People with kidney disease are more likely to be added to the waiting list for a kidney transplant if they've had a previous heart, lung or liver transplant, a new study suggests.
Most patients don't get "listed" for a kidney transplant until they've been on dialysis. But more than one in three patients with prior organ transplants got on the kidney waiting list before they needed dialysis, according to researchers who examined a U.S. registry of transplant recipients.
Such preemptive listing is known to improve survival chances, but happened only in about one in five kidney disease patients who hadn't received a transplant previously.
"This certainly may not have been intentional in any way but raises a serious ethical concern related to justice," said Kerry Bowman, a clinical ethicist at Mount Sinai Hospital in Toronto, Canada, who was not involved in the research.
More than 85,000 Americans are currently listed for a new kidney, according to the U.S. Department of Health & Human Services.
Getting a kidney transplant depends mainly on how long a patient has been on the list, whereas for hearts, lungs and livers, the sickest patients get top priority, said Dr. Titte Srinivas, who led the new study.
"People can wait for years before they get a kidney," said Srinivas, of the Cleveland Clinic in Ohio. Of those older than 60 years, he added, "about half of them won't live to be offered a kidney."
The new study, published in the Clinical Journal of the American Society of Nephrology, followed more than 330,000 people placed on the kidney waiting list between 1995 and 2008.
The number of candidates who'd had previous heart, lung or liver transplants more than tripled during that period, reaching almost 5,000 in total.
Women had better odds of being added to the list, as did patients who were white, had private insurance or had received a previous organ transplant.
One possible explanation, the researchers write, is that patients who've already had one transplant are in close contact with their transplant centers, where the doctors might recognize the need for a new kidney before a primary care doctor would.
"Physician advocacy is a positive aspect of medicine but cannot trump the elements of justice built into waiting lists," Bowman told Reuters Health in an e-mail. "Justice is the foundation and goal of transplant waiting lists and transplant ethics in general. Policy and procedures in this domain need attention on ethical grounds."
Srinivas said doctors might speed up things, wittingly or unwittingly, because patients with previous organ transplants tend to do poorly when holding on for a new kidney. On average, his results show, these people survived less than four years -- or about half as long as those on the waiting list who hadn't received a previous transplant.
"I don't think anybody is doing something really unfair," he said.
Dr. Gail Van Norman, an anesthesiologist and bioethicist at the University of Washington Medical Center in Seattle, said the uneven odds of making the waiting list could also reflect the type of patients who've had an earlier transplant.
"They are generally savvy, mainstream healthcare consumers, probably even before they received a transplant," Van Norman, who was not part of the new study, said in an e-mail to Reuters Health.
"It is well known that the transplant system is biased toward white, middle-to-upper class patients," she said. "They also have fewer fears about healthcare and are more likely to seek it out. They trust doctors more."
At this point, the best patients can do is pay attention to their kidney health, Srinivas said. And if they've had a prior transplant, he advised, they should be ready to accept lower-quality organs -- such as those from diabetic donors -- in order to up their chances of getting a kidney as soon as possible.
SOURCE: http://link.reuters.com/cew98n Clinical Journal of the American Society of Nephrology, online September 2, 2010.
