Why Organs Are Wasted, Not Transplanted
Why were more than 2,600 kidneys recovered from deceased donors and discarded last year while 4,720 people in the U.S. died awaiting kidney transplants?
According to a story last month in the New York Times, a significant number of discarded kidneys—maybe as many as half—could be transplanted if the system for allocating them was more efficient at matching the right organ to the right recipient.
Many industry observers say that outdated computer technology, over-regulation, over-reliance by doctors on inconclusive tests and laws against age discrimination all contribute to a system of organ rationing that puts fairness above saving lives.
The waiting list for deceased donor kidneys is more than 93,000 and has been for 25 years because of the federal policy of first come, first served. The Organ Procurement and Transplantation Network is managed under federal contract by the nonprofit United Network for Organ Sharing (UNOS). The system is considered simple and transparent, but many experts say it’s wasteful. For the first time in 25 years, UNOS is trying to revise it while satisfying multiple masters.
As The Times explains, the U.S. is divided into 58 donation districts. When a deceased donor kidney becomes available, the rules say it must be offered first to the compatible candidate within the district who has waited the longest. Other priorities are children, candidates with particularly difficult-to-match blood chemistry and to people particularly well matched to the donor. If there’s no local candidate, the electronic search expands.
But the kidney matching system ignores the projected life expectancy of the recipient and the urgency of the transplant. Those factors are considered by systems for allocating livers, hearts and lungs.
So kidneys that might function for decades can be transplanted into elderly patients with a short lifespan. When older, lower-quality kidneys become available, candidates atop the list and their doctors can decline them, and wait for better organs. Sometimes, those organs develop a reputation as unwanted when, in fact, they might suit some candidates perfectly well.
Time is always a factor in organ transplant. Even though recovered kidneys are placed on ice for evaluation, they begin to degrade. Surgeons want to transplant within 24 to 36 hours of harvest.
During that small window, organs are tested, recipient searches are conducted and the organs might undergo long drives or flights for transplant.
Last year, nearly 18 in 100 recovered kidneys were discarded. About one-fifth of them—nearly 500—were not transplanted because a recipient could not be found. Transplant surgeons speculate that as many as half of discarded kidneys could be transplanted.
Older donors are responsible for more than half the discarded kidneys. Age and health problems make them suspect. But last year, nearly 1,000 discarded kidneys came from donors younger than 60.
Transplant officials want to boost efforts to encourage people to register as donors, increase donor registration rates, remove financial and logistical obstacles and narrow extreme differences in wait-list time among states.
But the disconnect between need and the ability to meet it also involves doctors who decline an available kidney because they lack good diagnostic tools and succumb to pressure from regulators and insurers to maintain high transplant-success rates.
Recovered kidneys are analyzed for a variety of functions, and are discarded most often because hospitals reject the test results. But studies suggest that tests don’t always predict how long a transplanted organ might survive.
Federal scrutiny, transplant authorities say, further impairs transplant success rates. Federal oversight of Medicare requires that survival data for transplanted organs and recipients be made public. If a transplant program exceeds the acceptable number of failures by 50 percent twice in 30 months, it’s under probation. If it doesn’t improve, it can be decertified.
Medicare is the primary insurer for kidney transplants, but commercial insurers also use the survival ratings to make transplant contract decisions. The threat of government penalties and loss of business has made surgeons more cautious about the organs and patients they accepted, leading to more discards.
One transplant surgeon’s kidney program was cited by Medicare in 2008 after several unlikely failures. To avoid decertification, the surgeon cut the number of transplants by 40 percent and became far choosier about the organs and recipients he accepted.
The one-year transplant survival rate rose to 96 percent from 88 percent, but, as he told The Times, “Which serves America better? A program doing 100 kidneys and 88 percent of them are working, or a program that does 60 kidneys and 59 of them are working? It’s rationing health care under the guise of quality, and it’s a tragedy that we are throwing away perfectly good organs.”
An official with the Centers for Medicare and Medicaid Services agreed that individual hospitals had grown more cautious, but said there was no evidence that had led to more discards nationally because other hospitals picked up the slack. He refused to ignore that poor outcomes deserved scrutiny.
There’s that word: rationing. It’s in play whenever there is more organ demand than supply. But eight years after the UNOS asked its kidney transplantation committee to improve the system, there has been no change.
One proposal, The Times noted, called for rating each organ based on the donor’s age, height, weight and medical history. The top 20 percent of those kidneys would be allocated to recipients expected to live the longest. The rest would be matched to give priority to candidates within 15 years of the donor’s age.
The idea was rejected because the feds warned that discrimination laws would prohibit the use of age to determine who gets a transplant.
In Europe, which has no such age barrier, the number of older kidney donors has more than tripled since 1999, and discard rates are less than one-third of that in the U.S. There is no significant difference in survival rates for older patients in Europe and the U.S.
Last month, the kidney committee proposed that the top 20 percent of kidneys still would be matched to the recipients expected to survive the longest, but the remaining 80 percent would be allocated primarily by how long someone has been on the waiting list.
In August, a group of researchers proposed a different allocation in the American Journal of Transplantation. It would give individuals in different age bands an equal chance to get an organ in a given year. But it would reserve the best kidneys to the youngest recipients.
If you have an opinion about the system that delivers organs to people who need them, you may participate in the UNOS public comment period. Make your feelings known here.
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