Should age determine who gets a kidney transplant?
Controversial proposal would put younger patients higher on waiting list
By Judith Graham
Chicago Tribune staff reporter
February 9, 2007
If someone needs a kidney transplant today, it doesn't matter if she's 25 or 60 years old. What counts is how long she has spent waiting for a suitable organ to become available.
That would change under a controversial new proposal by the nation's organ transplant network that was unveiled Thursday in Dallas. The plan would give kidneys to patients who would live longest after a transplant, not those who have languished longest on waiting lists.
The goal is to make sure organs go to patients who can get the most benefit from a kidney transplant, extending more peoples' lives. But experts worry that older patients would be far less likely to get transplants if the plan is adopted.
"The thought is, if one person can live 15 years after a kidney transplant and another person can live five years, the organ should go to the person who lives the longest," said Dolph Chianchiano, vice president of health policy for the National Kidney Foundation.
The change would apply only to kidneys from deceased donors; organs from living donors wouldn't be affected.
The proposal, which may be altered and would not take effect until December at the earliest, comes from the Organ Procurement and Transplantation Network, which oversees all transplants in the U.S., and the agency that runs it, the United Network for Organ Sharing.
It would assess the benefit of a kidney transplant by estimating "extra years lived"--how long a patient with failing kidneys might expect to survive after a transplant versus how long the same patient might live on dialysis treatment.
Under this system, younger patients who haven't suffered the effects of age and attendant medical deterioration would be favored over patients in their 50s and above. Chances for a transplant also would get worse for older people with Type 2 diabetes, an increasingly common cause of kidney failure and source of medical complications such as hypertension and heart disease.
The change strikes some transplant experts and patients as unfair and potentially dangerous.
"How do you tell a 55-year-old: Too bad, you're too old, you're not getting a kidney because your life expectancy isn't that of a 35-year-old?" said Dr. Michael Abecassis, chief of organ transplantation at Northwestern's Feinberg School of Medicine. "How's the AARP going to react to that?"
"I don't have problems with trying to maximize this valuable resource--kidneys--which are in such short supply today," said Jack Fassnacht, 51, a Chicago lawyer with polycystic kidney disease who has had two transplants. "But I don't like the idea of suggesting the life of a 30-something has more value than the life of a 50-something. That just doesn't seem fair to me."
The change risks undermining public trust in the nation's transplant system, which depends on a reputation for treating all people equally and impartially, Abecassis said. If trust is compromised, fewer people may be willing to donate organs, aggravating a widening mismatch between demand for kidneys and supply.
But the current system for distributing kidneys has problems too. People with the most urgent medical needs often are not at the top of waiting lists. Increasingly, those spots are occupied by elderly individuals with underlying medical conditions such as heart disease or hypertension, who may not survive long under any circumstances.
That raises the prospect of a 75-year-old getting called by his hospital--we've found a match!--and rushing to receive a kidney from a 28-year-old killed in an auto accident. If the man lives only three more years, some wonder if that is a good use of the organ, especially when kidneys are in such short supply and the waiting lists so long.
Inequalities also occur in the current system because the supply of kidneys, the demand for organs and the availability of medical services vary by location, said Dr. Michael Shapiro, chief of transplantation at Hackensack University Medical Center in New Jersey.
For instance, the wait for a kidney is about 8 to 10 years in New York City but only 2 years in Albany, N.Y., Shapiro said. Waits in Chicago have reached about 5 years, according to several surgeons.
Data released at the Dallas meeting suggest transplant patients in the U.S. would live an extra 11,457 years under the new allocation scheme because more people would receive kidneys that would last longer.
"I think there are advantages to this approach. . . . Now that [this number] is on the table, it's hard for me to go back and say we shouldn't try to achieve this," said Dr. Mark Stegall, chief of transplantation surgery at the Mayo Clinic.
Stegall headed the study group that prepared the proposal for the Organ Procurement and Transplantation Network, which has government authority to oversee transplants.
He emphasized that the proposal hadn't been finalized. Preliminary plans call for several more meetings this year and a public comment period after a formal proposal is issued.
"Many of us feel there has not been enough discussion along the way in the development of this proposal and would like to see a much more robust public debate," said Dr. J. Richard Thistlethwaite, a transplant surgeon and professor at the University of Chicago. "People don't understand the implications of what's being suggested."
Thistlethwaite said he is uncomfortable with the value judgments he believes are inherent in the proposed system, particularly the emphasis on duration of life over quality of life. "How can we judge who's more deserving and whose life we value the most?" he said. "Where do we draw the line?"
It's a question also being asked by Norma Knowles, 38, a kidney recipient who lives in Columbia, Mo. Knowles, a social worker who works in a dialysis center, has polycystic kidney disease, as do her father and brother and as did her late uncle.
Eight years after a cousin donated a kidney to Knowles, it failed. Knowles went back on the transplant waiting list in July. To survive, this mother of four children administers dialysis to herself for three hours every night.
"Who's to say an older person's five years of life are any less important than a younger person's nine years?" she said. "The length of time doesn't necessarily determine what's best, and we have no right to judge. That's playing God and people aren't going to like it."
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jegraham@tribune.com
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