Allokation von Nieren im Zeitalter des Organmangels in Deutschland

Due to the opt-in solution currently in place in Germany, there is a substantial shortage of deceased organ donors. Therefore, it is critical that the allocation of available organs follows an optimized algorithm and that the potential of living donations is maximized; however, in this respect the current German legislation has major shortcomings. The human leukocyte antigen (HLA) matching system has a large impact on the standard kidney allocation (Eurotransplant kidney allocation system, ETKAS), that is no longer necessary to this extent in the era of modern immunosuppression but continues to put patients with rare HLA types at a disadvantage. As most points are effectively awarded for the accrual of waiting time, kidneys are often awarded to recipients with poor perspectives for organ survival. The aim of the Eurotransplant Senior Program (ESP) is primarily to minimize the cold ischemia time (CIT) even though it has been shown that CIT can be increased to up to 18 h without impairing allograft survival, also for high-risk organs from ≥ 70-year-old donors. At the same time, the preferential allocation of ESP organs within one subregion results in greatly different waiting times within Germany. Also, the only inclusion criterion for the ESP is recipient age, whereas other medical conditions and thus other recipient risk groups (e.g., diabetics) are disadvantaged. The ban on altruistic living kidney donations in Germany impairs the implementation of modern strategies, such as crossover donations, that have become standard internationally. In turn, the full potential of living kidney donations cannot currently be exploited in Germany. The allocation system should be modernized by incorporating new advances from transplantation research, e.g., by allocation according to life years gained.