Survival Benefit: Quality Versus Quantity and Trade-offs in Developing New Renal Allocation Systems

Almost every patient with end-stage renal disease (ESRD) who can survive a renal transplant operation will benefit from the transplant in terms of improved quality and quantity of life compared with continued dialysis (1). Moreover, because dialysis is very effective at preventing patients with ESRD from dying of their renal failure, patients being considered for renal transplantation do not face an immediate, short-term risk of dying once entered on the deceased donor waiting list. These two facts mean that the determination of need for renal transplantation and the prioritization of waiting renal transplant candidates cannot be adequately assessed by pretransplant mortality risk alone. Currently, most deceased donor kidney allocation protocols are primarily based on waiting time and this first-come, first-served, method for ranking patients gives no weight to waiting list mortality risk or probability of posttransplant patient or graft survival. It also does not take into account the heterogeneous spectrum of donor quality being offered at any given time. While there are advantages to waiting time-based systems such as simplicity and a degree of individual justice (‘if I wait long enough, I’ll get my turn’) there is increasing dissatisfaction with several aspects of the current system.