To the Editor:

Development of successful deceased donor (DD) kidney transplantation led to debate and discussion about the best system of organ allocation. When the Organ Procurement and Transplantation Network developed policies for allocation, discussion centered on balancing utility (the best results with each kidney) and justice (each candidate on the list having a fair opportunity to be transplanted). At that time the majority of DD kidneys were from relatively young trauma victims. Subsequently, the number of candidates on the list increased more than the donation rates, resulting in significantly increased waiting times and attempts to increase deceased donation (expanded criteria donors, donation after cardiac death).

In the context of this increasing waiting time and a limited number of ideal standard criteria donor kidneys, a number of special interest groups began advocating for priority allocation (rationing) for their candidates. Each argued that their candidate group does poorly on dialysis (pediatric patients, diabetic patients), are hard to find a kidney for (sensitized patients) or should have priority because of multiple organ failure (heart, lung, liver and pancreas). Each has argued that their individual candidate group is small, and prioritizing would have little effect on waiting time for remaining candidates; each has succeeded with that argument. Subsequent policy decisions have essentially resulted in using the ideal DD kidneys for these groups.

But who is pleading for donation to the common folk? The cumulative effect of allocating the “ideal” kidneys to special interest groups is not insignificant. Every age group and every disease category benefits from a successful transplant (vs. dialysis); for any patient, graft survival is better when receiving a younger versus older donor kidney [1, 2].

What are the results of these “privileged” transplants? The highest rate of death censored graft loss after kidney transplantation is in adolescent and young adult recipients [3], the lowest in those >60. Outcomes of kidneys rationed for liver/kidney transplants are worse than if the kidney had been used for a solitary transplant [4]. This is likely true for heart/kidney and lung/kidney transplants, and recent articles have questioned the implications of prioritizing multiple organ transplants in the context of the principles of equity and utility [4, 5]. Outcomes for highly sensitized patients, even when transplanted with a negative crossmatch, are not as good as for the nonsensitized patients. Furthermore, policy decisions about rationing may have unintended consequences. Prioritizing ideal DD transplants to children has resulted in decreased rates of living donation. And as many feared, those with diabetes are being told that they will be transplanted sooner if listed for a combined transplant rather than a kidney alone. One small step might be to promote a living donor as the primary (kidney) choice for a kidney transplant for children or for those in need of a multiple organ transplant.

The successes of transplantation in the last five decades are amazing. And every successful transplant is a joy—not only for the recipient, but also for family, friends and the transplant team. But we need to remember, we are rationing, not allocating kidneys. Every time one candidate receives a kidney, another 100 000 continue waiting. Each special interest group has made an important and highly logical argument. But where do we draw the line at appeasing special interest groups to the detriment of the common candidate?

  • A. J. Matas*

  • Department of Surgery, University of Minnesota, Minneapolis, MN

  • *Corresponding author: Arthur J. Matas,


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  2. Disclosure
  3. References

The author of this manuscript has no conflicts of interest to disclose as described by the American Journal of Transplantation.


  1. Top of page
  2. Disclosure
  3. References