Germany's Path to a National Kidney Exchange Program : An Assessment of the 2024 Legislative Proposal

Abstract

BACKGROUND: Kidney exchange programs (KEPs) facilitate organ exchanges among multiple donor-recipient pairs, enabling recipients to obtain immunologically well-matched kidneys through coordinated donor swapping. Despite the demonstrated benefits of such programs, Germany remains the only highly populated EU country in which kidney exchange is permitted only under very restrictive conditions. REFORM CONTEXT: In July 2024, the German Federal Cabinet approved draft legislation to amend the 1997 Transplantation Act, with the establishment of a national kidney exchange program (KEP) as one of its primary objectives. The Federal Parliament is expected to deliberate on the draft and consider potential revisions in 2026. EXPECTED RESULTS: The proposal is expected to alleviate the shortage of donor organs by mandating full nationwide participation from all transplant centers and by allowing longer exchange cycles as well as chains initiated by non-directed donors. In this paper, we present several international case studies and recent statistical evidence from European KEPs that highlight the potential benefits of including compatible donor-recipient pairs-a feature that is currently absent from the draft legislation. CONCLUSION: We believe that the draft law's exclusion of compatible donor-recipient pairs may ultimately undermine transplant quality, limit access, and reduce overall program efficiency. We therefore recommend a modest but essential amendment to the legislation before it is submitted for final approval by the Federal Parliament. Copyright © 2026 The Authors. Published by Elsevier B.V. All rights reserved.