Payments for live donor kidneys would increase the number of kidneys available to strangers on transplant waiting lists without causing undue and unjust inducements to donors, according to a study.

Scott D. Halpern, MD, PhD, of the University of Pennsylvania in Philadelphia, and colleagues studied the responses of 342 individuals who filled out questionnaires that present them with 12 scenarios related to their willingness to donate a kidney.

In these scenarios, the researchers varied the payments for a kidney (no payment, $10,000, and $100,000), the risk for renal failure after nephrectomy (0.1%, 1.0%, and 10%), and whether the kidney recipient was a family member or an unknown person on a renal transplant waiting list.

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Willingness to donate to a waiting list patient was more likely among lower-income than higher-income individuals, Dr. Halpern’s group reported in Annals of Internal Medicine (2010;152:358-365). When the payment was $100,000, the adjusted donation rate was 47.9% for subjects in the lowest income category (less than $20,000 a year) and 31.3% for participants in the highest income category (above $100,000). Payments made no significant difference in the willingness of people to donate a kidney to a family member.

As payments for a kidney increased, so did the willingness of people to donate a kidney to a waiting list patient. This trend occurred evenly across income levels, suggesting that payment is not an unjust inducement to living kidney donation. In addition, as the risk of renal failure increased, the likelihood of donating a kidney (either to a family member or a stranger) decreased, regardless of how much they would be paid for a kidney.

“Providing payments did not dull persons’ sensitivity to the risks associated with donor nephrectomy, suggesting that payment does not represent an undue inducement—one that would make rational choice difficult,” the authors wrote. “Furthermore, providing payments did not preferentially motivate poorer persons to sell a kidney, suggesting that payment does not represent an unjust inducement—one that would put substantially more pressure on poorer persons than on wealthier persons.”

The study also showed that paying for kidneys did not reduce altruistic donation. The proportions of scenarios in which subjects were willing to donate without payment were similar when the investigators presented these scenarios to participants before or after the introduction of financial incentives.

An important limitation of their study, the researchers pointed out, was that participants’ responses to hypothetical offers might not reflect decisions they would make if they really were offered payment for a kidney. They noted, for example, that “hypothetical offers of payment may be insufficient to blunt a person’s perception of risk, but real money might do just that.”

The investigators recommend “proceeding with a highly controlled and geographically limited test of such payments that is explicitly designed to detect both intended and unintended consequences of real-world payments for living kidney donation.” n