April 19, 2014
In discarding of kidneys, system reveals its flaws
Last year, 4,720 people died while waiting for kidney transplants in the United States. And yet, as in each of the last five years, more than 2,600 kidneys were recovered from deceased donors and then discarded without being transplanted, government data show.

Those organs typically wound up in a research laboratory or medical waste incinerator.

In many instances, organs that seemed promising for transplant based on the age and health of the donor were discovered to have problems that made them not viable.

But many experts agree that a significant number of discarded kidneys, perhaps even half, some believe, could be transplanted if the system for allocating them better matched the right organ to the right recipient in the right amount of time.

The current process is made inefficient, they say, by an outdated computer matching program, stifling government oversight, the overreliance by doctors on inconclusive tests and even federal laws against age discrimination. The result is a system of medical rationing that arguably gives all candidates a fair shot at a transplant but that may not save as many lives as it could.

“There is no doubt that organs that can help somebody and have a survival benefit are being discarded every day,” said Dr. Dorry Segev, a transplant surgeon at Johns Hopkins University School of Medicine.

For 25 years, the wait list for deceased donor kidneys, which stood at 93,413 on Wednesday, has remained stubbornly rooted in a federal policy that amounts largely to first come first served. As designed by the government’s Organ Procurement and Transplantation Network, which is managed under federal contract by the nonprofit United Network for Organ Sharing, the system is considered simple and transparent. But many in the field argue that it wastes precious opportunities for transplants.

One recent computer simulation, by researchers with the Scientific Registry of Transplant Recipients, projected that a redesigned system could add 10,000 years of life from just one year of transplants.

Currently, the country is divided into 58 donation districts. When a deceased donor kidney becomes available, the transplant network’s rules dictate that it is first offered to the compatible candidate within the district who has waited the longest. Additional priority is given to children, to candidates whose blood chemistry makes them particularly difficult to match and to those who are particularly well matched to the donor. If no taker is found locally, the electronic search expands to the region and eventually goes national.

The kidney matching system does not, however, consider the projected life expectancy of the recipient or the urgency of the transplant. By contrast, the systems for allocating livers, hearts and lungs have been revised to weigh those factors.

As a result, kidneys that might function for decades can be routed to elderly patients with only a few years to live. And when older, lower-quality kidneys become available, candidates atop the list and their doctors can simply turn them down and wait for better organs. If that happens too often, doctors say, a kidney can develop a self-fulfilling reputation as an unwanted organ.

Complicating matters is a race against the clock that starts as soon as a kidney is recovered and placed on ice for evaluation. Because kidneys start to degrade during this “cold ischemic time,” surgeons typically hope to transplant them within 24 to 36 hours.

But that short window can be devoured by testing, searches for a recipient and long drives or flights to transport the kidney. The organ procurement organization in each district is allowed to make offers to only a few hospitals at a time, usually three to five, and the hospitals have an hour to respond.

Missed opportunities

It is not precisely clear how often kidneys are discarded that might be useful.

Last year 2,644 of the 14,784 kidneys recovered were discarded, or nearly 18 percent, according to the United Network for Organ Sharing. About one-fifth of those discarded kidneys, nearly 500, were not transplanted because a recipient could not be found.

But transplant statisticians say that record-keeping is imprecise. And some authorities, like Dr. Barry M. Straube, a nephrologist who served for six years as Medicare’s chief medical officer, and Dr. Robert J. Stratta, the director of transplantation at Wake Forest School of Medicine, speculate that as many as half of discarded kidneys could be transplanted.

“I think you could argue about how many missed opportunities there are,” said Dr. Alan B. Leichtman, a nephrologist at the University of Michigan. “But not that there are missed opportunities.”

They were turned down by five area hospitals, six Midwestern ones and then 37 others nationwide, before finally being accepted by a center on the East Coast, according to LifeSource, the organ procurement organization in St. Paul. Although testing showed the kidneys to be similar, one was transplanted, while the other was not.

The East Coast hospital declined to be identified or comment on the case. But Meg Rogers, LifeSource’s director of organ procurement, said the hospital reported that Ms. Kurash’s right kidney had “timed out” after spending at least 24 hours on ice.

“Unfortunately, once that kidney is recovered, time isn’t on our side,” Ms. Rogers said. “It sometimes takes all the stars aligning.”

More than half of discarded kidneys come from older donors like Ms. Kurash whose age and health problems may have made them marginal for transplant. But in 2011, nearly 1,000 discarded kidneys came from donors who were younger than 60, according to the organ sharing network.

Success at a cost

The number of kidneys discarded each year has grown 76 percent over the last decade, more than twice as fast as the increase in kidney recoveries. Clearly, revamping the allocation system would help shorten the wait list.

But given that the list has grown 30 percent in five years, transplant officials say that more must also be done to encourage people to register as donors, increase donor registration rates, remove financial and logistical obstacles and narrow extreme differences in wait list time among states.

There are any number of reasons a doctor might turn away a kidney. But there is growing concern that those decisions are made without good diagnostic tools and under pressure from regulators and insurers to maintain high transplant-success rates.

When a kidney is removed, doctors often biopsy a slice and connect the organ to a pump that measures blood flow for signs of scarring and hardening of the vessels. When kidneys are discarded, hospitals cite biopsy results more than any other reason. Yet studies suggest that biopsies do not always do a good job of predicting how long a transplanted organ might survive.

Another factor, doctors and organ procurement officials say, is federal scrutiny of transplant success rates.

In 2007, following revelations of lax government oversight of poorly performing transplant centers, the federal agency that manages Medicare, required that survival data for transplanted organs and recipients be made public. The figures are adjusted for relative risk factors and compared with expected survival rates.

The penalty for underperformance can be severe. If the number of failures exceeds expected levels by 50 percent, transplant programs are flagged, explained Thomas E. Hamilton, director of survey and certification for the federal Centers for Medicare and Medicaid Services. If it happens twice in 30 months, the program’s administrators are given a brief probationary period to improve, or convince regulators that there were other factors. Otherwise, the program is decertified.

Because Medicare is the primary insurer for kidney transplants, such a ruling can effectively close a transplant program. Commercial insurers also use the survival ratings to make decisions on contracts. (Source: The New York Times/NBC News)
Story Date: September 21, 2012
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