Paying Kidney Donors — Necessary or Not?

There is a great shortage of transplantable kidneys based on the number of transplant candidates awaiting organs in the United States. Some thought leaders have proposed financial incentives for living donors as a means to overcoming this supply and demand mismatch. Recently published in AJKD, Martin and White challenge the idea that the supply and demand mismatch in US organ transplantation can be improved by incentivizing living donation. Although not considering the ethical principles of financial incentives, they suggest that other interventions to optimize the current system may fix the perceived problem. Subsequently published, a paper by Hippen challenges their suggestions. What results from these opposing views is an illustrative point-by-point discussion of organ procurement and transplantation policy. The major points of both papers are summarized below.

Drs. Martin and White argue against financial incentives:

  1. Martin and White contend that the organ shortage gap is real, but not as large as perceived based upon the number of patients listed as inactive.
  2. Many patients with ESRD who have not been referred for transplantation are unlikely to later be placed on the waitlist due to persistent unaddressed barriers, such as financial disincentives at the dialysis facility level, inadequate education, and poverty.
  3. Reducing discarded kidneys and increasing the use of high KDPI kidneys (donors with a kidney donor profile index > 85%) and DCD (donated after cardiac death) kidneys may reduce the organ shortage.
  4. Rather than add financial incentives for living donors, simply remove disincentives (which still exist), increase education of recipients, and grow kidney paired exchange.
  5. Proponents of financial incentives have not proposed specific payment schemes.
  6. Financial incentives are unlikely to significantly increase the number of living donors, and may actually hurt the already stressed altruistic donation system for both living and deceased donation.

Dr. Hippen argues for financial incentives:

  1. The waitlist is growing, and inactive patients are a small portion of the overall gap.
  2. The new kidney allocation system no longer incentivizes adding inactive patients to the wait list. In addition, transplant centers may not even list patients who are unlikely to be transplanted in the near future.
  3. There are many patients who would benefit from a transplant who are still not being referred to a transplant center. Thus, there is even a larger need for kidneys than appreciated.
  4. Dialysis facilities are not at fault for reduced access to transplantation. Federal guidelines require dialysis centers to educate patients about transplantation, and profit margins for dialysis facilities are actually quite small and likely to continue falling.
  5. Not all discarded kidneys can or should be used based on outcomes and the regulatory climate in the US. High KDPI and DCD kidneys are at higher risk of failure, and with the current regulatory and financial burdens in the U.S., transplant centers are cautious to risk lower than expected outcomes. Based on studies published in Europe, results using the same number of DCD kidneys in the US could lead to regulatory review and program closure.
  6. Although there have been many meetings and discussions on increasing available organs via altruistic donation, there has not been any substantial growth. Therefore, a trial on financial incentives is warranted.

As a practicing transplant nephrologist, organ procurement and transplant policy is of utmost importance to me. In region 9 of the US, the waiting time for a kidney transplant can be upwards of 5 years, and the reality is many patients who cannot find a living donor will never make it to transplantation. Our region imports greater than 50% of our kidneys (abstract 1348), and we are not reluctant to use DCD or high KDPI kidneys despite regulatory burden. Therefore, I must agree with Dr. Hippen that there is a substantial shortage of organs, and this gap seems to be growing. That being said, Martin and White offer important considerations. Optimization of our current system will help, but is unlikely to solve our current crises. I invite you to decide whether financial incentives can reduce the burden of organ shortage based on these two well-written papers.

Vinay Nair, DO
AJKD Blog Advisory Board Member


4 Comments on Paying Kidney Donors — Necessary or Not?

  1. We have an epedemic in the USA== a shortage of kidneys! With the new Kidney Allocation system…It has been detrimental to those over 50+years and those who have been waiting for a kidney on the transplant list for a long time. Those under 35 yrs and on dialysis a short time are favored to receive a deceased donor transplant.

    The goal is to try to have a kidney last longer and UNOS has determined that those who are younger are the best candidates.
    So those who have been waiting for a kidney the longest are no longer near the top of the list they have plummeted down the list. This age discrimination.
    Those over 50+years best chance at having a kidney transplant is through a living donor. A financial incentive ($2000) plus medical and transportation expenses covered may increase donors. even if it is $5000… it will say medicare so much money keeping the patients on dialysis.
    Please pass on to others.

    Please consider speaking out by making comments so this new system can be changed…Go to page

  2. From Dr. Vinay Nair:

    Thank you for your comment. I would like to make a few clarifications.

    Although the new allocation system has changed the demographics of who is being transplanted, it is not based on age per se. Essentially there are two new scores, the EPTS (estimated post transplant survival) and KDPI (kidney donor profile index), that range from 1-100. The KAS attempts to allocate kidneys with KDPI < 20 to patients with EPTS < 20 – or longevity matching. Though age does play a role it is not the only factor in calculating a candidates EPTS. See a brief review of the KAS on a prior post: This leaves 80% of patients unaffected by longevity matching. In addition not all kidneys with a KDPI < 20 are being allocated to patients with EPTS < 20. There are publicly available reports which give detailed data on the demographics of patients transplanted both before and after the new kidney allocation system started (see Based on the most recent report, there was a decrease in transplants to patients age 50-64. However, if you compare September 2014 to May 2015, the reduction in this age group was only from 41.5% to 39.4% of all transplants. In addition, I do not know of any data suggesting that patients under the age of 50 are being transplanted faster after the allocation change.

    All being said I agree that living donor kidney transplantation is the best option for patients over the age of 50, but its also the best option for those under the age of 50.

  3. Maria Collins // October 26, 2015 at 8:08 pm // Reply

    I think this is a very good idea to compensate for kidney donors! They will get more donors if paid & transportation is also great!

  4. ok this is just the start, under the cover of this emotional and justifiable reason but later on we will force the poorer to donate or may be we will open the borders for Mexicans to settle and sell their kidneys, from my point of view, this is opening the door of hell, and organ trafficking.

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