Remedies Sought for Inequities in Kidney Transplant Allocation

Wait times for kidney transplants throughout the United States vary widely, so that some individuals can receive a deceased donor’s kidney within just one year while others must wait up to a decade. Researchers are investigating the issues related to organ allocation inequities and are searching for ways to remedy them.

“The predominant variable influencing access to kidney transplantation in the United States, even more important than race or insurance status, is geography,” said Alan Leichtman, MD, of the University of Michigan in Ann Arbor. “When rates are compared across states, access to living donor transplantation and to waitlisting for deceased donor transplantation each vary twofold, while access to a deceased donor kidney transplant among waitlisted patients varies threefold.”

A variety of initiatives across the country are striving to change organ allocation practices and may help equalize these rates.

Donor exchange programs, which match an incompatible patient-donor pair with a patient-donor pair of the opposite incompatibility, can help encourage greater access to donated kidneys. In this situation, two patients receive donated organs, but not from the donor who is their own family member or loved one.

“A willing transplant candidate with a willing donor who is incompatible based on blood testing is a missed opportunity,” said Ajay Israni, MD, of the Hennepin County Medical Center in Minneapolis. “A paired-exchange program takes advantage of that opportunity and links up incompatible pairs that may, with luck, be compatible after exchanging donors.” Israni helped start a program that exchanges paired donor information among nine different centers in the Midwest.

Multi-organ donation, in which patients receive multiple organs—such as a heart, a liver, and a kidney—at one time, can complicate issues of organ allocation. “There are concerns that centers may use one organ to get faster access to another. For example, if you list someone for a liver plus kidney transplant, they will get the kidney much faster than if they were listed for a kidney alone,” said Viken Douzdjian, MD, of the Legacy Good Samaritan Hospital in Portland, Ore. Douzdjian added that the regulations for allocating organs for multiple transplants are vague and confusing.

“The rules about listing someone for a combined transplant are very loose compared to single organ transplants. We need minimum listing criteria for multiple organ transplants,” he said.

Varying qualities of deceased donors’ organs also complicate organ allocation. While receiving an organ from a standard criteria donor (a healthy person who is age 18 to 60 years) is ideal, an increasing number of available organs are from “non-ideal” sources. For example, a donated kidney may come from an older donor whose kidney function is not completely normal or from a donor who died from cardiac complications. Often, patients in need of kidney transplants agree to accept organs from these types of donors because it would increase their chance of having a transplant, given the national shortage of kidneys.

“These trends have resulted in a need to classify deceased donor organs to encapsulate both the physiologic insults and the expected functional quality of the organs—characteristics which may have significant impact on the expected graft and recipient outcomes,” said Akinlolu Ojo, MD, PhD, of the University of Michigan in Ann Arbor. Ojo noted that there are ongoing attempts to refine the classification of deceased donor kidneys to better inform the allocation system.

These issues related to organ allocation were discussed during a clinical nephrology conference on “Allocation of Deceased Donor Organs for Renal Transplantation.”