Deceased Organ Donation Organ Allocation

This is Why We RTFM (read the flipping manual)

Or in this case, the actual, honest-to-pete proposed kidney allocation policy.

First, the disclaimer: this is not a perfect policy, and I take issue with some aspects of it. However, the overall intent is good in my opinion, even though the public, who will only read Rob Stein and not the actual policy, will throw a tantrum over it. Mostly because they have no idea how any of this works.

As I explained before, under the current allocation policy, 70% of deceased donor kidney transplants were done on those 35-64, yet that same age group only donated 49.7% of the kidneys available for transplant. Either no one was aware of this, or no one cared until the media started screaming ‘ageism’ in light of this attempt to age-match organs and recipients. Because apparently, the public still seems to think that all kidneys are created equal, as are all recipients, and transplants are cure-alls for whatever ails ya.

Total hogwash.

From page 29 of the proposal:

Individuals with ESRD (whether on dialysis or having received a transplant) have shorter life-expectancies than individuals without ESRD. However, the detriment to overall life expectancy is not evenly distributed. Individuals who develop ESRD earlier in life are much less likely to achieve a “normal” lifespan, that is, they die sooner than the average person or the person who develops ESRD at an older age. An individual between the ages of 20-24 years without ESRD can expect to live an additional 56.9 years to about age 79 or so. With ESRD, that same individual could be expected to survive an additional 38.4 years with a transplant (about age 60.4), but only 14.9 years on dialysis (about age 36.9). Even with the best case scenario of a transplant, this individual is not expected to reach the lifespan of an individual who does not have ESRD.

In other words, a diagnosis of end-stage renal disease shortens the lifespan, period.

As I also mentioned in my prior post, younger kidneys have longer life spans (graft survival) than older kidneys. The current system gives 20-year organs to a recipient with a five-year expected life span (and vice versa, btw).

From page 30, regarding age-matching:

Rather, the proposed system provides better opportunities for all candidates to achieve as much of a normal lifespan as possible. The survival matching component takes into account the fact that some candidates will need an organ that could potentially function for decades. The age matching component recognizes that not everyone waiting requires such long organ survival. The proposed concepts recognize both needs and attempts to allocate kidneys in a way that will allow individuals to achieve as much of a normal life span as possible. [emphasis theirs]

Even if this all makes sense, I’m sure some folks are still wringing their hands over the idea that recipients over the age of 50 will never get a kidney (cuz they only donate 22% of kidneys available).

Again, not quite the case. From page 32:

The Committee reviewed the number of deceased donor kidneys recovered for transplant between 2005 and 2007 and found that there are a substantial number of kidneys discarded (Figure 16). Kidneys from donors over the age of 50 are more likely to be discarded than kidneys from donors under the age of 50. The Committee discussed this finding at length and agreed that at least some of these kidneys could have provided additional life years to candidates on the waiting list.

Uh-oh, viable kidneys are not being used. Not good.

The proposal goes on to speculate why these harvested kidneys are being discarded, but the biggest reason seems to be that transplant centers don’t want to look bad on their survival stats by transplanting older (and therefore, shorter lifespan) kidneys*. So, better a person gets no kidney than a five a year kidney?

How do we utilize more of these over-50 kidneys?

From page 33:

Eurotransplant is the international organization responsible for overseeing the organ transplantation network for Austria, Belgium, Croatia, Germany, Luxemburg, the Netherlands and Slovenia. In 1999, Eurotransplant instituted a set of policies referred to as the Eurotransplant Senior Program, which were designed to shorten the waiting time for elderly candidates by preferentially allocating organs from elderly donors (defined as >=65) to elderly candidates (also defined as >=65). Since the ESP was started in January 1999, Eurotransplant has seen a substantial increase in the number organs from donors >=65. A review of the Eurotransplant annual reports from 1997-2009 revealed a fourfold increase in the number of organs transplanted from donors in the >=65 age category from prior to implementation of ESP until 2008. The Committee predicts that increased utilization of older donor kidneys could be possible in the United States through this proposed allocation system. [emphasis mine]

The projections done on this proposed policy were based on the deceased donor organs actually transplanted in the past. Due to the age demographics of previously donated kidneys, this creates the illusion that recipients over 50 will not have access to as many organs/transplants. There is no proof of this. Through age-matching, transplant centers will be motivated to utilize the viable (but over 50) kidneys they otherwise would have discarded. This will increase the total number of kidneys available for transplant – for everyone.

Who knows, if the results of ESP are any indication, this policy might actually increase an older recipient’s chance of transplant in comparison to the current system.

Moral of the story: Source material isn’t motivated by page views; refer to it whenever possible.

*More bizarre is that CMS (Medicare) doesn’t expect older kidneys to live as long as younger kidneys, so they calculate that in their algorithm. Transplant centers may actually increase their survival rate by using these older kidneys because they could exceed expectations.

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