A Primer on Kidney Transplantation : Anatomy of the Shortage

Kidneys are unique among the solid organs due to the combination of the low risk of living donation, the feasibility of sustaining life on dialysis for several years following kidney failure, and Medicare coverage of dialysis and transplantation for kidney patients. Despite these advantages, thousands of Americans die each year while waiting for a kidney transplant, and the waiting list grows each year. In this kidney transplantation primer, we provide a quantitative description of the kidney shortage and discuss future trends and possible solutions. We demonstrate that the current system provides only about half as many kidneys as are needed for transplantation and the gap cannot be eliminated through an increase in deceased donation alone, because most kidneys from suitable deceased donors are already procured. The prospects for increasing living donations under the current system are also dim. Donations from living kidney donors have declined from their 2003 peak and nearly all living kidney donations are directed by the donor, usually to family members, rendering the current account of living kidney donation as “altruistic” somewhat misleading. For all of these reasons, we believe the time is ripe to reconsider financial incentives for kidney donation. Needless to say, a system that provided financial rewards for living donors could produce unsavory consequences, and would have to be carefully designed and managed. But without such a system, the most likely version of the future is a continuation of unnecessarily high rates of death and disability from kidney failure