Evaluating options for utility-based kidney allocation: Viewpoint

Over the last 5 years, a number of utility-based allocation systems have been proposed in an effort to increase the life-prolonging potential of deceased donor kidneys in the United States. These have included various adaptations of age-matching and net benefit, including the Eurotransplant Senior Program, Life Years From Transplant, and several systems for avoiding extreme donor/recipient mismatch. However, utility-based allocation is complex and raises issues regarding choice of metric, appropriateness of certain factors for use in allocation, accuracy of prediction models, transparency and perception, and possible effects on donation rates. Changing the role of utility in kidney allocation will likely cause changes to efficiency, equity, predictability, autonomy, controversy, trust and live donation. In this manuscript, various allocation systems are discussed, and a framework is proposed for quantifying the goals of the transplant community and evaluating options for utility-based kidney allocation in this context.