By now, you have most likely heard about the United Network for Organ Sharing’s Concepts for Kidney Allocation, which outlines potential changes to the way deceased-donor kidneys are, so to speak, “distributed” to any of the 85,000 people currently waiting for one. Depending on your source, however, what you have heard about the concept document probably varies from “It is an effort to make the best use of a limited resource” (true) to “No one over the age of 60 will get a kidney!” (erroneous and also, frankly, outrageous).
The simple fact is that there are not enough available kidneys in the United States to make a dent in the waiting list. UNOS’s concept document does not address the issue of how to increase donations (one manufactured controversy is sufficient for a single document). What it does is provide a rationale for ensuring that each available kidney finds its best possible match.
“We’re not going to create any new kidneys with this, unfortunately,” says John J. Friedewald, MD, Vice Chair of UNOS’s Kidney Transplantation Committee and Assistant Professor in Medicine–Nephrology and Surgery at Northwestern University. “What we are going to do, the idea of this, is to give the right kidney to the right person.”
Tremendous Shift in Transplant Recipients
Just who is the right person for each kidney? And why, after years of the traditionally accepted “first come, first served” method, would the US even need a change in plan?
For one thing, statistics from the US Renal Data System paint a picture of a changing kidney transplantation system. In 1991, three in 10 patients were older than 50; by 2008, that proportion had doubled to six in 10, and one in six was older than 65. Since 2000, the transplantation rate has decreased 30% for persons ages 29 to 50 and increased 49% for those older than 65.
“All of a sudden, we’ve had this tremendous shift, which has only just begun, to transplanting an elderly population,” says Barbara Weis Malone, CFNP, Senior Instructor in the Division of Renal Disease and Hypertension at the University of Colorado Health Sciences Center. “I remember when I started in the transplant community nine years ago, we would barely look at a 60-year-old, and now, regularly, we are transplanting 64-year-olds and occasionally even putting people at 70 on the transplant list.”
At the same time, the average deceased donor is still from among the younger portion of the population, which can lead to serious disparities between graft longevity and recipient longevity. No one is saying older persons don’t deserve a kidney as much as younger persons—but, realistically, does a 68-year-old man need a 6-year-old’s kidney?
“Currently, our system can give a very long-lived kidney to a person who is not expected to live very long,” Friedewald points out. “And vice versa, which is sometimes worse—give a short-lived kidney to someone who is expected to live really long. What that means is that person, usually a younger person, may need a second or even third transplant in his or her lifetime.”
Almost 15% of the waiting list represents people waiting for their second, third, fourth, or even fifth transplant, Friedewald says. Part of the return on investment if the concept document becomes policy could be a reduction in that number. “If we give organs to younger people who are going to live a long time with them, then eventually—not tomorrow; maybe in five, 10, or 15 years—there will be fewer people returning to the wait list,” according to Friedewald. (But we’re getting ahead of ourselves, because the document cannot even be accurately termed a proposal at this point.)
For clinicians in nephrology, seeing the current allocation system in action can be distressing, even though they want to provide the best care to all patients. A sweet, 66-year-old grandmother may end up with an 11-year-old’s kidney, while a 20-year-old, otherwise healthy man with glomerular nephritis may spend years waiting and not get the kidney he ideally needs, one that will last 30 years or longer.
“When I first came into kidney transplant, I thought, ‘It’s just the first person in line; that’s wonderful,’” says Weis Malone. “But now it kind of breaks my heart. As a medical professional, it’s hard to see your younger population who could really use a kidney tomorrow.”
In essence, along with the disparities comes a sense of wasted opportunity. “One in three people dies with a functioning kidney,” says Kim Zuber, PA-C, MSPS, DFAAPA, Chair of the National Kidney Foundation Council of Advanced Practitioners, who practices at Metropolitan Nephrology in Alexandria, Virginia, and Clinton, Maryland. “As far as I’m concerned, that’s a waste, because the kidney should fail before you die; then you’ve used it all up.”