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Author Topic: Under kidney transplant proposal, younger patients would get the best organs  (Read 7491 times)

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Offline Karol

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Under kidney transplant proposal, younger patients would get the best organs
By Rob Stein
Washington Post Staff Writer
Wednesday, February 23, 2011; 11:04 PM

The nation's organ-transplant network is considering giving younger, healthier people preference over older, sicker patients for the best kidneys.

Instead of giving priority primarily to patients who have been on the waiting list longest, the new rules would match recipients and organs to a greater extent based on factors such as age and health to try to maximize the number of years provided by each kidney - the most sought-after organ for transplants.

"We're trying to best utilize the gift of the donated organ," said Kenneth Andreoni, an associate professor of surgery at Ohio State University who chairs the committee that is reviewing the system for the United Network for Organ Sharing (UNOS), a Richmond-based private nonprofit group contracted by the federal government to coordinate organ allocation. "It's an effort to get the most out of a scarce resource."

The ethically fraught potential changes, which would be part of the most comprehensive overhaul of the system in 25 years, are being welcomed by some bioethicists, transplant surgeons and patient representatives as a step toward improving kidney distribution. But some worry that the changes could inadvertently skew the pool of available organs by altering the pattern of people making living donations. Some also complain that the new system would unfairly penalize middle-aged and elderly patients at a time when the overall population is getting older.

"The best kidneys are from young adults under age 35 years. Nobody over the age of 50 will ever see one of those," said Lainie Friedman Ross, a University of Chicago bioethicist and physician. "There are a lot of people in their 50s and 60s who, with a properly functioning kidney, could have 20 or more years of life. We're making it harder for them to get a kidney that will function for that length of time. It's age discrimination."

More than 110,000 Americans are listed as waiting for organs, including more than 87,000 who need kidneys. Only about 17,000 Americans get kidneys each year, and more than 4,600 die because they did not get one in time.

"It's a big shift," said Arthur C. Caplan, a University of Pennsylvania bioethicist. "For a long time, the whole program has been oriented toward waiting-list time. This is moving it away from a save-the-sickest strategy to trying to get a greater yield in terms of years of life saved."

If adopted, the approach could have implications for other decisions about how to allocate scarce medical resources, such as expensive cancer drugs and ventilators during hurricanes and other emergencies, Caplan said.

"This is a fascinating canary-in-a-cave kind of debate," he said. "We don't want to talk about rationing much in America. It's become taboo in any health-care discussion. But kidneys reminds us there are situations where you have to talk about rationing. You have no choice. This may shine a light on these other areas."

An evolving system
The current system, which dates to 1986, was first based largely on giving kidneys to the patients who matched the organs best, but it evolved to take a first-come, first-served approach made possible by safer, more powerful anti-rejection drugs. Today, the UNOS's Organ Procurement and Transplantation Network (OPTN) gives priority to patients seeking organs from someone who dies based mostly on who has waited the longest.

"It was just a fairness issue," Andreoni said. "You're next in line. It's your turn."

The problem is that, in some cases, elderly recipients get organs from much younger donors whose kidneys could have provided far more years of healthy life to younger, heathier patients. Younger patients can receive older or less-healthy organs that wear out more quickly, forcing them back onto the transplant list in a few years.

The 30-member UNOS Kidney Transplantation Committee, which has been reviewing the system for about six years, last week quietly began circulating for public comment a 40-page document outlining possible revisions.

Under one scenario, for 80 percent of kidneys, patients 15 years older or younger than the donor would get higher priority. The remaining 20 percent of organs - those deemed to have the best chance of lasting the longest based on the age and health of the donor and other factors - would be given to recipients with the best chances of living the longest based on criteria such as their age, how long they've been on dialysis and whether they have diabetes.

M. Jill McMaster, a UNOS board member representing the public, acknowledged that the new system would put older people at a disadvantage, but she argued that it is necessary.

"I'm 60 years old, and I have a transplant. But if I were to need a second transplant, I wouldn't have a chance of getting the best organs, whereas in the past I did have a chance," McMaster said. "What we're asking those on the list to do is hard when you are sick, which is to look at the needs of everybody. I think it's the right thing to do."

Although many of the details about how the new concept would be implemented still have to be worked out, McMaster said it is likely to be adopted.

Public comments invited
The public has until April 1 to comment on the idea, which would make the kidney system more similar to those used to allocate livers, hearts and lungs. The committee will take those comments into account before formally proposing the specific changes, which will be open to public comment again before going to the UNOS board of directors. The board could approve final changes by June 2012.

"I strongly endorse this," Robert M. Veatch, a bioethicist at Georgetown University, wrote in an e-mail. "I think it is defensible on both fairness and efficiency grounds."

But others worry that the changes could reduce the overall number of organs available for transplants or inadvertently further shift the matches between organs and recipients by affecting living donors, who are not regulated by UNOS. Some relatives who would have donated a kidney to a young patient might now decide not to, for example, putting pressure on other relatives to donate kidneys to older family members. In addition, the changes would do nothing to address the wide variation in waiting times in different parts of the country.

"If we really want to improve things, we need to address the variation in access to transplants based on geography," Ross said. "This factor, more than any other, would increase the overall number of life years gained from kidney transplantation."

Some argued that a better solution would be to give recipients the option of choosing what donor kidneys to accept.

"Some younger people may accept a donor that is higher risk and may not last as long if they could get it sooner," said Richard Freeman, chairman of surgery at Dartmouth Medical School. "It should be more patient-based and less driven by absolute gain in life years."

Others questioned the formula that would be used to match patients and organs. Because the system would be more complicated, it could backfire by creating suspicions of cheating, eroding confidence and reducing organ donations.

"It works well enough the way it is, and everyone understands it, which is important to maintain the public trust," said Benjamin Hippen, a kidney specialist at Metrolina Nephrology Associates in Charlotte.

http://www.washingtonpost.com/wp-dyn/content/article/2011/02/23/AR2011022306875_pf.html
Daughter Jenna is 31 years old and was on dialysis.
7/17 She received a kidney from a living donor.
Please email us: kidney4jenna@gmail.com
Facebook for Jenna: https://www.facebook.com/WantedKidneyDonor
~ We are forever grateful to her 1st donor Patrice, who gave her 7 years of health and freedom

Offline Eldonna Edwards

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I'm not sure I'm in favor of this. If we're talking about an 80 year-old patient, maybe, but I think those who have been waiting deserve consideration, so long as there is reasonable prospect of a new kidney providing a decade or more of healthy living. My (non-directed) recipient was 53 and had pretty much accepted his "death sentence". Now he is working out at the gym, engaged in life, and happy as a clam.

There are no guarantees in this life. A 20 year-old recipient could die in a car crash the day after release and a 60 year-old could live an extra 15 years. A lot of ethical questions here...
Author of Lost in Transplantation: Memoir of an Unconventional Organ Donor

Offline donor99

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I think its a reasonable compromise. 20% of the best kidneys are allocated to 20% of recipients with the best expected outcome. The remaining 80% are allocated to patients + or - 15 years. So if you are 50 you would be eligible for an organ from a donor between the ages of 35 and 65. Remember, a majority of organs come from donors > 50 in the first place. Plus there is always the option of a live donor for recipients of all ages.

Its a way of allocating the right organ for the right patient. Yes its fair in the current system for a 70 year old patient to get a 35 year old organ and enjoy several years of a better quality life free of dialysis. But is that right for the 35 year old who will never get to be 70 without an organ.

The debate will be on going but I think its a good place to start the conversation.

Offline Rob_h

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I am in favor of this idea, but expect it will get nowhere.  It will be seen as unfair.  I sort of accept that the UNOS mandate is always to organize the line, not expand the number of possible donors.  In the US millions of people pay out of pocket huge sums to have much more risky cosmetic surgery.  It has never made sense to me that people die for lack of a timely transplant.  To some degree fussing over the structure of the waiting list seems to accept as normal that some folks will die sooner than they had to.  Just my two cents,  Rob Halverson

Offline Karol

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Response from UNOS/OPTN:

March 1, 2011

Clarification of Media Reports on OPTN Kidney Allocation Concept Document

Recent news reports have inaccurately described a request for public feedback on concepts that may be considered as part of future OPTN kidney allocation policy. To be clear, there has been no change in existing national kidney allocation policy. Furthermore, no change is imminent. Media reports have also selectively reported on the intent and possible effects of only one part of the concept document.

The document out for public comment offers concepts and rationale that have been recommended by various experts with a professional or personal involvement in kidney transplantation. Only if these concepts receive considerable public support, will they be forwarded to the next level of scrutiny and consideration. The concepts could also be amended to address specific questions or recommendations from the public before any proposal is developed.

For several years, the OPTN/UNOS Kidney Transplantation Committee http://optn.transplant.hrsa.gov/members/committeesDetail.asp?ID=89  has considered a variety of possible approaches to improve the efficiency and effectiveness of deceased donor kidney allocation policy. Three primary concepts are addressed in the document. Much of the media reporting has focused on the idea of age-range matching between donor and potential recipient. This reporting has overlooked or given little consideration to certain key facts about the concept:

The document outlines how access to deceased donor kidneys for candidates of all ages will continue.
For most candidates, there would be no functional difference in which organs they may be offered first. Age-range matching, if adopted, would only be the first level of consideration of potential recipients for some donor organs. If no suitable candidate is found within the suggested age range (the recipient’s age is within 15 years, older or younger, of the donor’s age), other older or younger candidates would then be considered. In fact, under the existing kidney allocation system, the majority of kidney recipients are already within the same age range (within 15 years of the donor’s age) as discussed in the concept document.
We encourage anyone interested to read the details of the concepts and the rationale that accompanies them http://optn.transplant.hrsa.gov/SharedContentDocuments/KidneyConceptDocument.PDF . We welcome informed opinion and comment to help ensure that the kidney allocation system is as effective as possible and operates in the public trust.

From: http://www.unos.org/about/index.php?topic=newsroom&article_id=2652:73d22cb86f1b6a9bca969577811ddd84
Daughter Jenna is 31 years old and was on dialysis.
7/17 She received a kidney from a living donor.
Please email us: kidney4jenna@gmail.com
Facebook for Jenna: https://www.facebook.com/WantedKidneyDonor
~ We are forever grateful to her 1st donor Patrice, who gave her 7 years of health and freedom

 

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