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Global kidney exchange: Financially incompatible pairs are not transplantable compatible pairs

2017; Elsevier BV; Volume: 17; Issue: 10 Linguagem: Inglês

10.1111/ajt.14451

1600-6143

Michael A. Rees, Siegfredo R. Paloyo, Alvin E. Roth, Kimberly D. Krawiec, Obi Ekwenna, Christopher L. Marsh, Alexandra J. Wenig, Ty B. Dunn,

Renal Transplantation Outcomes and Treatments

Honest debate makes ideas better; we appreciate our colleagues' engagement. We agree with Wiseman and Gill that global kidney exchange (GKE) must be conducted in an ethical manner that is sensitive to the possibilities of commodification and exploitation and that it is important to be both careful with and transparent about how patient–donor pairs are selected from developing countries.1Rees MA Dunn TB Kuhr CS et al.Kidney exchange to overcome financial barriers to kidney transplantation.Am J Transplant. 2017; 17: 782-790Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar,2Wiseman AC Gill JS Financial incompatibility and paired kidney exchange: walking a tightrope or blazing a trail?.Am J Transplant. 2017; 17: 597-598Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar We further agree that GKE should continue to be run in a way that enhances rather than competes with local medical services. However, Wiseman and Gill approached GKE from their American and Canadian perspectives of near-universal access to health care for end-stage renal disease. They view GKE through a lens of commodification and exploitation because there was an ethnocentric assumption that the Filipino pair was no different from an immunologically compatible pair in the United States or Canada. Consequently, their editorial minimized the importance of financial incompatibility with the following statements:It is unclear whether the patient received a kidney of similar quality to the organ he would have received from his spouse… . At a societal level, American patients received a disproportionate share of the societal benefit enabled by the participation of the compatible Filipino pair in KPE, which may not be adequately remedied by the payment for transplantation and posttransplantation care. Ultimately, the selection of the Filipino pair based on their ability to facilitate transplantations in the United States commodifies the donor and recipient, the Filipino donor kidney was potentially undervalued, and the disproportionate benefit to American patients and the limited posttransplantation care provided to the Filipino recipient were probably inequitable. Let us be clear: without GKE, the Filipino husband was never going to receive his spouse's kidney. Without GKE, the husband was going to die, the wife was going to lose her spouse, and their son was going to be fatherless. That is exactly how the story was going to end without GKE. The goal of GKE is to change this fate for emotionally related pairs referred by our medical collaborators in their home country when financial barriers prevent transplantation. Our selection process aims to provide a transplant for every GKE-eligible pair who can provide sufficient savings to pay for a GKE transplant. It is not scalable to propose that GKE could take place without consideration of the savings produced by transplanting patients in the United States. There are not unlimited philanthropic resources available to overcome the needs of patients facing financial barriers to transplantation. By creating and using a portion of the savings produced by reducing the cost of dialysis in the United States through accelerated access to renal transplantation, GKE becomes scalable. However, the net savings produced by GKE must exceed the overall cost in order for US-based healthcare payers to participate. Thus, if we want to achieve GKE's first goal—to help impoverished patients by overcoming financial barriers to transplantation, GKE must take account of the savings produced. We have now performed 4 GKE transplantations—all funded through philanthropy. We simply evaluated every patient who presented for evaluation and moved forward with every instance where the projected savings from accelerated transplantation of American incompatible pairs in the Alliance for Paired Donation (APD) pool exceeded the cost of the GKE by an amount greater than the anticipated cost. To scale this concept, we are working to produce an ethical and legal process, built on sustainable business principles, so that it can scale to help as many rich and poor patients as possible. In this first case, an easy-to-match unsensitized blood type A GKE candidate with a blood type O donor easily produced more transplants/savings in the APD pool than would have occurred without their participation. No alternative existed for this Filipino pair and millions more like them.3Liyanage T Ninomiya T Jha V et al.Worldwide access to treatment for end-stage kidney disease: a systematic review.Lancet. 2015; 385: 1975-1982Abstract Full Text Full Text PDF PubMed Scopus (1094) Google Scholar GKE did not exploit this Filipino couple—it provided the mechanism for the wife to literally save her husband's life. They could not afford dialysis. Two months before traveling to the United States and after their identification and evaluation for participation in GKE, the couple's Filipino physician called to say that if the APD did not pay for the husband's continued dialysis in the Philippines, the husband was going to die as no additional funds were available to pay for dialysis. At a societal level, did American patients with access to dialysis really disproportionally benefit from the APD's "exploitation" of this patient by paying for 2 months of dialysis in the Philippines? When the husband lived instead of dying, was the Filipino donor's kidney really undervalued? We ask Wiseman and Gill to seriously consider whether the Filipino wife feels she disproportionately benefited American patients rather than her own family. For 3 years on Father's Day, the couple's child has written our team to thank us for saving his daddy's life. Two and a half years after this first GKE transplantation, both the Filipino donor and recipient have normal renal function, countering the editorial's accusation that "…limited posttransplantation care provided to the Filipino recipient [was] probably inequitable." While the gratifying success of the first case does not guarantee the same outcome for all future patients, it does demonstrate how GKE—even if inequitable—is able to add years of life to patients who would have died without it. Baines and Jindal suggest that we need to be cognizant of transcultural issues with GKE4Baines LS Jindal RM Comment: kidney exchange to overcome financial barriers to kidney transplantation.Am J Transplant. 2017; (https://doi.org/10.1111/ajt.14325.)Abstract Full Text Full Text PDF Scopus (2) Google Scholar We completely agree. Not stated in our manuscript was the fact that we arranged for the Filipino couple to stay in the homes of local Filipino caregivers who could speak their language, share a common faith, feed them Filipino food, transport them to and from the hospital for evaluation and treatment, and entertain them for the 3 months they stayed in the United States. Because the Filipino couple had never flown before they boarded the plane to Detroit, we arranged to have a local pastor accompany them on his way back from a mission trip to the Philippines. The couple's initial visit to the transplant center seemed filled with trepidation, so the following day the lead author visited the couple in the home where they stayed and built trust and understanding with the help of the family caring for them (we note that the father of this family was himself a Filipino physician who had practiced emergency medicine for more than 30 years in the United States). We have repeated this practice of having patients stay in homes of culturally sensitive families with our next 3 GKE transplant recipients, which have not yet been reported, with patients from both Mexico and the Philippines. We have also worked closely with our coauthor and US-trained Filipino transplant surgeon (SP) who provided counseling and evaluation in the Philippines for the couple before they came to the United States. Kute, Jindal, and Prasad express concern that GKE will not be a useful strategy to expand the donor pool in India5Kute V Jindal RM Prasad N Kidney paired-donation program versus global kidney exchange in India.Am J Transplant. 2017; (https://doi.org/10.1111/ajt.14324.)Abstract Full Text Full Text PDF Scopus (5) Google Scholar We do not imagine that GKE patients will come from those for whom Dr. Kute is planning to care, but rather from those who cannot receive treatment at home due to financial constraints. Clearly, financial barriers prevent more transplant procedures in India than any other barrier. We are interested in helping India develop its nascent kidney exchange program, spearheaded by the excellent work of Dr. Kute. Perhaps creating a pool of willing but incompatible pairs in India will lead to opportunities not only for kidney exchanges for Indians with Indians but also for international exchanges between India and citizens of other countries to overcome immunological barriers. When these opportunities are prevented by financial barriers, then we are open to Indian patients traveling to the United States for care or for Americans traveling to India for care. In so doing, GKE could help build the infrastructure of a developing country's transplant program. We would welcome the day when India is able to provide transplants for all of its citizens. Until then, we believe GKE could enhance access for both Indian patients and patients in the developed world. The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.