Quantifying the Effect of Consent for High-Kidney Donor Profile Index Deceased Donor Transplants in the United States

How do we increase deceased donor kidney utilization and reduce discard?

PURPOSE OF REVIEW

This review aims to address the critical issue of expanding deceased donor kidney pool and reducing the discard rates of viable kidneys in the United States. It highlights advances in organ preservation techniques and explores strategies for expanding the donor pool by leveraging suboptimal and high-risk nonuse kidneys, including those affected by acute kidney injury (AKI), hepatitis C virus (HCV), and hepatitis B virus (HBV).

RECENT FINDINGS

Innovations in organ preservation, including hypothermic and normothermic machine perfusion, have demonstrated efficacy in improving outcomes for marginal and extended-criteria kidneys. The integration of normothermic regional perfusion (NRP) for donation after cardiac death (DCD) donors has enhanced organ utilization and graft viability. Additionally, research confirms that kidneys from AKI and HCV-positive donors, when managed with appropriate protocols, yield comparable long-term outcomes to standard transplants. Emerging data on HBV-positive donor kidneys further underscore their potential to safely expand transplant access with targeted antiviral prophylaxis.

SUMMARY

Optimizing deceased donor kidney utilization requires a multi-faceted approach, including advancements in preservation technologies, evidence-based decision-making for high-risk organs, and policy innovations. Leveraging these strategies can help address the growing organ shortage, enhance transplant outcomes, and ensure broader access to life-saving kidney transplants.

Outcomes for Patients With a Deceased Donor Kidney Offer in the New Allocation System

Introduction

In the United States (US), disparities in access to kidney transplantation exist for waitlisted candidates with end-stage kidney disease. Meanwhile, changes in kidney allocation policy have been associated with a dramatic increase in the number of organ offers declined before an organ is successfully placed.

Methods

We describe transplant and mortality rates for waitlisted candidates from 2015 to 2022 following these allocation changes.

Results

Among 249,145 incident waitlisted adults, 180,039 received at least 1 offer and were included in the study. Of these, 37.7% received a deceased donor kidney allograft, 14.7% received a living donor allograft, 7.4% died while on the waiting list, 12.7% were removed, and 27.5% were still waitlisted by the study end period. Overall, candidates' median number of days to receiving their first offer declined from 20 (7-48) in 2015 to 5 (2-13) in 2022. Candidates who died while on the waiting list received a median of 25 (9-56) offers and candidates who were removed received a median of 22 (8-53) offers during the study period. The total number of offers generated by the match-run algorithm, including those from nonutilized kidneys, increased sharply from 7,911,688 offers in 2015 to 13,682,914 in 2019, and to 29,332,516 in 2022.

Conclusion

These findings emphasize the inefficiencies inherent in our current allocation algorithms and the need to rethink how waitlisted patients are prioritized for a given deceased donor organ in order to maximize the probability of appropriate utilization of lifesaving organs .