American Journal of Transplantation 2017; 17: 597–598
Wiley Periodicals Inc.
Editorial
Financial Incompatibility and Paired Kidney Exchange:
Walking a Tightrope or Blazing a Trail?
A. C. Wiseman1,* and J. S. Gill2
1
Division of Renal Diseases and Hypertension, Transplant
Center, University of Colorado Denver, Aurora, CO
2
Division of Nephrology, Department of Medicine and
Centre for Health Evaluation and Outcome Sciences,
University of British Columbia, Vancouver, BC
*Corresponding author: Alexander C. Wiseman,
alexander.wiseman@ucdenver.edu
Received 11 November 2016, revised 06 December
2016 and accepted for publication 07 December 2016
In this issue, Rees et al advance a novel strategy to
increase living donor kidney transplantation through kidney
paired exchange (KPE) (1). Global kidney exchange (GKE)
proposes the use of biologically compatible but “financially
incompatible” living donors and recipients from an under-
served country to increase KPE in the United States. The
health care savings generated by removing US patients
from dialysis would be used to cover the cost of transplan-
tation and posttransplant care including immunosuppres-
sant drugs for the recipient in their home country for a
period of 5 years in exchange for the compatible pair’s par-
ticipation in KPE. The report describes the first application
of GKE in which an indigent biologically compatible mar-
ried couple in the Philippines who could not afford to pro-
ceed with living donor kidney transplantation was brought
to the United States where the wife’s donation of a kidney
ultimately facilitated KPE transplants for 10 American
patients as well as for her husband.
While we applaud Rees et al’s efforts to advance a novel
approach to increase living donor kidney transplantation,
there are numerous considerations that require equipoise,
including the legality of this new definition of “financial
incompatibility.” The Charlie Norwood Act amended the
National Organ Transplant Act (NOTA) to allow human
organ paired donation between biologically incompatible
living donors and recipients (2). The use of compatible
donors and recipients on the basis of financial incompati-
bility may not be encompassed in current interpretation of
NOTA. While the authors offer a thoughtful rebuttal to this
consideration, expansion of GKE would probably require
amendment of NOTA.
The risk of exploitation (real or potential) in GKE is a sig-
nificant concern. The authors state that GKE is in
© 2016 The American Society of Transplantation
and the American Society of Transplant Surgeons
doi: 10.1111/ajt.14183
keeping with the ethical and legal principles of organ
donation within the United States, by adhering to the
concept of altruism and lack of financial consideration,
and that no individual was harmed or unduly influenced
by the paired exchange. However, this exchange can still
be viewed as an inequitable transaction, for even if an
individual derives benefits from a transaction, this in
itself does not justify the transaction. At the individual
level, the indigent Filipino couple were selected for GKE
based on their likelihood of facilitating other transplants
without further details regarding how this particular cou-
ple was identified, if other donor/recipient pairs were
considered, or if specific criteria were applied. It is
unclear whether the patient received a kidney of similar
quality to the organ he would have received from his
spouse. The concern of exploitation could be diminished
if a biologically incompatible pair had initiated the chain
(but would increase the logistical complexity), or if trans-
plants for Filipino patients with biologically incompatible
living donors were also facilitated. 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 ade-
quately remedied by the payment for transplantation and
posttransplant care. Furthermore, by diverting care to
another health system it could be argued that such a
strategy may undermine efforts to advance development
of transplant resources in the developing countries. Ulti-
mately, the selection of the Filipino pair based on their
ability to facilitate transplants in the United States com-
modifies the donor and recipient, the Filipino donor
kidney was potentially undervalued, and the dispropor-
tionate benefit to American patients and the limited post-
transplant care provided to the Filipino recipient were
probably inequitable.
Moving forward, the potential for undue influence in GKE
will be an important consideration. The inability to pay for
lifesaving dialysis (as in the case of the Filipino recipient)
places the potential donor in a vulnerable position. This
risk of unduly influencing donors is mitigated in the Uni-
ted States, where access to dialysis is ensured. Thus,
perhaps a less contentious strategy to increase living
donation would be to address the issues facing “finan-
cially incompatible but biologically compatible” donor
pairs within the United States. Given the ethical and
logistical considerations with GKE, alternative strategies
such as providing the recipient in a compatible pair an
597
Wiseman and Gill
opportunity to receive a younger or better HLA-matched
donor kidney through KPE (3), or expanding programs
such as the National Living Donor Assistance Center to
include reimbursement for lost wages (4,5) would seem
more feasible strategies to increase living donor trans-
plantation compared to GKE described by Rees et al.
In summary, this case of GKE represents a well-
intentioned first experience that again tests the ethical
questions applied to kidney donation. When considering
the worldwide underserved chronic kidney disease popu-
lation, the number of potential financially incompatible
but biologically compatible pairs may be staggering.
Rather than rushing forward, it is more likely that one
must walk a tightrope in expanding GKE from a case
report to an institutional construct and will require sensi-
tivity to the ethical pitfalls that have limited novel
approaches that have come before it.
Disclosure
The authors of this manuscript have no conflicts of
interest to disclose as described by the American Journal
of Transplantation.
598
References
1. Rees MA, Dunn TB, Kuhr CS, et al. Kidney exchange to over-
come financial barriers to kidney transplantation. Am J Transplant
2016; doi: 10.1111/ajt.14106.
2. An Act to amend the National Organ Transplant Act. The Senate
of the United States, 110th Congress, 1st Session ed. United
States 2007.
3. Bingaman AW, Wright Jr FH, Kapturczak M, Shen L, Vick S, Mur-
phey CL. Single-center kidney paired donation: The Methodist
San Antonio experience. Am J Transplant 2012; 12: 2125–2132.
4. Hays R, Rodrigue JR, Cohen D, et al. Financial neutrality for living
organ donors: Reasoning, rationale, definitions, and implementa-
tion strategies. Am J Transplant 2016; 16: 1973–1981.
5. Rodrigue JR, Schold JD, Morrissey P, et al. Direct and indirect
costs following living kidney donation: Findings from the KDOC
study. Am J Transplant 2016; 16: 869–876.
American Journal of Transplantation 2017; 17: 597–598