DOI: 10.1111/ajt.14451 LETTER TO THE EDITOR Global kidney exchange: Financially incompatible pairs are not transplantable compatible pairs Honest debate makes ideas better; we appreciate our colleagues’ facing financial barriers to transplantation. By creating and using a engagement. We agree with Wiseman and Gill that global kidney ex- portion of the savings produced by reducing the cost of dialysis in the change (GKE) must be conducted in an ethical manner that is sensi- United States through accelerated access to renal transplantation, GKE tive to the possibilities of commodification and exploitation and that becomes scalable. However, the net savings produced by GKE must it is important to be both careful with and transparent about how pa- exceed the overall cost in order for US-based healthcare payers to par- tient–donor pairs are selected from developing countries. 1,2 We fur- ticipate. Thus, if we want to achieve GKE’s first goal—to help impover- ther agree that GKE should continue to be run in a way that enhances ished patients by overcoming financial barriers to transplantation, GKE rather than competes with local medical services. However, Wiseman must take account of the savings produced. We have now performed and Gill approached GKE from their American and Canadian per- 4 GKE transplantations—all funded through philanthropy. We simply spectives of near-universal access to health care for end-stage renal evaluated every patient who presented for evaluation and moved for- disease. They view GKE through a lens of commodification and ex- ward with every instance where the projected savings from acceler- ploitation because there was an ethnocentric assumption that the ated transplantation of American incompatible pairs in the Alliance Filipino pair was no different from an immunologically compatible for Paired Donation (APD) pool exceeded the cost of the GKE by an pair in the United States or Canada. Consequently, their editorial min- amount greater than the anticipated cost. To scale this concept, we are imized the importance of financial incompatibility with the following working to produce an ethical and legal process, built on sustainable statements: 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 It is unclear whether the patient received a kidney of sim- blood type A GKE candidate with a blood type O donor easily produced ilar quality to the organ he would have received from his more transplants/savings in the APD pool than would have occurred spouse… . At a societal level, American patients received without their participation. a disproportionate share of the societal benefit enabled No alternative existed for this Filipino pair and millions more like by the participation of the compatible Filipino pair in KPE, them.3 GKE did not exploit this Filipino couple—it provided the mech- which may not be adequately remedied by the payment for anism for the wife to literally save her husband’s life. They could not transplantation and posttransplantation care. Ultimately, afford dialysis. Two months before traveling to the United States and the selection of the Filipino pair based on their ability to after their identification and evaluation for participation in GKE, the facilitate transplantations in the United States commodi- couple’s Filipino physician called to say that if the APD did not pay for fies the donor and recipient, the Filipino donor kidney was the husband’s continued dialysis in the Philippines, the husband was potentially undervalued, and the disproportionate benefit going to die as no additional funds were available to pay for dialysis. to American patients and the limited posttransplanta- At a societal level, did American patients with access to dialysis really tion care provided to the Filipino recipient were probably disproportionally benefit from the APD’s “exploitation” of this patient inequitable. by paying for 2 months of dialysis in the Philippines? When the husband lived instead of dying, was the Filipino donor’s kidney really un- Let us be clear: without GKE, the Filipino husband was never going dervalued? We ask Wiseman and Gill to seriously consider whether to receive his spouse’s kidney. Without GKE, the husband was going to the Filipino wife feels she disproportionately benefited American pa- die, the wife was going to lose her spouse, and their son was going to tients rather than her own family. For 3 years on Father’s Day, the be fatherless. That is exactly how the story was going to end without couple’s child has written our team to thank us for saving his daddy’s GKE. The goal of GKE is to change this fate for emotionally related pairs life. Two and a half years after this first GKE transplantation, both referred by our medical collaborators in their home country when finan- the Filipino donor and recipient have normal renal function, counter- cial barriers prevent transplantation. Our selection process aims to pro- ing the editorial’s accusation that “…limited posttransplantation care vide a transplant for every GKE-eligible pair who can provide sufficient provided to the Filipino recipient [was] probably inequitable.” While savings to pay for a GKE transplant. It is not scalable to propose that the gratifying success of the first case does not guarantee the same GKE could take place without consideration of the savings produced outcome for all future patients, it does demonstrate how GKE—even by transplanting patients in the United States. There are not unlimited if inequitable—is able to add years of life to patients who would have philanthropic resources available to overcome the needs of patients died without it. Am J Transplant. 2017;17:2743–2744. amjtransplant.com © 2017 The American Society of Transplantation and the American Society of Transplant Surgeons | 2743 2744 | LETTER TO THE EDITOR BAINE S AND JI NDAL LE TTE R TO THE E DI TO R: DI SC LO SUR E Baines and Jindal suggest that we need to be cognizant of transcul- The authors of this manuscript have no conflicts of interest to disclose tural issues with GKE.4 We completely agree. Not stated in our man- as described by the American Journal of Transplantation. uscript was the fact that we arranged for the Filipino couple to stay in the homes of local Filipino caregivers who could speak their lan- Keywords guage, share a common faith, feed them Filipino food, transport them donors and donation: incentives, donors and donation: paired to and from the hospital for evaluation and treatment, and entertain exchange, economics, editorial/personal viewpoint, ethics, ethics and them for the 3 months they stayed in the United States. Because the public policy, kidney transplantation/nephrology, law/legislation, Filipino couple had never flown before they boarded the plane to organ allocation, organ procurement and allocation Detroit, we arranged to have a local pastor accompany them on his M. A. Rees1 way back from a mission trip to the Philippines. The couple’s initial S. R. Paloyo2 visit to the transplant center seemed filled with trepidation, so the A. E. Roth3 following day the lead author visited the couple in the home where K. D. Krawiec4 they stayed and built trust and understanding with the help of the O. Ekwenna1 family caring for them (we note that the father of this family was him- C. L. Marsh5 self a Filipino physician who had practiced emergency medicine for A. J. Wenig1 more than 30 years in the United States). We have repeated this prac- T. B. Dunn6 tice of having patients stay in homes of culturally sensitive families 1 Department of Urology, University of Toledo, Toledo, OH, USA with our next 3 GKE transplant recipients, which have not yet been 2 Department of Surgery, Philippine General Hospital, University of the reported, with patients from both Mexico and the Philippines. We Philippines, Manila, Philippines have also worked closely with our coauthor and US-trained Filipino 3 Department of Economics, Stanford University, Stanford, CA, USA transplant surgeon (SP) who provided counseling and evaluation in the Philippines for the couple before they came to the United States. 4 5 School of Law, Duke University, Durham, NC, USA Scripps Clinic, Scripps Center for Organ and Cell Transplant, La Jolla, CA, USA 6 KUTE , JI NDAL, AND P RASAD LE TTE R TO THE E DI TO R : Department of Surgery, University of Minnesota, Minneapolis, MN, USA Correspondence Kute, Jindal, and Prasad express concern that GKE will not be a useful Michael A. Rees. strategy to expand the donor pool in India.5 We do not imagine that GKE Email: michael.rees2@utoledo.edu 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. REFERENCES 1. Rees MA, Dunn TB, Kuhr CS, et al. Kidney exchange to overcome financial barriers to kidney transplantation. Am J Transplant. 2017;17:782-790. 2. Wiseman AC, Gill JS. Financial incompatibility and paired kidney exchange: walking a tightrope or blazing a trail? Am J Transplant. 2017;17:597-598. 3. Liyanage T, Ninomiya T, Jha V, et al. Worldwide access to treatment for end-stage kidney disease: a systematic review. Lancet. 2015;385:1975-1982. 4. Baines LS, Jindal RM. Comment: kidney exchange to overcome financial barriers to kidney transplantation. Am J Transplant. 2017. https://doi. org/10.1111/ajt.14325. 5. Kute 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.