American Journal of Transplantation 2003; 4: 216–221
Blackwell Munksgaard
Copyright C© Blackwell Munksgaard 2003
doi: 10.1046/j.1600-6143.2003.00290.x
Payment for Living Donor (Vendor) Kidneys:
A Cost-Effectiveness Analysis
Arthur J. Matasa,∗ and Mark Schnitzlerb
aUniversity of Minnesota, Minnesota, MN
bWashington University School of Medicine, St. Louis,
MO, USA
∗Corresponding author: Arthur J. Matas,
matas001@tc.umn.edu
The supply of kidneys does not meet the demand. As
a consequence, the waiting time for a cadaver kid-
ney continues to lengthen, and there is renewed de-
bate about payment for living donors. To facilitate this
debate, we studied what amount of payment would
be cost-effective for society, i.e. what costs would be
saved (if any) by removing a patient from the wait-
ing list using a paid (living unrelated: LURD) donor-
vendor. A Markov model was developed to calcu-
late the expected average cost and outcome benefits
of increasing the organ supply and reducing waiting
times by adding paid LURD organs to the available
pool.
We found that a LURD transplant saved $94 579
(US dollars, 2002), and 3.5 quality-adjusted life years
(QALYs) were gained. Adding the value of QALYs, a
LURD transplant saved $269 319, assuming society val-
ues additional QALYs from transplantation at the rate
paid per QALY while on dialysis.
At a minimum, a vendor program would save society
>$90 000 per transplant and provides QALYs for the
ESRD population. Thus, society could break even while
paying $90 000/kidney vendor.
Key words: Kidneys, living donor, payment
Received 11 June 2003, revised 25 July and accepted
for publication 25 August 2003
The major clinical problem in kidney transplantation today
is the shortage of donor organs. The significant improve-
ment in transplant patient and graft survival in the last
two decades (1) and the clear demonstration that long-
term survival is better after a transplant (vs. dialysis) for
patients with end-stage renal disease (ESRD) (2,3) have
led an increasing number of patients with ESRD to opt for
transplantation. In addition, acceptance of older patients as
transplant candidates has markedly increased the potential
number of recipients.
A kidney transplant can come from either a living or ca-
daver donor. In the United States during the last decade,
despite numerous local and national educational attempts
and media promotions, there has been little increase in
the number of cadaver donors. With recognition of the ex-
cellent outcome with living unrelated donors (LURDs) and
in response to the organ shortage, there has been some
increase in the number of living donors (4).
The net result is that each year more patients join the
waiting list than are transplanted. As a consequence, the
waiting list and the resultant waiting time to transplanta-
tion have continued to increase (4). The Scientific Registry
of Transplant Recipients (SRTR) database shows that be-
tween 1988 and June 2002, the number of patients on the
waiting list for a kidney transplant increased from 13 943
to 52 766 (4). Currently, in most areas of the country, the
average waiting time for a cadaver kidney is approaching
or has exceeded 5 years. These long waits not only are
expensive (dialysis costs approximately $50 000 per year)
but also have a negative impact on post-transplant out-
come; both patient survival and graft survival are inversely
related to length of time on dialysis (5–7). In addition, the
number of patients dying while on the kidney transplant
waiting list has increased from 736 in 1988 to 2875 in
2000 (4).
Clearly, altruistic donation is not providing sufficient organs.
One potential solution is to consider payment to donors
or to donor families. Numerous authors have debated the
ethics for and against paid donation (8–34); and a proposal
has recently been made to consider a small payment to
families of cadaver donors as an ‘ethical incentive’ (34).
Herein, we do not debate the ethics, but we asked what
payment our society could potentially ‘afford’ to provide for
a living donor. Our answer helps establish the framework
for the ethical debate.
We studied what amount of payment to a living donor (ven-
dor) would be cost-effective for society, i.e. what costs
would be saved by removing a patient from the waiting list
using a paid LURD (vendor). We show, herein, that pay-
ment for living donor kidneys could be cost-effective for
the US health care system. For our analysis, we have as-
sumed the establishment of a government-regulated sys-
tem where a fixed price is paid to the donor, and where
the kidneys are allocated by a predefined algorithm similar
to the extant UNOS point system. Of note, in the United
216

Economics of Paying Donors
States, the government or private insurance pays the costs
of long-term dialysis.
Analysis
Details of the economic and quality of life analyses and
the structure of calculations that we used are found in
Birkmeyer et al. (35), Whiting (36), and Schnitzler et al. (37).
The expected average cost and outcome benefits of in-
creasing the organ supply and reducing waiting times were
calculated for the addition of paid LURD organs to the avail-
able pool (38). Factors included in calculations were pa-
tient survival, cost on dialysis, graft survival, death with
function, death after graft loss, cost of organ acquisition,
cost of transplant, maintenance costs with graft function,
and cost of return to dialysis for LURD transplantation. Our
analysis was carried out from society’s perspective (i.e.
overall costs) and assumes a regulated system and a pre-
defined allocation algorithm (36). Thus the first vendor kid-
neys would likely go to those candidates at or near the
top of the waiting list who had already accumulated a long
waiting time. We used the assumption that waiting time
would only be minimally reduced for these first recipients.
However, if vendor kidneys became a reality and a large
number of vendors came forward, the waiting time (for a
cadaver kidney) would be markedly reduced and, conse-
quently, potential savings to the health care system would
be increased.
A simplified tree diagram of the calculations is shown in
Figure 1. A patient may receive a vendor kidney or con-
tinue to wait on the list for a cadaver transplant. Patients
receiving a vendor kidney would end their first year post-
transplant in one of three conditions: graft function, return
to dialysis, or death. Each year, recipients beginning with
a functioning graft would end in one of these three con-
ditions. Patients who return to dialysis would end the fol-
lowing year in one of two conditions: survival on dialysis or
death. Patients that end a year with death exit calculations
at that point. The probability of ending a period in a given
condition is dependent on the entry condition, the year, and
the receipt of a LURD kidney, dialysis, or death. Similarly,
the outcomes, quality-adjusted life years (QALYs), and cost
associated with each condition are dependent on the en-
try state and the period. The possibility of retransplantation
after return to dialysis was not modeled explicitly but was
included in the estimates of return to dialysis probabilities
and outcome.
Adding a vendor kidney to the system removes a patient
from the waiting list who would have otherwise received a
cadaver organ now available for another patient. The sec-
ond patient would receive an organ now available for a
third patient and so on. This pattern continues until a pa-
tient undergoes a transplant who would have otherwise
died awaiting transplant. Therefore, the limiting factor to
Figure 1: Tree diagram representation of possible outcomes
for patients waiting vs. receiving a vendor kidney. In each pe-
riod following transplantation, a patient and his or her allograft will
survive to the next period, or the allograft will fail with the pa-
tient returning to dialysis (RTD), or the patient will die with graft
function (DWF). An additional organ transplant from any source
shortens the waits of a string of patients limited by the death rate
while waiting. This averages to one expected lifetime on dialysis
for a wait-listed patient. Therefore, outcomes for the reference
patient are calculated for a lifetime on dialysis. Each period for
this patient will end with continued dialysis or death. The probabil-
ities of events and associated outcomes were estimated from the
actual experiences of LURD kidney recipients and patients wait-
listed for transplant as recorded in the USRDS database. Relisting
and retransplantation outcomes were included in the estimates
of outcomes associated with return to dialysis. Calculations were
run through 20 years post-transplant. Each outcome is associated
with a cost and an impact on quality-adjusted life years (QALYs).
the benefits of additional organs for transplant is the death
rate while waiting, and the average effect of adding a ven-
dor kidney is the removal of one lifetime of dialysis from the
system. Thus, for reference, the outcomes and cost were
compared for a patient receiving a hypothetical LURD ven-
dor kidney vs. a hypothetical patient waiting a lifetime on
dialysis. This patient waiting on dialysis will end the first
year in one of two states: continuing dialysis or death.
The length of a calculation period was 1 year, with a
20-year timeframe. Within this time frame, the probabili-
ties of all possible outcomes, with associated QALYs and
costs, were calculated for receipt of a vendor kidney vs. re-
maining on dialysis. All monetary values and QALYs were
discounted at a rate of 5% per year (36).
The primary measure of interest in the study is expected fi-
nancial savings to the health care system (US dollars, 2002)
of using a vendor kidney. We also calculated the expected
change in QALYs with the use of a vendor kidney. From
an accounting perspective, society would ‘break even’ if
a kidney vendor were paid the amount saved by using a
LURD kidney. From a cost-effectiveness perspective, so-
ciety would ‘break even’ if a kidney vendor were paid an
amount so that the cost of care and vendor payments per
QALY were equivalent to a lifetime of dialysis.
American Journal of Transplantation 2003; 4: 216–221 217