Kidneys have to be compatible with the recipient, so not everyone healthy enough to donate a kidney can donate one to whom they wish. There is a considerable literature on the desirability or undesirability of allowing donors to be compensated, that we will not discuss here, but see Roth (2021) for a discussion of compensation controversies in a number of markets.) The single exception is the Islamic Republic of Iran, where there is a legal monetary market for kidneys, although there are also black markets elsewhere around the world. Note that it is against the law, in the U.S, and almost everywhere else, to pay a living donor to donate a kidney. Most people with kidney failure will die without receiving a transplant new research suggests breaking down boundaries between exchange programs may help ![]() Transplants are therefore in desperately short supply, and most people with kidney failure will die without receiving a transplant. We only manage about 17,000 transplants from deceased donors each year, with another 6,000 or so from living donors. at the moment, and about half a million on dialysis. However, there are almost 100,000 people on the waiting list for a deceased donor kidney in the U.S. Another source of kidneys for transplantation is from healthy living donors, who can safely give one of their kidneys to save someone with kidney failure. and many other countries, most transplants today come from deceased donors. The best treatment is transplantation, but no country is presently able to supply all the transplants required by its patient population. Kidney failure is a leading cause of death around the world. Breaking down these barriers will be challenging, but the potential rewards are large-both in terms of lives saved and reduced healthcare costs. However, barriers between kidney exchange programs, both within and across countries, continue to make it difficult to find matches for some patient-donor pairs. For logistical reasons, early exchanges involved just two patient-donor pairs, but the rise in donors without a particular recipient in mind has enabled long chains of non-simultaneous transplants. Kidney exchange is a way to increase the number of transplants by allowing incompatible patient-donor pairs to exchange kidneys. No country is presently able to supply all the kidney transplants required by its population, and most people with kidney failure will die without receiving a transplant. ![]() Early cross-border exchanges encountered some controversy, however, with some commentators claiming they should be regarded as organ trafficking careful market design will therefore be vitally important. These efforts face considerable challenges, but the potential rewards are large enabling transplants involving hard-to-match pairs across programs or borders would save both lives and years of costly dialysis. One step now being actively explored is breaking down the barriers between such programs in order to form larger pools of patient-donor pairs that can be searched to find matches for hard-to-match pairs. Collaborations between EU countries are facing similar challenges. ![]() Even if they enrol their hard-to-match pairs in one of the inter-hospital exchanges, the fact that easy-to-match pairs are being matched to each other makes it harder to find matches for hard-to-match pairs. In the U.S., for example, decentralization means that many transplant centers operate below efficient scale, and can only conduct exchanges among easy-to-match patient-donor pairs. There have also been innovations in financial engineering, which make it easier for hospitals with different cost structures to exchange with one another, Barriers between kidney exchange programs remain, however. Today, for example, kidney exchange donors no longer have to be geographically close as kidneys can be flown between cities. The industry continues to innovate in ways that should enable more and longer kidney exchange chains. In addition, chains begun by non-directed donors could be organized non-simultaneously, so that each patient-donor pair received a kidney before donating one of their own. These donors could facilitate more than a single transplant, by offering a kidney to the patient in a hard-to-match pair, whose donor could pass it forward to the patient in another such pair, whose donor could then donate to an individual on the waiting list for a deceased donor. However, as evidence accumulated that living donation by unrelated donors was successful, donations started to be accepted more frequently from non-directed donors, who didn’t have a particular recipient in mind. One important barrier to larger-scale exchanges was that initially all surgeries were performed simultaneously, in order to prevent a broken link whereby some pair gave a kidney but did not get one.
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