Organ Donation: Should Younger Patients Get Better Kidneys?

Feb. 25, 2011— -- Jerry Powell's kidneys may be dying, but the 50-year-old newlywed still has a lot of living to do. Within weeks, Powell will rely on dialysis to filter his blood. And ultimately, he'll need a kidney transplant. But the United Network for Organ Sharing (UNOS) -- the organization charged with allocating the nation's organs -- is considering a policy change that could impact Powell's standing.

Currently, those at the top of an 87,000-strong waiting list are next in line for a matched kidney -- regardless of age and health status.

"We started with what we thought was best at the time, but as things change we need to make improvements," said Dr. Christopher Marsh, chief of transplant surgery at the Scripps Center for Organ and Cell Transplantation and UNOS board member. "The current system is not fair. The new approach, from a medical and scientific standpoint, is an improvement."

The proposed change, which was released as a concept document Feb. 16 for public comment, would reserve 20 percent of donor organs for those receipients expected to live the longest after a transplant, and the remaining 80 percent for recipients age-matched to within 15 years of the donor.

"This would reduce the possibility that a candidate reasonably expected to live ten more years receives a kidney that may function for 40 years, or conversely that a candidate reasonably expected to live 40 more years receives a kidney that may function for only ten," Anne Paschke a spokeswoman for UNOS, said in a statement.

Only 17,000 Americans receive a transplant each year, and more than 4,600 die waiting.

"When faced with the prospect of rationing, the ethical responsibility is to use resources prudently and save the most lives and years of life," said Arthur Caplan, chair of medical ethics at the University of Pennsylvania. "It's the policy we follow during war: help those most likely to recover without doctors and intensive care beds. The sicker you are, the less likely you are to do well with a transplant."

Need for Change

Although the proposal was only recently made public, the idea has been around for almost a decade.

"It's been a long process," Marsh said. "We've come up with ideas and run up against barriers. Change is difficult, and patients and programs are used to a simple allocation system."

"Every policy change is always disconcerting because there are new winners and new losers," said Dr. Antonio Di Carlo, assistant professor at the University of Vermont College of Medicine and chief of transplant surgery at Fletcher Allen Healthcare.

According to the 40-page proposal, people over 50 would lose an advantage they currently hold. The donor pool for a 60-year-old could theoretically be cut by half.

"No matter how you look at it, there will be some people advantaged fairly and disadvantaged unfairly. But the same thing goes with the current policy. It's not right to have someone die with a pristine kidney while a young person needs two or three transplants throughout their lifetime."

For patients like Powell, the change could mean getting an older kidney with fewer functional years. It could also mean getting an "extended criteria donation" -- a kidney that, until recent years, would not have been transplanted at all.

"I think it my particular case, it would limit my options," Powell said.

Powell, who lives in Sallisaw, Okla., was healthy and active until he was attacked by three men in 1995. Since then, he's suffered from uncontrollable hypertension that has wreaked havoc on his kidneys. Powell's wife, Melissa, plans to get dialysis training so she can treat her husband at home.

Older patients with kidney failure tend to suffer from other health conditions, such as diabetes, that increase their risk of death while on dialysis. They are often offered extended criteria donations because, although the kidneys aren't perfect, they are better than dialysis.

"If you're older, this change would reduce the number of kidney you have access to, increase the age of kidney you can get and increase the likelihood of extended criteria donation," said Dr. Daniel Salomon, co-director of the Center for Organ and Cell Transplantation at Scripps Green Hospital.

Powell, father of four and grandfather of five, just wants a fair chance at a good kidney as soon as possible.

"I think we should give an individual as much opportunity to have a good quality of life as possible, regardless of what their age is."

But it's important to consider the ethical responsibility to donors, too, Caplan said.

"I don't think people donate organs so that everyone has an equal chance. I think they do it to save lives," he said.

Supply and Demand

Although the proposal raises sensitive issues surrounding health care and social justice, the topic of rationing is one that, at least for kidney transplants, is very real.

"Decisions about organ allocation are already being made. This proposal is just another way," said Jackie Hancock, president of the National Foundation for Transplants. "It's heart-wrenching that someone has to make these kinds of decisions, and that's the sad part about the whole thing. But the decisions have to be made because there are not enough organs."

UNOS is inviting feedback on the proposal until April 1.