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Advancing Kidney Transplants through Data, Donor Chains and Vouchers, Part 2

Until recently, compatible donors did not have the option to insure their loved ones with a kidney for a future transplant. Participants in standard donor chains were limited to those whose relatives needed a kidney at that time.

A voucher system was recently developed to solve for this challenge by enabling individuals to donate a kidney when they are younger and their surgical risks are low in return for a voucher that gives a loved one priority if and when he or she needs a kidney transplant. This system also expands the donor pool by rendering the donor a non-directed donor (NDD) at the start of a chain. It enables a grandparent to essentially procure kidney insurance for a grandchild at risk for kidney disease in the future. In fact, that is how the voucher idea originated. Harold Broadman, a retired California judge, wanted to donate a kidney to his grandson, Quinn, who had only one, underdeveloped, kidney.

UCLA Professor Marek Pycia, Jeffrey Veale, MD, and other UCLA, USC and Cornell practitioners jumped on the idea, developing a program that assured that Broadman and others like him could fulfill their donation wish, even though they might be chronologically mismatched with their loved one.

With more people donating earlier in their lives and before their loved one needs a transplant, the number of potential matches rises, increasing the length of the chain. While the voucher system is not a guarantee, voucher recipients receive priority for a transplant when they need one. The National Kidney Registry, the largest repository for donor and recipient information in the world, has generated a computer simulation of the needs of voucher holders 50 years out and found that the voucher system can fulfill the needs of voucher holders in a timely way.

To date, 35 transplant centers have signed onto the voucher system on the registry. The first three living donors in the voucher program enabled 25 transplants to occur.

Reversing the decreasing donor pool trend

A study by Rodrigue, Schold and Mandelbrot indicated that while the U.S. living donor pool rose 265 percent and peaked at 6,647 donors between 1988 and 2004, the pool has since declined, averaging 13 percent fewer donors over the subsequent years. The authors suggest that many factors contributed to the downward trend, including allocation changes for younger donors to more pediatric patients, tightened regulatory oversight of transplant programs, changes in donor criteria, the aging of America producing fewer healthy donors, the poorer health status of the population at large and financial disincentives to donate.

The number of NDD and altruistic donors with no relationship to the potential recipient is about three percent of the annual living donor pool. Raising the number of donors, both altruistic and grateful family members, will require a broad communications effort about the low risks, quick recovery and personal rewards involved in the act of donation. The public will also need to understand how the chain and voucher systems work as well as the extent of the need, which continues to grow each year. Finally, we need to find a mechanism for covering donors’ financial outlays beyond medical costs, which are often covered by insurance. They may include lost work time, transportation, hotel and other expenses. Physicians can take the lead in finding resolutions to these challenges.

Jeffrey Giullian, MD, MBA

Jeffrey Giullian, MD, MBA

Jeffrey Giullian, MD, serves as chief medical officer for DaVita Kidney Care. Dr. Giullian leads the transformation of kidney care through his commitment to providing holistic, integrated care that addresses the clinical and psychosocial needs of patients. Dr. Giullian is focused on pushing the boundaries on exemplary clinical care through innovation and expanding what is possible for patients living with kidney disease. Since joining DaVita in 2016, Dr. Giullian previously served as chief medical officer of hospital services, vice president of medical affairs and national group medical director at DaVita Kidney Care. Dr. Giullian relies on his past experiences in private practice and hospital leadership to advocate for patients, physicians and medical directors. He is active with the Renal Physicians Association (RPA) as a member of the Board of Directors, chairman of the Healthcare Payment Committee and member of the RPA’s team of advisors to the American Medical Association Relative Value Units Utilization Committee. Dr. Giullian trained in nephrology and transplantation at Vanderbilt University and received his MBA from the University of Colorado at Denver. Twitter: @Dr_Giullian_MD

Bryan Becker, MD, MMM, FACP, CPE

Bryan Becker, MD, MMM, FACP, CPE

Bryan N. Becker, MD, is chief medical officer of DaVita Integrated Care and has nearly 20 years of physician executive experience. He received his AB in English at Dartmouth College and MD from the University of Kansas, and, after training at Duke and Vanderbilt, he led the nephrology group at the University of Wisconsin and developed a new kidney care venture called Wisconsin Dialysis, Inc. He also served as CEO at the University of Illinois Hospital and Clinics and president of the National Kidney Foundation. Before joining DaVita Kidney Care, Dr. Becker served as President of the University of Chicago Medicine (UCM) Care Network, a more than 1,000 physician clinical integration organization, and Vice President, Clinical Integration and Associate Dean, Clinical Affairs at UCM. Twitter: @bnbeckermd