Deceased donor organ discards on weekends, in the the Annals of Transplantation

 Hospital resources and physician incentives can be stressed on weekends, and there is historical evidence that organ discards are higher on weekends.  Here's a study suggesting that is still a thing.

Yamamoto, T., A. Shah, M. Fruscione, S. Kimura, N. Elias, H. Yeh, T. Kawai, and J. F. Markmann.  Revisiting the "Weekend Effect" on Adult and Pediatric Liver and Kidney Offer Acceptance. Annals of Transplantation. 2022 Nov;27:e937825. DOI: 10.12659/aot.937825. PMID: 36329622.

"BACKGROUND: Weekends can impose resource and manpower constraints on hospitals. Studies using data from prior allocation schemas showed increased adult organ discards on weekends. We examined the impact of day of the week on adult and pediatric organ acceptance using contemporary data.

"MATERIAL AND METHODS: Retrospective analysis of UNOS-PTR match-run data of all offers for potential kidney and liver transplant from 1/1/2016 to 7/1/2021 were examined to study the rate at which initial offers were declined depending on day of the week. Risk factors for decline were also evaluated.

"RESULTS: Of the total initial adult/pediatric liver and kidney offers, the fewest offers occurred on Mondays and Sundays. The decline rate for adult/pediatric kidneys was highest on Saturdays and lowest on Tuesdays. The decline rate for adult livers was highest on Saturday and lowest on Wednesday. In contrast, the decline rate for pediatric livers was highest on Tuesdays and lowest on Wednesdays. Independent risk factors from multivariate analysis of the adult/pediatric kidney and liver decline rate were analyzed. The weekend offer remains an independent risk factor for adult kidney and liver offer declines, but for pediatric offers, these were not significant independent risk factors.

"CONCLUSIONS: Although allocation systems have changed, and the availability of kidneys and livers have increased in the USA over the past 5 years, the weekend effect remains significant for adult liver and kidney offers for declines. Interestingly, the weekend effect was not seen for pediatric liver and kidney offers.

Josh Morrison profiled in Vox

 Josh Morrison, the founder of WaitlistZero and 1DaySooner, is an unusually energetic and effective effective altruist.   

Here's a profile in Vox:

Josh Morrison took risks for science, and he thinks you can, too. From kidney donations to human challenge trials for Covid-19 vaccines, Josh Morrison shows the vast good any individual can do. By Muizz Akhtar

"Morrison first became familiar with this kind of direct public health participation when he read about kidney donations in the New Yorker when he was a law student in 2009. In the piece, people explained why they gave their kidneys to strangers in need — though there was slight risk to donors, the reward and benefit for the recipients was more than worth it. Two years later, he donated a kidney himself.

...

“The basic logic of my work in general is to try to use a sort of identity politics to get better political decision-making,” Morrison told me. “So with kidney donation, the theory is if kidney donors are more empowered in the political system as a sort of identity group, then the system will treat donors better and that will mean more people donate.”

HT: Frank McCormick

**********

I've mentioned Josh Morrison in many of my posts...

Reforming kidney care, by Drs. Ben Hippen and Thao Pascual.

 Ben Hippen is a transplant nephrologist who I encountered not too long after I started to think about kidney transplants. I've always found it enlightening to listen to him. And he's changed where he sits, most recently by taking a position with Fresenius, the big dialysis provider.

Here's a snippet of his professional history from his cv:

Current positions:

•Senior Vice President, Global Head of Transplant Medicine, Fresenius Medical Care. Sept 2021

•Clinical Professor of Internal Medicine, University of North Carolina, Chapel Hill School of Medicine. (Non-tenure track appointment) April 2015-present.

Past Positions:

•General and Transplant Nephrologist, Metrolina Nephrology Associates, P.A, Charlotte, North Carolina. 2005-2021

•Attending General and Transplant Nephrologist, Transplant Center, Carolinas Medical Center, Charlotte, North Carolina. 2005 - 2021

•Medical Director, FKC Baxter Street Hemodialysis Unit (in-center and home therapies).2009-2021.

Here are some of his current thoughts, with his colleague Dr. Pascual, in Medpage Today on how to advance kidney care and transplantation.

The Kidney Transplant Ecosystem Is Ripe for Reform— Here are the policies and payment systems that need to change  by Benjamin Hippen, MD, and Thao Pascual, MD

"A centralized data repository of patients' clinical evaluations, laboratory, and radiologic testing accessible by multiple transplant centers could reduce the time, expense, and waste of redundant or obsolete testing.

...

"Quality outcomes for transplant programs should be pegged to the patient outcome that really matters: Receiving a successful kidney transplant in the shortest period of time. A recent survey of patients with kidney disease regarding tradeoffs between being transplanted earlier and waiting for a "better organ" confirms that a wide majority of patients prioritize being transplanted sooner. "Transplant soon and well" should be the mantra for regulators and policy makers when considering nephrologist and dialysis provider-facing metrics to achieve the right outcomes for patients. 

...

"several reforms can be made to the transplant ecosystem to make it easier for transplant centers to be more aggressive in their organ acceptance behaviors. Changing the organ offer system to use the approach of "simultaneously expiring offers" can streamline organ placement timelines, placing higher-risk organs with more risk-tolerant centers more quickly and efficiently. Aligned with the goal of getting patients to transplant faster, regulators and payors (public and private) should prioritize shortening time to transplant over sky-high 1-year patient and graft survival thresholds. The lowest performing third of transplant centers are conferring longer and better survival rates to patients compared to any maintenance dialysis therapy. We should seek to remove regulatory and financial barriers to transplant centers seeking to safely make use of every gift of life. If we expect transplant centers to transplant higher-risk organs, we should recognize that it may cost more to perform those transplants successfully. The payment system for transplants should account for these higher costs so that transplant centers are not faced with losing money when transplanting higher-risk organs.

"A key component of the kidney transplant ecosystem is the generosity of living donors, and we should do more to support their decision to give the gift of life. This means protecting living donors from insurer efforts to exclude them from life or disability insurance coverage because of their donation. In addition, enhancing education efforts to increase living donor kidney transplants can help bridge the gap between organ need and supply. One pending solution to these challenges is the passage of the Living Donor Protection Act (H.R.1255/S.377). The bill would prohibit discrimination by insurers based on an individual's status as a living organ donor. Employers can also do their part through adjusting their paid leave policies for employees who become living donors, by joining the AST Living Donor Circle of Excellence."

"Benjamin Hippen, MD, is senior vice president and head of transplant medicine and emerging capabilities at Fresenius Medical Care. Thao Pascual, MD, is associate chief medical officer at U.S. Renal Care. They are both members of Kidney Care Partners."

********

As a long time, thoughtful  observer of kidney care and transplantation, Dr Hippen's point of view has shifted over time. Below are some (much) earlier blog posts featuring some of his earlier thoughts.

Wednesday, March 16, 2011

How not to assign kidneys

Saturday, April 9, 2011

Should there be a donor kidney market? Latest version of a familiar debate

Sunday, July 26, 2015

Ben Hippen on the economics of transplantation and dialysis

Three living kidney donors talk about their experience

 Tonight at 6pm Eastern, three donor stories from the National Kidney Donation Organization (NKDO)

Click Here to Register

Kidney news from Cambridge on possibility of removing blood type barriers

 Here's some very preliminary kidney news (a press release) in The Guardian and at Cambridge, that could have the potential to have an impact sooner rather than later in helping potential transplant recipients with blood type O, who can only receive blood type O kidneys (which can be received by patients of any blood type)...  

Researchers change blood type of kidney in transplant breakthrough University of Cambridge team’s work could significantly increase supply of organs for people with rarer blood types

"University of Cambridge researchers used a normothermic perfusion machine – a device that connects with a human kidney to pass oxygenated blood through the organ to better preserve it for future use – to flush blood infused with an enzyme through the deceased donor’s kidney.

"The enzyme removed the blood type markers that line the blood vessels of the kidney, which led to the organ being converted to type O."

*******

https://www.cam.ac.uk/stories/kidneybloodtype

The scientists mentioned are Professor Michael  Nicholson and PhD student Serena MacMillan .

Patient preferences for taking an offered kidney versus waiting for a better one

 Here's a paper whose title announces in its first two words that it's unusual for the transplant literature: "Patient Preferences."   It sensibly asks about preferences for a transplant now versus a long future wait.  That's relevant, because the waiting list for a kidney is often years long.

Patient Preferences for Waiting Time and Kidney Quality, by Sanjay Mehrotra, Juan Marcos Gonzalez, Karolina Schantz, Jui-Chen Yang, John J. Friedewald and Richard Knight, CJASN Aug 2022, CJN.01480222; DOI: 10.2215/CJN.01480222

Visual Abstract

Abstract

"Background and objectives Approximately 20% of deceased donor kidneys are discarded each year in the United States. Some of these kidneys could benefit patients who are waitlisted. Understanding patient preferences regarding accepting marginal-quality kidneys could help more of the currently discarded kidneys be transplanted.

Design, setting, participants, & measurements This study uses a discrete choice experiment that presents a deceased donor kidney to patients who are waiting for, or have received, a kidney transplant. The choices involve trade-offs between accepting a kidney today or a future kidney. The options were designed experimentally to quantify the relative importance of kidney quality (expected graft survival and level of kidney function) and waiting time. Choices were analyzed using a random-parameters logit model and latent-class analysis.

Results In total, 605 participants completed the discrete choice experiment. Respondents made trade-offs between kidney quality and waiting time. The average respondent would accept a kidney today, with 6.5 years of expected graft survival (95% confidence interval, 5.9 to 7.0), to avoid waiting 2 additional years for a kidney, with 11 years of expected graft survival. Three patient-preference classes were identified. Class 1 was averse to additional waiting time, but still responsive to improvements in kidney quality. Class 2 was less willing to accept increases in waiting time for improvements in kidney quality. Class 3 was willing to accept increases in waiting time even for small improvements in kidney quality. Relative to class 1, respondents in class 3 were likely to be age ≤61 years and to be waitlisted before starting dialysis, and respondents in class 2 were more likely to be older, Black, not have a college degree, and have lower Karnofsky performance status.

Conclusions Participants preferred accepting a lower-quality kidney in return for shorter waiting time, particularly those who were older and had lower functional status."

HT: Martha Gershun

Gary Becker's last paper: appropriately, on a monetary market for kidneys (with Julio Elias and Karen Ye, JEBO, 2022)

 Gary Becker, who passed away in 2014, has a new paper, finished by his coauthors Julio Elias and Karen Ye. It recounts how the shortage of transplantable kidneys has only increased as the demand has grown, and the argument for paying donors is as strong as ever.  (In the meantime, the obstacles to that approach haven't vanished.)

The shortage of kidneys for transplant: Altruism, exchanges, opt in vs. opt out, and the market for kidneys*  by Gary S.Becker, Julio Jorge Elias, and Karen J.Ye, Journal of Economic Behavior & Organization, Volume 202, October 2022, Pages 211-226 (Another link to the paper is here, temporarily.)

Abstract: "In 2007 we published a paper on organ transplants that used data from 1990–2005. We proposed a radical solution of paying individuals to donate kidneys, and claimed that this would clean out the waiting list for kidney transplants in a short period of time. In this paper, we revisit the topic, and examine 14 years of additional data to see if anything fundamental has changed. We show that the main altruistic based policies implemented, such as kidney exchanges or opt out systems for organ procurement, have been unable to solve the problem of shortages. Our analysis suggests that, because of the reaction of direct living donors to increases in other sources of donations, the supply curve of kidney transplants is highly inelastic to altruistic policies. In contrast, a market in organs would eliminate organ shortages and thereby eliminate thousands of needless deaths."

Here's the most relevant part of the first footnote:

*"We started working on this paper together with Gary Becker in 2011. In 2012, we presented the paper at the Law and Economics Workshop and the MacLean Center's Seminar Series of the University of Chicago. The paper was unfinished when Becker passed away in May 2014. In this version of the paper, we updated the data and made some additions. The paper preserves all the economic analysis that was developed in the last version that we collaborated with Becker.

"Becker wrote his first article about the organ shortage in 1997, as part of his monthly BusinessWeek Column. The article was entitled How Uncle Sam Could Ease the Organ Shortage. In the article, he “suggest(s) considering the purchase of organs only because other modifications to the present system so far have been grossly inadequate to end the shortage.”

"In the 2000s, Julio Elias collaborated with Becker in a paper that uses the economic approach to analyze the consequences of legalizing the purchase and sale of kidneys for transplants from both deceased and living donors. In 2014, Becker published with Julio Elias a column in the Saturday Essay section of the Wall Street Journal entitled Cash for Kidneys: The Case for a Market for Organs. For Becker, the problem of the organ shortage and finding ways to solve it was a lifelong project. This paper reflects some of his last thoughts on this problem."

Here are their conclusions:

"The current state of the market of kidney transplants is a disaster. Over the last years, the waiting list has grown in over 4000 individuals each year, while transplants have grown by only about 250 per year. The result has been longer and longer queues to receive organs. 4000 patients died each year while waiting 3 and a half years on average for a transplant. According to our estimations, the annual social cost of those who die while waiting for kidney transplants is over $7 billion.

"Neither kidney exchange programs nor opt out systems nor educational campaigns to increase donations from altruistic donors have solved the problem of shortages. The main reason for their mild effects, as we show in this paper, is that the altruistic supply curve of kidney transplants is highly inelastic to these type of policies because of the reaction of direct living donors to increases in other sources of donations.

"The only feasible way to eliminate the large queues in the market for kidney transplants is by significantly increasing the supply of kidneys. The introduction of monetary incentives could increase the supply of organs sufficiently to eliminate the large queues and thereby eliminate thousands of needless deaths, and it would do so without increasing the total cost of kidney transplant surgery by a large percent.

"A market for the purchase and selling of organs would appear strange at first. However, much as the voluntary military today has universal support, the selling of organs would come to be accepted over time. " advantages of accepting payment for organs would eventually become clear, and people will wonder why it took so long for such an ovious and sensible remedy to the organ shortage to be implemented.

***********

Some related earlier posts:

Another take on compensating donors:

Tuesday, August 16, 2022

Kim Krawiec interviews Frank McCormick on the kidney shortage (and how to end it)

Commentary on the  legal monetary market for kidneys in Iran (and how it differs from illegal black markets):

Monday, June 27, 2022

A Forum on Kidneys for Sale in Iran, in Transplant International

The Pontifical Academy of Science says that compensating donors is a crime against humanity:

Friday, February 17, 2017

Vatican statement on organ transplantation

All my posts on compensation for donors (not just kidney donors) are here.

And here's my 2007 paper on repugnance (that came out in the same issue of JEP as the Becker and Elias paper), and was a first attempt at understanding some of the obstacles that face proposals to compensate donors of kidneys (and other things):

• Roth, Alvin E. "Repugnance as a Constraint on Markets", Journal of Economic Perspectives, 21:3, Summer, 2007, pp. 37-58.

I'm slowly writing a book that will expand on it.

Returning to your place in the queue following a failed kidney transplant

 Here's a forthcoming paper that proposes that rejections of marginal kidneys could be reduced if recipients were guaranteed a shorter waiting time for a subsequent transplant if a marginal kidney that they accepted failed.

Tunç, Sait, Burhaneddin Sandıkçı, and Bekir Tanrıöver. "A Simple Incentive Mechanism to Alleviate the Burden of Organ Wastage in Transplantation." Management Science (2022).

Abstract: Despite efforts to increase the supply of donated organs for transplantation, organ shortages persist. We study the problem of organ wastage in a queueing-theoretic framework. We establish that self-interested individuals set their utilization levels more conservatively in equilibrium than the socially efficient level. To reduce the resulting gap, we offer an incentive mechanism that recompenses candidates returning to the waitlist for retransplantation, who have accepted a predefined set of organs, for giving up their position in the waitlist and show that it increases the equilibrium utilization of organs whilealso improving social welfare. Furthermore, the degree of improvement increases monotonically with the level of this nonmonetary compensation provided by the mechanism. In practice, this mechanism can be implemented by preserving some fraction of the waiting time previously accumulated by returning candidates. A detailed numerical study for the U.S. renal transplant system suggests that such an incentive helps significantly reduce the kidney discard rate (baseline: 17.4%). Depending on the strength of the population’s response to the mechanism, the discard rate can be as low as 6.2% (strong response), 12.4%(moderate response), or 15.1% (weak response), which translates to 1,630, 724, or 338 more  transplants per year, respectively. Although the average quality of transplanted kidneys deteriorates slightly, the resulting graft survival one-year post transplant remains stable around 94.8% versus 95.0% for the baseline. We find that the optimal Kidney Donor Profile Index score cutoff, defining the set of incentivized kidneys, is around 85%, which coincides with the generally accepted definition of marginal kidneys in the medical community."

Kim Krawiec interviews Frank McCormick on the kidney shortage (and how to end it)

Here is Kim Krawiec's latest podcast (click on this link to listen, not the picture below...:): 

Taboo Trades 

AUGUST 06, 2022 KIM KRAWIEC

Taboo Trades

Bonus Episode: Ending the Kidney Shortage with Frank McCormick

00:00|44:40

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Frank McCormick is an economist and the author of numerous articles focused on the shortage of kidneys for transplantation. He is retired from the Bank of America where he was Vice-president and Director of U.S. Economic and Financial Research. Today, we’re discussing his recent article, Projecting the Economic Impact of Compensating Living Kidney Donors in the United States: Cost-Benefit Analysis Demonstrates Substantial Patient and Societal Gains, co-authored with Philip J. Held, Glenn Chertow, Thomas G. Peters, and John P. Roberts. It is published in the journal, Value in Health and is available here: https://www.sciencedirect.com/science/article/pii/S109830152201957X/

*************

In an email to his extensive mailing list, McCormick writes:

If you don’t have 45 minutes to spare, the key points I have to make are:

1. The death toll due to the shortage of transplant kidneys is much greater than is generally realized.  The Health Resources and Services Administration (HRSA) misleads everyone by saying only 19 people a day die waiting for a transplant organ -- because it counts only patients who die while on the waiting lists (for kidneys alone that number is about 13 deaths per day).

But HRSA does not count:

A. Patients who are removed from the wait list because their health has become so poor they may not survive a transplant operation (or for other reasons) who soon die;

B. Patients who are never placed on the waiting list to begin with, but who could be saved from a premature death by transplantation if there were no kidney shortage.

Adding the latter two groups raises the death toll due to the kidney shortage to more than 110 deaths per day (40,000 per year).

 2. This appalling death toll due to the kidney shortage could be completely ended if the government compensates kidney donors about $77,000 per donor (with a wide range of uncertainty surrounding that estimate).  But even if the required compensation is two or three times this amount, it would be trivial compared to:

A. The value of a longer and healthier life to a kidney recipient (and their caregiver), which my co-authors and I estimate at about $1.5 million.

B. The savings (mainly to taxpayers) from the kidney recipient not needing expensive dialysis therapy, which we estimate at about $1.2 million per recipient.

In the long run, this program of government compensation of kidney donors would not cost taxpayers anything; rather it would save them about $7 billion per year.

 References:

1. McCormick F, Held PJ, Chertow GM.  The Terrible Toll of the Kidney Shortage.   J Am Soc Nephrol 2018;29:2775-2776. https://jasn.asnjournals.org/content/jnephrol/29/12/2775.full.pdf.

 2. McCormick F, Held PJ, Chertow GM, Peters TG, Roberts JP.  Perspectives: Projecting the Economic Impact of Compensating Living Kidney Donors in the United States: Cost-Benefit Analysis Demonstrates Substantial Patient and Societal Gains.  Value in Health, online 9 June 2022.  https://doi.org/10.1016/j.jval.2022.04.1732.