These patients receive an average of 16 donation offers, but transplant teams reject many of them, states the study published on August 30 in JAMA Network Open.
The researchers reviewed a list of 280,041 patients on an organ wait list and found those who died while waiting for a kidney had received an average of 16 offers of kidneys over 651 days. Those who had successful transplants received an average of 17 offers over 422 days.
Concern about failure rates may cause transplant teams to reject organs that could save patients’ lives, says John Dale Dunn, an emergency physician in Brownwood, Texas and a policy advisor to The Heartland Institute, which publishes Health Care News.
“The transplant teams are rejecting kidneys that were possibly injured at death or in the final illness, or maybe the organs were from donors who were unhealthy,” said Dunn. “The motive for transplant teams is they don’t want to go on the list of bad transplant teams with unacceptable failure rates. As long as transplant teams are under the gun, there won’t be any loosening of acceptance levels for donor kidneys. The downside is too much to ignore.”
The physicians’ incentives are not aligned with those of their patients, says Alex Tabarrok, director of the Center for Study of Public Choice.
“Physicians may want perfect organs to keep up their track record of successful transplants,” Tabarrok said. “Physicians look bad when transplants do not go well, but not when a patient is removed from the transplant list while under their care. Patients are more concerned with getting off the waiting list. With the waiting list for transplants long and lengthening, we should use more of the organs that are available and not make the perfect the enemy of the good.”
Patients should have more of a voice in the process, says Paul Conway, chair of policy and global affairs for the American Association of Kidney Patients.
“Transparency around discarded organs is badly needed,” said Conway. “We need to know why so many donated kidneys are going to waste.”
The study authors note an additional reason why rejected organs deserves scrutiny.
“This study suggests that a large number of deceased donor kidney offers are received by candidates but are declined on their behalf, resulting in what appears to be many missed opportunities for a transplant before death or removal from the waiting list,” the article states.
In July, the Trump administration issued an executive order on end-stage kidney care which called for, among other things, “modernizing” the kidney donation process and creating incentives for organ donation in order to allow patients to end dialysis. The executive order also called for greater transparency throughout the donation process.
Conway says the president’s order should increase patients’ input into the decisions.
“A patient who is dying of kidney failure may, understandably, be willing to accept a higher-risk kidney than their transplant team will allow, and the patient’s voice should be respected,” said Conway.
Ashley Herzog ([email protected]) writes from Avon Lake, Ohio.
S. Ali Husain, Kristen L. King, and Stephen Pastan, “Association Between Declined Offers of Deceased Donor Kidney Allograft and Outcomes in Kidney Transplant Candidates,” JAMA Network Open, August 30, 2019: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2749266