Newsletter - April 2021

Welcome Message

Welcome to the April issue of the DICG newsletter.

In this newsletter we highlight new legislation in organ donation and transplantation, past meetings and thematic discussions, publications concerning the GKE as well as other important topics.

We are also excited to announce the launch of the DICG Course on Ethical Issues in Transplantation and The Declaration of Istanbul.

The DICG Course on Ethical Issues in Transplantation and The Declaration of Istanbul

We are excited to launch the the DICG Course on Ethical Issues In Transplantation and The Declaration of Istanbul. The course was designed to give a complete overview of the DOI. There are three main modules in the curriculum. History of the DOI, 2018 Edition of the DOI and Ethical Issues Related to the DOI. There is also a series of regional updates. While the Modules are all available at this time, periodically, there will be updates and additions to the content.

The course is free and open to all participants who want to learn about ethics in transplantation, the DOI and the DICG. Upon completion, all participants will be eligable for a certificate.

Please encourage your colleagues, fellows and trainees to participate!

In The News

This month, we are highlighting new laws and regulations accross the globe relating to organ donation and transplantation.

If you would like to offer comments on the articles posted by us, we request you to email This email address is being protected from spambots. You need JavaScript enabled to view it.. Our executive will consider your submission and if found suitable will carry it.

Recent Publications: GKE Edition

The Global Kidney Exchange (GKE) is a cross-border paired kidney exchange between pairs from countries with different economic backgrounds and healthcare systems. While the idea is noble and could hold solutions to the global crisis in organ shortages, we believe the particular benefit-sharing model is deceptive, provides disproportionate benefits to high-income countries and puts donor-recipient pairs from low-to-middle-income countries at risk for organ trafficking and exploitation.

Since the start of the GKE, the program methodology has been much contested and remains controversial. While the DICG leaders condemn the program in its current form, we believe that DICG members should stay up to date and informed with the debate on the GKE. As Marino et al. (2017) aptly titled one of their response letters: “Open dialogue between professionals with different opinions builds the best policy”.

Our regular newsletter contributor, Maryn Reyneke, has recently published an article on the GKE. We’ve used the moment and asked her to provide us with a literature update.

Read the full article...

The Global Kidney Exchange basics

The GKE concept has been introduced and piloted by a group of clinicians, ethicist and economist lead by Prof Michael Rees in the United States. While they envision the GKE concept to be replicated by other clinical centres1 they are currently the only known centre to have implemented a GKE program. Their first publication in 2017 on the pilot study, titled ‘Kidney Exchange to Overcome Financial Barriers to Kidney Transplantation’2, a letter to the editor in response to commentary on the first article3 and a 3-year review4, provide us with the program methodology, some practicalities and clinical findings.

Supporting, condemning and commentary on the Global Kidney Exchange

The GKE evoked much controversy and various international groups and organisations have taken positions for or against the GKE concept in its current form. Shortly after the publication of ‘Kidney Exchange to Overcome Financial Barriers to Kidney Transplantation’2, the WHO Task Force on Donation and Transplantation of Human Organs and Tissues5, the Council of Europe's Committee on Organ Transplantation6, and the Declaration of Istanbul Custodian Group7 condemned the GKE, while the American Society of Transplant Surgeons8 publicly approved it. This initial wave of position statements and various editorial letters by leaders in the field of transplantation (9–12) strongly focussed on questions of financial neutrality, exploitation and organ trafficking.

In 2019, the bioethicists Minerva, Savulescu and Singer 13 published an article supporting the GKE concept. They described the GKE as a benefit-sharing transaction with certain risks carried by both the high-income country pairs and the low to middle-income country (LMIC) pairs. They also viewed the GKE through a different philosophical lens. While most opponents of the GKE, so far, argued from a deontological perspective and based their arguments on principles like the principles of the Declaration of Istanbul, this group asked what is the greatest good for the greatest number. From this perspective, some burdens may be allowed if it saves lives.

A publication by the European Society for Organ Transplantation14 in 2020 focused the GKE debate on a more practical level, raising concerns related to the management of escrow funds and potential corruption. This publication furthermore highlighted the need for empirical research and patient views.14 The latest publication related to the GKE, published by a DICG member, picked up the initial concern of exploitation and viewed it through different theoretical lenses15. This article also placed the focus on the previously unnamed stakeholder group namely, future end-stage renal disease patients who could carry additional burdens if present benefit-sharing decisions do not take them into account.15

The vast majority of authors commenting on the GKE are from high-income countries. While some Indian and Egyptian authors briefly mentioned cross-cultural challenges and logistics as reasons why LMICs should not participate in global or transnational exchanges,16,17 the voices of LMICs remains underrepresented in the literature.


1. Roth AE, Marino IR, Ekwenna O, et al. Global Kidney Exchange should expand wisely. Transplant International. Published online 2020:0-2. doi:10.1111/tri.13656

2. Rees MA, Dunn TB, Kuhr CS, et al. Kidney Exchange to Overcome Financial Barriers to Kidney Transplantation. American Journal of Transplantation. 2017;17(3):782-790. doi:10.1111/ajt.14106

3. Rees MA, Paloyo SR, Roth AE, et al. Global kidney exchange: Financially incompatible pairs are not transplantable compatible pairs. American Journal of Transplantation. 2017;17(10):2743-2744. doi:10.1111/ajt.14451

4. Bozek DN, Dunn TB, Kuhr CS, et al. Complete Chain of the First Global Kidney Exchange Transplant and 3-yr Follow-up. European Urology Focus. 2018;4(2):190-197. doi:10.1016/j.euf.2018.07.021

5. WHO Task Force on Donation and Transplantation of Human Organs and Tissues. Position Statement on the Proposal for a Global Kidney Exchange as Adopted by the WHO Task Force on Donation and Transplantation of Human Organs and Tissues.; 2018. Accessed May 4, 2020.

6. Council of Europe. CD-P-TO Position Statement on Global Kidney Exchange Concept.; 2018.

7. DICG. Statement of the Declaration of Istanbul Custodian Group concerning Ethical Objections to the Proposed Global Kidney Exchange Program. Published 2018. Accessed December 4, 2019.

8. American Society of Transplant Surgeons. ASTS Position on Global Kidney Exchanges. Published 2017. Accessed December 27, 2019.

9. Delmonico FI, Ascher NL. Opposition to irresponsible global kidney exchange. American Journal of Transplantation. 2017;17:2745-2746. doi:10.1111/ajt.14473

10. Pullen LC. Global Kidney Exchange: Overcoming the Barrier of Poverty. American Journal of Transplantation. 2017;17(10):2499-2500. doi:10.1111/ajt.14469

11. Valera L, Carrasco MA. On the Global Kidney Exchange programme. The Lancet. 2020;395(10235):1484-1485. doi:10.1016/S0140-6736(20)30625-5

12. Brunner R, Ekwenna O, Reese S, et al. Global Kidney Exchange: An international approach to expanding living donor kidney transplantation in minority groups. 2018.

13.Minerva F, Savulescu J, Singer P. The ethics of the Global Kidney Exchange programme. The Lancet Health Policy. 2019;394(394):1775-1778. doi:10.1016/S0140-6736(19)32474-2

14. Ambagtsheer F, Haase-Kromwijk B, Dor JMF, et al. Global Kidney Exchange: Opportunity or Exploitation? An ELPAT/ESOT Appraisal. Transplant International. Published online 2020.

15. Reyneke M, Borry P. The Global Kidney Exchange: Revisiting exploitation arguments. Developing World Bioethics. 2021;44(November 2020):1-8. doi:10.1111/dewb.12311

16. Kute V, Jindal RM, Prasad N. Kidney Paired-Donation Program Versus Global Kidney Exchange in India. American Journal of Transplantation. 2017;17(10):2740-2741. doi:10.1111/ajt.14324

17. Elrggal ME, Tawfik M, Gawad MA, Sheasha HA. Kidney paired donation program, a national solution against commercial transplantation? Journal of The Egyptian Society of Nephrology and Transplantation. 2018;18:6-10. doi:10.4103/jesnt.jesnt_1_18

Thematic Discussion

The DICG council hosts thematic discussions around topics relating to the DOI's concerns, including emerging issues in ethics and equity in global transplantation.

In March, the DICG held another thematic discussion on "Gender disparity in access to transplantation" which was lead by Nancy Ascher.

Click below to view a snapshot from the thematic discussion presented by Curie Ahn (South Korea) where she discusses findings from a recent Women in Transplantation Meeting about gender disparity in Asia.

DICG Session at WCN 2021:

On April 14th, 2021, a DICG session was organized during the World Congress of Nephrology 2021. This session was chaired by Dr John Gill (Vancouver, Canada) and Dr Eric Rondeau (Paris, France) and included 4 presentations given by outstanding speakers.

The first speaker was Dr Nancy Ascher (San Francisco, USA) who recalled the history of the Declaration of Istanbul and the many actions of DICG since its creation. She also encouraged young professionals involved in transplantation to become DICG members.

The second speaker was Dr Marie-Chantal Fortin (Montréal, Canada) who spoke about the transplantation of foreign nationals (non citizens, non residents) in North America. She noted that the ethical issues are numerous and the organizations may vary from one state/province to another.

The third speaker was Dr Jim Rodrigue (Boston, USA) who analyzed what does financial neutrality for living donors means, and discussed payment, incentives and financial neutrality for living donors.

Finally, Dr Toby Coates (Adelaïde, Australia), described the Global Organ Trafficking Registry (GOTR) project that DICG is about to launch, to improve our knowledge of potential cases of organ trafficking and hotspots for illegal travels for transplantation.

Those who were registered for WCN2021 but missed the session can log in and view it Here.

View Past Newsletters

The newsletter is brought to you on behalf of the executive council of the Declaration of Istanbul Custodian Group which works to protect and promote the principles enunciated in the Declaration of Istanbul(DOI), a landmark document in the history of global transplantation.


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