an air transit hub, with two international airlines. Emirates has a hub in the Emirate of Dubai, and Etihad has a hub in Abu Dhabi. So a big portion of the world's population is within a few hours of direct air travel to the UAE.  (When I went to the UAE this summer in connection with the UAE-Israel kidney exchange, I took a direct flight from San Francisco to Dubai, but that takes sixteen hours...)

My main goal in the UAE was to meet with various mostly government bodies engaged in an effort, in collaboration with the Alliance for Paired Kidney Donation, to make domestic and international kidney exchange a regular part of medical care there. To that end, we met with the Ministries of Health in Dubai and in Abu Dhabi, with the national health insurance, with the Red Crescent (which is able to get involved in care of patients and donors after they return home), and others.

The key player in organizing this collaboration, and in transplantation generally in the UAE is  Dr Ali Abdulkareem Al Obaidli, transplant nephrologist and Chairman of the UAE National Transplant Committee. Two other key figures from the APKD are Mike Rees and Atul Agnihotri. Many of our meetings ended in photos, and I'm with those three in all pictures below. 







I expect to write some more about this. In the meantime, here are related posts.

Thursday, September 30, 2021

Friday, October 1, 2021

And this older one:

Friday, August 7, 2020

Global kidney exchange between Abu Dhabi and Kerala (India)


Here's a slide from a talk I'll be giving shortly at the annual conference of the Indian Society of Transplantation (ISOT) that provides some more information about this UAE-India exchange