American Journal of Transplantation 2014; 14: 22042205

Wiley Periodicals Inc.

Editorial

Copyright 2014 The American Society of Transplantation

and the American Society of Transplant Surgeons
doi: 10.1111/ajt.12865

Whose Kidney Is It Anyway? The Complexities of

Sharing Deceased Donor Kidneys
K. A. Andreoni1,2,* and R. N. Formica Jr.3,4
1

Department of Surgery, University of Florida, Gainesville,

FL
2
United Network of Organ Sharing, Richmond, VA
3
Yale University, New Haven, CT
4
OPTN/UNOS Kidney Transplantation Committee,
Richmond, VA

Corresponding author: Kenneth A. Andreoni,
kandreoni@ufl.edu

Received 05 May 2014, revised 27 May 2014 and

accepted for publication 06 June 2014

Disparities in Access to Kidney Transplantation Between

Donor Services Areas in Texas by Lewis et al is a clarion call
for wider geographic sharing of donated kidneys in this
country (1). The arbitrary boundaries of donor service areas
(DSAs) are the impediment to equitable access for patients
and Texas, although not unique, is a case study in how
gerrymandering DSAs to serve individual transplant center
agendas results in disenfranchisement of patients. However,
eliminating geographic disparity is more than erasing
DSAs boundaries, and while we agree with the sentiment
expressed by the authors, we disagree that the solution is to
consolidate the organ procurement organizations (OPOs)
existing within a states borders into one. Fixing the
geographic disparity that exists in kidney transplantation
requires doing what is in the best interest of patients and
understanding how the transplant profession must justify
the trust society places in it for the stewardship of a precious
national resource.
Were the solution to the problem as easy as keeping
kidneys within the states that they are recovered, our work
would be done. However, defining, much less fixing,
geographic disparity is more complex. The root of the
problem is defining what is local. Is it alternative
allocation units (ALUs), DSAs, individual states or a larger
district? All of these definitions are currently in use. The
lament of the authors over the loss of the opportunity to
acquire an ALU for their center is exemplary of the mindset
that believes further subdivision of DSAs into smaller
components will solve the problem of inequitable access to
kidney transplantation.
2204

It is reasonable to question what is the best way to

distribute organs, over smaller more local areas or larger
areas that ignore DSA, state and regional boundaries? We
argue for the latter. While superficially an ALU appears to
improve access to transplantation for the patients it serves,
it does so at the expense of others. With no ALU in place, all
patients on a DSA waiting list (or any larger geographic area
list) will have the same waiting time as a similar patient in
that DSA. Admittedly, individual transplant centers may
receive more or less kidneys, however, this is a center
concern and not a patient problem. In order to address the
problem of disparity in access to kidney transplantation the
profession must reject the self-interest that drives transplant centers to lobby for policies that serve only to protect
their financial plans.
The authors express doubt that the new kidney allocation
system (KAS) (2) will improve geographic disparity. This
remains to be seen. The new KAS is not perfect but it does
represent the result of 10 years of formulation, analysis and
compromise. It is true that wider sharing of high kidney
donor profile index (KDPI) kidneys (>0.85) will not completely
eliminate disparity. However, it is also true that the shortage
of donated organs compared to the number of waitlisted
candidates is the number one challenge faced. Therefore,
the first step to improve disparity is to maximize the
recovery and transplantation of available kidneys. Across
DSAs, the use of expanded criteria donor (ECD) kidneys
ranges from 3% to 25% and that of donation after cardiac
death kidneys from 1% to 35% (3). This heterogeneity in
utilization is why regional sharing of high (KDPI) kidneys was
added to the allocation system (2). Prior to mandating
sharing of organs over larger geographic areas, it is
necessary and a political reality that the recovery of currently
available kidneys must be maximized. The intent of the KAS
is to incentivize OPOs to recover high KDPI kidneys by
providing more rapid access to centers that will use them.
With increased utilization of high KDPI kidneys outcome
pressures from the Organ Procurement and Transplantation Network and the Centers for Medicare & Medicaid
Services cannot be ignored. Policy cannot on the one hand
encourage the use of higher risk kidneys and on the other
hand penalize programs for not achieving the current
standard of outcomes obtained by avoiding the higher risk
organs and candidates. Policy must allow transplant
centers to pair appropriate recipients with donor organs
without undo fear of running afoul of regulatory agencies.

Editorial

Broader sharing without thoughtful allocation details could

result in a system that is less efficient and regulations must
be changed to avoid being a disincentive to organ use.
After the implementation of the KAS, the larger questions
of what defines allocation equality can begin to be
addressed. However, preliminary work done by the United
Network of Organ Sharing Kidney Transplantation Committee suggests this will be a complicated task. For example,
will the average time to transplant or average offers per
patient suffice as a definition? Will equity be achieved by
having similar KDPI organ offer rates to patients with similar
Estimated Post Transplant Survival (EPTS)? Will use of
living donor organs be taken into account? Should there be a
correction for center acceptance practices? Will it be
dictated exactly which kidney a patient must accept in order
to make the national system result in perfectly fair
outcomes? A true national allocation system is easy to
aspire to but difficult to achieve. It will only be achieved
through an iterative process that develops national
consensus, and the details will make the difference.
Disparities in access to kidney transplantation exist and the
current arbitrary patchwork of DSAs is a primary cause. The
new KAS will not completely eliminate these disparities;
however, it does make meaningful first steps; national
sharing for highly sensitized patients and regional sharing
for high KDPI (ECD) kidneys serves as a test to evaluate the
logistics of wider sharing. The elimination of paybacks for
shared kidneys establishes that donated organs are a
national resource and the dissolution of variances and

American Journal of Transplantation 2014; 14: 22042205

ALUs, moves the discussion to wider geographic sharing.

Most importantly the new KAS was designed to include
allocation principles the community is comfortable with and
to be easily overlaid on future larger geographic areas with
minimal modification. With the implementation of the new
KAS the arbitrary nature of kidney allocation in this country
will be undone, local fiefdoms dismantled and a new
baseline established. With a new benchmark to compare
to, the work of eliminating disparity in access to kidney
transplantation through wider geographic sharing can
begin.

Disclosure
The authors of this manuscript have no conflicts of interest
to disclose as described by the American Journal of
Transplantation.

References
1. Lewis RM, Sankar A, Pittman J. Disparities in access to kidney
transplantation between donor service areas in Texas. Am J
Transplant 2014; 14: 23032309.
2. Proposal to substantially revise the national kidney allocation
system. Available at: http://optn.transplant.hrsa.gov/PublicComment/pubcommentPropSub_311.pdf. Accessed May 5, 2014.
3. Israini AK, Zaun D, Rosendale JD, Snyder JJ, Kasiske BL. OPTN/
SRTR2012 annual report: Deceased organ donation. Am J
Transplant 2013; 14: 167183. Available at: http://onlinelibrary.
wiley.com/doi/10.1111/ajt.12585/pdf. Accessed May 5, 2014.

2205