Overhaul meant to improve system regulating kidney allocation for transplants

Anthony Lockett has end-stage renal disease. To stay alive, he must undergo dialysis three times a week. Each appointment takes four hours.

A new kidney would eliminate this need and significantly improve his quality of life, but Lockett has yet to near the top of the transplant waiting list despite being on it for more than two years and on dialysis for more than three. Demand for organs far exceeds supply, and his blood type, the rare B, makes a match difficult.

His chance of getting a kidney will increase come mid-December, though, when the United Network of Organ Sharing, or UNOS, as most know it, begins a new allocation system. The changes will make more deceased-donor kidneys available to candidates such as Lockett and will make better use overall of the organs.

"The current kidney allocation system goes back to the mid-'80s. This is the first major overhaul," said Dr. Mark Aeder, transplant surgeon and vice chair of the kidney-transplantation committee for the nonprofit UNOS, which serves as the U.S. Organ Procurement and Transplantation Network under contract with the federal government.

This topic and other organ-donation-awareness efforts will be front and center July 11-15 when the Transplant Games of America comes to Houston. The event brings thousands of organ transplant recipients and living donors to compete in 15 medal events, including basketball, cycling, swimming, tennis and track and field, at venues including BBVA Compass Stadium, Memorial Park and Rice University.

One change in the organ-allocation system's new rules will directly affect Lockett. Currently, candidates with blood type B - the majority of whom are African-American or Asian - generally cannot receive a kidney from a donor with the more common blood type A, unless the donor falls into a certain blood subtype. The new system will give first priority for those kidneys to type B candidates who prove a match.

"I was happy to hear about that change because it will give me a broader donor base," Lockett said. He teaches health-care certification classes to supplement disability payments but would prefer to make better use of the MBA he earned before receiving his diagnosis of kidney disease as a result of a connective tissue syndrome.

Another change involves transplant wait times. UNOS currently looks at when a candidate was listed. The new system will instead use the date on which dialysis began, or other medical criteria were met, when determining placement on the waiting list. Many candidates with serious kidney disease, despite the need, do not immediately register for a transplant.

"Sometimes they are scared and sick and just not ready to consider it," said Dr. Horacio E. Adrogué, Lockett's physician and the medical director of renal and pancreas transplantation at Memorial Hermann-Texas Medical Center.

Patients also may be in a medically underserved area and not offered the option of a transplant.

Other changes to come with the new kidney-allocation system are giving increased priority to candidates who may have donated an organ - any organ - and giving those with immune-system sensitivity improved access to kidneys they are not likely to reject.

However, the biggest and most complex change to come involves factoring in longevity, or survival after the transplant. In the new system, both candidates and deceased-donor kidneys will be scored according to certain criteria. Age, length of time on dialysis, previous transplants and a current diagnosis of diabetes will factor into a candidate's estimated post-transplant survival (EPTS) score.

Age, height, weight, ethnicity, certain causes of death, history of high blood pressure or diabetes, hepatitis C virus exposure and kidney function will factor into a kidney donor profile index (KDPI) score. In the current system, only donor age, history of hypertension, kidney function and certain causes of death are considered when matching.

"The way it works now, someone could come in at age 90 and get the kidney of someone who was 20, and someone who is 20 may get the kidney of someone who was 90, said Adrogué of the importance of life expectancy.

The EPTS and KDPI scores will allow UNOS to match the organs expected to function for the longest time to the candidates who will need them the longest. This also should reduce the number of second transplants needed, which affects organ availability for all.

The organization also will be able to offer kidneys expected to function for a shorter time to those candidates with a more immediate need, such as those who cannot stay on dialysis, and to those farther away. In doing so, UNOS hopes to reduce the number of available kidneys that never get transplanted.

"We're finding a lot of discards. They go through the local transplant units and don't get used because they may not have the right candidate. By the time that kidney is offered out within the region, it's already old and from a more challenged donor," Aeder said. "We're hoping that by widening the potential recipient area, we will give more transplant centers and more people opportunities at these kidneys."

This change, in particular, will have an impact on LifeGift, the not-for-profit organ-procurement organization that recovers organs and tissues for transplant in Harris County as well as 108 other counties in the state.

"The kidneys will be shared on a broader basis, which means more transportation and logistical tasks that we need to manage," said Kevin A. Myer, president and CEO of LifeGift, adding that it will "continue doing everything we can to realize every organ- and tissue-donation opportunity presented to us."

Projections by UNOS have the new kidney-allocation system adding about 8,000 life years for future transplant recipients. Lockett looks forward to getting the call that puts him in that group.

"I could work normal hours, earning a living using my degree, go watch my son play basketball and be home in the evenings," he said. "Getting a kidney would bring me back to normalcy."