Nothing grabs headlines or the public's attention faster than alarming statistics about the growing organ transplant wait list, the organ shortage and would-be transplant recipients' deaths. But just how transparent is the official data?

 

History

The deceased organ donor wait list was established under NOTA 1984 and contracted to UNOS upon its implementation in 1986. To help defray costs, a federally mandated fee* is paid to UNOS for each new registration, which has increased incrementally over the past twenty-five years.

Living donor organs were intended to be a tiny minority of transplants conducted each year. However, as the benefits to recipients became evident, (and added profit and scheduling convenience for hospitals and surgeons), living kidney donor transplants increased, surpassing deceased donor kidney transplants for the first time in 2002.

This development was troubling from UNOS' perspective because the vast majority of these would-be transplant recipients were never registered on the transplant wait list, denying UNOS revenue. So in 2003, based on no authority whatsoever, UNOS decided to charge the same registration fee for living donor transplants as they did for deceased donor transplants. So far, no one has complained, even though this fee is generally charged to Medicare, which is supported solely by the tax payers.

 

*UNOS also charges two non-mandated (aka voluntary) fees to transplant centers.

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Are there really 100,000+ people in the US waiting for a transplant?

In 2003, UNOS/OPTN changed policy allowing kidney candidates/registrants considered 'inactive' (ineligible to receive an kidney transplant, due to being too sick, not sick enough, or other reasons) to accrue time on the kidney wait list indefinitely.

This has caused massive over-inflation. At the end of 2003, 16.1% of transplant candidates were inactive as compared to 32.8% at the end of 2007. (57) More telling, 52% of patients on the wait list who died in 2007 were 'inactive' as compared with 31% in 2003 (81).

Rob Stein of The Washington Post wrote about this manipulation in 2007. In 2009, OPTN discussed the matter during one of their regular committee meetings. They decided against correcting it, despite how it misleads the public. (135)

Kidneys are the only organs that still consider wait time in determining allocation. This encourages kidney transplant programs to register candidates on the wait list as early as possible, often before it's necessary, also artificially inflating the real need for donor kidneys.

 

 

In addition, approximately 10% of names on the transplant waitlist are duplicates, otherwise referred to as 'multiple listings' (108). People like Steve Jobs, who have the money and resources, can afford to be evaluated and listed at more than one transplant center (with a cost of tens of thousands of dollars per evaluation) in order to increase their chances of obtaining a deceased organ. [See "lengthy wait" section below for a more detailed explanation on this]

Finally, up to 5% of a transplant center's listings can be foreign nationals (207). Other countries, including England, have prioritized their citizens by forbidding such registrations and transplants. [see these three posts about deceased donor organs allocated to non-US resident, non-citizens]

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Is the transplant wait list growing, and/or is the organ shortage increasing?

 

Not according to OPTN's presentation at the 2011 spring regional meetings where they reported a 'flattening' of the wait list since 2007, especially in regards to kidneys.

 

 

(see first chart for liver and kidney information)

 

It's imperative to remember that organ transplants are not cures. Most recipients will need multiple transplants to achieve a 'normal' life span.  According to SRTR, approximately 18% of candidates on the wait list at any given time have already had at least one transplant.

From 1999 to 2003, there was a 23% increase in active patients (corresponding to an average increase of 5.3% per year). In 2004, there was a slight decrease, and the yearly percentage increase afterwards was 2%, 2%, 3% and 4% in 2008 (compared with 2007). (138)

 

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17-20 people (or 10-12% of the list) die every day because they can't get an organ.


52% of patients on the organ transplant wait list who died in 2007 were 'inactive' (81).

Also, the average onset of end stage renal disease is 64.4 years in the US, according to the US Renal Data System. Older wait list candidates generally are afflicted with other health problems (co-morbidities) in addition to their kidney failure, which affects prognosis and mortality.

Finally, a certain percentage of folks with ESRD, some studies estimate up to 20%, will choose to discontinue their treatment. Their deaths are also included in the official waitlist mortality statistic.

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But what about that lengthy wait for a deceased organ?


While NOTA 1984 established a national deceased donor organ transplant system, allocation and management are handled locally. Each of OPTN's 11 region are administered by an OPO, or organ procurement organization. The transplant center that harvests the deceased organs first tries to match them with their facility's patients, then offers them to other programs in the region, and finally, to the entire nation. This has resulted in geographic organ hording and death, as well as discrepancies in wait time depending on where one is registered. 

Among new candidates listed between 1999 and 2005, there has been relatively little change in the median time to receive any kidney transplant, that is, from either a Deceased Donor or Living Donor. (138)

In order to comply with NOTA, which calls for a 'fair and equitable' system, regions and DSA's must be eliminated in favor or real national procurement and allocation.

 

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What Can Be Done?

- Eliminate wait time as a factor in kidney allocation

- Implement concrete standards for adding a candidate to the wait list

- Utilize all donated organs, especially from donors over 50 (202)

- Eliminate geographic disparities and offer all organs nationally

- Implement first-person consent in all states (next of kin couldn't override donor's wishes)

- Increase diagnosis, prevention and treatment of diabetes and kidney disease

- Consider opt-out deceased donation system (see Spain)

 

 

 

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