HEALTH CARE/Joan Retsinas

More Patients Wait for Kidneys

This recession Americans have gotten to know genuine scarcity, as wells — not just oil, but the fiscal ones — have run low. And we have all conceded, if reluctantly, the need to change our patterns of consumption: the status quo simply will not hold.

But the status quo is rooted in inertia, and any proposed change will spark protests. The allocation of kidneys presents another tale of scarcity, where soaring demand far outstrips the not-so-soaring supply. Last year about 15,000 people got kidneys; 88,000 were on the waiting list. Ten thousand people have waited five or more years.

The nation has tried to increase the supply of organs. Organ donation cards, exchanges for donation of organs from living donors, publicity campaigns — we do them. Thanks to medical advances, we accept more kidneys from elderly donors. We don’t pay donors — a practice in those countries where wealthy Americans travel for organs.

And we don’t take organs from prisoners — a practice not unheard of in totalitarian countries. So, until scientists develop an artificial kidney, thousands of Americans will stay on dialysis, hoping to get a call that they have advanced up the waiting list. Twenty-five years ago, UNOS (the United Network for Organ Sharing), the federally-designated allocation system, set the key criterion: time on the list. The longer you waited, the better your chances – unless you died while waiting, or grew too ill for a transplant.

This criterion favored the oldest, the sickest waiters. Back then, it seemed the fairest system. Yet back then, the waiting list was much smaller (16,000 patients). More than half got kidneys.

And a higher percentage went to people under age 17 (7.4%), far fewer (2.4%) to people over age 65. Last year 4.4% of kidneys went to people under age 17; 16.7% to people over age 65. The kidney from a 60-year old donor will probably not last for another 30 years, yet today, a 30-year old on dialysis might receive a new kidney that will fail after 10 years.

This is a poor use of organs: we are dooming the younger recipient of an old kidney to eventual kidney failure, perhaps another transplant. And we are wasting years of a viable kidney on a recipient who will die decades before the kidney dies.

Also, this criterion overlooks the survival prospects of recipients. With a donated organ, healthy young recipients may well thrive, gaining a lifetime of pain-free productive living. Older recipients, particularly those with chronic illnesses, may gain a few more years, not necessarily free of pain and disability. It is tempting to say that every life is equal, but we are inevitably choosing: thirty years for a 20-year old, versus 10 years for a septuagenarian. The current system favors the latter.

UNOS has proposed to make the allocation more effective. Under the proposal, UNOS will rate each donated kidney according to the criteria that includes the donor’s age and health (did the donor have diabetes? Or hepatitis? What was the cause of death?)

Currently 20% of donated kidneys would quality as “highest-quality.” UNOS will give those organs to recipients with the “highest estimated post transplant survival;” in short, healthy younger recipients. As of now, those younger patients represent a tiny portion of the list: about 800 patients are younger than age 17, compared to roughly 16,000 patients over age 65.

For the remaining 80% of donated kidneys, UNOS will establish a 30-year window around each recipient. A recipient will get a kidney that is no more than 15 years older than s/he, no less than 15 years younger. That change will correct the status quo imbalance where older people get young kidneys, and, tragically, younger people get old kidneys.

Protesters are protesting. No surprise: somebody will always yell “no” to any change. Yet this change marks a thoughtful response to the scarcity of organs. We can do very little about the scarcity; but we can insure a more equitable distribution. UNOS has invited public comment (kdneypolicy@unos.org). This is your chance to speak out.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email retsinas@verizon.net.

From The Progressive Populist, April 1, 2011