Supply, Demand & Kidney Transplants

By Satel, Sally | Policy Review, August-September 2007 | Go to article overview

Supply, Demand & Kidney Transplants


Satel, Sally, Policy Review


IN MAY 2002, Clois Guthrie, an 85-year-old retired osteopathic surgeon, got the phone call he was waiting for: A suitable kidney had just become available for him. A renal transplant would mean liberation from the dialysis machine to which he had been tethered for two miserable years. Elated, Guthrie and his wife raced to the Porter Adventist Medical Center from their home in North Denver one hundred miles away. (1) Yet mere hours before the operation was to take place, the center's transplant surgeons were engaged in anguished deliberation over whether Guthrie was actually the right person to get that kidney. He was, after all, 85 years old. How much longer would he live with a new kidney? Shouldn't the organ, taken from a healthy 30-year-old motorcyclist who had died from head trauma, be given to a younger person who would get many more years of life from it?

The doctors decided to proceed, but in the end, there was a technical glitch and the operation did not take place. Guthrie went back on dialysis. Two-and-a-half years later he was dead of a heart attack at age 88. The ethical dilemma sparked by his case, however, did not die with him. Indeed, the question of "how old is too old for a transplant?" is being asked with increasing urgency by transplant professionals as the chasm between supply and demand widens inexorably.

Uneasy questions of allocation arise in environments of scarcity. Who will get to stay on the crowded lifeboat and who will be tossed overboard? This age-old tension between utility to society--the maximum good for the maximum number--and fairness to the individual is notoriously hard to resolve. In the case of the shortage of transplantable kidneys, it is made gratuitously more difficult by a "transplant community" that resists experimenting with bold ideas to increase the supply.

Dire shortage, modest remedies

ORGAN TRANSPLANTATION IS one of the crowning achievements of medical science. Yet from 1954--the year of the first renal transplant--to the present, there have never been enough organs to meet demand. The dearth includes all transplantable organs--hearts, livers, lungs, pancreases--but because dialysis can keep patients with renal failure alive, the shortage of kidneys is most acute in terms of volume. Indeed, over three-quarters of the national wait-list population comprises those waiting for a kidney.

In January 2007, roughly 70,000 people were waiting for a kidney, according to the United Network for Organ Sharing (UNOS), which maintains the national registry of transplant candidates under monopoly contract with the Department of Health and Human Services. In big cities, where the ratio of needy patients to available organs is highest, the wait for a kidney ranges from five to eight years. This time is spent undergoing dialysis, a procedure that circulates the patient's blood through a machine (once called an "artificial kidney") that purifies it, siphons off accumulated water, and returns it to the body. Patients typically visit a dialysis center for treatment three times a week, for four hours each time. Many patients are deeply ambivalent about dialysis. They acknowledge its life-preserving role yet resent it as a vast intrusion into daily life that is often uncomfortable and debilitating.

Commitment to dialysis ends when a patient receives a transplant or dies. In 2006, only 17,804 people--or about one-quarter of the population waiting at the beginning of the year--received kidneys. Meanwhile, over 3,813 died waiting and 1,190 became too sick to transplant. It is a grim picture that is guaranteed to worsen. By 2010, the median waiting time is projected to be at least ten years long, extending well beyond the length of time that most adults, especially those over 65, are able to survive on dialysis.

Despite decades of public education about the virtues of donating organs at death, the supply of cadaver organs has remained disappointingly steady over the years. …

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