Who Gets the Kidney? 5 Changes to the Allocation System

More than 96,000 Americans are currently on the waiting list for a life-saving kidney and if this year follows the trend of years past, there will only be about 16,500 kidneys donated. Clearly, the demand is far greater than the supply and therefore, no policy for allocating donor kidneys can possibly match every patient in need with a donor. However, when it comes to deceased donor transplants, recently announced changes to the allocation rules are an improvement over the current system. These changes were made by the Organ Procurement and Transplant Network (OPTN) and the United Network for Organ Sharing (UNOS).

1)     Priority for the Most Highly-Sensitized

Transplant candidates who are only likely to match with 0-2% of deceased donors (CPRA score of 100%-98%) because they are highly-sensitized will be placed at the top of the kidney transplant wait list in order to help increase their chance of receiving a transplant. 

Candidates with a less than 1% likelihood of matching (CPRA score of 100%) will also get first priority at receiving a kidney from anywhere in the country if that kidney couldn’t be matched to a highly-sensitized patient with a CPRA score of 100-98% in the local transplant unit or region where the organ was donated.  While these candidates are still likely to remain on the list for five or more years, this new prioritization will provide them more opportunities to receive a transplant than under the current system. 

In addition, under the new policy, candidates with a CPRA score of 20% or above will be assigned priority points that will help improve their chance at receiving a transplant when a match is available.

2)     Blood Type B and Minority Access

People on the waiting list whose blood type is B will be able to receive kidneys from donors with blood types A₂ and A₂B under the new policy.  However, not all candidates with type B blood can successfully accept a kidney from A₂ and A₂B donors, so the candidate will first have to undergo a blood test to see how their body will respond to a donation with these blood types. 

Since many minorities have blood type B, expanding the blood types from which type B candidates can receive donor kidneys may slightly increase the number of minorities receiving kidney transplants. This can, help reduce racial disparities in access to kidney transplantation.

3)     Improvements to the Waitlist

The new policy sets back the clock for adults 18 years and older who are on the transplant waiting list to the day they started dialysis.  Candidates will still be able to accrue time on the wait list when registered with a GFR of 20 ml/minute or less.  So regardless of when a patient is actually evaluated for the transplant waiting list, once they are placed on the list, their time spent on dialysis counts in regards to how they are prioritized on the list. This policy reduces disparities in transplantation among the under-served who may not have been prepared to pursue the option of transplantation when first starting dialysis.  For children under 18, waitlist time is established based on the day they registered for a kidney transplant or the day they began dialysis, whichever occurred first.  Children will still be able to accrue waiting time without being on dialysis. 

4)     Life-Expectancy Matching for the Top 20% of Kidneys
The new policy will match recipients and deceased donors according to the “life expectancy” of the kidney in about 20% of the kidneys. Candidates who are expected to need a kidney for the longest amount of time will be matched with the kidneys expected to function the longest. 

This policy scores deceased donor kidneys using the kidney donor profile index (KDPI) to determine how long the kidney is expected to last.  Transplant candidates are also scored using the Estimated Post-transplant Survival (EPTS).  The EPTS is not a score based solely on age, but on other health factors such as whether the patient had received a prior transplant, diabetes status and time on dialysis.

While it is likely that mostly younger, healthier patients will end up with lower EPTS scores and receive priority for the kidneys with a KDPI between 0-20% (the top 20% of kidneys expected to function the longest), this policy will encourage more efficient matching of donated kidneys.  It may also reduce the number of repeat transplants for these recipients.  In addition, candidates will have to consent to receive a kidney in the bottom 15% (a KDPI of 85% or higher) since these kidneys are expected to have a shorter functioning life span than kidneys with a lower KDPI. Kidneys with a KDPI of 85% or higher will also be offered to a wider geographic area. For those candidates who are more likely to immediately benefit from a transplant rather than remain on dialysis, this will allow quicker access to a kidney transplant.

5)     Priority for Living Organ Donors

In the rare instances where a living donor (of any organ or part of an organ) needs a kidney transplant, they will also be given priority assignment for organs with any KDPI score, including those in the top 20%.  The National Kidney Foundation believes prioritizing prior living organ donors is ethical and fairly honors the gift they made.

Exceptions
While rarely used, a transplant physician’s right to give a donated kidney out of order, due to medical urgency is protected under this policy. However, all physicians in the local transplant region must agree to the change.  

The National Kidney Foundation anticipates that this new kidney allocation policy will protect the gift of life.  The policy will extend the length of time a transplanted kidney functions for a recipient, improve equity in the waitlist and improve the ability for those with rare blood types and high sensitivity to receive a deceased donor transplant. 

However, there are still too few kidney donors to meet the needs of the more than 96,000 patients on the kidney transplant waitlist. Learn more about organ donation today!