Hundreds of thousands of Americans suffer from end stage renal disease (ESRD) — essentially, kidney failure. Within 5 years, most of them will be dead. It doesn’t have to be this way.
There are two main treatments for ESRD – dialysis, and kidney transplant. Dialysis is rough – it involves visiting a clinic and being hooked up to a machine that pumps your blood outside your body and cleans it. This takes hours, and you have to do it three times a week. 20% of dialysis patients die within a year, and 65% die within five years. Even for the survivors, dialysis is exhausting [1].
It’s also expensive; about $88,000 per patient per year. The US government, through Medicare, picks up most of the tab, more than $30B per year. This is around 1% of the federal government budget, every year.
The other treatment is a kidney transplant. With a successful transplant, a patient doesn’t have to do dialysis at all. You do have to take immunosuppressant drugs (forever) to make sure your body doesn’t reject the new kidney — it’s not nothing, but it’s a lot better than dialysis. The five-year survival rate after a transplant is ~80%. Compared to dialysis, transplants offer recipients a much better and longer life.
Transplants are also cheaper than dialysis. The initial surgery is about $35,000, and the per-year costs of the immunosuppressant drugs and other care is about $25,000 per patient per year.
Transplants aren’t perfect, but they are better for the patient’s health and less expensive. So why are so many people on dialysis?
To do a kidney transplant, you need a kidney. The main source of kidneys for transplant in the US are deceased organ donors. They provide about 14,000 kidneys per year for transplant. Unfortunately, most people don’t die in a way that allows them to donate their organs. About 60% of Americans are signed up as organ donors. More would help, but it won’t be enough to close the gap. Around 80,000 Americans are currently on the waiting list for a kidney transplant. The average wait time is 5 years; by then there’s a good chance a dialysis patient will have died.
Luckily, there is another (better [3]) source of kidneys. Everyone is born with two functional kidneys, and you only need one. About 5,500 living people donate kidneys each year. Most Americans could be living kidney donors. But it isn’t as simple as giving blood. Removing a kidney is a major surgery; recovery takes days or weeks, and, like every major surgery, donors run a small risk of death. There are also some long-term health risks, including increased chance of future kidney failure.
Most people aren’t willing to undergo major surgery out of sheer altruism. Some wonderful people are, but we would need tens of thousands of additional donors every year to give a transplant to everyone who wants one.
That’s a shame, because the benefits to recipients are so large. Donors give up a few weeks to prepare for and recover from the surgery, and take on some small health risks; recipients are given lives free of dialysis, and *years* of additional life expectancy. Because dialysis is so expensive, the government even saves money with every transplant.
With such large benefits on one side, and substantial but much smaller costs on the other, I see an obvious solution: make a deal. We should compensate donors for their time and their risk. At almost any price, a kidney would be a bargain [2], so there’s plenty of room to make sure we compensate donors fairly. Everyone wins.
This is the biggest “free lunch” US policy I know of, by which I mean that the conclusions are relatively certain and ~everybody ends up better off. The gains are large – tens of thousands of years of extra life expectancy annually and billions of dollars saved annually.
[1] A year living on dialysis is estimated to be worth around 0.5 QALY. QALY stands for “quality adjusted life year”. It is meant to represent the value of living one year in good health. To say that a year on dialysis is worth 0.5 QALYs is to say that a typical dialysis patient would be willing to give up one year on dialysis to live for six months in good health.
[2] A low-end estimate for the value of a QALY in the US is $50,000. If a kidney donation takes a patient from 5 years of 0.5 QALY/year life expectancy to 10 years of 0.8 QALY/year life expectancy, it’s worth $275,000 in QALYs alone. The financial savings compared to dialysis are worth another $155,000, using the assumptions in this post. Even paying $100,000 per donor would be worth it.
[3] Kidneys from living donors work better than kidneys from deceased donors. “A living donor kidney functions, on average, 12 to 20 years, and a deceased donor kidney from 8 to 12 years. “
Bit Wise, Pound Foolish 
I tend to agree. My personal experience is with bone marrow donation though, not kidney donation. There are several very important differences, number 1 being that there is even less risk to the donor. There’s barely enough risk during the procedure to be statistically significant and there’s no long term change in the donor’s health profile. I think it’s also less reliably beneficial to the recipient, depending on the specific type of leukemia they have.
That being said I know that the donation “agency” or registry gets a lot of money from the recipient (or generally the recipient’s insurance), and the donor themselves get…a free night in a hotel room during the procedure. So it basically is pure altruism. I think compensating donors (in this case far less than for a kidney donation) would make the process more fair and improve participation. The fact that the middlemen are getting paid kind of takes the air out of the altruism balloon a little bit and makes donors feel somewhat taken advantage of.
My main question after reading this though is why does the government fully subsidize dialysis, but not other forms of long term care? What’s the reasoning behind that (if there is any)?
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+1 for compensating donors in that case; it’s pretty frustrating that everyone involved gets paid *except* the donor!
Regarding the history: https://www.nap.edu/read/1793/chapter/6
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Would it make sense to also make it so that if you donated a kidney and you later suffer renal failure, you’re given some priority? That is, assuming a non-perfect system where just because this is enacted, there is still some wait for a kidney but you, as a previous donor, put yourself as a higher risk?
Also, could a system like this work for other living-donor donations? (Liver, bone marrow, etc)?
Final question and I hate having to ask it: $80,000 x 1-5 years is less than $25,000 for 20-30+ years. So the cost may be higher. Doesn’t mean we shouldn’t do it, but updated life expectancy has to factor somewhere.
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+1 for prior donors getting priority for renal failure; that is one of the bigger risks of donation, and mitigating it seems fair.
Compensation for liver, bone marrow, etc. sounds like a good idea to me, although I’m not familiar with the details for those cases (how bad is the shortage? how much better is transplant than the next best treatment? health risks for donor? costs? etc)
Unfortunately, 20-30 years is optimistic, even for a transplant from a living donor. More like 15 (I’m not sure why). You’re right that my financial estimate in footnote [2] is a little optimistic (although that means the QALY estimate is even better). As far as medical treatments go, $25,000 for a year of good life is very cheap! But we’d definitely want to run the numbers more carefully.
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