A New Approach to Kidney Donations

A New Approach to Kidney Donations

More than 83,000 Americans are waiting for a kidney transplant, but in 2008 there were only a little more than 16,000 transplants performed. It's a classic case of demand far exceeding supply. 

Though many patients have a friend or loved one willing to donate, immune system and blood type incompatibilities often prevent them from doing so, according to the Alliance for Paired Donation, a group that is trying to promote new approaches to kidney donation. About 12 people on the national kidney transplant waiting list die every day, many because they cannot find a compatible donor in time, the alliance estimates.

But what if the pool of donors could somehow be expanded? In 2007, the Alliance for Paired Donation helped develop a new approach to doing just that called Non-simultaneous Extended Altruistic Donor (NEAD) chains.

NEAD chains rely on altruistic donors who volunteer a kidney without having a designated recipient. That altruistic donor is matched with another kidney patient who has a willing but incompatible donor. In turn, that incompatible donor agrees to donate his or her kidney at a future date when he or she is matched with another incompatible donor/recipient pair, and the chain of donations continues.

"Donors are now recognizing that contributing to a 'kidney chain' would not just help one person, as in a traditional donor-recipient relationship, but several," says Tricia Howard, an assistant professor at South University — Savannah and director of Academic Education, Physician Assistant program.

One of the longest kidney chains, with 10 donors, was noted in a recent article in the New England Journal of Medicine. The chain began with Matt Jones, a 28-year-old man from Michigan who donated his kidney to a 53-year-old woman in Arizona whose husband promised his kidney to another recipient because he was not a match for his wife.

"Matt Jones' donation sparked 10 recipients so far who got a kidney, and we still have a donor at the end of the chain willing to give, but she's the rarest of blood types — AB," says Laurie Reece, executive director of the Alliance for Paired Donation.

And because of the exponential reach kidney chains offer, many argue they make good business sense.

Treatment for patients with end-stage renal disease requires dialysis, which is costly, points out Howard. Those patients often require frequent hospitalization as a result of their disease, Howard adds, creating an even greater financial burden on the federal health system.

"When you figure there are about 500,000 people in the U.S. who are on dialysis, you can see how that gets to be a lot of money," Reece says, adding that kidney transplant costs over a five-year period can be much less expensive than dialysis.

But kidney chains are not without their challenges.

The practice has received some criticism among the medical community, where some question the ethics of allowing a perfectly healthy person to subject themselves to surgery to help someone they don't know. As a white paper from the United Network for Organ Sharing (UNOS) points out: "The recipient enjoys a disproportionate share of the benefits (improved health and life expectancy), while the donor assumes the burden of an invasive surgical procedure and its potential long-term adverse consequences."

And as the kidney chain practice expands, there likely will be cases where those who have pledged to donate renege on the deal once their loved one receives his or her kidney.

"The most controversial issue in the case of a NEAD chain is whether paired donors can or should be trusted to donate a kidney after their own coregistered recipients have received transplants," doctors wrote last year in the New England Journal of Medicine. "Until now, paired donations in the United States have been performed simultaneously to eliminate the possibility of a donor reneging. ... It is not possible to predict the rate at which potential donors in NEAD chains will renege on their agreement to donate, though it seems likely that the risk will be increased if the outcome of the coregistered recipient's transplantation is poor or if the bridge donor has to wait a very long time to donate."

Still, the Alliance for Paired Donation isn't the only group pushing for the growth of paired kidney donations. In the fall of 2009, UNOS — the Virginia-based nonprofit group that coordinates the nation's organ donation network — launched an interim implementation of a kidney paired donation pilot program. The program aims to take living donors who discover they are unable to donate to the person they originally hoped would receive their kidney, and match them with another kidney patient/incompatible donor pair. The goal of the program, according to the UNOS website, is to identify as many compatible pairs as possible and maximize the number of matched pairs.

Kidney chains do create some financial puzzles for health insurers, hospitals, and even donors.

Donors must undergo a psychiatric evaluation to make sure they are donating for the right reasons as well as a thorough medical examination. Those tests can cost thousands of dollars and not all insurance companies will cover them, Reece said.

"The donor's insurance should never be billed, because it is not their responsibility," Reece says, adding that the recipient's insurer should pay. "But the reality is, some recipients insurance companies, once they find out the donor isn't compatible, don't want to pay for further testing. In that case, the transplant center itself has to pay for the testing, and put the expenses on their cost report. They will then get partially reimbursed by Medicare, but they won't get fully reimbursed."

Healthcare reform could ease some of those pressures, Reece says, adding: "It would certainly help if we had a more affordable (insurance) option for everyone. ... We do get altruistic donors that don't have health insurance and we're a little reluctant to take them sometimes."

Donors must also bear the cost of travel as well as the added cost of the time they would need to take off from work for the surgery and recovery.

Even with these costs, Reece thinks that in a few years NEAD chains could generate another 2,000 to 3,000 transplants annually.

"To make [that] happen, we'll have to have a sustainable funding mechanism in place," she said. "We're going to have to get the government involved. We need them to say, 'We really do think this is the wave of the future. We'll help you pay for this.' "

Written by freelance talent for South Source.

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