Responses to Potential Questions/Comments on the Kidney Allocation Concept Document

Responses to potential questions/comments on the Kidney Allocation Concept Document Developed by UNOS

Is this a policy or a policy proposal? When will it be voted on as national policy? It’s not policy, and it’s incorrect even to call the concept document a “proposal” at this point. It is a document that outlines a series of concepts that may be part of a future proposal to improve the national system of kidney allocation. We are seeking public comment on the various concepts in the document. We welcome reasoned consideration and feedback – but we encourage everyone to read the concept document and the rationale first, rather than relying on incomplete information in news articles or blogs.

Some news reports have suggested there will be a deadline to vote on this “policy” in June 2012. That’s at least two “ifs” removed from reality. Based on feedback to public comment, the Kidney Transplantation Committee will likely develop a proposal; it may include some or all of the concepts discussed. That proposal would have a separate round of public comment, which again might influence the specifics of any final proposal to the OPTN/UNOS Board of Directors. The earliest any of this could lead to a Board vote is June 2012, but there is no specific timetable at this point.

Is age-matching a form of age discrimination? “Age discrimination” implies we have made a categorical judgment about the relative social worth of people based on age, and we might deny or restrict people’s access to organs on that basis. This is not true and has no basis in what the age-range matching concept is about.

In our role as administrators of the national Organ Procurement and Transplantation Network (OPTN), we are charged with allocation of a scarce medical resource. Were enough organs available today, the matching criteria would be very easy. With the extreme scarcity of available kidneys, we are charged with determining how they can be matched with candidates with the best overall benefit for everyone in need.

A transplant candidate’s age could be a useful factor, among several others, in determining how we can revise organ allocation policy to create greater overall benefit for all recipients (and honor the wishes of organ donors by making best use of their lifesaving gift).

We know that some candidates could survive 40 years or longer if they receive a kidney transplant. We know that others probably will live 10 years or less if they receive a transplant. We want both groups of candidates to benefit from transplantation. Age is one factor, among others, in knowing the relative amount of time a recipient may survive. Ten good years of expected survival for an older recipient may be just as meaningful for their own lives, and for their participation in society, as 40 years of survival for a younger recipient.

We also know, with some precision, some deceased donor kidneys are likely to last about 10 years if transplanted and others may last 40 or more. If a donor becomes available with a kidney that can last 40 years, we believe we can do better than our current system does in determining the most efficient use of that organ. That would argue that the person who should be considered first would be the person most likely to need it for 40 years.

Relatively few kidneys would be expected to last 40 years – many more of them that come available could be expected to last 10 to 15 years. For the organ offers that have exceptional potential, those should be offered first to those who may benefit for the longest amount of time. The majority of kidney offers would be considered for those people who have more common expectations of survival.

Would this concept cause a major shift in kidney allocation for most candidates? No. Under current kidney allocation policy, the majority of recipients of deceased donor kidneys get one from a donor within 15 years of their age (the same range as described in the concept document).

In fact, even if there were no age-range matching policy put in place, the number of older recipients from age-matched donors should continue to increase as the overall U.S. population (and thus the potential donor population) continues to age. However, under current policy, a disproportionate number of kidneys from older donors are discarded because a suitable recipient is not identified quickly. Age-range preference could mean that, for example, kidneys from a 65-year-old donor could be more readily identified (and accepted) for candidates between 50 and 80, rather than being initially considered (and refused) for many transplant candidates younger than 50.

Also, if adopted, age-range matching would only be a first level of consideration for candidates, not an absolute. For example, kidneys from a 55-year-old donor might first be considered for candidates between 40 and 70 years of age. If no recipients are identified as a suitable match, the kidneys would then be considered for both older and younger potential recipients.

Another fact overlooked in early reporting is that there is already age range preference given to kidney transplant candidates younger than age 18. There are relatively few candidates this young, and it’s well documented that younger candidates suffer growth and developmental problems if not transplanted quickly. Under existing policy, kidneys from all deceased donors under the age of 35 are first considered for any suitable candidates age 18 or younger. Again, this is only a first level of consideration, and since there are relatively few pediatric candidates, many deceased donor kidneys are then offered to adult candidates. This policy has existed for several years with no major public controversy.

I think the current first-come, first-serve system is fair; why change it? “Fairness” is highly subjective. The allocation system strives for equity – ensuring that candidates in similar need and with similar characteristics have essentially the same chance of receiving an organ offer. Equity has at least some potential measures of objective comparison.

“First-come, first-serve” would be truly fair if everyone eventually benefits, and if every person receives an organ of the same relative quality. Unfortunately, neither statement is true. Some people wait a long time for a donor kidney and never receive one. Waiting time priority is arguably “fair” to those who eventually receive a transplant, but not to those who don’t. In addition, waiting time alone cannot predict whether a specific candidate is objectively more in “need” of an organ offer than others, or whether the offer he or she receives will yield the maximum possible years of potential function. Waiting time should remain a tiebreaker among candidates of equal potential benefit, just as it is with other organ allocation policies. But under existing policy, waiting time is a major factor affecting when candidates receive organ offers. This should be better balanced to allow more precise matching of donor offers with the specific need of the candidate.