Old, Sick and Need a Kidney? Good Luck

Bloomberg View , December 08, 2014

When I donated a kidney to a friend in 2006, there were about 66,000 people on the national waiting list for kidney transplants. At the time, that seemed like an enormous number. But it was tiny compared to today. As of the end of November, nearly 102,000 Americans were officially waiting for kidneys.

Despite a record 11,163 kidneys transplanted from deceased donors in 2013, an ever-growing waiting list seems inevitable. With an aging population and increasing rates of diabetes -- the most common cause of kidney failure -- more and more people are developing kidney disease. Although transplant centers have gotten very good at persuading the bereaved families of deceased potential donors to give the “gift of life,” too few people die in ways that keep their organs healthy for transplant. The waiting list reflects an absolute physical shortfall.

Within a few years, new rules about allocating kidneys, which went into effect last week, could shrink the waiting list. But this apparent improvement will be an illusion -- an artifact of the incentives the new rules create, not genuine progress. Changing who gets priority for scarce kidneys will help some patients and hurt others, and it might squeeze out a few more total years of healthy living for the lucky recipients. But a different process for managing the existing supply of kidneys won’t make a serious difference for the skyrocketing number of patients who need transplants.

In the past, how long you’d been on the waiting list was the main factor that determined how close you were to getting a compatible kidney. (Some blood types are harder to match than others, so someone with less compatible type O blood would wait longer than someone with type A.) The longer you waited, the further you moved up the list. The clock started when your transplant center did the necessary tests and listed you as a transplant candidate.

The old system hurt those patients, most of whom were black, who had spent years on dialysis before they got referred for transplants, whether because of medical factors, insufficient health insurance or complacent nephrologists. (About a third of the patients, about 35,000 people, currently on the waiting list are black.) The new system instead starts the clock when a patient goes on dialysis.

“In the previous system, it would make sense to list somebody even if they weren’t quite ready to get a transplant, so they could accrue waiting time,” Benjamin E. Hippen, a transplant nephrologist at Carolinas Medical Center in Charlotte, North Carolina, explained in an interview. Now, since they won’t have a shot at a kidney for years, there’s no reason to put them on the waiting list so soon. “It’s going to look like the overall list has shrunk,” he predicted, “when really it’s just a strategic move by the transplant center.”

While arguably fairer, counting dialysis years creates much more uncertainty. Every time a new patient is added, that person’s dialysis history rejiggers the list. It’s like waiting for an airline upgrade: If you’re a lowly gold status member, you may start out at the head of the line, only to end up in coach as platinum and executive platinum travelers put in their requests and push you down the queue. In this case, there’s a lot more at stake than more legroom and better meals.

The new system also changes who qualifies for which kidney. Its primary goal is to get more years out of each organ, essentially by matching younger, healthier patients with younger, healthier organs. Assuming the statistical models are correct, better matching is supposed to give kidney recipients an additional 9,000 years of life -- a number that sounds huge but amounts to less than one additional year per transplant patient. (When potentially compatible organs come up, the system also gives high priority to hard-to-match “sensitized” patients, often previous transplant recipients, who have developed many antibodies that can cause their bodies to reject most transplants.)

News reports on the revised rules have been relentlessly upbeat, emphasizing that they “give some patients a better shot at a longer-lasting organ,” “make kidney transplants more fair” or “make it easier to find organs for the right people.” The losers -- the wrong people? -- apparently don’t warrant a mention. But that doesn’t mean they won’t exist. In fact, this policy makes the top 20 percent of recipients better off while sticking the rest with less desirable kidneys.

“The people who lose in all this are going to be the people who are a little older, who are diabetic and who don’t have a lot of years of waiting time -- which is most patients,” said Hippen, a critic of the new system. “That sort of describes the average new patient.”

“Older” under the new rules doesn’t mean "elderly." Although demographics vary from place to place and locals get first crack when kidneys become available, someone over 50 isn’t likely to qualify for the best kidneys anywhere. The rules are well intended, but their cold equations undeniably value young lives over middle-age or old ones, and they penalize patients with diabetes or high blood pressure.

“A younger, healthier kidney is going to confer a better outcome,” regardless of the recipient’s health or age, Hippen said. The new system doesn’t expand the number of good kidneys -- or of kidneys in general. It merely changes who wins the lottery.

No allocation scheme, however cruelly “rational,” is going to alleviate the fundamental problem: not enough organs to meet the need. For that, we need more living donors.