Is Living Kidney Donation Threatened by a New Allocation Concept?

By Doug Penrod, RN, Transplant Nurse Coordinator

The first successful living donor (LD) kidney transplant occurred in 1954. A majority of kidney transplants until the 1970s were LD transplants, until brain death laws were enacted in all states, allowing for more successful recovery of deceased donor (DD) organs. The introduction of the anti-rejection drug cyclosporine in 1983 further shifted the use of LD downward, as DD transplants became more successful and the waiting time was minimal by today's standards. As the demand for DD kidneys grew in the late 1980s and 90s, the waiting time became years, rather than months, and subsequently LD kidney transplants increased. This was facilitated by the introduction of minimally invasive surgery to perform the LD nephrectomy, making it more attractive to potential donors. In 1988, only 20% of all kidney transplants were from LD versus 42% in 2004. Since their peak in 2004, the numbers of LD transplants has declined and some speculate the past and current economic climate could be a part of the reason for the decline. LD kidney transplants still have the best patient and graft survival rates of any type of transplant.

Impact of a New Kidney Allocation System on Live Donation

The revised kidney allocation concept document recently released for public comment has created some discussion about the potential effects on living donation. Some have cited the “Share 35” pediatric initiative, as the cause of the subsequent decline in LD transplants in pediatric candidates, which gave children absolute priority and survival matching on the DD list. They postulate the same thing would happen under the proposed allocation concept for adults. The June 2009 report from the Organ Procurement and Transplantation Network/United Network for Organ Sharing (OPTN/UNOS) Pediatric Transplantation Committee to the Board of Directors discussed the observed decline in living kidney donations to kids and concluded that "It is unlikely that the absolute source of the decrease in pediatric kidney patients receiving living donor transplants will be completely sorted out. It is likely a combination of the overall decrease in living donation throughout the country and all the tangible and intangible aspects of ‘Share 35.’”

It was further noted that trends of LD kidney transplants in kids seemed to vary by age group and region. OPTN/UNOS has 11 transplant regions in the country and only Region 7, comprising 22 active kidney transplant centers in Illinois, Wisconsin, Minnesota, North and South Dakota, have performed more LD kidney transplants than DD transplants since 2001 by over 400 transplants. The new allocation concept does not address geography at all. Nor does it promise to eliminate waiting time or significantly shorten the wait for the majority of patients on the list.

LD transplantation is the one sure way a patient can avoid having to start dialysis or to shorten their time on dialysis. The new allocation concept would also have little to no impact on the OPTN/UNOS Kidney Paired Donation (KPD) Pilot programs, which are now entering their first full year in operation with over 80 transplant centers signed up. The purpose of the program is to facilitate live donation by matching incompatible donor/recipient pairs with other pairs who have the same problem of blood type and/ or cross match incompatibility. The KPD program is hoping to produce a net increase in kidney transplants after it becomes a true national program.

It does not appear the kidney allocation system concept, as currently presented, would have any significant impact on LD transplantation. What is more concerning is the lack of sustained growth in DD transplants and the decline in LD transplants. Neither helps, regardless of the allocation system.

Editor’s Note:
Doug was a non–directed living kidney donor in a 4–way domino kidney paired donation in 2008.