Original Articles

Deciding Eligibility for Transplantation

When a Donor Kidney Becomes Available
JOHN HORNBERGER, MD, MS, JAE-HYEON AHN, PhD

The expectation of transplant success for some patient/donor-kidney matches can be

so low that transplantation is not considered an option. The issue may be framed as

deciding the minimum expectation of transplant success that would justify a patient’s
eligibility for transplantation with an available donor kidney. If the minimum is set too
high, the patient will be eligible for very few donor kidneys and will wait excessively
for transplantation. If the minimum is set too low, the patient has a greater risk of graft
failure once transplantation has been done. A decision model calculates the minimum
predicted one-year graft survival rate that would determine eligibility for an available
donor kidney, with the goal of maximizing quality-adjusted life expectancy. The mini-
mum predicted one-year graft survival rate depends on the patient’s health and dem-
ographic characteristics and attitudes about quality of life with kidney-replacement ther-
apies. Graft survival rates and quality-adjusted life expectancies may increase by as
much 6.7% and 1.6 months, respectively, with only a slight increase (<0.4 months) in
the quality-adjusted waiting time until transplantation. Key words: transplantation;
health services research; decision analyses; rationing. (Med Decis Making 1997;17:
160-170)

More than 30,000 patients with end-stage renal dis-
ease await kidney transplantation in the United
States, but fewer than 11,000 transplants are done
per year.’ This imbalance between the supply of do-
nor kidneys and the numbers of transplant candi-
dates has led experts to examine carefully the pro-
cess of allocating donor kidneys.2-14 The United
Network for Organ Sharing (UNOS) developed and
revised a point system to help decide which candi-
date should receive the transplant when a donor
kidney becomes available. 15 Before applying the
point system, some matches between a donor kid-
ney and a transplant candidate have such low ex-
pectations of transplant success (e.g., short- and
long-term graft functioning) that transplantation is
deemed unacceptable. Commonly applied rules for
deciding that a match is unacceptable include ABO
blood-group incompatibility or a significant
Received July 10, 1995, from the Department of Health Re-
search and Policy, Stanford University School of Medicine, Stan-
ford, California (JH), and AT&T Bell Labs, Murray Hill, New Jer-
sey (J-HA). Revision accepted for publication May 1, 1996.
Presented at the annual meeting of the Society of Medical De-
cision Making, October 1994, Cleveland, Ohio Supported in part
by NIH grant R01 DK47805-01. Dr. Hornberger is funded as a
Picker/Commonwealth Scholar.
Address correspondence and reprint request to Dr Hornber-
ger Department of Health Research and Policy, Stanford Uni-
versity School of Medicine, HRP Redwood Building, Rm T254A,
Stanford, CA 94305-5092. e-mail: (jch@osiris.stanford.edu).
match reaction between the candidate’s and donor
kidney’s white blood cells.15
The allocation of an available donor kidney is ef-
fectively a two-step process. In the first step, the pool
of transplant candidates is separated into two
groups of eligible and ineligible candidates for trans-
plantation with an available donor kidney. Ineligible
candidates become part of a new pool of candidates
waiting for the next available donor kidney. At the
next step, one of the eligible candidates is selected
to receive the donor kidney based on the allocation
policies of the transplant center (for descriptions of
decision-analytic-based kidney transplantation al-
location policies, refer to Yuan et al.16 and O’Brien 17).
Eligible candidates not selected for transplantation
become part of the new pool of candidates waiting
for the next available donor kidney.
cross-
Implicit in deciding whether a candidate is eligible
for transplantation with a particular donor kidney is
an understanding that the expectation of transplant
success must be higher than some minimum stan-
dard. Yet, the question of how high or low to set this
minimum has not been formally addressed, partic-
ularly using accepted decision-theoretic principles.
Setting a high minimum enhances the candidate’s
probability of successful engraftment once the do-
nor kidney is transplanted. However, the candidate
with a high minimum would be eligible for fewer
donor kidneys, thereby prolonging the waiting time

160

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 161

until transplantation. Settinglow minimum makes

a
the candidate eligible for donor kidneys,
more

thereby decreasing the waiting time until transplan-

tation. However, the candidate who has a low min-
imum would be placed at a higher risk of graft fail-
ure once the kidney was transplanted and at a

higher risk of needing more immunosuppressive

therapy to prevent graft failure.
The minimum expectation of transplant success
also may depend on the demographic and health
characteristics of the candidate and on the candi-
date’s attitudes about quality of life with the various
renal-replacement therapies. For instance, for some
candidates, the quality of life on dialysis may be so
poor that they would be willing to take a chance
being eligible for a donor kidney with a lower ex-
pectation of transplant success. In contrast, for
other candidates, the quality of life on dialysis may
be sufficiently good that they would prefer stricter
eligibility criteria to ensure a successful transplant
outcome.
We designed a decision model to estimate the
minimum expectation of transplant success, using
predicted one-year graft survival rate as the measure
of transplant success, to decide the eligibility of a

FIGURE 1 Tree diagram for deciding eligibility for transplantation when a donor kidney becomes available. For each candidate/donor-
kidney pair, the predicted one-year graft survival rate, X, is estimated If X exceeds the minimum one-year graft survival rate, d*, then
the candidate is eligible for transplantation with that donor kidney; otherwise, the candidate is ineligible and returns to the waiting
list. An eligible candidate has a probability y of receiving the transplant. Once the donor kidney has been transplanted, the probability
of transplant success is equal to n. Xf (X) dxlf’d- f(x) dx and the probability of transplant failure is equal to n. (1 - x)f(x) dx/
f i· f (X1 dx Six months after transplant failure, a patient has a probability 8 of returning to the waiting list (not shown). The model
estimates the level of d* that will maximize quality-adjusted life expectancy while the candidate is on the transplant waiting list.

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162
candidate for transplantation when a donor kidney
becomes available. Specifically, the model finds the
minimum predicted one-year graft survival that,
when used to judge eligibility for a donor kidney,
will maximize the candidate’s quality-adjusted life
expectancy. We assess the effects of this approach
on quality-adjusted life expectancy, rates of one-year
graft survival once the kidney is transplanted, and
quality-adjusted time until transplantation. We also
examine how age, gender, race, diabetic status, type
of transplant (first and repeat), and quality of life on
renal-replacement therapies influence these out-
comes.
Methods
We adapted for this study a model designed to
help identify criteria upon which to base a deci-
sion.18-29 A classic example is the so-called &dquo;secre-
tary problem,&dquo; in which an employer compares the
characteristics of an applicant, e.g., speed of typing,
criterion values to decide whether to hire
against set
an or continue the search process. The
applicant
model estimates the criterion values, e.g., typing
speed more than 100 words per minute, that maxi-
mize the employer’s stated objectives.
Our analysis applies only to patients with end-
stage renal disease who are undergoing dialysis and
awaiting transplantation of cadaveric donor kidneys.
To implement the model, we must select a summary
measure of transplant success to decide eligibility of
transplantation. In this instance, we chose predicted
one-year graft survival rates because one-year graft
survival rates correlate with long-term graft survival
rates and data on one-year graft survival rates reflect
more recent patterns of care than do data on long-
term graft survival rates.
MODEL STRUCTURE
Figure 1 shows a tree diagram for deciding eligi-
bility for transplantation when a donor kidney be-
comes available. Assume there are three alive states:
1) undergoing dialysis, awaiting transplantation, 2)
functioning graft at one year requiring no dialysis,
and 3) failed graft at one year with the patient re-
suming dialysis. Denote quality-adjusted life expec-
tancy upon entry into the ith state as QALE,. Denote
x as the predicted one-year graft survival rate for a
candidate and donor-kidney pair (i.e., the propor-
tion of grafts still functioning among all alive trans-
plant recipients at one year), based on the observed
characteristics of the candidate and the donor kid-
ney. Denote f (x) as the probability density function
of predicted one-year graft survival rates that a can-
didate may expect for an available donor kidney. As
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we show below, the mean and variance of f (x) vary
as a function of the health and demographic char-
acteristics of the candidate. Let d* represent the
minimum predicted one-year graft survival rate that
would determine eligibility for transplantation. That
is, if x > d*, then the candidate would be eligible
for transplantation with the available donor kidney.
If x < d*, then the candidate would be ineligible for
the donor kidney. If the candidate becomes eligible
for transplantation, the probability of being chosen
to receive the donor kidney is equal to y. The value
of y depends on the policy goals of the transplant
center, e.g., the UNOS Point System, and the distri-
bution of candidate and donor-kidney characteris-
tics at that center. The base-case example assumes
that the candidate who has waited the longest for
transplantation has priority for receiving a donor
kidney if found eligible for transplantation with that
donor kidney, i.e., y is equal to 1. We assess in sen-
sitivity analyses the effects of varying levels ofy. Once
the kidney is transplanted, the patient can have a
successful transplantation with quality-adjusted life
expectancy of QALE, or have a failed transplantation
with quality-adjusted life expectancy of QALE,. If the
patient does not receive the transplant, he or she
may have a quality-adjusted life expectancy associ-
ated with continuing on dialysis and awaiting trans-
plantation of QALE1. The appendix shows the cal-
culations used to estimate the minimum predicted
one-year graft survival rate.
DISTRIBUTION OF GRAFT SURVIVAL RATE OF A
FUTURE DONOR KIDNEY
Based on an analysis of more than 30,000 kidney
transplants performed in the United States between
1985 and 1989, Gjertson predicted one-year graft
survival rates as a function of 16 candidate and do-
nor-kidney characteristics (table 1).~ These char-
acteristics included the candidate’s and donor’s age,
gender, and race/ethnic background, cause of the
candidate’s end-stage renal disease, the candidate’s
responsiveness to foreign antigens (highest pre-
transplant antibodies), the facility where the trans-
plantation was performed, cold-ischemia time (i.e.,
how long the donor kidney has been unperfused
with blood at normal body temperature), and num-
ber of mismatches of human leukocyte antigen
(HLA) markers, which are known to reflect immu-
4
nologic candidate-donor kidney mismatching.&dquo;
We selected at random characteristics of 500 do-
nor kidneys in proportion to the distribution of
these characteristics in the more than 30,000 donor
kidneys transplanted between 1985 and 1989 (see ta-
ble 1).34 We calculate x for each of these donor kid-
neys and obtain f (x) by fitting these data to a beta
distribution:
 163

Table 1 * Scores for Predicting One-year Observed Graft Survival Rates*

Repnnted with permission, David W Gjertson, UCLA Tissue Typmg Laboratory, Los Angeles, CA 34
*The overall fraction ofgraft survival at one year for adjustment was 79.9%.

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164

Figure 2 illustrates how f (x) varies as a function

of transplant-candidate characteristics; in this case,
we compare the distributions of predicted one-year

graft survival rates of first- and repeat-transplant

candidates. First-transplant candidates are expected
to have a greater proportion of donor kidneys with
high predicted one-year graft survival rates than re-

peat-transplant candidates.

PATIENT AND GRAFT SURVIVAL RATES

To estimate quality-adjusted life expectancy from

each state in the model, we must specify monthly
survival rates for patients while they are undergoing
dialysis and after transplantation, and survival rates
of transplanted kidneys among alive recipients (graft
survival rate) after the first posttransplant year. We
chose monthly transitions because more frequent
transitions are rare and little precision is lost by us-
ing monthly rates. To obtain these rates, we used
data from the U.S. Renal Data System (USRDS) Case-
Mix/Severity study. The USRDS Case-Mix/Severity da-
tabase has a random sample of 5% of all patients
enrolled in the U.S. Medicare ESRD program in the
years 1986 and 1987, 5,535, who were subsequently
followed to at least January 1, 1992. Details of the
reliability and validity of this database have been
One-year graft survival rate published elsewhere. 30 We estimated monthly pa-
tient survival rates for patients while they were un-
FIGURE 2. Probability density function, f(x), of one-year graft
survival rates of donor kidneys expected to become available dergoing dialysis and after transplantation by apply-
each month, by type of transplant (first versus repeat). ing Weibull regression to the USRDS Case-Mix
Severity database. We also estimated graft survival
rates after the first posttransplant year. Regression
diagnostics3’ revealed that a Weibull model provided
a good fit of the data (R2 > 0.95). We used these
results to estimate survival rates by age, gender,
race, and diabetic status on dialysis and with trans-
The two parameters of~ po and p, are calculated
plantation (for ease of illustration, table 2 shows data
by solving the two simultaneous equations in which as annual survival rates, though monthly survival

the mean of f (x) is

to
equal
________PoPi________
- (po P. *’ Pi)
and the vari- rates were used for all subsequent analyses).! Pa-
tient survival rates on dialysis are higher, on average,
for women, blacks, non-diabetics, and first-trans-
ance
ance ,..is
~ &dquo; its
of f~ equal
~
&pohorbar;&ho+rbar;&PI)horbar;_, ~&ho(POrbar;&horbar;+-&horbPIar;&horbar+;&horba1r;-.
two
plant candidates than for men, whites, diabetics,

Table 2 . Estimated Annual Survival Rates

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 165

Table 3 ’ Minimum One-year Graft Survival Rates, Fraction of Donor Kidneys Expected to Satisfy This Minimum, Expected
Benefits in Quality-adjusted Life Expectancy, and Loss in Waiting Time until Transplantation, by Age Group, Gender,
Race, Diabetic Status, and Transplant Type

*Quality-adjusted life expectancy if patient used minimum one-year graft survival rate as criterion for accepting a donor kidney.
tQuatity-adjusted life expectancy if patient had no minimum one-year graft survival rate criterion for accepting a donor kidney.
#equal to the difference in quality-adjusted life expectancies with and without minimum criterion.
§Corresponds to the mean one-year graft survival rates shown in figure 1.
~Average waiting time is assumed to be 16 months without the minimum criterion. Difference in expected waiting times in quality-adjusted months
calculated as: [Waiting time with minimum criterion - 16]. [difference m quality of life between dialysis and transplantation (=0.84 - 0.68)].

and repeat-transplant candidates, respectively. No- dialysis, having a functioning transplant with no re-

tably, there was less variability in patient survival jection episode or side effect of the immunosup-
rates after transplantation. Graft survival rates are pressive therapy, having a failed transplantation, and
higher, on average, for women, whites, non-diabet- experiencing side effects of immunosuppression
ics, and first-transplant candidates, compared with therapy. For this study, we assigned quality-of-life
men, blacks, diabetics, and repeat-transplant can- adjustments for these states based on data collected
didates, respectively. from patients undergoing renal-replacement ther-
apy’ and a literature review from a MEDLINE
search.34-36 For the base-case analyses, we assigned
QUALITY-OF-LIFE ADJUSTMENTS AND a quality of life of 0.68 to being on dialysis, 0.84 to
MEDICAL COSTS having a functioning transplant, 0.65 to having a
failed transplant, and 0.80 to having side effects of
We assume that quality of life is rated on a 0-to-1 the immunosuppression regimen. Based on a pre-
scale in which the highest attainable health, e.g., life viously reported cost analysis,3’ we assumed the
without end-stage renal disease, other illnesses, or monthly cost of dialysis is $4,280 and the monthly
functional disabilities, has a score of 1 and death has cost of successful transplantation after the first year
a score of 0. We anticipate that many candidates can is $1,160. All future life years and medical costs were
provide ratings of the qualities of life associated with discounted at a fixed annual rate of 3%.

t Let t be a random variable denoting the time of death. Let

X represent a vector of case-mix variables, then the hazard func- Results
tion conditional on B<f~L for a Weibull distribution is À(t!X)
X,
=
Bp(Bf)’’’’ exp{Xj3}, where À, p and [3 are parameters to be The minimum predicted one-year graft survival
estimated from the data Denote A, p, and (3
as the estimated

values of À, p, and p, then survival at time t conditional on X, rate that determines eligibility varies as a function
S(f~),is calculated as: S(t!X) = exp[-Bp(Bf)&dquo; exp{X(3}]. of transplant-candidate characteristics (table 3). For

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166

FIGURE 3. A (left), average minimum one-year graft survival rates and predicted one-year graft survival rates, by number of HLA
mismatches and cold ischemia time. Candidates, on average, would be eligible for the types of donor kidneys above the line.
B (right) The effect of expected quality of life with a failed transplant on minimum one-year graft survival rate and the types of donor
kidneys that would, on average, be eligible for transplantation. A higher expected quality of life with a failed transplant results in a
higher minimum

example, the minimum one-year graft survival rate
is 84.3% for patients aged 21-49 years, compared
with 81.0% for patients aged 8-20 years. Notably,
minimum predicted one-year graft survival rates are
lower for men, blacks, diabetics, and repeat-trans-
plant candidates than for women, whites, non-dia-
betics, and first-transplant candidates, respectively.
Although the minimum predicted one-year graft
survival rate is lower for repeat-transplant candi-
dates than for first-transplant candidates, the frac-
tion of all potential donor kidneys with predicted
one-year graft survival rates expected to exceed this
minimum also is lower for repeat-transplant can-
didates (see table 3). In fact, if repeat-transplant can-
didates were to have a minimum as high as that of
first-transplant candidates, then an even smaller
fraction of donor kidneys would be eligible for
transplantation and repeat-transplant candidates
would wait at least twice as long for transplantation.
A similar pattern is found in the comparison of
white and black candidates. In summary, these data
show that patients with characteristics that predict
transplant success, such as first-transplant candi-
dates, will maximize their quality-adjusted life ex-
pectancy by having a higher minimum than patients
with characteristics that predict comparably worse
graft outcomes.
All groups have higher quality-adjusted life expec-
tancies when a minimum is used for deciding eligi-
bility compared with not using a minimum, with
gains in quality-adjusted life expectancy between 0.7
and 1.6 months (see table 3). Though blacks have
lower predicted one-year graft survival rates than
whites, blacks have longer quality-adjusted life expec-
tancies, on average, because of their higher patient
survival rates while undergoing dialysis. Predicted
one-year graft survival rates also increase in all
groups when a minimum is used, with one-year graft
survival rates estimated to increase between 4.1% and
6.7% (see table 3). The largest gains in predicted one-
year graft survival are expected for black candidates
and repeat-transplant candidates. Alhough having a
higher minimum results in candidates’ becoming el-
igible for fewer donor kidneys, quality-adjusted wait-
ing times increase by only 0.2 to 0.4 months.
Figure 3A shows the types of donor kidneys (char-
acterized by numbers of HLA mismatches and cold-
ischemia time) for which a candidate should be el-

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igible. For instance, a candidate should be eligible
for transplantation with a zero- or one-antigen-mis-
matched donor kidney when the cold-ischemia time
is less than 50 hours. When the cold-ischemia time
exceeds 28 hours, the candidate also should be eli-
gible for transplantation with a donor kidney with
fewer than four HLA mismatches.
Eligibility for transplantation also varies as a func-
tion of quality-of-life ratings (see figure 3B). We es-
timated the minimum one-year graft survival rates
when the quality-of-life rating of a failed transplant
equaled 0 and when it equaled 0.68, where a rating
of 0 reflects a quality of life effectively that of death
and a rating of 0.68 reflects the same quality of life
as if the patient had never received a transplant. As
shown in figure 3B, a very low quality-of-life rating
should result in a higher minimum to limit the risk
of graft failure once transplanted. One-year graft
survival rates and quality-adjusted life expectancy
are estimated to vary by as much as 5% and three
months, respectively. In summary, these analyses
show that number of HLA mismatches, cold-ische-
mia time, and quality-of-life ratings are more im-
portant indicators of eligibility than patient age, gen-
der, race, diabetic status, and type of transplant.
Among eligible candidates, the probability of being
chosen to receive the donor kidney, y, also affects
the minimum. If the probability of transplantation is
very low, as it is with patients who have very rare
HLA antigens in centers using the UNOS Point Sys-
tem, then the minimum may decline substantially to
less than 70%, thus making the candidate eligible for
all ABO-compatible and negatively crossmatched do-
nor kidneys. If the probability of transplantation is
high, as it might be for a patient who has the highest
priority for transplantation (i.e., the candidate who
has waited the longest in a center willing to give
such a candidate the first option to refuse an avail-
able donor kidney), then the minimum should be
set at a higher level (e.g., >84%).
The added duration until transplantation when
applying a higher minimum equaled 3.4 months, re-
sulting in an added $14,712 spent on dialysis. In con-
trast, the 4% to 7% increase in annual graft survival
rate is estimated to increase expected duration with
a functioning graft by about two years, with an as-
sociated cost savings of $78,249. The net cost savings
of applying a higher minimum then is $63,537.
Discussion
This study applies accepted principles of decision
theory determine the minimum predicted rate of
to
transplant success that, if used to decide eligibility
for transplantation of an available donor kidney,
maximizes a candidate’s quality-adjusted life expec-
tancy. Our findings suggest that the adoption of
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167
more stringent criteria for determining eligibility for
transplantation of an available donor kidney could
increase candidates’ quality-adjusted life expectan-
cies and graft survival rates. Specifically, we estimate
that candidates could experience, on average, a 0.7-
to 1.4-month increase in quality-adjusted life expec-
tancy and a 4% to 7% increase in one-year graft sur-
vival. Beside taking into account ABO blood-type
compatibility and crossmatch as criteria for eligibil-
ity, the number of HLA mismatches, cold-ischemia
time, and candidate’s quality of life with renal-re-
placement therapy also appear to be relevant con-
siderations.
Not candidates’ health outcomes likely to
only are
improve, on by using the method shown
average,
here, but the per-candidate cost of medical care of
waiting a slightly longer time for transplantation is
offset by the lower expected costs of higher graft
survival rates and, thus, longer graft function.
Higher graft survival rates also should reduce the
number of repeat-transplant candidates competing
with first-transplant candidates for scarce donor
kidneys. 37
This study is
the first to show that transplant out-
comes may be improved by considering the patients’
ratings quality of life with renal-replacement ther-
of
apies. Patients should have more stringent eligibility
criteria if they expect to be very dissatisfied with di-
alysis after a failed transplant or if they are very con-
cerned about the side effects of the immunosup-
pression regimen.
Waiting times for patients with the same ABO
blood type should be similar, regardless of the un-
derlying health and demographic characteristics of
the candidates. However, differences in the distri-
butions of ABO blood types in the donor and can-
didate pools may cause differences in waiting times
to persist among some groups.12,28 38 Sanfilippo and
colleagues found that the ABO blood type accounted
for more than a 12-month difference in transplant
times (median waiting times, 0 =
waiting 16.9
months; B = 18.7 months, A = 7.9 months, AB =
4.9
months) after adjusting for patient and donor-kidney
characteristics. 12 To reduce differences in transplant
waiting times among these groups, it would be nec-
essary for policymakers to revise allocation systems
that would award points to groups with long
more
expected transplant waiting times.9&dquo;9&dquo;’ Notably, we
found that the minimum one-year graft survival rate
does not change as a function of the duration of the
expected transplant waiting time. It is just as unde-
sirable to receive a donor kidney with a high prob-
ability of graft failure after a long waiting time as
after a short waiting time.
Deciding eligibility for transplantation when a do-
nor organ becomes available should be feasible. At
the first evaluation with the transplant team, can-
168
didates could view an educational program that ex-
plains the risks and benefits of transplantation. They
then could rate their current quality of life on dial-
ysis and expected quality of life with successful
transplantation and with failed transplantation. A
computer program could automatically compute a
minimum one-year graft survival rate, taking into
consideration the candidate’s demographic and
health characteristics, the candidate’s quality-of-life
ratings with renal-replacement therapies, and the
distribution of predicted one-year graft survival rates
among future donor kidneys. We anticipate that dis-
tribution of one-year graft survival rates can be es-
timated as described in the methods section using
either local or national registry data. Based on these
results, the computer would provide information
about the characteristics of donor kidneys for which
the candidate would expect to be eligible and the
expected time until transplantation. As each donor
kidney became available, its characteristics would
be entered into the database and the candidates
who were eligible for transplantation identified.
The findings of this study suggest, but do not nec-
essarily prove, that significant improvements in
quality-adjusted life expectancy and graft-survival
rates may be achievable with new approaches de-
scribed here for allocating transplant organs. One
concern is whether establishing stricter eligibility
criteria would substantially reduce the number of
eligible candidates and thus result in some donor
kidneys’ not being used. This scenario is highly un-
likely, however, because of the very large number of
candidates awaiting transplantation-it should be
possible to find at least one candidate nationally who
would be eligible for transplantation with an avail-
able donor kidney. Increased sharing of some donor
organs among transplant centers may be desirable
to ensure that donor kidneys do not go unused and
thus improve the average quality-adjusted life ex-
pectancy and graft survival rate of U.S. transplant
candidates.
We also anticipate further refinements and eval-
uation of the methods presented here before apply-
ing them at a national or local level. Using Bayesian
network theory, we are developing new prediction
models of graft survival and patient survival that re-
lax the distributional assumptions associated with
conventional (e.g., logistic) regression models. These
models also impute data that may be missing for
some, but not all, variables. Though studies in a va-
riety of settings have established that patients with
end-stage renal disease are able and willing to make
the types of judgments about their quality of life that
are necessary with this method,32,33 the reliability
and validity of respondents’ judgments about future
health states should undergo prospective evaluation
in transplant candidates.
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Conclusion
study suggests that basing eligibility for trans-
Our
plantation with an available donor kidney on a min-
imum predicted one-year graft survival rate should
increase, on average, transplant candidates’ quality-
adjusted life expectancies and one-year graft survival
rates. These benefits in candidate health outcomes
are expected with a comparably small increase in
the candidate’s time until transplantation and are
likely to lower the societal costs of transplantation.
Dr. Ahn completed much of the work in this study while a grad-
uate student in the Department of Engineering-Economic Sys-
tems at Stanford University. The data reported were supplied by
the United States Renal Data System (USRDS). The interpre-
tation and reporting of these data are the responsibility of the
authors and in no way should be seen as the official policy or
interpretation of the U.S. government. The authors thank Jennie
Best, Laurence Baker, John Scandling, and two anonymous re-
viewers for their comments on this manuscript.
References
1 U.S Renal Data System 1995 Annual Data Report. U.S De-
partment of Health and Human Services, Health Care Fi-
nancing Administration, Bureau of Data Management and
Strategy, United States Renal Data System, 1995
2 Brock D Ethical issues in recipient selection for organ trans-
plantation. In Mathieu D (ed) Organ Substitution Technol-
ogy: Ethical, Legal, and Public Policy Issues. Boulder, CO.
Westview, 1988:86-99.
3. Gjertson D. National allocation of cadaveric
kidneys by HLA
matching. Engl J Med 1991;324:1032-6.
N
4 Gjertson DW. Update: center effects in the clinical trans-
plants 1990. In Terasaki PI, Cecka JM (eds). Clinical Trans-
plants 1990 Los Angeles, CA: UCLA Tissue Typing Labora-
tory, 1991.375-83.
5. Port FK, Held PJ, Wolfe RA, Garcia JR, Rocher LL. The impact
of nonidentical ABO cadaveric renal transplantation on wait-
ing times and graft survival. Am J Kidney Dis 1991;17:519-
23
6 Held PJ, Pauly MV, Bovbjerg RR, Newmann J, Salvatierra O
Access to kidney transplantation has the United States elim-
inated income and racial differences? Arch Intern Med. 1988,
148:2594-600.
7. Held P, Kahan B, Hunsicker L, et al. The impact of HLA mis-
matches the survival of first cadaveric kidney transplants.
on
N Engl J Med 1994;331.765-70.
8. Terasaki PI. Histocompatibility testing, crossmatching, and
allocation of cadaveric kidney transplants. In: Danovitch GM
(ed). The Handbook of Kidney Transplantation Boston, MA:
Little, Brown and Company, 1992:43-66
9 Gaston R, Ayres I, Dooley L, Diethelm A. Racial equity in renal
transplantation: impact of HLA-based allocation. JAMA 1993,
270:1352-6.
10. Cook D, Terasaki PI. Recipient pool sizes for pri-
Mickey M,
oritized HLA matching. Transplantation. 1989;47:400-3.
11. Opetz G. The benefit of exchanging donor kidneys among
transplant centers N Engl J Med 1988,318:1289-94.
12 Sanfilippo FP, Vaughn WK, Peters TG, et al Factors affecting
the waiting time of cadaveric kidney transplant candidates
in the United States. JAMA. 1992,267:247-52
 169

13 United Network for Organ Sharing. 1995 Annual Report of 22289-92.

the U.S. Scientific Registry of Transplant Recipients and the 27. Navarro E. Decision analysis with uncertain future oppor-
Organ Procurement and Transplantation Network, Trans- tunities. Doctoral dissertation, Department of Engineering-
plant data 1988-1993. U.S. Department of Health and Human Economic Systems, Stanford University, Stanford, CA, 1987.
Services, Public Health Service, Health Resources and Ser- 28. Ruth RJ. Kidney transplantation: a simulation model for ex-
vices Administration, Bureau of Health Resources Develop- amining demand and supply. Management Sci. 1985;31~515-
ment, Division of Organ Transplantation, No. 240-90-0051 26.
and 240-90-0064, 1995. 29. Samuels SM. Secretary problems. In. Ghosh BK, Sen PK
14. Wujciak T, Opelz G. A proposal for improved cadaver kidney (eds). Handbook of Sequential Analysis. New York: M Dek-
allocation. Transplantation. 1993;56~1513-7. ker, 1991.
15. Danovitch GM. Immunosuppressive medications and pro- 30. Held PJ. The latest information from the USRDS. XII Annual
tocols for kidney transplantation. In: Danovitch GM (ed) Kid- Conference on Peritoneal Dialysis, Seattle, WA, 1992.
ney Transplantation. Boston, MA: Little, Brown and Com- 31. Kalbfleish JD, Prentice RL. The statistical analysis of failure
pany, 1992:67-103. time data. In: Bradley RA, Hunter JS, Kendall DG, Watson GS
16. Yuan Y, Gafni A, Russell J, Ludwin D. Development of a cen- (eds). Wiley Series in Probability and Mathematical Statistics.
tral matching system for the allocation of cadaveric kidneys: New York: John Wiley & Sons, 1980 321.
a simulation of clinical effectiveness versus equity. Med Decis 32. Hornberger JC, Habraken H, Bloch DA. Minimum data
Making. 1994;14:124-36. needed on patient preferences for accurate, efficient medical
17. O’Brien BJ. A game-theoretic approach to donor kidney decision making. Med Care. 1995;33:297-310.
sharing. Soc Sci Med. 1988;26:1109-16. 33. Hornberger JC, Chernew M, Petersen J, Garber AM. A mul-
18. Ahn JH. Optimal option-exercising strategy with an applica- tivariate analysis of mortality and hospital admissions with
tion for kidney transplant decisions. Doctoral dissertation, high-flux dialysis. J Am Soc Nephrol. 1992;3:1227-37.
Department of Engineering-Economic Systems, Stanford 34 Hornberger JC. The hemodialysis prescription and quality-
University, Stanford, CA, 1993. adjusted life expectancy. J Am Soc Nephrol. 1993;4~1004-20.
19. Cayley A. Mathematical questionswith their solutions. The 35. Hornberger JC, Redelmeier DA, Petersen J. Variability among
Education Times. 1875;23:18-9. six methods of assessing patients’ well being: consequent ef-
20. David I, Yechiali U. A time-dependent stopping problem with fect on a cost-effectiveness analysis. J Clin Epidemiol. 1992;
application to live organ transplants. Operations Research. 45 505-12.
1985;33:491-504. 36. Torrance G. Utility approach to measuring health-related
21. Gardner M. Mathematical games. Scientific American. 1960; quality of life J Chronic Dis. 1987;40 593-600.
202:150-4. 37 Hornberger JC, Best J, Garrison L Cost-effectiveness of re-

22. Guttmann I. On a problem of L. Moser. Canadian Math Bull. peat medical procedures kidney transplantation as an ex-

1960;3:35-9. ample Med Decis Making (in press).

23. Howard RA. Dynamic Probabilistic Systems. Volumes I and 38. Kasiske BL, Neylan JF, Riggio RR. The effect of race on access

II New York: Wiley & Sons, 1971. and outcome in transplantation N Engl J Med. 1991;324:
24. Howard RA, Matheson JE. Readings on the Principles and 302-7.
Applications of Decision Analysis. Palo Alto, CA: Strategic De- 39. Ayres I, Dooley L, Gaston R, Lively D, Triantis G. Unequal
cisions Group, 1983. racial access to kidney transplantation Vanderbilt Law Re-
25. Lindley DV. Dynamic programming and decision theory. view. 1993;46:806-63.
Appl Sci. 1961;10 39-52. 40. Braun W. Allocation of cadaver kidneys new pressures, new

26. Moser L. On a problem of Cayley. Scripta Mathematica 1956; solutions. Am J Kidney Dis. 1994,24.526-30.

APPENDIX

Mathematically, quality-adjusted life expectancy from state 1 is:

where a equals i minus the fixed monthly discount rate,

QOL, represent the candidate’s quality of life in the ith
state, and P,, equals the monthly transition rate from state
i to state j. After the first year, the patient may have a
successful transplant, with quality-adjusted life expec-
tancy of QALEz. We assume quality of life in
the overall
state 2 isequal to the
patient’s quality of life without
stated
any side effect of transplantation minus the loss in quality After the first year of successful transplantation, the
of life associated with side effects of immunologic drugs, patient may continue to have a successful transplant, have
such as infection or cancer. Specifically, Imm represents a failed transplant, or die. Let quality-adjusted life expec-

the loss of quality of life of these side effects, and we as- tancy after the first year of a successful transplant equal
sume that these side effects are proportional to the prob- S:
ability of graft failure, 1 - x. The quality-adjusted life ex-
pectancy during the first year then is:

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170

Solving,

After six months, some patients may no longer be eligible

for retransplantation because of debilitated health or
life expectancy their own choice. Denote 8 as the probability of becoming
Combining equations, quality-adjusted
at entry into state 3 is: eligible for retransplantation. Quality-adjusted life expec-
tancy after the first six months of a failed transplant then
equals:

When a patient suffers a failed transplant, he or she is

assured to wait at least six months before becoming eli-
gible for retransplantation, reflecting the duration on av-
erage that retransplant patients wait longer than first-
transplant patients for a transplant.12 The quality-adjusted
life expectancy of a failed transplant in the first six months
then is:

Equation 2 then becomes:

Equation 11 is differentiated with respect to d, and the

resulting equation is set to 0 to find the d* that maximizes
quality-adjusted life expectancy while awaiting transplan-
tation in state 1. We used Mathematical software to com-

pute d*.

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