Oversimplification and Misplaced Blame Will Not Solve the Complex Kidney Underutilization Problem

Abstract

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Beyond donation to organ utilization in the USA

“…The migration of organ allocation policies to the continuous distribution framework [44] provides an opportunity to tune the system towards efficiency by prioritizing candidates and hospitals most likely to accept hard-to-place organs [45]. Advanced approaches to developing continuous distribution systems, such as goal-driven optimization [46 ▪ ], and bold policy ideas for combating organ nonusage [9,47 ▪▪ ,48], should continue to be explored. To avoid organ nonuse, an increasing number of OPOs deviate from the prescribed patient sequence by expediting placement to specific centres [49,50]: such practices could be codified into continuous distribution policy to improve organ utilization, standardizing a process that currently varies markedly across OPOs.…”

“…Although these trends are encouraging for patients in need, more recovered organs only benefit patients if they are actually accepted and utilized for transplant. Nonutilization of kidneys recovered for transplant is not primarily due to shipping failures, organ damage or other mishaps subsequent to acceptance; rather, most are simply not accepted by any transplant hospital [8,9]. High offer refusal rates have been implicated in hampering utilization of livers, hearts and lungs as well, with dire consequences for waitlisted patients [10][11][12][13][14].…”

Renal transplantation: the last iteration of the rest of the world

“…Despite major steps to transform allocation, United States renal allocation is still far from its last iteration. As Stewart et al states in a recent summary of the state of US renal allocation, ‘major changes to organ allocation do not come easy’, and for good reason [21 ▪▪ ]. When the currency we are dealing in is patient lives, the cost of making risky bets on new and innovative allocation schemes could be steep.…”

“…Examples of such potential improvements include implementing an ‘equal opportunity allocation supplemented by fair innings’ to address equity and ‘dealing from the bottom of the deck’ to expedite allocation to likely accepting candidates and transplant centers as opposed to the ‘first come first served’ approach in current allocation [17,21 ▪▪ ]. The ‘first come first served’ strategy approaches equity by placing candidates with very long wait times at the top of the list.…”

“…The ‘first come first served’ strategy approaches equity by placing candidates with very long wait times at the top of the list. Proposed alternatives advocate for reconsidering how waiting time is used to prioritize patients and instead, ‘get the right kidney to the right person at the right time’, however, that is defined [21 ▪▪ ].…”