First kidney exchange in South Africa

South Africa's Daily Maverick has the story:
Saving lives: South Africa joins paired kidney exchange revolution, ANDREA TEAGLE  SOUTH AFRICA 06 AUG 2015

"On March 6, 2015, South Africa’s first kidney exchange took place at the Donald Gordon Medical Centre in Johannesburg. After having been kept alive by dialysis for years, 24-year-old Vivek [not his real name] and 60-year-old Allison Stevenson were both given a new lease on life.
...
"This was South Africa’s first paired kidney exchange. And it happened almost by chance.
“This youngster in Port Elizabeth – his mother was so anxious about him, she phoned the transplant centre in Johannesburg … It was like the next week that I phoned up.” Stevenson recalls, “And there, Belinda (a transplant coordinator), had this file on her desk, where the aunt didn’t match the nephew. It just so happened that she matched me, and Sally matched Vivek.”
...
"South Africa relies primarily on deceased kidney donations. Of the 4,300 people on the waiting list for life saving, most are waiting for a kidney. There is only a small hope of getting one: just 0.2% of the population are registered as organ donors. And a host of medical requirements need to be satisfied for a match. The waiting list is like a mile long tightrope to life and many people never make it across.
...
"This is an example of what economists call a mismatched market. And for at least one economist, Stanford Professor Alvin Roth, it posed an exciting challenge. Roth and his colleagues were able to apply a model to the problem they had initially built out of mathematical curiosity. In 2012, this work won him a joint Nobel Prize in Economics.
Roth’s matching program builds little bridges between supply and demand. The simplest case is a two-way exchange like Stevenson’s. By decoupling the donors from their intended (but incompatible) recipients, and recoupling them with compatible ones, long chains of transplants can take place that otherwise would have been impossible.
...
"In South Africa this type of optimised matching is but a dream.
The National Health Act allows for living donors to donate to a blood relative or a spouse. If the donor is not a relative, he or she must apply for special permission from the Department of Health. In South Africa – as in every other country in the world with the exception of Iran – the sale of organs is illegal.
The hesitancy to implement paired matching, although the law does not in fact prohibit it, is likely partly due to fear of abuses through monetary exchange. (It is, however, lawful for the donor to be reimbursed for “reasonable costs” associated with the transplant.)
However, Stevenson’s case shows that paired exchanges can be subjected to the same careful scrutiny as direct donations. Only after establishing that neither donor had been coerced, misled or financially incentivised, did the Department of Health give the go-ahead. Further, the pairs were not allowed to meet or communicate prior to the operation, so Stevenson has never met her actual donor.
...
"The successful matching is an important step towards overcoming what surgeon Francis Delmonico, who was involved in the original matching program in the US, described as “the frustration of a biological obstacle to transplantation”. However, without a registry of living donors, finding a paired match will require hours of effort, and many will not be as lucky as Stevenson."

Kidney exchange in Turkey, and the state of Turkish transplantation

Here are two articles from the June issue of Transplantation Proceedings

First International Paired Exchange Kidney Transplantations of Turkey    

M. Tuncer

, S. Tekin

, Y. Yuksel

, L. Yücetin

, L. Dosemeci

, A. Sengul

 and A. Demirbaş

Transplantation Proceedings, 2015-06-01, Volume 47, Issue 5, Pages 1294-1295, Copyright © 2015 Elsevier Inc.

Abstract

Objective

We estimated that many patients on the waiting list for kidney transplantation in Turkey have immunologicaly incompatible suitable living donors. Paired exchange kidney transplantation (PETx) is superior to desensitization for patients with incompatible donors. Recently we decided to begin an international PETx program.

Methods

We report three international living related paired kidney transplantations which occurred between May 14,2013, and March 7, 2014. The international donor and recipient operations were performed at Medical Park Hospital, Antalya, Turkey. All pairs were living related and written proofs were obtained according to Turkish laws. As with the donor procedures, the transplantation procedures were performed at the same time.

Results

The uniqueness of these transplantations was that they are the first international exchange kidney transplantations between Turkey and Kirghizia. Currently all recipients are alive with wel-functioning grafts.

Conclusion

In our institute, a 5% increase was obtained in living-related kidney transplantations by the help of PETx on a national basis. We believe that international PETx may also have the potential to expand the donor pool.

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

State of Turkish Transplantation    

• Sukru H. Emre Prof.
•  and Ulug Eldegez Prof.

Transplantation Proceedings, 2015-06-01, Volume 47, Issue 5, Pages 1243-1243, Copyright © 2015 Elsevier Inc.

The 10th Congress of the Turkish Transplantation Centers Coordination Association (TTCCA) was held on October 15–18, 2014 in the ancient city of Bodrum, Turkey (formerly Halicarnassus), where one of the Seven Wonders of the Ancient World, “Mausoleum at Halicarnassus,” resides.

This congress also marked the 20th anniversary of the TTCCA. Since its inaugural meeting, TTCCA's congresses have hosted international leaders in the fields of transplantation in transplant immunology, hepatology, nephrology, surgery, radiology, infectious disease, intensive care, nursing, and other related disciplines. Throughout the years, these congresses have served as a great training ground for young Turkish physicians, surgeons, and scientists to meet with world experts and discuss cases. These congresses have also helped Turkish physicians develop international networks so that they may visit transplant centers around the world.

Twenty years ago, TTCCA was established by two pioneers of Turkish transplant surgery: Professors Tuncer Karpuzoglu and Ulug Eldegez. These men were the ones who approached the young transplant surgeons, physicians, immunologists, and nurses to welcome them, encourage them, guide them and point them in the right direction. TTCCA has had bi-annual national meetings since its inception. These meetings have brought almost all transplantation centers in Turkey together under the TTCCA and initiated a nationwide deceased organ distribution system for kidney, liver, and heart transplantations. This effort was sponsored by a grant provided by Novartis. This was the first attempt in Turkey to institute the equal, fair sharing of organs procurred from deceased organ donors. After almost 10 years of serving in this capacity, TTCCA partnered with the Ministry of Health of Turkey (MoH) to achieve the current organ allocation system. During the development of the new organization under the auspices of the MoH, TTCCA leadership and many members have played crucial roles by serving on many committees of this national organization.

As a result of these efforts ignited by TTCCA, solid organ transplantation in Turkey has became a routine procedure with reasonably good outcomes.

Despite these achievements, there are many areas that the transplantation society and MoH can work on:

• 1. 
  Based on the 2014 statistics, approximately 80% of kidney and liver transplants were done with living donors and only 20% of organs were from deceased donors. In living donor liver transplantation, Turkey is the one of the leading countries in the world together with South Korea. These ratios are the opposite to the ratios of Europe and the US where most of donations are from deceased donors. Therefore, there is an ample opportunity to increase deceased organ donation in Turkey. This effort requires continuous education of the public on organ donation.
• 2. 
  It is imperative to establish a Turkish Transplantation Network similar to UNOS. Besides what has been achieved, this organization should be in charge of increasing the number of deceased donors, more detailed organ specific data from transplant centers, auditing, controlling the quality of transplant centers in terms of policies, processes, quality and accreditation of medical and surgical staff involved in transplant centers, education, and monitoring transplant related disease transmission.

TTCCA and MoH have been working with The Transplantation Society (TTS), World Health Organization (WHO), EuroTrans and the Declaration of Istanbul on Organ Trafficking and Transplantation Tourism leadership to honor the concept of the “gift of life,” prevent organ trafficking and increase the number of deceased donors for transplantation. I hope that these commendable efforts would be honored by TTS by allowing the 2020 World Congress to be held in Istanbul, Turkey.

It has been my pleasure to live through these amazing improvements in Turkish Transplantation along the last 20 years.

NPR's Marketplace: Ryssdal interviews Dubner about his newest Freakonomics podcast--the four minute version

An algorithm that matches kidney patients and donors

The link above will take you to the four-minute version of the fifty minute Freakonomics podcast in which Dubner interviews me about my new book.

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Doctors from Johns Hopkins Hospital in Baltimore, Maryland, transplant a kidney. 

Interview by Kai Ryssdal, Interview with Stephen Dubner

Wednesday, June 17, 2015 - 14:49

• STORY

Matching markets are markets where money isn’t allowed to do what it usually does. For example, school admissions — colleges don’t just raise the tuition price until demand meets supply. Or how new M.D.’s get assigned to their residencies — they can’t just buy their way into the hospital they want. In each case, you have to find a way to match a candidate with an available slot.

You also can't buy a kidney, or pay for somebody's college education to get a kidney, or purchase a car for them in exchange of a kidney.

So how can you make a market for something that is indivisible and can’t put a price on? Al Roth, a professor of economics at Stanford, realized that this model could be adapted to help kidney patients find a potential donor.

"Let’s pretend you and I, Kai, we both need a kidney transplant. And that both of us have a relative who’s willing to donate one, but your relative is not a biological match for you and mine isn’t for me," says Stephen Dubner, author of "Freakonomics." "Wouldn’t it be awesome if you could enter all your data and all of the donor's data into some algorithm that could magically sort these data from all the transplant centers in the country and match up donors and patients?"

Roth’s algorithm has helped save a lot of lives. Ruthanne Leishman from the United Network for Organ Sharing says the United States has about 600 kidney paired donation transplants per year right now. In 2000, the U.S only had two.

Featured in: Marketplace for Wednesday, June 17, 2015

About the author

Kai Ryssdal is the host and senior editor of Marketplace, the most widely heard program on business and the economy in the country.

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San Francisco is becoming a center for kidney exchange

UCSF Medical Center, CPMC Join Forces for 18-Patient Kidney Transplant Chain

"A unique collaboration between UCSF Medical Center and Sutter Health’s California Pacific Medical Center (CPMC) resulted in what is believed to be one of the nation’s first nine-way kidney transplant chains occurring in one city over a 36-hour period.

The chain started on Thursday morning (June 4), with an altruistic patient donating a kidney as a token of gratitude for his good health. It concluded with a recipient who has been on dialysis for several years.

The surgeries involved the above donor and recipient and an additional 16 patients – eight recipients, each paired by a friend or family member. These pairs were either blood type or immunologically incompatible with each other but were compatible with other pairs in the group.
...
"“This collaboration with CPMC enables us to broaden our pool of kidney transplant donors and recipients and treat them at two medical centers separated by only a few miles,” said John Roberts, MD, professor of surgery and chief of UCSF Medical Center Transplant Service. “The proximity of the hospitals means the donated kidney can be swiftly transplanted, minimizing risks to patients. This paired kidney exchange also benefits those on the transplant waiting list and moves up others who are still waiting.”

Review of living kidney donor outcomes, in The Lancet

In The Lancet
Volume 385, Issue 9981, 16–22 May 2015, Pages 2003–2013

Living kidney donation: outcomes, ethics, and uncertainty
Dr Peter P Reese, MD,  Prof Neil Boudville, MD, Prof Amit X Garg, MD

Here's the summary:
"Since the first living-donor kidney transplantation in 1954, more than half a million living kidney donations have occurred and research has advanced knowledge about long-term donor outcomes. Donors in developed countries have a similar life expectancy and quality of life as healthy non-donors. Living kidney donation is associated with an increased risk of end-stage renal disease, although this outcome is uncommon  (less than .5 percent increase in incidence at 15 years). Kidney donation seems to elevate the risks of gestational hypertension and pre-eclampsia. Many donors incur financial expenses due to factors such as lost wages, need for sick days, and travel expenses. Yet, most donors have no regrets about donation. Living kidney donation is practised ethically when informed consent incorporates information about risks, uncertainty about outcomes is acknowledged when it exists, and a donor's risks are proportional to benefits for the donor and recipient. Future research should determine whether outcomes are similar for donors from developing countries and donors with pre-existing conditions such as obesity."


And this...
"In many countries, living kidney donation is the only affordable treatment for kidney failure. This is evident across large regions of India and Pakistan, for example, where chronic dialysis is rationed in units supported by government or community donations, or is only available with payments that are prohibitive for most patients. In this respect, chronic dialysis is viewed as a bridge to a life-saving kidney transplant from a living donor. In many developing countries, the infrastructure to procure deceased-donor organs does not exist.

"Unrelated and incompatible donors
Living kidney donation in unrelated donors (eg, friends, spouses, or distant relatives of the recipient) are becoming more common. In the USA, the proportion of living kidney donations from unrelated donors increased from 30% to 57% between 1999 and 2013. Similar trends are evident in Europe, Australia, and New Zealand.

"This rise in unrelated living kidney donation is largely associated with a declining emphasis on close HLA matches between donor–recipient pairs. With advances in immunosuppressive therapy, the longevity and function of the transplanted organ is now less dependent on the genetic donor–recipient relationship than in the past. The rise in unrelated donors has also been helped by so-called kidney paired donation, a strategy used to overcome donor–recipient incompatibility if the transplant candidate has antibodies to the donor's blood or HLA type. Such antibodies greatly increase the risk of donated-organ rejection and, in the case of anti-HLA antibodies, might develop because of previous pregnancies, blood transfusions, or transplants. As shown in figure 2, registries of incompatible donor–recipient pairs have enabled transplantation to proceed through paired exchanges, or donation chains in which each donor provides a kidney to an unrelated compatible recipient. Paired exchange has been helped by the transportation of living-donor kidneys between centres and by non-synchronous transplants, in which one or more donors wait to donate until new pairs enter the chain. In some cases, a transplantation chain begins when an individual with no relationship to any recipient donates a kidney (termed non-directed donation). In 2012, this type of altruistic donation enabled a 30-transplant chain to proceed."

Recent travels...Nigeria

Nigeria's Daily Independent covers the talk I gave there on Monday:
Exchange Programme’ll Improve Kidney Transplant In Africa – Expert

By Oyeniran Apata, Lagos

A Nobel Prize winner for Economic Science, Professor Alvin Roth, has declared that the poor state of Nigerian patients with chronic renal disease can be improved through effective kidney exchange programme.

Roth identified high cost of management, poor infrastructure, low awareness and non-direct donors as some of the factors contributing to the prevalence of the pitiable conditions in the country and the continent of Africa as a whole.

Delivering a paper as the keynote speaker at the second Covenant University International Conference on African Development Issues tagged, “Biotechnology, ICT, Materials and Renewable Energy: Potential Catalyst for African Development,” Roth lamented that Nigeria with a poor renal registry was able to successfully carry out only 143 Kidney Transplants (KTs) in 10 years against 11,000 carried out successfully in the United States of America.

Professor Ruth in his paper entitled, “Kidney Disease in Nigeria and the U.S. and Possibilities of Co-operation and Mutual Aid,” lamented that despite the huge number of successes recorded in the U.S., America is still falling behind in the treatment of kidney failure.

“I want to talk to you today about how we have taken some initial steps to increase kidney transplant in the U.S. through kidney exchange, and how such a programme might be extended to Africa and be a catalyst to build medical infrastructure in Africa,” he said.

He added that the kidney transfer waiting list in the USA was getting longer year in year out as more people are dying while waiting to be treated.

"In his words he said, “In 2003, 83,000 Americans were in immediate need of a kidney transplant; in 2014, 100,000 Americans were in immediate need of a kidney transplant. More patients on the wait list are dying every year. In 2003, 4,000 Americans died waiting for a kidney transplant, in 2013, 4,500 Americans died waiting for a kidney.”



He lamented that as similar epidemiological data is hard to come by in Africa, the prevalence of chronic renal failure and End Stage Renal Disease (ESRD) have remained high worldwide and the epidemiology has changed significantly in the last decade in industrialised countries, contending that patients’ outcome is still appalling in developing countries.

He added: “There is paucity of information on the magnitude of the burden of renal disease in our environment. Obtaining accurate data is hampered by the poor socio-economic status of most patients with lack of access to specialised care in tertiary institutions, where most of the data are generated.”

Chancellor of the university and General Overseer of the Living Faith Bible Church Worldwide, Dr. David Oyedepo, stated that the conference was aimed at enabling the country to benefit from the wealth of experience of the experts and particularly Roth’s application of economic theory in finding solutions for “real world” problems."

***********
Update: here's some more coverage: Faith-Based Organizations, Private Sector, Crucial to Successes in Kidney Transplantation – Professor Alvin Roth

2nd Covenant University – International Conference on African Development Issues – 2015

I'll speak tomorrow in Nigeria, about kidney exchange and the possibilities it might offer for mutual aid between Africa and the U.S. in battling kidney disease, at the 2nd Covenant University – International Conference on African Development Issues – 2015

"Covenant University, in her continued quest for significant local and global impact, established the International Conference of African Development Issues (ICADI) series. ICADI is aimed at creating a unique platform for making innovative contributions towards value enhancement and capacity development of the black man and indeed, the African continent from the Covenant University context.

"As a sequel to the success of the first International Conference on African Development Issues (ICADI) that was held in 2014, we are again motivated to organize the second edition of ICADI between 11 – 13 May 2015 at the African Leadership Development Centre, Covenant University, Ota. The University has secured the commitment of a Nobel Laureate, Prof. Alvin Roth as the Keynote Speaker. Al Roth is a Professor of Operations Research from Stanford University, USA, who has done a lot of groundbreaking research in the areas of game theory and market design with specific applications to healthcare. The conference has also enlisted other notable experts as guest speakers. The conference will feature keynote addresses, panel/roundtable discussions, research and industry track papers as well as presentations, workshops and exhibitions.

   Dates: May 11 – 13, 2015

     Theme: Biotechnology, ICT, Materials and Renewable Energy: Potential Catalyst for African Development

    Sub themes:
Biotechnology and sustainable development in Africa
ICT and developing the knowledge economy in Africa
Climate change and renewable energy solutions for African Development
Material science and engineering for African development
Policy frameworks for technology-oriented development paradigms in Africa
 
 Target Audience: Professionals and executives of agro-allied, pharmaceutical, health, chemical industries, ICT providers, engineering firms, research institutes, governmental agencies, policy makers, investors, researchers, academic institutions etc."

Kidney exchange in the NY Times Magazine

Kidney exchange and public relations sometimes go hand in hand, which isn't a bad thing at all, since the more people who know about kidney exchange, the more transplants will be possible. A modest 6-transplant non-directed donor chain in California has attracted a nice story in this week's NY Times Magazine: The Great American Kidney Swap by By Malia Wollan.

Here's some of what the NY Times article has to say:

"A law-abiding American in need of a kidney has two options. The first is to wait on the national list for an organ donor to die in (or near) a hospital. The second is to find a person willing to donate a kidney to you. More than half the time, such donor-and-recipient pairs are incompatible, because of differences in blood type or the presence, in the donor’s blood, of proteins that might trigger the recipient’s immune system to reject the new kidney. The genius of the computer algorithms driving the kidney chains is that they find the best medical matches — thus increasing the odds of a successful transplant — by decoupling donors from their intended recipients. In the United States, half a dozen of these software programs allow for a kind of barter market for kidneys. This summer, doctors will most likely complete the last two operations in a record-breaking 70-person chain that involved flying donated kidneys on commercial airlines to several hospitals across the country.
...
"Economists call an arrangement like this a matching market. “It is not fundamental to economic theory to assume people are selfish,” Alvin E. Roth, an economist who teaches at Stanford University, told me. Roth won the Nobel Prize in economics in 2012 for his work using game theory to design matching markets, which pair unmatched things in mutually beneficial ways — students with public schools and doctors with hospitals. In such markets, money does not decide who gets what. Instead, these transactions are more akin to elaborate courtships.

"The classic example of a matching market is the college-admissions process. Every year, tens of thousands of students apply to Harvard University. But just because a student wants a spot in the freshman class and can afford tuition does not mean he gets in. Harvard must also want him to attend. In the case of kidney exchange, this matchmaking happens at a microcellular level. White blood cells contain genetic markers, proteins that help our immune systems distinguish between our bodies and foreign invaders. The more closely a transplant recipient’s genetic markers match a donor’s, the more likely the body is to adopt that foreign kidney as its own rather than attacking it."
*********

The average chain length for nondirected donor chains in the U.S. has lately been around 5, The latest longest chain accomplished 34 transplants (so it involved 68 people, donors and recipients).It's possible that that the number of transplants in the chain in this story was limited by the particular, proprietary commercial software that was used. One of the interesting things about kidney exchange is that most of the software is provided for free by the researchers who develop it, and is described in the open scientific literature. The  software used by the UNOS kidney paired donation pilot program is designed by Tuomas Sandholm and his colleagues at CMU, and Itai Ashlagi (at MIT until next year, when he comes to Stanford) and his colleagues have software that is very widely used by kidney exchange networks and large transplant centers, and the latest version of this software was described in January in the Proceedings of the National Academy of Science.

You can download kidney exchange software from Itai's web page: here I've copied his instructions:

Kidney exchange source code. Instructions for how to compile can be found here. An older version in c# can be found here (for both cycles and chains), which also generates patient-donor pairs as well as compatibility matrices. The software finds an allocation that maximizes the number of transplants using cycles and chains each of a different bounded length. CPLEX is needed to use.

The latest, longest kidney exchange chain, involving 68 people, 34 transplants

The National Kidney Registry has completed a new, long non-simultaneous nondirected donor chain, maybe the longest to date. Here are some stories, from the local press at some of the hospitals involved.

Kidney exchange in which Allegheny General Hospital participates enables 34 transplants
 "A Somerset County man and 33 other renal disease patients received new kidneys this year in an unprecedented national chain of organ transplants, Allegheny General Hospital announced Wednesday.
The North Side hospital is among 26 domestic transplant centers that participated in the exchange, run through March by the nonprofit National Kidney Registry. It is the largest multi-center paired kidney exchange so far in the United States, the registry said."

The final link: UW Hospital completes longest chain of kidney donations

"A Wisconsin woman received the final kidney transplant at the University of Wisconsin Hospital in March, completing the longest chain of kidney donations.

"UW Hospital is a member of the National Kidney Registry, an organization that works to match kidney donors with recipients for transplants. The registry organized the completed kidney chain, which started and ended at UW Hospital.
...
"Of the 68 people in the kidney chain, 34 donors and 34 recipients, five were connected through UW Hospital, Miller said."

D.C., Md., Va. hospitals participate in largest-ever multi-hospital kidney transplant chain
"With 34 donors and 34 recipients, Chain 357, nicknamed a “chain of love,” is the country's largest-ever multi-hospital kidney transplant chain. The National Kidney Registry worked with 26 hospitals across the country to make sure every link of the chain connected.
"Since Jan. 6, the chain has bounced across the country, including stops at MedStar Georgetown Transplant Institute in Washington, D.C.; Walter Reed National Military Medical Center in Bethesda, Md.; University of Virginia Hospital in Charlottesville, Va.; and two bouts at the University of Maryland Medical Center in Baltimore, Md." 

Kidney exchange in Switzerland

Here's a paper reviewing kidney exchange around the world, from an Australian perspective (Paolo Ferrari has been one of the Australian pioneers), and advocating for a national kidney exchange program in Switzerland...

Kidney paired donation: a plea for a Swiss National Programme

Karine Hadayaa,b, Thomas Fehrc, Barbara Rüsic, Sylvie Ferrari-Lacrazd, Jean Villardd, Paolo Ferrarie,f

a Service of Nephrology. Geneva University Hospital, Geneva, Switzerland
b Service of Transplantation, Geneva University Hospital, Geneva, Switzerland
c Service of Nephrology and Histocompatibility laboratory, Zurich University Hospital, Switzerland
d Transplant Immunology Unit and National Reference Laboratory for Histocompatibility (LNRH), Division of Immunology, Allergy and Laboratory Medicine, Geneva, Switzerland
e Department of Nephrology, Prince of Wales Hospital and Clincal School, University of New South Wales, Randwick, Sydney, Australia
f Organ and Tissue Authority, Australia

Summary

Growing incidence of end-stage renal disease, shortage of kidneys from deceased donors and a better outcome for recipients of kidneys from living donor have led many centres worldwide to favour living donor kidney transplantation programmes. Although criteria for living donation have greatly evolved in recent years with acceptance of related and unrelated donors, an immunological incompatibility, either due to ABO incompatibility and/or to positive cross-match, between a living donor and the intended recipient, could impede up to 40% of such procedures. To avoid refusal of willing and healthy living donors, a number of strategies have emerged to overcome immunological incompatibilities. Kidney paired donation is the safest way for such patients to undergo kidney transplantation. Implemented with success in many countries either as national or multiple regional independent programmes, it could include simple exchanges between any number of incompatible pairs, incorporate compatible pairs and non-directed donors (NDDs) to start a chain of compatible transplantations, lead to acceptance of ABO-incompatible matching, and integrate desensitising protocols. Incorporating all variations of kidney paired donation, the Australian programme has been able to facilitate kidney transplantation in 49% of registered incompatible pairs. This review is a plea for implementing a national kidney paired donation programme in Switzerland.

Swiss Med Wkly. 2015;145:w14083