The transplant surgeon, looking alarmingly young, gave me a confident grin as I lay on a gurney outside the operating room.
"Live related donor transplant, eh?" he said. "That should be good for a half-life of about 33 years."
In the event, the kidney transplant from my sister, my second transplant, lasted only two years, and never really kicked in properly. There were special circumstances. We had undertaken what amounted to an experiment in tissue compatibility. My sister and I shared what is called a "B-cell antigen antibody," which recommended against a transplant at all. A new pre-transplant treatment with immunoglobulin promised to overcome that antibody. It did to a degree. But then it didn't. And the kidney failed fast in its second year.
Nonetheless, the young surgeon's confidence points to the high degree of success with kidney transplants. With a host of new drugs and new procedures, transplantation has expanded from its earliest days, from kidneys at first to hearts, lungs, livers, and liver and pancreatic sections. Kidney transplant success rates have increased from about 50-50, when I had my first transplant in 1981, to 70-80 percent today.
Kidney transplant, in other words, has become so successful that one may be tempted to recommend new donation policies for this particular organ -- and to separate those protocols from the riskier liver, heart, and lung procedures.
IN 1984, CONGRESS PASSED the National Organ Transplant Act. NOTA set up the Organ Procurement and Transplantation Network and awarded a contract to the nonprofit United Network for Organ Sharing (www.unos.org) to administer the program. UNOS has divided the country into 11 regions, a necessary step because transplanted organs have to be as fresh as possible -- you can't transport them too far. Organ Procurement Organizations, OPOs, nonprofits in each of those regions, facilitate the actual matching up of donor organs to recipients.
From the beginning, there have been far fewer donors than would-be recipients. The UNOS website currently lists 88,564 "waiting list candidates," 6,804 transplants performed from January through March, 2005, and 3,528 donors. Those numbers reflect all kinds of organ transplants; about three-quarters are kidneys.
End-stage renal disease, or kidney failure, affects about half a million people in the nation at any one time. Every year, about 20 percent of those people die, and every year, the ESRD population gets renewed. Some medical studies suggest that increasing frequency of diabetes will also increase the ESRD population; diabetes can destroy kidneys.
HOW TO GET MORE KIDNEYS into the system? Spain and Belgium operate on a "presumed consent" basis -- that is, any person who dies is presumed to consent to having his organs used for transplant. As a result -- so I hear -- live related donor transplants in those countries have become practically unknown, since the supply of cadaver kidneys is virtually unlimited.
In America, the emotional objection to that policy would make it impossible. There is already abroad -- check Internet chat -- a widespread suspicion that doctors are just waiting, scalpels in hand, to turn any accident victim into a dugout canoe, whether he's really truly dead or not. Unfounded this fear may be, it still exists.
Organs may, some suggest, be sold; at least there might be some compensation system set up for donations. The fear here is that the well-to-do would exploit the poor for organs.
A network of Boston hospitals has begun transplanting formerly excluded kidneys -- organs that would have been discarded because of age (over 60) or disease factors in the donors. As one doctor explained, he couldn't see the sense of transplanting a kidney from a youthful donor into a 70-year-old. And 27 states have passed laws forbidding relatives from rescinding a would-be donor's permission to have organs harvested at death; many relatives, confronting a sudden death in the family, try to reverse the donor's intent. Some other venues have experimented with organ swaps, that is, matching up two pairs of transplant donor-recipients to get suitable matches. Insurance companies have balked at paying donor expenses, which has largely quashed that program.
THE CURRENT REGIME HAS drastic regional inequities. In Northeastern states, it takes five to seven years to get a kidney from the donor list. In Florida and Wisconsin, it takes more like two. Why? As an old-time kidney doctor explained to me with a nudge and a wink, "I think Wisconsin may be doing presumed consent without publicizing it." And Florida has lots of high-speed highways.
Truthfully, it should not be that much of a problem. Out of a population of nearly 300 million, the United States needs perhaps 60,000 kidney transplants now. Let's suppose that 5,000 of those could be taken care of by live donors, friends and relatives. That leaves 55,000, which means, to put it bluntly, 55,000 dead donors. A doctor told me that about 80 percent of donated kidneys are usable. Let us say therefore 70,000 dead donors.
How many donor cards would have to be signed to produce those 70,000? Truly, not many. There is a current shortfall, of course. But once that gets overcome, transplants could be supplied with just enough card signers to provide a constant corresponding donor pool for the half million people with ESRD. Even to overcome the shortfall, it's hard to imagine that more than ten million donor cards would have to be signed at any one time, barely more than six percent of the U.S. adult population.
The question is, why aren't more organ donor cards signed? Perhaps what's required is less a change in policy than a truly effective national advertising program.
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