The kidney supply chain

The Minneapolis Star Tribune has given its health reporter Josephine Marcotty unusual scope to write about kidney transplantation in a multi-part series on kidney failure, treatment, and transplantation, and she has done them proud.

Part 1: 'Survival of the savviest' explored the challenges of being on dialysis, waiting for a deceased donor, and looking for a live one.

"But the two supply systems -- living and deceased -- remain radically different. Organs from deceased donors are viewed as a public asset -- like national parks -- and their allocation is highly regulated for fairness and transparency. There are disparities in who earns a spot on the deceased donation list, but they are generally viewed as a consequence of inequities in the overall health care system. A living donation, on the other hand, is a private gift from one person to another. Except for a federal law that makes selling organs a felony, there is no oversight and no support for living donation by the government or the transplant community. As a consequence, finding a living donor is often a matter of wealth, social advantage -- or pure luck."

Part 2: Balancing life and death looks at the process by which willing live kidney donors are accepted or rejected, a process that involves both whether their kidney is compatible with their intended recipient, and their own health. The story says that the first undirected living donor was accepted in Minnesota. More generally,

"Competition between transplant centers is fierce. Minnesota, for example, has four hospitals that compete for kidney patients and organs. If one transplant center changes its standards, sooner or later the others often follow. One reason is that everyone, except perhaps the living donor, benefits. Patients fare better because kidneys from living people tend to be better quality than those from the deceased. The doctors have more control over the complex surgeries. Hospitals, for their part, make more money. Medicare pays an average of $106,000 for a transplant, regardless of whether the kidney comes from a living or deceased donor. And living donor transplants generally cost less -- about 15 to 20 percent less at the university hospital, for example. That means the hospital stands to make 15 to 20 percent more per surgery."... "Nevertheless, taking a kidney from a living person presents daunting ethical questions. In the early days of transplant medicine, things were simpler. Only genetically related relatives were accepted as donors. But family dynamics are complex; doctors and hospital social workers sometimes had to find ways to say "no'' on behalf of reluctant relatives who couldn't find the courage to say no themselves. "There's much more coercion in families than outside of families," said Dr. Stephen Textor, a kidney specialist at the Mayo Clinic. In other cases, saying no was next to impossible. "The people who really pushed it? Spouses," Garvey said. "You have your husband sitting in front of you, dying. They were telling us, 'Who are you to tell me I can't be a donor?' They were right." "

Kidney failure, Part 3: A revolution: trading donors is the installment that first caught my eye, as it deals with kidney exchange. Marcotty reports on what must have been some long interviews with Mike Rees, the surgeon responsible for many of the most important innovations in kidney exchange.
The article begins with this subheadline:
"Kidney exchanges use the oldest economic model of all - trade. Computer matching can start a chain of transplants, but the idea has a long way to go."

I even make a cameo appearance in her story, where I often am, on the phone:
"Then in December 2006, Rees spent an hour-and-a-half on the phone with Alvin Roth, a Harvard economist who specializes in matching theory.
Roth has devised many matching programs, including the national system that fits medical students with specialty training centers.
He also studies what has been jokingly described as "ick-onomics" -- the economics of repugnance. For instance, most people abhor the idea of selling human body parts for transplant. But trade? That doesn't usually trigger the same kind of visceral reaction, he said."

Marcotty describes how Rees initiated the first non-simultaneous chain, through the words of the altruistic donor, Matt Jones, who started it off.

"It began with Matt Jones, a 30-year-old father of five who worked for Enterprise car rental in Petoskey, Mich. He was determined to give his kidney to anyone who needed it.
His first attempt to donate fell apart when the patient unexpectedly got a kidney from the deceased list. But after putting time and money into travel and testing, and persuading his fiancé at the time that it was a good idea, he wasn't about to give up. He called Rees.
"He tells me, 'I have this idea of doing a chain,'" Jones said in an interview. "'It's never been done. There are some people who think I'm crazy.'
"I said, 'Sounds like a great idea.' "

(Mike spends a lot of time on the phone too:)

(Here's my earlier post about that first non-simultaneous chain.)

Marcotty continues the story of non-simultaneous chains: "In March, Rees described his chain in a New England Journal of Medicine article titled "A nonsimultaneous, extended, altruistic-donor chain.... The number of transplants from swaps and chains is growing exponentially. In July, an eight-way multi-hospital series of transplants was conducted in four states over three weeks. In March, a series of six transplants was conducted at three hospitals around New York in 36 hours.
In Boston last spring, kidney exchanges were one of the hottest topics at the American Transplant Congress, a major international conference. Hundreds of surgeons, nurses and social workers absorbed PowerPoint slides that illustrated intricate webs of matches by race, age, medical condition, genetics and blood type. Instead of presentations on anti-rejection drugs, they learned about software programs."

Part 4: The ethics of kidney donation: Two views

The two views are pro and con on whether compensation for donors would improve the supply of donor kidneys, or whether this is too repugnant to contemplate. The pro position is taken by Dr. Arthur Matas, an eminent surgeon and former president of the American Transplant Society. His bottom line:

"It is immoral to stand by and watch patients die when we have the means to save them. A regulated system of compensation for donation has the potential of saving lives, shortening the waiting list and improving transplant outcomes. A regulated system protects the interests of donors. Unless Congress lifts the ban against compensation and allows pilot programs, we are guaranteed more needless death and suffering."

The con position is taken by Jeffrey Kahn, a bioethicist. His bottom line:

"Organ donation has always relied on the altruism of donors and their loved ones, with the hope that any risk for the patient is balanced by the benefit of the good deed. But most people have a price at which they might ignore whatever qualms they have about donation and become willing sellers. That changes the relationship -- from giving a gift to being paid enough to ignore the risk.
A market allows this shift, and it is a change we should be loath to accept."