HEALTH - Transplant Kidney System Flawed

"In Discarding of Kidneys, System Reveals Its Flaws" by KEVIN SACK, New York Times 9/19/2012

Excerpt

Last year, 4,720 people died while waiting for kidney transplants in the United States. And yet, as in each of the last five years, more than 2,600 kidneys were recovered from deceased donors and then discarded without being transplanted, government data show.

Those organs typically wound up in a research laboratory or medical waste incinerator.

In many instances, organs that seemed promising for transplant based on the age and health of the donor were discovered to have problems that made them not viable.

But many experts agree that a significant number of discarded kidneys — perhaps even half, some believe — could be transplanted if the system for allocating them better matched the right organ to the right recipient in the right amount of time.

The current process is made inefficient, they say, by an outdated computer matching program, stifling government oversight, the overreliance by doctors on inconclusive tests and even federal laws against age discrimination. The result is a system of medical rationing that arguably gives all candidates a fair shot at a transplant but that may not save as many lives as it could.

“There is no doubt that organs that can help somebody and have a survival benefit are being discarded every day,” said Dr. Dorry Segev, a transplant surgeon at Johns Hopkins University School of Medicine.

For 25 years, the wait list for deceased donor kidneys — which stood at 93,413 on Wednesday — has remained stubbornly rooted in a federal policy that amounts largely to first come first served. As designed by the government’s Organ Procurement and Transplantation Network, which is managed under federal contract by the nonprofit United Network for Organ Sharing, the system is considered simple and transparent. But many in the field argue that it wastes precious opportunities for transplants.

One recent computer simulation, by researchers with the Scientific Registry of Transplant Recipients, projected that a redesigned system could add 10,000 years of life from just one year of transplants.

Currently, the country is divided into 58 donation districts. When a deceased donor kidney becomes available, the transplant network’s rules dictate that it is first offered to the compatible candidate within the district who has waited the longest. Additional priority is given to children, to candidates whose blood chemistry makes them particularly difficult to match and to those who are particularly well matched to the donor. If no taker is found locally, the electronic search expands to the region and eventually goes national.

The kidney matching system does not, however, consider the projected life expectancy of the recipient or the urgency of the transplant. By contrast, the systems for allocating livers, hearts and lungs have been revised to weigh those factors.

As a result, kidneys that might function for decades can be routed to elderly patients with only a few years to live. And when older, lower-quality kidneys become available, candidates atop the list and their doctors can simply turn them down and wait for better organs. If that happens too often, doctors say, a kidney can develop a self-fulfilling reputation as an unwanted organ.

Complicating matters is a race against the clock that starts as soon as a kidney is recovered and placed on ice for evaluation. Because kidneys start to degrade during this “cold ischemic time,” surgeons typically hope to transplant them within 24 to 36 hours.

But that short window can be devoured by testing, searches for a recipient and long drives or flights to transport the kidney. The organ procurement organization in each district is allowed to make offers to only a few hospitals at a time — usually three to five — and the hospitals have an hour to respond.