Kidney Donation Costs: Too High for Potential Donors with Low Income?

Kidney Donation Costs: Too High for Potential Donors with Low Income?

Although living kidney donation increased 125 percent between 1990 and 1999, the rates have been declining since 2005 for unknown reasons. A new study indicates that the financial implications of donation may play a role.

“This study identifies socioeconomic status—specifically income—as an important barrier to living donation, and more importantly, implies that this barrier is becoming more difficult to overcome over time,” said lead author Jagbir Gill, MD, MPH, of the University of British Columbia in Vancouver. The findings are published in the Journal of the American Society of Nephrology.

Decline in donations

Beyond the obvious benefits of improved survival and quality of life for transplant patients, each living kidney donation is estimated to result in a net health care savings of $100,000. For donors, however, the reported costs of living donation have been as high as $20,000, with an average estimated cost of $5000, which means that living donation amounts to more than one month’s salary for most donors. These costs usually relate to travel, lodging, services such as child care or elder care, and lost wages. Research indicates that more than 20 percent of living kidney donors report financial hardship after donation. Many states have developed ways to reimburse at least some of the costs, but these initiatives have not been consistently associated with an increase in living donation.

To look at the potential links between costs and donation rates, Gill and his colleagues divided the population of the United States on the basis of the median household income level of residents’ zip codes and examined the rates of living donation between 1999 and 2010 in high-income and low-income populations. The 33,178 zip codes in the US Census were grouped into the following income quintiles: Q1 (<$30,962), Q2 ($30,962 to $37,314), Q3 ($37,315 to 44,723), Q4 ($44,724 to $56,580), and Q5 (>$56,580).

Between 1999 and 2004, the rate of growth in living donation per million population was directly related to income, increasing progressively from the lowest to the highest income quintile, with annualized changes of 0.55 for Q1 and 1.77 for Q5. Between 2005 and 2010, donation declined in Q1, Q2, and Q3; was stable in Q4; and continued to grow in Q5. These findings indicate that lower-income populations consistently had lower rates of living donation compared with higher-income populations and that the difference in living donation rates between lower-income and higher-income populations was much larger in recent years than in the past.

“Since 2004, lower-income populations experienced a large decline in living donation, while living donation in higher-income populations was more stable,” Gill said.

Factors that sustained living donation, at least for higher-income populations, likely include the advancement of minimally invasive surgical techniques, increased patient education, and insufficient numbers of deceased donors to meet transplant demands. Factors that may have contributed to disparities in living donation between income groups include a higher prevalence of obesity, diabetes, and other chronic health conditions in low-income populations, which can interfere with living donation; a higher proportion of individuals without health insurance in low-income populations; and differences in health literacy between income groups.

Overcoming financial barriers

Although addressing the costs of living organ donation may not bring levels back to where they were in the 1990s, it could certainly boost the numbers, especially during periods of economic volatility.

“These results suggest that financial barriers to living donation need to be further addressed in order to make it easier for patients to consider and pursue living kidney donation,” said Gill.

Doing so could have far-reaching effects, noted Didier Mandelbrot, MD, who was not involved with the study and is a nephrologist at the University of Wisconsin School of Medicine and Public Health in Madison. “These financial barriers end up limiting the number of recipients who can benefit from live donation, and also limit the financial benefits of live donation to society,” he said.

Mandelbrot stressed that although programs to reduce financial burdens of live donation, such as the National Living Donor Assistance Center (NLDAC), exist in the United States, these programs appear to have limited impact. “Unlike the Canadian program for living donors, the US program does not reimburse lost wages and incidental expenses such as child care,” he said.

In addition, NLDAC’s requirement for means testing to determine whether recipients and donors qualify for assistance adds to the paperwork and difficulty in using the program. The Canadian program does not include means testing. Expanding NLDAC to more closely resemble the Canadian program may help reduce financial barriers to live kidney donation, and therefore improve outcomes for kidney transplantation, according to Mandelbrot.

Study coauthors include Jianghu Dong, MSc and John Gill, MD, MS.

Disclosures: The authors reported no financial disclosures.

The article, entitled “Population Income and Longitudinal Trends in Living Kidney Donation in the United States,” is available online at http://jasn.asnjournals.org/.