Transforming kidney transplant policy

May 18 2007

A new article published in American Journal of Transplantation examines the dilemmas faced in trying to change kidney transplant policy; addressing the need to balance the benefits of immediate transplants with those to be had from waiting for a more suitable match.

The article highlights some of the important points to be considered in any new policy-making, and suggests a new method for allocation, whereby the patients are involved in the decision process.

The majority of deceased-donor kidneys are allocated to patients with end-stage renal disease on a ,first-come, first-serve, basis, rather than through careful matching, despite the fact that there is little risk of immediate death from renal ailments. As a result, donated kidneys in excellent condition may be given to patients who are almost certain to die long before the replacement organ wears out, while patients with longer life expectancies may be given organs with a high chance of graft failure, making second or even third transplants necessary later in life.

Recent attention has been focused on designing new methods of prioritization, one that allocates kidneys based on matches with the most favorable risk factors for long-term graft survival. Patients would be ranked based on the expected gain in years-of-life compared to continuing dialysis. However, such a system comes with a number of significant trade-offs, with some ethnic and age groups being more likely to benefit from transplants, and therefore ranking higher than others. The challenge for policy makers is to create a ranking system that takes into account those who do not meet maximum benefit requirements.

In this editorial, Richard B. Freeman, Jr., M.D. presents a solution suggesting that patients themselves decide what level of graft failure risk he or she deems acceptable. Recipients would only be offered kidneys that meet their own standards, rather than being directed by arbitrary allocation policies. Freeman claims that such a system ,would have many benefits, including better educating patients so that they could make informed decisions, allowing patients to personally decide where the trade-off between the qualitative and quantitative benefit of a transplant lies, as well as speeding up the organ placement program." An approach of this sort would not prevent low risk grafts from being given to patients with short life expectancies, or vice-versa, but it would ensure that the decision rests with the patient, in contrast to a system where quantitative benefit would always take priority with no patient or care giver input.