Multiple-Listing for Cadaveric Kidney and Liver Transplantation
Transplant candidates are permitted to register on multiple waiting lists. We examined multiple-listing practices and outcomes, using data on 81,481 kidney and 26,260 liver candidates registered between 7/1/95 and 6/30/00. Regression models identified factors associated with multiple-listing and its effect on relative rates of transplantation, waiting list mortality, kidney graft failure, and liver transplant mortality. Overall, 5.8% (kidney) and 3.3% (liver) of candidates multiple-listed. Non-white race, older age, non-private insurance, and lower educational level were associated with significantly lower odds of multiple-listing. While multiple-listed, transplantation rates were significantly higher for nearly all kidney and liver candidate subgroups (relative rate [RR]= 1.42-2.29 and 1.82-7.41, respectively). Waiting list mortality rates were significantly lower while multiple-listed for 11 kidney subgroups (RR = 0.22-0.72) but significantly higher for 7 liver subgroups (RR = 1.44-5.93), suggesting multiple-listing by healthier kidney candidates and sicker liver candidates. Graft failure was 10% less likely among multiple-listed kidney recipients. Multiple- and single-listed liver recipients had similar post-transplant mortality rates. Although specific factors characterize those transplant candidates likely to multiple-list, transplant access is significantly enhanced for almost all multiple-listed kidney and liver candidates.

The gap between the number of transplantable organs from deceased donors and the number of patients awaiting transplantation continues to increase each year. The complex debate over the merits, ethics, propriety, and even legality of patients placing their names on more than one waiting list for transplantation, a practice known as multiple-listing, persists amid the growing imbalance between supply and demand. After the Organ Procurement and Transplantation Network (OPTN) was formed by the National Organ Transplant Act of 1984, policies designed to promote fair and equitable organ allocation were developed and adopted in 1987 by the Board of Directors of the United Network for Organ Sharing, the organization acting as the OPTN contractor. Multiple-listing was explicitly permitted. In early 1988, equity concerns led to a recommendation to rescind the option of multiple-listing. However, based on public comments received later that year, the policy remained. Proposed bans on multiple-listing were heatedly discussed again in the 1990s, but no further policy actions were taken or implemented. During the past 2 years, the OPTN has again begun to debate the issue. Aside from kidney transplant candidates in the state of New York, patients anywhere in the United States are permitted to multiple-list.

Opponents maintain that the opportunity to multiple-list is not available to (or even known by) all transplant candidates and is utilized by only a small proportion of them. Multiple-listed candidates, it is argued, have an unfair advantage in terms of access to organs. Further, the characteristics of those who multiple-list differ significantly from those who do not, which appears to exacerbate existing demographically defined inequalities in transplant access. Advocates of multiple-listing assert that patient choice is an important element of US medical practice and that those who have interest and the means to multiple-list should be free to do so. Furthermore, regional differences in access to transplant organs, which are of striking magnitude, may be ameliorated through the practice of multiple-listing by increasing effective organ distribution areas. This effect is of very limited impact, however, as it occurs on a patient-by-patient basis.

Few systematic studies of the practice and outcomes of multiple-listing for kidney transplantation have been published, and none have been published relating to liver transplantation. We report here the results of analyses concerning the relationship of multiple-listing to access to transplantation and outcomes for patients with end-stage renal and liver disease.