February 24, 2011
New Kidney Transplant Policy Would Favor Younger Patients
By GARDINER HARRIS

Younger patients would be more likely than older ones to get the best kidneys under a proposal being considered by the nation’s organ transplant network.

The new policy would replace the current first-come-first-served system and is intended to provide better matches between the life expectancies of recipients and the functional life of donated kidneys.

“Right now, if you’re 77 years old and you’re offered an 18-year-old’s kidney, you get it,” said Dr. Richard N. Formica, a transplant physician at Yale University and a member of the panel that wrote the proposed policy. “The problem is that you’ll die with that kidney still functioning, while a 30-year-old could have gotten that kidney and lived with it to see his kids graduate from college.”

Under the proposal, patients and kidneys would each be graded, and the healthiest and youngest 20 percent of patients and kidneys would be segregated into a separate pool so that the best kidneys would be given to patients with the longest life expectancies. The remaining 80 percent of patients would be put into a pool from which the network that arranges for organ matches, called the United Network for Organ Sharing, would try to ensure that the age difference between kidney donors and recipients was no more than 15 years. News of the latest proposal was first reported in The Washington Post.

The proposal is supported by many transplant surgeons and medical ethicists, but it faces an uncertain reception by kidney transplant patients and legislators. A previous proposal to better match the health of patients and donor kidneys was scrapped in 2005 after the network was flooded with negative comments. The network is hoping that this effort, which relies on a less complex formula than the earlier one, will get a better reception.

Donation systems for livers, hearts, lungs and other organs have already been reformed or changed in recent years, said Anne Paschke, a spokeswoman for the organ network. However, kidney donations are by far the most common.

The kidney proposal does nothing to fix geographic disparities that cause patients in New York and Chicago to wait years longer than those in Florida. Such local distribution results not only from concerns that far-away organs might not arrive in time but also because of distribution issues and turf battles between transplant centers.

Dr. Lainie Friedman Ross, associate director of the McLean Center for Clinical Medical Ethics at the University of Chicago, said she opposed the new kidney transplant policy because “the biggest problem is geography, and they’re doing nothing to fix that.” Dr. Ross said she also worried that any policy that favored young patients for the provision of kidneys from dead donors might reduce or redirect to the elderly donations from living donors, who are unaffected by the proposed policy.

Dr. Trent Tipple, a 37-year-old neonatologist from Columbus, Ohio, who got a kidney transplant when he was 21 and is again on a transplant waiting list after his donated kidney failed, said he favored the proposal. As the scope of kidney transplants expanded in recent years, older patients began to crowd out younger ones from waiting lists, “and I think there has to be some degree of reset,” he said. Dr. Tipple would benefit under the new proposal.

Medical rationing in the United States is common but is usually done by default. Proposals to systematize rationing are rarely embraced, and Dr. Formica and others involved with the proposal took great pains to explain that it would not disadvantage most patients on waiting lists. Dr. Formica admitted, however, that older patients would have a harder time getting a kidney under the proposal.

Dr. Ross was even more blunt: “Under this policy, if you’re 65, you might as well give up before you even get on the wait list.”

The most common causes of kidney failure are hypertension and diabetes, so some of those waiting for kidney transplants got there because of their own poor choices. Both diabetes and hypertension are linked with genetic and lifestyle factors.

Nearly 90,000 people are currently waiting for kidney transplants. In 2009, there were 10,442 kidney transplants from dead donors and another 6,387 from live donors who generally specify the recipient.

The intent of a system that favors the youngest and the healthiest is to ensure the best and longest use of donated kidneys. But its effect will likely be to favor those for whom lifestyle choices are less likely to have played a role in their illness.

Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania, said the proposed policy was sensible.

“If it’s a choice between saving grandpa or granddaughter, I think you save granddaughter first,” Dr. Caplan said. “It doesn’t make sense to give people equal access to something if some people fail to benefit.”

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