Besides making better use of the available kidneys, the revised allocation system would also make use of more kidneys, by eliminating the previous designation of “expanded criteria donor,” or ECD, kidneys. Some patients turn down ECD kidneys when they are offered, because they may consider the designation a kind of stigma.
“People think ‘expanded criteria’ is this horrible kidney that came from someone who was very old or who probably drank his whole life or had HIV and hepatitis B,” Weis Malone says. “But it could be a 55-year-old person who was taking one blood pressure medication. Right now, there is something like a 12% waste of kidneys that are just being thrown away. As the transplant list grows, it would be nice to utilize those kidneys.”
Obviously, no one would object to someone turning down a kidney from, say, a known IV drug user who was testing negative at the time of death. But does it make sense for a 70-year-old man to turn down an ECD kidney with a creatine level of 1.3, indicative of slight kidney damage? “When you’re talking about someone who has all kidney damage,” Zuber says, “you want to say, ‘What are you thinking? You don’t need a perfect kidney; you need a kidney.’”
Two other provisos: The revised allocation criteria do not affect persons waiting for a multiple-organ transplant (such as kidney/pancreas, kidney/heart, or kidney/liver). They also would apply to the adult (18 and older) population; pediatric candidates would continue to have priority, because as Zuber says, “If you don’t transplant a child, they will lose growth. It makes a huge difference when you’re a child, whereas when you’re an adult, it doesn’t matter if you’re 20 or 50.”
Focus on Prevention, Solutions
As indicated above, Concepts for Kidney Allocation is the latest step in the process of revising how kidneys are allocated. The Kidney Transplantation Committee will assess the feedback it receives, determine if there is a consensus, then issue a final proposal. UNOS and the Health Resources and Services Administration will be the groups that vote on whether to adopt the recommendations as policy.
In the meantime, other aspects of kidney allocation and transplantation will continue to be discussed and debated, whether officially or among the general public. Among the questions: How can the pool of living donors be increased? Should the US adopt a “presumed consent” policy that would require people to expressly opt out of organ donation? What other methods might increase donations—better education, payment of funeral expenses for the deceased donor, or something as yet undetermined?
For nephrology clinicians, the goal remains keeping people alive while they await transplantation. “Even when I’m doing a perfect job—that’s a perfect job, and at few times in my life am I perfect—I am no better than 15% of a kidney,” Zuber says of her dialysis work. At the same time, it must be accepted that even transplantation is “not a cure,” as Weis Malone points out. “It’s a treatment, just like dialysis is a treatment. Not everyone does well with it.”
For Weis Malone, “the focus always needs to be on the prevention of kidney disease, especially as diabetes continues to grow massively in this country. Probably 30% to 40% of people who start dialysis had no idea they had kidney disease. So that’s where it has to start, with the education of the medical community that the only way you can tell kidney function is through a blood test or a urine dip.”
And the search for solutions to the growing problem of kidney disease, and subsequent kidney failure, will continue. “This is what the public debate is about: what is acceptable,” Friedewald says. “There is no right or wrong here. But what is acceptable, and what kind of trade-offs are we willing to make to get more out of a scarce resource?”