Donor Compensation, Not Kidney Swaps, is the Only Solution to Growing Kidney Shortage in U.S.

Saturday's New York Times article "60 Lives, 30 Kidneys, All Linked" features "the longest chain of kidney transplants ever constructed, linking 30 people who were willing to give up an organ with 30 who might have died without one."  The article has been getting a lot of attention and is currently the second most e-mailed NY Times article and fourth most viewed.

After a similar 13-kidney exchange in December 2009, which at that time was the world's largest ever, Sally Satel and I wrote an article in the Washington Post, and excerpts of that article appear below, with some minor edits and updating:

Such organ exchanges are a godsend for sick people with loved ones who are willing to give them a kidney but are not biologically compatible with them. In an exchange, unmatched couples switch partners to form compatible pairs.

But now for the bad medical news. There are more than 90,000 Americans with renal failure on the national waiting list for kidneys, a grim new high (see top chart above). Almost 13 patients on the waiting list die each day. In addition, almost 7 people are removed each day from the waiting list because they are too sick to survive a transplant operation.  As ingenious, painstaking and justifiably attention-getting as domino swaps are, they shouldn't blot out the dismal news that rates of kidney donation, from both living and deceased donors, fall woefully short of the need.

As the number of renal transplant operations remains mired between 16,000 and 17,000 a year, the number of candidates on the waiting list mounts. Within the last seven years, for example, the list grew by 50%, from about 60,000 patients in 2004 to 90,500 at the end of last year.

This means that only one kidney transplant operation was performed in 2011 for every 5.4 needy patients, making the chance last year of getting an organ less than one in five -- an all-time low of only 18.5%. As recently as the early 1990s, patients on the waiting list had a greater than 50 percent chance of receiving a kidney in a given year, but the situation has worsened every year since 1991 (see bottom chart).  Thus, even if surgeons were able to schedule an additional 30-kidney swap operation every day this year, more than 62,000 patients would still languish on dialysis, facing premature death.

The only realistic long-term solution to the growing kidney shortage in the United States is not kidney swaps, but rather it is to allow some form of donor compensation (which was never mentioned in the NY Times article). This would require Congress to amend the National Organ Transplant Act of 1984 so that people who give organs could receive a benefit, perhaps a tax credit, tuition voucher, lifetime health coverage or a contribution to a retirement plan. Such compensation would be regulated by the government, with kidneys allocated to ill patients according to the national formula being used across the country.

We should surely celebrate the world's largest-ever 30-kidney exchange and hope that more of them occur. Yet we shouldn't lose sight of the reality that the most promising long-run solution to the kidney shortage is a system of donor compensation.