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Nonsimultaneous Extended Donor Chains and Domino Paired Donation Nonsimultaneous Extended Donor Chains and Domino Paired Donation A Comparison of two Market Design Approaches applied to the German Market for Kidneys Master Thesis im Fachgebiet Volkswirtschaftslehre vorgelegt von: Dominik Bernhard Wullers vorgelegt am: 04. Juli 2011 Studienbereich: Volkswirtschaftslehre Matrikelnummer: 831710 Erstgutachterin: Univ.-Prof.’in Dr. Radosveta Ivanova-Stenzel Eidesstattliche Erkl¨arung Ich erkl¨are, die vorliegende Arbeit selbstst¨andig verfasst und keine anderen als die im Quellen- und Literaturverzeichnis genannten Hilfsmittel genutzt zu haben. Alle aus Quellen und Literatur w¨ortlich oder sinngem¨aentnomme- nen Stellen habe ich als solche kenntlich gemacht und einzelne Fundstellen nachgewiesen. Dar¨uber hinaus versichere ich, dass die eingereichte elektron- ische Fassung mit den gedruckten Exemplaren identisch ist. Hamburg, den 04. Juli 2011 Master Thesis Nonsimultaneous Extended Donor Chains and Domino Paired Donation A Comparison of two Market Design Approaches applied to the German Market for Kidneys Dominik B. Wullers Nonsimultaneous Extended Donor Chains and Domino Paired Donation Contents 1. Introduction 1 2. Hypothesis 3 3. Literature Review 5 3.1. A brief history of Market Design . 5 3.2. Kidney Exchanges . 8 3.3. Non-Simultaneous Altruistic Donor Chains and Domino Paired Donation 10 4. Background 14 4.1. Medical Background . 14 4.2. KidneyTransplantsOverview . 17 4.3. Legal Situation . 19 4.4. Eurotransplant . 21 5. Theory 22 5.1. StochasticProcesses .............................. 22 5.2. PoissonProcesses................................ 23 5.3. QueueTheory.................................. 25 6. Data 28 7. Simulation 32 8. Results 40 8.1. Regression Results, AB Bridge Donors and Exact ABO Matching . 40 8.2. Low Complexity, No Delay . 47 8.3. LowComplexity,DelayOn .......................... 53 8.4. High Complexity, Delay Off .......................... 58 8.5. High Complexity, Delay On . 64 8.6. Additional Results . 70 9. Conclusion 75 Bibliography 77 A. Tables 82 i Nonsimultaneous Extended Donor Chains and Domino Paired Donation Acronyms BD Bridge Donor. BDR Bridge Donor Reneging. CSL Chain Size Limit. DPD Domino Paired Donation. ESRD End Stage Renal Disease. ET Eurotransplant. ETKAS Eurotransplant Kidney Allocation System. HLA Humane Leucocyte Antigene. KPD Kidney Paired Donation. NDD Non Directed Donor. NEAD Nonsimultaneous Extended Altruistic Donor. NEPKE New England Program for Kidney Exchange. PRA Panel Reactive Antibodies. ii Nonsimultaneous Extended Donor Chains and Domino Paired Donation List of Tables Table 1: Eurotransplant Patient Waiting Times Table 2: Eurotransplant Kidney Waitlist Overview Table 3: Relative ABO and PRA distribution for patients Table 4: Age distribution among patients and donors Table 5: Factor effect linear regression results Table 6: Exact ABO matching: Relative ABO blood type frequencies Table 7: Exact ABO matching: Effects on Performance Table 8: Correlation of performance indicators Table 9: AB bridge donors: Two sample t test results Table 10: NEAD vs DPD I Table 11: DPD and NEAD vs ET performance results I Table 12: NEAD vs DPD II Table 13: DPD and NEAD vs ET performance results II Table 14: NEAD vs DPD III Table 15: DPD and NEAD vs ET performance results III Table 16: High vs low complexity: Comparison of performance I Table 17: NEAD vs DPD IV Table 18: DPD and NEAD vs ET performance results IV Table 19: High vs low complexity: Comparison of performance II Table 20: Frequency of O patients among transplanted patients Table 21: Frequency of live donations among all transplantations Table 22: HLA-ABDR Relative Frequencies Table 23: Distribution tests for NEAD in high vs low complexity settings I Table 24: Distribution tests for NEAD in high vs low complexity settings II Table 25: Distribution tests for NEAD in high vs low complexity settings III Table 26: Distribution tests for NEAD in high vs low complexity settings IV Table 27: NEAD: Same setting distribution tests I Table 28: NEAD: Same setting distribution tests II Table 29: NEAD: Same setting distribution tests III Table 30: NEAD: Same setting distribution tests IV iii Nonsimultaneous Extended Donor Chains and Domino Paired Donation List of Figures Figure 1: Domino Paired Donation Figure 2: Non-simultaneous Extended Altruistic Donor Chain Figure 3: The Eurotransplant Kidney Waiting List Figure 4: Graft Survival Rates Figure 5: Queue Development I Figure 6: Queue Development II Figure 7: Queue Development III Figure 8: Adverse Effects of Bridge Donor Reneging I Figure 9: Queue Development IV Figure 10: Queue Development V Figure 11: Queue Development VI Figure 12: Adverse Effects of Bridge Donor Reneging II Figure 13: Queue Development VII Figure 14: Queue Development VIII Figure 15: Adverse Effects of Bridge Donor Reneging III Figure 16: Queue Development IX Figure 17: Queue Development X Figure 18: Adverse Effects of Bridge Donor Reneging IV Figure 19: Adverse Effects of Bridge Donor Reneging V Figure 20: Distribution of Blood Type O Among Transplanted Patients iv Nonsimultaneous Extended Donor Chains and Domino Paired Donation 1. Introduction As of 2011, many economists are concerned with kidney transplantations. However, it is not to the author’s knowledge that any of the economists who wrote on the topic in the past decade suffered or suffer from renal disease, required a live saving kidney transplant, or do so now. The interest is rather, and indeed, an economic interest. The reason for that is a new field of economics that seeks to integrate theory and practice in designing markets. Economists have always had a theoretic interest in mar- kets but somewhat frowned on the managerial sciences that concerned themselves with the not-so-scientific making and maintaining of markets and businesses. Fueled by the expanding field of game theory, however, economists became more and more involved in the creation process behind such important multi-billion dollar markets such as the one for radio frequencies.1 Inspired by the newly gained knowledge about practical problems of markets, economists began to explore other aspects than the equilibrium price. Only a few markets are ac- tually large and efficient enough to qualify for an analysis with the classical economic tools. Most markets are governed by their own sets of rules and constraints. One very important constraint, as Roth (2007) [44] stresses, is repugnancy. A repugnant market, i.e. a market that a majority (excluding the participants) deems disgusting or distasteful, is often heavily regulated. There are historic and current exam- ples of markets with a questionable reputation, such as the markets for political favors (corruption), affection (prostitution), or cheap labor (slavery). Nevertheless, there is demand and supply in these markets, no matter how much societies and states try to regulate or prevent them. While the regulation of the previously named markets might be unanimously advocated from an ethical standpoint, the prohibition of certain other repugnant markets generates massive negative externalities for the participants, such as death. One such repugnant market is the market for organ transplants. Patients that need a new organ mostly face the problem that there is only one solution for a prolongation of their own lives, namely that somebody else dies and leaves an organ for them. End-stage renal disease is such an illness that requires transplantation. For a while, patients can bridge the time until a transplant arrives with dialysis. The mechanical cleansing of the blood, however, can only last for so long. Veins get thicker and retract into the body the more often they are used to be attached to the dialysis machines. Patients can, in fact, run out of access points for dialysis. The kidney market has compared to all other markets for internal organs another feature. Namely, that it is not necessary to die to donate. Each healthy human being 1Cf. Milgrom (2004) [30] 1 Nonsimultaneous Extended Donor Chains and Domino Paired Donation can easily survive on one kidney and could donate one of the two he or she possesses. However, eliciting extra donations by paying for them is regarded repugnant in Western civilization.2 Hence, many patients suffer and die from the repugnancy-inspired rules and regulations imposed on this market. Economists have argued in two directions. The classic idea, the introduction of money to the market, was recently brought forward again by Becker and Elias (2007) [6]. How- ever, a new proposal has been developed. The field of market design, which will be briefly introduced later, currently explores options to raise the efficiency of organ al- location while accepting the repugnant character of monetary exchanges. One way is the promotion of Kidney Paired Donation (KPD) in which two pairs of incompatible patient-donor dyads donate crosswise. Economists calculated the most efficient way to conduct such exchanges and helped founding the New England Program for Kidney Ex- change (NEPKE). Another opportunity are Nonsimultaneous Extended Altruistic Donor (NEAD) chains. These chains rely on ”good samaritans”: individuals who decide to donate a kidney without an intended recipient. A so gained transplant is offered to an incompatible patient-donor pair. Their now unused kidney is then offered to the next pair and so on. A second and conflicting view proposes the Domino Paired Donation (DPD) mechanism which advocates that the last donor in such a chain should not wait for the next pair to arrive but give to the kidney queue instead to keep donations simultaneous. These two mechanisms will be of central interest in this work. The economic idea behind this thesis is to show how NEAD and DPD chains can in- crease allocation efficiency of altruistic donations while accepting the externally imposed rules of the market. Queue theory will be used to analyze the dynamic and evolving as- pects of the transplant waiting list for the case of Germany. The model will be extended by diverse options to show how closer approximations of reality minimize or increase effects. Both mechanisms will be compared in four different settings to explore which instrument is better suited to ease the pressure on the market for transplants.
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