Crossover kidney donation in Germany : Statement on the "Entwurf eines Dritten Gesetzes zur Änderung des Transplantationsgesetzes - Novellierung der Regelungen zur Lebendorganspende und weitere Änderungen"

The primary goal of living crossover kidney donation is to overcome medical incompatibility between donor and recipient through organ exchange and thereby increase the number of kidney transplants. Internationally, a number of best practices have been established on which our statement and recommendations are based. The Federal Ministry of Health in Germany presented an "Entwurf eines Dritten Gesetzes zur Änderung des Transplantationsgesetzes - Novellierung der Regelungen zur Lebendorganspende und weitere Änderungen" to introduce a kidney exchange program and allow new variants of living kidney donations in Germany. This represents significant progress in addressing the challenges of organ shortage and improving outcomes both for many donors and for patients with end-stage renal disease. We particularly welcome the inclusion of variants of crossover-donation (3-way exchange, non-directed donation) and the mandatory participation of transplant centers in a centralized crossover-donation system in the proposed bill and demonstrate below that these are important elements of an effective system (Section 2). We make two important recommendations for adjustments to the bill, both of which are consistent with international best practices for kidney exchange systems. First, compatible donor-recipient pairs should be allowed to participate in the exchange system. Although these pairs could perform a transplant directly, their participation can not only significantly increase the total number of transplants and shorten the waiting list (simulations suggest that the inclusion of compatible pairs could increase the number of kidney transplants through exchange by up to 160%), it is also often possible to allocate a higher quality kidney (younger donor, better tissue compatibility) to the recipient of the compatible pair through exchange (Section 3). Second, while the current provisions of the proposed bill imply the use of non-directed (anonymous) donations primarily for immediate matches with the best possible tissue compatibility on the waiting list, non-directed donations should preferably be used to initiate chains of exchanges. Kidney chains allow for more and higher quality transplants than direct allocation of the initial donation (Section 4). We also point out some ambiguities or potential errors in the bill regarding the simultaneity of operations, the exclusion of liver transplants, and cost estimates. Overall, the proposed changes have enormous potential to increase the effectiveness of the planned kidney exchange programs in Germany and to enable many more patients with renal insufficiency to receive a life-saving transplant. We hope that our paper will contribute to the best possible design of the reform.