Does the New Kidney Allocation Concept Discriminate Against Older Candidates?

By Jack Fassnacht, kidney transplant recipient; Past Chair – NKF transAction Council Executive Committee

Does the New Kidney Allocation Concept Discriminate Against Older Candidates?After the “Concepts for Kidney Allocation” (CKA) document was published, some members of the public and media expressed the opinion that the allocation system, if adopted, would discriminate against older transplant candidates. The reasoning goes like this: Waiting list candidates in the "top" 20% in terms of expected post-transplant survival – those eligible for the "top" 20% of donor kidneys – tend to be younger, so older candidates would lose out in greater proportion to younger candidates if this "survival matching" feature is adopted. In addition, the donor population tends to be younger than the candidate population, so the age matching feature – in which kidneys would first be offered to candidates within 15 years of the donor age – also favors the young.

Perhaps. But here are four reasons not to worry if you are an older candidate on the kidney transplant waiting list, and perhaps even to be encouraged:

  • More Closely Matched Transplants: The proposed system will result in more transplants between closely matched donors and recipients. Under the current system it is estimated that 28.2% of transplants occur between closely age matched donors and recipients (defined as plus or minus 15 years). Under the proposed kidney allocation system, it is estimated that 40.5% of transplants would occur between closely age matched donors and recipients. Your new kidney will look more like you.
  • Not Everyone Needs a Fifty Year Warranty: The survival matching component of the system takes into account the fact that some candidates will need a kidney that could potentially function for decades, while others may not. The age matching component also recognizes that not every candidate on the waiting list requires a kidney with such a long term survival possibility. The proposed system provides a better opportunity for all candidates to achieve as much of a normal lifespan as possible.
  • Younger Candidates Will Be Less Likely To Be Crowded Out by Older Candidates: Older candidates make up an increasingly larger share of the waiting list and so are getting an increasing share of transplants. From 1990 to 2009 the percentage of all transplants received by persons ages 50 to 64 increased from 23% to 39%, and by persons over age 65 from 3% to 15%, mostly at the expense of younger candidates. During that same time the percentage of transplants going to person ages 18-34 decreased from 30% to 13%. These facts are among those that prompted a reexamination of the current allocation system.
  • Potentially More Donor Kidneys Will be Transplanted Under the Proposed System: Finally, if the kidney allocation concept is adopted, it is expected that more kidneys from extended criteria donors (ECD) and from donors over age 50 will be transplanted, rather than be discarded as many currently are, since these kidneys may be perfectly useful to older candidates, especially those over age 65.