Wasting Kidneys: The Multivisceral Transplant Conundrum.

• Author: Brannon, Ike
• Position: BRIEFLY NOTED

Some 18,000 kidney transplants are performed in the United States each year. People who need a kidney often receive a donor organ from a relative, but people who don't have that option must turn to an organ transplant waiting list. Prioritization on these lists is based on how long a patient has been on dialysis, his current health, and how long he has been on the waitlist. The longer the wait and sicker the patient (but not too sick!), the higher he is on the list.

However, patients who need a transplanted liver are treated differently. It is fairly common for a liver recipient to also receive one of the deceased donor's kidneys in a procedure known as a multivisceral transplant. These constitute about 10% of all kidney transplants done each year. It is worth noting that the kidneys that typically accompany these transplants tend to be especially good organs, coming from young, otherwise healthy individuals, who make for the best liver donors.

There are two ostensible reasons for transplanting both organs together. First, people with liver failure typically develop kidney failure concomitantly, a condition known as hepatorenal syndrome. Second, even if the recipient does not have an immediate, urgent need for a kidney, it can be economical to do both surgeries at the same time if doctors believe the patient may one day need a kidney; the dual-transplant surgery would require just one anesthesiologist, one operating room, and one six-to-eight-hour surgery window.

Multivisceral transplant candidates get priority on the kidney transplant list. Someone who recently became afflicted with liver disease and who may not even be on a kidney list will routinely get a kidney along with his new liver, as long as a nephrologist--a kidney specialist--approves the procedure. In these cases, it is the liver transplant list that dictates kidney priority.

Here's the rub: in many cases, the transplant kidney ends up being completely redundant. Liver function greatly affects kidney function, and the successful transplantation of a healthy liver restores many recipients' ailing kidneys to working order. In other words, for these patients, the Quality-Adjusted Life-Years (QALYs) that the kidney transplant adds is low. Nonetheless, the surgeons proceed with the multivisceral transplant, leaving the original kidneys in place. As a result, many of these transplant recipients end up with three functioning kidneys.

These transplants reduce the already tight supply...