For the roughly 35,000 Canadians who suffer from end-stage kidney disease, the logic is simple and cruel. In order for them to get a transplant, one of two things has to happen. Someone has to die in a way that leaves at least one kidney available for transplantation, or someone who matches up with them genetically has to be persuaded to give them a spare. There’s no third choice.
The bad news for patients is that there are fewer “cadaveric donors” every year; according to the Canadian Organ Replacement Register, there were 15.3 donors per million population in 2000, and 14.7 in 2008. Continual small improvements to trauma care, automobile and highway engineering, and treatment for strokes and brain aneurysms all mean that kidney patients have to spend a little longer on dialysis. Nationwide, transplants were performed at a rate of eight per 100 patient-years of kidney dialysis in 2000; in 2008 the figure was just six.
That’s why Canada is, slowly and quietly, getting more serious about encouraging kidney donation by the living. Last week, Alberta announced that it would become the fourth provincial government—following B.C., Manitoba and Ontario—to fund a pilot program reimbursing donors for lost work time, travel expenses and other costs of living kidney donation. (Living donations of lungs and parts of livers, though performed extremely rarely, are covered, too.) Nova Scotia is, before long, expected to become the fifth.
For the transplantation network and the health care system, reimbursement programs are win-win. They liberate the recipient from the tiresome living prison of dialysis, and replace years of expensive treatment with a one-time surgery at a very low morbidity cost to the donor. Nola Johnson, the donor in Canada’s first-ever kidney transplant, saved the life of her ailing identical twin in 1958, when they were both 15; she is alive and well today, and still grateful she was able to give 29 more years of life to her sister Moira.
B.C.’s reimbursement program was the country’s first and is serving as the model for other provinces. The Living Organ Donor Expense Reimbursement Program (LODERP) is carefully designed to eliminate any perception of paying for organs per se; the payouts are capped at a maximum of $5,500, a number close to high-end estimates of the average donor’s cash costs, and the reimbursement is receipt-based. Indeed, it is not unlike redeeming corporate expenses from an accounting department. (“Parking: up to a maximum of $12 per day for a maximum of 10 days.”) The disbursements are being handled by provincial branches of the Kidney Foundation, and are kept strictly separate from the transplant infrastructure and the health ministries.
LODERP began with $300,000 from the B.C. government, which was intended to cover three years’ worth of donor reimbursements. “What ended up happening is that we didn’t use anywhere near that amount,” says Lorraine Gerard, executive director of the Kidney Foundation’s B.C. branch. Most donors did not file for the full $5,500, and workplace health insurers have proven surprisingly amenable to covering the seven or so weeks of recovery time a donor typically requires. LODERP is on the verge of becoming a permanent B.C. government program, and although its three-year pilot status has just expired, it has enough leftover cash to keep funding reimbursements while it awaits a final political decision.
Meanwhile, another program to encourage living kidney donation is finding its feet, 18 months after its launch. The Living Donor Paired Exchange (LDPE) Registry, run by Canadian Blood Services, is designed to help recipients who have willing donors with whom they are incompatible. Where A is willing but genetically unable to give a kidney to spouse, friend, or relative B, registry computers search for another cross-compatible pair they can swap with: A donates to D, B gets C’s kidney.
This can lead to long sequences of “domino” surgeries, especially when, as occasionally happens, an altruistic donor goes on the registry without a prearranged partner. On Nov. 19, 2008, four Canadians got new kidneys on the same day, thanks to a “non-directed” contribution from retired Hamilton schoolteacher Kathryn McIntyre. (The U.S. record for a “domino” transplant series, set last year, is eight recipients.)
For now, under Canada’s LDPE program, the surgeries are done simultaneously, to avoid the risk of the second donor withdrawing or becoming medically ineligible after his or her partner receives the transplant. So far, only 107 donor-recipient pairs and 14 non-directed donors have joined the LDPE registry, but a remarkable 39 transplants have resulted with nine more on the way.
Most of the medical profession opposes the existence of an unrestricted free market in organs, but these schemes deliver some of the benefits of a market without the moral hazards, and without raising major questions of unequal access. Whether they will shorten queues noticeably is still an open question. Living donors now provide about two-fifths of transplanted kidneys in Canada, but kidney demand is rising, in part because of widespread obesity and type 2 diabetes.
And there is probably still room to expand cadaveric donation, which, in the case of kidneys, offers twice the benefit of a living donation. Deceased-donor rates in other countries are much higher, and while international comparisons are tricky—the U.S. has more transplants per capita, but more transplant-friendly violent deaths, too—Canada is thought to be lagging because its patchwork system of signatures on driver’s licences or health care cards has encouraged passivity. These documents are often unavailable in the intensive care unit or the emergency room, making it essential for Canadians who wish to offer their organs posthumously to make their wishes known to family members and loved ones, as well as notifying provincial donor registries (in B.C. and Ontario).