GOING NATIONAL
So where does paired exchange go from here? Johns Hopkins’ Montgomery organized a consensus meeting in March to discuss the possibility of creating a national network; Hiller, Rees, and Delmonico attended.
“I think our goal should be to one day have a national program,” Rees says. “But shipping somebody from Toledo down to Cincinnati is a lot easier to sell to a patient than shipping somebody from Toledo to Los Angeles. And the logistics of trying to do that when you have a whole different set of insurance companies … would be a lot more complicated. So, I think the way to begin is to do it on a more regional basis and prove that the concept works, that people can be satisfied with it, and then begin to expand it.”
Delmonico also thinks a national program is essential. “We need to enlarge the possibility of paired donation and exchange,” he says. “It will not happen successfully in a regional system. There aren’t enough patients that can be identified.” Questions to be answered before such a program could exist, Delmonico notes, include where the system will be based and who will administer it.
“There was a lot of agreement—though not total consensus—on the fact that UNOS, the United Network for Organ Sharing, would be the most likely place to ‘house’ and to manage the data,” Hiller reports. “They have all those systems in place already [and] are capable of managing this large database.”
Delmonico, as Vice President of UNOS, points out, “We have no authority to do that yet. Whether or not the country wants us to do that also remains to be determined.” But the UNOS Board of Directors is open to the idea; last year, they endorsed the concept of establishing a national paired exchange program with the understanding that details would have to be worked out over time, according to a UNOS spokesperson.
Another obstacle to widespread paired donation may be perceptions of it in the eyes of the government and critics: Could it be construed as a violation of the 1984 National Organ Transplant Act, which says that an organ should not be transplanted for a “value consideration”? Legal experts have assured Delmonico that paired exchanges can be interpreted as a gift.
“The government is also, properly, not wanting to see this as a slope toward buying and selling organs,” Delmonico says. “And I am adamantly opposed to that. In the instances that we’ve done paired exchange here, that’s not in the mix. That’s not our motivation, nor has it been the motivation of these donors. We wouldn’t do it if we felt that was the case.”
Montgomery says it will take several years to get a national system set up. But the bottom line for transplant surgeons is that a national paired kidney exchange program would do a world of good, two people at a time. “This is clearly what is best for our patients,” Montgomery says.
“The bigger we can get, if we can spread it nationally, the more people it will help,” Rees says. “And so we have to think of a way to do this so that we’re all satisfied that it’s moving forward in a way that will make everyone happy.”
Reprinted from Clinician News. 2005;9(5):cover, 3, 15.