Imagine you’re suffering from kidney disease, on dialysis, waiting for a new organ that will ultimately save your life.
You can take a faulty kidney with a 10 percent chance of working in the next two years. Or you can wait days or weeks and receive the perfect one.
The second option—if it is an option—is the one most patients would choose.
And so the first kidney becomes one of dozens that get discarded every year in Maryland, said Dr. Dorry Segev, associate professor of surgery and epidemiology and associate vice chair for research in Johns Hopkins’ surgery department.
“A kidney for you is one that you are better off with than not,” said Segev, who sits on the board of the Scientific Registry of Transplant Recipients. “We’re always playing that balancing game in Maryland.”
More than a quarter of organs recovered for donation in Maryland last year were discarded before they were transplanted, up from around one in five the year before.
“I think we’re seeing a lot more organs being discarded than in previous years, and it’s complicated,” said Charlie Alexander, the president of the Living Legacy Foundation of Maryland.
Living Legacy is the organ procurement organization that serves most of Maryland’s donors and recipients. Maryland has two transplant centers, Johns Hopkins and the University of Maryland Medical Center.
Alexander said organizations like his, known as OPOs, face two divergent sets of goals. First, there’s a push to recover as many organs as possible to donate, he said. But there’s also a heavy emphasis placed upon the outcome of the transplant. The industry standard is a 95 percent success rate post-transplant.
“The outcomes of these transplants are tied to a very, very high set of standards,” Alexander said.
On top of this, Maryland is a comparatively needy state when it comes to organ transplants, Segev said. It’s the number two importer of out-of-state organs, trailing only New York.
“When patients in the organ-rich places turn down a faulty organ, that organ will come to a place that is desperate for organs,” Segev said.
Like Maryland.
According to last year’s data, all but 12 kidneys recovered in Maryland were transplanted at Johns Hopkins or University of Maryland. By contrast, Living Legacy transplanted 184 kidneys recovered from out of the area.
Discarded kidneys
Kidneys have the highest discard rate both nationally and in Maryland, but there’s also more kidneys recovered than any other organ, according to data from the United Network for Organ Sharing, the Richmond, Va.-based nonprofit that coordinates U.S. organ transplant activities.
Of the 123,000 people on the national waiting list for organs, more than 100,000 need a kidney, according to the National Kidney Foundation. Fewer than 17,000 people receive one each year.
Last year, 253 kidneys were recovered in Maryland, and 93—more than a third of them—were discarded. In 2012, 63 kidneys were tossed before being transplanted.
Maryland’s discard rate for kidneys over the last two years was higher than the national average. About 18 percent of the 14,756 kidneys recovered last year were discarded, roughly the same as the year before.
Because organs can be hard to come by here, the state takes an aggressive approach to importing organs that have been turned down in other states with more choices, Segev said.
“Imagine we get a call from California or Georgia, for a kidney that is not wanted locally,” he said. “We’ll bring it here, do a biopsy, look at the organ. We’ll take a chance.”
And some of those organs aren’t viable, which he said this could be the reason why Maryland’s discard rates for kidneys surpass the national rate.
“If an organ is useless—discarding it is the right thing to do,” Segev said.
Kidneys are a more sensitive organ than others, Alexander said. For example, diseases like diabetes and hypertension and high blood pressure can be hard on kidneys and ultimately make them unable to be transplanted.
According to data from UNOS, a full third of kidneys were discarded in 2012 and 2013 due to biopsy findings.
“There is an important caveat to this story,” Alexander said. “Just because the kidneys aren’t being transplanted, doesn’t mean other organs aren’t being transplanted.”
Dr. Sumit Mohan, associate professor of medicine at Columbia University Medical Center and director of the center’s outcomes research program for transplants, said it is a little misleading to look at kidney discards as an absolute number.
“It has been increasing, but right now, it is relatively stable,” Mohan said. “It is a problem the kidney transplant community is well aware of.”
Among other organs, a high percentage of pancreata are also discarded, though there are far fewer recoveries of this organ. Last year, eight out of 22 pancreata, or 36 percent, were thrown out in Maryland.
Discards of liver and lung donations in Maryland hover at just more than 10 percent. Discarded hearts are rare; of the 18 donated last year, all of them were transplanted, according to UNOS.
“We definitely are trying to save every organ we possibly can,” said Dr. David Mulligan, chief of transplantation and immunology at Yale University and chairman of liver and intestinal transplant committee for UNOS.
The national Association of Organ Procurement Associations released a two-page statement on the issue in August 2012, in response to a New York Times inquiry on discarded kidneys.
So many variables influence why kidneys may get thrown out, said Yilian Fraga, donor services manager for the Life Alliance Organ Recovery Agency. For donors, that includes blood type, size, health history, anatomy and current health and function of the organ.
Recipients, too, also have a large range of variables, including immune sensitivities and their current health. Transplant programs also vary widely in terms of their resources, level of expertise and local regulatory oversights.
Fraga said it is difficult to quantify how many viable organs could have been transplanted, and weren’t.
Possible changes
Matt Niles, director of clinical services at the Washington Regional Transplant Community, the OPO that serves Montgomery, Prince George’s and Charles counties, points out that organs that can’t be transplanted can often be used for scientific research.
Last year, 12 percent of the organs donated through WRTC were used for scientific research.
The donor, or his or her family, must grant permission for organs to be used for science, Niles said. But it’s a good alternative for organs that might otherwise be headed for the discard pile.
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Discards are still enough of a concern that UNOS is forming a committee charged with re-evaluating benchmarks for transplants.
Alexander expects the committee to present UNOS with recommendations with the next 12 to 18 months.
“Our goal is to look at how we define a successful transplant,” said Alexander, who will sit on the committee along with researchers, scientists and doctors. “Is an 85 or 90 percent success rate acceptable?”
Mulligan said UNOS is also looking at more efficient ways to match organ transplants with the right recipient—even one that’s all the way across the country. An organ that’s wrong for one recipient might be exactly the right match for another, he said.
By taking advantage of new technology and tweaking the formulas OPOs use to help match organs, Mulligan is hoping to see 100 more lives saved every year.
“We have a very scarce resource,” Mulligan said. “Can we do a better job?”
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