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Kidney transplantation or renal transplantation is the organ transplant of a kidney into a patient who has end-stage renal disease. Kidney transplantation is typically classified as deceased-donor (formerly known as cadaveric), or living-donor transplantation, depending on the source of the donor organ.
Living-donor renal/kidney transplants are further characterized as genetically related (living-related) or nonrelated (living-unrelated) transplants, depending on whether a biological relationship exists between the donor and recipient.
Exchanges and chains are a novel approach to expand the living donor pool. In February 2012, this novel approach to expand the living donor pool resulted in the largest chain in the world, involving 60 participants, organized by the National Kidney Registry. In 2014, the record for the largest chain was broken again by a swap involving 70 participants.
One of the earliest mentions about the real possibility of a kidney transplant was by American medical researcher Simon Flexner, who declared in a reading of his paper on "Tendencies in Pathology" in the University of Chicago in 1907 that it would be possible in the then-future for diseased human organs to be substituted for healthy ones by surgery, including arteries, stomach, kidneys and the heart.
In 1933, surgeon Dr. Yuriy Voroniy from Kherson in the then Soviet Union, attempted the first human kidney transplant, using a kidney removed six hours earlier from a deceased donor, to be reimplanted into the thigh. He measured kidney function by using a connection between the kidney and the skin. His first patient died two days later, because the graft was incompatible with the recipient's blood group and was thus rejected.
It was not until June 17, 1950, when a successful transplant could be performed on Ruth Tucker, a 44-year-old woman who had polycystic kidney disease, by Dr. Richard Lawler at Little Company of Mary Hospital in Evergreen Park, Illinois. Although the donated kidney was rejected 10 months later because no immunosuppressive therapy was available at the time—the development of effective anti-rejection drugs was years away. However, the intervening time provided enough time for Tucker's remaining kidney to recover, resulting in her living an additional five years.
The first kidney transplants between living patients were performed in 1952 at the Necker hospital in Paris France, by Dr. Jean Hamburger. Unfortunately, the kidney transplant failed after only three weeks of satisfactory function  and later in 1954 in Boston Massachusetts. The Boston transplantation, which was performed on December 23, 1954, at Brigham Hospital, was performed by Drs. Joseph Murray, J. Hartwell Harrison, John P. Merrill and others. The procedure was conducted between identical twins Ronald and Richard Herrick, in order to eliminate any problems of an immune reaction. For this and later work, Dr. Murray received the Nobel Prize for Medicine in 1990. The recipient, Richard Herrick, died eight years after the transplantation procedure.
In 1955, Charles Rob, William James "Jim" Dempster (St. Marys and Hammersmith, London UK) carried out the first deceased donor transplant in the United Kingdom, which was unsuccessful. In July 1959, "Fred" Peter Raper (Leeds) performed the first successful (eight months) deceased donor transplant in the UK. One year later, in 1960, the first successful living kidney transplant in the UK occurred, when Dr. Michael Woodruff performed one between identical twins in Edinburgh.
Until the routine use of medications to prevent and treat acute rejection that were introduced in 1964, deceased donor transplantation was not performed. The kidney was considered to be the easiest organ to transplant, because: Tissue typing was simple, the organ was relatively easy to remove and implant, live donors could be used without difficulty, and in the event of failure, kidney dialysis was available from the 1940s onward, but not widely available for several decades. Tissue typing was acknowledged to be essential to the success, as early attempts in the 1950s on sufferers from Bright's disease had been very unsuccessful.
The major barrier to organ transplantation between genetically nonidentical patients lay in the recipient's immune system, which would treat a transplanted kidney as a "nonself" or foreign body to be attacked, and immediately or chronically reject it. Thus, having medications to suppress the immune system was essential. However, suppressing an individual's immune system places that individual at greater risk of infection and cancer (particularly skin cancer and lymphoma), in addition to the very difficult side effects of the medications.
The basis for most immunosuppressive regimens is prednisolone, a corticosteroid. Prednisolone suppresses the immune system, but its long-term use at high doses causes a multitude of side effects, including glucose intolerance and diabetes, substantial weight gain, osteoporosis, muscle weakness, hypercholesterolemia and cataract formation. Prednisolone alone is usually inadequate to prevent rejection of a transplanted kidney. Thus other, nonsteroid immunosuppressive agents are needed, which also allow lower doses of prednisolone.
The indication for kidney transplantation is end-stage renal disease (ESRD), regardless of the primary cause. This is defined as a glomerular filtration rate of < 15 ml/min/1.73 m2. Common diseases leading to ESRD include malignant hypertension, infections, diabetes mellitus, and focal segmental glomerulosclerosis. The genetic causes include polycystic kidney disease, a number of inborn errors of metabolism, plus autoimmune conditions such as lupus.
Diabetes is the most common known cause of kidney transplantation, accounting for approximately 25% of those in the US. The majority of renal transplant recipients are maintained on dialysis (peritoneal dialysis or hemodialysis) at the time of transplantation. However, individuals with chronic kidney disease who have a living donor available may undergo pre-emptive transplantation before dialysis is needed, while the odds of success are still favorable. If a patient is placed on the waiting list for a deceased donor transplant early enough, they may also be transplanted pre-dialysis.
Contraindications include both cardiac and pulmonary insufficiency, as well as hepatic disease and some cancers. Concurrent tobacco use and morbid obesity are also among the indicators that place a patient at a higher risk for surgical complications.
Kidney transplant requirements vary from program to program and country to country. Many transplant programs place limits on age (e.g. the person must be under a certain age, in order to be added to the waiting list), and require that one must be in good health (aside from the kidney disease). Significant cardiovascular disease, incurable terminal infectious diseases and cancer are often considered to be transplant exclusion criteria. In addition, transplant candidates are typically screened to determine if they will be compliant with their medications, which is essential for survival of the transplant. Patients who have mental illness and/or significant on-going substance abuse issues may often be excluded.
HIV was at one point considered to be a complete contraindication to transplantation. There was fear that immunosuppressing someone with a depleted immune system would result in the progression of the disease. However, some research seem to suggest that immunosuppressive drugs and antiretrovirals may work synergistically to help both HIV viral loads/CD4 cell counts and prevent active rejection.
Since medication to prevent rejection is so effective, donors do not need to be completely similar to their recipient. Most donated kidneys are procured from deceased donors. However, the use of living donors in the United States has been rising in recent years. In 2006, 47% of donated kidneys were from living donors. This varies by country: for example, only 3% of kidneys transplanted during 2006 in Spain came from living donors. In Spain, all citizens are potential organ donors in the case of their death, unless they explicitly opt out during their lifetime, but this is not the case in the US and many other countries worldwide.
Approximately one in three donations in the US, UK and Israel is now from a live donor. Potential donors are carefully evaluated, based on medical and psychological grounds. This ensures that the donor is fit for surgery and has no disease that could bring undue risk or likelihood of a poor outcome for either the donor or recipient. The psychological assessment is to ensure the donor gives informed consent and is not coerced. In countries where paying for organs is illegal, the authorities may also seek to ensure that a donation has not resulted from a financial transaction.
The relationship the donor has to the recipient has evolved over the years. In the 1950s, the first successful living donor transplants were between identical twins. In the 1960s–1970s, live donors were genetically related to the recipient. However, during the 1980s–1990s, the donor pool was expanded further to emotionally related individuals (spouses, friends). Now the elasticity of the donor relationship has been stretched to include acquaintances and even strangers ('altruistic donors'). In 2009, Minneapolis transplant recipient Chris Strouth received a kidney from a donor who connected with him on Twitter, which is believed to be the first such transplant arranged entirely through social networking.
The acceptance of altruistic donors has enabled chains of transplants to form. Kidney chains are initiated when an altruistic donor donates a kidney to a patient who has a willing but incompatible donor. This incompatible donor then 'pays it forward' and passes on the generosity to another recipient who also had a willing but incompatible donor. Michael Rees from the University of Toledo developed the concept of open-ended chains. This was a variation of a concept developed at Johns Hopkins University. On July 30, 2008, an altruistic donor kidney was shipped via commercial airline from Cornell to the University of California, Los Angeles, thus triggering a chain of transplants. The shipment of living donor kidneys, computer-matching software algorithms, and cooperation between transplant centers has enabled long-elaborate chains to be formed.
In carefully screened kidney donors, survival and the risk of end-stage renal disease appear to be similar to those in the general population. However, some more recent studies suggest that lifelong risk of chronic kidney disease is several-fold higher in kidney donors although the absolute risk is still very small. A 2017 article in the New England Journal of Medicine suggests that persons with only one kidney including those who have donated a kidney for transplantation should avoid high protein diet and limit their protein intake to less than one gram per kilogram body weight per day in order to reduce the long-term risk of chronic kidney disease. Women who have donated a kidney have a higher risk of gestational hypertension and preeclampsia than matched nondonors with similar indicators of baseline health. Traditionally, the donor procedure has been through a single incision of 4–7 inches (10–18 cm), but live donation is being increasingly performed by laparoscopic surgery. This reduces pain and accelerates recovery for the donor. Operative time and complications decreased significantly after a surgeon performed 150 cases. Live donor kidney grafts have higher long-term success rates than those from deceased donors. Since the increase in the use of laparoscopic surgery, the number of live donors has increased. Any advance which leads to a decrease in pain and scarring and swifter recovery has the potential to boost donor numbers. In January 2009, the first all-robotic kidney transplant was performed at Saint Barnabas Medical Center through a two-inch incision. In the following six months, the same team performed eight more robotic-assisted transplants.
In 2004 the FDA approved the Cedars-Sinai High Dose IVIG therapy which reduces the need for the living donor to be the same blood type (ABO compatible) or even a tissue match. The therapy reduced the incidence of the recipient's immune system rejecting the donated kidney in highly sensitized patients.
In 2009 at the Johns Hopkins Medical Center, a healthy kidney was removed through the donor's vagina. Vaginal donations promise to speed recovery and reduce scarring. The first donor was chosen as she had previously had a hysterectomy. The extraction was performed using natural orifice transluminal endoscopic surgery, where an endoscope is inserted through an orifice, then through an internal incision, so that there is no external scar. The recent advance of single port laparoscopy requiring only one entry point at the navel is another advance with potential for more frequent use.
In the developing world, some people sell their organs illegally (on the black market), an underground practice that began in small quantities as early as the mid-1980s, as first reported on "60 Minutes" at that time. Then in following years, major newspapers in the U.S., and medical trade journal articles, began reporting an increased incidence of the practice. The incidence because so widespread and notorious, as often reported in "Nephrology News & Issues," that federal legislation in the U.S. to ban the sale of organs and tissues, was proposed by Senator Al Gore, which became federal law in 1984, which was named the "National Organ and Transplant Act." The federal legislation in the U.S. remains in effect to this day.
Such potential human donors who are often living in India and Asia, routinely live in what is considered to be grave or extreme poverty and who are therefore exploited by profit-motivated salespersons who may take advantage of the donor's desperate need to survive or pay for such basics as food, medical care and housing. The people who travel to make use of these kidneys are often known as "transplant tourists." This practice is opposed by a variety of human rights groups, including Organs Watch, a group established by medical anthropologists, which was instrumental in exposing illegal international organ selling rings. These patients may have increased complications owing to poor infection control and lower medical and surgical standards. One surgeon has said that organ trade could be legalized in the UK to prevent such tourism, but this is not seen by the National Kidney Research Fund as the answer to a deficit in donors.
In the illegal black market, the donors may not receive sufficient after-operation care, the price of a kidney may be above $160,000, middlemen take most of the money, the operation is more dangerous to both the donor and receiver, and the buyer often is infected with hepatitis or HIV. In legal markets of Iran, the price of a kidney is reported to be $2,000 to $4,000.
An article by Gary Becker and Julio Elias on "Introducing Incentives in the Market for Live and Cadaveric Organ Donations" said that a free market could help solve the problem of a scarcity in organ transplants. Their economic modeling was able to estimate the price tag for human kidneys ($15,000) and human livers ($32,000).
Deceased donors can be divided in two groups:
Although brain-dead (or "heart beating") donors are considered to be dead, the donor's heart continues to pump and maintain the circulation. This makes it possible for surgeons to start operating while the organs are still being perfused (supplied with blood). During the operation, the aorta will be cannulated, after which the donor's blood will be replaced by an ice-cold storage solution, such as UW (Viaspan), HTK or Perfadex. Depending on which organs are transplanted, more than one solution may be used simultaneously. Due to the temperature of the solution, and since large amounts of cold NaCl-solution are poured over the organs for a rapid cooling, the heart will stop pumping.
"Donation after Cardiac Death" donors are patients who do not meet the brain-dead criteria, but due to the unlikely chance of recovery, have elected via a living will or through family wishes, to have support withdrawn. In this procedure, treatment is discontinued (mechanical ventilation is shut off). After a time of death has been pronounced, the patient is rushed to the operating room, where the organs are recovered/removed. Storage solution is then flushed through the organs. Since the blood is no longer being circulated, coagulation must be prevented with large amounts of anti-coagulation agents such as heparin. Several ethical and procedural guidelines must be followed; most importantly, the organ recovery team should not participate in the patient's care in any manner until after death has been officially declared.
In general, the donor and recipient should be in the ABO blood group and crossmatch (human leukocyte antigen -- HLA) compatible. If a potential living donor is incompatible with his/her recipient, the donor could be exchanged for a compatible kidney. Kidney exchange, also known as "kidney paired donation" or "chains," have recently gained in popularity.
In an effort to reduce the risk of rejection during incompatible transplantation, ABO-incompatible and desensitization protocols using intravenous immunoglobulin (IVIG) have been developed, with the aim to reduce ABO and HLA antibodies that the recipient may have to the donor.
In the 1980s, experimental protocols were developed for ABO-incompatible transplants using increased immunosuppression and plasmapheresis. Through the 1990s these techniques were improved, and an important study of long-term outcomes in Japan was published. Now, a number of programs around the world are routinely performing ABO-incompatible transplants.
The level of sensitization to donor HLA antigens is determined by performing a panel reactive antibody test on the potential recipient. In the US, up to 17% of all deceased donor kidney transplants have no HLA mismatch. However, HLA matching is a relatively minor predictor of transplant outcomes. In fact, living nonrelated donors are now almost as common as living (genetically)-related donors.
In most cases, the barely functioning existing kidneys are not removed, as removal has been shown to increase the rates of surgical morbidity. Therefore, the kidney is usually placed in a location different from the original kidney. Often this is in the iliac fossa, so it is often necessary to use a different blood supply:
The donor ureter is anastomosed with the recipient bladder.
There is disagreement in surgical textbooks regarding which side of the recipient’s pelvis to use in receiving the transplant. Campbell's Urology (2002) recommends placing the donor kidney in the recipient’s contralateral side (i.e. a left-sided kidney would be transplanted in the recipient's right side) to ensure the renal pelvis and ureter are anterior, in the event that future surgeries are required. In an instance where there is doubt over whether there is enough space in the recipient’s pelvis for the donor's kidney, the textbook recommends using the right side, because the right side has a wider choice of arteries and veins for reconstruction. Smith's Urology (2004) states that either side of the recipient's pelvis is acceptable; however, the right vessels are "more horizontal" with respect to each other and are therefore easier to use in the anastomoses. It is unclear what is meant by the words "more horizontal." Glen's Urological Surgery (2004) recommends placing the kidney in the contralateral side in all circumstances. No reason is explicitly put forth; however, one can assume the rationale is similar to that of Campbell, i.e., to ensure that the renal pelvis and ureter are most anterior, in the event that future surgical correction becomes necessary.
Regarding who receives a donated organ, "The organs are distributed locally first, and if no match is found they are then offered regionally, and then nationally, until a recipient is found. Every attempt is made to place donor organs," explains the United Network for Organ Sharing, which contracts to administer the US organ donation procedures at all transplant and procurement centers.
On March 21, 1984, UNOS was incorporated as an independent, nonprofit organization, currently based in Richmond Virginia, committed to saving lives through uniting and supporting the efforts of donation and transplantation professionals. Learn more >
Also in 1984, in the US, the National Organ Transplant Act (NOTA) called for an Organ Procurement and Transplantation Network (OPTN) to be created and run by a private, nonprofit organization under federal contract. The federal Final Rule provides a regulatory framework for the structure and operation of the OPTN. UNOS was first awarded the national OPTN contract in 1986 by the U.S. Department of Health and Human Services. Today, UNOS continues as the only organization ever to operate the OPTN.
As of March 18, 2018, there were 114,859 people waiting for an organ transplant in the US, according to UNOS. For 2017, there were 19,850 kidney transplant procedures, with roughly three times as many deceased donor procedures as living-related: 12,250 vs. 5,628.
UNOS reports that:
-- 1 organ donor can save up to 8 lives.
-- Every 10 minutes another name is added to the national organ transplant waiting list.
-- Sadly, an average of 20 people die each day because the organs they need are not donated in time. More than 7,000 candidates died in 2016 while on the wait list, or within 30 days of leaving the list for personal or medical reasons, without receiving an organ transplant.
TO REGISTER TO BECOME AN ORGAN DONOR, PLEASE VISIT: [www.registerme.org]
|All Donor Types||428,299||3,106||19,850||19,060||17,878||17,109||16,896||16,487||16,816||16,900||16,830||16,521||16,634||17,095||16,485||16,007||15,138||14,781||14,279||13,631||12,767||12,454||11,709||11,411||11,084||10,646||10,359||9,738||9,678||9,416||8,656||8,878|
Data subject to change based on future data submission or correction.
|All Donor Types||726,952||5,448||34,771||33,610||30,974||29,540||28,955||28,053||28,540||28,662||28,460||27,964||28,366||28,940||28,118||27,041||25,473||24,911||24,239||23,274||22,029||21,524||20,316||19,765||19,396||18,299||17,630||16,134||15,756||15,001||13,140||12,623|
Data subject to change based on future data submission or correction.
Occasionally, the kidney is transplanted together with the pancreas. University of Minnesota surgeons Drs. Richard Lillehei and William Kelly performed the first successful simultaneous pancreas-kidney transplant in the world in 1966. This is conducted in patients who have diabetes mellitus type 1. In those patients, the diabetes is due to destruction of the beta cells of the pancreas and in whom the diabetes has caused renal failure (diabetic nephropathy). This is almost always a deceased donor transplant. Only a few living donor (partial) pancreas transplants have been conducted, though. For individuals who have diabetes and renal failure, the advantages of earlier transplant from a living donor (if available) are far superior to the risks of continued dialysis until a combined kidney and pancreas transplant procedure becomes available from a deceased donor. A patient can either receive a living kidney followed by a donor pancreas at a later date (PAK, or pancreas-after-kidney), or a combined kidney-pancreas from a donor (SKP, simultaneous kidney-pancreas).
Transplanting just the islet cells from the pancreas is still in the experimental stage, but the procedure shows promise. This procedure involves taking a deceased donor pancreas, breaking it down, and extracting the islet cells that make insulin. The cells are then injected through a catheter into the recipient and they generally lodge in the liver. The recipient still needs to take immunosuppressants to avoid rejection, but no surgery is required. Most people require 2-3 such injections, and many are not completely insulin-free.
The transplant surgery typically takes about three hours. The donor kidney will be placed in the lower abdomen, and its blood vessels are connected to arteries and veins in the recipient's body. When this process is complete, blood will be allowed to flow through the kidney again. The final step is connecting the ureter from the donor kidney to the bladder. In most cases, the kidney will soon start producing urine, and often instantaneously, according to surgeons, depending on its quality.
Living donor kidneys normally require 3–5 days to reach normal functioning levels, while cadaveric donations stretch that interval to 7–15 days. Hospital stay is typically for 4–10 days. If complications arise, additional medications (diuretics) may be administered, in order to help the kidney produce urine.
Immunosuppressant drugs are used to suppress (block) the immune system from rejecting the donor kidney. These medicines must be taken for the rest of the recipient's life. The most common medication regimen today is a mixture of tacrolimus, mycophenolate and prednisolone. Some recipients may instead be administered cyclosporin, sirolimus or azathioprine. The risk of early rejection of the transplanted kidney is increased if corticosteroids are avoided or withdrawn after the transplantation. Cyclosporin, which was considered to be a major breakthrough immunosuppressive when first discovered in the 1980s, ironically causes nephrotoxicity. That can result in iatrogenic damage to the newly transplanted kidney. Tacrolimus, which is a similar drug, also causes nephrotoxicity. Blood levels of both must be monitored closely. Thus, if the recipient seems to be experiencing declining renal function or proteinuria, a biopsy may be necessary to determine whether this is due to rejection, or ciclosporin or tacrolimus intoxication.
Post-operatively, kidneys are periodically imaged by ultrasound, in order to assess the physiologic changes that often accompany transplant rejection. Imaging also allows the evaluation of supportive structures such as the anastomosed transplant artery, vein and ureter, so as to ensure they are stable in appearance.
The major sonographic scale in quantitative ultrasound assessment is with a multipoint assessment of the resistive index (RI), beginning at the main renal artery and vein, then ending at the arcuate vessels. It is calculated as follows:
The normal value is ≈ 0.60, with 0.70 being the upper limits of normal.
Kidney transplant recipients are discouraged from consuming grapefruit, pomegranate and green tea products. These food products are known to interact with the transplant medications, specifically tacrolimus, cyclosporin and sirolimus; the blood levels of these drugs may be increased, potentially leading to an overdose.
Acute rejection occurs in 10-25% of people after the transplantation procedure is completed, during the first 60 days. Rejection does not necessarily mean the loss of the organ, but it may necessitate additional treatment and medication adjustments.
Problems after a transplant procedure may include:
A patient's age and health condition before transplantation affect the risk of complications. Different organ transplant centers have different success at managing complications, and therefore, complication rates are different from center to center. For a current list of the 254 approved US organ transplant centers, including phone numbers and some URLs, visit: [medicalcalendar.org]
Regarding longevity of the transplanted organ, the average lifetime for a donated kidney is 10–15 years. When a transplant fails, a patient may opt for a second transplant, and may have to return to dialysis for some intermediary time.
Infections due to the immunosuppressant drugs used in people with kidney transplants most commonly occur in mucocutaneous areas (41%), the urinary tract (17%) and respiratory tract (14%). The most common infective agents are bacterial (46%), viral (41%), fungal (13%) and protozoan (1%). Of the viral illnesses, the most common agents are human cytomegalovirus (31.5%), herpes simplex (23.4%) and herpes zoster (23.4%). BK virus is now being increasingly recognized. Infection is the cause of death in about one third of patients who received renal transplants, while pneumonias account for 50% of the patient deaths from infection.
Kidney transplantation is a life-extending procedure. The typical patient will routinely live at least 10–15 years longer with a kidney transplant than if kept on dialysis. The increase in longevity is greater for younger patients, but even 75-year-old recipients (the oldest group for which there is data) gain an average of at least four more years of life. The transplant recipients are generally considered to have more energy, have to follow a less restricted diet, and experience fewer complications with a kidney transplant than if they remain on conventional dialysis.
Some studies seem to suggest that the longer a patient remains on dialysis before the transplant, the less time the kidney will last, or the less opportunity there will be to receive a transplant. It is not clear why this occurs, but it underscores the need for rapid referral to a transplant program. Ideally, a kidney transplant should be pre-emptive, i.e., take place before the patient begins dialysis. The reason why kidneys fail over time after transplantation has been elucidated in recent years. Apart from recurrence of the original kidney disease, also rejection (mainly antibody-mediated rejection) and progressive scarring (multifactorial) play a decisive role. Avoiding rejection by strict medication adherence is of utmost importance to avoid failure of the kidney transplant.
At least four professional athletes have made a comeback to their sport after receiving a transplant: New Zealand rugby union player Jonah Lomu, German-Croatian Soccer Player Ivan Klasnić, and NBA basketballers Sean Elliott and Alonzo Mourning.
|Country||Year||Cadaveric donor||Living donor||Total transplants|
In addition to nationality, transplantation rates differ based on race, sex and income. A study conducted with patients beginning long-term dialysis showed that the socio-demographic barriers to renal transplantation are relevant even before patients are on the transplant list. For example, different socio-demographic groups express different interest and complete pre-transplant workup at different rates. Previous efforts to create fair transplantation policies have focused on patients currently on the transplantation waiting list.
Regarding the wait for transplant candidates to receive a new organ: "Once you are added to the national organ transplant waiting list, you may receive an organ that day, or you may wait many years. Factors affecting how long you wait include how well you match with the donor, how sick you are, and how many donors are available in your local area compared to the number of patients waiting," notes UNOS.
In the United States, according to the United Network for Organ Sharing (UNOS)
-- In 1954, the kidney was the first human organ to be transplanted successfully.
-- UNOS manages the national transplant waiting list, matching donors to recipients 24 hours a day, 365 days a year.
-- Every transplant hospital in the US must meet specific requirements.
-- Transplantation has saved and enhanced the lives of more than 700,000 people in the U.S.
-- Each organ type has its own allocation policy, reflecting the unique medical considerations of each type of transplant.
Transplant recipients must take immunosuppressive anti-rejection drugs for as long as the transplanted kidney functions. The routine immunosuppressives are tacrolimus (Prograf), mycophenolate (Cellcept), and prednisolone; these drugs typically cost US$1,500 per month. In 1999, the United States Congress passed a law that restricts Medicare from paying for more than three years for these drugs, unless the patient is otherwise Medicare-eligible. Transplant programs may not transplant a patient unless the patient has a reasonable plan to pay for medication after the Medicare expires. However, patients are almost never turned down for financial reasons alone. Half of end-stage renal disease (ESRD) patients only have Medicare coverage.
In March 2009, a bill was introduced in the U.S. Senate, SB 565 and in the House, H.R. 145,8 that will extend Medicare coverage of the drugs for as long as the patient has a functioning transplant. This means that patients who have lost their jobs and insurance will not also lose their kidney and be forced back on dialysis. Dialysis is currently receiving $17 billion annually of Medicare funds. Total care of these patients amounts to over 10% of the entire Medicare budget.
The United Network for Organ Sharing, which oversees the organ transplants in the United States, allows transplant candidates to register at two or more transplant centers, a practice known as "multiple listing." The practice has been shown to be effective in mitigating the dramatic geographic disparity in the waiting time for organ transplants, particularly for patients who reside in high-demand regions such as Boston. The practice of multiple-listing has also been endorsed by medical practitioners.