Paired Exchanges, Chain Donations, and Organ Markets

This chapter introduces the use of an innovation called “paired exchange,” a way to encourage donations even when there is no match. The chapter shows a graphic presentation to simply describe the idea of paired donation exchange. It explains the risks of paired exchange for the donors' and recipients' perspective, arguing that the risks were the same from the donors' perspective, while the outcomes from the recipients' perspective would be much better as a result of receiving a histocompatible organ than they would be if they received their own designated recipient's organ. The chapter also offers some legal questions after lawyers wondered whether a paired kidney exchange was a sort of barter and thus the beginning of a gray market in organs. Ultimately, the chapter looks at another suggestion of creating a serial chain of donor–recipient pairs, with the world's first kidney–liver swap took place in 2017.

The Countdown Begins

This chapter begins with Deb Porter Gill and the author's discussion about directed donation after their chain in the paired exchange called off. The chapter then displays Deb's frustrations with the Mayo Clinic's lack of communication and attention to detail in the process of her impending surgery and other necessary tests. It then turns to highlight the author's biggest obstacle: the dry ice saga. The author received an email from Mayo, with template language saying they were required to recheck blood for HIV and hepatitis within twenty-eight days of all organ donation surgeries. The chapter describes how the author struggled to find a dry ice source and shipment to ship the HIV-hepatitis lab kit back to Mayo on time.

Living Kidney Donation: Practical Considerations on Setting Up a Program

Living kidney donation represents the best treatment for end stage renal disease patients, with the potentiality to pre-emptively address kidney failure and significantly expand the organ pool. Unfortunately, there is still limited knowledge about this underutilized resource. The present review aims to describe the general principles for the establishment, organization, and oversight of a successful living kidney transplantation program, highlighting recommendation for good practice and the work up of donor selection, in view of potential short- and long-terms risks, as well as the additional value of kidney paired exchange programs. The need for donor registries is also discussed, as well as the importance of lifelong follow up.

In Search of a Better Outcome: Opting Into the Live Donor Paired Kidney Exchange Program

Background: Live donor (LD) kidney transplantation is the best option for patients with end-stage kidney disease (ESKD). However, this may not be the best option if a patient’s donor is older and considerably smaller in weight. Patient (A) with a less than ideal donor (Donor A) might enter into a live donor paired exchange (LDPE) program with the hopes of swapping for a better-quality organ. A second patient (B) who is in the LDPE may or may not benefit from this exchange with Donor A. Methods: This medical decision analysis examines the conditions that favor Patient A entering into the LDPE compared to directly accepting a kidney from their intended donor, as well as the circumstances where Patient B also benefits by accepting a lower-quality organ. Results: Under select circumstances, a paired exchange could benefit both Patients A and B. For example, a 30-year-old Patient A with a lower-quality donor might gain 1.201.521.84 quality adjusted life years (QALYs) by entering into a LDPE for a better-quality kidney, whereas a 60-year-old Patient B might gain 0.931.031.13 QALYs by accepting Donor A’s kidney rather than waiting longer in the LDPE. The net benefit (or loss) of entering the LDPE differs by recipient age, donor organ quality, likelihood of Patient B being transplanted in LDPE, and likelihood of Patient A finding an ideal donor in the LDPE. Conclusion: This study shows there are ways to increase live donor utilization and effectiveness that require further research and potentially changes to the LDPE process.