American Journal of Transplantation 2014; 14: 2204–2205 Wiley Periodicals Inc.
Editorial
C
Copyright 2014 The American Society of Transplantation and the American Society of Transplant Surgeons doi: 10.1111/ajt.12865
Whose Kidney Is It Anyway? The Complexities of Sharing Deceased Donor Kidneys K. A. Andreoni1,2,* and R. N. Formica Jr.3,4 1
Department of Surgery, University of Florida, Gainesville, FL 2 United Network of Organ Sharing, Richmond, VA 3 Yale University, New Haven, CT 4 OPTN/UNOS Kidney Transplantation Committee, Richmond, VA Corresponding author: Kenneth A. Andreoni, [email protected]
Received 05 May 2014, revised 27 May 2014 and accepted for publication 06 June 2014
Disparities in Access to Kidney Transplantation Between Donor Services Areas in Texas by Lewis et al is a clarion call for wider geographic sharing of donated kidneys in this country (1). The arbitrary boundaries of donor service areas (DSAs) are the impediment to equitable access for patients and Texas, although not unique, is a case study in how gerrymandering DSAs to serve individual transplant center agendas results in disenfranchisement of patients. However, eliminating geographic disparity is more than erasing DSAs boundaries, and while we agree with the sentiment expressed by the authors, we disagree that the solution is to consolidate the organ procurement organizations (OPOs) existing within a state’s borders into one. Fixing the geographic disparity that exists in kidney transplantation requires doing what is in the best interest of patients and understanding how the transplant profession must justify the trust society places in it for the stewardship of a precious national resource. Were the solution to the problem as easy as keeping kidneys within the states that they are recovered, our work would be done. However, defining, much less fixing, geographic disparity is more complex. The root of the problem is defining what is ‘‘local.’’ Is it alternative allocation units (ALUs), DSAs, individual states or a larger district? All of these definitions are currently in use. The lament of the authors over the loss of the opportunity to acquire an ALU for their center is exemplary of the mindset that believes further subdivision of DSAs into smaller components will solve the problem of inequitable access to kidney transplantation. 2204
It is reasonable to question what is the best way to distribute organs, over smaller more local areas or larger areas that ignore DSA, state and regional boundaries? We argue for the latter. While superficially an ALU appears to improve access to transplantation for the patients it serves, it does so at the expense of others. With no ALU in place, all patients on a DSA waiting list (or any larger geographic area list) will have the same waiting time as a similar patient in that DSA. Admittedly, individual transplant centers may receive more or less kidneys, however, this is a center concern and not a patient problem. In order to address the problem of disparity in access to kidney transplantation the profession must reject the self-interest that drives transplant centers to lobby for policies that serve only to protect their financial plans. The authors express doubt that the new kidney allocation system (KAS) (2) will improve geographic disparity. This remains to be seen. The new KAS is not perfect but it does represent the result of 10 years of formulation, analysis and compromise. It is true that wider sharing of high kidney donor profile index (KDPI) kidneys (>0.85) will not completely eliminate disparity. However, it is also true that the shortage of donated organs compared to the number of waitlisted candidates is the number one challenge faced. Therefore, the first step to improve disparity is to maximize the recovery and transplantation of available kidneys. Across DSAs, the use of expanded criteria donor (ECD) kidneys ranges from 3% to 25% and that of donation after cardiac death kidneys from 1% to 35% (3). This heterogeneity in utilization is why regional sharing of high (KDPI) kidneys was added to the allocation system (2). Prior to mandating sharing of organs over larger geographic areas, it is necessary and a political reality that the recovery of currently available kidneys must be maximized. The intent of the KAS is to incentivize OPOs to recover high KDPI kidneys by providing more rapid access to centers that will use them. With increased utilization of high KDPI kidneys outcome pressures from the Organ Procurement and Transplantation Network and the Centers for Medicare & Medicaid Services cannot be ignored. Policy cannot on the one hand encourage the use of higher risk kidneys and on the other hand penalize programs for not achieving the current standard of outcomes obtained by avoiding the higher risk organs and candidates. Policy must allow transplant centers to pair appropriate recipients with donor organs without undo fear of running afoul of regulatory agencies.
Editorial
Broader sharing without thoughtful allocation details could result in a system that is less efficient and regulations must be changed to avoid being a disincentive to organ use. After the implementation of the KAS, the larger questions of what defines allocation equality can begin to be addressed. However, preliminary work done by the United Network of Organ Sharing Kidney Transplantation Committee suggests this will be a complicated task. For example, will the average time to transplant or average offers per patient suffice as a definition? Will equity be achieved by having similar KDPI organ offer rates to patients with similar Estimated Post Transplant Survival (EPTS)? Will use of living donor organs be taken into account? Should there be a correction for center acceptance practices? Will it be dictated exactly which kidney a patient must accept in order to make the national system result in perfectly ‘‘fair’’ outcomes? A true national allocation system is easy to aspire to but difficult to achieve. It will only be achieved through an iterative process that develops national consensus, and the details will make the difference. Disparities in access to kidney transplantation exist and the current arbitrary patchwork of DSAs is a primary cause. The new KAS will not completely eliminate these disparities; however, it does make meaningful first steps; national sharing for highly sensitized patients and regional sharing for high KDPI (ECD) kidneys serves as a test to evaluate the logistics of wider sharing. The elimination of paybacks for shared kidneys establishes that donated organs are a national resource and the dissolution of variances and
American Journal of Transplantation 2014; 14: 2204–2205
ALUs, moves the discussion to wider geographic sharing. Most importantly the new KAS was designed to include allocation principles the community is comfortable with and to be easily overlaid on future larger geographic areas with minimal modification. With the implementation of the new KAS the arbitrary nature of kidney allocation in this country will be undone, local fiefdoms dismantled and a new baseline established. With a new benchmark to compare to, the work of eliminating disparity in access to kidney transplantation through wider geographic sharing can begin.
Disclosure The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.
References 1. Lewis RM, Sankar A, Pittman J. Disparities in access to kidney transplantation between donor service areas in Texas. Am J Transplant 2014; 14: 2303–2309. 2. Proposal to substantially revise the national kidney allocation system. Available at: http://optn.transplant.hrsa.gov/PublicComment/pubcommentPropSub_311.pdf. Accessed May 5, 2014. 3. Israini AK, Zaun D, Rosendale JD, Snyder JJ, Kasiske BL. OPTN/ SRTR2012 annual report: Deceased organ donation. Am J Transplant 2013; 14: 167–183. Available at: http://onlinelibrary. wiley.com/doi/10.1111/ajt.12585/pdf. Accessed May 5, 2014.
2205
Editorial
C
Copyright 2014 The American Society of Transplantation and the American Society of Transplant Surgeons doi: 10.1111/ajt.12865
Whose Kidney Is It Anyway? The Complexities of Sharing Deceased Donor Kidneys K. A. Andreoni1,2,* and R. N. Formica Jr.3,4 1
Department of Surgery, University of Florida, Gainesville, FL 2 United Network of Organ Sharing, Richmond, VA 3 Yale University, New Haven, CT 4 OPTN/UNOS Kidney Transplantation Committee, Richmond, VA Corresponding author: Kenneth A. Andreoni, [email protected]
Received 05 May 2014, revised 27 May 2014 and accepted for publication 06 June 2014
Disparities in Access to Kidney Transplantation Between Donor Services Areas in Texas by Lewis et al is a clarion call for wider geographic sharing of donated kidneys in this country (1). The arbitrary boundaries of donor service areas (DSAs) are the impediment to equitable access for patients and Texas, although not unique, is a case study in how gerrymandering DSAs to serve individual transplant center agendas results in disenfranchisement of patients. However, eliminating geographic disparity is more than erasing DSAs boundaries, and while we agree with the sentiment expressed by the authors, we disagree that the solution is to consolidate the organ procurement organizations (OPOs) existing within a state’s borders into one. Fixing the geographic disparity that exists in kidney transplantation requires doing what is in the best interest of patients and understanding how the transplant profession must justify the trust society places in it for the stewardship of a precious national resource. Were the solution to the problem as easy as keeping kidneys within the states that they are recovered, our work would be done. However, defining, much less fixing, geographic disparity is more complex. The root of the problem is defining what is ‘‘local.’’ Is it alternative allocation units (ALUs), DSAs, individual states or a larger district? All of these definitions are currently in use. The lament of the authors over the loss of the opportunity to acquire an ALU for their center is exemplary of the mindset that believes further subdivision of DSAs into smaller components will solve the problem of inequitable access to kidney transplantation. 2204
It is reasonable to question what is the best way to distribute organs, over smaller more local areas or larger areas that ignore DSA, state and regional boundaries? We argue for the latter. While superficially an ALU appears to improve access to transplantation for the patients it serves, it does so at the expense of others. With no ALU in place, all patients on a DSA waiting list (or any larger geographic area list) will have the same waiting time as a similar patient in that DSA. Admittedly, individual transplant centers may receive more or less kidneys, however, this is a center concern and not a patient problem. In order to address the problem of disparity in access to kidney transplantation the profession must reject the self-interest that drives transplant centers to lobby for policies that serve only to protect their financial plans. The authors express doubt that the new kidney allocation system (KAS) (2) will improve geographic disparity. This remains to be seen. The new KAS is not perfect but it does represent the result of 10 years of formulation, analysis and compromise. It is true that wider sharing of high kidney donor profile index (KDPI) kidneys (>0.85) will not completely eliminate disparity. However, it is also true that the shortage of donated organs compared to the number of waitlisted candidates is the number one challenge faced. Therefore, the first step to improve disparity is to maximize the recovery and transplantation of available kidneys. Across DSAs, the use of expanded criteria donor (ECD) kidneys ranges from 3% to 25% and that of donation after cardiac death kidneys from 1% to 35% (3). This heterogeneity in utilization is why regional sharing of high (KDPI) kidneys was added to the allocation system (2). Prior to mandating sharing of organs over larger geographic areas, it is necessary and a political reality that the recovery of currently available kidneys must be maximized. The intent of the KAS is to incentivize OPOs to recover high KDPI kidneys by providing more rapid access to centers that will use them. With increased utilization of high KDPI kidneys outcome pressures from the Organ Procurement and Transplantation Network and the Centers for Medicare & Medicaid Services cannot be ignored. Policy cannot on the one hand encourage the use of higher risk kidneys and on the other hand penalize programs for not achieving the current standard of outcomes obtained by avoiding the higher risk organs and candidates. Policy must allow transplant centers to pair appropriate recipients with donor organs without undo fear of running afoul of regulatory agencies.
Editorial
Broader sharing without thoughtful allocation details could result in a system that is less efficient and regulations must be changed to avoid being a disincentive to organ use. After the implementation of the KAS, the larger questions of what defines allocation equality can begin to be addressed. However, preliminary work done by the United Network of Organ Sharing Kidney Transplantation Committee suggests this will be a complicated task. For example, will the average time to transplant or average offers per patient suffice as a definition? Will equity be achieved by having similar KDPI organ offer rates to patients with similar Estimated Post Transplant Survival (EPTS)? Will use of living donor organs be taken into account? Should there be a correction for center acceptance practices? Will it be dictated exactly which kidney a patient must accept in order to make the national system result in perfectly ‘‘fair’’ outcomes? A true national allocation system is easy to aspire to but difficult to achieve. It will only be achieved through an iterative process that develops national consensus, and the details will make the difference. Disparities in access to kidney transplantation exist and the current arbitrary patchwork of DSAs is a primary cause. The new KAS will not completely eliminate these disparities; however, it does make meaningful first steps; national sharing for highly sensitized patients and regional sharing for high KDPI (ECD) kidneys serves as a test to evaluate the logistics of wider sharing. The elimination of paybacks for shared kidneys establishes that donated organs are a national resource and the dissolution of variances and
American Journal of Transplantation 2014; 14: 2204–2205
ALUs, moves the discussion to wider geographic sharing. Most importantly the new KAS was designed to include allocation principles the community is comfortable with and to be easily overlaid on future larger geographic areas with minimal modification. With the implementation of the new KAS the arbitrary nature of kidney allocation in this country will be undone, local fiefdoms dismantled and a new baseline established. With a new benchmark to compare to, the work of eliminating disparity in access to kidney transplantation through wider geographic sharing can begin.
Disclosure The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.
References 1. Lewis RM, Sankar A, Pittman J. Disparities in access to kidney transplantation between donor service areas in Texas. Am J Transplant 2014; 14: 2303–2309. 2. Proposal to substantially revise the national kidney allocation system. Available at: http://optn.transplant.hrsa.gov/PublicComment/pubcommentPropSub_311.pdf. Accessed May 5, 2014. 3. Israini AK, Zaun D, Rosendale JD, Snyder JJ, Kasiske BL. OPTN/ SRTR2012 annual report: Deceased organ donation. Am J Transplant 2013; 14: 167–183. Available at: http://onlinelibrary. wiley.com/doi/10.1111/ajt.12585/pdf. Accessed May 5, 2014.
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