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Nair SS, Thorp AN, Hanna W, Johnson BK, Smith B, Iyengar S, Howe EA, Mour GK. Effectiveness of education and attitudes toward different types of deceased donor kidneys: Survey analysis of single-center experience. Front Public Health 2023; 11:1116823. [PMID: 37064665 PMCID: PMC10090271 DOI: 10.3389/fpubh.2023.1116823] [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: 12/05/2022] [Accepted: 02/02/2023] [Indexed: 04/18/2023] Open
Abstract
Background We lack data on the effectiveness of education and the patient's attitude toward different deceased donor kidney types. A prospective study was performed to evaluate patient attitudes, baseline knowledge, and effectiveness of our kidney transplant education process. We also analyzed the knowledge retention of our waitlist patients. Design We prospectively surveyed a patient cohort using a paired analysis pre and post education with initial evaluation visit. Knowledge retention among waitlist patients was assessed with annual waitlist visit. Results One hundred four patients received paired surveys to assess the baseline knowledge and effectiveness of education. Forty-three patients received a single survey with their annual waitlist evaluation to assess knowledge retention. Paired survey showed mixed results, with no statistically significant improvement in the kidney donor profile index domain. Significant improvement was seen in the hepatitis C virus-positive donor domain and the Public Health Service (PHS) increased-risk donor domain. For the waitlist cohort, overall knowledge retention ranged from excellent to fair, with a decline in knowledge for the PHS increased-risk donor domain. Conclusion Our study suggests that the education intervention regarding different deceased donor kidney types is effective overall and transplant candidates retain the knowledge while waiting for transplant.
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Affiliation(s)
- Sumi S. Nair
- Division of Nephrology, Mayo Clinic, Phoenix, AZ, United States
| | - Andrea N. Thorp
- Department of Nursing, Mayo Clinic, Phoenix, AZ, United States
| | - Wael Hanna
- Dallas Nephrology Associates, Dallas, TX, United States
| | - Bradley K. Johnson
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, United States
| | - Byron Smith
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, United States
| | - Savitha Iyengar
- Manager Transplant Quality and Compliance, Mayo Clinic, Rochester, MN, United States
| | | | - Girish K. Mour
- Division of Nephrology, Mayo Clinic, Phoenix, AZ, United States
- *Correspondence: Girish K. Mour
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Substantial Missed Transplant Opportunity From Underutilization of Donors Not Meeting OPTN Eligible Death Definition. Transplantation 2022; 106:1526-1527. [DOI: 10.1097/tp.0000000000004085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kelly YM, Zarinsefat A, Tavakol M, Shui AM, Huang CY, Roberts JP. Consent to organ offers from public health service “Increased Risk” donors decreases time to transplant and waitlist mortality. BMC Med Ethics 2022; 23:20. [PMID: 35248038 PMCID: PMC8898499 DOI: 10.1186/s12910-022-00757-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 02/17/2022] [Indexed: 08/30/2023] Open
Abstract
Background The Public Health Service Increased Risk designation identified organ donors at increased risk of transmitting hepatitis B, hepatitis C, and human immunodeficiency virus. Despite clear data demonstrating a low absolute risk of disease transmission from these donors, patients are hesitant to consent to receiving organs from these donors. We hypothesize that patients who consent to receiving offers from these donors have decreased time to transplant and decreased waitlist mortality. Methods We performed a single-center retrospective review of all-comers waitlisted for liver transplant from 2013 to 2019. The three competing risk events (transplant, death, and removal from transplant list) were analyzed. 1603 patients were included, of which 1244 (77.6%) consented to offers from increased risk donors. Results Compared to those who did not consent, those who did had 2.3 times the rate of transplant (SHR 2.29, 95% CI 1.88–2.79, p < 0.0001), with a median time to transplant of 11 months versus 14 months (p < 0.0001), as well as a 44% decrease in the rate of death on the waitlist (SHR 0.56, 95% CI 0.42–0.74, p < 0.0001). All findings remained significant after controlling for the recipient age, race, gender, blood type, and MELD. Of those who did not consent, 63/359 (17.5%) received a transplant, all of which were from standard criteria donors, and of those who did consent, 615/1244 (49.4%) received a transplant, of which 183/615 (29.8%) were from increased risk donors. Conclusions The findings of decreased rates of transplantation and increased risk of death on the waiting list by patients who were unwilling to accept risks of viral transmission of 1/300–1/1000 in the worst case scenarios suggests that this consent process may be harmful especially when involving “trigger” words such as HIV. The rigor of the consent process for the use of these organs was recently changed but a broader discussion about informed consent in similar situations is important.
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Roth EM, Haque OJ, Yuan Q, Kotton CN, Markmann JF, Eckhoff DE, Elias N. Heterogeneity in transplant center responses to the minimum acceptance criteria across UNOS regions. Clin Transplant 2021; 36:e14551. [PMID: 34843130 DOI: 10.1111/ctr.14551] [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: 09/23/2021] [Revised: 11/02/2021] [Accepted: 11/18/2021] [Indexed: 11/29/2022]
Abstract
Transplantation of organs from increased risk donors for infection transmission (IRDs) is increasing. These organs confer survival benefit to recipients. This study examined transplant center acceptance policies for IRD kidneys across United Network for Organ Sharing (UNOS) regions, based on transplant centers' annual responses to the Minimum Acceptance Criteria (MAC) for acceptance of IRD kidneys, and the association with national and regional IRD kidney utilization. De-identified MAC responses from all transplant centers in the United States from 2007 to 2019 were obtained. Implementation of MAC responses into practice was evaluated based on annual rates of recovery and transplantation of IRD kidneys, by MAC and UNOS region. Nationally, the number of transplant centers willing to accept IRD kidneys across all criteria increased from 22% in 2007 to 64% in 2019. Acceptance rates increased markedly from donors with intravenous drug use and other potential HIV exposures. However, significant heterogeneity exists in transplant center willingness to accept IRD kidneys, both regionally and between criteria. Trends towards increasing acceptance are strongly associated with higher rates of recovery and transplantation of IRD kidneys. Further research on provider- and center-based refusal to consider IRD kidneys for waitlisted patients is needed to improve utilization of this organ pool.
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Affiliation(s)
- Eve M Roth
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Omar J Haque
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Division of Transplant Surgery, Department of Surgery, Massachusetts General Hospital, Center for Transplantation Sciences, Boston, Massachusetts, USA
| | - Qing Yuan
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Camille N Kotton
- Harvard Medical School, Boston, Massachusetts, USA.,Transplant Infectious Disease and Compromised Host Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - James F Markmann
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Transplant Surgery, Department of Surgery, Massachusetts General Hospital, Center for Transplantation Sciences, Boston, Massachusetts, USA
| | - Devin E Eckhoff
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Nahel Elias
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Transplant Surgery, Department of Surgery, Massachusetts General Hospital, Center for Transplantation Sciences, Boston, Massachusetts, USA
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5
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Anderson B, Jezewski E, Sela N, Westphal S, Hoffman A. Public health service increased risk donor kidney grafts for transplant into children, a survey of pediatric nephrologists. Pediatr Transplant 2021; 25:e13863. [PMID: 33027552 DOI: 10.1111/petr.13863] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/20/2020] [Accepted: 08/24/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Kidney transplant is the best treatment for end-stage renal disease (ESRD); however, access is limited by severe organ shortage. Public Health Service increased risk donors (PHS-IRD) represent a significant portion of available organs which are discarded at disproportional rates. METHODS Pediatric nephrologists were surveyed regarding PHS-IRD kidneys to understand attitudes and perceived barriers to the use of these grafts in children. We sought to elucidate what methods may help increase the likelihood of PHS-IRD acceptance. RESULTS Twenty-two responses were received from United States pediatric nephrologists representing 11 UNOS regions (response rate 5.9%). Of respondents, 50% had been practicing for 20+ years, 77% in academic hospitals, and 63% in cities with over 1 000 000 people. All respondents worked in an institution with a kidney transplant program. 41% reported that they would not accept PHS-IRD kidneys under any circumstance, 45% would accept depending on the candidate's medical status, and 14% routinely accepted PHS-IRD kidneys. Infectious transmission was the biggest disincentive reported (59%), with only 55% of respondents feeling comfortable counseling families on the associated risks. 82% of respondents did not perceive all PHS-IRD as the same, and 90% supported stratifying PHS-IRD into tiers based on risk, which would increase the likelihood of organ acceptance (82%) and assist in counseling families (91%). CONCLUSIONS With improved utilization, PHS-IRD kidneys offer a step toward decreasing the organ shortage. These findings suggest hesitance in use of PHS-IRD kidneys for pediatric recipients. Further stratification of risk could aid in provider organ acceptance and counseling patients.
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Affiliation(s)
- Blaire Anderson
- Division of Transplantation Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Emily Jezewski
- College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Nathalie Sela
- Division of Transplantation Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Scott Westphal
- Division of Nephrology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Arika Hoffman
- Division of Transplantation Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
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Jones JM, Kracalik I, Levi ME, Bowman JS, Berger JJ, Bixler D, Buchacz K, Moorman A, Brooks JT, Basavaraju SV. Assessing Solid Organ Donors and Monitoring Transplant Recipients for Human Immunodeficiency Virus, Hepatitis B Virus, and Hepatitis C Virus Infection - U.S. Public Health Service Guideline, 2020. MMWR Recomm Rep 2020; 69:1-16. [PMID: 32584804 PMCID: PMC7337549 DOI: 10.15585/mmwr.rr6904a1] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The recommendations in this report supersede the U.S Public Health Service (PHS) guideline recommendations for reducing transmission of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) through organ transplantation (Seem DL, Lee I, Umscheid CA, Kuehnert MJ. PHS guideline for reducing human immunodeficiency virus, hepatitis B virus, and hepatitis C virus transmission through organ transplantation. Public Health Rep 2013;128:247-343), hereafter referred to as the 2013 PHS guideline. PHS evaluated and revised the 2013 PHS guideline because of several advances in solid organ transplantation, including universal implementation of nucleic acid testing of solid organ donors for HIV, HBV, and HCV; improved understanding of risk factors for undetected organ donor infection with these viruses; and the availability of highly effective treatments for infection with these viruses. PHS solicited feedback from its relevant agencies, subject-matter experts, additional stakeholders, and the public to develop revised guideline recommendations for identification of risk factors for these infections among solid organ donors, implementation of laboratory screening of solid organ donors, and monitoring of solid organ transplant recipients. Recommendations that have changed since the 2013 PHS guideline include updated criteria for identifying donors at risk for undetected donor HIV, HBV, or HCV infection; the removal of any specific term to characterize donors with HIV, HBV, or HCV infection risk factors; universal organ donor HIV, HBV, and HCV nucleic acid testing; and universal posttransplant monitoring of transplant recipients for HIV, HBV, and HCV infections. The recommendations are to be used by organ procurement organization and transplant programs and are intended to apply only to solid organ donors and recipients and not to donors or recipients of other medical products of human origin (e.g., blood products, tissues, corneas, and breast milk). The recommendations pertain to transplantation of solid organs procured from donors without laboratory evidence of HIV, HBV, or HCV infection. Additional considerations when transplanting solid organs procured from donors with laboratory evidence of HCV infection are included but are not required to be incorporated into Organ Procurement and Transplantation Network policy. Transplant centers that transplant organs from HCV-positive donors should develop protocols for obtaining informed consent, testing and treating recipients for HCV, ensuring reimbursement, and reporting new infections to public health authorities.
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7
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Holscher CM, Bowring MG, Haugen CE, Zhou S, Massie AB, Gentry SE, Segev DL, Garonzik Wang JM. National Variation in Increased Infectious Risk Kidney Offer Acceptance. Transplantation 2019; 103:2157-2163. [PMID: 31343577 PMCID: PMC6703966 DOI: 10.1097/tp.0000000000002631] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Despite providing survival benefit, increased risk for infectious disease (IRD) kidney offers are declined at 1.5 times the rate of non-IRD kidneys. Elucidating sources of variation in IRD kidney offer acceptance may highlight opportunities to expand use of these life-saving organs. METHODS To explore center-level variation in offer acceptance, we studied 6765 transplanted IRD kidneys offered to 187 transplant centers between 2009 and 2017 using Scientific Registry of Transplant Recipients data. We used multilevel logistic regression to determine characteristics associated with offer acceptance and to calculate the median odds ratio (MOR) of acceptance (higher MOR indicates greater heterogeneity). RESULTS Higher quality kidneys (per 10 units kidney donor profile index; adjusted odds ratio [aOR], 0.94; 95% confidence interval [CI], 0.92-0.95), higher yearly volume (per 10 deceased donor kidney transplants; aOR, 1.08, 95% CI, 1.06-1.10), smaller waitlist size (per 100 candidates; aOR, 0.97; 95% CI, 0.95-0.98), and fewer transplant centers in the donor service area (per center; aOR, 0.88; 95% CI, 0.85-0.91) were associated with greater odds of IRD acceptance. Adjusting for donor and center characteristics, we found wide heterogeneity in IRD offer acceptance (MOR, 1.96). In other words, if listed at a center with more aggressive acceptance practices, a candidate could be 2 times more likely to have an IRD kidney offer accepted. CONCLUSIONS Wide national variation in IRD kidney offer acceptance limits access to life-saving kidneys for many transplant candidates.
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Affiliation(s)
- Courtenay M Holscher
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mary G Bowring
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christine E Haugen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - 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
| | - Sommer E Gentry
- Department of Mathematics, United States Naval Academy, Annapolis, 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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8
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Kizilbash SJ, Rheault MN, Wang Q, Vock DM, Chinnakotla S, Pruett T, Chavers BM. Kidney transplant outcomes associated with the use of increased risk donors in children. Am J Transplant 2019; 19:1684-1692. [PMID: 30582274 DOI: 10.1111/ajt.15231] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 12/11/2018] [Accepted: 12/12/2018] [Indexed: 01/25/2023]
Abstract
Increased risk donors (IRDs) may inadvertently transmit blood-borne viruses to organ recipients through transplant. Rates of IRD kidney transplants in children and the associated outcomes are unknown. We used the Scientific Registry of Transplant Recipients to identify pediatric deceased donor kidney transplants that were performed in the United States between January 1, 2005 and December 31, 2015. We used the Cox regression analysis to compare patient and graft survival between IRD and non-IRD recipients, and a sequential Cox approach to evaluate survival benefit after IRD transplants compared with remaining on the waitlist and never accepting an IRD kidney. We studied 328 recipients with and 4850 without IRD transplants. The annual IRD transplant rates ranged from 3.4% to 13.2%. IRDs were more likely to be male (P = .04), black (P < .001), and die from head trauma (P = .006). IRD recipients had higher mean cPRA (0.085 vs 0.065, P = .02). After multivariate adjustment, patient survival after IRD transplants was significantly higher compared with remaining on the waitlist (adjusted hazard ratio [aHR]: 0.48, 95% CI: 0.26-0.88, P = .018); however, patient (aHR: 0.93, 95% CI: 0.54-1.59, P = .79) and graft survival (aHR: 0.89, 95% CI: 0.70-1.13, P = .32) were similar between IRD and non-IRD recipients. We recommend that IRDs be considered for transplant in children.
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Affiliation(s)
- Sarah J Kizilbash
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Michelle N Rheault
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Qi Wang
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, Minneapolis
| | - David M Vock
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota
| | | | - Tim Pruett
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Blanche M Chavers
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
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9
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Development and Preliminary Evaluation of IRD-1-2-3: An Animated Video to Inform Transplant Candidates About Increased Risk Donor Kidneys. Transplantation 2019; 104:326-334. [PMID: 31107826 DOI: 10.1097/tp.0000000000002763] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Current educational interventions about increased risk donors (IRDs) are less effective in improving knowledge among African American (AA) kidney transplant candidates compared to other races. We aimed to develop an IRD educational animated video culturally responsive to AAs and conduct feasibility testing. METHODS Between May 1, 2018, and June 25, 2018, we iteratively refined a culturally targeted video for AAs with input from multiple stakeholders. We then conducted a one group pre-post study between June 28, 2018, and October 29, 2018, with 40 kidney transplant candidates to assess the feasibility and acceptability of the video to improve participant knowledge and obtain feedback about IRD understanding, self-efficacy, and willingness. A mixed population was chosen to obtain race-specific acceptability data and efficacy estimates to inform a larger study. RESULTS Three themes emerged and informed video development; misattribution of IRD to kidney quality, IRD terminology as a barrier to meaningful understanding, and variable reactions to a 1:1000 risk estimate. The study cohort was 50% AA. Median IRD knowledge increased from 5 to 7.5 (P = 0.001) overall and from 5 to 7 (P < 0.001) among AAs. The frequency of positive responses increased pre-post video for understanding of (23% vs 83%, P < 0.001), self-efficacy to decide about (38% vs 70%, P < 0.001), and willingness to accept IRD kidneys (25% vs 72%, P < 0.001). Over 90% of participants provided positive ratings on each of the 6 acceptability items. CONCLUSIONS A culturally responsive IRD educational video was developed in collaboration with key stakeholders. Quantitative results indicate the video was acceptable and promising to impact IRD knowledge among AA and non-AA kidney transplant candidates.
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10
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Expanding deceased donor kidney transplantation: medical risk, infectious risk, hepatitis C virus, and HIV. Curr Opin Nephrol Hypertens 2019; 27:445-453. [PMID: 30169460 DOI: 10.1097/mnh.0000000000000456] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Due to the organ shortage, which prevents over 90 000 individuals in the United States from receiving life-saving transplants, the transplant community has begun to critically reevaluate whether organ sources that were previously considered too risky provide a survival benefit to waitlist candidates. RECENT FINDINGS Organs that many providers were previously unwilling to use for transplantation, including kidneys with a high Kidney Donor Profile Index or from increased risk donors who have risk factors for window period hepatitis C virus (HCV) and HIV infection, have been shown to provide a survival benefit to transplant waitlist candidates compared with remaining on dialysis. The development of direct-acting antivirals to cure HCV infection has enabled prospective trials on the transplantation of organs from HCV-infected donors into HCV-negative recipients, with promising preliminary results. Changes in legislation through the HIV Organ Policy Equity Act have legalized transplantations from HIV-positive deceased donors to HIV-positive recipients for the first time in the United States. SUMMARY Critical reexamination of deceased donor organs that were previously discarded has resulted in greater utilization of these organs, an increased number of deceased donor transplants, and the provision of life-saving treatment to more transplant waitlist candidates.
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11
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Implications of declining donor offers with increased risk of disease transmission on waiting list survival in lung transplantation. J Heart Lung Transplant 2018; 38:295-305. [PMID: 30773195 DOI: 10.1016/j.healun.2018.12.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 11/12/2018] [Accepted: 12/18/2018] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Donors with characteristics that may increase the likelihood of disease transmission with transplantation are noted as increased risk via Public Health Service criteria. This study aimed to establish the implications of declining an increased-risk donor (IRD) organ offer in lung transplantation. METHODS Adult candidates waitlisted for isolated lung transplantation in the United States using the Organ Procurement and Transplantation Network /United Network of Organ Sharing registry from 2007 to 2017 were identified. Individual match run files identified candidate recipients who matched to an IRD offer. Competing-risks analysis ascertained the likelihood of survival to transplantation. A stratified Cox model and restricted mean survival times estimated the survival benefit associated with the acceptance of an IRD organ. RESULTS A total of 6,963 candidates met inclusion criteria, and 1,473 (21.2%) accepted an IRD offer. Candidates who accepted an IRD offer were older, more likely to be male, and had a higher lung allocation score at the time of listing (all p < 0.05). At 1 year after an IRD offer decline, 70.5% of candidates underwent a lung transplant, 13.8% died or decompensated, and 14.9% were still awaiting transplant. Compared with those who declined, candidates who accepted the IRD offer had significantly improved cumulative mortality at 1 year (14.1% vs 23.9%, p < 0.001) and 5 years (48.4% vs 53.8%, p < 0.001). CONCLUSIONS IRD organ declination is associated with a decreased rate of lung transplantation and worse survival. Overall post-transplant survival rates for those who survive to transplantation are equivalent.
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12
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Brown KA, Hassan M. Utilizing Donors with Hepatitis C Antibody Positivity and Negative Nucleic Acid Testing. CURRENT TRANSPLANTATION REPORTS 2018. [DOI: 10.1007/s40472-018-0218-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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13
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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: 7.2] [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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14
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Rahnemai-Azar AA, Perkins JD, Leca N, Blosser CD, Johnson CK, Morrison SD, Bakthavatsalam R, Limaye AP, Sibulesky L. Unintended Consequences in Use of Increased Risk Donor Kidneys in the New Kidney Allocation Era. Transplant Proc 2018; 50:14-19. [PMID: 29407297 DOI: 10.1016/j.transproceed.2017.11.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 09/09/2017] [Accepted: 11/03/2017] [Indexed: 01/21/2023]
Abstract
BACKGROUND The new kidney allocation system (KAS) intends to allocate the top 20% of kidneys to younger recipients with longer life expectancy. We hypothesized that the new KAS would lead to greater allocation of Public Health Service (PHS) increased-risk donor organs to younger recipients. METHODS Analyses of the Organ Procurement and Transplantation Network data of patients who underwent primary deceased kidney transplantation were performed in pre- and post-KAS periods. RESULTS The allocation of PHS increased-risk kidney allografts in various age groups changed significantly after implementation of the new KAS, with an increased proportion of younger individuals receiving increased-risk kidneys (7% vs 10% in age group 20-29 y and 13% vs 18% in age group 30-39 y before and after KAS, respectively; P < .0001). This trend was reversed in recipients 50-59 years old, with 31% in the pre-KAS period compared with 26% after KAS (P < .0001). CONCLUSIONS The new KAS resulted in a substantial increase in allocation of PHS increased-risk kidneys to candidates in younger age groups. Because increased-risk kidneys are generally underutilized, future efforts to optimize the utilization of these organs should target younger recipients and their providers.
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Affiliation(s)
- A A Rahnemai-Azar
- Division of Transplant Surgery, Department of Surgery, University of Washington Medical Center, Seattle, Washington
| | - J D Perkins
- Division of Transplant Surgery, Department of Surgery, University of Washington Medical Center, Seattle, Washington
| | - N Leca
- Division of Nephrology, Department of Medicine, University of Washington Medical Center, Seattle, Washington
| | - C D Blosser
- Division of Nephrology, Department of Medicine, University of Washington Medical Center, Seattle, Washington
| | - C K Johnson
- Division of Nephrology, Department of Medicine, University of Washington Medical Center, Seattle, Washington
| | - S D Morrison
- Division of Plastic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, Washington
| | - R Bakthavatsalam
- Division of Transplant Surgery, Department of Surgery, University of Washington Medical Center, Seattle, Washington
| | - A P Limaye
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington Medical Center, Seattle, Washington
| | - L Sibulesky
- Division of Transplant Surgery, Department of Surgery, University of Washington Medical Center, Seattle, Washington.
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15
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Durand CM, Bowring MG, Thomas AG, Kucirka LM, Massie AB, Cameron A, Desai NM, Sulkowski M, Segev DL. The Drug Overdose Epidemic and Deceased-Donor Transplantation in the United States: A National Registry Study. Ann Intern Med 2018; 168:702-711. [PMID: 29710288 PMCID: PMC6205229 DOI: 10.7326/m17-2451] [Citation(s) in RCA: 153] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The epidemic of drug overdose deaths in the United States has led to an increase in organ donors. OBJECTIVE To characterize donors who died of overdose and to analyze outcomes among transplant recipients. DESIGN Prospective observational cohort study. SETTING Scientific Registry of Transplant Recipients, 1 January 2000 to 1 September 2017. PARTICIPANTS 138 565 deceased donors; 337 934 transplant recipients at 297 transplant centers. MEASUREMENTS The primary exposure was donor mechanism of death (overdose-death donor [ODD], trauma-death donor [TDD], or medical-death donor [MDD]). Patient and graft survival and organ discard (organ recovered but not transplanted) were compared using propensity score-weighted standardized risk differences (sRDs). RESULTS A total of 7313 ODDs and 19 897 ODD transplants (10 347 kidneys, 5707 livers, 2471 hearts, and 1372 lungs) were identified. Overdose-death donors accounted for 1.1% of donors in 2000 and 13.4% in 2017. They were more likely to be white (85.1%), aged 21 to 40 years (66.3%), infected with hepatitis C virus (HCV) (18.3%), and increased-infectious risk donors (IRDs) (56.4%). Standardized 5-year patient survival was similar for ODD organ recipients compared with TDD organ recipients (sRDs ranged from 3.1% lower to 3.9% higher survival) and MDD organ recipients (sRDs ranged from 2.1% to 5.2% higher survival). Standardized 5-year graft survival was similar between ODD and TDD grafts (minimal difference for kidneys and lungs, marginally lower [sRD, -3.2%] for livers, and marginally higher [sRD, 1.9%] for hearts). Kidney discard was higher for ODDs than TDDs (sRD, 5.2%) or MDDs (sRD, 1.5%); standardization for HCV and IRD status attenuated this difference. LIMITATION Inability to distinguish between opioid and nonopioid overdoses. CONCLUSION In the United States, transplantation with ODD organs has increased dramatically, with noninferior outcomes in transplant recipients. Concerns about IRD behaviors and hepatitis C among donors lead to excess discard that should be minimized given the current organ shortage. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Christine M Durand
- Johns Hopkins University School of Medicine, Baltimore, Maryland (C.M.D., M.G.B., A.G.T., L.M.K., A.C., N.M.D., M.S.)
| | - Mary G Bowring
- Johns Hopkins University School of Medicine, Baltimore, Maryland (C.M.D., M.G.B., A.G.T., L.M.K., A.C., N.M.D., M.S.)
| | - Alvin G Thomas
- Johns Hopkins University School of Medicine, Baltimore, Maryland (C.M.D., M.G.B., A.G.T., L.M.K., A.C., N.M.D., M.S.)
| | - Lauren M Kucirka
- Johns Hopkins University School of Medicine, Baltimore, Maryland (C.M.D., M.G.B., A.G.T., L.M.K., A.C., N.M.D., M.S.)
| | - Allan B Massie
- Johns Hopkins University School of Medicine and Johns Hopkins School of Public Health, Baltimore, Maryland (A.B.M.)
| | - Andrew Cameron
- Johns Hopkins University School of Medicine, Baltimore, Maryland (C.M.D., M.G.B., A.G.T., L.M.K., A.C., N.M.D., M.S.)
| | - Niraj M Desai
- Johns Hopkins University School of Medicine, Baltimore, Maryland (C.M.D., M.G.B., A.G.T., L.M.K., A.C., N.M.D., M.S.)
| | - Mark Sulkowski
- Johns Hopkins University School of Medicine, Baltimore, Maryland (C.M.D., M.G.B., A.G.T., L.M.K., A.C., N.M.D., M.S.)
| | - Dorry L Segev
- Johns Hopkins University School of Medicine and Johns Hopkins School of Public Health, Baltimore, Maryland, and Scientific Registry of Transplant Recipients, Minneapolis, Minnesota (D.L.S.)
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16
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Bowring MG, Holscher CM, Zhou S, Massie AB, Garonzik-Wang J, Kucirka LM, Gentry SE, Segev DL. Turn down for what? Patient outcomes associated with declining increased infectious risk kidneys. Am J Transplant 2018; 18:617-624. [PMID: 29116674 PMCID: PMC5863756 DOI: 10.1111/ajt.14577] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 10/20/2017] [Accepted: 10/30/2017] [Indexed: 01/25/2023]
Abstract
Transplant candidates who accept a kidney labeled increased risk for disease transmission (IRD) accept a low risk of window period infection, yet those who decline must wait for another offer that might harbor other risks or never even come. To characterize survival benefit of accepting IRD kidneys, we used 2010-2014 Scientific Registry of Transplant Recipients data to identify 104 998 adult transplant candidates who were offered IRD kidneys that were eventually accepted by someone; the median (interquartile range) Kidney Donor Profile Index (KDPI) of these kidneys was 30 (16-49). We followed patients from the offer decision until death or end-of-study. After 5 years, only 31.0% of candidates who declined IRDs later received non-IRD deceased donor kidney transplants; the median KDPI of these non-IRD kidneys was 52, compared to 21 of the IRDs they had declined. After a brief risk period in the first 30 days following IRD acceptance (adjusted hazard ratio [aHR] accept vs decline: 1.22 2.063.49 , P = .008) (absolute mortality 0.8% vs. 0.4%), those who accepted IRDs were at 33% lower risk of death 1-6 months postdecision (aHR 0.50 0.670.90 , P = .006), and at 48% lower risk of death beyond 6 months postdecision (aHR 0.46 0.520.58 , P < .001). Accepting an IRD kidney was associated with substantial long-term survival benefit; providers should consider this benefit when counseling patients on IRD offer acceptance.
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Affiliation(s)
- Mary G. Bowring
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - 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
| | | | - Lauren M. Kucirka
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sommer E. Gentry
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Mathematics, United States Naval Academy, Annapolis, 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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17
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Effect of a Mobile Web App on Kidney Transplant Candidates' Knowledge About Increased Risk Donor Kidneys: A Randomized Controlled Trial. Transplantation 2017; 101:1167-1176. [PMID: 27463536 DOI: 10.1097/tp.0000000000001273] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Kidney transplant candidates (KTCs) must provide informed consent to accept kidneys from increased risk donors (IRD), but poorly understand them. We conducted a multisite, randomized controlled trial to evaluate the efficacy of a mobile Web application, Inform Me, for increasing knowledge about IRDs. METHODS Kidney transplant candidates undergoing transplant evaluation at 2 transplant centers were randomized to use Inform Me after routine transplant education (intervention) or routine transplant education alone (control). Computer adaptive learning method reinforced learning by embedding educational material, and initial (test 1) and additional test questions (test 2) into each chapter. Knowledge (primary outcome) was assessed in person after education (tests 1 and 2), and 1 week later by telephone (test 3). Controls did not receive test 2. Willingness to accept an IRD kidney (secondary outcome) was assessed after tests 1 and 3. Linear regression test 1 knowledge scores were used to test the significance of Inform Me exposure after controlling for covariates. Multiple imputation was used for intention-to-treat analysis. RESULTS Two hundred eighty-eight KTCs participated. Intervention participants had higher test 1 knowledge scores (mean difference, 6.61; 95% confidence interval [95% CI], 5.37-7.86) than control participants, representing a 44% higher score than control participants' scores. Intervention participants' knowledge scores increased with educational reinforcement (test 2) compared with control arm test 1 scores (mean difference, 9.50; 95% CI, 8.27-10.73). After 1 week, intervention participants' knowledge remained greater than controls' knowledge (mean difference, 3.63; 95% CI, 2.49-4.78) (test 3). Willingness to accept an IRD kidney did not differ between study arms at tests 1 and 3. CONCLUSIONS Inform Me use was associated with greater KTC knowledge about IRD kidneys above routine transplant education alone.
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18
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The “PHS Increased Risk” Label Is Associated With Nonutilization of Hundreds of Organs per Year. Transplantation 2017; 101:1666-1669. [DOI: 10.1097/tp.0000000000001673] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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19
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Henderson ML, Gross JA. Living Organ Donation and Informed Consent in the United States: Strategies to Improve the Process. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2017; 45:66-76. [PMID: 28661285 DOI: 10.1177/1073110517703101] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
About 6,000 individuals participate in the U.S. transplant system as a living organ donor each year. Organ donation (most commonly a kidney or part of liver) by living individuals is a unique procedure, where healthy patients undergo a major surgical operation without any direct functional benefit to themselves. In this article, the authors explore how the ideal of informed consent guides education and evaluation for living organ donation. The authors posit that informed consent for living organ donation is a process. Though the steps in this process are partially standardized through national health policy, they can be improved through institutional structures at the local, transplant center-level. Effective structures and practices aimed at supporting and promoting comprehensive informed consent provide more opportunities for candidates to ask questions about the risks and benefits of living donation and to opt out voluntarily Additionally, these practices could enable new ways of measuring knowledge and improving the consent process.
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Affiliation(s)
- Macey L Henderson
- Macey L. Henderson, J.D., Ph.D., is an Instructor of Surgery, Division of Transplant Surgery at Johns Hopkins School of Medicine in Baltimore, Maryland. She received her J.D. from the Indiana University Maurer School of Law-Bloomington, Indiana and Ph.D. in Health Policy and Management from the Indiana University Fairbanks School of Public Health in Indianapolis, Indiana. Jed Adam Gross, J.D., M.Phil., is a Bioethicist at Toronto General Hospital in Toronto, Ontario, a Ph.D. candidate in History at Yale University in New Haven, Connecticut, and a member of the Massachusetts bar. He earned his B.A. from the University of Pennsylvania in Philadelphia, Pennsylvania, and his postgraduate degrees from Yale University
| | - Jed Adam Gross
- Macey L. Henderson, J.D., Ph.D., is an Instructor of Surgery, Division of Transplant Surgery at Johns Hopkins School of Medicine in Baltimore, Maryland. She received her J.D. from the Indiana University Maurer School of Law-Bloomington, Indiana and Ph.D. in Health Policy and Management from the Indiana University Fairbanks School of Public Health in Indianapolis, Indiana. Jed Adam Gross, J.D., M.Phil., is a Bioethicist at Toronto General Hospital in Toronto, Ontario, a Ph.D. candidate in History at Yale University in New Haven, Connecticut, and a member of the Massachusetts bar. He earned his B.A. from the University of Pennsylvania in Philadelphia, Pennsylvania, and his postgraduate degrees from Yale University
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20
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Gaffey AC, Doll SL, Thomasson AM, Venkataraman C, Chen CW, Goldberg LR, Blumberg EA, Acker MA, Stone F, Atluri P. Transplantation of “high-risk” donor hearts: Implications for infection. J Thorac Cardiovasc Surg 2016; 152:213-20. [DOI: 10.1016/j.jtcvs.2015.12.062] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 12/07/2015] [Accepted: 12/26/2015] [Indexed: 12/12/2022]
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21
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A Survey of Increased Infectious Risk Donor Utilization in Canadian Transplant Programs. Transplantation 2016; 100:461-4. [PMID: 26285016 DOI: 10.1097/tp.0000000000000843] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Donors at increased risk of transmitting viral infections are a potential source of transplantable organs. Studies demonstrate that organs from increased risk donors (IRDs) are associated with excellent outcomes. However, considerable variation in practice likely exists. METHODS We performed a cross-country survey of Canadian Organ Transplant centers to determine organ utilization practices from IRDs. RESULTS Of 40 surveys sent to transplant programs across Canada, 24 (60%) were returned. Of those, 60.9% (15/24) had a formal policy for their use, and 21.7% (5/24) had never accepted an IRD. Only 41.7% (10/24) had access to timely nucleic acid testing (NAT), and respondents were more likely to accept IRD if NAT was available. For example the likelihood of using organs from an intravenous drug user increased from 12.5% (4/24) with serology negative donors to 70.8% (17/24) if NAT was available and the donor had no increased activity within the window period (P < 0.001). Only 37.5% (9/24) discussed the use of IRDs with candidates at listing, with 54.2% (13/24) stating that having a standardized consent would increase utilization of IRDs. CONCLUSIONS The results suggest that availability of NAT would increase IRD utilization. In addition written policies and procedures on IRD use and the consent process would be recommended in many Canadian centers.
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22
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Affiliation(s)
- David Serur
- Kidney and Pancreas Transplant Program, New York Presbyterian-Weill Cornell Rogosin Institute, New York, New York
| | - Elisa J Gordon
- Comprehensive Transplant Center, Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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23
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Gordon EJ, Ison MG. Decision aids for organ transplant candidates. Liver Transpl 2014; 20:753-5. [PMID: 24806135 PMCID: PMC4834713 DOI: 10.1002/lt.23908] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 05/02/2014] [Indexed: 12/13/2022]
Affiliation(s)
- Elisa J Gordon
- Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL; Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
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