Paying living donors for their kidneys would reduce the number of end-stage renal disease (ESRD) patients on dialysis and transplant wait lists, and save the healthcare system money, researchers in Canada concluded.
Using decision analysis modeling, they estimated that a $9,648 ($10,000 Canadian) payment per living donor would increase the number of kidneys available for transplant by 5%, with an incremental cost savings of around $328 ($340 Canadian) per patient and a gain of 0.11 quality-adjusted life years (QALYs).
If the payment resulted in a 10% increase in kidneys available for transplant, the model projected that this would translate into an incremental cost savings of $1,582 in U.S. dollars and an incremental QALY gain of 0.21, researcher Lianne Barnieh, PhD, of the University of Calgary, and colleagues wrote online in the Clinical Journal of the American Society of Nephrology.
If there were a 20% increase in donated kidneys, incremental savings would be $3,888 and incremental QALY gain would be 0.39.
The decision analysis examined only the financial and patient outcome impact of paying for living donor kidneys and not the ethical concerns surrounding the practice, which is illegal in the U.S., Canada and most other nations.
Donation Encouragement Needed
Barnieh told MedPage Today that the widening the gap between the number of kidneys donated and the number needed for transplant brings new urgency to the search for alternative strategies to encourage kidney donation.
"We need more living kidney donors and we need to at least consider paying them," she said. "If nothing else, I think this research may raise awareness and foster a debate about how we can move forward, respecting the laws and ethical considerations."
In a survey published last year, Barnieh and colleagues found that close to 65% of respondents from the general public considered financial incentives an acceptable strategy for increasing kidney donations from living donors.
An earlier cost-effectiveness study examining the issue had methodological flaws and was published almost a decade ago, the researchers noted.
"Given these limitations, we use contemporaneous information on the cost of dialysis and kidney transplantation, and decision analysis to estimate the cost-effectiveness of a paid living donor strategy, compared to the current system of organ donation, in waitlisted dialysis patients," they wrote.
In their estimate, the researchers assumed that the number of donors each year would increase by 5% if all living donors were paid $10,000. Transplantation rates and survival on the transplant wait lists were estimated from a large contemporary cohort of waitlisted dialysis patients, while patient and graft survival after transplantation were estimated from a national Canadian cohort of patients with ESRD.
The costs of dialysis and kidney transplantation were calculated from recently published Canadian data, and this information was combined with the decision analysis.
Both univariate sensitivity analyses and scenario analyses were performed for the cost-assessment model, and the researchers varied both the payment ($10,000 to $50,000) and the increase in resulting transplantations (1% to 50%) in their calculations.
"Determining the cost-effectiveness of strategies to increase kidneys for donation by paying living donors is challenging since there are no trials definitively establishing the net impact payment would have on living donor rates," they wrote. "We did, however, demonstrate that a paid living donor strategy is attractive from a cost-effectiveness perspective, even under conservative estimates of effectiveness. These estimates of effectiveness, though assumptions, were based on a survey where 54% of those who previously would not consider donating while alive, (said they) would consider donating a kidney to a relative for a payment of $10,000."
Ethical Concerns Must Be Addressed
In an accompanying editorial, Peter P. Reese, MD, and Matthew Allen, BA, of the University of Pennsylvania Perelman School of Medicine in Philadelphia, wrote that a limited clinical trial examining the impact of direct payments or other financial incentives on live-donor kidney donation could address most, but not all, of the ethical concerns about the practice.
Nondirect incentives could include indirect payment (e.g. tax benefits), reimbursement for all expenses and/or lost wages, or the promise of health or life insurance.
They cited several ethical arguments against live-donor payment, including:
- The 'unjust inducement' argument, which suggests that the vulnerable poor might feel compelled to sell a kidney to feed their family or meet other financial needs.
- The 'undue inducement' critique, which suggests that paying for kidneys will undermine informed consent by coercing people into accepting medical risk that they would otherwise consider unacceptable.
- The 'crowding out' critique, which suggests that paying for kidneys will crowd out the thousands of people who donate kidneys out of altruism.
- The 'commodification' argument, which considers selling a part of the body degrading to personal dignity.
"The first three critiques could be verified through a trials of financial incentives for living kidney donation, but the commodification critique is not empirically testable," the editorialists wrote.
Reese told MedPage Today that he would favor a very limited, heavily supervised study examining direct payments to living kidney donors.
"The really big barrier to this, in addition to finding someone to pay for this research, is that we would have change the law," he said. "My sense is that there is no political will to do this right now, but I wouldn't rule out the possibility that there will be in the future. We should also explore financial incentives that are legal and less controversial than direct payment."
Barnieh and two coauthors received financial support from Alberta Innovates-Health Solutions.
The authors reported that they have no conflicts of interest to disclose.
- Reviewed by Zalman S. Agus, MD Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner
Clinical Journal of the American Society of NephrologySource Reference: Barnieh L, et al "The cost-effectiveness of using payment to increase living donor kidneys for transplantation" Clin J Am S Neph 2013; DOI: 10.2215/CJN03350313.