Responses to potential questions/comments on the Kidney Allocation Concept Document
Developed by UNOS
Is this a policy or a policy proposal? When will it be voted on as national policy? It’s not policy, and
it’s incorrect even to call the concept document a “proposal” at this point. It is a document that outlines
a series of concepts that may be part of a future proposal to improve the national system of kidney
allocation. We are seeking public comment on the various concepts in the document. We welcome
reasoned consideration and feedback – but we encourage everyone to read the concept document and
the rationale first, rather than relying on incomplete information in news articles or blogs.
Some news reports have suggested there will be a deadline to vote on this “policy” in June 2012. That’s
at least two “ifs” removed from reality. Based on feedback to public comment, the Kidney
Transplantation Committee will likely develop a proposal; it may include some or all of the concepts
discussed. That proposal would have a separate round of public comment, which again might influence
the specifics of any final proposal to the OPTN/UNOS Board of Directors. The earliest any of this could
lead to a Board vote is June 2012, but there is no specific timetable at this point.
Is age-matching a form of age discrimination? “Age discrimination” implies we have made a categorical
judgment about the relative social worth of people based on age, and we might deny or restrict people’s
access to organs on that basis. This is not true and has no basis in what the age-range matching concept
is about.
In our role as administrators of the national Organ Procurement and Transplantation Network (OPTN),
we are charged with allocation of a scarce medical resource. Were enough organs available today, the
matching criteria would be very easy. With the extreme scarcity of available kidneys, we are charged
with determining how they can be matched with candidates with the best overall benefit for everyone
in need.
A transplant candidate’s age could be a useful factor, among several others, in determining how we can
revise organ allocation policy to create greater overall benefit for all recipients (and honor the wishes of
organ donors by making best use of their lifesaving gift).
We know that some candidates could survive 40 years or longer if they receive a kidney transplant. We
know that others probably will live 10 years or less if they receive a transplant. We want both groups of
candidates to benefit from transplantation. Age is one factor, among others, in knowing the relative
amount of time a recipient may survive. Ten good years of expected survival for an older recipient may
be just as meaningful for their own lives, and for their participation in society, as 40 years of survival for
a younger recipient.
We also know, with some precision, some deceased donor kidneys are likely to last about 10 years if
transplanted and others may last 40 or more. If a donor becomes available with a kidney that can last
40 years, we believe we can do better than our current system does in determining the most efficient
use of that organ. That would argue that the person who should be considered first would be the
person most likely to need it for 40 years.
Relatively few kidneys would be expected to last 40 years – many more of them that come available
could be expected to last 10 to 15 years. For the organ offers that have exceptional potential, those
should be offered first to those who may benefit for the longest amount of time. The majority of kidney
offers would be considered for those people who have more common expectations of survival.
Would this concept cause a major shift in kidney allocation for most candidates? No. Under current
kidney allocation policy, the majority of recipients of deceased donor kidneys get one from a donor
within 15 years of their age (the same range as described in the concept document).
In fact, even if there were no age-range matching policy put in place, the number of older recipients
from age-matched donors should continue to increase as the overall U.S. population (and thus the
potential donor population) continues to age. However, under current policy, a disproportionate
number of kidneys from older donors are discarded because a suitable recipient is not identified quickly.
Age-range preference could mean that, for example, kidneys from a 65-year-old donor could be more
readily identified (and accepted) for candidates between 50 and 80, rather than being initially
considered (and refused) for many transplant candidates younger than 50.
Also, if adopted, age-range matching would only be a first level of consideration for candidates, not an
absolute. For example, kidneys from a 55-year-old donor might first be considered for candidates
between 40 and 70 years of age. If no recipients are identified as a suitable match, the kidneys would
then be considered for both older and younger potential recipients.
Another fact overlooked in early reporting is that there is already age range preference given to kidney
transplant candidates younger than age 18. There are relatively few candidates this young, and it’s well
documented that younger candidates suffer growth and developmental problems if not transplanted
quickly. Under existing policy, kidneys from all deceased donors under the age of 35 are first considered
for any suitable candidates age 18 or younger. Again, this is only a first level of consideration, and since
there are relatively few pediatric candidates, many deceased donor kidneys are then offered to adult
candidates. This policy has existed for several years with no major public controversy.
I think the current first-come, first-serve system is fair; why change it? “Fairness” is highly subjective.
The allocation system strives for equity – ensuring that candidates in similar need and with similar
characteristics have essentially the same chance of receiving an organ offer. Equity has at least some
potential measures of objective comparison.
“First-come, first-serve” would be truly fair if everyone eventually benefits, and if every person receives
an organ of the same relative quality. Unfortunately, neither statement is true. Some people wait a
long time for a donor kidney and never receive one. Waiting time priority is arguably “fair” to those
who eventually receive a transplant, but not to those who don’t. In addition, waiting time alone cannot
predict whether a specific candidate is objectively more in “need” of an organ offer than others, or
whether the offer he or she receives will yield the maximum possible years of potential function.
Waiting time should remain a tiebreaker among candidates of equal potential benefit, just as it is with
other organ allocation policies. But under existing policy, waiting time is a major factor affecting when
candidates receive organ offers. This should be better balanced to allow more precise matching of
donor offers with the specific need of the candidate.