Germany’s move toward kidney paired exchange and non-directed donation: lessons

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https://www.kireports.org/article/S2468-0249(26)02930-X/fulltext

EDITORIAL
July 09, 2026
Open Access
Germany's move toward kidney paired exchange and non-directed donation: governance lessons from abroad
Louise Benning1 Send email to louise.benning@med.uni-heidelberg.de ∙ Wan-Zi Lu2 ∙ Klemens Budde3 ∙ Michelle Josephson4
Kidney International Reports, 2026

In 1986 F.T. Rapaport outlined a core idea behind kidney paired exchange: that a registry can coordinate incompatible donor-recipient pairs so that incompatibility becomes a solvable matching problem rather than a barrier to transplantation1. Today, forty years later, Germany is on the verge of making that coordination legally possible. In October 2025, the German federal cabinet approved a draft amendment to the Transplantation Act that would enable kidney paired exchange and non-directed anonymous living kidney donation, while strengthening donor protection and establishing the legal basis for a national program with a central matching function. If operationalized, Germany would move from a restrictive framework for living kidney donation, historically tied to a strict requirement of a close relationship between donor and recipient, toward a governance model that supports kidney exchange and donor chains at scale.

This moment is internationally relevant because Germany now faces the same policy questions that have shaped kidney paired exchange implementation elsewhere. The impending change creates an opportunity to learn from other countries on key issues, including who should govern a registry, which safeguards ensure legitimacy, how to balance privacy and transparency regarding organ quality, and how to promote access without risking commercialization. Rather than being mere technical considerations, these questions are constitutive for the legitimacy and public trust required for kidney paired exchange to function as a public good.

Historical lessons on altruism, donor safeguards, and public legitimacy

Early debates about living kidney donation repeatedly straddled suspicion and admiration. In the 1970s, living non-related and particularly non-directed donors were sometimes portrayed in medical discourse as psychologically unstable or even pathological, raising concerns about whether such donors should be permitted to proceed2,3. Interestingly, Fellner and Schwartz reported broad public support for donation beyond family ties, with 54% participants of a U.S.-based survey stating they would probably or definitely donate to a stranger in need (compared with 93% to a family member), demonstrating that public morale did not necessarily align with professional paternalistic gatekeeping back then3. Moreover, the Transplantation Society explicitly recognized altruism in a statement as a valid motivation rather than an inherently pathological one2. These early debates highlighted that living donation already relied not only on individual motivation but also on institutional trust and credible information.

History offers two more lessons: (i) Donor protection and respecting donor agency are not mutually exclusive: psychosocial assessment, independent counseling, and rigorous consent procedures can reduce coercion and misunderstanding while still recognizing donors as autonomous agents making a deliberate moral choice. (ii) Public legitimacy is fragile and easily lost: If suspicion dominates, programs risk being viewed as illegitimate or unfair. If, on the other hand, enthusiasm and implementation moves faster than safeguards, programs risk scandal, backlash and, ultimately, lose public support. Germany's 2012 transplant scandal, involving the manipulation of patient data to improve waiting-list positions, offers a cautionary example of how deficits in transparency and accountability can erode trust in transplantation more broadly and disrupt an entire program4.

Why coordination is political

Rapaport outlined a national registry for kidney paired exchange which later became rather clearinghouses and national programs1. Ethical discussions in the 1990s framed kidney paired exchange as ethically permissible and socially desirable if programs address risks and benefits, informed consent, privacy, and seek public acceptance5. When kidney paired exchange began to grow in the United States in the early 2000s, program architecture became central: regional and state-based clearinghouses emerged in a fragmented health care system6. This experience demonstrates a persistent trade-off where decentralization can limit match potential and complicate governance while central coordination can increase efficiency but raises questions of accountability, transparency and public trust7.

As kidney paired exchange grew, market design approaches helped formalize how to maximize transplants6,7. The ethical core, however, remained largely unchanged, meaning that kidney paired exchange depends on collective coordination and shared rules, enforcing that legitimacy must be earned not only through outcomes (more transplants) but also through careful process (ensuring fairness, transparency, and safeguards).

The reform begins after the law

Germany's 2025 cabinet decision is best understood as a legal basis of a governance project. The draft reform explicitly points towards a central body to coordinate matching for paired exchange and non-directed anonymous donation, binding medical guidelines that set eligibility criteria and procedural rules for matching and implementation, and strengthened donor protections, including psychosocial evaluation and independent donor accompaniment. For program implementation, three policy choices seem decisive:

1) Registry governance and accountability
A kidney paired exchange program is only as credible as the institution that runs it. Germany must decide how the central matching authority is governed, audited, and protected from potential conflict of interests. Key questions include how criteria are adopted (which organs will be accepted in paired exchange?), how ties will be broken (for example, if two possible match runs yield the same number of transplants, which run is chosen? If different chains could be started by a non-directed donor, which one will be chosen?), and how outcomes are reported. The draft's emphasis on a central matching authority raises the opportunity for national standardization but also increases the need for transparent oversight.

2) Medical guidelines in rulemaking
Germany's system relies on medical self-governance, with the Federal Medical Association (Bundesärztekammer, BÄK) issuing binding guidelines in (transplantation) medicine. The 2025 draft reform extends this guideline-based governance to kidney paired exchange and non-directed anonymous donation, placing eligibility criteria, procedural standards, and matching rules largely in the hands of BÄK rulemaking. Because these guidelines will determine eligibility and operational rules, the program's legitimacy will hinge on whether guideline development is transparent, evidence-based, inclusive of all stakeholders, and publicly accountable.

3) Visible and trusted donor safeguards

Historically, controversies around living donation have led to suspicious perceptions regarding coercion, undue influence, and commercialization. Germany's draft reform addresses this by strengthening donor protection: in addition to the regular mandatory psychosocial counseling and evaluation through an independent commission of the regional physicians' chamber, the transplant centers must appoint an independent living donation companion to support donors throughout the process.

These instruments matter not only clinically, but also socially as they can communicate to the public that the state and profession are committed to optimal donor welfare while also reducing the likelihood that isolated adverse events will delegitimize an entire program.

Guardrails: Issues to watch early

Germany's comparably late adoption of kidney paired exchange provides an opportunity to build legitimacy from the very beginning. This, however, requires attention to at least three dimensions that can influence participation and trust: transparent reporting, equity and access, as well as professional culture (Table 1). 
https://www.kireports.org/action/showFullTableHTML?isHtml=true&tableId=tbl1&pii=S2468-0249%2826%2902930-X

When guardrails are not implemented or at least not visible, patients can be failed in predictable, structural ways when incentives, discretion and oversight do not align, as is currently a concern in the US kidney paired exchange9. For example, questions arise around registries that effectively rule themselves rather than operating within a publicly accountable allocation framework: hospitals must pay to participate, and registries retain discretion over where "bonus" kidneys are allocated to. This would pose a problem because donated kidneys would, in effect, no longer be treated as a national public resource distributed through transparent rules to the best available candidate, but rather as network assets distributed through internal policies. Further, incentives and penalties could intensify pressure on hospitals to pay higher fees to remain in the system, which means no less than monetizing organ flow. Financial conflicts of interest and reduced transparency on behalf of network operators would pose another central threat as this means that not solely patient welfare but potentially revenue might be driving forces, particularly when there is limited government oversight.

These structural concerns matter most when translated into human risk. Evidently, the most emotionally potent failure happens when paired exchange is not a true swap anymore, for instance in non-simultaneous chains or voucher donation, which can create an asymmetry of risk that pairs may not fully understand when being counseled. If not carefully governed and communicated, this can undermine trust in the program. In this context, however, it is important to note that some of these vulnerabilities may be amplified by the US insurance and reimbursement environment and may be less applicable to publicly regulated, solidarity-based European healthcare systems.

The German system should therefore seek to overcome these limitations by embedding KPE within a publicly accountable allocation framework: the matching algorithm, priority rules, and use of chain-ending kidneys should be specified in advance, transparent to participating centers and regulators, and subject to independent audit. Equity should be actively monitored through regular public reporting of participation, match rates, waiting times, and outcomes across patient groups, including highly sensitized patients and those with difficult-to-match blood types. Established European programs, such as STEP in Scandinavia and the Dutch KPE program, offer relevant experience that can inform the development of transparent matching and governance structures in Germany.

Ultimately, decades of debates and global experience have shown that kidney paired exchange is not merely a technical matching problem but, foremost, a challenge of governance. Germany's reform is therefore less a technical innovation than an institutional one: its success will depend on whether a national program is implemented with clear accountability, transparent rules, and strong, independent donor safeguards. If implemented well, kidney paired exchange and non-directed donation can expand access while strengthening public trust in transplantation, particularly living donation. More broadly, establishing such trust-based, well-governed frameworks may also shape the societal and institutional conditions needed for future reforms in the German transplant system, including the introduction of donation after circulatory death programs and the potential shift toward an opt-out organ donation policy.