Ethical issues in increasing living kidney donations by expanding kidney paired exchange programs

Introduction. In 1997, Ross et al, proposed to increase the supply of livin g kidney donations by using kidneys from living ABO-incompatible donors thr ough an exchange arrangement between two living kidney donor-recipient pair s. Although many transplant centers are exploring this option, only a small fraction of potential donor-recipient pairs are eligible for an exchange o n the basis of ABO incompatibility. In this article, we explore three varia tions that have potentially great clinical relevance. Methods. The three potential variations discussed are: (1) altruistically u nbalanced living donor-recipient exchanges; (2) an indirect exchange (an ex change between a living donor-recipient pair with a cadaveric donor-recipie nt pair) on the basis of a positive crossmatch; and (3) an indirect exchang e on the basis of ABO incompatibility. Discussion. The goal of kidney paired exchange programs is to increase the supply of kidneys available for transplantation ethically. We acknowledge t hat all exchanges increase the potential for coercion, and we currently rej ect the proposal of altruistically unbalanced exchanges because of the pote ntial for coercion. However, we believe that voluntary consent can be achie ved for indirect exchanges. The indirect ABO-compatible exchange creates no new ethical concerns to our original living paired exchange program and we support its implementation. The indirect ABO-incompatible exchange does cr eate a new ethical concern because it may increase the vulnerability of O b lood group recipients. If mechanisms can be developed to avoid increasing t he waiting time for blood group O recipients, we would support the implemen tation of the indirect ABO-incompatible exchange.