Financial Incompatibility and Paired Kidney Exchange:Walking a Tightrope or Blazing a Trail?

A. C. Wiseman1, and J. S. Gill

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Epub; 7 December 2016


In this issue, Rees et al advance a novel strategy to increase living donor kidney transplantation through kidney paired exchange (KPE). Global kidney exchange (GKE) proposes the use of biologically compatible but “financially incompatible” living donors and recipients from an underserved 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 transplantation and posttransplant care including immunosuppressant drugs for the recipient in their home country for a period of 5 years in exchange for the compatible pair’s participation in KPE. The report describes the first application of GKE in which an indigent biologically compatible married couple in the Philippines who could not afford to proceed 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. The use of compatible donors and recipients on the basis of financial incompatibility 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 significant concern...

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