Table 4.

Strength and weakness of international kidney exchange

Strength	Weakness
Increase access to better and effective health care of end stage renal disease patients for transplantation	Inequalities between donor recipient pairs from participating countries result from differences in regulatory, legal and reimbursement policy. Increase inequality and inequity in participating countries particularly for low/middle income countries
Quality of medical care increase from existing and participating National programs	Logistics are complex in immunological evaluation of pairs, management of clinical data and simultaneous surgery
Increase pool size, optimization and diversity of pairs increase quality of matching, number of transplants and increase transplant rate for difficult to match pairs who remain unmatched within their own country	Emerging less well established programs are likely to benefit less than well-funded established program. Limiting development of national program to become self-sufficient in organ donation and transplantation
Mutual learning between different National programs. Promote collaboration, best practice and spread of kidney exchange in interested countries	Adequate financial support for effective and equitable follow-up must be available in low/middle income countries
	Risk for donor recipient pairs with less adequate health care system to manage medical complications and long term follow up care
Facilitate legal, ethical expansion of kidney exchange program with International organ donation and transplantation community	Risks reducing the effectiveness and equity of existing well established program due to practical, logistical and organisational considerations associated with trans-national kidney exchange program
Dialysis is replaced with kidney exchange which is best and cost effective living donor kidney transplantation	Reputational risk and loss of public trust interest confidence in organ donation and transplantation if international kidney exchange involve Nations without appropriate legal and ethical policy to support best practice