A Chance to Cut is a Chance to Cure

Sunday, March 11, 2007

Distributing the Beans.......
From The Wall Street Journal, a change in how donor kidneys are allocated: More Kidneys For Transplants May Go to Young

The nation's organ-transplant network is preparing a major change in how it rations scarce kidneys that would favor young patients over old in an effort to wring more life out of donated organs.

The new policy is being developed by the United Network for Organ Sharing, the nonprofit body that develops organ-distribution policy under a government contract.
Surgeons and others leading the process expect the final proposal will rely significantly -- though not exclusively -- on the concept of "net benefit," which seeks to give kidneys first to those who will benefit most from them.

"Waiting time is arbitrary," said Alan Leichtman, a University of Michigan kidney doctor helping to craft the policy. "It seems like a real shame that we're not being better stewards of the organs."

Time on the list usually trumps all concerns, but the scarcity of available organs has caused some to reconsider this. Looking at the numbers:

Deceased donors provided 10,816 kidneys for transplant in 2005. Another 6,500 came from living donors, who usually give to a close friend or relative. But those organs fall far short of meeting demand, and the waiting list for a kidney has grown to more than 70,000 people. The reasons include the surge of diabetes, a principal cause of kidney failure, and the aging U.S. population. Some 4,000 people die waiting each year

Not all of those in the transplant community are pleased that the rules may be altered;

The concept is gaining traction among transplant doctors but creating anxiety for some patients and surgeons who worry the new system won't be fair to all. "Is it correct or permissible for the system to say the five or six more years of life that a 60-year-old is going to get are less valuable, less important than the 15 more years of life the 30-year-old is going to get?" asked Richard Freeman, a transplant surgeon at Tufts-New England Medical Center in Boston.......
......Supporters of keeping the current approach say it's the fairest because it ensures that those waiting, if they hold out and stay alive, will eventually make it to the top of the list.

"We need a system which offers hope to all regardless of age," said Glenda Rosenbloom, a liver-transplant recipient, at a recent forum in Dallas organized by UNOS. Ms. Rosenbloom, who spoke on behalf of the Transplant Recipients International Organization, said she is in her 60s.

The rationale is that younger recipients do better than older ones.

Statistics show that age is by far the biggest factor predicting how long someone will live after a transplant. A typical 25-year-old diabetic will gain an extra 8.7 years of life from a transplant, while a typical 55-year-old diabetic will gain only 3.6 extra years, according to the Scientific Registry of Transplant Recipients, a private group in Ann Arbor, Mich., that tracks data under a government contract. Other factors affecting survival include underlying illness and whether a person is overweight or has had a previous transplant. They, too, are included in the "net-benefit" calculation.

Transplants performed under the existing system generate about 44,000 extra years of life for the people who receive new kidneys each year, according to the registry. If all kidneys were distributed using a net-benefit calculation, that number would rise to more than 55,000 years, it says.

The registry has also calculated how the ages of recipients would change if net benefit became the decisive factor. The calculation shows that the share of kidneys going to patients in their 20s would rise to 19% from 6% today. Just 2.7% of kidneys would go to patients 65 and up, versus nearly 10% today.

Young diabetics would get a particular boost. They typically do poorly on dialysis -- where a machine performs the blood-cleansing function of the kidney -- but well with a transplant. Older diabetics who developed the disease as adults now get 18% of the kidneys but would get just 4.5% under a pure net-benefit system.

The final plan may take age into account, so older patients get older kidneys:

The committee is likely to revise the net-benefit formula to account for how long someone has been on dialysis, Dr. Stegall said. Under the leading idea, he said, the healthiest kidneys would be distributed through a formula that relies largely on net benefit, while the formula for kidneys coming from older or sicker donors would give greater weight to time on dialysis.

In effect, this system would tell older people who have been on dialysis a long time that they could still have a shot at a kidney, but the chances would be much better if they took a lesser-quality one. Patients, working with their doctors, could calculate the odds and decide how poor a kidney they were willing to accept.

This system could have the added benefit of getting more patients to accept marginal kidneys when they are offered, experts said. As it is, patients near the top of the waiting list often pass on these kidneys when they become available, knowing they will remain at the top of the list for the next high-quality kidney.(Emphasis mine)

So, the recipients game the system as well, it seems. But there is one issue that UNOS isn't planning to touch with a ten foot pole:

The UNOS committee has sidestepped one explosive issue. Computer modeling shows that African-American patients do better than average on dialysis and therefore gain less "net benefit" with a transplant. The committee specifically ruled out using race as an explicit factor in allocating kidneys.

A sidebar of the article summarises the upcoming changes:

ISSUE: Perfect matches
Current policy: Donor kidneys that match a recipient on all six antigens are automatically given to that recipient. About one in five kidneys is allocated this way. Regions that receive kidneys from other areas must pay back the donor region with a future kidney.
Possible change: Eliminate these "zero mismatch" trumps, which provide less of a medical advantage than they once did due to better drugs. Eliminate paybacks.

ISSUE: Waiting time
Current policy: Transplant candidates get one point for every year they have been waiting on the list, making this the dominant factor in kidney allocation
Possible changes: Substitute time on list with time on dialysis; use time as a secondary factor in allocating kidneys, particularly for the best-quality kidneys

ISSUE: Children on the waiting list
Current policy: Kidneys from donors under age 35 are automatically offered first to children under 18, if any are on waiting list in same region.
Possible change: Policy not likely to change.

ISSUE: Living donors
Current policy: Living donors who have given away one of their two kidneys or any other organ get extra points if they need a kidney transplant
Possible change: Likely to maintain advantage for prior living donors

ISSUE: B blood type
Current policy: No special treatment. Because there are more patients than donors with B type blood, the wait is much longer. Black patients are more likely to have B blood type, so they are particularly disadvantaged.
Possible change: Allow some A blood type kidneys, which are compatible with A or B patients, to be offered to B-type patients.

ISSUE: Highly sensitized patients
Current policy: Some patients have antibodies that make them unable to accept 80% of kidneys and get extra points to help them snag those kidneys that are a good match
Possible change: Likely to maintain advantage for highly sensitized patients

These are issues dealing with the distribution of a rather fixed supply, suitable kidneys from agreeable donors. What is not mentioned is one idea that could increase the availability of organs, payment to donor families.
The pro payment side believes that the number of available organs would increase and that most of the other players int the game benefit financially, the donor's family should as well.
Those opposed to payment raise objections based on ethical concerns such as exploiting the poor and other unsavory procurement methods.
Another potential way to increase donors would be to adopt an opt-out system as currently seen in Europe.
A old white paper from UNOS can be found here.

So.....go sign your donor cards.

Labels: Transplantation