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.

ON THE TABLE

 

The United Network for Organ Sharing is overhauling its policy for distribution of donated kidneys. Some considerations in kidney policy, and how they might be affected by the new policy:

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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.

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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

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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.

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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

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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.

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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

Today, a donated kidney generally goes to the person who has been waiting longest in the region in which it becomes available, with exceptions made for certain medical factors. A kidney from a 25-year-old donor could be transplanted into a 75-year-old, who is likely to die years before the kidney would have stopped working.

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."

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.

The UNOS board has yet to receive a specific proposal, and any decision by the board must be approved by the U.S. Department of Health and Human Services. Because of the concern over the "net-benefit" approach, waiting time is likely to remain a factor in the formula calculating who gets a kidney.

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.

The federal government, through the Medicare program, pays for kidney transplants, which account for more than half of all organ transplants.

The question of how to distribute kidneys from deceased donors presents a classic conflict between utility, which seeks to provide the greatest good for the greatest number, and equity, which seeks fairness for all individuals. The rules for allocating kidneys have been revised before -- to downgrade the importance of tissue matching between donor and recipient, for instance -- but the changes now under way are the most significant since a national allocation policy was first developed 20 years ago.

Federal Direction

The Department of Health and Human Services directed UNOS in 1999 to revise its allocation policies and submit them for review. Specifically, the department said UNOS should seek the best use of donated organs and de-emphasize waiting time in favor of objective medical criteria. UNOS has already overhauled its rules for livers, hearts and lungs.

"We understand that some people will gain and some people will lose, but in the end the purpose is to make the system a more sensible one," said Gabriel Danovitch, medical director of the University of California, Los Angeles, kidney-transplant program. Under current rules, said Dr. Danovitch, who is helping craft the new policy, he may be offered a kidney from an 18-year-old and the first name on the waiting list is a 70-year-old. "I say, 'OK, that's the rule.' In my heart I say that's not right," he said.

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 new kidney proposal was impelled by research suggesting that donated kidneys could bring considerably more years of life to recipients under a different system.

Biggest Factor

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.

Talk of change makes some patients nervous. Clive Grawe, 54, a traffic engineer for the city of Los Angeles, fears for himself and his daughter. They both have polycystic kidney disease, a genetic condition that typically doesn't cause problems until middle age. Those who take care of themselves can forestall kidney failure until they are older, said Mr. Grawe, but that would make it harder to get a transplant. "Should my daughter be penalized for living a healthy life, if her kidneys fail at 50 rather than in her 40s?" he said. "It's not only for me that I'm fighting but it's for my daughter too."

Kevin Sandes, 31, of Raleigh, N.C., sees it differently. The former restaurant manager has been on dialysis since Thanksgiving 2006 and is on disability. "After doing the dialysis the first couple weeks you're like, 'I can't do this for five years because it's horrible,'" he said. "If this [policy change] happened when I was 50 or 60 years old, I don't know how I would feel about it then. Right now, I feel like it makes perfect sense."

Modifying System

Transplant doctors and others involved in the discussions have pushed UNOS to modify the system to give older patients a better shot. "I don't think we should say waiting time doesn't count for anything," said John Roberts, chief of the division of transplantation at the University of California-San Francisco.

Mark Stegall, chairman of the UNOS kidney committee, said it is working to refine its original concept in a way that would gain more life from existing kidneys while maintaining "as much hope and equity in the system" as possible.

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.

Issue of Race

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.

Still, some worry that elements of the new formula will tend to hurt black patients anyway. For instance, it was going to give a boost to people who have a particular antigen, or protein, that is advantageous in extending life but that blacks are less likely to have. That provision may be scrapped.

The committee is likely to make a tweak that would help black patients. Blacks are much more likely than whites to have blood type B, but there are not as many "B" organ donors. That's a major obstacle for blacks waiting for kidney transplants. The committee is considering allowing certain A-blood type kidneys, which work effectively in both A and B patients, to be made available to patients with blood type B.

The new policy is also likely to scrap rules that automatically send a donor kidney to anyone who is a "perfect match" on six antigens relevant to kidney transplantation. This policy, which accounts for how 20% of the donated kidneys are distributed, does less to improve outcomes nowadays because of better antirejection drugs.

Any changes in policy may be phased in so as not to harm those who have been already waiting for a long time.