Would You Reject a New Kidney from Someone Who Died of a Drug Overdose?

A kidney transplant is performed at Johns Hopkins Hospital in Baltimore in 2012.
A kidney transplant is performed at Johns Hopkins Hospital in Baltimore in 2012.
A kidney transplant is performed at Johns Hopkins Hospital in Baltimore in 2012.

A kidney transplant is performed at Johns Hopkins Hospital in Baltimore in 2012.

By: Lena Sibulesky, MD and Vanessa L. Weiland, MSN

It’s hard to fathom any goodness coming from the opioid crisis and the family tragedies it causes every day. But it does, in the form of an increase in organs available to people who need new hearts, livers, kidneys, and other organs.

By their ages only, many of those dying of overdoses would be considered in the prime of life. Their organs have years of vitality left, and can give the thousands of Americans on organ wait lists the chance for new lives.

We specialize in kidney transplantation. In the United States, about 20,000 kidney transplants are performed each year, too slow a pace for the 95,000 Americans waiting for new kidneys. Getting a donor kidney is a yearslong wait, and thousands succumb to kidney failure each year before a potential match becomes available.

Given the huge shortage of donors, it is bewildering and disheartening when an individual who needs a kidney declines one from a donor who died of an overdose.

Here’s why this happens: Before organs are removed from prospective donors, they are screened for hepatitis B and C, HIV, and other infections that might make their organs unfit for transplant. Even when no such infections are found, donors associated with any of the criteria the U.S. Public Health Service deems as risky must be identified as “increased risk.” The criteria include things like male-male sex, three consecutive days in jail, or non-medical injection drug use in the previous year.

The “increased risk” label signifies the potential that a donor contracted hepatitis B, hepatitis C, or HIV within a week of his or her death, raising the possibility that the infection wouldn’t be detected by screening.

According to guidelines set by the federal Organ Procurement and Transplantation Network, increased risk does not describe the quality of the donor organ or its likely longevity. And, to be clear, the risk of virus transmission from donor to recipient is slight — there’s less than a 1-in-1,000 chance that a recipient will contract hepatitis B, hepatitis C, or HIV from a donor kidney.

But “increased risk donor” is a powerful label, carrying the stigma of an overdose death. It wards off many people from accepting kidneys, often to their own detriment.

Consider a recent analysis that examined more than 100,000 instances of kidney transplant candidates declining increased risk donor kidneys. Five years later, 20 percent of those candidates had died and 15 percent were still on the wait list. Thirty percent went on to receive a standard-risk kidney, but those organs had worse functional scores, on average, than the so-called increased risk kidneys those patients had turned away. You read that right: The kidneys of people who overdose are, on average, no worse than standard donor kidneys and in many cases are healthier.

The analysis concluded that accepting an increased risk donor kidney “was associated with substantial long-term survival benefit.”

We share this information and more with our transplant candidates. We make every patient aware of the risks of transplant, especially those involving the prospective donor organ. We tell them we cannot guarantee that any donor organ, even one from a healthy person who never drank alcohol or used drugs illicitly, will succeed. We tell them about medications that, in the exceedingly small chance of virus transmission, would eradicate the condition (hepatitis C) or make it manageable (HIV or hepatitis B).

We hope they’ll see why it makes sense to accept an increased risk donor kidney and get off dialysis or avoid it, as well as detach from the emotional burden of waiting for a donor kidney to appear.

That logic doesn’t sway everyone. “I don’t need another problem,” fairly characterizes the mindset of transplant candidates who declined increased risk donor kidneys in our recent study of patients’ decisions.

“I didn’t want to get one of these diseases and maybe pass it to my family,” said one woman who underwent dialysis for more than three years and declined multiple increased risk donor organs before finally accepting one.

She later acknowledged that the education we provided reduced her “what-if” fears. In that way she represented the 92 percent of patients in our study who had declined an increased risk donor kidney but, after learning more, said they would be more open to accept such an organ in the future.

It is a shame that our culture has so stigmatized drug use that kidneys from people who die of opioid overdoses are routinely turned away by those whose lives might depend on these organs. That the altruistic intention of those donors or the generosity of their families could be spurned by a misunderstanding. That fear could so overwhelm probability.

If we could see these increased risk donors — as well as all people addicted to opioids — as victims of a disease, we could honor them for their precious gifts of life, just as we honor every other organ donor. It’s something to think about as both populations, drug-overdose victims and people who need kidney transplants, show few signs of shrinking.

Vanessa L. Weiland, M.S.N., is an advanced registered nurse practitioner and teaching associate in nephrology at the University of Washington School of Medicine. Lena Sibulesky, M.D., is a transplant surgeon and associate professor of surgery at the University of Washington School of Medicine.

Source: STAT News