Showing posts with label kidneys. Show all posts
Showing posts with label kidneys. Show all posts

Monday, March 11, 2024

Global disparities in kidney disease and care

 Here's a report on the availability of treatment of kidney disease around the world.  If you are unlucky enough to have kidney failure (which is a top 10 cause of death), it's good to be in North America or Western Europe. Most countries (70%) have at least a minimal capacity to perform transplants. But if I read the map correctly, preemptive kidney transplants (i.e. transplants before dialysis, in map D below) are relatively common only in the U.S., Britain, and Norway. (And worldwide, a transplant costs less than two years of dialysis...)

Bello, A.K., Okpechi, I.G., Levin, A., Ye, F., Damster, S., Arruebo, S., Donner, J.A., Caskey, F.J., Cho, Y., Davids, M.R. and Davison, S.N., 2024. An update on the global disparities in kidney disease burden and care across world countries and regions. The Lancet Global Health, 12(3), pp.e382-e395.

"Background

"Since 2015, the International Society of Nephrology (ISN) Global Kidney Health Atlas (ISN-GKHA) has spearheaded multinational efforts to understand the status and capacity of countries to provide optimal kidney care, particularly in low-resource settings. In this iteration of the ISN-GKHA, we sought to extend previous findings by assessing availability, accessibility, quality, and affordability of medicines, kidney replacement therapy (KRT), and conservative kidney management (CKM).

...

"Findings

The literature review used information on prevalence of chronic kidney disease from 161 countries. The global median prevalence of chronic kidney disease was 9·5% (IQR 5·9–11·7) with the highest prevalence in Eastern and Central Europe (12·8%, 11·9–14·1). For the survey analysis, responses received covered 167 (87%) of 191 countries, representing 97·4% (7·700 billion of 7·903 billion) of the world population. Chronic haemodialysis was available in 162 (98%) of 165 countries, chronic peritoneal dialysis in 130 (79%), and kidney transplantation in 116 (70%). However, 121 (74%) of 164 countries were able to provide KRT to more than 50% of people with kidney failure. Children did not have access to haemodialysis in 12 (19%) of 62 countries, peritoneal dialysis in three (6%) countries, or kidney transplantation in three (6%) countries. CKM (non-dialysis management of people with kidney failure chosen through shared decision making) was available in 87 (53%) of 165 countries. The annual median costs of KRT were: US$19 380 per person for haemodialysis, $18 959 for peritoneal dialysis, and $26 903 for the first year of kidney transplantation. Overall, 74 (45%) of 166 countries allocated public funding to provide free haemodialysis at the point of delivery; use of this funding scheme increased with country income level. The median global prevalence of nephrologists was 11·8 per million population (IQR 1·8–24·8) with an 80-fold difference between low-income and high-income countries. Differing degrees of health workforce shortages were reported across regions and country income levels. A quarter of countries had a national chronic kidney disease-specific strategy (41 [25%] of 162) and chronic kidney disease was recognised as a health priority in 78 (48%) of 162 countries.



Figure 3 Worldwide incidence of general, deceased-donor, living-donor, and pre-emptive kidney transplantations (cases pmp per year) (A) Incidence of kidney transplantation. (B) Incidence of deceased-donor kidney transplantation. (C) Incidence of living-donor kidney transplantation. (D) Incidence of pre-emptive kidney transplantation. pmp=per million population

Even in the U.S., we aren't able to supply enough transplantable kidneys for everyone who needs one. Domestic kidney exchange helps fill some of the gap, but the gap, and the resulting number of premature deaths, is still huge.  It's enough to make you think about global kidney exchange...

Thursday, March 7, 2024

Increasing kidney transplants by reducing discards of risky kidneys

 Kidneys from deceased donors are too often discarded. Dr. Joshua Mezrich, a transplant surgeon at U. Wisconsin, writes in Stat about how to reduce the rate at which high risk kidneys are discarded (after being on ice for a long time while being rejected by many patients). He proposes that kidneys that can be identified as high risk even before being recovered from the deceased donor  be offered promptly to patients/transplant centers that have indicated a willingness to take them. It would require transplant centers to keep current blood tests available for patients who are candidates for high risk kidneys (who may be candidates in part because they are far from the front of the waiting list...)

Too many donor organs go to waste. Here’s how to get them into the patients who need them  By Joshua Mezrich, Stat, March 2, 2024 

"So here is the fix. High-risk kidneys should immediately be offered to transplant centers that opt into a high-risk program as an open offer to their wait list rather than to a specific patient, on a rotating schedule with weight put on proximity to the donor hospital. Ideally the offer should be made prior to procurement of the organ, with final acceptance once it is removed and anatomy and biopsy results can be reviewed by the accepting surgeon.

"If the biopsies show significant disease and the function of the kidney would be inadequate for a recipient, the receiving center can request both kidneys for a single patient, termed a dual transplant (which has been shown to have good outcomes). If a center accepts a kidney, it can then choose the patient who will benefit the most from the transplant and has a long predicted wait time for a low-risk transplant, with informed consent. That would entail a discussion with the patient about expectations regarding the quality of the kidney, how long and how well it might work, and how much longer they might need to wait for a lower-risk kidney. The ability to match the kidney to a recipient is important, as high-risk kidneys need to go into patients who can tolerate the slow initial function. Centers that opt into the high-risk program will need to maintain an updated list of informed patients who are predicted to benefit from these kidneys, who can be called in as soon an offer becomes available. For them, taking a chance beats remaining on dialysis.

Thursday, February 8, 2024

Morally contested markets on NPR's Planet Money (including kidneys, revenge and insider trading)

 The NPR show Planet Money discusses kidney sales, revenge, and insider trading. The hosts are enthusiastic about at least thinking about all of these.* 

They start with a discussion of organ transplants, and in the first 9 minutes of the show you can hear some parts of an interview with me, discussing tradeoffs (and possible titles for a book I'm working on).  Then they talk to Siri Isaksson about retaliation, and after that to Chester Spatt about insider trading.

 

They write:

"There are tons of markets that don't exist because people just don't want to allow a market — for whatever reason, people feel icky about putting a price on something. For example: Surrogacy is a legal industry in parts of the United States, but not in much of the rest of the world. Assisted end-of-life is a legal medical transaction in some states, but is illegal in others.

"When we have those knee-jerk reactions and our gut repels us from considering something apparently icky, economics asks us to look a little more closely.

"Today on the show, we have three recommendations of things that may feel kinda wrong but economics suggests may actually be the better way. First: Could the matching process of organ donation be more efficient if people could buy and sell organs? Then: should women seek revenge more often in the workplace? And finally, what if insider trading is actually useful?"

##########

*In their enthusiasm, they mis-state how few kidney exchanges were done before my colleagues and I got involved. (There weren't many, but more than two...)

As it happens, earlier this week I blogged about another interview, in the NYT, by Peter Coy (in print, not audio) that focused on kidney exchange:

Tuesday, February 6, 2024

Update (5pm): now I see that on the Planet Money site there's a transcript.  Here's the part that I participated in:

SYLVIE DOUGLIS, BYLINE: This is PLANET MONEY from NPR.

(SOUNDBITE OF COIN SPINNING)

MARY CHILDS, HOST:

A couple decades ago, Al Roth was working on solving this problem - people who needed kidneys weren't getting matched effectively with people who had kidneys to donate.

AL ROTH: Part of the kind of work I do is called matching theory.

GREG ROSALSKY, HOST:

Al helped create this, like, beautiful, elegant algorithm that would match kidney donors with recipients.

CHILDS: You obviously won a pretty big prize for this work.

ROTH: I did. I recommend it.

CHILDS: OK. Yeah (laughter). You like the prize. It's a good prize.

ROTH: Yeah.

CHILDS: That's good to know.

ROTH: A week long of parties.

CHILDS: The prize he won? - it was the Nobel Prize in economics.

ROSALSKY: As you might know, Al's matching work vastly improved the way people get kidneys and saved literally thousands of lives. Like, in the year 2000, before Al's work, there were only two paired kidney transplants - two. Thanks to Al's algorithm, there are now about a thousand per year.

CHILDS: But, Al says, his Nobel Prize-winning algorithm - it isn't even the best way to get people kidneys. Technically, he says, the best way is to grow kidneys in a lab, so it's not even the second-best way.

I'm just envisioning you doing all this matching work knowing that this is, like, a little goofy. Like...

ROTH: Oh.

CHILDS: ...There's a easier way.

ROTH: I hope it's a lot goofy...

CHILDS: (Laughter).

ROTH: ...The work I'm doing, anyway.

CHILDS: (Laughter).

ROTH: No, no. That's right. So could we figure out a way to have more donors to have fewer deaths? I bet we could.

ROSALSKY: OK, so there is a much easier, more efficient way to get people kidneys. It's the way people get most things - with money. Like, what if we could just buy and sell organs?

ROTH: Oh, we'd have a lot more organs. That's how we get most of our stuff. There's a famous passage quoted from Adam Smith, which I'm going to paraphrase, but it says something like, it's not through the generosity of the butcher and the baker that you get your food. You buy it from them. It's how they - that's how they sustain their families - is by selling you food. And that's how you get food, and that's why there's enough food.

CHILDS: Right. The kidney market already has supply and demand. It just doesn't have prices to balance them because buying and selling kidneys is illegal in basically the entire world. So here we are. We don't have enough kidneys. We desperately need more, and yet, we refuse to pay more than $0 for them.

ROSALSKY: And as Al saw while working on kidneys, people had moral objections to the idea of paying for organs. They had concerns that just didn't really make sense to him as an economist.

ROTH: But when I started to look, it turns out there are lots of markets like that.

CHILDS: Lots of markets where people just don't want to allow a market. They feel icky about putting a price on something. Al has a list - for example, surrogacy - a legal and flourishing industry in much of the U.S., not in much of the rest of the world; assisted end of life - perfectly fine medical transaction in Oregon, illegal where I am in Virginia.

ROSALSKY: Al is actually working on a book about all of this.

ROTH: Its working title is "Repugnant Transactions And Controversial Markets." And the idea is that sometimes economists have perfectly good ideas that other people don't think are perfectly good.

ROSALSKY: Al has sort of made his own little subdiscipline in economics about this.

ROTH: "Ickonomics" (ph), "Yuckonomics" (ph) - you know, I trade in book titles. I'm open to suggestions.

CHILDS: You can email Al with your book title suggestions, though honestly, that's kind of hard to beat. In the meantime, when we have those knee-jerk reactions and our gut repels us from considering the icky thing, economics would like to humbly submit that maybe we should.

(SOUNDBITE OF JORDACHE V. GRANT AND SKINNY WILLIAMS' "OLDER HEADS")

CHILDS: Hello, and welcome to PLANET MONEY. I'm Mary Childs.

ROSALSKY: And I'm Greg Rosalsky. Today on the show, we apply an elegant economic framework to Al's market, the trading of human organs, to whether or not we should exact revenge on our enemies, and to whether or not we should trade on inside information.

(SOUNDBITE OF JORDACHE V. GRANT AND SKINNY WILLIAMS' "OLDER HEADS")

CHILDS: When we face difficult situations that don't have an absolutely clear right answer, economist Al Roth says borrowing tools from economics can be useful.

ROTH: Economists deal in trade-offs, and one of the things about trade-offs is you have to say to yourself, supposing there's something we really don't like, what will happen if we ban it? And if the answer is it won't go away, but it'll go underground or become criminalized or become very irregular, then you might prefer to regulate it rather than ban it.

ROSALSKY: And there are real problems with banning things. For example, remember that time we tried to ban alcohol, like, in the 1920s and 1930s?

ROTH: We discovered that it gave rise to a big criminal economy and didn't completely wipe out alcohol at all. So we legalized it. And the legal market for alcohol, with all its problems, is a lot nicer in many ways, a lot more socially useful than the criminal market - you know, Al Capone and the Saint Valentine's Day massacre and, you know, Eliot Ness.

CHILDS: Alcohol, as you may know, is legal today. Selling kidneys - no, not legal - with kidneys, we are in our Prohibition era.

ROTH: There is a black market for kidneys. And often it's pretty terrible because the almost-universal laws against compensating kidney donors have driven that market underground. And what underground often means is out of the hospitals and into hotel suites and apartments...

CHILDS: Eugh (ph).

ROTH: ...And - yes, so medically very bad, as well as, you know, not just illegal but dealing with criminals - medically very bad, bad for the donors, bad for the recipients.

CHILDS: And that's what we have today. That's the market we have chosen. We have the black market with money and the legal market with no money.

ROSALSKY: So Al has been thinking about solutions to this. Like, what can we do realistically to incentivize more kidney donations? How else could we go about creating a market for kidneys to be, as Al likes to put it, more generous to kidney donors?

CHILDS: And when Al thinks about how to design a market, he prioritizes investigating what exactly it is that we're objecting to so he can build a market that fixes or avoids those problems. And in the case of kidneys...

ROTH: There are metaphysical objections. You know, it's just wrong. But the objections that seem to touch on the world seem to say that you can't do this without exploiting poor people because poor people are so vulnerable that just offering them money takes away their agency.

CHILDS: The first reaction is just a gut reaction, which doesn't help inform Al on design. The second reaction is that money can be coercive, that if people have no money and you offer them money to participate in a study, they might have to do the study, especially if you offer a huge amount, like a life-changing amount of money. It's just too compelling. They wouldn't have a choice.

ROSALSKY: This argument does strike Al as unreasonable.

ROTH: There's lots of jobs that we pay people to do because otherwise no one would do them. And you can earn a decent living being a meatpacker. But that's one of the things that bothers people. They say, why should we allow a market that will be mostly - most of the participants will be in the lower parts of the income range? And of course, that isn't very sympathetic to people who are lower income, right? In other words...

CHILDS: Right.

ROTH: ...We need jobs that people with lower income can get. That's why they have some income - is that there are jobs.

CHILDS: Luckily, there is a really obvious, easy solution to this objection - just solve poverty.

ROTH: There'd be a lot less repugnance to monetary transactions if there was no income inequality.

CHILDS: (Laughter).

ROTH: If you wanted to sell me your kidney, but we all had the same income and the same prospects, it just might not be a big thing.

CHILDS: OK, failing that, Al mentioned another way to create a kidney market, a way to get kidneys only from people who aren't that poor - a tax break.

ROTH: People who are wealthy enough to benefit from tax credits on income tax aren't the poorest of the poor. So it might be that the way to start paying kidney donors is to say, we will give you a tax break on everything after the first $10 million of income in the year that you - you know, and then only hedge fund managers would donate kidneys, and that would be repugnant.

CHILDS: But there's a twisted logic to it because at least they could - like, should something go awry in the surgery or in the...

ROTH: Yeah, they'd be fine. They'd be fine. Yeah.

ROSALSKY: Perfect. Like, now we have a few ideas of how to make this happen without paying people for kidneys. We could resolve income inequality, or we could just, you know, do a tax credit and receive only hedge fund manager kidneys. And - right? - there's something a little goofy about all this because these solutions are trying to account for objections that are just hard to design around 'cause those objections are at least partly stemming from some messy human feeling or intuition that just won't let us exchange things in the normal way.

CHILDS: So do you think there'll ever be a U.S. market for kidneys?

ROTH: Well, I think we're not doing a good job yet and that we ought to find a way to be more generous to donors so that we have more of them.

CHILDS: And what that looks like - you're open to suggestion?

ROTH: I'm open to suggestions.

Sunday, January 21, 2024

Legislative proposals to help living kidney donors

 Martha Gershun brings us up to date on various proposed pieces of legislation to help organ donors and increase access to transplants.

Legislative Efforts to Support Living Kidney Donors,  by Martha Gershun, Guest Blogger

"As a member of the Expert Advisory Panel to the Kidney Transplant Collaborative, I have been honored to provide input during the development of the organization’s priority legislation, the Living Organ Volunteer Engagement (LOVE) Act.  This legislation would help build a comprehensive national living organ donor infrastructure that would support a national donor education program, create a donor navigator system, ensure appropriate donor cost reimbursement, collect essential data, and improve all aspects of living organ donation across the country, substantially reducing barriers that limit participation today.

Key provisions of the LOVE Act would:

  • Provide reimbursement for all direct and indirect costs for living donation, including lost wages up to $2,500 per week.
  • Provide life and disability insurance for any necessary care directly caused by donation.
  • Modify NLDAC rules so neither the recipient’s income nor the donor’s income would be considered for eligibility.
  • Provide for new public education program on the importance and safety of living organ donation.
  • Provide for new mechanisms to collect and analyze data about living organ donation to enable evidence-based continuous process improvement.

Numerous other federal proposals are also currently vying for support to address barriers to living donation on a national level.  They include:

Living Donor Protection Act (H.R. 2923, S. 1384)

  • Prohibits insurance carriers from denying, canceling, or imposing conditions on policies for life insurance, disability insurance, or long-term care insurance based on an individual’s status as a living organ donor.
  • Specifies that recovery from organ donation surgery constitutes a serious health condition that entitles eligible employees to job-protected medical leave under the Family and Medical Leave Act.

Organ Donor Clarification Act (H.R. 4343)

  • Clarifies that reimbursement to living organ donation is not “valuable consideration” (I.e., payment), which is prohibited under the National Organ Transplant Act (NOTA)
  • Allows pilot programs to test non-cash compensation to living organ donors.
  • Modifies NLDAC rules so the recipient’s income would no longer be considered for eligibility.

Living Organ Donor Tax Credit Act (H.R. 6171)

  • Provides a $5,000 federal refundable tax credit to offset living donor expenses.

Honor Our Living Donor (HOLD) Act (H.R. 6020)

  • Modifies NLDAC rules so the recipient’s income would no longer be considered for eligibility.
  • Requires public release of annual NLDAC report.

Helping End the Renal Organ Shortage (HEROS) Act

  • Provides a $50,000 refundable federal tax credit over a period of five years for non-directed living kidney donors.
############
And here's one more, from the Coalition to Modify NOTA



Thursday, December 21, 2023

Cash for kidneys report in the Telegraph

 The Telegraph has this story, by Samuel Lovett, Nandi Theint,  and Nicola Smith. For some reason I can't copy the headline, but the URL is pretty informative: https://www.telegraph.co.uk/global-health/science-and-disease/kidney-organ-trafficking-scandal-private-healthcare-india-myanmar/   3 December 2023 • 9:00am

"One of the world’s biggest private hospital groups is embroiled in a ‘cash for kidneys’ racket in which impoverished people from Myanmar are being enticed to sell their organs for profit.

"India’s Apollo Hospitals, a multi-billion dollar company with facilities across Asia, boasts that it conducts more than 1,200 transplants a year, with wealthy patients arriving for operations from all over the world, including the UK.

"Paying for organs is illegal in India, as it is across most of the world, but a Telegraph investigation has revealed that desperate young villagers from Myanmar are being flown to Apollo’s prestigious Delhi hospital and paid to donate their kidneys to rich Burmese patients.

“It’s big business,” one of the racket’s ‘agents’ told an undercover Telegraph reporter. Those involved “work together to get around the obstacles between the two governments,” she added. The hospital “asks the official questions. And on this side they tell the official lies.”

"The scam involves the elaborate forging of identity documents and staging of ‘family’ photographs to present donors as the relatives of would-be patients. Under Indian and Burmese laws, a patient cannot receive an organ donation from a stranger in normal circumstances.

"Apollo Hospitals said it was “completely shocked” by the Telegraph’s findings and would launch an internal investigation. “Any suggestion of our wilful complicity or implicit sanctioning of any illegal activities relating to organ transplants is wholly denied,” it added.

Friday, November 17, 2023

Report From a Multidisciplinary Symposium on the Future of Living Kidney Donor Transplantation

 How might we increase the number of lifesaving transplants from living kidney donors? Might we one day be able to reward donors? And what might we do until then, while we wait for something that will eventually replace human organ transplantation?  Here's the published account of last year's symposium.

Thomas G. Peters, John J. Fung, Janet Radcliffe-Richards, Sally Satel, Alvin E. Roth, Frank McCormick, Martha Gershun, Arthur J. Matas, John P. Roberts, Josh Morrison, Glenn M. Chertow, Laurie D. Lee, Philip J. Held, and Akinlolu Ojo, “Report From a Multidisciplinary Symposium on the Future of Living Kidney Donor Transplantation,” Progress in Transplantation  (forthcoming), Online first, Nov 15, 2023 https://journals.sagepub.com/doi/full/10.1177/15269248231212911  (pdf here).

Abstract: Virtually all clinicians agree that living donor renal transplantation is the optimal treatment for permanent loss of kidney function. Yet, living donor kidney transplantation has not grown in the United States for more than 2 decades. A virtual symposium gathered experts to examine this shortcoming and to stimulate and clarify issues salient to improving living donation. The ethical principles of rewarding kidney donors and the limits of altruism as the exclusive compelling stimulus for donation were emphasized. Concepts that donor incentives could save up to 40 000 lives annually and considerable taxpayer dollars were examined, and survey data confirmed voter support for donor compensation. Objections to rewarding donors were also presented. Living donor kidney exchanges and limited numbers of deceased donor kidneys were reviewed. Discussants found consensus that attempts to increase living donation should include removing artificial barriers in donor evaluation, expansion of living donor chains, affirming the safety of live kidney donation, and assurance that donors incur no expense. If the current legal and practice standards persist, living kidney donation will fail to achieve its true potential to save lives.

#######
Links to videos of the symposium presentations are here:

Wednesday, October 25, 2023

Why living kidney donors in England should be financially compensated

 Here's an article suggesting why England should pilot a program to compensate kidney donors.  Perhaps the argument is generalizable to other countries as well...

Rodger, Daniel, and BonnieVenter,  A fair exchange: why living kidney donors in England should be financially compensated. Medicine, Health Care and Philosophy (2023). https://doi.org/10.1007/s11019-023-10171-x

Abstract: Every year, hundreds of patients in England die whilst waiting for a kidney transplant, and this is evidence that the current system of altruistic-based donation is not sufficient to address the shortage of kidneys available for transplant. To address this problem, we propose a monopsony system whereby kidney donors can opt-in to receive financial compensation, whilst still preserving the right of individuals to donate without receiving any compensation. A monopsony system describes a market structure where there is only one ‘buyer’—in this case the National Health Service. By doing so, several hundred lives could be saved each year in England, wait times for a kidney transplant could be significantly reduced, and it would lessen the burden on dialysis services. Furthermore, compensation would help alleviate the common disincentives to living kidney donation, such as its potential associated health and psychological costs, and it would also help to increase awareness of living kidney donation. The proposed system would also result in significant cost savings that could then be redirected towards preventing kidney disease and reducing health disparities. While concerns about exploitation, coercion, and the ‘crowding out’ of altruistic donors exist, we believe that careful implementation can mitigate these issues. Therefore, we recommend piloting financial compensation for living kidney donors at a transplant centre in England."

They set the stage in their Introduction:

"In 2019, the Human Tissue Act 2004 (HT Act) was amended to allow England to adopt an opt-out system of organ donation, which was subsequently passed as The Organ Donation (Deemed Consent) Act 2019 and implemented in May 2020. This amendment aims to change the way donor consent is given for transplantable organs and tissues. Its intention is to increase the number of organs available for transplantation to save lives and improve the quality of life of those on the wait list. It was estimated by the United Kingdom (UK) Government that this amendment would save 700 lives per year (Dyer 2019). Despite these intentions, this amendment is unlikely to make a significant difference to the number of available organs.

"Currently, there is no definitive evidence to suggest that merely adopting an opt-out system will increase the pool of available organs (Etheredge 2021). Nevertheless, even if the pool of organs were to increase, it is not necessarily a panacea. Spain, though not strictly an opt-out system because it does not have an opt-out register (Etheredge 2021), is considered the gold-standard system for organ transplantation. But despite their success, Spain still has an insufficient number of organs, a growing kidney transplant wait list, and patients still die waiting for a transplant (Crespo et al. 2021). Kidney transplant wait lists continue to increase despite improving infrastructure, education, and the adoption of opt-out systems. Because only around 1% of people who die each year in the UK are eligible to donate their organs (NHS Blood and Transplant, 2022), it is becoming increasingly necessary to consider alternative approaches to increase the number of available organs for transplant."

Wednesday, October 4, 2023

Pakistan police bust organ trafficking ring --transplants were carried out in private homes

 Outlawing compensation for donors doesn't end black markets for kidneys from living donors, but may succeed in driving them out of hospitals, and making them increasingly dangerous and black.

The BBC has the story:

Pakistan police bust organ trafficking ring that took kidneys from hundreds By Rachel Russell

"Eight members of an organ trafficking ring in north-east Pakistan have been arrested, police say.

"The ring's alleged leader, Fawad Mukhtar, is accused of extracting the kidneys of more than 300 people and transplanting them into rich clients.

...

"At least three people died from having their organs harvested in this way, authorities said.

...

"The transplants were carried out in private homes - often without the patient knowing, the chief minister of Punjab province Mohsin Naqvi said.

"A car mechanic is said to have worked as Mr Mukhtar's surgical assistant and helped lure vulnerable patients from hospitals.

"The kidneys were then sold for up to 10 million rupees (£99,000; $120,000) each, Mr Naqvi added.

...

"The commercial trade of human organs was made illegal in Pakistan in 2010.

"The punishment for those caught includes a decade-long jail term and huge fines in the hope that this will stop sales to overseas clients by exploitative doctors, middlemen, recipients and donors.

"However, there has been a rise in organ trafficking in the country as people struggle with low wages and a poor enforcement of the law."

HT: Jlateh Vincent Jappah

Thursday, August 24, 2023

Before pig kidneys can be transplanted into human patients...

 Here's a paper in the Lancet suggesting some of the work that remains before pig kidneys can be transplanted into human patients:

Immune response after pig-to-human kidney xenotransplantation: a multimodal phenotyping study, by Prof Alexandre Loupy, MD PhD, Valentin Goutaudier, MD MSc, Alessia Giarraputo, PhD, Fariza Mezine, MSc, Erwan Morgand, PhD, Blaise Robin, MSc, Karen Khalil, PharmD, Sapna Mehta, MD, Brendan Keating, PhD, Amy Dandro, MSc, Anaïs Certain, MSc, Pierre-Louis Tharaux, MD PhD, Prof Navneet Narula, MD, Prof Renaud Tissier, DVM PhD, Sébastien Giraud, PhD, Prof Thierry Hauet, MD PhD, Prof Harvey I Pass, MD, Aurélie Sannier, MD PhD, Ming Wu, MD, Adam Griesemer, MD, David Ayares, PhD, Vasishta Tatapudi, MD, Jeffrey Stern, MD, Prof Carmen Lefaucheur, MD PhD, Prof Patrick Bruneval, MD, Massimo Mangiola, PhD, Prof Robert A Montgomery, MD PhD, August 17, 2023 DOI:https://doi.org/10.1016/S0140-6736(23)01349-

"Background: Cross-species immunological incompatibilities have hampered pig-to-human xenotransplantation, but porcine genome engineering recently enabled the first successful experiments. However, little is known about the immune response after the transplantation of pig kidneys to human recipients. We aimed to precisely characterise the early immune responses to the xenotransplantation using a multimodal deep phenotyping approach.

...

"Interpretation: Despite favourable short-term outcomes and absence of hyperacute injuries, our findings suggest that antibody-mediated rejection in pig-to-human kidney xenografts might be occurring. Our results suggest specific therapeutic targets towards the humoral arm of rejection to improve xenotransplantation results."

********

Yesterday:

Wednesday, August 23, 2023

Wednesday, August 23, 2023

Transplanted pig kidney functions for a week in brain dead patient

 Here's a report on a kidney from a genetically engineered pig, that was transplanted into a brain dead patient maintained on a ventilator, and which functioned successfully for seven days.  I'm beginning to think it's possible that xenotransplants of pig kidneys may be available for living patients in my lifetime.

Locke JE, Kumar V, Anderson D, Porrett PM. Normal Graft Function After Pig-to-Human Kidney Xenotransplant. JAMA Surg. Published online August 16, 2023. doi:10.1001/jamasurg.2023.2774

"Thirty-seven million adults in the US have chronic kidney disease (CKD), many of whom will ultimately progress to end-stage kidney disease (ESKD). Kidney transplant is the gold-standard therapy for patients with ESKD, yet annually, only 25 000 individuals receive a kidney. The gap between supply and demand is so vast that 40% of listed patients die within 5 years while waiting for a kidney transplant. Although xenotransplant represents 1 potential solution for the kidney shortage, previous reports of pig-to-human kidney xenotransplant using a preclinical human brain death model have shown xenograft urine production but not creatinine clearance, a necessary function to sustain life.1,2 Thus, no study to date has shown the ability of a xenograft to provide life-sustaining kidney function in a human.

...


"Discussion | The findings from this case series show that pigto-human xenotransplant provided life-sustaining kidney function in a deceased human with CKD. Future research in living human recipients is necessary to determine long-term xenograft kidney function and whether xenografts could serve as a bridge or destination therapy for ESKD. Because our study represents a single case, generalizability of the findings is limited. This study showcases xenotransplant as a viable potential solution to an organ shortage crisis responsible for thousands of preventable deaths annually."

Monday, August 14, 2023

The high out-of-pocket cost of donating a kidney. By Martha Gershun

 Martha Gershun continues to write eloquently about the obstacles to kidney donation.  

Here she is in Stat:

The high out-of-pocket cost of donating a kidney. By Martha Gershun 

"Five years have now passed since I donated my kidney, and both Deb and I are doing well....

"My husband and I are comfortable financially. We could afford the $5,000 in gasoline, hotels, and food for the 19 nights we spent travelling to the Mayo Clinic for my medical evaluation, surgery, recovery, and six-month follow-up visit. Our children are grown and our parents are gone, so we had no child care or elder care expenses (though we did have to pay a cat sitter for the time we travelled). And neither of us had to forgo any wages: At 61, I had already retired from paid work, and the generous PTO policy at the nonprofit where my husband was CEO covered the 128 hours of work he missed to travel with me and help with my recovery.

 "We did not qualify for assistance from the National Living Donor Assistance Center (NLDAC), because my recipient’s income was more than 300% of the current Health and Human Services (HHS) Poverty Guidelines (this has recently been raised to 350%). In fact, my recipient generously insisted on reimbursing us for our out-of-pocket expenses. This is not considered direct compensation for an organ, so is legal under the National Organ Transplant Act (NOTA).

But all of that was just our good fortune. What about potential organ donors without our resources? It is very easy to imagine someone in a low-wage hourly job who wants to donate a kidney to their sister, a married mother of two, who, along with her spouse, has an annual household income slightly above $105,000, which is 350% of the current HHS Poverty Guidelines. That potential donor, unable to access help from NLDAC, would be unable to afford the out-of-pocket expenses or lost wages. There would be no living donation; the patient would remain on the kidney transplant waiting list, along with 93,000 others.

Every living kidney donor saves private insurance or Medicare significant expense — experts estimate between $250,000 and $500,000 over the lifetime cost of dialysis for each kidney patient they help. Every living kidney donor enables the hospital and the surgeons, nephrologists, nurses, and other staff who work there to earn money for their transplant work. But the kidney donor — the one person who gives away a part of their body to make this miracle possible — is forced to incur financial losses to participate.

Recognizing this problem, New York state recently passed the Living Donor Support Act, the first law that provides living organ donors in the United States reimbursement for donation-related expenses, including lost wages, travel, lodging, and child care.

"Congress just revised the 1984 law that set up the United Network for Organ Sharing (UNOS) as the sole contract holder to run the country’s organ transplant system. Hopefully, this will have a tremendous impact on the way the system procures, allocates, and distributes organs from deceased donors. A better functioning transplant system, with improved technology and a better process for wait list management, could help living donors, but this legislation does nothing to help living donors overcome the financial barriers to organ donation.

...

"Individuals should not have to pay out of their own pocket to save someone else’s life."

Monday, July 31, 2023

Altruistic kidney donors in Israel

 The Forward has the story

Why Israel has more altruistic kidney donors than any other country in the world By Michele Chabin

"Israel is in the bottom half of countries when it comes to organs harvested after death, the type used in most transplants globally. ...

"But ...for more than a decade the number of Israelis who have donated kidneys while they are still alive and well has increased to the point that Israel is the worldwide leader in live donations per capita.

"That’s in large part thanks to the Jerusalem-based nonprofit ... Matnat Chaim, Hebrew for “gift of life,” which recruits and encourages individuals in good health to donate a kidney for purely altruistic reasons. 

"Of the more than 1,450 live kidney donations Matnat Chaim has facilitated, more than 80% percent were altruistic – donated by individuals who had no connection to the recipient. According to the group’s records, it made at least half of the matches between recipients and live donors in Israel from 2015 to 2022.

"Rabbi Yeshayahu Heber, whose life was saved by kidney from a live donor, founded Matnat Chaim in 2009 with his wife Rachel. Rabbi Heber, who died from COVID-19 in April 2020, had said he was moved to recruit volunteer donors after watching other kidney patients die for lack of transplants. 

"On Israel Independence Day this spring, Rachel Heber was awarded the prestigious Israel Prize in honor of the couple’s lifesaving work. 

...

Broadly speaking, the medical definition says that death occurs when the brain is no longer functioning, even if the heart is still beating. There are exceptions, but most ultra-Orthodox rabbis say death occurs when the heart stops beating and the person stops breathing.

“The problem is, if you wait until the heart stops, you can’t harvest the organs,” said Judy Singer, Matnat Chaim’s assistant director.

"For these reasons, Heber made it his mission to recruit live kidney donors.

"With other groups, including the Halachic Organ Donor Society and the Israel Transplant Authority, Matnat Chaim has convinced many religious Jewish communities to encourage members to donate altruistically. “Today, religious Jews, and haredim especially, are at the forefront of live kidney donations,” Singer said. “They say, I can’t donate an organ after death, but take my kidney and help someone now.”About 90% percent of Matnat Chaim’s kidney donors belong to the Modern Orthodox or ultra-Orthodox streams of Judaism.

“That number used to be 97%, but we’re always looking to increase the number of secular donors and Arab donors,” Singer said.

"The group has arranged for “many” Arab Israelis to receive transplants, she said, but did not share numbers for those recipients. Matnat Chaim is looking to work with an Arab group or individual to increase the number of Arab donors and recipients in the future, she added.

...

"According to the Ministry of Health, 656 transplants were carried out in Israel in 2022. Of those about half — 326 — came from living donors. By comparison in the U.S. that same year, about 15% of all organ donations came from living donors.

"Though transplant rates have been rising in both countries, many are still dying for lack of a donor. In Israel, 77 people died waiting for one in 2022."