It’s hard to overstate what a big deal this is.
I hesitated to post anything on it till I’d had a chance to digest it and try to learn if it’s as great as it seems. Frankly, even if it’s less than it appears—some of it rests on the continuation of the Affordable Care Act, need I say more?—and takes longer to go into effect than we think, it’s still a big deal. Given that it’s one of the biggest sets of changes in kidney health care in five decades, attention must be paid. As my friends at WELD (Women Encouraging Living Donation) put it, “Regardless of your feelings about the messenger, the message here is breaking the logjam…” (the “logjam” being the often 5-to-10-year wait for the roughly 100,000 people waiting for a kidney in the United States).
The whole system is in need of repair, so not surprisingly, the executive order/kidney health initiative has a few pieces to it:
1. Helping living donors. The exciting decision to cover a donor’s lost wages, child care, and other family expenses (and expand the pool of those eligible) alone can be a game changer for so many potential donors. This is the proposal that I provided public comment for in May when the federal Health Resources and Services Administration’s (HRSA’s) advisory committee was considering it [see post]. Waitlist Zero founder/director Josh Morrison (a living kidney donor himself) whose organization was behind the effort, estimates conservatively that the revised policy could increase the number of living donors by 25%. Simply put, helping living donors helps kidney patients. Getting a kidney from a living donor not only shortens that recipient’s wait, it removes one person from the waitlist for a deceased organ and generally offers a better outcome.
2. Early Detection and Research. The new Medicare fee structure will provide incentives for physicians to take the time to discuss and screen kidneys at an earlier point. For example, people with diabetes or high blood pressure, particularly African Americans with those conditions, are at higher risk for chronic kidney disease, which is a gradual loss of kidney function. For most people, unless they have a family history, it’s not on their radar. I’ve heard several young people say that they didn’t learn their kidneys were failing until they had a screening at a health fair or went to the ER for something else. That’s why it’s called a “silent killer”—it often has no noticeable symptoms until it reaches the point of kidney failure and sometimes not even then. The initiative also calls for increased funding for research.
3. In-Home Dialysis. The initiative aims to enable most dialysis patients to do it at home (currently only 12% do so by a variety of options, including while they sleep). It plans to improve support to make it more feasible financially and logistically. Life on dialysis is an enormous burden, sapping one’s energy, strength, and time. For the majority of patients, who receive it at a center, it means traveling three days a week to the facility, which might be more than an hour’s drive from home, and being connected to a machine, currently 4 hours at a time. My son, who was on dialysis for 20 months before his transplant in 2006, recalls being on dialysis as “the worst experience of my life” [see post]. Doing dialysis at home, which, admittedly would still not be everyone’s preference, would make it easier for more dialysis patients to continue working.
4. Overhauling allocation of deceased organs. The initiative aims to make thousands more kidneys available by reducing the number discarded for a variety of reasons, due to waste and for medical factors. The system is very complicated, so I won’t even try to analyze these changes. The trend in recent years already has been to consider the benefits of using “high-risk” donor organs; organ transplants that were once almost unthinkable—say, between HIV-positive donors and recipients—have been successful. By the way, the oft-cited “national waiting list” is actually a network of myriad regional lists. When a deceased organ becomes available, they look for the best match, usually in the same region so it can be transplanted ASAP, which can lead to geographic disparities. “Matching” a donor and recipient isn’t just a question of blood type—it’s also based on age, how long someone’s been on the list, and other factors. Also, to be clear, the waitlist isn’t like a numbered list, where you might move from number 2,000 to number 1,999 and so on.
Some of these steps will take years, but some are expected to begin as soon as January 2020. But kidney patients and their families and friends should certainly rejoice at this news. I know I do.
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