Some years ago, the New England Journal of Medicine carried an article on the economic implications of HLA matching in cadaveric renal transplantation, in the context of local versus national allocation of organs and a debate of sorts ensued. This particular topic is relevant in India today because people feel that it is time that the Chennai/Vellore-based INOS went national.

Mark A. Schnitzler, PhD, and colleagues from the Washington University School of Medicine, St .Louis, MO, wrote the article with the above-mentioned title based on a study which analyzed the economic costs associated with the transplantation of cadaveric kidneys with various numbers of mismatches and examined the potential economic benefits of a local, as compared with a national, system designed to minimize HLA mismatches between donor and recipient in first cadaveric renal transplantations.

They found that average Medicare payments for renal transplantation recipients in the three years after transplantation increased from $60,436 per patient for fully HLA-matched kidneys (those with no HLA-A, B or DR mismatches) to $80,807 for kidneys with six HLA mismatches between donor and recipient, a difference of 34% (P<0.001).By three years after transplantation, the average Medicare Payments were $64,119 for transplantations of kidneys with less than 12 hours of cold-ischemia time and $74,997 for those with more than 36 hours (P<0.001). In simulations, the assignment of cadaveric kidneys to recipients by a method that minimized HLA mismatching within a local geo graphic area (i.e., within one of the approximately 50 organ procurement organizations, which cover widely varying geographic areas) produced the largest cost savings ($4,290 per patient over a period of three years) and the largest improvements in the graft-survival rate (2.3 %). When the potential costs of longer cold-ischemia time were considered, no additional savings were estimated to result from a national allocation program, because the additional costs of longer old-ischemia time were greater than the advantage of optimizing HLA matching. Following this article, Steven K, Take motto, PhD, and colleagues from the UCLA School of Medicine, Los Angeles, CA wrote in saying that Schnitzler and colleagues probably overstated the economic benefits of a strictly local organ-allocation system and over estimated the fraction of local recipients who would receive a locally procured HLA-matched cadaveric kidney. In regions with 750waiting patients (the local-pool size used by Schnitzler &colleagues) only 4% of donors would be able to provide an HLA match for a recipient and not 14%, as claimed by Schnitzler and colleagues. In addition, only 1to 2% of kidney went to HLA-matched patients before the implementation of the United Network for Organ Sharing (UNOS) national sharing policy; 14% went to HLA-matched patients there after. Take motto and colleagues concluded that national distribution of HLA-matched cadaveric kidneys must precede local al location for the reported economic gains in renal transplantations due to HLA matching to be achieved. Schnitzler and colleagues, while agreeing with the above conclusion, clarified that their study was designed as an economic comparison of the current system of allocating cadaveric kidneys with an alternative system in which all organs and not just those with zero HLA mismatches would be shared. UNOS policy states that for every kidney with zero HLA mismatches that is received by an organ procurement organization, another kidney must be shared on a national level. Payback kidneys generally have some HLA mismatches and have relatively long cold-ischemia times and the study shows that longer periods of cold-ischemia are associated with considerable expense. The Current allocation system improves the clinical and economic outcomes of approximately 15% of cadaveric kidney transplantations through the sharing of kidney with zero HLA mismatches, perhaps at the expense of increased cold-ischemia times for payback kidneys. Schnitzler and colleagues again reiterated that discouraging transplantation of kidneys with four or more HLA mismatches might be a reasonable alternative policy. This would improve the clinical and economic outcomes of as many as half of cadaveric kidney transplantations without the costs in terms of longer cold-ischemia times that are associated with national allocation.

[ NEJM (Volume 341:1440-1446, November 4,1999, Number 19)and NEJM (Volume 342:820-821, March 16, 2000 Number 11)]