1
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Kilambi V, Barah M, Formica RN, Friedewald JJ, Mehrotra S. Evaluation of Opening Offers Early for Deceased Donor Kidneys at Risk of Nonutilization. Clin J Am Soc Nephrol 2024; 19:233-240. [PMID: 37943856 PMCID: PMC10861110 DOI: 10.2215/cjn.0000000000000346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 10/30/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Reducing nonutilization of kidneys recovered from deceased donors is a current policy concern for kidney allocation in the United States. The likelihood of nonutilization is greater with a higher kidney donor risk index (KDRI) offer. We examine how opening offers for organs with KDRI >1.75 to the broader waitlist at varying points of time affects usage rates. METHODS We simulate kidney allocation using data for January 2018 to June 2019 from Organ Procurement and Transplantation Network. For the simulation experiment, allocation policy is modified so that KDRI >1.75 organs are offered to all local candidates (same donation service area) after a set amount of cold time simultaneously. Open offers to candidates nationally are similarly examined. RESULTS Simulation results ( n =50 replications) estimate that opening offers locally for KDRI >1.75 after 10 hours yields a nonutilization rate of 38% (range: 35%-42%), less than the prevailing rate of 55% of KDRI >1.75 kidneys. Opening offers after 5 hours yields 30% (range: 26%-34%), reducing the prevailing nonutilization rate by 45%. Opening offers nationally after 10 and 5 hours yields nonutilization rates of 11% (range: 8%-15%) and 6% (range: 4%-9%) for KDRI >1.75 kidneys, respectively. CONCLUSIONS Simulation findings indicate that opening offers and adjusting their timing can significantly reduce nonutilization of high-KDRI kidneys.
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Affiliation(s)
- Vikram Kilambi
- Department of Engineering and Applied Sciences, RAND Corporation, Arlington, Virginia
- RAND Health Care, Access and Delivery Program, RAND Corporation, Arlington, Virginia
| | - Masoud Barah
- Department of Industrial Engineering and Management Sciences, Northwestern University, Evanston, Illinois
| | - Richard N. Formica
- Department of Nephrology, Yale School of Medicine, New Haven, Connecticut
| | - John J. Friedewald
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Nephrology, Department of Medicine, Northwestern University, Chicago, Illinois
- Center for Engineering and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sanjay Mehrotra
- Department of Industrial Engineering and Management Sciences, Northwestern University, Evanston, Illinois
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Nephrology, Department of Medicine, Northwestern University, Chicago, Illinois
- Center for Engineering and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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2
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Stratta RJ. Kidney utility and futility. Clin Transplant 2022; 36:e14847. [PMID: 36321653 DOI: 10.1111/ctr.14847] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/01/2022] [Accepted: 10/29/2022] [Indexed: 11/25/2022]
Abstract
Changes in kidney allocation coupled with the COVID-19 pandemic have placed tremendous strain on current systems of organ distribution and logistics. Although the number of deceased donors continues to rise annually in the United States, the proportion of marginal deceased donors (MDDs) is disproportionately growing. Cold ischemia times and kidney discard rates are rising in part related to inadequate planning, resources, and shortages. Complexity in kidney allocation and distribution has contributed to this dilemma. Logistical issues and the ability to reperfuse the kidney within acceptable time constraints increasingly determine clinical decision-making for organ acceptance. We have a good understanding of the phenotype of "hard to place" MDD kidneys, yet continue to promote a "one size fits all" approach to organ allocation. Allocation and transportation systems need to be agile, mobile, and flexible in order to accommodate the expanding numbers of MDD organs. By identifying "hard to place" MDD kidneys early and implementing a "fast-track" or open offer policy to expedite placement, the utilization rate of MDDs would improve dramatically. Organ allocation and distribution based on location, motivation, and innovation must lead the way. In the absence of change, we are sacrificing utility for futility and discard rates will continue to escalate.
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Affiliation(s)
- Robert J Stratta
- Department of Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
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3
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Stewart D, Tanriover B, Gupta G. Oversimplification and Misplaced Blame Will Not Solve the Complex Kidney Underutilization Problem. KIDNEY360 2022; 3:2143-2147. [PMID: 36591359 PMCID: PMC9802557 DOI: 10.34067/kid.0005402022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 09/27/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Darren Stewart
- Department of Surgery, New York University Langone Health, New York, New York
| | - Bekir Tanriover
- Division of Nephrology, The University of Arizona, Tucson, Arizona
| | - Gaurav Gupta
- Division of Nephrology, School of Medicine, Virginia Commonwealth University, Richmond, Virginia,Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, Virginia
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4
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King KL, Husain SA, Cohen DJ, Schold JD, Mohan S. The role of bypass filters in deceased donor kidney allocation in the United States. Am J Transplant 2022; 22:1593-1602. [PMID: 35090080 DOI: 10.1111/ajt.16967] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 01/25/2023]
Abstract
Kidney transplant centers set organ offer filters enabling all candidates at their center to be bypassed during allocation of deceased donor kidneys from the UNOS Organ Center. These filters aim to increase allocation efficiency by preemptively screening out offers unlikely to be accepted. National data were used to compare filter settings of 175 centers in 2007 and in 2019. We examined characteristics of centers whose settings became increasingly restrictive over time, and associations between filter settings and organ offer acceptance. Overall, centers became more open to receiving offers over time, from a median 62% of filters open to receiving national offers in 2007 to 73% in 2019. Intravenous drug use filter settings changed most, from 63 to 153 willing centers. Centers with more open filter settings had higher transplant volume and offer acceptance ratios across all risk categories despite preemptively screening out fewer offers compared to centers with less open settings, but similar transplant rates. There was significant geographic heterogeneity in the distribution of centers with more open filter settings. Current center bypass filters may impact patients' access to transplantation without achieving their full potential for improving allocation efficiency.
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Affiliation(s)
- Kristen L King
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - S Ali Husain
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - David J Cohen
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Jesse D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
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5
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King KL, Husain SA, Perotte A, Adler JT, Schold JD, Mohan S. Deceased donor kidneys allocated out of sequence by organ procurement organizations. Am J Transplant 2022; 22:1372-1381. [PMID: 35000284 PMCID: PMC9081167 DOI: 10.1111/ajt.16951] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/20/2021] [Accepted: 01/03/2022] [Indexed: 01/25/2023]
Abstract
Deceased donor kidney allocation follows a ranked match-run of potential recipients. Organ procurement organizations (OPOs) are permitted to deviate from the mandated match-run in exceptional circumstances. Using match-run data for all deceased donor kidney transplants (Ktx) in the US between 2015 and 2019, we identified 1544 kidneys transplanted from 933 donors with an OPO-initiated allocation exception. Most OPOs (55/58) used this process at least once, but 3 OPOs performed 64% of the exceptions and just 2 transplant centers received 25% of allocation exception Ktx. At 2 of 3 outlier OPOs these transplants increased 136% and 141% between 2015 and 2019 compared to only a 35% increase in all Ktx. Allocation exception donors had less favorable characteristics (median KDPI 70, 41% with history of hypertension), but only 29% had KDPI ≥ 85% and the majority did not meet the traditional threshold for marginal kidneys. Allocation exception kidneys went to larger centers with higher offer acceptance ratios and to recipients with 2 fewer priority points-equivalent to 2 less years of waiting time. OPO-initiated exceptions for kidney allocation are growing increasingly frequent and more concentrated at a few outlier centers. Increasing pressure to improve organ utilization risks increasing out-of-sequence allocations, potentially exacerbating disparities in access to transplantation.
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Affiliation(s)
- Kristen L King
- Department of Medicine, Division of Nephrology, Columbia University Vagelos College of Physicians & Surgeons, New York, NY
- The Columbia University Renal Epidemiology (CURE) Group, New York, NY
| | - S Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University Vagelos College of Physicians & Surgeons, New York, NY
- The Columbia University Renal Epidemiology (CURE) Group, New York, NY
| | - Adler Perotte
- Department of Biomedical Informatics, Columbia University, New York, NY
| | - Joel T. Adler
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, TX
| | - Jesse D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Vagelos College of Physicians & Surgeons, New York, NY
- The Columbia University Renal Epidemiology (CURE) Group, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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6
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Stratta RJ, Harriman D, Gurram V, Gurung K, Sharda B. The use of marginal kidneys in dual kidney transplantation to expand kidney graft utilization. Curr Opin Organ Transplant 2022; 27:75-85. [PMID: 34939967 DOI: 10.1097/mot.0000000000000946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to chronicle the history of dual kidney transplantation (DKT) and identify opportunities to improve utilization of marginal deceased donor (MDD) kidneys through DKT. RECENT FINDINGS The practice of DKT from adult MDDs dates back to the mid-1990s, at which time the primary indication was projected insufficient nephron mass from older donors. Multiple subsequent studies of short- and long-term success have been reported focusing on three major aspects: Identifying appropriate selection criteria/scoring systems based on pre- and postdonation factors; refining technical aspects; and analyzing longer-term outcomes. The number of adult DKTs performed in the United States has declined in the past decade and only about 60 are performed annually. For adult deceased donor kidneys meeting double allocation criteria, >60% are ultimately not transplanted. MDDs with limited renal functional capacity represent a large proportion of potential kidneys doomed to either discard or nonrecovery. SUMMARY DKT may reduce organ discard and optimize the use of kidneys from MDDs. New and innovative technologies targeting ex vivo organ assessment, repair, and regeneration may have a major impact on the decision whether or not to use recovered kidneys for single or DKT.
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Affiliation(s)
- Robert J Stratta
- The Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - David Harriman
- The Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Venkat Gurram
- The Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Komal Gurung
- The Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Berjesh Sharda
- The Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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7
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Stratta RJ, Harriman D, Gurram V, Gurung K, Sharda B. Dual kidney transplants from adult marginal donors: Review and perspective. Clin Transplant 2021; 36:e14566. [PMID: 34936135 DOI: 10.1111/ctr.14566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 10/08/2021] [Accepted: 12/13/2021] [Indexed: 11/28/2022]
Abstract
The practice of dual kidney transplantation (DKT) from adult marginal deceased donors (MDDs) dates back to the mid-1990s with initial pioneering experiences reported by the Stanford and Maryland groups, at which time the primary indication was estimated insufficient nephron mass from older donors. Multiple subsequent studies of short and long-term success have been reported focusing on three major aspects of DKT: Identifying appropriate selection criteria and developing scoring systems based on pre- and post-donation factors; refining technical aspects; and analyzing mid-term outcomes. The number of adult DKTs performed in the United States has declined in the past decade and only about 60 are performed annually. For adult deceased donor kidneys meeting double allocation criteria, >60% are ultimately not transplanted. Deceased donors with limited renal functional capacity represent a large proportion of potential kidneys doomed to either discard or non-recovery. However, DKT may reduce organ discard and optimize the use of kidneys from MDDs. In an attempt to promote utilization of MDD kidneys, the United Network for Organ Sharing introduced new allocation guidelines pursuant to DKT in 2019. The purpose of this review is to chronicle the history of DKT and identify opportunities to improve utilization of MDD kidneys through DKT. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Robert J Stratta
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, One Medical Center Blvd., Winston-Salem, NC, 27157, United States
| | - David Harriman
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, V5Z1M9, Canada
| | - Venkat Gurram
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, One Medical Center Blvd., Winston-Salem, NC, 27157, United States
| | - Komal Gurung
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, One Medical Center Blvd., Winston-Salem, NC, 27157, United States
| | - Berjesh Sharda
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, One Medical Center Blvd., Winston-Salem, NC, 27157, United States
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8
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Zhang Y, Wong G, Yang JYH. Trash or Treasure: Rescuing Discard Kidneys. Transplantation 2021; 105:1914-1915. [PMID: 33534532 DOI: 10.1097/tp.0000000000003663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Yunwei Zhang
- School of Mathematics and Statistics, The University of Sydney, Sydney, NSW, Australia
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Jean Yee Hwa Yang
- School of Mathematics and Statistics, The University of Sydney, Sydney, NSW, Australia
- Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
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9
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Ibrahim M, Vece G, Mehew J, Johnson R, Forsythe J, Klassen D, Callaghan C, Stewart D. An international comparison of deceased donor kidney utilization: What can the United States and the United Kingdom learn from each other? Am J Transplant 2020; 20:1309-1322. [PMID: 31758833 DOI: 10.1111/ajt.15719] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 10/28/2019] [Accepted: 11/15/2019] [Indexed: 01/25/2023]
Abstract
In transplant, meaningful international comparisons in organ utilization are needed. This collaborative study between the United Kingdom (UK) and the United States (US) aimed to develop a kidney utilization metric allowing for legitimate intercountry comparisons. Data from the UK and US transplant registries, including all deceased donor kidneys recovered from 2006 to 2017, were analyzed. To identify a potentially comparable kidney utilization rate (UR), several denominators were assessed. We discovered that the proportion of transplanted kidneys from elderly donors in the UK (10.7%) was 18 times greater than that in the US (0.6%). Conversely, en bloc pediatric kidney transplant was more common in the US. Donation after circulatory death utilization has risen in both countries but is twice as prevalent in the UK (39% of transplants) vs the US (20%). In addition, US and UK URs are not directly comparable due to fundamental system differences. However, using a suite of URs revealed practice areas likely to yield the most benefit if improved, such as efforts to increase kidney offer acceptance in the US and to reduce postacceptance discard in the UK. Methods used in this study, including novel intracountry risk-adjusted UR trend logistic regression analyses, can be translated to other international transplant registries in pursuit of further global learning opportunities.
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Affiliation(s)
- Maria Ibrahim
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK.,National Health Service Blood and Transplant, Bristol, UK
| | - Gabe Vece
- United Network for Organ Sharing, Richmond, Virginia
| | - Jenny Mehew
- National Health Service Blood and Transplant, Bristol, UK
| | - Rachel Johnson
- National Health Service Blood and Transplant, Bristol, UK
| | - John Forsythe
- National Health Service Blood and Transplant, Bristol, UK
| | - David Klassen
- United Network for Organ Sharing, Richmond, Virginia
| | - Chris Callaghan
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK.,National Health Service Blood and Transplant, Bristol, UK
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10
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Mankowski MA, Kosztowski M, Raghavan S, Garonzik-Wang JM, Axelrod D, Segev DL, Gentry SE. Accelerating kidney allocation: Simultaneously expiring offers. Am J Transplant 2019; 19:3071-3078. [PMID: 31012528 PMCID: PMC6812592 DOI: 10.1111/ajt.15396] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 03/17/2019] [Accepted: 04/03/2019] [Indexed: 01/25/2023]
Abstract
Using nonideal kidneys for transplant quickly might reduce the discard rate of kidney transplants. We studied changing kidney allocation to eliminate sequential offers, instead making offers to multiple centers for all nonlocally allocated kidneys, so that multiple centers must accept or decline within the same 1 hour. If more than 1 center accepted an offer, the kidney would go to the highest-priority accepting candidate. Using 2010 Kidney-Pancreas Simulated Allocation Model-Scientific Registry for Transplant Recipients data, we simulated the allocation of 12 933 kidneys, excluding locally allocated and zero-mismatch kidneys. We assumed that each hour of delay decreased the probability of acceptance by 5% and that kidneys would be discarded after 20 hours of offers beyond the local level. We simulated offering kidneys simultaneously to small, medium-size, and large batches of centers. Increasing the batch size increased the percentage of kidneys accepted and shortened allocation times. Going from small to large batches increased the number of kidneys accepted from 10 085 (92%) to 10 802 (98%) for low-Kidney Donor Risk Index kidneys and from 1257 (65%) to 1737 (89%) for high-Kidney Donor Risk Index kidneys. The average number of offers that a center received each week was 10.1 for small batches and 16.8 for large batches. Simultaneously expiring offers might allow faster allocation and decrease the number of discards, while still maintaining an acceptable screening burden.
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Affiliation(s)
- Michal A. Mankowski
- Computer, Electrical and Mathematical Sciences and Engineering Division, King Abdullah University of Science and Technology, Thuwal, Saudi Arabia
| | - Martin Kosztowski
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Subramanian Raghavan
- Smith School of Business and Institute for Systems Research, University of Maryland, College Park, Maryland
| | | | - David Axelrod
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
- Scientific Registry of Transplant Recipients, Minneapolis, Minnesota
| | - Sommer E. Gentry
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Scientific Registry of Transplant Recipients, Minneapolis, Minnesota
- Department of Mathematics, United States Naval Academy, Annapolis, Maryland
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11
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Bell R, Farid S, Pandanaboyana S, Upasani V, Baker R, Ahmad N. The evolution of donation after circulatory death renal transplantation: a decade of experience. Nephrol Dial Transplant 2019; 34:1788-1798. [PMID: 29955846 DOI: 10.1093/ndt/gfy160] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 05/01/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND This study compared long-term outcomes of renal transplantation from donors following donation after circulatory death (DCD) with those following donation after brain death (DBD) from one of the largest centres in the UK. METHOD Recipients of renal transplants from deceased donors between 2002 and 2014 were identified from a prospectively maintained database. Outcomes were compared between DCD (468) and DBD (905) donors and between standard criteria donors (SCDs) and extended criteria donors (ECDs). RESULTS Graft survival (GS) and patient survival (PS) from DCD and DBD donors were comparable up to 10 years (GS: 61 versus 55%, P = 0.780; PS: 78 versus 71%, P = 0.285, respectively). Graft function was comparable after 3 months. GS and function were worse in the ECD groups, with no difference between EC-DBD and EC-DCD. PS in the ECD groups was worse than the SCD groups and PS in the EC-DCD group was worse than in the EC-DBD group. DCD donors were an independent risk factor for delayed graft function. Post-operative complications and EC-DCD donation were independent risk factors for reduced GS and PS. CONCLUSION This study supports the use of DCD renal grafts with comparable long-term survival and function to DBD grafts. The use of EC-DCD grafts is justified in selected recipients and provides acceptable function and survival advantages over dialysis.
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Affiliation(s)
- Richard Bell
- Department of Hepatobiliary and Transplant Surgery, Grafton, Auckland, New Zealand
| | - Shahid Farid
- Department of Hepatobiliary and Transplant Surgery, Grafton, Auckland, New Zealand
| | - Sanjay Pandanaboyana
- Department of Hepatobiliary and Transplant Surgery, Grafton, Auckland, New Zealand.,Department of Hepatopancreaticobiliary and Transplant Surgery, Grafton, Auckland, New Zealand
| | - Vivek Upasani
- Department of Hepatobiliary and Transplant Surgery, Grafton, Auckland, New Zealand
| | - Richard Baker
- Department of Nephrology, St James University Hospital, Leeds, UK
| | - Niaz Ahmad
- Department of Hepatobiliary and Transplant Surgery, Grafton, Auckland, New Zealand
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12
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Zhou S, Massie AB, Holscher CM, Waldram MM, Ishaque T, Thomas AG, Segev DL. Prospective Validation of Prediction Model for Kidney Discard. Transplantation 2019; 103:764-771. [PMID: 30015701 PMCID: PMC6330256 DOI: 10.1097/tp.0000000000002362] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Many kidneys are discarded every year, with 3631 kidneys discarded in 2016 alone. Identifying kidneys at high risk of discard could facilitate "rescue" allocation to centers more likely to transplant them. The Probability of Delay or Discard (PODD) model was developed to identify marginal kidneys at risk of discard or delayed allocation beyond 36 hours of cold ischemia time. However, PODD has not been prospectively validated, and patterns of discard may have changed after policy changes such as the introduction of Kidney Donor Profile Index and implementation of the Kidney Allocation System (KAS). METHODS We prospectively validated the PODD model using Scientific Registry of Transplant Recipients data in the KAS era (January 1, 2015, to March 1, 2018). C statistic was calculated to assess accuracy in predicting kidney discard. We assessed clustering in centers' utilization of kidneys with PODD >0.6 ("high-PODD") using Gini coefficients. Using match run data from January 1, 2015, to December 31, 2016, we examined distribution of these high-PODD kidneys offered to centers that never accepted a high-PODD kidney. RESULTS The PODD model predicted discard accurately under KAS (C-statistic, 0.87). Compared with utilization of low-PODD kidneys (Gini coefficient = 0.41), utilization of high-PODD kidneys was clustered more tightly among a few centers (Gini coefficient, 0.84 with >60% of centers never transplanted a high-PODD kidneys). In total, 11684 offers (35.0% of all high-PODD offers) were made to centers that never accepted a high-PODD kidney. CONCLUSIONS Prioritizing allocation of high-PODD kidneys to centers that are more likely to transplant them might help reduce kidney discard.
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Affiliation(s)
- Sheng Zhou
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Allan B Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Courtenay M Holscher
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Madeleine M Waldram
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Tanveen Ishaque
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alvin G Thomas
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
- Scientific Registry of Transplant Recipients, Minneapolis, MN
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13
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Narvaez JRF, Nie J, Noyes K, Leeman M, Kayler LK. Hard-to-place kidney offers: Donor- and system-level predictors of discard. Am J Transplant 2018; 18:2708-2718. [PMID: 29498197 DOI: 10.1111/ajt.14712] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 02/02/2018] [Accepted: 02/19/2018] [Indexed: 01/25/2023]
Abstract
Understanding risk factors for deceased-donor kidney nontransplantation is important since discard rates remain high. We analyzed DonorNet® data of consecutive deceased-donor nonmandatory share primary kidney-only offers to adult candidates at our center and beyond between July 1, 2015 and March 31, 2016 for donor- and system-level risk factors of discard, defined as nontransplantation at our or subsequent transplant centers. Exclusions were hepatitis C virus/hepatitis B virus core antibody status, blood type AB, and donor <1 year based on low candidate waitlist size. Of 456 individual kidney offers, from 296 donors, 73% were discarded. Most were national (93%) offers from Kidney Donor Profile Index 35-85% (n = 233) or >85% (n = 208) donors late in the allocation sequence with prior refusals logged for numerous candidates. On multivariate regression, factors significantly associated with discard were donor cerebrovascular accident (adjusted odds ratio [aOR]: 3.32), cancer transmission concern (aOR: 6.5), renal artery luminal compromise (aOR: 3.97), biopsy score ≥3 (aOR: 5.09), 2-hour pump resistive index >0.4 (aOR: 3.27), absence of pump (aOR: 2.58), nonspecific kidney abnormality (aOR: 2.76), increasing offer cold ischemia time category 11-15, 16-20, and >21 hours (aOR: 2.07, 2.33, 2.82), nighttime notification (aOR: 2.19), and neither kidney placed at time of offer (aOR: 2.74). Many traditional determinants of discard lack discriminatory value when granular factors are assessed. System-level factors also influence discard and warrant further study.
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Affiliation(s)
- J Reinier F Narvaez
- Department of Surgery, University at Buffalo, Buffalo, NY, USA.,Department of Epidemiology and Environmental Health, University at Buffalo School of Public Health and Health Professions, Buffalo, NY, USA
| | - Jing Nie
- Department of Epidemiology and Environmental Health, University at Buffalo School of Public Health and Health Professions, Buffalo, NY, USA
| | - Katia Noyes
- Department of Epidemiology and Environmental Health, University at Buffalo School of Public Health and Health Professions, Buffalo, NY, USA
| | - Mary Leeman
- University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Liise K Kayler
- Department of Surgery, University at Buffalo, Buffalo, NY, USA.,University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA.,Transplant and Kidney Care Regional Center of Excellence, Erie County Medical Center, Buffalo, NY, USA
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14
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Cooper M, Formica R, Friedewald J, Hirose R, O’Connor K, Mohan S, Schold J, Axelrod D, Pastan S. Report of National Kidney Foundation Consensus Conference to Decrease Kidney Discards. Clin Transplant 2018; 33:e13419. [DOI: 10.1111/ctr.13419] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 09/29/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Matthew Cooper
- Medstar Georgetown Transplant Institute; Georgetown University; Washington District of Columbia
| | - Richard Formica
- Department of Medicine, Section of Nephrology; Yale School of Medicine; New Haven Connecticut
| | - John Friedewald
- Northwestern University Comprehensive Transplant Center; Chicago Illinois
| | - Ryutaro Hirose
- Department of Surgery; University of California San Francisco; San Francisco California
| | | | - Sumit Mohan
- Division of Nephrology, Department of Medicine; Vagelos College of Physicians & Surgeons, Columbia University; New York New York
- Department of Epidemiology, Mailman School of Public Health; Columbia University; New York New York
| | - Jesse Schold
- Department of Quantitative Health Sciences; Cleveland Clinic; Cleveland Ohio
| | - David Axelrod
- Department of Surgery; Lahey Hospital and Medical Center; Burlington Massachusetts
| | - Stephen Pastan
- Renal Division, Department of Medicine; Emory University School of Medicine; Atlanta Georgia
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15
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Stewart DE, Wilk AR, Toll AE, Harper AM, Lehman RR, Robinson AM, Noreen SA, Edwards EB, Klassen DK. Measuring and monitoring equity in access to deceased donor kidney transplantation. Am J Transplant 2018; 18:1924-1935. [PMID: 29734498 DOI: 10.1111/ajt.14922] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 04/01/2018] [Accepted: 04/29/2018] [Indexed: 01/25/2023]
Abstract
The Organ Procurement and Transplantation Network monitors progress toward strategic goals such as increasing the number of transplants and improving waitlisted patient, living donor, and transplant recipient outcomes. However, a methodology for assessing system performance in providing equity in access to transplants was lacking. We present a novel approach for quantifying the degree of disparity in access to deceased donor kidney transplants among waitlisted patients and determine which factors are most associated with disparities. A Poisson rate regression model was built for each of 29 quarterly, period-prevalent cohorts (January 1, 2010-March 31, 2017; 5 years pre-kidney allocation system [KAS], 2 years post-KAS) of active kidney waiting list registrations. Inequity was quantified as the outlier-robust standard deviation (SDw ) of predicted transplant rates (log scale) among registrations, after "discounting" for intentional, policy-induced disparities (eg, pediatric priority) by holding such factors constant. The overall SDw declined by 40% after KAS implementation, suggesting substantially increased equity. Risk-adjusted, factor-specific disparities were measured with the SDw after holding all other factors constant. Disparities associated with calculated panel-reactive antibodies decreased sharply. Donor service area was the factor most associated with access disparities post-KAS. This methodology will help the transplant community evaluate tradeoffs between equity and utility-centric goals when considering new policies and help monitor equity in access as policies change.
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Affiliation(s)
- D E Stewart
- Research Department, United Network for Organ Sharing, Richmond, VA, USA
| | - A R Wilk
- Research Department, United Network for Organ Sharing, Richmond, VA, USA
| | - A E Toll
- Research Department, United Network for Organ Sharing, Richmond, VA, USA
| | - A M Harper
- Research Department, United Network for Organ Sharing, Richmond, VA, USA
| | - R R Lehman
- Research Department, United Network for Organ Sharing, Richmond, VA, USA
| | - A M Robinson
- Research Department, United Network for Organ Sharing, Richmond, VA, USA
| | - S A Noreen
- Research Department, United Network for Organ Sharing, Richmond, VA, USA
| | - E B Edwards
- Research Department, United Network for Organ Sharing, Richmond, VA, USA
| | - D K Klassen
- Chief Medical Officer, United Network for Organ Sharing, Richmond, VA, USA
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16
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Mohan S, Chiles MC, Patzer RE, Pastan SO, Husain SA, Carpenter DJ, Dube GK, Crew RJ, Ratner LE, Cohen DJ. Factors leading to the discard of deceased donor kidneys in the United States. Kidney Int 2018; 94:187-198. [PMID: 29735310 PMCID: PMC6015528 DOI: 10.1016/j.kint.2018.02.016] [Citation(s) in RCA: 184] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 01/31/2018] [Accepted: 02/01/2018] [Indexed: 01/22/2023]
Abstract
The proportion of deceased donor kidneys procured for transplant but subsequently discarded has been growing steadily in the United States, but factors contributing to the rising discard rate remain unclear. To assess the reasons for and probability of organ discard we assembled a cohort of 212,305 deceased donor kidneys recovered for transplant from 2000-2015 in the SRTR registry that included 36,700 kidneys that were discarded. 'Biopsy Findings' (38.2%) was the most commonly reported reason for discard. The median Kidney Donor Risk Index of discarded kidneys was significantly higher than transplanted organs (1.78 vs 1.12), but a large overlap in the quality of discarded and transplanted kidneys was observed. Kidneys of donors who were older, female, Black, obese, diabetic, hypertensive or HCV-positive experienced a significantly increased odds of discard. Kidneys from donors with multiple unfavorable characteristics were more likely to be discarded, whereas unilaterally discarded kidneys had the most desirable donor characteristics and the recipients of their partner kidneys experienced a one-year death-censored graft survival rate over 90%. There was considerable geographic variation in the odds of discard across the United States, which further supports the notion that factors beyond organ quality contributed to kidney discard. Thus, while the discard of a small fraction of organs procured from donors may be inevitable, the discard of potentially transplantable kidneys needs to be avoided. This will require a better understanding of the factors contributing to organ discard in order to remove the disincentives to utilize less-than-ideal organs for transplantation.
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Affiliation(s)
- Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA; Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA; The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA.
| | - Mariana C Chiles
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA; The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - Rachel E Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Emory University, Atlanta, Georgia, USA; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Stephen O Pastan
- Department of Medicine, Renal Division, Emory University School of Medicine, Emory University, Atlanta, Georgia, USA
| | - S Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA; The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - Dustin J Carpenter
- Department of Surgery, Division of Transplantation, Columbia University Medical Center, New York, New York, USA
| | - Geoffrey K Dube
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA
| | - R John Crew
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA
| | - Lloyd E Ratner
- Department of Surgery, Division of Transplantation, Columbia University Medical Center, New York, New York, USA
| | - David J Cohen
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA
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17
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Husain SA, Chiles MC, Lee S, Pastan SO, Patzer RE, Tanriover B, Ratner LE, Mohan S. Characteristics and Performance of Unilateral Kidney Transplants from Deceased Donors. Clin J Am Soc Nephrol 2018; 13:118-127. [PMID: 29217537 PMCID: PMC5753314 DOI: 10.2215/cjn.06550617] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 09/29/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND OBJECTIVES The fraction of kidneys procured for transplant that are discarded is rising in the United States. Identifying donors from whom only one kidney was discarded allows us to control for donor traits and better assess reasons for organ discard. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a retrospective cohort study using United Network for Organ Sharing Standard Transplant Analysis and Research file data to identify deceased donors from whom two kidneys were procured and at least one was transplanted. Unilateral pairs were defined as kidney pairs from a single donor from whom one kidney was discarded ("unilateral discard") but the other was transplanted ("unilateral transplant"). Organ quality was estimated using the Kidney Donor Risk Index and Kidney Donor Profile Index (KDPI). We compared all-cause graft failure rates for unilateral transplants to those for bilateral transplant Kaplan-Meier methods, and life table methodology was used to evaluate 1-, 2-, 3-, and 5-year survival rates of transplants from bilateral and unilateral donors. RESULTS Compared with bilateral donors (i.e., both kidneys transplanted) (n=80,584), unilateral donors (i.e., only one kidney transplanted) (n=7625) had higher mean terminal creatinine (1.3±2.1 mg/dl versus 1.1±0.9 mg/dl) and KDPI (67%±25% versus 42%±27%), were older, and were more likely to have hypertension, diabetes, hepatitis C, terminal stroke, or meet Centers for Disease Control and Prevention high-risk donor criteria. Unilateral discards were primarily attributed to factors expected to be similar in both kidneys from a donor: biopsy findings (22%), no interested recipient (13%), and donor history (7%). Anatomic abnormalities (14%), organ damage (11%), and extended ischemia (6%) accounted for about 30% of discards, but were the commonest reasons among low KDPI kidneys. Among kidneys with KDPI≥60%, there was an incremental difference in allograft survival over time (for unilateral versus bilateral transplants, 1-year survival: 83% versus 87%; 3-year survival: 69% versus 73%; 5-year survival: 51% versus 58%). CONCLUSIONS A large number of discarded kidneys were procured from donors whose contralateral kidneys were transplanted with good post-transplant outcomes.
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Affiliation(s)
- Syed Ali Husain
- Division of Nephrology, Department of Medicine and
- The Columbia University Renal Epidemiology Group, New York, New York
| | - Mariana C. Chiles
- Division of Nephrology, Department of Medicine and
- The Columbia University Renal Epidemiology Group, New York, New York
| | - Samnang Lee
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | | | - Rachel E. Patzer
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia; and
| | - Bekir Tanriover
- Division of Nephrology, Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas
| | - Lloyd E. Ratner
- Division of Transplantation, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine and
- The Columbia University Renal Epidemiology Group, New York, New York
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
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18
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Stewart DE, Klassen DK. Early Experience with the New Kidney Allocation System: A Perspective from UNOS. Clin J Am Soc Nephrol 2017; 12:2063-2065. [PMID: 29162594 PMCID: PMC5718276 DOI: 10.2215/cjn.06380617] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2017_11_21_CJASNPodcast_18_1_v.mp3.
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19
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20
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Hobeika MJ, Miller CM, Pruett TL, Gifford KA, Locke JE, Cameron AM, Englesbe MJ, Kuhr CS, Magliocca JF, McCune KR, Mekeel KL, Pelletier SJ, Singer AL, Segev DL. PROviding Better ACcess To ORgans: A comprehensive overview of organ-access initiatives from the ASTS PROACTOR Task Force. Am J Transplant 2017; 17:2546-2558. [PMID: 28742951 DOI: 10.1111/ajt.14441] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 06/25/2017] [Accepted: 07/13/2017] [Indexed: 01/25/2023]
Abstract
The American Society of Transplant Surgeons (ASTS) PROviding better Access To Organs (PROACTOR) Task Force was created to inform ongoing ASTS organ access efforts. Task force members were charged with comprehensively cataloguing current organ access activities and organizing them according to stakeholder type. This white paper summarizes the task force findings and makes recommendations for future ASTS organ access initiatives.
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Affiliation(s)
- M J Hobeika
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - C M Miller
- Liver Transplantation Program, Cleveland Clinic, Cleveland, OH, USA
| | - T L Pruett
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - K A Gifford
- American Society of Transplant Surgeons, Arlington, VA, USA
| | - J E Locke
- University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL, USA
| | - A M Cameron
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - M J Englesbe
- Department of Surgery, Section of Transplantation, University of Michigan, Ann Arbor, MI, USA
| | - C S Kuhr
- Virginia Mason Medical Center, Seattle, WA, USA
| | - J F Magliocca
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - K R McCune
- Department of Surgery, Columbia University, New York, NY, USA
| | - K L Mekeel
- Division of Transplantation and Hepatobiliary Surgery, University of California San Diego, San Diego, CA, USA
| | - S J Pelletier
- Division of Transplant Surgery, Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - A L Singer
- Transplant Center, Mayo Clinic, Phoenix, AZ, USA
| | - D L Segev
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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21
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Mohan S, Chiles MC. Achieving Equity through Reducing Variability in Accepting Deceased Donor Kidney Offers. Clin J Am Soc Nephrol 2017; 12:1212-1214. [PMID: 28751578 PMCID: PMC5544510 DOI: 10.2215/cjn.06220617] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York; and
- Department of Epidemiology, Mailman School of Public Health and
- The Columbia University Renal Epidemiology Group, New York, New York
| | - Mariana C. Chiles
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York; and
- The Columbia University Renal Epidemiology Group, New York, New York
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22
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Mittal S, Adamusiak A, Horsfield C, Loukopoulos I, Karydis N, Kessaris N, Drage M, Olsburgh J, Watson CJ, Callaghan CJ. A Re-evaluation of Discarded Deceased Donor Kidneys in the UK: Are Usable Organs Still Being Discarded? Transplantation 2017; 101:1698-1703. [PMID: 27779574 DOI: 10.1097/tp.0000000000001542] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND A significant proportion of procured deceased donor kidneys are subsequently discarded. The UK Kidney Fast-Track Scheme (KFTS) was introduced in 2012, enabling kidneys at risk of discard to be simultaneously offered to participating centers. We undertook an analysis of discarded kidneys to determine if unnecessary organ discard was still occurring since the KFTS was introduced. METHODS Between April and June 2015, senior surgeons independently inspected 31 consecutive discarded kidneys from throughout the United Kingdom. All kidneys were biopsied. Organs were categorized as usable, possibly usable pending histology, or not usable for implantation. After histology reports were available, final assessments of usability were made. RESULTS There were 19 donors (6 donations after brain death, 13 donations after circulatory death), with a median (range) donor age of 67 (29-83) years and Kidney Donor Profile Index of 93 (19-100). Reasons for discard were variable. Only 3 discarded kidneys had not entered the KFTS. After initial assessment postdiscard, 11 kidneys were assessed as usable, with 9 kidneys thought to be possibly usable. Consideration of histological data reduced the number of kidneys thought usable to 10 (10/31; 32%). CONCLUSIONS The KFTS scheme is successfully identifying organs at high risk of discard, though potentially transplantable organs are still being discarded. Analyses of discarded organs are essential to identify barriers to organ utilization and develop strategies to reduce unnecessary discard.
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Affiliation(s)
- Shruti Mittal
- 1 Department of Nephrology and Transplantation, Guy's Hospital, London, United Kingdom. 2 Department of Histopathology, Guy's Hospital, London, United Kingdom. 3 Department of Surgery University of Cambridge, Cambridge, United Kingdom. 4 NIHR Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, United Kingdom
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23
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Stewart DE, Kucheryavaya AY, Klassen DK, Turgeon NA, Formica RN, Aeder MI. Changes in Deceased Donor Kidney Transplantation One Year After KAS Implementation. Am J Transplant 2016; 16:1834-47. [PMID: 26932731 DOI: 10.1111/ajt.13770] [Citation(s) in RCA: 203] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 02/21/2016] [Accepted: 02/24/2016] [Indexed: 01/25/2023]
Abstract
After over a decade of discussion, analysis, and consensus-building, a new kidney allocation system (KAS) was implemented on December 4, 2014. Key goals included improving longevity matching between donor kidneys and recipients and broadening access for historically disadvantaged subpopulations, in particular highly sensitized patients and those with an extended duration on dialysis but delayed referral for transplantation. To evaluate the early impact of KAS, we compared Organ Procurement and Transplantation Network data 1 year before versus after implementation. The distribution of transplants across many recipient characteristics has changed markedly and suggests that in many ways the new policy is achieving its goals. Transplants in which the donor and recipient age differed by more than 30 years declined by 23%. Initial, sharp increases in transplants were observed for Calculated Panel-Reactive Antibody 99-100% recipients and recipients with at least 10 years on dialysis, with a subsequent tapering of transplants to these groups suggesting bolus effects. Although KAS has arguably increased fairness in allocation, the potential costs of broadening access must be considered. Kidneys are more often being shipped over long distances, leading to increased cold ischemic times. Delayed graft function rates have increased, but 6-month graft survival rates have not changed significantly.
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Affiliation(s)
- D E Stewart
- Research Department, United Network for Organ Sharing, Richmond, VA
| | - A Y Kucheryavaya
- Research Department, United Network for Organ Sharing, Richmond, VA
| | - D K Klassen
- Office of the Chief Medical Officer, United Network for Organ Sharing, Richmond, VA
| | - N A Turgeon
- Department of Surgery, Emory University, Atlanta, GA
| | - R N Formica
- Department of Medicine and Surgery, Yale School of Medicine, New Haven, CT
| | - M I Aeder
- Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH
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