Separating Kidney Donation from Time: Advanced Kidney Paired Donation in the Age of Vouchers

Several years ago, the leadership at the UCLA Kidney Transplantation Exchange Program received a unique proposition from a man with a dilemma. The man explained that his grandson, a small child, had chronic kidney disease, and would likely someday need a kidney transplant. The man was a good match for his grandson, but at age 64, feared that he would be too old to donate by the time the child needed a transplant. Given this circumstance, the man proposed that he donate a kidney to the Program immediately in exchange for a guarantee that his grandson would receive a living donor kidney when his time for a transplant arrived.

Shortly thereafter, the world’s first advanced kidney paired donation (KPD) voucher was arranged. On receipt of the grandfather’s kidney, his grandson received a voucher for a future kidney transplant.KPD has been available in the United States for almost two decades. While the benefits of KPD include longer kidney survival and quicker recovery, the chief advantage is shortened time to transplantation.

The simplest way to describe KPD is with another illustration. In its simplest rendering, KPD involves an incompatible donor/recipient pair—Al and Bob. Al wishes to donate his kidney to Bob, but the pair have different blood types. To resolve this, the two enter a KPD program, where they are paired with Carl, a "non-directed" altruistic donor who is compatible with Bob, and Denise, a previously unknown recipient, who is a compatible match for Al. Al then donates to Denise, while Carl donates to Bob, usually in a simultaneous series of operations.

But let us now suppose that Al, a national guard member, is abruptly sent overseas a week before the intended transplant, or that Denise’s condition improves to the point that she no longer needs an immediate transplant. What then?

The concept of advanced kidney paired donation (AKPD) addresses just such scenarios, and other issues relevant to kidney donation. A recent and unique innovation, AKPD separates the act of kidney transplantation from the impediment of time.

At the Penn Transplant Institute, the AKPD program is coordinated by Robert R. Redfield, III, MD, FACS. Dr. Redfield has studied KPD and its participants closely to ascertain the apprehensions and barriers that prevent individuals from participating as living donors.

“The primary barriers to living donation are worry on the part of the donor for his or her future should kidney disease harm the remaining kidney, and the financial barriers to donation,” Dr. Redfield said in a recent interview.

These and other barriers to living donation have now been addressed by the National Kidney Registry (NKR), the nation’s largest facilitator of living donor transplantation.

To address the fear of future kidney failure in living kidney donors, the NKR provides 'kidney prioritization' to all NKR swap donors. This effort ensures that a donor will be prioritized in the NKR program to receive a living donor kidney should his or her remaining kidney ever fail. Prior living kidney donors also receive prioritization on the national deceased donor wait list.

In addition, Dr. Redfield explains, the NKR can provide a replacement living-donor kidney if the first kidney fails immediately after surgery. The second-mentioned barrier to donation, financial burden, confronts one of the stark realities of kidney donation—loss of work during post-transplant recuperation.

“Donors are out of commission for up to 8 weeks,” Dr. Redfield says. “And many are expected to cover the costs of travel and lodging to donate a kidney.”

In a 2017 study that appeared in the journal Transplantation, more than half of living kidney donors who received a local or national grant upon donation still dipped into savings, borrowed from friends or family, took out a loan, and/or had engaged in fundraising to offset the ensuing financial burden. A separate study of long-term follow-up of donors found that a quarter returned to work before feeling fully recovered.

A number of strategies are underway to address these concerns. The NKR now offers disability insurance to living donors, and reimbursement for travel, lodging and lost wages to cover the costs incurred at transplant and for potential complications occurring post-surgery.

The standard and family advanced donation voucher programs are among the NKR’s most innovative initiatives. Both apply to donors with intended recipients—but involve donating to the NKR’s kidney bank, which reaches both intended and non-intended recipients.

A standard voucher applies when a donor donates a kidney to the NKR within one year of an intended recipient’s surgery, receiving a voucher for the intended recipient. In this instance, a husband and wife (to take one example) might arrange their procedures to accommodate healing time from surgery for each other as these surgeries occur.

Family vouchers are designed to accommodate up to five pre-designated potential recipients. Here, donors whose partners or children have a kidney disease, for example, can guarantee that a living donor kidney will be available for them in their future time of need. All of the efforts for advanced living donorship, Dr. Redfield observes, have been designed to better achieve a need not currently being met by deceased organ donation.

“There are about 100,000 people on the kidney waiting list today in the United States and about 200 million adults in the country—which means that if living donation could increase to one half of one percent of the population, the kidney waiting list would disappear.”

Please visit the Living Kidney Donor Program at Penn Medicine for more information.

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The Penn Physician Blog is a resource for health care professionals featuring Penn Medicine physicians and their research, innovations, programs and events. 

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