The Honeymoon Phase and Studies of Nonsimultaneous Chains in Kidney-Paired Donation

Abstract

Kidney-paired donation programs have been successfully incorporating nondirected donors into nonsimultaneous extended (NEAD) chains (1). Including nondirected donors in either NEAD chains or domino-paired donations (DPDs, chains that end in the waiting list rather than a bridge donor) increases match opportunities for incompatible pairs. When interpreting the performance of NEAD chain programs, though, we must recognize that the honeymoon phase (where many transplants are facilitated by a single donor) may not last forever. After the initial months or years of operation, bridge donors will accumulate, competing for scarce matches or dropping out altogether after long waits. Clinical experience in the longest-running registries also shows that many chains do not operate indefinitely, but dissipate as hard-to-match bridge donors languish.A recent report of Ashlagi et al. (2) highlights the need to recognize the honeymoon phase, as the data demonstrate that inferences from the early stages can be overturned and reversed as registries operate over longer periods of time. Ashlagi et al. reproduced our computational findings (3) that NEADs would not facilitate more transplants than DPDs over 24 periods, or months, of operation. Then, using 8-period simulations with longer segments (our simulation limited concurrent segments to three pairs without limiting overall chain length), Ashlagi et al. argued that NEADs with longer segments facilitate more transplants than DPDs. However, comparing Figure 2 with Figure 3 of their manuscript illustrates that the ostensibly minor detail of switching from a 24-period simulation to an 8-period simulation was actually the decisive factor in reversing the predicted benefit of DPDs over NEAD chains, not the longer segments.Our simulations showed that after 24 periods in mature registries, NEAD is not superior to DPD when segment lengths are limited to three. Figure 2 of Ashlagi et al. reproduces this result, with the endpoint of the NEAD-3 line below 1 (near 0.98). Figure 3 shows the opposite result for the exact same experiment when simulating only the first eight periods (the honeymoon phase): the endpoint of the NEAD-3 line in Figure 3 is above 1 (near 1.015). That is, NEAD chains seem superior to DPDs in Figure 3 but not in Figure 2, where the only difference is the number of periods simulated.Contrary to their honeymoon phase results, the data that Ashlagi et al. present actually prove that in mature registries, the advantage of DPD over NEAD is larger with chains that allow longer concurrent segments. Figure 2 compares DPD with NEAD for segments of length 4 and shows that for all renege rates, DPD gives an equal or greater number of transplants than NEAD. Figures 3-10 show valid data for honeymoon phase inferences, but cannot elucidate what will happen as NEAD chains deteriorate over time.Matching algorithms are also susceptible to the honeymoon phase problem. Ashlagi et al. limited their studies to only 8-period simulations because, as they stated, optimizing matches for later p...

Planning for Uncertainty and Fallbacks Can Increase the Number of Transplants in a Kidney-Paired Donation Program

“…Simulation parameters and conditions follow those in Ashlagi et al (9), although we also note the simulations by Gentry et al (8) (16) suggesting that simultaneous DPD chains are preferable to longer NEAD chain segments in certain situations. We consider DPD chains with a maximum length of 2 (with implicit final donation to the deceased donor list), as well as NEAD chain segments with maximum allowable chain segment lengths of 3, 4 and 5 (denoted NEAD3, NEAD4, and NEAD5).…”

Price of Fairness in Kidney Exchange.

“…Fielded kidney exchanges also gain great utility through the use of chains (see, e.g., [4,14,16,17,21,22,23,28]). Chains start with an altruistic donor donating his kidney to a patient, whose paired donor donates her kidney to another patient, and so on.…”

Six end-stage renal disease patients benefited from first non-simultaneous single center 6-way kidney exchange transplantation in India

“…DPD is ideal in balancing the principles of utility and justice[12,13]. A non-directed donor into non-simultaneous extended chain is not superior to DPD when segment lengths are limited to three[14]. …”