Deceased Organ Donation OPTN Organ Allocation

Proposed Kidney Allocation And Age

OPTN (or UNOS as the media likes to erroneously report) has asked for public comment on proposed changes to the kidney allocation policy. Organ allocation is a complicated matter, made worse by a lack of transparency. The changes are equally so, and the media isn’t helping the matter by seizing on only one aspect of it. Because the media is doing a poor job explaining the issue, the public (or rather, those leaving comments on the media coverage) are spouting some really uninformed and frankly, dangerous, things.

I’m not going to issue a blanket statement on the proposed policy, because I haven’t taken the time to pore over it yet (Full disclosure: but I did read about it in the ACOT notes from August 2010). But I think it’s important to clear up a misconception flying around so that people can at least issue an informed opinion.

– UNOS has the been the contractor for OPTN since 1986. The US transplant system as we know it was created by the National Organ Transplant Act in 1984, implemented two years later. The law called for the ‘fair and equitable’ allocation of organs.

– In 2003, modifications to NOTA prioritized allocation based on ‘medical need’*.

In truth, the US transplant system has never achieved its goal of fair and equitable allocation. At the time of its conception, technology to preserve donated organs was limited, so the country was divided into regions to facilitate allocation and ease administration. This resulted in what is referred to as ‘death by geography’. This means that some areas of the country have a much longer wait time than others, and the odds of procuring a needed organ varied depending on where the would-be recipient lived (or was registered for the list). This is the loophole Steve Jobs used to get his liver.

In 2003, the Sec of Health tried to eliminate these regions, creating a true national allocation. The transplant industry, headed by Walter Graham of UNOS, lead a lobbying campaign against this changes, because they were concerned how it would affect the transplants done at their particular centers. In other words, they didn’t care if it was better for patients, they wanted to protect their profit margins. (end rant, sort of)

The proposed policy in question addresses nothing related to geographical discrepancies but would allow for the age matching of donated organs and would-be recipients, plus or minus 15 years. The reasons for this are as follows:

1. Transplants are not cures, but treatments. The majority of recipients need multiple transplants to achieve a ‘normal’ lifespan.

2. There is a correlation between younger organs & longer graft survival. The idea behind this proposal is that it makes more sense for a 45 yr old to get a 30 yr old kidney as opposed to a 75 yr old, because a 45 yr old will use the kidney for a longer period of time and the kidney will survive longer (longer than a 75 yr old would live, even with a transplant).

The reason some folks (Caplan, Ross, Rob Stein, etc) are squawking that age-matching would ‘favor’ the young is based on donation and recipient statistics (Mind you, that none of them have bothered to cite, state or write about so far, which is why the reading public is all confused). If we turn to SRTR, the official national database of such things, here’s what we’ll find:

From 1999 to to 2008, deceased donor kidneys were in the following age groups:
18-34 – 26%
35-49 – 27.5%
50-64 – 22.2%

75,7% of deceased donor organs are 18-64 years old.

Meanwhile, during that same time period, deceased donor kidney recipients were:

18-34 – 17.6%
35-49 – 34.9%
50-64 – 34.7%

For a whopping total of 87.2%.

Based on these numbers alone, if we view them through a specific paradigm of fairness, it appears that 18-34 year old recipients aren’t getting their fair share of kidneys in comparison to those donated. Conversely, 50-64 yrs old are bogarting all the ‘good’ donated kidneys (so are 35-49 year olds, but to a much lesser extent).

The conclusion then is that if kidneys and recipients are age-matched, the latter numbers will more closely resemble the former, leaving everyone over the age of 50 screwed.

A. The policy provides a 30 year window, 15 years either way.

B. The policy isn’t absolute. If a so-called age appropriate recipient isn’t available, the kidney will go to someone. It’s not as if they’ll throw it out.

Age-matching, if it is implemented, will only be one of multiple factors that determine allocation. Right now, such factors include:

– blood type
– HLA/Tissue matching
– if the recipient is a child (yes, there is already priority given for children)
– blood antibody levels, sometimes referred to as ‘sensitivity’
– body size of both candidate and recipient.

Another current consideration, time spent on the waitlist, is also suggested for removal in this latest proposal. I’ll write about that tomorrow.

Just for fun, let’s take a look at the demographics of the currenet waiting list. (Bear in mind I used the ‘inflated’ list, meaning that 1/3 of these folks are inactive; also, a certain percentage have already undergone at least one transplant)

18-34 – 8909 (10.1%)
35-49 – 23,860 (27.1%)
50-64 – 37,944 (43.2%)

Compare it with the latest year available 2008, deceased donor kidney recipients:

18-34 – 1055 (12.2%)
35-49 – 2482 (28.7%)
50-64 – 3441 (39.8%)

2008, deceased kidney donors:

18-34 – 1967 (27.3%)
35-49 – 1865 (25.9%)
50-64 – 1998 (27.8%)

Conclude what you will…

TOMORROW: Wait Time on the List is Neither Fair Nor Efficient
LATER: The Living Donor Factor

*So, internet imbeciles, it has nothing to do with Obama.

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