Balancing Multiple and Conflicting Allocation Goals: A Logical Path Forward

At the end of 4 years of consensus building and two public forums, it is disappointing we have not implemented a better allocation algorithm for kidney transplants. However, the process has been instructive, and a clear path forward is evident. The current national allocation system no longer provides an adequate algorithm for allocating an increasingly limited and diverse donor pool of kidneys to an increasingly older group of recipients. This system has resulted in donor kidneys with excellent predicted longevity being transplanted into recipients with poor expected posttransplant survival. Conversely, donor kidneys with poor expected longevity and poor glomerular mass are transplanted into recipients who have a long expected survival. The current donor service areas (DSAs) evolved without design, resulting in widely disparate waiting times in adjacent areas. Attempts by the Organ Procurement Organization (OPO) to improve the allocation system have resulted in 67% of them incorporating variances to the current standard allocation system based on waiting time and human leukocyte antigen DR (HLA DR) matching. It is imperative that we initiate a national allocation system that will standardize allocation and eliminate the alternative allocation systems. Although these variances historically have served an important function to permit regions to test potentially progressive alternative systems, it is time to evaluate the efficacy of these variances. Successful variances should be incorporated into a uniform national algorithm, as was the original intent of allowing the existence of the alternative systems. Ongoing variances are making programming and implementation of any progressive changes to the national system difficult, time consuming, and expensive; further stretching valuable and limited technology resources. Valuable technologic resources that could be applied to other important programs to increase the annual number of kidney transplants, such as kidney paired donation, are drained. The allocation system that is eventually implemented has to be applied to all OPO’s and must permit subsequent modifications based on evolving data collection and correlation with outcomes. It is increasingly evident that this system will have to be transparent, comprehensible for health care workers and transplant candidates, permit potential recipients to have a reasonable estimation of waiting times, permit a smooth transition for the nearly 80 000 people already waiting for kidneys and provide for better matching between the expected longevity of a donor organ with the expected posttransplant survival of the recipient.