Perspectives on the Strengths and Weaknesses of the National Kidney Allocation System

On December 4, 2014 a new system for allocating deceased donor kidneys, the National Kidney Allocation System (KAS) went into effect. The original KAS was introduced in 1987 (¹) with the formation of the United Network of Organ Sharing, and one throw of a computer switch wiped away an antiquated system that was constructed of layered ad hoc fixes to real and perceived needs of different regions of the country and varied patient constituencies. Although most of these “variances” to the system were well intentioned, in aggregate they resulted in a method of allocating kidneys that had no guiding principles and had become so cumbersome that meaningful improvements were logistically impossible from an information technology perspective. This stagnation produced an allocation system that used time on the waiting list as its sole means of distributing organs. As a result, kidney transplantation, the first organ successfully transplanted and the “recipient” of a Nobel Prize (²), became the only transplanted organ not to be allocated on the basis of medical necessity or with guiding principles about how to distribute and ration a scare resource.

Changing an entrenched system is hard, and KAS was born of the hard work and dedication of six Organ Procurement and Transplantation Network Kidney Committee Chairpersons, 167 different committee members, two national consensus conferences, and two formal requests for public comment (³). In all, the process took 12 years. However, because the process was long and iterative, the final product has been widely accepted despite its imperfections. The goals of the KAS were to add medical criteria and need to the allocation process (estimated post-transplant survival, kidney donor profile index score), to improve equity and access for disenfranchised groups (waiting time calculated from dialysis start date and a biologically rational approach to highly sensitized patients), and to fundamentally leave access for older citizens intact while continuing to prioritize children and prior living donors.

The results are in, and the 1- and 2-year outcomes speak to the wisdom of a publicly vetted and inclusive process of policy development. KAS has successfully paired patients with the longest expected survival with kidneys expected to last the longest, rescued highly sensitized patients from the despair of indefinite dialysis, and achieved social justice in that recipients of all races are treated fairly and equally. All while still allowing children to be transplanted with minimal waiting time and distributing 54% of all kidneys to persons over 50 years of age (³).

But there is more to do. Kidney discards remain unacceptably high. Geographic disparity in access to kidney transplantation remains unaddressed, and the system still has inefficiencies that limit its potential. In this issue of the Clinical Journal of the American Society of Nephrology, six veterans of KAS, from regulatory, transplant center, and organ procurement organization perspectives, take stock of its successes and look to the future for needed improvements. The development of KAS has been a success for the transplant community, and proves that well intentioned people can marshal their forces to achieve a societal good.

In this issue of the Clinical Journal of the American Society of Nephrology, six veterans of Kidney Allocation System, from regulatory, transplant center, and organ procurement organization perspectives, take stock of its successes and look to the future for needed improvements in three separate Perspectives (^4–6).

Disclosures

None.