This post was written by Daniela Shuman, Ruby Rorty, and Steven Levitt. 

• We can save lives by helping eager living kidney donor candidates who fall short of eligibility requirements (e.g., BMI thresholds) overcome these barriers and qualify for surgery. 
• Project Donor is an initiative incubated at the Center for RISC, a think tank at UChicago founded by Steven Levitt. Project Donor is scaling eligibility support for living donor candidates by offering free weight loss, smoking cessation, and emotional support resources to help candidates safely achieve transplant. 
• In a 2-year pilot program with 353 previously rejected candidate donors, 14% ultimately donated at a cost of ~$66 per QALY added for the services provided.
• Efforts to help willing donors overcome barriers to eligibility are likely more cost-effective than recruitment interventions to increase the pool of willing living and deceased donors.
• At our current rate of growth, we project that the cost of enabling one additional donation will be $1,408 by EOY 2025.
• Medicare could save up to ~$750 million annually in averted dialysis costs. 
• This intervention is currently being scaled in the U.S. by a small team at the University of Chicago, but is generalizable and could be rolled out in any nation with living organ transplant infrastructure
• We are seeking funders, advisors, and fresh ideas to help make this high-potential intervention more cost effective and scalable. 

The Problem

About 37 million Americans have kidney disease, making it the fastest-growing noncommunicable disease in the U.S. Of these, 807,000 live with kidney failure, also known as end-stage renal disease (ESRD) or end-stage kidney disease (ESKD). At this advanced stage, the kidneys can no longer perform their life-sustaining function of filtering waste from the bloodstream. Without a transplant, a person with kidney failure will be on dialysis for the rest of their lives. Dialysis is costly, time consuming, deeply uncomfortable, and prevents people from working full-time, leading to lost wages and financial insecurity.

Further, ESRD is expensive to taxpayers. Across a patient’s lifetime, dialysis costs on average $1.19 million, the majority of which is fronted by the government - dialysis currently makes up 1% of the total annual federal budget. 

Relative to those who stay on dialysis, patients who receive a kidney transplant have better long-term survival and experience a better quality of life. Also, transplants from living donors last up to twice as long as those from deceased donors (15-20 years, rather than 10-15). Living donors are also highly motivated, as they are typically donating in order to save the life of a loved one. 

Still, of the more than 90,000 Americans placed on the kidney transplant waitlist in 2022, only about 1 in 4 received a kidney and only about 20% of those kidneys came from living donors. As a result, 6,000 Americans die each year waiting for a kidney transplant. 

Despite this dire need for kidneys, less than 2% of potential donors who start the process ever undergo surgery, according to National Kidney Registry statistics. About one-third of kidney donors are rejected based on mutable health conditions like high body mass index (BMI) and use of tobacco products. 

More information about the challenges of living kidney donations are in RISC’s April 2024 report, Living Kidney Donation: Challenges and Opportunities.

Project Donor’s Solution

Project Donor is an initiative launched in 2022 by Freakonomics author Professor Steven Levitt's Center for Radical Innovation for Social Change (RISC), a nonprofit incubator and social impact lab at the University of Chicago. Project Donor increases the supply of kidneys and livers  from living donors by helping donor candidates who fall short of eligibility requirements achieve transplant eligibility. We provide free access to weight loss resources, smoking cessation resources, and mental health resources, as well as individual case management, to help candidates overcome mutable barriers to eligibility. 

We have partnered with a nationwide network of over 50 transplant centers and nonprofits, including UPenn, Alabama Birmingham, UCSF, National Kidney Registry (NKR), and NKF. Our partners refer donor candidates to our program if they have been screened out for high body mass index (BMI), tobacco use, or minor mental health history. Interested donor candidates consult with a Project Donor case manager, who connects them with top-of-the-line nutrition, mental health, and nicotine replacement resources at no charge to the participant. Once onboarded, the participant receives the codes to access the resource or resources that best fits their eligibility goals and lifestyle. Our resource partners include Noom nutrition, WW (formerly WeightWatchers), and BetterHelp online therapy. 

After a 2-year pilot period, Project Donor has onboarded over 680 participants and facilitated 60 transplants. 284 additional Project Donor candidates are currently working to achieve transplant donation eligibility. 

Cost-Effectiveness of Project Donor

(See a detailed report here)

Project Donor has proved to be cost effective compared to other life-saving interventions. In order to evaluate cost effectiveness relative to other life-saving interventions, we performed an analysis to determine the cost per additional Quality Adjusted Life Year (QALY) produced by Project Donor. We only included participants who onboarded into our program in these calculations. 

We found that just $66 spent by Project Donor on eligibility resources results in one additional QALY. Top GiveWell charities produce a Quality Adjusted Life Year for approximately $50, indicating that Project Donor is within the ballpark cost-effectiveness of today’s most efficient life-saving interventions. 

Further, through our partnerships and labor efficiencies, we believe our costs per participant will decrease while the likelihood of participants donating will increase, further decreasing the marginal cost of an additional QALY produced by Project Donor.

Projection

We expect Project Donor to grow by an average of 46 people per month for the next year. The rate of growth is steadily increasing. We expect our administrative team to shrink from 6 people to 4 due to these 2 analysts departing in June. Therefore, our current projections suggest that Project Donor will cost $55 per participant per month by EOY 2025, as opposed to $111 at the end of 2024. 

At this current rate of growth, we project that the cost of enabling one additional donation will be $1,408 by EOY 2025 (calculations). 

Avenues for Scalability

Global Impact

Globally, Kidney and liver disease account for over 4 million annual deaths. Project Donor’s intervention is generalizable and could be exported to any nation with kidney transplant infrastructure, minimally resulting in a doubling of our potential impact (based on numbers from IRODaT, the International Registry on Organ Donation and Transportation). There were approximately 6,100 kidney donations in the US in 2022. In that same year, there were approximately 13,100 globally (outside of the US) in a well regulated organ donation registry. This suggests that Project Donor’s global impact could be on the order of 2.1x boost in living kidney donations. We have not been able to find other eligibility support programs for living kidney donors internationally. 

Contributions to Living Kidney Donation Discourse

Project Donor also conducts rigorous research and qualitative analyses to address the dearth of information in the live kidney donation space. We are currently working on multiple peer-reviewed articles with transplant surgeons.

In addition to our life-saving work through the program, we publish work with multimedia sources to shed light on barriers to organ donation, and attend transplant conferences to raise awareness about eligibility support for living donor candidates. Our work has been featured by NKDO, Chicago Tribune, The Journey Continues, Donor Diaries, National Kidney Registry, and on Noom on Yahoo Finance. 

Taxpayer Benefits

In addition to being a cost effective approach to saving lives and improving public health, enabling more living kidney transplants is a fiscally responsible intervention, freeing up significant federal funds. 

We estimate that in two years of operation, Project Donor’s enabled transplant surgeries saved Medicare at least $8,000,000 in averted dialysis costs (conservatively). 

Medicare currently covers preoperative evaluation and surgery-related costs for living kidney donor candidates. If Medicare were to extend its coverage to include basic weight-loss and smoking-cessation support, at least 2,000 lives and ~$750,000,000 could be saved annually (calculations). 

Our Immediate Asks

As Project Donor continues to scale-up its cost-effective, life-saving work, donations are welcome. We are also seeking to grow our impact with transplant center partners, sustainable sources of funding, and fresh ideas for cost-effective interventions to boost living kidney donation. Please sign up for a call on our website or email us at [email protected] if you’d like to get in touch.  

For any questions, please contact Daniela Shuman at [email protected].

Additionally, please consider donating a kidney. Anyone is welcome to sign up to Project Donor’s program here.