Local impacts of innovations in kidney transplantation: Looking back and looking forward

Since the first successful kidney transplant nearly 60 years ago, technical innovations have substantially increased the safety of both donation and transplant, enabling hundreds of thousands of lifesaving transplants worldwide. Now the need is greater than ever. Over 95,000 people are on waiting lists for kidney transplants in the United States. In 2012, only 13,752 people received a kidney transplant – the fewest in over a decade – with only 4,680 receiving transplants from living donors – important because they function nearly twice as long as those from deceased donors. Those waiting for transplants face potentially severe quality of life deficits, enormous healthcare costs, and death.

Using administratively collected data dating from 1964 from a large transplant program in Southern California, we looked back at decades of innovations, their impact on the living donor pool, and their indication of what the future may hold. The launch of cyclosporine immunosuppression in 1983 provided dramatic improvements in graft survival, which allowed physicians, donors, and patients alike to view kidney transplantation as a therapy with real promise. Following this innovation, living donations nearly quintupled from the 1980s to the 1990s. Similarly, the development of a minimally invasive donor nephrectomy offered donors shorter recovery times, less post-operative pain, and improved cosmesis; the decade after its implementation saw a 77% increase in living donations over the previous decade. Changes in ethical opinion have led to expansions in acceptable donor-recipient relationships from biological relatives only, to spouses, to friends and coworkers, to complete strangers. Exchanges began allowing incompatible donor-recipient pairs to swap kidneys with other pairs, thus allowing patients who otherwise would have been placed on waiting lists to enjoy the benefits of living donation and reducing the burden on waiting lists. Exchanges now provide 25% of living donations at this center, allowing continued growth while the national donor pool shrinks.

Based on our retrospective study, we believe that future efforts in increasing access to transplantation depends more on social changes, like those surrounding donor-recipient relationships, then on biological and surgical improvements. Improving and expanding exchange programs seem a promising avenue for improvement, offering a potentially enormous increase in living donations and appearing to bolster growth of this program in dry times. While addressing differential access to living donation between groups is essential, we believe that truly equitable utilization is impossible without reducing the immense gap between need for transplantation and kidney donation.