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Voucher Program Solving Chronological Incompatibility
Kidney voucher
An innovation designed to increase living kidney donations, which started at UCLA in 2014 and is now run by the National Kidney Registry (NKR) with nearly 80 participating transplant centers, has resulted in an uptick in living donations, according to a recent UCLA-led analysis published in JAMA Surgery.
The NKR Voucher Program allows living-kidney donors to choose the most convenient time frame for their surgery, even if their intended recipient doesn’t yet need a transplant. The donated kidney goes to a matched recipient on the waiting list with an immediate need, and the donor receives a voucher that can be used to prioritize a friend or family member to receive a living-donor kidney through the NKR if and when they need a transplant in the future.
In a review of data compiled by the NKR, Jeffrey L. Veale, MD, a renal transplant surgeon who directs the UCLA Kidney Exchange Program, found that between 2014 and 2021, a total of 250 donations were made at 79 transplant centers under the voucher program, with six recipients redeeming their vouchers. During that time, the average waiting period for individuals enrolled with the NKR dropped by three months.
Dr. Veale and his colleagues concluded that the voucher program has helped otherwise willing altruistic donors overcome a hurdle to their moving forward by ensuring that loved ones who might need a kidney in the future will be taken care of. It also removes another common obstacle — when there is an intended recipient who doesn’t yet need the organ at the time that an older family member is ready to give. “A new term came out of this program: chronological incompatibility,” Dr. Veale says. “Many people are incompatible not by blood type, but by time. They’re able to donate now, but their relative or friend won’t need the kidney for a number of years.”
Chronological incompatibility was the issue facing Howard Broadman, a 64-year-old retired San Diego County judge, when he approached the UCLA Kidney Transplant Program in 2014 with an unusual request: If he donated to a stranger now, could his then-4-year-old grandson, Quinn, who had chronic kidney disease but didn’t yet need dialysis, receive priority for a transplant if needed later in life? “Quinn wasn’t likely to require dialysis for 10-to-15 years, and by that time Judge Broadman would be close to 80 and too old to qualify as a donor,” Dr. Veale explains. “We thought it was a great idea, and UCLA backed us up.”
Photo: Courtesy of Dr. Jeffrey L. Veale
As an altruistic, nondirected donor, Broadman’s act — and the actions of those who followed suit under the voucher program as it was launched at UCLA before going national under the NKR’s administration — initiated a so-called transplant chain, in which a recipient who has an incompatible donor receives a kidney, that incompatible donor pays it forward to another person with an incompatible donor, and so on. The voucher concept was initially met with skepticism in the transplant community, but it has since been embraced, notes H. Albin Gritsch, MD, surgical director of the UCLA Kidney Transplant Program. “There was a lot of reluctance to accept that someone would donate a kidney and not know who would receive it, but people like the judge showed that they are just trying to make the world a better place while providing some insurance for their family,” Dr. Gritsch says. “This is really the ultimate philanthropic gift.”
The support of the NKR has been integral to the growth of the voucher concept, Dr. Gritsch notes, since it dramatically expands the pool of centers at which participants can donate and from which designated recipients can redeem their voucher in the future. The program offers participants either a standard voucher — when a family member or friend is expected to need a kidney transplant within a year and the donor would like to donate sooner rather than later — and a family voucher, when there is not an immediate need for a kidney transplant but the donor wants to help others now, in exchange for a voucher that can be redeemed by one of five family members that donor designates.
At any given time, the number of people eligible for a life-saving kidney transplant exceeds the supply, and Drs. Gritsch and Veale note that the majority of organs still come from deceased individuals who have declared themselves as organ donors on their driver’s license or discussed the matter with family members. But innovations pioneered at UCLA such as the voucher program, chain transplants, and direct exchanges among incompatible donor-recipient pairs have increased the number of living donations, and that has helped to make a dent in the waiting list, which had exceeded 105,000 and is now down to approximately 90,000.
“The demand for kidneys is going to continue,” Dr. Gritsch says. “But innovations such as these are making a big difference.”
For more information about the UCLA Kidney Exchange Program >
“Voucher-Based Kidney Donation and Redemption for Future Transplant,” JAMA Surgery, June 23, 2021.
