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Author Topic: Kidney Exchange to Overcome Financial Barriers to Kidney Transplantation  (Read 2938 times)

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Offline Clark

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http://onlinelibrary.wiley.com/doi/10.1111/ajt.14106/abstract?campaign=wolacceptedarticle

Kidney Exchange to Overcome Financial Barriers to Kidney Transplantation
Authors
      M. A. Rees, et al.,
      First published: 19 December 2016
      DOI: 10.1111/ajt.14106
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.
Unrelated directed kidney donor in 2003, recipient and I both well.
620 time blood and platelet donor since 1976 and still giving!
Elected to the OPTN/UNOS Boards of Directors & Executive, Kidney Transplantation, and Ad Hoc Public Solicitation of Organ Donors Committees, 2005-2011
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Offline Clark

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http://onlinelibrary.wiley.com/doi/10.1111/ajt.14183/full

Editorial
Financial Incompatibility and Paired Kidney Exchange: Walking a Tightrope or Blazing a Trail?
A. C. Wiseman, J. S. Gill
24 January 2017
DOI: 10.1111/ajt.14183

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.

In this issue, Rees et al advance a novel strategy to increase living donor kidney transplantation through kidney paired exchange (KPE) [1]. Global kidney exchange (GKE) proposes the use of biologically compatible but “financially incompatible” living donors and recipients from an underserved country to increase KPE in the United States. The health care savings generated by removing US patients from dialysis would be used to cover the cost of transplantation and posttransplant care including immunosuppressant drugs for the recipient in their home country for a period of 5 years in exchange for the compatible pair's participation in KPE. The report describes the first application of GKE in which an indigent biologically compatible married couple in the Philippines who could not afford to proceed with living donor kidney transplantation was brought to the United States where the wife's donation of a kidney ultimately facilitated KPE transplants for 10 American patients as well as for her husband.
While we applaud Rees et al's efforts to advance a novel approach to increase living donor kidney transplantation, there are numerous considerations that require equipoise, including the legality of this new definition of “financial incompatibility.” The Charlie Norwood Act amended the National Organ Transplant Act (NOTA) to allow human organ paired donation between biologically incompatible living donors and recipients [2]. The use of compatible donors and recipients on the basis of financial incompatibility may not be encompassed in current interpretation of NOTA. While the authors offer a thoughtful rebuttal to this consideration, expansion of GKE would probably require amendment of NOTA.
The risk of exploitation (real or potential) in GKE is a significant concern. The authors state that GKE is in keeping with the ethical and legal principles of organ donation within the United States, by adhering to the concept of altruism and lack of financial consideration, and that no individual was harmed or unduly influenced by the paired exchange. However, this exchange can still be viewed as an inequitable transaction, for even if an individual derives benefits from a transaction, this in itself does not justify the transaction. At the individual level, the indigent Filipino couple were selected for GKE based on their likelihood of facilitating other transplants without further details regarding how this particular couple was identified, if other donor/recipient pairs were considered, or if specific criteria were applied. It is unclear whether the patient received a kidney of similar quality to the organ he would have received from his spouse. The concern of exploitation could be diminished if a biologically incompatible pair had initiated the chain (but would increase the logistical complexity), or if transplants for Filipino patients with biologically incompatible living donors were also facilitated. 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. Furthermore, by diverting care to another health system it could be argued that such a strategy may undermine efforts to advance development of transplant resources in the developing countries. Ultimately, the selection of the Filipino pair based on their ability to facilitate transplants in the United States commodifies the donor and recipient, the Filipino donor kidney was potentially undervalued, and the disproportionate benefit to American patients and the limited posttransplant care provided to the Filipino recipient were probably inequitable.
Moving forward, the potential for undue influence in GKE will be an important consideration. The inability to pay for lifesaving dialysis (as in the case of the Filipino recipient) places the potential donor in a vulnerable position. This risk of unduly influencing donors is mitigated in the United States, where access to dialysis is ensured. Thus, perhaps a less contentious strategy to increase living donation would be to address the issues facing “financially incompatible but biologically compatible” donor pairs within the United States. Given the ethical and logistical considerations with GKE, alternative strategies such as providing the recipient in a compatible pair an opportunity to receive a younger or better HLA-matched donor kidney through KPE [3], or expanding programs such as the National Living Donor Assistance Center to include reimbursement for lost wages [4, 5] would seem more feasible strategies to increase living donor transplantation compared to GKE described by Rees et al.
In summary, this case of GKE represents a well-intentioned first experience that again tests the ethical questions applied to kidney donation. When considering the worldwide underserved chronic kidney disease population, the number of potential financially incompatible but biologically compatible pairs may be staggering. Rather than rushing forward, it is more likely that one must walk a tightrope in expanding GKE from a case report to an institutional construct and will require sensitivity to the ethical pitfalls that have limited novel approaches that have come before it.
Unrelated directed kidney donor in 2003, recipient and I both well.
620 time blood and platelet donor since 1976 and still giving!
Elected to the OPTN/UNOS Boards of Directors & Executive, Kidney Transplantation, and Ad Hoc Public Solicitation of Organ Donors Committees, 2005-2011
Proud grandpa!

 

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