More than half a million Americans have end-stage kidney disease. Dialysis is time consuming and costly—in 2009, for example, management of kidney disease cost the US Government an estimated US$29 billion. Even accounting for a need for immunosuppression, life expectancy and quality of life for a kidney transplant recipient far exceeds that of a patient treated with dialysis. The problem is that the present kidney donor pool is not nearly large enough to provide a transplant for the 91 000 Americans awaiting a kidney. In 2008, 4500 people died while waiting for a kidney transplant. The gap between supply and demand of kidneys for transplantation keeps on widening due to the increasing prevalence of the main risk factors for kidney disease (principally hypertension, diabetes, and obesity), which not only result in an increased incidence of end-stage kidney disease requiring prompt treatment but also diminish the number of people who might be suitable kidney donors.

In the USA, each April is Donate Life Month, a time to pause and think how the present opt-in and consent-driven organ donation system can be improved to increase the much needed supply of kidneys for transplantation. One strategy that can expand the pool of available kidneys is to enhance living organ donations through nationwide establishment of chains of paired donations. In paired kidney donation, incompatible donor-recipient pairs are matched until a suitable donor is located for every recipient. The system has all the potential to succeed: highly functioning matching software exists; living donor kidneys have higher rates of immediate function than do kidneys from deceased donors and better short term survival for the allograft and the recipient; and donor travel can be circumvented since shipping of living donor kidneys has been shown to be a viable option. So why were only 429 of the 16 812 kidney transplants done in the USA last year through paired kidney donations?

Another issue with paired living organ donation is that few hospitals in the USA presently participate, standardisation of donor and recipient allocation nationwide is not done, and not all pairs are listed in a single registry. Recipients' insurance policies do not generally cover the necessary 4—6 weeks' loss of wages. Data are also missing for long-term outcomes for kidney donors. Finally, interventions that investigate individual willingness to donate kidneys are scarce.

It is good news and very welcome that the US Food and Drug Administration has recognised the need to foster innovations that might improve the management of end-stage kidney disease. On April 9, three experimental kidney devices were selected to participate in the agency's new Innovation Pathway programme. Three manufacturers, one academic and two from the private sector, have different devices under development: a dialysis device containing live kidney cells that is implanted into the gut, a wearable artificial kidney, and a valve that modulates blood flow between dialysis and regular kidney functions, respectively. Under the programme, the companies will get more opportunities to meet regulators and scientific experts to explain what their devices do and prove they are safe and effective before they begin clinical trials. The aim is that prioritisation of these three new technologies will accelerate their progression through clinical evaluation and into practice.

Most individuals with kidney disease are not aware that they have the disease. Health-care providers must therefore increase efforts not only to convey clearly that diabetes, high-blood pressure, being aged 60 years or older, and family history of the disease are risk factors for kidney disease, but also to improve efforts toward diagnosis. The ultimate goal must be to prevent the development of end-stage kidney disease and reduce the need for treatment as much as possible.