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The worsening kidney shortage has pushed the transplant community to try and find new donors. But it also wants to become more efficient with the ones it already has.
For Dr. A. Osama Gaber, the transplant director at Methodist Hospital, there is nothing more frustrating than having a patient with a friend or relative who is willing to donate, but unable because he's not the right match.
That's where the concept of paired donations comes in. People with incompatible donors can make a trade.
"Now what we're saying is if that donor's not good for you, he may be good for somebody else," Gaber says.
Paired donations have become more common over the last five years, but the kinks are still being worked out. To ensure that one donor doesn't get cold feet once the other has gone through with the surgery, the two transplants must be done simultaneously. This makes for a logistical nightmare — four operation rooms in action at once.
And the paired donation networks currently up and running are strictly regional. Making pairing readily available on a national level would require a massive and detailed database.
The United Network for Organ Sharing, which keeps the kidney waiting list, has just started laying the groundwork. Dr. Matthew Cooper, the director of kidney transplants at the University of Maryland, who chairs the UNOS Living Donor Committee, says the program is still in its infancy. Once everything is up and running, though, it might add 4,000 to 5,000 transplants a year.
Cooper adds that such a database might also be used for a creative twist on the pairing concept that's known as kidney chains.
Chains have developed thanks to the appearance of purely altruistic donors — people who donate a kidney with no recipient in mind. In such a situation, Gaber says, a regular transplant would be a waste. Instead, the unsolicited kidneys are used to leverage a chain of paired donations. Using complex mathematical calculations that are still being ironed out, one altruistic donor has so far led to as many as 15 transplants.
This gives those who think the government should compensate donors one of their most interesting arguments — what if unsolicited donors were, well, solicited?
Sally Satel, M.D., a resident scholar at the conservative American Enterprise Institute and author of When Altruism Isn't Enough: The Case for Compensating Kidney Donors, thinks it's worth a shot.
"If we could [offer incentives] to become part of a donor chain, how many people would step forward? I think a lot," she says.
The idea of compensation provokes some impassioned ethical objections that it doesn't seem likely to overcome in the near future. But according to Cooper, the transplant community may one day be headed for what could be another contentious debate.
UNOS is considering a new paradigm for determining who gets priority for a kidney transplant — one more heavily weighted toward how much mileage a recipient is likely to get out of it. The current system is almost entirely based on time spent on the waiting list.
"It's going to turn a lot of heads. But ultimately the reason is a very valuable, but very limited, resource, and many people dying on the waiting list," Cooper says. "We certainly don't want a kidney to be lost because of patient death, when perhaps we could have gotten many more life years out of the kidney with a different recipient."