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Who Receives a Kidney Transplant First?

While the field of transplantation is quite young, substantial advancements and success have led to the current imbalance between the supply of organs and the demand for them. The United Network for Organ Sharing (UNOS) coordinates the nation's transplant system through a point system based primarily on wait time, sensitization and HLA matching.

When a match occurs, the kidney is offered to the person at the top of the national list. A recent editorial in the American Journal of Transplantation discusses the fairness and equality in kidney allocation, particularly as UNOS is reevaluating its allocation system and will receive recommendations from a sub-committee this year.

The issue of the allocation of deceased donor organs is not new, and there have been two somewhat conflicting philosophical approaches, says author Ron Shapiro, M.D. One states that organs are scarce resources and should be allocated preferentially to the lower risk candidates to maximize the longevity of the transplanted organ. The second strives to maximize access for all potential candidates and utilizes waiting time as an important criterion. These correspond to the "utility" versus "equity" views.

Concerns have been raised that there will be less equality in the new allocation system, even though it should be emphasized that no formal proposal has been made to date. The debate is only further complicated by the reality that deceased donor kidneys are variable in their quality while patients, to a large extent, rely on their doctors to make appropriate decisions for them regarding candidacy and allocation.

Patients have an expectation that the system will be fundamentally fair, and any modification to the system that may be perceived as unfair runs the risk of undermining patient confidence. Transplantation is the only technologically advanced field of medicine that is totally dependent on public understanding and support, for without donors and recipients, transplantation would simply not exist, says Shapiro.


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