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McMichael LC, Gill J, Kadatz M, Lan J, Landsberg D, Johnston O, Keenan S, Ferre E, Harriman D, Gill JS. High-Functioning Deceased Donor Kidney Transplant System Characteristics: The British Columbia Experience With an Opt-In System. Kidney Med 2024; 6:100812. [PMID: 38665993 PMCID: PMC11044131 DOI: 10.1016/j.xkme.2024.100812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
Rationale & Objective A high level of cooperation between organ procurement organizations and transplant programs may help maximize use of deceased donor kidneys. The practices that are essential for a high functioning organ donation and transplant system remain uncertain. We sought to report metrics of organ donation and transplant performance in British Columbia, Canada, and to assess the association of specific policies and practices that contribute to the system's performance. Study Design A retrospective observational study. Setting & Participants Referred deceased organ donors in British Columbia were used in the study from January 1, 2016, to December 31 2019. Exposures Provincial, organ procurement organization, and center level policies were implemented to improve donor referral and organ utilization. Outcomes Assessment of donor and kidney utilization along steps of the critical pathway for organ donation. Analytical Approach Deceased donors were classified according to the critical pathway for organ donation and key donation and transplant metrics were identified. Results There were 1,948 possible donors referred. Of 1,948, 754 (39%) were potential donors. Of 754 potential donors, 587 (78%) were consented donors. Of 587 consented donors, 480 (82%) were eligible kidney donors. Of 480 eligible kidney donors, 438 (91%) were actual kidney donors. And of 438 actual kidney donors, 432 (99%) were utilized kidney donors. One-year all-cause allograft survival was 95%. Practices implemented to improve the system's performance included hospital donor coordinators, early communication between the organ procurement organization and transplant nephrologists, dedicated organ recovery and implant surgeons, aged-based kidney allocation, and hospital admission of recipients before kidney recovery. Limitations Assignment of causality between individual policies and practices and organ donation and utilization is limited in this observational study. Conclusions In British Columbia, consent for donation, utilization of donated kidneys, and transplant survival are exceptionally high, suggesting the importance of an integrated deceased donor and kidney transplant service.
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Affiliation(s)
- Lachlan C. McMichael
- Division of Nephrology, Kidney Transplant Program, University of British Columbia, Vancouver, Canada
- Transplant Epidemiology Group, Australia and New Zealand Dialysis and Transplant Registry, South Australian Health and Medical Research Institute, Adelaide, Australia
- Adelaide Medical School, Faculty of Health & Medical Sciences, The University of Adelaide, Adelaide, Australia
| | - Jagbir Gill
- Division of Nephrology, Kidney Transplant Program, University of British Columbia, Vancouver, Canada
- Centre for Advancing Health Outcomes, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Matthew Kadatz
- Division of Nephrology, Kidney Transplant Program, University of British Columbia, Vancouver, Canada
- Vancouver Coastal Health Research Institute, Vancouver, Canada
| | - James Lan
- Division of Nephrology, Kidney Transplant Program, University of British Columbia, Vancouver, Canada
- Vancouver Coastal Health Research Institute, Vancouver, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | - David Landsberg
- Division of Nephrology, Kidney Transplant Program, University of British Columbia, Vancouver, Canada
| | - Olwyn Johnston
- Division of Nephrology, Kidney Transplant Program, University of British Columbia, Vancouver, Canada
| | - Sean Keenan
- British Columbia Transplant, Vancouver, Canada
| | | | - David Harriman
- Department of Urologic Sciences, University of British Columbia, Vancouver, Canada
| | - John S. Gill
- Division of Nephrology, Kidney Transplant Program, University of British Columbia, Vancouver, Canada
- Centre for Advancing Health Outcomes, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Division of Nephrology, Tufts Medical Center, Boston
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Budhiraja P, Heilman R, Smith BH, Kaplan B. The limitation of using procurement biopsy findings in the assessment of deceased donor kidney quality and outcomes. Am J Transplant 2023; 23:1471-1472. [PMID: 37230254 DOI: 10.1016/j.ajt.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 05/18/2023] [Accepted: 05/18/2023] [Indexed: 05/27/2023]
Affiliation(s)
- Pooja Budhiraja
- Division of Medicine, Mayo Clinic, Scottsdale, Arizona, USA.
| | | | - Byron H Smith
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Bruce Kaplan
- Department of Medicine, Colorado Center for Transplantation Care, Research and Education, University of Colorado, Aurora, Colorado, USA
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Puttarajappa CM, Hariharan S, Zhang X, Tevar A, Mehta R, Gunabushanam V, Sood P, Hoffman W, Mohan S. Early Effect of the Circular Model of Kidney Allocation in the United States. J Am Soc Nephrol 2023; 34:26-39. [PMID: 36302599 PMCID: PMC10101588 DOI: 10.1681/asn.2022040471] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 07/21/2022] [Accepted: 08/16/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND In March 2021, the United States implemented a new kidney allocation system (KAS250) for deceased donor kidney transplantation (DDKT), which eliminated the donation service area-based allocation and replaced it with a system on the basis of distance from donor hospital to transplant center within/outside a radius of 250 nautical miles. The effect of this policy on kidney discards and logistics is unknown. METHODS We examined discards, donor-recipient characteristics, cold ischemia time (CIT), and delayed graft function (DGF) during the first 9 months of KAS250 compared with a pre-KAS250 cohort from the preceding 2 years. Changes in discards and CIT after the onset of COVID-19 and the implementation of KAS250 were evaluated using an interrupted time-series model. Changes in allocation practices (biopsy, machine perfusion, and virtual cross-match) were also evaluated. RESULTS Post-KAS250 saw a two-fold increase in kidneys imported from nonlocal organ procurement organizations (OPO) and a higher proportion of recipients with calculated panel reactive antibody (cPRA) 81%-98% (12% versus 8%; P <0.001) and those with >5 years of pretransplant dialysis (35% versus 33%; P <0.001). CIT increased (mean 2 hours), including among local OPO kidneys. DGF was similar on adjusted analysis. Discards after KAS250 did not immediately change, but we observed a statistically significant increase over time that was independent of donor quality. Machine perfusion use decreased, whereas reliance on virtual cross-match increased, which was associated with shorter CIT. CONCLUSIONS Early trends after KAS250 show an increase in transplant access to patients with cPRA>80% and those with longer dialysis duration, but this was accompanied by an increase in CIT and a suggestion of worsening kidney discards.
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Affiliation(s)
- Chethan M. Puttarajappa
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sundaram Hariharan
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Xingyu Zhang
- Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Amit Tevar
- Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Rajil Mehta
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Vikraman Gunabushanam
- Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Puneet Sood
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - William Hoffman
- Transplant Nephrology, UPMC Pinnacle, Harrisburg, Pennsylvania
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians and Surgeons and Department of Medicine, Mailman School of Public Health, Columbia University, New York, New York
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Husain SA, King KL, Cron DC, Lentine KL, Adler JT, Mohan S. Influence of organ quality on the observed association between deceased donor kidney procurement biopsy findings and graft survival. Am J Transplant 2022; 22:2842-2854. [PMID: 35946600 DOI: 10.1111/ajt.17167] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 07/17/2022] [Accepted: 08/05/2022] [Indexed: 01/25/2023]
Abstract
Deceased donor kidney procurement biopsies findings are the most common reason for kidney discard. Retrospective studies have found inconsistent associations with post-transplant outcomes but may have been limited by selection bias because kidneys with advanced nephrosclerosis from high-risk donors are typically discarded. We conducted a retrospective cohort study of kidneys transplanted in the United States from 2015 to 2019 with complete biopsy data available, defining "suboptimal histology" as glomerulosclerosis ≥11%, IFTA ≥mild, and/or vascular disease ≥mild. We used time-to-event analyses to determine the association between suboptimal histology and death-censored graft failure after stratification by kidney donor profile index (KDPI) (≤35%, 36%-84%, ≥85%) and final creatinine (<1 mg/dl, 1-2 mg/dl, >2 mg/dl). Among 30 469 kidneys included, 36% had suboptimal histology. In adjusted analyses, suboptimal histology was associated with death-censored graft failure among kidneys with KDPI 36-84% (HR 1.22, 95% CI 1.09-1.36), but not KDPI≤35% (HR 1.24, 0.94-1.64) or ≥ 85% (HR 0.99, 0.81-1.22). Similarly, suboptimal histology was associated with death-censored graft failure among kidneys from donors with creatinine 1-2 mg/dl (HR 1.39, 95% CI 1.20-1.60) but not <1 mg/dl (HR 1.07, 0.93-1.23) or >2 mg/dl (HR 0.95, 0.75-1.20). The association of procurement histology with graft longevity among intermediate-quality kidneys that were likely to be both biopsied and transplanted suggests biopsies provide independent organ quality assessments.
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Affiliation(s)
- S Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians & Surgeons, New York, New York, USA
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - Kristen L King
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians & Surgeons, New York, New York, USA
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - David C Cron
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Krista L Lentine
- Department of Surgery, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Joel T Adler
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas, USA
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians & Surgeons, 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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Schold JD, Huml AM, Poggio ED, Reese PP, Mohan S. A tool for decision-making in kidney transplant candidates with poor prognosis to receive deceased donor transplantation in the United States. Kidney Int 2022; 102:640-651. [PMID: 35760150 DOI: 10.1016/j.kint.2022.05.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/27/2022] [Accepted: 05/20/2022] [Indexed: 12/01/2022]
Abstract
The primary outcomes for kidney transplant candidates are receipt of deceased or living donor transplant, death or removal from the waiting list. Here, we conducted a retrospective analysis of national Scientific Registry of Transplant Recipients data to evaluate outcomes for 208,717 adult kidney transplant candidates following the 2014 Kidney Allocation System in the United States. Competing risks models were utilized to evaluate Time to Equivalent Risk (TiTER) of deceased donor transplantation (DDTX) and death versus waitlist removal. We also evaluated TiTER based on kidney donor profile index (KDPI) and donor age. For all groups, the cumulative incidence of DDTX was initially higher from time of listing than death or waitlist removal. However, following accrued time on the waiting list, the cumulative incidence of death or waitlist removal exceeded DDTX for certain patient groups, particularly older, diabetic, blood type B and O and shorter pre-listing dialysis time. TiTER for all candidates aged 65-69 averaged 41 months and for 70 and older patients 28 months. Overall, 39.6% of candidates were in risk groups with TiTER under 72 months and 18.5% in groups with TiTER under 24 months. Particularly for older candidates, TiTER for kidneys was substantially shorter for younger donors or lower KDPI. Thus, our findings reveal that a large proportion of waitlisted patients in the United States have poor prognoses to ever undergo DDTX and our data may improve shared decision-making for candidates at time of waitlist placement. Hence, for specific patient groups, TiTER may be a useful tool to disseminate and quantify benefits of accepting relatively high risk donor organs.
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Affiliation(s)
- Jesse D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio; Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Anne M Huml
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Emilio D Poggio
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Peter P Reese
- Renal Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York; The Columbia University Renal Epidemiology Group, Columbia University, New York, New York
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Stewart DE, Foutz J, Kamal L, Weiss S, McGehee HS, Cooper M, Gupta G. The Independent Effects of Procurement Biopsy Findings on Ten-Year Outcomes of Extended Criteria Donor Kidney Transplants. Kidney Int Rep 2022; 7:1850-1865. [PMID: 35967103 PMCID: PMC9366372 DOI: 10.1016/j.ekir.2022.05.027] [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: 04/12/2022] [Accepted: 05/23/2022] [Indexed: 11/01/2022] Open
Abstract
Introduction Methods Results Conclusion
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Lentine KL, Fleetwood VA, Caliskan Y, Randall H, Wellen JR, Lichtenberger M, Dedert C, Rothweiler R, Marklin G, Brockmeier D, Schnitzler MA, Husain SA, Mohan S, Kasiske BL, Cooper M, Mannon RB, Axelrod DA. Deceased Donor Procurement Biopsy Practices, Interpretation, and Histology-Based Decision Making: A Survey of U.S. Transplant Centers. Kidney Int Rep 2022; 7:1268-1277. [PMID: 35685316 PMCID: PMC9171615 DOI: 10.1016/j.ekir.2022.03.021] [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: 02/01/2022] [Revised: 03/13/2022] [Accepted: 03/21/2022] [Indexed: 10/31/2022] Open
Abstract
Introduction Methods Results Conclusion
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8
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Mohan S, Parikh CR. Underscoring the Case for Better Markers of Kidney Injury in Deceased Donors. Am J Kidney Dis 2021; 79:156-158. [PMID: 34742616 DOI: 10.1053/j.ajkd.2021.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 08/10/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Vagelos College of Physicians & Surgeons, New York, New York; Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Chirag R Parikh
- Division of Nephrology, School of Medicine, Johns Hopkins University, Baltimore, Maryland; Department of Epidemiology, School of Public Health, Johns Hopkins University, Baltimore, Maryland.
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