Copyright C Blackwell Munksgaard 2002American Journal of Transplantation 2002; 2: 889–890

Blackwell Munksgaard ISSN 1600-6135

Editorial

Managing the Enlarging Waiting List

Francis L. Delmonicoa,* and James J. Wynnb

a Department of Surgery, Harvard Medical School,

Massachusetts General Hospital, MA, b Department of

Surgery, Medical College of Georgia, GA

*Correspondence: Francis L. Delmonico, Francis_

Delmonico@neob.com

Received 23 July 2002, revised and accepted forpublication 6 August 2002

In this issue of the American Journal of Transplantation, DrDanovitch and his colleagues propose calculating renal trans-plant waiting time from the point the patient begins chronicdialysis (reference page number of this issue of AJT). TheEurotransplant experience cited in the Danovitch paper pro-vides a sound reference for the incorporation of this proposalin the US kidney allocation system. Following the endorse-ment of this approach at a national conference on the waitinglist in Philadelphia in March 2002, the United Network forOrgan Sharing (UNOS) Kidney and Pancreas TransplantationCommittee has recently approved and submitted such a pro-posal for public comment.

Making the system fairer to patients by computing waitingtime from the onset of dialysis will address one aspect ofthe inequitable access to kidney transplantation. The currentprocess of listing includes several steps (Table1) before un-dergoing transplantation, each of which can be a majorhurdle for a particular patient to overcome. Patients may bedisadvantaged by the practices of the center at which theydialyze, where they live, their insurance coverage, comorbidillnesses, and the efficiency of the communication betweenthe referring nephrologist and the transplant center.

Transplant centers have become aware that they should bemore involved in the transition of a patient to the list. How-ever, the focus of the transplant center upon the obstaclesand inequities of patients gaining access to the list is limitedbecause transplant centers are currently overwhelmed with

Table1: From diagnosis of end stage renal failure to listing for kid-ney transplantation

Referral of a patient from a nephrologist to a transplant centerEvaluation by a transplant physician and surgeonAssessment of insurance coverageDetermination of HLA type and panel reactive antibodyPlacement of patients awaiting accessible kidneys on a list

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the demands of care for those already listed. The waiting listhas become so large that insuring that each patient on thewaiting list is medically suitable for transplantation continu-ously has become a daunting if not impossible task. Thus,we wish to propose additional strategies to be formally con-sidered that are in concert with the Danovitch goals:

Currently, most kidneys are transplanted into unsensitized pa-tients (�10%) who has been on the list for the longest wait-ing time. However, the clinical condition of such patients mayhave changed during the several years (computed by theinitiation of dialysis or not) of waiting. Thus, we suggest thefollowing:

1. The transplant center should insure that the longest wait-ing unsensitized patients in each blood group be recently re-evaluated; and that they are currently medically suitable fortransplantation.

2. Those patients most likely to receive a 0 HLA-mismatchedkidney should be identified, based upon a predictive fre-quency of HLA matching, and should be medically evaluatedto insure ongoing suitability for transplantation.

The UNOS Kidney and Pancreas Committee is also recom-mending that allocation points for HLA B locus matching beeliminated from the kidney allocation algorithm and that amaximum of two points be awarded for identity at the DRlocus. As patients are awarded one point for each year ofwaiting on the list, those who have waited at least 2years willpredictably rank higher on the allocation list for all kidneys,irrespective of their match with the donor. These changes willallow the center to focus their evaluation resources on thosepatients with the longer waiting times while increasing thenumber of kidney offers to minority candidates.

The second strategy of predicting 0-mm identity will requirethe input of the histocompatibility community, but such acontribution will have enormous impact upon the overwhelm-ing task that the transplant center currently faces (1). Other-wise, it is impossible for the transplant center to keep a cur-rent account of the medical condition of all patients on thelist. There must be a strategy (widely practiced) to contendwith what has become an insurmountable problem, the everenlarging list.

Although the Organ Procurement Transplant Network FinalRule requires the waiting list priority to be ordered from mostto least medically urgent, the rule also recognizes that life-sustaining technologies (such as hemodialysis) may allow

Delmonico and Wynn

alternative approaches to waiting list rankings (2). Despitethe observation that renal transplantation provides substantialrelative improvement in patient survival, absolute survival re-mains excellent for patients having undergone transplan-tation and for wait-listed patients (3). Waiting time remainsan international determinant of priority ranking of potentialkidney recipients. Therefore, it is our responsibility to insurethat waiting time is awarded equitably as proposed by Dano-vitch, and that those patients who have waited the longestand have risen to the top of the list are appropriately preparedto receive a kidney transplant.

890 American Journal of Transplantation 2002; 2: 889–890

References

1. Mahanty H, Lou C, Chang J, Roberts J, and Baxter-Lowe LA. Whatare your chances of getting a zero mismatched kidney (Abstract 138).Am J Transplant 2001; 1 (Suppl. 1): 170. Presented at the AmericanTransplant Congress in Chicago, May 2001.

2. Organ Procurement and Transplantation Network. Final Rule. FederalRegister 1999; 64: 56650–56661.

3. Ojo AO, Ettenger RE, Agodoa LY et al. Comparison of mortality in allpatients on dialysis, patients on dialysis awaiting transplantation, andrecipients of a first cadaveric transplant. N Engl J Med 1999; 3411725–1730.