The numbers speak for themselves. There are currently 121,678 people waiting for life-saving organ transplants in the US. Of these, 100,791 await kidney transplants. A patient is added to the kidney waitlist every 14 minutes and 13 people die every day waiting for a kidney transplant (1). These numbers and their implications led to the Kidney Week 2017 session, Political Correctness? Public Policy Influences on Transplantation, moderated by Roy D. Bloom, MD, and Michelle A. Josephson, MD.
In the segment Kidney Allocation Changes: Past, Present, and Future, Richard N. Formica, MD, of the Yale School of Medicine, outlined where the Organ Procurement and Transplantation Network (OPTN) Kidney Allocation System (KAS) changes of December 2014 have led. Formica is professor of medicine and surgery and director of transplant medicine at Yale.
He laid out several precepts for consideration:
An organ allocation system without disparities is probably not possible.
Equity may not always be desirable if other goals are adversely affected.
Allocation policy only addresses disparities in allocation for waitlisted patients—it does not address disparities in access to the kidney waitlist itself.
Simply put, getting on the waitlist is an access issue, and receiving a kidney is an allocation issue.
Prior to revisions to the KAS, disparities existed in several areas. Revisions to the KAS were designed to address four of these areas (Table 1).
One of the key revisions now shaping allocation policy is the introduction of longevity matching, which basically pairs those patients with the longest life expectancy with kidneys expected to last the longest. This is the first of four pillars of the current KAS. The remaining three pillars are:
Matching the allocation score to the biological need of the highly sensitized recipient.
Recalculating waiting time to start at the date of dialysis initiation instead of the date of listing.
Improving access for minority candidates by allocating donor organs with blood type A2 to B blood type recipients.
Issues of insurance and geography still persist. Those with the resources can be waitlisted in multiple locations, increasing their chances of moving up the waitlist. Those without those resources may be affected by living in a donor service area with much lower rates of transplantation. Formica pointed out that under section 121.8 of the OPTN Final Rule, organ allocation, “shall not be based on the candidate’s place of residence or place of listing, except to the extent required by paragraphs (a)(1)-(5) of this section.” The presence of geographic disparities seems to be, on its face, in violation of stated policy. The next big challenge according to Formica was access to the transplant list itself.
Schold JD. Evaluation of flagging criteria of United States kidney transplant center performance: how to best define outliers? Transplantation 2017; 101:1373–1380.
Weinhandl ED, et al.. Effect of comorbidity adjustment on CMS criteria for kidney transplant center performance. Am J Transplant 2009; 9:506–516.
Schold JD, et al.. Prominent impact of community risk factors on kidney transplant candidate processes and outcomes. Am J Transplant 2013; 13: 2374–83.
Schold JD, et al.. Association of candidate removals from the kidney transplant waiting list and center performance oversight Am J Transplant 2016; 16:1276–84.