Monthly Archives: January 2014

Kidneys, Part II: The Limits of Deceased Donor Proposals

Table 3

In my last post, I discussed a new paper, A Primer on Kidney Transplantation: Anatomy of the Shortage, that Phil Cook and I just posted to SSRN.  The paper provides a quantitative description of the kidney shortage and future trends, and yields some insights on possible policy solutions (and non-solutions) to the kidney shortage.

We wanted to provide a more fine-grained picture of the kidney shortage than what is typically presented, by documenting the flows on and off the kidney waiting list for a single year, 2011. For the sake of brevity I won’t repeat that analysis here, but we conclude that unmet need is at least 21,000 kidneys per year, and very likely more than that.  Those interested in the specifics should consult Table 1, Figure 2, and the discussion in Parts IV and V of the article.

In considering where to look for more kidneys, we begin with the basic demographics: the typical criteria that are applied to identifying suitable deceased donors have the effect of disqualifying all but a small fraction of the 2.5 million U.S. deaths per year.  Table 3 from our paper, reproduced above right, provides some detail on this “winnowing” process for 2010, gathered by sorting the 2.5 million records from the National Vital Statistics multiple cause mortality dataset according to particular fields in the electronic records, beginning with age.  We begin with the fact that almost 2/3 of all deaths are over 70 and hence almost always deemed medically unacceptable due to age alone.  Of the remainder, most are uncontrolled deaths out of the hospital, or deaths in the hospital from causes like cancer, diabetes, and renal disease that ordinarily are disqualifying.

The result is that, in 2010, only about 9,000 deaths were “eligible” by either the standard criteria or expanded criteria, and in 70% of those cases the kidneys were in fact donated.  (In addition, there were 928 others who became donors after cardiac death, which is uncommon because it is a difficult, though expanding, procedure, which we discuss in more detail in the paper).

One lesson from these statistics is that even a deceased organ consent and allocation system with a 100% success rate would have yielded only an additional 2751 donors, or roughly 5500 kidneys.  This is not nearly enough to satisfy current need, particularly if any progress is to be made on the backlog.

Those who believe that the kidney shortage can be eliminated through presumed consent, priority systems, funeral vouchers, or other proposals aimed at improving rates of deceased donation are thus mistaken.  Additional kidneys from deceased donors would be welcome, of course, but will not be nearly enough to satisfy current need.  Barring a major breakthrough in recovering organs from patients that are currently deemed unsuitable, increasing donations from living donors is the only plausible means to close the gap.

In my next post, I’ll conclude with some more specific policy implications of our paper.

Related posts:

Cash for Kidneys: Reality is Complicated

Kidneys, Part II: The Limits of Deceased Donation Proposals

Innovation and Incentives: Beyond “Cash For Kidneys”

More Organs & Inducements

Share:Tweet about this on TwitterShare on FacebookDigg thisShare on RedditShare on StumbleUponEmail this to someone

Cash for kidneys: reality is complicated

 

Discussing my new paper with Phil Cook, A Kidney Transplantation Primer: An Anatomy of the Shortage

In this weekend’s Wall Street Journal, Gary Becker and Julio Elias have an essay, Cash for Kidneys: The Case for a Market for Organs, in which they argue that paying donors for their organs would eliminate the supply-demand gap without greatly increasing the cost of a kidney transplant.  This is an extension of their prior work, with which many Loungers may be familiar.  The article has generated a fierce (though largely misinformed) debate in the comments section and Al Roth has a typically thoughtful post on point, questioning why repetition of these arguments and evidence has failed to make headway, and urging a more thorough understanding of the nature of the opposition to organ markets.

The WSJ piece is notable for several reasons, however.  First, this is not the usual short op-ed, but a fairly extended treatment.  I can’t help but think that such a piece in the mainstream press by two prominent economists signals something about the current salience of the kidney shortage.  That same sense was the motivation behind the recent Organs & Inducements symposium that Phil Cook and I hosted last year at Duke.  Second, as Phil and I demonstrate in a forthcoming article just posted to SSRN, the prospects for reducing the kidney deficit under the current system have only become more daunting since Becker & Elias published on this topic in 2007.

To illustrate, the accompanying figure (figure 2 from our paper) provides a historical account of the gap between kidney need and supply. That gap appeared when the UNOS data system first went on line in 1995, and has widened over the years since then. Between 1995 and 2006 both flows (new additions and transplants) increased steadily, with the need increasing faster than the supply of kidneys available for transplant. Since 2006 the need has continued to increase each year (albeit more slowly), but the rate of transplants has plateaued.  (We discuss this and other trends in more detail in the paper)

The Becker and Elias WSJ piece is also timely from my perspective, given that our paper, A Primer on Kidney Transplantation: Anatomy of the Shortage, reaches largely the same conclusion, but also contains some important differences that are worth highlighting.   The primer, part of the Organs & Inducements symposium, is intended as a quantitative description of the kidney shortage and future trends.  That analysis yields some insights on possible policy solutions to the kidney shortage and, perhaps most importantly, demonstrates the limitations of many popular proposals aimed at reducing the gap between supply and need.

In my next few posts, I’ll take readers through a few key pieces of evidence and arguments in the paper.  We are still very much in draft form, so constructive feedback is most welcome.  As a preview, the main takeaways from the paper that I plan to hit in these posts are the following:

  • When properly measured, the gap between kidney need and supply is even larger than typically assumed and there is little reason to expect that trend to abate under current conditions
  • The prospects are dim for increasing kidney donation rates under the current system: donation levels have been static overall since 2006, and donations from living kidney donors have actually declined from their 2003 peak. Moreover, most kidneys from suitable deceased donors are already procured — even a perfect deceased organ consent and allocation system would not yield nearly enough kidneys to cover the amount needed per year to satisfy unmet demand
  • Kidney transplantation is less expensive and results in better health outcomes than dialysis.  Furthermore, living donor kidneys provide health advantages as compared to deceased donor kidneys.
  • Many current innovations in transplantation are positive and should be encouraged, but will not increase kidney transplants in sufficient numbers to close the need-supply gap, at least not in the foreseeable future

I’ll be back with more on this later.  In the meantime, you can download the full paper here.

Related posts:

Cash for Kidneys: Reality is Complicated

Kidneys, Part II: The Limits of Deceased Donation Proposals

Innovation and Incentives: Beyond “Cash For Kidneys”

More Organs & Inducements

Share:Tweet about this on TwitterShare on FacebookDigg thisShare on RedditShare on StumbleUponEmail this to someone