How kidneys and other donated organs are allocated for transplants

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

New York state has more than 7,000 people on the waiting list for kidney transplants. It's an organ in short supply. With me to explain how kidneys are allocated is the chief of transplant services at Upstate, Dr. Reza Saidi. Welcome back to "The Informed Patient," Dr. Saidi.

Reza Saidi, MD: Thanks, Amber. Glad to be here.

Host Amber Smith: I know there are more people who need an organ transplant than there are people who are donating their organs. So what is the general system in the United States for organ allocation?

Reza Saidi, MD: Yeah, as you pointed out, the major obstacle that we have in a transplantation is to have enough organs to transplant

Because of incidence of kidney disease increasing in this country, every day more and more people are added to the list to receive organ transplantation. As we speak, there are more than a hundred thousand patients on the list to receive a kidney transplant. And we don't have enough organs, roughly in this country around 25,000 transplants are done, and because there are not enough organs around, there's a lot of regulation goes on with how, who are receiving these organs? As you know, there are two types of transplants for a patient who needs a kidney transplant. One is a live donor (for someone) who doesn't want to receive that organ from a deceased donor.

Obviously if a patient has a live donor -- that is a story that we can talk about later -- but to receive the deceased donor, there's a lot of regulation that goes in, as to who's going to receive this organ. Some of them have to do with the chance for the patient to survive, for example. And for example, kids usually get priority on the list to receive organ transplantation.

And some of them have to do with what's the predictive value of a successful kidney transplant. And all these factors go in. Or another thing is how long you've been waiting on the list, on dialysis, for example. All these goals factor in, and computers eventually generate a score for a patient. Based on that score, patients go up and down the list to get organ transplantation.

Recently, I think in March of last year, we changed the allocation system so that patients can get a broader sharing of all these kidneys that are available. For example, in the past, people in the state of New York were offered kidneys that were available in the state of New York or maybe Vermont, but now we go250 nautical miles from the donor hospital to increase the chance that patients would get organ transplantation. And this is something that we're actively monitoring, and so far, we've seen this system help our patients in Syracuse. And since these allocations changed in March of 2021, the number of transplants that we are able to do increased by 50%.

Host Amber Smith: Let me make sure I understand. So when we hear about this waiting list, is that for deceased donors?

Reza Saidi, MD: Yes. That's for deceased donors.

Host Amber Smith: OK. So what you're saying is, there's a list of people who need a kidney transplant; the person whose name is at the top of the list isn't necessarily the person who's going to get the next kidney. There's some other factors that go into it.

Reza Saidi, MD: After the list is generated, that first person on the list, they offer that kidney to that person. If that patient refuses, they go to the next person.

Host Amber Smith: I see. Now is this allocation for organs handled the same way for other organs, hearts, lungs, things like that?

Reza Saidi, MD: No, they're different. For example, for heart and lung or liver, because the chance of dying waiting for organ transplant is much higher, their allocation system is a little bit different and has to do with their severity of the disease and the chance that they might die without a transplant. If they're sicker, they go higher on the list. But for kidneys, it's different because we can still have some time because we can maintain the patient on dialysis.

Each organ has a different allocation system.

Host Amber Smith: So if you're living in Syracuse, and you need a kidney transplant, did I hear you correctly that there's a 250 nautical mile radius that that kidney could come from a deceased donor?

Reza Saidi, MD: Yes.

Host Amber Smith: OK. Now, if someone needs a kidney and a pancreas transplant, are they on a different waiting list, or how is that handled?

Reza Saidi, MD: Yes, that's actually a very good point because a patient who has diabetes and kidney disease, they have very high mortality on dialysis. That's why these patients who need to combine kidney and pancreas transplants, they get priority on the list. And because of that, the wait times for those patients are less, because they do worse on dialysis.

The average wait time for the patient who needs a kidney/pancreas transplant is about two years compared to five years for the patient just for the kidney transplant.

Host Amber Smith: Now could somebody get on a waiting list in another part of the country? Could they be on more than one list at a time? Like if they live here, but they also spend time in Florida, could they get on a waiting list down in Florida?

Reza Saidi, MD: Yes. Also that's allowable, if you're listed at the other centers outside the state where you're living. A lot of states have the rule that in your state, you can just be listed in one program. But if you can establish residency in other states, you can be listed in other states, and different states have different requirements to consider you as a resident.

Host Amber Smith: I see. Well, we're going to focus on kidneys, since Upstate transplant surgeons specialize in the kidney. How does someone go about getting on the list for a potential kidney transplant? What does the evaluation consist of?

Reza Saidi, MD: As soon as somebody realizes that they have chronic kidney disease, I would encourage them to get in touch with the transplant program and be evaluated; it's an extensive evaluation that makes sure that they can tolerate a transplant surgery, and they havecompliance, for example, that they can take their medication after transplant.

And we extensively evaluate these patients from a heart standpoint, lung standpoint and from a compliance standpoint, to make sure they're a candidate for a kidney transplant.

Host Amber Smith: Is there anything that would disqualify them from being on the waiting list, such as age?

Reza Saidi, MD: No, age is not actually a contraindication. Actually recently we have transplanted an 80-year-old gentleman who was very active. Age itself is not (a disqualifier) , but if they have significant comorbidity, like, for example, significant heart problems or significant lung problems, they cannot undergo surgery, or they have a history of active cancer, for example. They have to treat the cancer first and then come back for transplant. Or they have a history of substance abuse. Those are things that actually are a contraindication for transplant, or they have active psychiatric problems that they cannot comply with the regimen post-transplant. Those are the things for exclusion from organ transplant.

Host Amber Smith: Transplant recipients are considered immunocompromised, right? Pretty much for life?

Reza Saidi, MD: Yes. Unfortunately, still, despite all the progress that we've made, patients have to take these immunosuppression agents to prevent rejection for the rest of their life. The patients are immunosuppressed for the rest of their life. That's why they need to have close monitoring.

Host Amber Smith: Thinking about COVID, the vaccines for COVID and the boosters: Are they offering enough protection to organ transplant recipients?

Reza Saidi, MD: Yes, we know that after the third dose, 75% of patients will basically produce the antibodies. And even after a fourth dose, close to 85% will boost antibodies, but it's still about 10 to 15% of patients will not boost antibodies because their immune system is suppressed, and they have to be cautious, still wear a mask and be aware of social distancing and be very careful.

Host Amber Smith: In the news lately, there've been stories about people who needed organ transplants, but they refused to be vaccinated against COVID, and so they were not given the transplant. So why is it important for a recipient to be vaccinated?

Reza Saidi, MD: Yes, I think that's very important because patients who are immunosuppressed have a significant chance of dying because of COVID, compared to the general public. The general public, the chance that they have developed COVID and the chance of dying is about 1%, but for sick patients who are immunosuppressed because they're taking these immunosuppressive drugs after organ transplantation, their chance of dying is almost 10, 20 times higher.

That's why it's very important for these patients to get vaccinated before transplant, because after transplant, even if you vaccinate them, the chance that they may respond, and develop the antibodies against COVID is much less because of this anti-rejection medication that they're on.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith, talking with Dr. Reza Saidi, the chief of transplant services at Upstate, about how someone qualifies to join the kidney transplant waiting list.

Now can someone who is on the waiting list for a deceased donor kidney, can they move to the front of the line, so to speak, if they're able to find a compatible living donor, a friend or a relative who's willing to donate their kidney?

Reza Saidi, MD: Yes. And anybody who has a living donor can get their transplant, and they don't have to go on the waiting list. The waiting list is only for deceased donors. And as I pointed out, because there's a huge organ shortage, the wait time is higher if you go on a deceased donor list. That's why we always encourage our patients to find a living donor, that they can be transplanted on a faster pace. And usually the patients who had a living donor, after live donor kidney transplant, they have a better outcome. That's why our No. 1 choice that we recommend to the patient (is): Go out there and find somebody, a family member or friend, who can donate.

Host Amber Smith: So the survival rate for someone who receives a kidney from a living donor versus a deceased donor is much better for the person who got a living donation?

Reza Saidi, MD: Yeah, that's correct. Because we screen the living donors. You pick out the best. And also the patients who have a living donor, they don't have that much wait time on dialysis, because dialysis can make you sicker and sicker over time. The healthier folks have a living donor, and the quality of the organ that's received is always better than with a deceased donor. That's why the outcome is much better compared to the deceased donors.

Host Amber Smith: I wanted to ask you how the COVID pandemic has affected kidney transplants and transplant patients. I know you've still been able to do quite a few kidney transplants during the pandemic, but how has this impacted the practice?

Reza Saidi, MD: You know, in 2019, the pandemic started; the number of organ transplantations in 2019 and 2020 actually decreased nationwide, but in 2021 we were able to catch up, and the number of organ transplantations basically increased compared to 2020 and 2019.

As I pointed out, in our program, since the allocation change, we increased the number of all transplants by 50%, but also were able to increase the number of live donor kidney transplants by close to 80%.

Host Amber Smith: I understand nationally the number of kidney transplants set a record in 2021, with more than 24,000, and the United Network for Organ Sharing says part of that increase comes from donation from individuals who died of cardiorespiratory failure, as opposed to brain death. Can you explain the difference?

Reza Saidi, MD: Yeah, that's also a trend that we see, that some of these donors are not brain dead, but they have significant brain damage because of head trauma or stroke or anoxia (lack of oxygen). You know, we see a huge surge of donors that, unfortunately, died of opioid overdose. And some of them have (such) significant anoxic damage to their brain that they're not going to have a meaningful life, even if they survive. And based on the patient's previous wishes or the family's wishes, they withdraw care. And if they die between one or two hours after they withdraw care, we rush them to the OR and remove their organs.

And because of this opioid pandemic, I think we see a lot of the donors who are not brain dead, but they have significant brain damage. And after they withdraw care, we can, basically remove their organs and use their organs for transplantation.

Host Amber Smith: Well, what does the person need to do if they want to make sure their organs are donated when they die?

Reza Saidi, MD: One thing: They can basically sign, on their, driver's license, that I want to be an organ donor. The other thing is, just talk to a family member and tell him, "If I became sick enough that I have no chance of survival, or even if I survive, my quality of life is going to be significantly impaired, I want to be an organ donor."

That's what people have to understand: Basically, communicate those wishes to their loved ones. And unfortunately, if that moment happens, their loved ones at the end have to make that determination. And if they express willingness to do that, a majority of people honor that wish and will proceed with donation.

Host Amber Smith: Well, I appreciate you making time for this interview, Dr. Saidi.

Reza Saidi, MD: Thank you.

Host Amber Smith: My guest has been Dr. Reza Saidi. He's the chief of transplant services at Upstate. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York. Find our archive of previous episodes at upstate.edu/informed. I'm your host, Amber Smith, thanking you for listening.