How to better enable kidney exchanges to save lives and money

Nearly 100,000 people with failing kidneys are on waiting lists for a kidney transplant in the United States, with an average wait of three to five years.

Organs come from one of two sources: living donors, usually a friend or family member willing to spare one of their own kidneys; or from a transplant donor who has died.

Kidney exchange platforms such as the National Kidney Registry and the Alliance for Matching Giving provide a lifesaver for people waiting by expanding the pool of potential donors.

Imagine a situation in which a husband is willing to donate to his wife, but has a blood group that is incompatible. An exchange platform, which receives pairs of donors and patients from different hospitals, can match the husband to a different patient with the same blood group, while pairing his wife with another donor who has the same blood type. same type as her. linking several different pairs of patient-donors, exchanges can significantly increase the number of people who can receive live donor transplants.

But a new study shows that trading platforms are not as effective as they could be. In fact, they miss 25 to 55% of live donor encounters that might otherwise be possible. "Despite significant success, the kidney market is suffering from market failures resulting in hundreds of lost transplants per year," says Itai Ashlagi, assistant professor of science and management engineering, and his collaborators Nikhil Agarwal and Ömer Karaduman of MIT and Eduardo Azevedo and Clayton Featherstone of the Wharton School of the University of Pennsylvania

The reason, they say, is that transplant hospitals are encouraged to match the kidney exchanges internally and tend to use trade as a last resort. It might be fine, except that researchers have found that hospitals are not as effective as exchanges by matching good donors with the right patients.

The problem begins with the fact that some types of donors and patients only others. A donor with O-type blood can give an organ to people with different types of blood, while an O-type patient can only accept a transplant of another type O. An effective match would then mean linking O-type donors relatively rare to type O When Ashlagi and colleagues analyzed data from thousands of live donor transplants, they found that with internal hospital exchanges, only 77% of kidney donations O were intended for O-type patients.

In contrast, almost 94% of O-type donor kidneys on major exchange platforms went to O-type patients. In other words, hospitals that They organized their own matches and transplanted many valuable type-O kidneys into patients who could have been associated with other types of common blood. Even large hospitals are not big enough to always find effective connections internally. Exchange platforms, which provide more donors and beneficiaries, are the most effective at making the most difficult matches.

Ashlagi says that the system could be improved by further encouraging hospitals to use the exchange platforms more frequently. They should be encouraged to register patient-donor pairs that help to generate more transplants. In addition, hospitals face most of the costs associated with trading in kidneys, while most benefits accrue to insurance companies. Costs involve varied platform fees, hiring full-time exchange coordinators, doing blood tests, and so on. All of these expenses suddenly reduce the benefit of each surgery.

A potential solution, says Ashlagi, is a point system. loyalty program that gives hospitals additional rewards for providing valuable donors. For example, by offering a type O donor to an exchange center, a hospital could get additional compensation when it tries to get a transplant for one of its patients. This will create a more liquid pool by removing the incentive of the corresponding pairs internally. Indeed, the National Kidney Exchange has already launched a scoring system in this direction, although it is too early to say what impact it has had.

A loyalty program will not solve everything. Beyond that, researchers say, exchanges and perhaps government decision-makers should look for ways to compensate hospitals for the exchange-related costs that they currently have to absorb on their own. This would be particularly important for smaller hospitals that may not be involved in transplant exchanges because of prohibitive costs.

Each additional kidney transplant yields a large health and financial dividend. Transplants usually give patients several years of extra life compared to dialysis. Dialysis treatment alone represents a whopping 7 percent of Medicare spending, so cuts out there would benefit the public purse. If the transplant centers submitted most of their patients and donors to the bursaries, the researchers estimate that 200 to 400 more transplants of living donors would be possible each year. This would translate into annual savings of $ 220 to $ 440 million for the entire medical system, before taking into account the extra years of productive life for patients who desperately need it.

"Small repairs to improve trade meaning," says Ashlagi.

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The calculator estimates the success of kidney transplants with particular donor-recipient pairs