Transplant policy session highlights continued need to create equitable, ethical, and cost-effective measures for transplant recipients and donors

Speakers at a “Controversies in Organ Transplant Policy” session at Renal Week 2010 described a range of issues affecting both kidney donors and recipients.

Gabriel Danovitch, MD, director of the Kidney Transplant Program at UCLA, described the steps taken this year by the Declaration of Istanbul Custodian Group (DICG) to create a framework of “muscles and tendons” across the “skeleton” of the Declaration. The Declaration of Istanbul was created in 2008 by representatives of scientific and medical bodies from around the world to protect the poor and vulnerable from the negative effects of transplant tourism and organ trafficking.

Although the Declaration has been widely accepted and endorsed by all major transplant organizations, it is not a legal document. The DICG works to monitor, implement, and enforce the principles laid out in the Declaration and has split into six task forces covering various organ trafficking and tourism aspects. While Danovitch would like to see greater widespread acceptance, using the Declaration of Helsinki as a goal, he said tremendous progress has already been made since the Declaration was published. For more information, visit www.declarationofistanbul.org.

Roger Evans, PhD, president and CEO of the United Network for the Recruitment of Transplantation Professionals, described the ongoing struggle to pass legislation providing Medicare reimbursement for immunosuppressive medication to transplant recipients who are only Medicare-eligible due to their end stage renal disease after three years. Evans laid out an argument for lifetime coverage using data recently published in the Clinical Journal of the American Society of Nephrology (PMID: 20847093) describing the economic burden of “cost-related nonadherence” (CRN). In a nationwide transplant center survey done by Evans and colleagues, 70 percent of patients reported having problems paying for medication, and 68 percent reported deaths and graft losses attributable to cost-related immunosuppressive medication nonadherence.

Alan Leichtman, MD, medical director of Kidney and Pancreas Transplant Programs at the University of Michigan, discussed alternative systems for deceased donor allocation. The National Organ Transplant Act (NOTA), instituted in 1984, requires the Organ Procurement and Transplantation Network (OPTN) to determine medical criteria ensuring equitable organ allocation, which for kidneys is currently based on HLA status, wait time accrual, sensitization, and donor kidney type (standard vs. extended criteria).

The current system has been highly criticized as being a subjective process not accounting for special needs, inequities in access, and differences in outcomes across populations, in stark contrast to the original NOTA mandate. Leichtman reviewed current, proposed allocation policy changes including a new kidney allocation score (KAS) based on expected life years from transplant (LYFT score), time on dialysis, sensitization, and a donor profile index. Other alternatives to the current system include removing the allocation system all together, using a lottery-based system, or basing allocation on social and economic (versus medical) conditions. For more information on the proposed system, visit: http://optn.transplant.hrsa.gov/kars.asp.