Old, Sick and Need a Kidney? Good Luck

[Clark]

http://www.bloombergview.com/articles/2014-12-08/old-sick-and-need-a-kidney-good-luck

Old, Sick and Need a Kidney? Good Luck
By Virginia Postrel

When I donated a kidney to a friend in 2006, there were about 66,000 people on the national waiting list for kidney transplants. At the time, that seemed like an enormous number. But it was tiny compared to today. As of the end of November, nearly 102,000 Americans were officially waiting for kidneys.

Despite a record 11,163 kidneys transplanted from deceased donors in 2013, an ever-growing waiting list seems inevitable. With an aging population and increasing rates of diabetes -- the most common cause of kidney failure -- more and more people are developing kidney disease. Although transplant centers have gotten very good at persuading the bereaved families of deceased potential donors to give the “gift of life,” too few people die in ways that keep their organs healthy for transplant. The waiting list reflects an absolute physical shortfall.

...

“A younger, healthier kidney is going to confer a better outcome,” regardless of the recipient’s health or age, Hippen said. The new system doesn’t expand the number of good kidneys -- or of kidneys in general. It merely changes who wins the lottery.

No allocation scheme, however cruelly “rational,” is going to alleviate the fundamental problem: not enough organs to meet the need. For that, we need more living donors.

To contact the author on this story:
Virginia Postrel at vpostrel@bloomberg.net

[Clark]

 Virginia, I was "in the room" for three years while a large team of experts and public representatives labored to improve the practice of deceased donor kidney allocation. Three public forums and consideration of thousands of public comments on drafts and the final proposal over nearly ten years are what went into the improvement that finally passed the OPTN/UNOS board and was implemented last week on December 4th. I understand and agree, somewhat, that this limited improvement, which includes politically driven compromises, _seems_ arcane, complex, and of trivial positive impact. This is, in my view, a context problem obscuring the real, important, simplifying, and openly developed qualities of this step. This is the first time we truly have a national system, modular, dynamic, and sensitive to the complexities of patients' conditions and predictable responses to transplantation therapy. Granted, geographic disparities still exist. This modular, national approach will allow modification through time to respond to real results, and is a necessary condition to remove the entrenched, truly arcane and complex system that was in place. The science and statistical work behind the coefficients you list is available in the literature for all to review. The algorithm itself is amazingly simple, the result of repeated pressure against more nuanced approaches. This is the reality you agree we must recognize and account for. I disagree with your negative portrayal of the impact of 9,000 additional life years saved. That's per year, and will rapidly accumulate impact as fewer and fewer younger recipients will need to be relisted sooner. That's a real reduction of the list. Of even greater impact, independent from allocation, has been coverage of anti-rejection medications past three years post transplant as well as access to insurance despite pre-existing conditions. That vastly reduces the relisting by clockwork of younger, healthier recipients. I disagree with your negative focus about dialysis time counting as only adversely impacting predictability on the list. For the first time, all experiencing End Stage Renal Disease, even if initially only referred to dialysis, have equal access to transplants as therapy. The transition period, likely a year or less, may involve uncertainty, but the new steady state will include this previously shut out population. To wrap what's already too long a comment, there's no logical if-then relationship between deceased donor policy, no matter what it is, and living donor policy, no matter what it is. Medically, surgically, legally, politically, sociologically, this is is a divide we must bear in mind: the living are not the dead, and the dead are not the living. Failing to modify "donor" by "living" or "dead" in this context leads professionals and lay people to confuse policy and practice discussions.