Since the first successful kidney transplant in 1954, outcomes have improved dramatically for patients who undergo the often life-saving procedure. Today, kidneys are the most commonly and reliably transplanted organs, representing the best option for people with end-stage renal failure brought on by diabetes, uncontrolled hypertension, and many other causes. However, advances in kidney transplantation have come with a price.
“We’re victims of our own success,” said Mark Siegler, MD, Director of the MacLean Center for Medical Ethics. “Organ transplantation has become so effective and so relatively safe and beneficial, that more and more people, appropriately, want to be recipients and want to have their lives saved. But we have a fairly flat line of donors.”
Close to 100,000 Americans are currently on waiting lists for transplant kidneys, a number that has almost doubled since 2000. At the same time, the number of kidneys available has stagnated, which has contributed to increasing wait-list mortality. Last year, only 14,000 transplants took place in the US. The majority of these–roughly two-thirds–came from deceased organ donors, while the rest are from from living donors, often relatives or friends of the patient.
Speaking on a panel at the American Association for the Advancement of Science (AAAS) annual meeting in Chicago, held from Feb. 13-17, Siegler laid out the framework for a potentially provocative solution to this shortage crisis.
“Or proposal is to substantially increase the amount of living donors. In fact, to make living donors the preferential choice in organ donation,” said Siegler.A physician and medical ethicist, Siegler addressed key questions regarding his proposal. The growing gap between waiting list and available organs cannot be solved without living donors, he argued, because the potential supply is far, far greater than the potential supply of deceased donors. “The potential number of living donors is essentially unlimited,” Siegler said. In addition, organs from living donors are of far better quality and have longer survival post-transplantation.
But is it ethical to use living kidney donors, and to encourage and promote such action? For Siegler, the answer is a clear yes. He reaffirmed the need for physicians to be vigilant of safety risks to donors, which he argues are statistically small, and for support systems such as strong health insurance to be in place.
“The living operation operation has been done more than a quarter of a million times, in 40 countries around the world, and none of those countries has prohibited or made illegal the use of living donors,” Siegler said. “That large number and the fact that every country accepts it is reasonable evidence that the world and ethics community regard it as ethical.”
To increase the supply of living kidney donors, Siegler gave six suggestions:
- The bioethics community needs to make it clear that living kidney donation is ethical.
- Government policies should make living kidney donation the preferred and encouraged route.
- Expansion of donor chains, by which donors can exchange recipients with other donors.
- Expansion of marketing campaigns encouraging living donation.
- Standards of informed consent should be maintained at the highest level.
- And lastly, and perhaps most controversial, he recommended that financial incentives, or decreasing financial disincentives, be considered.
Siegler said such incentives could include a potential regulated market for kidneys, help with job security and coverage for donation-related expenses. “Increasing the supply of kidneys for transplantation is an effort that would save lives, improve quality of lives, and that we therefore regard as an ethical imperative,” he said.
Other speakers on the panel included Michael Abecassis, MD, chief of the transplant program at Northwestern University, who gave an overview of the current issues facing organ allocation; John Friedewald, MD, a transplant nephrologist from Northwestern University, discussed proposed changes in kidney allocation developed during his recent term as chair of the United Network for Organ Sharing Kidney Transplantation Committee; Nobel laureate and Stanford University economist Alvin Roth, PhD, discussed the evolution of innovative solutions to the organ shortage, including the use of mathematical models to optimize kidney paired donation and the impact of increasing the number of kidney transplants from living donors; and Sanjay Mehrotra, PhD, of Northwestern University, discussed how use of evidence-based modeling to develop organizational changes in the organ transplant system could save hundreds of lives annually.