Course Authors
Eli A. Friedman, M.D.
Dr. Friedman has received grant/research support from Alteon within the past three years.
Estimated course time: 1 hour(s).
Albert Einstein College of Medicine – Montefiore Medical Center designates this enduring material activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
In support of improving patient care, this activity has been planned and implemented by Albert Einstein College of Medicine-Montefiore Medical Center and InterMDnet. Albert Einstein College of Medicine – Montefiore Medical Center is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Upon completion of this Cyberounds®, you should be able to:
Describe the reality of cadaver donor organ shortage
Balance the need for rationing of health care services among the ethical concerns in contemporary practice of nephrology
List the differing professional views on criteria for allocation of a scarce life-sustaining resource such as cadaver donor kidneys.
As observed by Hirsch et al., virtually no reports describe current practice in selecting patients for dialysis in ESRD, especially for those with a poor prognosis.(1) Whether based on psychosocial problems,(2) or advanced age,(3) exclusion from ESRD therapy is a decision that induces anxiety in the medical team and, frequently, death in the individual who is not selected.
Jacobs, reviewing acceptance for ESRD treatment in France, calls an "age-based patient selection unfounded,"(4) citing a cohort of 213 peritoneal dialysis-treated elderly patients (mean age 79 years) who had a three-year survival rate of 45%. Sesso et al.,(5) reviewing acceptance practice in Brazil, found that a substantive number of patients were not admitted to dialysis programs because of advanced age (over 79 years) and renal diagnosis (congenital diseases, chronic pyelonephritis). In Canada, a survey mailed to 1,779 family practitioners and internists stimulated 728 replies. These responses indicated that rationing of dialysis resulting from non-referral of individuals anticipated to have a "short life expectancy" resulted in exclusion of the elderly and those with "excessive comorbidity."(6)
Given the reality that rationing of ESRD treatment is unavoidable, both inclusion and exclusion criteria must be defined. Presently, the wait for a cadaver donor kidney transplant is approximately three years. Consequently, a substantive number of dialysis patients who desire a renal transplant are likely to die before receiving an allograft. Furthermore, as the mean age of new ESRD patients rises progressively, so does the severity of their extrarenal comorbidity. Therefore, both age and concurrent extrarenal disease loom as potential rationing criteria. Variables considered as possible qualifications for kidney transplant allocation include: age, gender, race, citizenship, religion, wealth, political importance, personal behavior, medical diagnoses and value to society. Transplant teams will face difficult choices. As an example, should a patient with past noncompliance with a medical regimen be considered favorably for a renal transplant?(7)
Cyberounds® survey on attitudes towards distribution of organs for kidney transplantation was conducted through the Web in the summer and early fall of 1997. It generated unique and provocative information. Clearly, the attempt to conduct an ethical medical practice under the stress of rationing is distressing. Interpretation of the survey results demands appreciation of its limitations:
- The number of data points (answers) is small.
- The phrasing of questions may have elicited biased answers.
- Participants who replied may be an atypical subset of the total membership.
Results of Kidney Allocation Survey
Who Responded
A total of 35 people answered the questionnaire, of whom there were eleven nephrologists, six internists, four medical students and two surgeons. 43% of the responders were academicians, 20% were private practitioners and 17% were government based. A majority of the sample has been in practice for more than ten years, while almost a quarter of the respondents have practiced for more than 20 years. 57% were American, 11% Brazilian and 11% European.
Accelerated Transplantation
Cyberounds® participants strongly favored priority allocation of cadaver kidneys to children over adults (71%). But neither the Pope nor the U.S. President were viewed as deserving of a kidney ahead of others by the majority of respondents. In general, a strong majority (74%) disagreed with the statement that value to society was an acceptable modifying factor.
Denied a Kidney Transplant
Undesirable personal habits were grounds for denial of a kidney transplant according to the majority who advocated the exclusion of substance abusers (68%), prisoners (54%), cigarette smokers (51%) and the obese (51%). Most felt that illegal aliens should not be given a cadaver kidney (58%) but nonresident aliens should share the donor pool (51%). Nearly two-thirds of the sample believe that failure of a kidney transplant should not be viewed as sufficient reason to deny a subsequent transplant even though its anticipated duration of function will be reduced.
Acceptable Ranking Criteria
Most respondents supported current practice in organ distribution. Duration of waiting time (80%), HLA typing (66%) and age (74%) were criteria endorsed by the majority.
Regulation of Allocation System
A surprising percentage of respondents (40%) supported government controlled markets in organ sales, while a smaller minority (26%) approved an individual's right to sell a kidney or purchase a "foreign" kidney (23%). There was marginal (31%) support for compensation to the family of a cadaver kidney donor.
No Simple Solution
Respondents did not favor a "first come first served" policy (20%) or empowering the patient's physician to decide (29%). More than half (54%) of those who replied were dissatisfied with policies now in place for cadaver organ transplants.
Comments
Based on my daily immersion in the arena of determining options in uremia therapy, I have developed an interest in exploring low cost alternative treatments(sorbents, diarrhea, genetically engineered bacteria) for those economically unable to obtain dialysis and/or renal transplantation. For those able to pay for a kidney transplant but who lack an intrafamilial (or emotionally related) donor the only resource is a cadaver donor kidney. I have gradually come to the admittedly minority opinion that an acceptable approach to increasing the number of kidney transplants is a structured program of organ sale and purchase. This survey does not support my position. What the survey does provide, however, is further stimulus for a dialogue on the subject. In that context, I have appended some of the comments I received and invite any reader to participate in the discussion to the left.
Cyberounds Members Comments
"It's a mess at present. It's a mess in Ireland and England- though perhaps not quite as much of a mess as you describe for the USA. My own view is that age is not an unfair criterion for transplant- but that it shouldn't be absolute. Perhaps some kind of lottery could be devised- where peoples age- and waiting time on the list would be taken into account. After the Humana affair in London I am convinced that only an absolute ban on selling organs- whether from cadavers or living donors will work. I would favour continent wide selection programs- like Eurotransplant- but with teeth. Thank you for setting up this survey."
"Survey should allow for a third category - "undecided" or "in some circumstances." I have experience of a colleague who has done very well on his third cadaveric renal transplant. Some of the yes / no answers are not simply amenable to dichotomous responses."
"Unfair question. Popes are generally old and frail persons; your Presidents -- on the contrary-- are usually young and apparently healthy people... Popes -- although deserving them -- would not tolerate tx very well -- and most likely would turn it down anyway if they knew they were about to "bypass" someone else."
"I guess illegal aliens need more than a transplant -- they need, of course, follow-up medications. All this is impossible to obtain without legal situation in the country. At least for me the most important considerations to have opportunity to receive a renal transplant are: higher degree of compatibility; minimum titers in PRA; longer periods of waitings in list; minimum possibility to obtain another donor and exclude contraindications(age isn't a contraindication)."
"The primary rationing system in the United States is via the dollar. This seems cold and unfair. But in a capitalistic society the citizens "vote" with their dollars. If an individual is of more value in society's view -- they will raise the money. We tend to prefer a "wise" committee made up of medical people and other hand chosen intellectuals. Sounds a little like the communist party to me. On the other hand -- I feel that children are the ultimate investment in our society's future and they should receive preferential treatment on this basis."
"We have a provincially mandated organ retrieval and donation program. As for our policies -- there is clearly queue jumping -- but it is not reported on -- with rare exceptions. There need to be studies including persons aged 70+ -- and continuing for 10 years -- indicating the rates of complications from transplantation- dialysis- and the natural history of renal failure managed conservatively. Measurement of complications must include function- mood- and cognition of the patient- burden of illness on family and family members' employers (excluding health plan costs)."
"Due to increased survival, HLA matching should be the main priority for organ allocation- other (softer) criteria should be age- need to raise family (e.g., single parent)- and medical compliance (drug abuse- smoking- compliance with medications-etc.). I should like to ask a question. In the US does an insured patient get the transplant ahead of a non-insured one? In for-profit hospitals who gets the tranplant first? Please reply to: Jose Suassuna (jsuassuna@ax.apc.org) Division of Nephrology- Pedro Ernesto University Hospital Rio de Janeiro State University- Brazilkas."
"Some of the questions were worded negatively and difficult to answer (e.g., repeat transplants or yes we have no bananas). Age as legit allocation criteria - when people answer this question- to what age are they referring? Thank you for the survey, opportunity and the article."
"Current allocation system is open and fair. It has been established after much public debate. All UNOS allocation policies are formulated by active participation from many sources. The disparity seen in the current system is primarily a one of economics. This disparity of access is found in not only organ transplantation- but in all areas of health care. Organ transplants by their very nature- have undergone much closer scrutiny than any other area, e.g., open heart surgery. A wealthy individual is able to "game" the system by being listed in multiple centers, etc. This may not be fair but is a current reality in all areas of health care. The actual allocation of organs is performed by the organ procurement agency and not the transplant centers. When making a specific organ offer- a specific recipient is identified for that organ- the organ procurement staff have no control over selecting certain individuals. The allocation method is completed by a very set method of point allocation that is frequently debated in public forums and open to amendment by the UNOS policy development system."