Development of a central matching system for the allocation of cadaveric kidneys: a simulation of clinical effectiveness versus equity.

OBJECTIVES: 1) To develop a computer-based simulation to prospectively study the impacts of explicitly incorporating different equity criteria into the process of allocating kidneys to recipients, given the scarcity of this resource. 2) To assess the tradeoffs between systems that allocate kidneys based only on medical criteria, systems that allocate kidneys based only on equity criteria, and systems that consider both medical and equity criteria.
METHODS: A computer-based simulation was developed that describes the flows of patients and kidneys. This model provides information at various time points about the number of patients in the system who are awaiting transplants, the number of kidneys available for transplantation, the number of transplantations performed for each matching algorithm, and the number of kidneys discarded (when applicable), as well as the means and standard deviations of the HLA-match scores, number of days from registration to transplantation, and number of days (from registration) of those who are still waiting for transplants. Five different matching algorithms were compared, ranging from determination of the allocation by a single medical criterion (i.e, HLA match) to determination by a single equity criterion (i.e., relative position in the waiting queue). The remaining algorithms represent different strategies of weighting these two considerations. Estimates regarding the main parameters of the model were derived utilizing data collected through the Multiple Organ Retrieval and Exchange Programme of Ontario, Canada.
RESULTS: The simulation was set to run for a period of ten years. A tradeoff between graft survival (or improved HLA matching) and equal treatment of patients regardless of their likelihood to benefit was found. It is clear that an algorithm that allocates kidneys based only on temporal location of patient on the waiting list is likely to be unacceptable because of the very poor average HLA-match scores that it yields. Pool size was found to be a major determinant in the attainment of optimal matching from a medical perspective.
CONCLUSIONS: 1) The final choice about any allocation algorithm to be used requires that a value judgment be made, i.e., how great a reduction in HLA-match score should be traded in order to improve equity score (or vice versa). 2) A computer-based simulation model is a feasible way to prospectively test the impact of any given allocation algorithm on any given system.