Kidney Exchange

4th Barcelona Economics Lecture

Hospital Clinic, Barcelona
8 November 2004
Roth, Alvin E., Tayfun Sönmez, and M.
Utku Ünver, “Kidney Exchange,”
Quarterly Journal of Economics, 119,
2, May, 2004, 457-488.
____ “Pairwise Kidney Exchange,”
June 2004.
_____ “The Importance of Three Way
Kidney Exchange,” in preparation

2
 Proposal
New England Center for
Kidney Donor Exchange
Presented to the ROTC
September 20, 2004
(Approved!)
Frank Delmonico, MD (NEOB and MGH)
Susan Saidman, PhD (MGH Histocompatibility Lab)
Al Roth, PhD (Prof. of Economics & Business Admin, Harvard)
Tayfun Somnez, PhD (Dept. of Economics, Koc University
Utku Unver, PhD (Dept. of Economics, Koc University
• On Saturday I gave a companion talk as the
Pareto Lecture, at a conference of economic
theorists
• In that talk I emphasized some of the
theoretical issues that arise in designing a
Kidney Exchange.
• Today I’ll speak more of practical issues,
and how those shape what can be done (and
what kind of theory is needed).

4
 Economists As Engineers
• In recent years, game theorists have become usefully
involved in the design of markets.
– See e.g. Roth and Peranson (1999), Roth (2002,medical
labor markets) Wilson (2002, electricity markets),
Abdulkadiroğlu and Sönmez (2003, schools), Milgrom
(2004, auctions), Niederle and Roth (2004,
gastroenterologist labor market)
• A certain amount of humility is called for: successful
designs most often involve incremental changes to
existing practices, both because
– It is easier to get incremental changes adopted, rather than
radical departures from preceding practice, and
– There may be lots of hidden institutional adaptations and
knowledge in existing institutions, procedures, and customs.
5
 Kidney transplants
• There are over 60,000 patients on the waiting list for
cadaver kidneys in the U.S.
• In 2003 there were over 8,500 transplants of cadaver
kidneys performed in the U.S. (and over 2,000 in Spain,
which has one of the most effective cadaver organ
donation systems in the world)
• In the same year, about 3,500 patients died while on the
waiting list.
• In 2003 there were also over 6,000 transplants of kidneys
from living donors in the US, a number that has been
increasing steadily from year to year.
• (I don’t know the local statistics, but I understand that the
Hospital Clinic is one of the places at which live donor
transplants are done here.)
6
 Live-donor transplants are much less
organized than cadaver transplants
• The way such transplants are typically arranged is
that a patient identifies a willing donor and, if the
transplant is feasible, it is carried out.
• Otherwise, the patient remains on the queue for a
cadaver kidney, while the donor returns home.
• Recently, however, in a small number of cases,
additional possibilities have been utilized:
– Paired exchanges: exchanges between incompatible
couples
– Indirect exchanges: an exchange between an
incompatible couple and the cadaver queue
7
Paired Exchange (still relatively rare)

8
Baltimore Center Carries Out Triple-Swap Transplants
August 2, 2003, New York Times

“The triple-swap kidney transplant operation was

announced in a news conference today at the Johns
Hopkins Comprehensive Transplant Center, which said it
believed that this was the first time three simultaneous
kidney transplants have been performed…
“Months in the making, the exchange was the only way all
three recipients could have received a kidney, the lead
surgeon, Dr. Robert A. Montgomery, said, because of
tissue, blood or antibody incompatibilities among the
donors and their originally designated recipients.”

• Johns Hopkins has recently hired a paired kidney

exchange coordinator to facilitate further
exchanges 9
 How might more frequent and larger-scale
kidney exchanges eventually be organized?
• Building on existing practices in kidney
transplantation, we consider how exchanges might
be organized to produce efficient outcomes,
providing consistent incentives (dominant strategy
equilibria) to patients-donors-doctors.
• Why are incentives/equilibria important?
(becoming ill is not something anyone chooses…)
– But if patients, donors, and the doctors acting as their
advocates are asked to make choices, we need to
understand the incentives they have, in order to know
the equilibria of the game and understand the resulting
behavior.
– Experience with the cadaver queues make this clear…
10
 Incentives: liver transplants
Chicago hospitals accused of transplant fraud
2003-07-29 11:20:07 -0400 (Reuters Health)
CHICAGO (Reuters) – “Three Chicago hospitals were accused
of fraud by prosecutors on Monday for manipulating
diagnoses of transplant patients to get them new livers.
“Two of the institutions paid fines to settle the charges.
‘By falsely diagnosing patients and placing them in intensive
care to make them appear more sick than they were, these
three highly regarded medical centers made patients eligible
for liver transplants ahead of others who were waiting for
organs in the transplant region,’ said Patrick Fitzgerald, the
U.S. attorney for the Northern District of Illinois.”
• These things look a bit different to economists than to
prosecutors: it looks like these docs may simply be acting in the
interests of their patients…
11
 Incentives and efficiency:
Neonatal heart transplants
• Heart transplant candidates gain priority through time
on the waiting list
• Some congenital defects can be diagnosed in the
womb.
• A fetus placed on the waiting list has a better chance
of getting a heart
• And when a heart becomes available, a C-section
might be in the patient’s best interest.
– But fetuses (on Mom’s circulatory system) get healthier, not
sicker, as time passes and they gain weight.
– So hearts transplanted into not-full-term babies may have
less chance of surviving.
Michaels, Marian G, Joel Frader, and John Armitage [1993], "Ethical Considerations in
Listing Fetuses as Candidates for Neonatal Heart Transplantation," Journal of the
American Medical Association, January 20, vol. 269, no. 3, pp401-403 12
 Kidney Matching
• Two genetic characteristics play key roles :
1. ABO blood-type: There are four blood types A, B, AB
and O.
• Type O kidneys can be transplanted into any patient;
• Type A kidneys can be transplanted into type A or type
AB patients;
• Type B kidneys can be transplanted into type B or type
AB patients; and
• Type AB kidneys can only be transplanted into type
AB patients.
• So type O patients are at a disadvantage in finding
compatible kidneys. 13
2. Tissue type or HLA type:
• Combination of six proteins, two of type A,
two of type B, and two of type DR.
• Prior to transplantation, the potential recipient
is tested for the presence of antibodies against
HLA in the donor kidney. The presence of
antibodies, known as a positive crossmatch,
significantly increases the likelihood of graft
rejection by the recipient and makes the
transplant infeasible.

14
 Goals of a structured method of direct
kidney exchange
1. Assemble a database of incompatible patient-
donor pairs. (Right now, the incompatible
donors are largely lost.)
2. Identify which exchanges are possible, and
which sets of exchanges make best use of
available donor kidneys
1. allow not only for paired-exchange but also other
forms of exchange such as a three-way exchange.

15
 Some relevant economics papers
• Shapley, Lloyd and Herbert Scarf (1974), “On Cores
and Indivisibility,” Journal of Mathematical
Economics, 1, 23-37.
• Roth, Alvin E. and Andrew Postlewaite (1977), “Weak
Versus Strong Domination in a Market with
Indivisible Goods,” Journal of Mathematical
Economics, 4, 131-137.
• Roth, Alvin E. (1982), “Incentive Compatibility in a
Market with Indivisible Goods,” Economics Letters, 9,
127-132.
• Atila Abdulkadiroğlu and Tayfun Sönmez [1999]
House allocation with existing tenants. Journal of
Economic Theory 88, 233-260. 16
DONOR KIDNEY EXCHANGE FOR
INCOMPATIBLE RECIPIENTS
• by Francis L. Delmonico, MD 1, Paul E.
Morrissey, MD 1, George S. Lipkowitz, MD 2,
Jeffrey S. Stoff, MD 1, Jonathan Himmelfarb,
MD 1, William Harmon, MD 1, Martha Pavlakis,
MD 1, Helen Mah 1, Jane Goguen 1, Richard
Luskin 1, Edgar Milford, MD 1 and Richard J.
Rohrer, MD 1. 1, New England Organ Bank,
Newton, MA and 2, LifeChoice Donor
Services, Windsor, CT.

• Reports two live donor exchanges (4

recipients) and 8 list paired exchanges (16
recipients) from 2001-02.
17
 House allocation
• Shapley & Scarf [1974] housing market model: n agents
each endowed with an indivisible good, a “house”.
• Each agent has preferences over all the houses and there
is no money, trade is feasible only in houses.
• Gale’s top trading cycles (TTC) algorithm: Each agent
points to her most preferred house (and each house points
to its owner). There is at least one cycle in the resulting
directed graph (a cycle may consist of an agent pointing
to her own house.) In each such cycle, the corresponding
trades are carried out and these agents are removed from
the market together with their assignments.
• The process continues (with each agent pointing to her
most preferred house that remains on the market) until no
agents and houses remain. 18
 Theorem (Shapley and Scarf): the
allocation x produced by the top trading
cycle algorithm is in the core (no set of
agents can all do better than to participate)

• When preferences are strict, Gale’s TTC algorithm

yields the unique allocation in the core (Roth and
Postlewaite 1977).

19
Theorem (Roth ’82): if the top trading cycle
procedure is used, it is a dominant strategy for
every agent to state his true preferences.
• The idea of the proof is simple, but it takes some work
to make precise.
• When the preferences of the players are given by the
vector P, let Nt(P) be the set of players still in the
market at stage t of the top trading cycle procedure.
• A chain in a set Nt is a list of agents/houses a1, a2, …ak
such that ai’s first choice in the set Nt is ai+1. (A cycle
is a chain such that ak=a1.)
• At any stage t, the graph of people pointing to their
first choice consists of cycles and chains (with the
‘head’ of every chain pointing to a cycle…). 20
Cycles and chains

21
 The cycles leave the system (regardless of
where i points), but i’s choice set (the chains
pointing to i) remains, and can only grow

22
• Paired kidney exchanges similarly seek the gains from
trade among patients with willing donors, but (with the
recent Johns Hopkins 3-pair exchange being a notable
exception) mostly among just two pairs.
• In the context of kidney exchange, if we consider
exchange only among patients with donors, the
properties of the housing market model essentially carry
over unchanged (as long as donor preferences coincide
with those of their intended recipient).
• However donors (unlike houses) have preferences. So
all parts of a live-donor exchange are done
simultaneously, to avoid incentive problems.
23
 How big are the welfare gains?

• Theory show us how to go from inefficient to

efficient procedures, but it doesn’t tell us how big
the gains are likely to be.
• For that we turn to computational simulations,
using data on the mismatch frequencies, patient
demographics, etc.
• We first consider unrelated donor-patient pairs.
(About 25% all living-donor transplants were in
this category in 2001.)
24
 Patient and Donor Characteristics
• Population: Caucasian ESRD patient population between
18 and 79 years of age in the U.S. Renal Data System
(USRDS).
• Blood-type and age distribution: Distributions for new
ESRD waitlist patients recorded between January 1995
and April 2003 in the USRDS database.
• Gender distribution: Data recorded between 1992 and
2001.
• HLA distribution: The distribution reported in Zenios
[1996] using the USRDS registration data for years
between 1988 and 1991.
• We assume that all HLA proteins and blood type are
independently distributed following Zenios [1996]. 25
 Simulated patient preferences
• Preferences are determined using the graft survival
analysis of Mandal et. al. [2003]. We assume that the
preferences of each patient depends on the donor age
and the number of HLA mismatches. Using the graft
survival analysis of Mandal et. al. [2003], MRS is
determined as
• 5.14 years of younger donor age per each additional
HLA mismatch for patients younger than 60 years of
age, and
• 5.10 years of younger donor age per each additional
HLA mismatch for patients older than 59 years of age
26
How big are the benefits? N=30

27
How big are the benefits? N=100

28
 How about actual patient
populations?
• While the simulated results look good, they are
drawn from general patient distributions.
• Actual patient populations will consist of
incompatible patient-donor pairs.
• Patients who are already known to be
incompatible with one donor may be much harder
to match…e.g. they are more likely to be highly
sensitized

29
 MGH Dataset
(constructed by Susan Saidman)
• MGH patients w/ incompatible (ABO or XM) donor(s)
• Data included
• ABO type of patient & donor
• HLA type of patient & donor
• Most recent class I and II PRAs
• Called abs or safe antigens
• Relationship of donor to recipient
• Reason donor was incompatible

• If donor not HLA typed, HLA types were assigned

from list of UNOS deceased donors
• 44 patients and 68 donor/patient pairs
– 23 O; 13 A; 6 B; 2 AB
30
 Example of two-pair exchange (B-O,O-B)
Cl I Cl II
Rec Called Don Relat Reason
ABO PR PR ABO Donor HLA type
ID abs or ID ’n incompat
A A
D28.
R28 O 0 0 Sib B DR52 ABO
2
R45 B 0 41 DR53 D45 Child O DR51, 53 Class II ab

Exchange – D45 gives to R28; D28.2 gives to R45

Cl I Cl II
Rec Called Don
ABO PR PR Relat’n ABO Donor HLA type
ID abs or ID
A A
R28 O 0 0 D45 - O DR51, 53 -
D28.
R45 B 0 41 DR53 - B DR52 -
2 31
 Example of three-pair exchange (A-B,B-B,B-A)
Cl I Cl II Don
Rec Called Reason
ABO PR PR or Relat’n ABO Donor HLA type
ID abs incompat
A A ID
DR12; DR2, 3; DQ1,
R19 B 0 50 DQ2,7
D19 Child B Pos B XM
DQ2
R43 A 0 0 - D43 Spouse B DR2, 8; DQ1, 4 ABO

R31 B 0 0 - D31 Spouse A DR7, DQ2, 3 ABO

Exchange – D43 gives to R19, D31 gives to R43, and D19 gives to R31

Cl I Cl II
Rec Calle Dono
ABO PR PR Relat’n ABO Donor HLA type
ID d abs r ID
A A
DR12;
R19 B 0 50 DQ2,7
D43 B DR2, 8; DQ1, 4

R43 A 0 0 - D31 A DR7, DQ2, 3

DR2, 3; DQ1, 32
R31 B 0 0 - D19 B
DQ2
 Note that
• The initial screening and computer match
identifies potentially compatible donor and
recipient pairs
• A crossmatch will always be required before
pair can be confirmed to be compatible
• Extensive antibody screening of patients and
careful identification of all antibody
specificities by a sensitive and specific
method can help prevent unexpected positive
crossmatches
33
Summary of analysis of MGH dataset
• If only two way exchanges allowed
– 8 patient-donor pairs in the dataset can
potentially exchange kidneys (2 ABO-O; 3
ABO-A; 3 ABO-B)
• If three way exchanges allowed
– 11 patient-donor pairs in the dataset can
potentially exchange kidneys (3 ABO-O; 3
ABO-A; 4 ABO-B; 1 ABO-AB)
• There is also a possible five way exchange
– Allows 12 patient-donor pairs to potentially
exchange kidneys
34
– But logistics currently not practical
Properties of Cycles for n=30

35
Properties of cycles for N=100

36
 Discussion of the Computational Results
• The computational results (for both the
simulated data and the MGH data) suggest that
adoption of the TTC mechanism will
significantly improve the utilization rate of
potential living-donor kidneys.

• But under the TTC mechanism,

average/maximal sizes of exchanges grow as
the population grows. For large populations of
patient-donor pairs, some of the efficient
exchanges may be impractically large. 37
Suppose exchanges involving more than
two pairs are impractical?

• Our New England surgical colleagues have 0-1

(feasible/infeasible) preferences over kidneys.
• Initially, exchanges may be restricted to pairs.
(see also Bogomolnaia and Moulin (2004)
– This involves a substantial welfare loss compared to the
unconstrained case
– But it allows us to tap into some elegant graph theory
for constrained efficient and incentive compatible
mechanisms.

38
 Pairwise matchings and matroids
• Let (V,E) be the graph whose vertices are
incompatible patient-donor pairs, with mutually
compatible pairs connected by edges.
• A matching M is a collection of edges such that no
vertex is covered more than once.
• Let S ={S} be the collection of subsets of V such
that, for any S in S, there is a matching M that
covers the vertices in S
• Then (V, S) is a matroid:
– If S is in S, so is any subset of S.
– If S and S’ are in S, and |S’|>|S|, then there is a point in
S’ that can be added to S to get a set in S.
39
 Pairwise matching with 0-1 preferences
• All maximal matchings match the same number of
couples.

• If patients have priorities, then a “greedy” priority

algorithm produces the efficient (maximal) matching
with highest priorities.

• Any priority matching mechanism makes it a dominant

strategy for all couples to
– accept all feasible kidneys
– reveal all available donors

• So, there are efficient, incentive compatible 40

mechanisms in the constrained case also.
41
Gallai-Edmonds Decomposition

42
 Summary
There are several potential sources of increased
efficiency from assembling a database of
incompatible pairs (aggregating across time
and space), including
1. More couple exchanges
2. longer cycles of exchange, instead of just
pairs
If longer cycles of exchange aren’t (initially)
feasible, constrained efficient matches can
still be achieved with good incentive
properties
43
 Why 3-way exchanges add so much
• Example: Consider a population of 9 incompatible
patient donor pairs consisting of
– O-A, O-B (difficult to match O patients)
– A-B, A-B, B-A (more A-B than B-A pairs)
– A-A, A-A, A-A (odd number of A-A pairs)
– B-O (scarce O donor)
• 3 two-way exchanges are possible: 6 transplants
– (A-B,B-A); (A-A,A-A); (B-O,O-B)
• If three-way exchanges are also feasible: 8
transplants
– (A-B,B-A); (A-A,A-A,A-A); (B-O,O-A,A-B)

44
 Four-way exchanges add less
• In connection with blood type (ABO)
incompatibilities, 4-way exchanges add
less, but make additional exchanges
possible when there is a (rare) incompatible
patient-donor pair of type AB-O.
– (AB-O,O-A,A-B,B-AB) is a four way exchange
in which the presence of the AB-O helps three
other couples…
• Incompatibilities involving positive cross
matches may sometimes generate larger
exchanges, but it appears that these are
relatively rare 45
 Summary (for surgeons):What do the
economists bring to the table?
• To arrange exchanges efficiently in a population
of patients with incompatible donors, there are
distributional issues, not just issues of medical
compatibility.
– For example, consider four incompatible patient-donor
pairs P1, P2, P3, P4, and suppose pairwise exchanges
are possible between P1 and P2; P2 and P3, and P1 and
P4.
– Then the exchange P1-P2 results in two
transplantations, but the exchanges P1-P4 and P2-P3
results in four.
46
 Summary (for economists)
• As game theorists start to take a more active role
in practical market design, we have to deal with
constraints, demands, and situations different than
those that arise in the simplest theoretical models
of mechanism design
• Here we address some of the issues that have
come up as we try to help surgeons implement an
organized exchange of live-donor kidneys
• Not only do these issues appear to allow
satisfactory practical solutions, they suggest new
directions in which to pursue the underlying
theory.
47