WSJ Article on Moneyless Exchanges of Live Donors

[Guest guest]

Easing the Kidney Shortage

Renal Donors Swap Recipients

If Blood Types Don't Match;

Cheating on Priority Lists

June 17, 2004; Page B1

(Wall Street Journal Online)

As of noon yesterday, 58,470 people in the U.S. were waiting for a kidney

transplant. Most won't get one this year. There aren't enough donated

kidneys to go around. Surgeons transplanted just 15,129 kidneys last year.

Now a band of transplant surgeons and economists are trying to fix that by

creating a moneyless market for exchanging kidneys.

Most transplanted kidneys come from a person who has died, a supply that

grows slowly because of ignorance about the need for donations or grieving

relatives' reluctance. But a kidney taken from a live donor works better,

and almost everyone has a spare. As techniques improve for removing

healthy kidneys and for suppressing the body's tendency to reject a

transplant, doctors increasingly turn to kidneys from living donors,

usually relatives. Last year, 43% of kidneys transplanted in the U.S. came

from living donors, up from 28% a decade ago.

But a biological barrier often blocks a transplant from a relative. In

about a third of all would-be pairs, blood types are incompatible. In

others, the sick person has antibodies that can initiate a rejection of

the donated organ. It's heartbreaking " to have the treasure of the live

donor and then have that not go forward because of a biological obstacle, "

says Massachusetts General Hospital transplant surgeon Francis DelMonico.

Occasionally, transplant centers spot a way out: One New England father

with blood type A couldn't donate a kidney to his daughter with blood type

B. So he gave a kidney to a teenager with blood type A, and the teenager's

sister gave a kidney for the man's daughter. New England's transplant

centers have done six such exchanges. Baltimore's s Hopkins University

has done seven.

In the past year, Hopkins also has done two exchanges that involved three

transplants each, an undertaking that requires six operating rooms and 60

medical professionals (see diagram). In New England, Washington, D.C., and

elsewhere, would-be donors unable to give a kidney to a loved one instead

have given a kidney to a stranger. The loved one, in turn, is rewarded by

being moved up on the waiting list for a dead person's kidney.

Such swaps occur, though, only when the right combination appears or a

flurry of e-mails among transplant centers produces the right mix. A

highly organized system alerts transplant centers when a dead person's

kidney is available; there isn't any system for a man who can't give to,

say, his wife, but wants to advertise his willingness to make a swap.

Hopkins transplant surgeon Montgomery figures that 2,000 or more

people could get transplants each year if there were a national database

of such donors.

Transplants are expensive: s Hopkins says the cost is roughly $120,000

when everything is included. Medicare usually foots the bill for patients

without private insurance, though it doesn't pay that much. Buying or

selling a kidney in the U.S. is illegal.

Donors, recipients and relatives involved in three-way kidney transplant

at s Hopkins Hospital in Baltimore last year

Lawyers and ethicists, after substantial deliberation, decided a few years

ago that kidney swaps like those done in Boston and Baltimore are

acceptable. And doctors agree on some simple rules: The donor must travel

to the hospital where the recipient is; participants may keep identities

private if they choose; all operations in a swap begin simultaneously to

avoid anyone backing out halfway through the swap.

While the doctors were working all this out, Harvard economist Alvin Roth,

a specialist in designing moneyless markets like the one that matches

medical residents to teaching hospitals, was pondering the problem. He

proposed to a visiting protégé, Utku Ünver of Istanbul's Koc University,

that the two teach a course using kidneys as an example. Thinking about

kidney donors and recipients, it turned out, was similar to thinking about

the way colleges allocate dorm rooms, a problem Mr. Ünver and colleagues

had studied.

The result was an article published in the Quarterly Journal of Economics

last month by the two men and a colleague from Koc, Tayfun Sönmez, that

describes how to structure a kidney exchange to identify potential swaps

among a large pool of people with rules that make it very hard for anyone

to cheat.

Cheating is an issue in transplants. In Chicago, for instance, cardiac

doctors have been accused by local prosecutors of overstating the severity

of patients' illnesses to move them up on the priority list for hearts.

And rules, such as those that depend on how long one has been waiting for

an organ, don't always anticipate human cleverness; rules had to be

changed, for instance, when doctors began to put babies on waiting lists

for heart transplants before they were born.

The economists' premise is simple: Don't expect anyone to do anything that

isn't in his or her self-interest. As long as a computer can identify the

one kidney in the pool that best suits a patient, the system is foolproof,

the economists say.

Massachusetts General's Dr. DelMonico admits to some skepticism when the

economists approached him last fall. But the collaboration has blossomed

over the past few months. Dr. DelMonico handles the intricacies of forging

a consensus among the 14 transplant centers in New England and finding

money to support a computerized system to implement the economists'

design.

Harvard tissue-typing specialist Saidman, meanwhile, is working to

perfect a computer system to simplify the process of checking to be sure

potential recipients don't have antibodies that could cause them to reject

an otherwise suitable donor's kidney.

The most compelling moment so far came when Dr. Saidman gave the

economists details on 45 pairs in which the would-be donor was unable to

give a kidney to the intended recipient. Even though each of the 45 had a

donor willing to spare a kidney, all were stuck waiting for the right

person to die. With swaps involving two kidneys, the economists found,

eight transplants were possible. If swaps involving three kidneys were

possible, then 11 transplants were possible.

   

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