A Race Against Time

Organ donation and transplantation remains one of the most controversial topics in health policy, medical ethics, and healthcare in general. Yet, for patients with severely diseased organs, donation remains the most viable surgical solution. In this article, I will focus on kidney donation.

I chose kidney transplantation because of the drastic disparity in quality of life between patients who receive a donation and patients who do not. Patients with kidney disease and who opt out of a transplant generally remain on dialysis, visiting a center two to three times per week and spending four to five hours per visit to receive life-saving treatment. On the other hand, patients who receive a kidney donation have significantly improved health outcomes, given few surgical errors and long-term prescription medication.

You might ask, why doesn’t every patient with kidney disease opt for a transplant…

Did you know that it takes between 3 to 5 years for the average kidney patient to receive a transplant? Considering the significant mortality rate associated with dialysis, it is urgent that policymakers take a hard look at transplant policies.

Kidney donation is the preferred surgical treatment in four cases:

• Patients with ESKD (End Stage Kidney Disease) may experience a ten year lifetime increase through kidney transplantation. (1)

• Patients with later-stage CKD (Chronic Kidney Disease) might seek a transplant to improve kidney function before their condition worsens. (2)

• Some children and adolescents with CKD may be recommended to receive a transplant since surgical procedures are more effective in younger individuals.

• Patients with early-stage CKD and with other comorbidities or preexisting conditions might be encouraged to receive a transplant since kidney disease might pose additional risks. (3)

Below, I include a brief summary of kidney disease staging, reflecting the severity of disease from slightly impaired to end-stage. Patients generally develop ESKD overtime and with an early intervention, end-stage disease may be avoided.

To highlight the importance of this issue, let me put these two diseases into context: CKD affects roughly 37 million Americans or 1 in 7 US adults. (4) Additionally, ESKD affects roughly 810,000 Americans yet only 30% of those affected have received a transplant.

Those who are not provided a transplant must receive dialysis to maintain renal function. However, dialysis outcomes, while improving, are still generally poorer than that of the average individual. After one year of treatment, those on dialysis have a mortality rate of 15-20% and those receiving dialysis have a five year survival rate of less than 50%. (5) However, the list of individuals who need a kidney transplant in the US is rising by approximately 8% in the US and approximately 12 people die everyday waiting for a transplant. (6)

There are two types of kidney transplants: living donor transplants provided by a living individual and deceased donor transplants provided by a recently deceased individual.

From the graph above, you can tell that the vast, vast majority of kidney transplants performed are from deceased donors. (7) The graph reveals two important problems related to kidney transplantation: first, very few individuals in need of a kidney transplant actually receive one, and second, most transplants that occur are from deceased donors, yet the best health outcomes occur from living donor transplants. If a patient receives a kidney transplant from a live donor, they would need only one donated kidney to replace two natural diseased kidneys. On the other hand, if a patient receives a kidney transplant from a deceased donor, they would need both donated kidneys to restore function. (8) This essentially means that living donor transplants are twice as effective as deceased donor transplants. Below, I include a chart describing some of the benefits of living donor transplants as compared to deceased donor transplants.

Clearly, living donor transplants are superior, yet for some reason, our current transplant system is structured around providing patients with more available organs that may result in poorer long-term outcomes. Do patients know that deceased donor transplants may result in poorer outcomes? If so, perhaps they would wait longer to receive a healthier kidney instead of opting for the first one they find. Furthermore, if a patient is given no alternatives besides receiving the organ from a deceased individual, perhaps a family member with a matching kidney who was on the fence about donating would decide to donate if provided this information.

Like my previous article about Tuberculosis, I hope to conclude with a short multi-component intervention that may help solve this issue.

• The first step involves developing a tracking system to increase the speed at which potential donors are matched with patients seeking transplants. Approximately 3,600 or 30% of donated kidneys are wasted in the US every year. (9) Considering that between 40 and 50 thousand transplants occur every year, this loss in donated organs is very significant in terms of limiting patient access to improved outcomes. Thus, a network must be developed helping donation facilities track donated organs and quickly match them to patients seeking care.

• The second step involves increasing the kidney donation pool through research and by supporting potential donors on the fence. On average, individuals in the US must wait 5 years for a transplant; however, individuals with type O blood type have an average wait time of 10 years. (10, 11) By providing monetary support and heavily subsidized post-operative care to kidney donors, perhaps the number of live kidney donations will increase, improving patient outcomes. Furthermore, research is underway attempting to find new sources of kidney donors. Researchers have successfully implanted pig kidneys into human patients, restoring function and many in the field of regenerative medicine are identifying ways through which technology may restore proper function in previously diseased kidneys. (12)

Kidney transplantation is a vital solution for patients with severe kidney disease (specifically those with ESKD or CKD), significantly improving their quality of life and overall health outcomes. However, disparities in organ availability and patient outcomes highlight the urgency for comprehensive interventions, including better tracking systems to match donors with recipients and strategies to increase the pool of living kidney donors. These efforts are essential to bridge the gap between growing demand for kidney transplants and limited supply, enhancing patient longevity and improving health equity.