Virginia Postrel on the new allocation rules for deceased donor kidneys

Virginia Postrel is skeptical about the new rules for allocating deceased donor kidneys, and thinks there is likely to be some good news (about slower-growing waiting lists) that will just be an artifact of removing some incentives to get on the list early.

Old, Sick and Need a Kidney? Good Luck

"Within a few years, new rules about allocating kidneys, which went into effect last week, could shrink the waiting list. But this apparent improvement will be an illusion -- an artifact of the incentives the new rules create, not genuine progress. Changing who gets priority for scarce kidneys will help some patients and hurt others, and it might squeeze out a few more total years of healthy living for the lucky recipients. But a different process for managing the existing supply of kidneys won’t make a serious difference for the skyrocketing number of patients who need transplants.

In the past, how long you’d been on the waiting list was the main factor that determined how close you were to getting a compatible kidney. (Some blood types are harder to match than others, so someone with less compatible type O blood would wait longer than someone with type A.) The longer you waited, the further you moved up the list. The clock started when your transplant center did the necessary tests and listed you as a transplant candidate.

The old system hurt those patients, most of whom were black, who had spent years on dialysis before they got referred for transplants, whether because of medical factors, insufficient health insurance or complacent nephrologists. (About a third of the patients, about 35,000 people, currently on the waiting list are black.) The new system instead starts the clock when a patient goes on dialysis.

“In the previous system, it would make sense to list somebody even if they weren’t quite ready to get a transplant, so they could accrue waiting time,” Benjamin E. Hippen, a transplant nephrologist at Carolinas Medical Center in Charlotte, North Carolina, explained in an interview. Now, since they won’t have a shot at a kidney for years, there’s no reason to put them on the waiting list so soon. “It’s going to look like the overall list has shrunk,” he predicted, “when really it’s just a strategic move by the transplant center.”

While arguably fairer, counting dialysis years creates much more uncertainty. Every time a new patient is added, that person’s dialysis history rejiggers the list. It’s like waiting for an airline upgrade: If you’re a lowly gold status member, you may start out at the head of the line, only to end up in coach as platinum and executive platinum travelers put in their requests and push you down the queue. In this case, there’s a lot more at stake than more legroom and better meals."

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“The people who lose in all this are going to be the people who are a little older, who are diabetic and who don’t have a lot of years of waiting time -- which is most patients,” said Hippen, a critic of the new system. “That sort of describes the average new patient.”