The president recently signed a groundbreaking executive order that could make more kidney transplants available to patients suffering from kidney disease.
Known as the “Advancing American Kidney Health Initiative,” it promises to address some of the toughest issues within kidney care and provides support for a growing method of donation that has the potential to turn one lucky match into dozens—known as living donor chains.
The concept of living donor chains began in the 1980s as an outgrowth of the more traditional paired-exchange method. Living donor chains extend the paired exchanges to a larger number of unrelated people. With this approach, a hospital or multiple hospitals can match multiple pairs to one another, creating a chain of transplants that can touch many more lives. In fact, the longest kidney transplant chain in the nation surpassed 100 donations in 2018 at The University of Alabama at Birmingham.
More than 113,000 men, women and children were on the national organ transplant waiting list as of January, according to the U.S. Department of Health and Human Services. The lack of available donors and the difficult task of finding the right match means that thousands of Americans are left waiting for their chance at life. Advancements in transplant science and logistical coordination of the living donor chain have helped increase the donor pool.
We hope to see this pool expand even further with the president’s initiative, which calls for expanding support for living donors with compensation for expenses like childcare and lost wages that are incurred due to donating. There is more support today for living donor chains, yet many hospitals have not yet embraced this method for facilitating this life-saving process.
I’ve experienced the benefits of living donor chains first-hand as a transplant surgeon at Banner–University Medicine Transplant Institute. In 2007, our team participated in one of the first living donor transplant chains.
It started with a single altruistic donor, someone who was willing to donate a kidney to anyone in need. Usually, these kidneys are given to whoever is next on the waiting list; thus, only one person gets transplanted. Working with Dr. Michael Rees from the Alliance for Paired Kidney Donation, we set up a chain of living donor transplants among previously incompatible pairs. Since the chain started with an altruistic donor, the transplants did not have to be simultaneous.
After one donor’s loved one received a transplant, that donor’s kidney went to the next pair. In this situation, if a donor backs out, the chain is interrupted; however, no one donates without their loved one receiving a kidney. Fortunately, donors rarely back out. With this one altruistic donor, 10 transplants were performed over an eight-month period in six different transplant centers across the country.
Living donor chains save lives and improve the quality of life for those who otherwise would be on hemodialysis or worse. Beyond that, there are many other benefits for health systems that expand the scope of their transplant effort to include living donor chains.
Patients suffering end-stage renal disease represent only about 1 percent of the U.S. Medicare population, but the cost of their hemodialysis is so great that they use up 7 percent of the country’s Medicare budget, according to the National Institutes of Health. That’s a particularly alarming statistic, especially given how long many patients must remain on dialysis while they await a kidney. The dialysis costs an annual average of $89,000 per patient in the United States. By contrast, the one-time cost of transplant surgery averages $32,000, plus $25,000 in post-operative care, and eliminates the ongoing financial and personal burden of expensive dialysis.
Coordinating and performing living donor chains is actually more cost-effective and less complicated for hospitals than performing multiple paired exchanges. This is because living donor chains do not require the transplants to occur simultaneously. With paired exchanges, the transplant surgeries must take place at the same time to avoid one donor withdrawing and leaving the other pair without a kidney. Paired exchanges require multiple surgeons, staff, rooms and other extensive resources all at once. With a living donor chain, donors are not required to make their donations at the same time, which frees up the hospital resources and also allows smaller hospitals to participate.
Transplanting live organs will always be preferable to organs from the deceased, mainly because they will last much longer. And living donor chains increase the number of quality live organs available to patients who need them. Additionally, this approach improves the rate of matching donors with recipients.
Living donor chains are an exceptional approach to organ donations.
Hospitals large and small can get involved in this system and even work across state lines to make chains successful. The United Network for Organ Sharing (UNOS), as well as the Alliance for Paired Kidney Donation can be contacted to enlist patients interested in participating. Due to the large number of pairs registered with these programs, there is a good chance of finding a match for your patients. Physicians and hospitals should consider taking part in this process and determine whether it is the right fit for your organization and your patients.
Alfredo Fabrega, M.D., FACS has been a transplant surgeon for over 25 years. He is the director for the Kidney and Pancreas Transplant Programs at Banner - University Transplant Institute in Phoenix, Arizona.