The Global Kidney Exchange basics
The GKE concept has been introduced and piloted by a group of clinicians, ethicist and economist lead by Prof Michael Rees in the United States. While they envision the GKE concept to be replicated by other clinical centres1 they are currently the only known centre to have implemented a GKE program. Their first publication in 2017 on the pilot study, titled ‘Kidney Exchange to Overcome Financial Barriers to Kidney Transplantation’2, a letter to the editor in response to commentary on the first article3 and a 3-year review4, provide us with the program methodology, some practicalities and clinical findings.
Supporting, condemning and commentary on the Global Kidney Exchange
The GKE evoked much controversy and various international groups and organisations have taken positions for or against the GKE concept in its current form. Shortly after the publication of ‘Kidney Exchange to Overcome Financial Barriers to Kidney Transplantation’2, the WHO Task Force on Donation and Transplantation of Human Organs and Tissues5, the Council of Europe's Committee on Organ Transplantation6, and the Declaration of Istanbul Custodian Group7 condemned the GKE, while the American Society of Transplant Surgeons8 publicly approved it. This initial wave of position statements and various editorial letters by leaders in the field of transplantation (9–12) strongly focussed on questions of financial neutrality, exploitation and organ trafficking.
In 2019, the bioethicists Minerva, Savulescu and Singer 13 published an article supporting the GKE concept. They described the GKE as a benefit-sharing transaction with certain risks carried by both the high-income country pairs and the low to middle-income country (LMIC) pairs. They also viewed the GKE through a different philosophical lens. While most opponents of the GKE, so far, argued from a deontological perspective and based their arguments on principles like the principles of the Declaration of Istanbul, this group asked what is the greatest good for the greatest number. From this perspective, some burdens may be allowed if it saves lives.
A publication by the European Society for Organ Transplantation14 in 2020 focused the GKE debate on a more practical level, raising concerns related to the management of escrow funds and potential corruption. This publication furthermore highlighted the need for empirical research and patient views.14 The latest publication related to the GKE, published by a DICG member, picked up the initial concern of exploitation and viewed it through different theoretical lenses15. This article also placed the focus on the previously unnamed stakeholder group namely, future end-stage renal disease patients who could carry additional burdens if present benefit-sharing decisions do not take them into account.15
The vast majority of authors commenting on the GKE are from high-income countries. While some Indian and Egyptian authors briefly mentioned cross-cultural challenges and logistics as reasons why LMICs should not participate in global or transnational exchanges,16,17 the voices of LMICs remains underrepresented in the literature.
References
1. Roth AE, Marino IR, Ekwenna O, et al. Global Kidney Exchange should expand wisely. Transplant International. Published online 2020:0-2. doi:10.1111/tri.13656
2. Rees MA, Dunn TB, Kuhr CS, et al. Kidney Exchange to Overcome Financial Barriers to Kidney Transplantation. American Journal of Transplantation. 2017;17(3):782-790. doi:10.1111/ajt.14106
3. Rees MA, Paloyo SR, Roth AE, et al. Global kidney exchange: Financially incompatible pairs are not transplantable compatible pairs. American Journal of Transplantation. 2017;17(10):2743-2744. doi:10.1111/ajt.14451
4. Bozek DN, Dunn TB, Kuhr CS, et al. Complete Chain of the First Global Kidney Exchange Transplant and 3-yr Follow-up. European Urology Focus. 2018;4(2):190-197. doi:10.1016/j.euf.2018.07.021
5. WHO Task Force on Donation and Transplantation of Human Organs and Tissues. Position Statement on the Proposal for a Global Kidney Exchange as Adopted by the WHO Task Force on Donation and Transplantation of Human Organs and Tissues.; 2018. Accessed May 4, 2020. https://www.who.int/transplantation/donation/GKE-statement.pdf
6. Council of Europe. CD-P-TO Position Statement on Global Kidney Exchange Concept.; 2018. https://www.edqm.eu/sites/default/files/statement-transplantation-global-kidney-exchange-concept-april2018.pdf
7. DICG. Statement of the Declaration of Istanbul Custodian Group concerning Ethical Objections to the Proposed Global Kidney Exchange Program. Published 2018. Accessed December 4, 2019. http://declarationofistanbul.org/resources/policy-documents/795-statement-of-the-declaration-of-istanbul-custodian-group-concerning-ethical-objections-to-the-proposed-globalkidney-exchange-program
8. American Society of Transplant Surgeons. ASTS Position on Global Kidney Exchanges. Published 2017. Accessed December 27, 2019. https://asts.org/about-asts/position-statements#.XgWWuRdKjfY
9. Delmonico FI, Ascher NL. Opposition to irresponsible global kidney exchange. American Journal of Transplantation. 2017;17:2745-2746. doi:10.1111/ajt.14473
10. Pullen LC. Global Kidney Exchange: Overcoming the Barrier of Poverty. American Journal of Transplantation. 2017;17(10):2499-2500. doi:10.1111/ajt.14469
11. Valera L, Carrasco MA. On the Global Kidney Exchange programme. The Lancet. 2020;395(10235):1484-1485. doi:10.1016/S0140-6736(20)30625-5
12. Brunner R, Ekwenna O, Reese S, et al. Global Kidney Exchange: An international approach to expanding living donor kidney transplantation in minority groups. 2018.
13.Minerva F, Savulescu J, Singer P. The ethics of the Global Kidney Exchange programme. The Lancet Health Policy. 2019;394(394):1775-1778. doi:10.1016/S0140-6736(19)32474-2
14. Ambagtsheer F, Haase-Kromwijk B, Dor JMF, et al. Global Kidney Exchange: Opportunity or Exploitation? An ELPAT/ESOT Appraisal. Transplant International. Published online 2020.
15. Reyneke M, Borry P. The Global Kidney Exchange: Revisiting exploitation arguments. Developing World Bioethics. 2021;44(November 2020):1-8. doi:10.1111/dewb.12311
16. Kute V, Jindal RM, Prasad N. Kidney Paired-Donation Program Versus Global Kidney Exchange in India. American Journal of Transplantation. 2017;17(10):2740-2741. doi:10.1111/ajt.14324
17. Elrggal ME, Tawfik M, Gawad MA, Sheasha HA. Kidney paired donation program, a national solution against commercial transplantation? Journal of The Egyptian Society of Nephrology and Transplantation. 2018;18:6-10. doi:10.4103/jesnt.jesnt_1_18
