Are Transplant Chains the Answer to Our Kidney Deficit?

Melissa Laracy, 2017 PharmD Candidate
Published Online: Thursday, August 18th, 2016
A Massive Undertaking
Several nonprofit agencies facilitate the formation of chains. Registries use complex software algorithms to find the best match for each patient. Some organ transplant centers conduct exchanges exclusively at their center. The use of national registries, however, expands the donor pool and provides patients with a greater likelihood of successful transplant and increased graft survival times. The NKR has the largest donor pool in the world, prompting better matches and more opportunities to repair failed swaps.8 Registry software is designed to optimize ABO and HLA compatibility. Other patient-specific characteristics are factored in, such as age and travel preference.12
One potential problem that arises from national registries is location. If donor-recipient matches span the country, the donor or the organ will need to travel. Many donors prefer to stay at home where they can recover near friends and family; in these cases, organ shipment is usually preferred. Organs can be shipped on commercial airlines at minimal cost. Local organ procurement organizations deal with these transactions’ details.24 Such organizations also manage the transportation of deceased donor organs successfully. Some experts have reservations about the function of kidneys that have prolonged cold ischemic times. This may be why some transplant specialists prefer conducting local exchanges at the same center, even if the match isn’t as strong.12 However, studies have shown that prolonged cold ischemia time does not affect graft function.25
Leaders in the field of kidney transplants attended a conference in Herndon, Virginia, in 2012 to discuss the formation of a national registry. Opinions were split between establishing one registry or having multiple registries (the current arrangement) to manage the matching and allocation processes. Mathematically, one large pool of donors creates more potential matches than 2 smaller pools do. In addition, including pairs in multiple registries could create problems with chain construction if two registries want to use the same donor. However, competing registries prefer remaining separate. Competition fuels innovation, which unification of the registries may destroy. The general consensus was to work toward the formation of single national registry in the future.26
Successful Chains
The benefits of kidney transplant chains are already being realized. They multiply the impact that altruistic donors create.16 Currently, the longest living kidney donor chain is the University of Alabama at Birmingham Kidney Chain. Started in December 2013, it has since grown to include 112 individuals, yielding a total of 56 kidney transplants as of December 2015.27
The longest multihospital chain to date involved 68 individuals, 34 kidneys, and 26 hospitals across the United States.28 It happened over the course of 3 months, ending on March 26, 2015.29 Kathy Hart was the Good Samaritan who started this chain, ending with Mitzi Neyens. After living with kidney disease for 30 years, Neyens’ condition began to rapidly decline at the age of 77, but her age precluded her from being added to the DDWL. Living organ donation was her only option, and without this chain, she probably wouldn’t have found a donor. This particular chain included 16 highly-sensitized individuals who could have waited years on the DDWL before a compatible match was identified.28
Many multicenter transplant chains wouldn’t be possible without the efforts of national registries. The NKR alone has initiated 329 chains, facilitating 1513 kidney transplants. It has also arranged 83 loops (a series of swaps without an altruistic donor), facilitating 194 transplants. The NKR is responsible for organizing a total of 1827 kidney transplants as of July 2016. Table 2 lists the longest and most successful chains/swaps from the NKR. The longest chain to date is Chain #357, which enabled 35 transplants.
Table 2: Longest National Kidney Registry Chains
Chain Number Transplants Facilitated
(multiply by 2 for total number of participants)
5 21
10 11
18 12
19 12
20 10
21 10
61 11
69 10
95 16
122 11
124 30
178 10
187 12
192 12
221 28
225 10
266 12
268 10
282 10
293 13
306 11
313 11
330 16
357* 35
412 16
459 19
464 13
476 13
494 10
* = longest chain
Future Possibilities
Kidney transplant chains aren’t only saving lives; they’re also saving money, as a national registry could save $750 million every year.22 Kidney disease treatments consume 7% of the total Medicare budget, costing $30 billion every year. Medicare spending in 2013 on hemodialysis was $84,550 per patient per year (PPPY), peritoneal dialysis was $69,919 PPPY, and transplant was $29,920 PPPY.30 Compared with the average cost of Medicare coverage for a kidney failure patient on dialysis, the surgery is considerably less expensive. Each patient who exits dialysis due to a kidney transplant saves Medicare $500,000 to $1 million.23 Increasing the number of kidney transplants produces savings that can be used for other health conditions.
These chains hold great potential for the 100,000 patients currently in need of kidney transplants. Research and computer models show that thousands more transplants could be possible annually if transplant specialists, donors, and recipients understood paired exchange and chain donation better. A national registry listing all donors and recipients also has the potential to improve donation.26
Convenient care clinicians can educate patients about kidney transplants, specifically the different types of living donation. By increasing public awareness about kidney registries and chains, they can improve these processes and increase the number of kidney transplants.
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