United Network for Organ Sharing
700 North 4th Street
Richmond, Virgina 23219

Dear Kidney RFI Coordinator,

I am writing this letter in response to the document titled: Kidney Allocation System - Request for Proposals.   In review of the complicated donor profile index as described in the document, I believe that as the algorithm strays from strict objective criteria, i.e. HLA matching - the overall survival of the transplant recipient will be lower.  This statement is supported by an extensive body of work from Cecka, et al. regarding donor-recipient matching.  

From a patient centric viewpoint, I believe that the recipient would benefit the most from a well matched organ than one randomly assigned.  From a cellular viewpoint, the success of the organ depends upon the composite sum of the each cell working in a supportive milieu (the physiology).  Immunosuppression allows that to proceed and unfortunately has separate risk profile which is not clearly reflected in the quality of life studies.  

Unfortunately the changes made in donor allocation are subtle and may take years to develop trends.  Meanwhile, there are new machine perfusion methods for prolonging organ preservation that may obviate the issue of organ degradation from prolonged transport times.  Hence, it is my expert opinion that the first criterion for organ allocation should be made by blood type followed closely by HLA matching and then combined with other objective (scientific) criteria. 

Furthermore, the Life Years from Transplant Formula (LYFT)  is inadequately described in the document.  The full formula is not presented for an adequate public assessment.  The formula description implies that there is a measureable value to be gained from the transplant.  Taken to the extreme, this valuation makes the kidney a commodity of which is negotiable at the transplant center level.  This commoditization of the organ is most likely the reason for failure of the “Kidney Payback System,” of which some transplant centers benefit unequally.  Also, the prediction of recipient life expectancy into decades is highly risky and the generalization cannot be applied to individual patient outcomes.

In conclusion, any movement of the algorithm to dilute strict objective matching criteria will cause a cascade of events leading to worsening transplant recipient survival and failure of equitable organ allocation.  Finally, I cannot emphasize enough how important it is to simplify the algorithm to its essential components.  As proposed the LYFT algorithm is too complicated to be adequately described by the document.  Priority related to dialysis time is based upon the essential element of justice, which is a moral definition; that with centuries of debate remains unreconciled.  Alternatively, providing appropriate navigation through the organ allocation process using objective criteria with regular expert review; the OPTN will inherently provide justice.

Sincerely yours,

Andrew L. Rivard, M.D, M.S.