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:
- 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.
- 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.
- 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.
- Rather than add financial incentives for living donors, simply remove disincentives (which still exist), increase education of recipients, and grow kidney paired exchange.
- Proponents of financial incentives have not proposed specific payment schemes.
- 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:
- The waitlist is growing, and inactive patients are a small portion of the overall gap.
- 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.
- 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.
- 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.
- 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.
- 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