As a transplant surgeon, I have always felt privileged to watch the strength and dignity of patients who are dealing with their illnesses. But one group of patients I take care of, that includes both young and old members, affects me more than most: patients with kidney failure. Kidney failure is caused by many diseases, including congenital kidney disease, autoimmune kidney disease, hypertension, and diabetes. Few of these patients are responsible for their illness. All of them are suffering greatly. Patients with kidney failure have only one real hope: a kidney transplant. It is my job to help them, but all too often I can’t.
The transplant community has made great advances in the last few decades in performing kidney transplants, but the most significant problem in our discipline in the 1970s remains the biggest problem now. We don’t have enough organs.
Is this solvable? I think it is.
Currently, there are about 100,000 people on the wait list for a kidney transplant in this country. A majority of these patients are on dialysis, and many are on hemodialysis. The annual cost for hemodialysis is greater than $80,000 per year, assuming there aren’t any major health complications.
This cost does not capture the poor quality of life most of these patients endure, and I can’t count the number of times patients on dialysis have told me “it’s necessary, but no way to live.” The best option for these patients, in terms of quality of life, quantity of life, and cost to the healthcare system, is kidney transplantation.
Kidneys can be obtained from both deceased donors and living donors. About 10,000 deceased-donor kidneys and 6,000 living donors are transplanted each year in the United States. While both of these types of donors improve quality of life and survival of recipients, the half-life for deceased-donor kidneys is about 10 years, and for living donors 15 years. The yearly cost of a kidney transplant patient is estimated at $30,000 per year, and the cost of the initial transplant may be as high as $200,000. So after four years, the functioning transplant would have cost about $320,000, and dialysis would also have cost $320,000. Thereafter, the transplant would save $50,000 per year, not to mention the proven increased survival and excellent quality of life. If the kidney lasts for 15 years total, the cost savings alone would be $550,000.
In the transplant community, we are constantly trying to increase donor rates and utilization of kidneys that are available. But because of the shortage of organs and long wait list, we are forced to use kidneys that we know will fail before the recipient has finished using them. Unfortunately, at my medical center, as many as 30 percent of the transplants we do are re-transplants in patients whose kidneys have failed.
It is clear that the solution to this problem is to increase the number of living donors, which last longer and function at a higher level. We evaluate donors very carefully in this country, avoiding medical problems that could increase their risks. In well-evaluated donors, the risk of renal failure (after donating a kidney) over their lifetime is 90 in 10,000 (similar to the rate in the population in general), with a risk of death of three in 10,000.
The donor surgery is performed laparoscopically (through small ports in the abdomen through which a camera and instruments are inserted). The length of stay in the hospital is two-to-three days, and most patients return to work within one month of donating. More recently, we have been performing the surgery through a small single incision in the bellybutton, and by six months after surgery there is virtually no scar. (It is true that sometimes outies become innies.)
Donors do not need to be related to recipients; they just need to be healthy. The recipient’s insurance pays for the donor’s costs for the evaluation and transplant. When someone donates to a friend or loved one, they are giving one of the greatest gifts that a person can give. And when someone donates to the pool of recipients rather than to a known individual (a humanitarian donor), a chain of transplants can result (using donor-recipient pairs that have potential donors who are not compatible with them), which can travel across the country and save numerous lives.
So how do we increase the number of living donors in this country?
Some have proposed paying donors, but this remains controversial, with many feeling that this would lead to an inordinate amount of underprivileged donors. But why not provide living donors with either free or subsidized health insurance? One option would be to make them eligible for Medicare; kidney recipients are already Medicare-eligible due to their renal failure.
While this might seem expensive, the average adjusted yearly cost per beneficiary is roughly $10,000. Donors are by definition healthy, so one would predict that their healthcare costs would be even lower. And the costs saved for the recipient would more than cover this added cost—still $40,000 each year saved per donor.
For donors that have healthcare through their employer, the responsibility for healthcare payments could be subsidized instead or switched to Medicare, saving money for employers and employees. Combining this incentive with increased education would likely improve our country’s health while saving money at the same time. How often do we do that in the healthcare system?
A variant of this proposal was published in 2006 and recommended offering donors health insurance, life insurance, and compensation, but it failed to gain traction, likely due to the controversial nature of compensating donors.
I am not the first to suggest providing free health insurance to kidney donors, a benefit that would certainly be supported in the transplant community. Given our increased understanding of the excellent long-term outcomes enjoyed by kidney donors, along with the rapidly growing wait list and decreasing availability of living donors in this country, the idea makes intuitive sense.
We would still need to explore how much this type of incentive would increase donation. Perhaps the transplant community has simply not spent enough time educating people about the process of being a donor, both living and deceased. But it is hard to find an argument against free healthcare for donors, either ethically or financially.