Kidney exchange in Germany

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Status quo

Paired kidney transplantations have recently been performed in Germany.
Deutsche Version -- Appeared in the magazine  DIATRA 4-2021.
English version -- Translated from German by Matthew A. Hood and Raquel Rojas.

Kidney transplant is considered the best treatment option for people facing kidney failure because it can increase their chances of living a long and healthy life. In Germany, 30% of all kidney transplants come from a living donor. However, willing donors are often not compatible with the patient they are related to, which makes a direct transplant impossible. In a crossover kidney donation, a patient with a willing but incompatible donor can "swap" his / her donor with that of the other patient in a similar position.

Such crossover donations are practiced regularly worldwide. Moreover, most of the developed countries run their centrally organized kidney exchange program. The medical data of incompatible patient-donor pairs are collected, and a computer program calculates the matches between the pairs, so that specific targets are reached, such as cost-efficiency or the maximal number of saved patients. While these kidney exchange programs are becoming more and more important worldwide, Germany is lagging far behind the rest of Europe on this issue.

The legal basis for a living donation in Germany is a relationship or close personal connection between donor and recipient. Even though the patient and the donor are closely related in each of the two pairs participating in a crossover donation, the law prohibits the transplant, because the physical graft a patient receives technically comes from the relative of the other saved patient. Administering changes to these rules in the special case of crossover donations has been articulated by several experts, such as the Economics Nobel Laureate Alvin Roth, because it could save lives and costs immediately.

Activism

A powerful campaign was launched by the activist Susanne Reitmaier, whose daughter waited in vain for a transplant in Germany, but was later operated as part of the Spanish kidney exchange program. Her request for a law change was already presented at the Bundestag. 

We maintain a pool of incompatible patient-donor pairs willing to undertake an exchange. We have built a database out of the voluntarily submitted medical data of incompatible patient-donor pairs are regularly check it for possible crossover donations among these pairs. The first two quadruples were transplanted in 2021 and 2022, in two paired donations.  More identified quadruples are waiting in different stages in the medical and legal process. 

I reached out for public awareness as an invited speaker at the 5th Digital Future Science Match in May 2019 in Berlin.  I reported on the progress to the members of the  European Network for Collaboration on Kidney Exchange Programmes (ENCKEP) at their meeting in December 2019 in Glasgow.

Obstacles

Most of the time, progressive countries in a fortunate economical situation are at the frontier of organ exchange practices. So how come Germany is not one of them? The answer lies in the assumed potential risks of kidney exchange, namely: 1. organ trafficking, 2. psychological pressure on donors, and 3. a donor withdrawing from donation. Let us take a closer look on how permitting crossover donations influences each of these risks.

• Organ trafficking.

We propose no other change to the current law than to allow crossover transplants. Patients will still have to bring their closely related donor,  the connection between them and the willingness of the donor will be examined just as carefully as earlier. Allowing crossover transplants thus has no effect whatsoever on the risks of organ trafficking.

• Psychological pressure on donors.

Having a beloved one in critical medical condition puts an enormous psychological load on a person. Unfortunately, only for very few illnesses does one have an option to actively act and save the life of the beloved one with this action. Kidney failure is one of these illnesses. Donating a kidney is a safe procedure, but as all surgeries, it is not without inconveniences and risks.

Regardless of permitting or prohibiting crossover donations, each potential donor might feel inner or outer pressure to volunteer to donate. This is why a thorough psychological examination must happen before each living-donor donation, besides numerous other medical examinations. During the conversation, the future donor can tell the psychologist directly or indicate subconsciously that (s)he does not feel really comfortable with donating an organ. As a consequence, the donor will be classified as 'not suitable for donation', and the exact cause of such an examination outcome is not disclosed.

• A donor withdrawing from donation.

Crossover donations always happen exactly at the same time. The two kidneys are taken out of the two donors at the same time, and likewise, the two patients receive the two organs at the same time. The four surgical teams are connected via phone to coordinate the procedure safely. 

Crossover donations carry no larger risk than the direct living donor transplant in these matters. Prohibiting them, however, forces patients to look for alternative donors and to search for a transplant in abroad. The earlier clearly puts psychological pressure on these alternative donors, while the latter results in a cruel socioeconomic selection of survivors, because a transplant in abroad is only an option for patients with a very solid financial background.