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Under kidney transplant proposal, younger patients would get the best organs

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Washington Post Staff Writer
Wednesday, February 23, 2011; 11:04 PM

The nation's organ-transplant network is considering giving younger, healthier people preference over older, sicker patients for the best kidneys.

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Instead of giving priority primarily to patients who have been on the waiting list longest, the new rules would match recipients and organs to a greater extent based on factors such as age and health to try to maximize the number of years provided by each kidney - the most sought-after organ for transplants.

"We're trying to best utilize the gift of the donated organ," said Kenneth Andreoni, an associate professor of surgery at Ohio State University who chairs the committee that is reviewing the system for the United Network for Organ Sharing (UNOS), a Richmond-based private nonprofit group contracted by the federal government to coordinate organ allocation. "It's an effort to get the most out of a scarce resource."

The ethically fraught potential changes, which would be part of the most comprehensive overhaul of the system in 25 years, are being welcomed by some bioethicists, transplant surgeons and patient representatives as a step toward improving kidney distribution. But some worry that the changes could inadvertently skew the pool of available organs by altering the pattern of people making living donations. Some also complain that the new system would unfairly penalize middle-aged and elderly patients at a time when the overall population is getting older.

"The best kidneys are from young adults under age 35 years. Nobody over the age of 50 will ever see one of those," said Lainie Friedman Ross, a University of Chicago bioethicist and physician. "There are a lot of people in their 50s and 60s who, with a properly functioning kidney, could have 20 or more years of life. We're making it harder for them to get a kidney that will function for that length of time. It's age discrimination."

More than 110,000 Americans are listed as waiting for organs, including more than 87,000 who need kidneys. Only about 17,000 Americans get kidneys each year, and more than 4,600 die because they did not get one in time.

"It's a big shift," said Arthur C. Caplan, a University of Pennsylvania bioethicist. "For a long time, the whole program has been oriented toward waiting-list time. This is moving it away from a save-the-sickest strategy to trying to get a greater yield in terms of years of life saved."

If adopted, the approach could have implications for other decisions about how to allocate scarce medical resources, such as expensive cancer drugs and ventilators during hurricanes and other emergencies, Caplan said.

"This is a fascinating canary-in-a-cave kind of debate," he said. "We don't want to talk about rationing much in America. It's become taboo in any health-care discussion. But kidneys reminds us there are situations where you have to talk about rationing. You have no choice. This may shine a light on these other areas."

An evolving system

The current system, which dates to 1986, was first based largely on giving kidneys to the patients who matched the organs best, but it evolved to take a first-come, first-served approach made possible by safer, more powerful anti-rejection drugs. Today, the UNOS's Organ Procurement and Transplantation Network (OPTN) gives priority to patients seeking organs from someone who dies based mostly on who has waited the longest.

"It was just a fairness issue," Andreoni said. "You're next in line. It's your turn."

The problem is that, in some cases, elderly recipients get organs from much younger donors whose kidneys could have provided far more years of healthy life to younger, heathier patients. Younger patients can receive older or less-healthy organs that wear out more quickly, forcing them back onto the transplant list in a few years.


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