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Edginton O, George M, Bandara C, Johnston M, Rao A, Howse M, Ridgway D, Goldsmith P. Renal transplantation in older adults: retrospective cohort study to examine the impact of the new 2019 kidney offering scheme on older adult transplant recipients. Ann R Coll Surg Engl 2024. [PMID: 39377692 DOI: 10.1308/rcsann.2024.0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/09/2024] Open
Abstract
INTRODUCTION In 2019, a new kidney offering scheme was launched in the United Kingdom, aiming to better match estimated patient survival and graft life expectancy. The scheme's impact on older patients undergoing kidney transplantation (KT) is unknown. This study aims to compare the outcomes of older adult KT recipients before and after introduction of the 2019 scheme. METHODS A retrospective observational cohort study of older adults who underwent KT was undertaken. Group 1 were transplanted between 1 September 2017 and 31 August 2019 (2006 allocation scheme) and group 2 between 1 September 2019 and 31 August 2021 (2019 offering scheme). An older adult was any person ≥60 years old at the time of KT. Univariable binary logistic regression analysis was performed to determine odds ratios (OR) and 95% confidence intervals (CI). RESULTS There were 107 older adult deceased donor KT recipients, 62 from group 1 and 45 from group 2. Median age at transplantation was 68 (interquartile range [IQR] 62-71) and 67 (IQR 64-73) years, respectively. Univariable analysis showed that re-intervention (OR 6.486, 95% CI 1.306-32.216, p = 0.022) and critical care admission (OR 5.619, 95% CI 1.448-21.812, p = 0.013) were significantly more likely in group 2. Group 2 recipients were significantly more likely to have a level 4 human leucocyte antigen (HLA) mismatch (OR 4.667, 95% CI 1.640-13.275, p = 0.004) and to have undergone previous KT (OR 4.691, 95% CI 1.385-15.893, p = 0.013). CONCLUSIONS The introduction of the 2019 offering scheme was associated with re-intervention and critical care admission for older KT recipients. We also observed less-favourable HLA matches but more KT in difficult-to-match groups.
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Affiliation(s)
| | | | - C Bandara
- Liverpool University Hospitals NHS Foundation Trust, UK
| | - M Johnston
- Liverpool University Hospitals NHS Foundation Trust, UK
| | - A Rao
- Liverpool University Hospitals NHS Foundation Trust, UK
| | - M Howse
- Liverpool University Hospitals NHS Foundation Trust, UK
| | - D Ridgway
- Liverpool University Hospitals NHS Foundation Trust, UK
| | - P Goldsmith
- University of Liverpool, UK
- Liverpool University Hospitals NHS Foundation Trust, UK
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2
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Ali H, Mohamed M, Molnar MZ, Fülöp T, Burke B, Shroff A, Shroff S, Briggs D, Krishnan N. Deceased-Donor Kidney Transplant Outcome Prediction Using Artificial Intelligence to Aid Decision-Making in Kidney Allocation. ASAIO J 2024; 70:808-818. [PMID: 38552178 DOI: 10.1097/mat.0000000000002190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024] Open
Abstract
In kidney transplantation, pairing recipients with the highest longevity with low-risk allografts to optimize graft-donor survival is a complex challenge. Current risk prediction models exhibit limited discriminative and calibration capabilities and have not been compared to modern decision-assisting tools. We aimed to develop a highly accurate risk-stratification index using artificial intelligence (AI) techniques. Using data from the UNOS database (156,749 deceased kidney transplants, 2007-2021), we randomly divided transplants into training (80%) and validation (20%) sets. The primary measure was death-censored graft survival. Four machine learning models were assessed for calibration (integrated Brier score [IBS]) and discrimination (time-dependent concordance [CTD] index), compared with existing models. We conducted decision curve analysis and external validation using UK Transplant data. The Deep Cox mixture model showed the best discriminative performance (area under the curve [AUC] = 0.66, 0.67, and 0.68 at 6, 9, and 12 years post-transplant), with CTD at 0.66. Calibration was adequate (IBS = 0.12), while the kidney donor profile index (KDPI) model had lower CTD (0.59) and AUC (0.60). AI-based D-TOP outperformed the KDPI in evaluating transplant pairs based on graft survival, potentially enhancing deceased donor selection. Advanced computing is poised to influence kidney allocation schemes.
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Affiliation(s)
- Hatem Ali
- From the University Hospitals of Coventry and Warwickshire, United Kingdom
| | | | - Miklos Z Molnar
- Division of Nephrology & Hypertension, Department of Internal Medicine, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah
| | - Tibor Fülöp
- Division of Nephrology, Department of Medicine, Medical University Hospitals of South Carolina
- Medicine Service, Ralph H Johnson VA Medical Center, Charleston, South Carolina
| | - Bernard Burke
- Research Centre for Health and Life Sciences, Coventry University, Coventry, United Kingdom
| | | | | | - David Briggs
- Histocompatibility and Immunogenetics NHS Blood and Transplant, Birmingham, United Kingdom
- Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom
| | - Nithya Krishnan
- From the University Hospitals of Coventry and Warwickshire, United Kingdom
- Research Centre for Health and Life Sciences, Coventry University, Coventry, United Kingdom
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3
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Niroomand A, Nita GE, Lindstedt S. Machine Perfusion and Bioengineering Strategies in Transplantation-Beyond the Emerging Concepts. Transpl Int 2024; 37:13215. [PMID: 39267617 PMCID: PMC11390383 DOI: 10.3389/ti.2024.13215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 08/19/2024] [Indexed: 09/15/2024]
Abstract
Solid organ transplantation has progressed rapidly over the decades from the first experimental procedures to its role in the modern era as an established treatment for end-stage organ disease. Solid organ transplantation including liver, kidney, pancreas, heart, and lung transplantation, is the definitive option for many patients, but despite the advances that have been made, there are still significant challenges in meeting the demand for viable donor grafts. Furthermore, post-operatively, the recipient faces several hurdles, including poor early outcomes like primary graft dysfunction and acute and chronic forms of graft rejection. In an effort to address these issues, innovations in organ engineering and treatment have been developed. This review covers efforts made to expand the donor pool including bioengineering techniques and the use of ex vivo graft perfusion. It also covers modifications and treatments that have been trialed, in addition to research efforts in both abdominal organs and thoracic organs. Overall, this article discusses recent innovations in machine perfusion and organ bioengineering with the aim of improving and increasing the quality of donor organs.
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Affiliation(s)
- Anna Niroomand
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Lund Stem Cell Center, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery and Transplantation, Skåne University Hospital, Lund, Sweden
| | - George Emilian Nita
- Department of Transplantation Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
- Division of Transplantation Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Sandra Lindstedt
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Lund Stem Cell Center, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery and Transplantation, Skåne University Hospital, Lund, Sweden
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
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4
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Hakeem AR, Asthana S, Johnson R, Brown C, Ahmad N. Impact of Asian and Black Donor and Recipient Ethnicity on the Outcomes After Deceased Donor Kidney Transplantation in the United Kingdom. Transpl Int 2024; 37:12605. [PMID: 38711816 PMCID: PMC11070942 DOI: 10.3389/ti.2024.12605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 04/09/2024] [Indexed: 05/08/2024]
Abstract
Patients of Asian and black ethnicity face disadvantage on the renal transplant waiting list in the UK, because of lack of human leucocyte antigen and blood group matched donors from an overwhelmingly white deceased donor pool. This study evaluates outcomes of renal allografts from Asian and black donors. The UK Transplant Registry was analysed for adult deceased donor kidney only transplants performed between 2001 and 2015. Asian and black ethnicity patients constituted 12.4% and 6.7% of all deceased donor recipients but only 1.6% and 1.2% of all deceased donors, respectively. Unadjusted survival analysis demonstrated significantly inferior long-term allograft outcomes associated with Asian and black donors, compared to white donors. On Cox-regression analysis, Asian donor and black recipient ethnicities were associated with poorer outcomes than white counterparts, and on ethnicity matching, compared with the white donor-white recipient baseline group and adjusting for other donor and recipient factors, 5-year graft outcomes were significantly poorer for black donor-black recipient, Asian donor-white recipient, and white donor-black recipient combinations in decreasing order of worse unadjusted 5-year graft survival. Increased deceased donation among ethnic minorities could benefit the recipient pool by increasing available organs. However, it may require a refined approach to enhance outcomes.
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Affiliation(s)
- Abdul Rahman Hakeem
- Division of Surgery, Department of Transplantation, St. James’s University Hospital, Leeds, United Kingdom
| | - Sonal Asthana
- Division of Surgery, Department of Transplantation, St. James’s University Hospital, Leeds, United Kingdom
| | - Rachel Johnson
- National Health Service Blood and Transplant (NHSBT), Bristol, United Kingdom
| | - Chloe Brown
- National Health Service Blood and Transplant (NHSBT), Bristol, United Kingdom
| | - Niaz Ahmad
- King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
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5
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Kim JJ, Curtis RMK, Reynolds B, Marks S, Drage M, Kosmoliaptsis V, Dudley J, Williams A. The UK kidney donor risk index poorly predicts long-term transplant survival in paediatric kidney transplant recipients. Front Immunol 2023; 14:1207145. [PMID: 37334377 PMCID: PMC10275486 DOI: 10.3389/fimmu.2023.1207145] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 05/16/2023] [Indexed: 06/20/2023] Open
Abstract
Background The UK kidney offering scheme introduced a kidney donor risk index (UK-KDRI) to improve the utility of deceased-donor kidney allocations. The UK-KDRI was derived using adult donor and recipient data. We assessed this in a paediatric cohort from the UK transplant registry. Methods We performed Cox survival analysis on first kidney-only deceased brain-dead transplants in paediatric (<18 years) recipients from 2000-2014. The primary outcome was death-censored allograft survival >30 days post-transplant. The main study variable was UK-KDRI derived from seven donor risk-factors, categorised into four groups (D1-low risk, D2, D3 and D4-highest risk). Follow-up ended on 31-December-2021. Results 319/908 patients experienced transplant loss with rejection as the main cause (55%). The majority of paediatric patients received donors from D1 donors (64%). There was an increase in D2-4 donors during the study period, whilst the level of HLA mismatching improved. The KDRI was not associated with allograft failure. In multi-variate analysis, increasing recipient age [adjusted HR and 95%CI: 1.05(1.03-1.08) per-year, p<0.001], recipient minority ethnic group [1.28(1.01-1.63), p<0.05), dialysis before transplant [1.38(1.04-1.81), p<0.005], donor height [0.99 (0.98-1.00) per centimetre, p<0.05] and level of HLA mismatch [Level 3: 1.92(1.19-3.11); Level 4: 2.40(1.26-4.58) versus Level 1, p<0.01] were associated with worse outcomes. Patients with Level 1 and 2 HLA mismatches (0 DR +0/1 B mismatch) had median graft survival >17 years regardless of UK-KDRI groups. Increasing donor age was marginally associated with worse allograft survival [1.01 (1.00-1.01) per year, p=0.05]. Summary Adult donor risk scores were not associated with long-term allograft survival in paediatric patients. The level of HLA mismatch had the most profound effect on survival. Risk models based on adult data alone may not have the same validity for paediatric patients and therefore all age-groups should be included in future risk prediction models.
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Affiliation(s)
- Jon Jin Kim
- Department of Surgery, University of Cambridge, Cambridge, United Kingdom
- Department of Paediatric Nephrology, Nottingham University Hospitals, Nottingham, United Kingdom
| | - Rebecca M. K. Curtis
- Statistics and Clinical Research, NHS Blood and Transplant, Bristol, United Kingdom
| | - Ben Reynolds
- Department of Paediatric Nephrology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Stephen D. Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
- NIHR Great Ormond Street Hospital Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Martin Drage
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Vasilis Kosmoliaptsis
- Department of Surgery, University of Cambridge, Cambridge, United Kingdom
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, University of Cambridge, Cambridge, United Kingdom
| | - Jan Dudley
- Department of Paediatric Nephrology, Bristol Children’s Hospital, Bristol, United Kingdom
| | - Alun Williams
- Department of Paediatric Nephrology, Nottingham University Hospitals, Nottingham, United Kingdom
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6
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Ettenger R, Venick RS, Gritsch HA, Alejos JC, Weng PL, Srivastava R, Pearl M. Deceased donor organ allocation in pediatric transplantation: A historical narrative. Pediatr Transplant 2023; 27 Suppl 1:e14248. [PMID: 36468338 DOI: 10.1111/petr.14248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Since the earliest clinical successes in solid organ transplantation, the proper method of organ allocation for children has been a contentious subject. Over the past 30-35 years, the medical and social establishments of various countries have favored some degree of preference for children on the respective waiting lists. However, the specific policies to accomplish this have varied widely and changed frequently between organ type and country. METHODS Organ allocation policies over time were examined. This review traces the reasons behind and the measures/principles put in place to promote early deceased donor transplantation in children. RESULTS Preferred allocation in children has been approached in a variety of ways and with varying degrees of commitment in different solid organ transplant disciplines and national medical systems. CONCLUSION The success of policies to advantage children has varied significantly by both organ and medical system. Further work is needed to optimize allocation strategies for pediatric candidates.
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Affiliation(s)
- Robert Ettenger
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Robert S Venick
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Hans A Gritsch
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Juan C Alejos
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Patricia L Weng
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Rachana Srivastava
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Meghan Pearl
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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7
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Leal R, Pardinhas C, Martinho A, Sá HO, Figueiredo A, Alves R. Strategies to Overcome HLA Sensitization and Improve Access to Retransplantation after Kidney Graft Loss. J Clin Med 2022; 11:5753. [PMID: 36233621 PMCID: PMC9572793 DOI: 10.3390/jcm11195753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 09/24/2022] [Accepted: 09/26/2022] [Indexed: 12/12/2022] Open
Abstract
An increasing number of patients waitlisted for kidney transplantation have a previously failed graft. Retransplantation provides a significant improvement in morbidity, mortality, and quality of life when compared to dialysis. However, HLA sensitization is a major barrier to kidney retransplantation and the majority of the highly sensitized patients are waiting for a subsequent kidney transplant. A multidisciplinary team that includes immunogeneticists, transplant nephrologists and surgeons, and adequate allocation policies is fundamental to increase access to a kidney retransplant. A review of Pubmed, ScienceDirect, and the Cochrane Library was performed on the challenges of kidney retransplantation after graft loss, focusing on the HLA barrier and new strategies to overcome sensitization. Conclusion: Technical advances in immunogenetics, new desensitization protocols, and complex allocation programs have emerged in recent years to provide a new hope to kidney recipients with a previously failed graft.
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Affiliation(s)
- Rita Leal
- Nephrology Department, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
| | - Clara Pardinhas
- Nephrology Department, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
| | - António Martinho
- Coimbra Histocompatibility Center, Portuguese Institute of Blood and Transplantation, 3041-861 Coimbra, Portugal
| | - Helena Oliveira Sá
- Nephrology Department, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
| | - Arnaldo Figueiredo
- Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
- Urology and Kidney Transplantation Unit, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
| | - Rui Alves
- Nephrology Department, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
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8
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Time to Move on: HLA Matching Should Be Reconsidered in Modern Deceased Donor Kidney Allocation. Transplant Direct 2022; 8:e1295. [PMID: 35368986 PMCID: PMC8966965 DOI: 10.1097/txd.0000000000001295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 12/20/2021] [Indexed: 01/12/2023] Open
Abstract
HLA matching has been the cornerstone of deceased donor kidney allocation policies worldwide but can lead to racial inequity. Although HLA matching has been shown to improve clinical outcomes, the long-term impacts of nonallogenic factors are being increasingly recognized. This has led some transplant programs to include points for nonallogenic factors, for example, age. Our study looks at long-term graft and patient outcomes based on allocation cohorts rather than individual number of HLA mismatches.
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9
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Stewart D. Moving Toward Continuous Organ Distribution. CURRENT TRANSPLANTATION REPORTS 2021. [DOI: 10.1007/s40472-021-00352-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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10
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Peacock S, Briggs D, Barnardo M, Battle R, Brookes P, Callaghan C, Clark B, Collins C, Day S, Diaz Burlinson N, Dunn P, Fernando R, Fuggle S, Harmer A, Kallon D, Keegan D, Key T, Lawson E, Lloyd S, Martin J, McCaughan J, Middleton D, Partheniou F, Poles A, Rees T, Sage D, Santos-Nunez E, Shaw O, Willicombe M, Worthington J. BSHI/BTS guidance on crossmatching before deceased donor kidney transplantation. Int J Immunogenet 2021; 49:22-29. [PMID: 34555264 PMCID: PMC9292213 DOI: 10.1111/iji.12558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/27/2021] [Accepted: 08/31/2021] [Indexed: 12/12/2022]
Abstract
All UK H&I laboratories and transplant units operate under a single national kidney offering policy, but there have been variations in approach regarding when to undertake the pre‐transplant crossmatch test. In order to minimize cold ischaemia times for deceased donor kidney transplantation we sought to find ways to be able to report a crossmatch result as early as possible in the donation process. A panel of experts in transplant surgery, nephrology, specialist nursing in organ donation and H&I (all relevant UK laboratories represented) assessed evidence and opinion concerning five factors that relate to the effectiveness of the crossmatch process, as follows: when the result should be ready for reporting; what level of donor HLA typing is needed; crossmatch sample type and availability; fairness and equity; risks and patient safety. Guidelines aimed at improving practice based on these issues are presented, and we expect that following these will allow H&I laboratories to contribute to reducing CIT in deceased donor kidney transplantation.
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Affiliation(s)
- S Peacock
- Tissue Typing Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - D Briggs
- H&I Laboratory, NHSBT Birmingham Vincent Drive, Birmingham, UK
| | - M Barnardo
- Clinical Transplant Immunology, Churchill Hospital, Oxford, UK
| | - R Battle
- H&I Laboratory, SNBTS, Edinburgh, UK
| | - P Brookes
- H&I Laboratory, Harefield Hospital, Harefield, UK
| | - C Callaghan
- Department of Nephrology and Transplantation, Guy's Hospital, London, UK
| | - B Clark
- H&I Laboratory, Leeds Teaching Hospitals NHS Trust, UK
| | - C Collins
- H&I Laboratory, NHSBT Birmingham Vincent Drive, Birmingham, UK
| | - S Day
- H&I Laboratory, Southmead Hospital, Bristol, UK
| | - N Diaz Burlinson
- Transplantation Laboratory, Manchester Royal Infirmary, Manchester, UK
| | - P Dunn
- Transplant Laboratory, Leicester General Hospital, Leicester, UK
| | - R Fernando
- H&I Laboratory, The Anthony Nolan Laboratories, Royal Free Hospital, UK
| | - S Fuggle
- Organ Donation & Transplantation, NHSBT, Stoke Gifford, Bristol, UK
| | - A Harmer
- H&I Laboratory, NHSBT Barnsley Centre, Barnsley, UK
| | - D Kallon
- H & I Laboratory, Royal London Hospital, London, UK
| | - D Keegan
- Department of H&I, Beaumont Hospital, Dublin, UK
| | - T Key
- H&I Laboratory, NHSBT Barnsley Centre, Barnsley, UK
| | - E Lawson
- Organ Donation and Transplantation, NHSBT, Birmingham, UK
| | - S Lloyd
- Welsh Transplantation & Immunogenetics Laboratory, Cardiff, UK
| | - J Martin
- H&I Laboratory, Belfast Health and Social Care Trust, Belfast, UK
| | - J McCaughan
- H&I Laboratory, Belfast Health and Social Care Trust, Belfast, UK
| | - D Middleton
- H&I Laboratory, Liverpool Foundation Trust, Liverpool, UK
| | - F Partheniou
- H&I Laboratory, Liverpool Foundation Trust, Liverpool, UK
| | - A Poles
- H&I Laboratory, University Hospitals Plymouth, Plymouth, UK.,H&I Laboratory, NHSBT Filton, Bristol, UK
| | - T Rees
- Welsh Transplantation & Immunogenetics Laboratory, Cardiff, UK
| | - D Sage
- H&I Laboratory, NHSBT Tooting Centre, London, UK
| | - E Santos-Nunez
- H&I Laboratory, Imperial College Healthcare NHS Trust, London, UK
| | - O Shaw
- H&I Laboratory, Viapath, Guys & St Thomas, London, UK
| | - M Willicombe
- Department of Immunology and Inflammation, Imperial College London, UK
| | - J Worthington
- Transplantation Laboratory, Manchester Royal Infirmary, Manchester, UK
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11
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Pearson R, Asher J, Jackson A, Mark PB, Shumeyko V, Clancy MJ. Viability assessment and utilization of declined donor kidneys with rhabdomyolysis using ex vivo normothermic perfusion without preimplantation biopsy. Am J Transplant 2021; 21:1317-1321. [PMID: 33021059 DOI: 10.1111/ajt.16329] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/11/2020] [Accepted: 09/14/2020] [Indexed: 01/25/2023]
Abstract
The role of ex vivo normothermic perfusion (EVNP) in both organ viability assessment and reconditioning is increasingly being demonstrated. We report the use of this emerging technology to facilitate the transplantation of a pair of donor kidneys with severe acute kidney injury (AKI) secondary to rhabdomyolysis. Donor creatinine was 10.18 mg/dl with protein (30 mg/dl) present in urinalysis. Both kidneys were declined by all other transplantation units and subsequently accepted by our unit. The first kidney was perfused with red cell-based perfusate at 37°C for 75 min, mean renal blood flow was 110 ml/min/100 g and produced 85 ml of urine. Having demonstrated favorable macroscopic appearance and urine output, the kidney was transplanted into a 61-year-old peritoneal dialysis dependent without complication. Given the reassuring information from the first kidney provided by EVNP, the second kidney was not perfused with EVNP and was directly implanted to a 64-year-old patient. The first kidney achieved primary function and the second functioned well after delayed graft function. Recipient eGFR have stabilized at 88.5 and 55.3, respectively (ml/min/1.73 m2 ), at 2 months posttransplant.
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Affiliation(s)
| | - John Asher
- Queen Elizabeth University Hospital, Glasgow, UK
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12
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Agarwal N, Ashlagi I, Rees M, Somaini P, Waldinger D. Equilibrium Allocations under Alternative Waitlist Designs: Evidence from Deceased Donor Kidneys Kidneys. ECONOMETRICA : JOURNAL OF THE ECONOMETRIC SOCIETY 2021; 89:37-76. [PMID: 34294944 PMCID: PMC8294653 DOI: 10.3982/ecta17017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Waitlists are often used to ration scarce resources, but the trade-offs in designing these mechanisms depend on agents' preferences. We study equilibrium allocations under alternative designs for the deceased donor kidney waitlist. We model the decision to accept an organ or wait for a preferable one as an optimal stopping problem and estimate preferences using administrative data from the New York City area. Our estimates show that while some kidney types are desirable for all patients, there is substantial match-specific heterogeneity in values. We then develop methods to evaluate alternative mechanisms, comparing their effects on patient welfare to an equivalent change in donor supply. Past reforms to the kidney waitlist primarily resulted in redistribution, with similar welfare and organ discard rates to the benchmark first come first served mechanism. These mechanisms and other commonly studied theoretical benchmarks remain far from optimal. We design a mechanism that increases patient welfare by the equivalent of an 18.2 percent increase in donor supply.
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Affiliation(s)
- Nikhil Agarwal
- Agarwal: Department of Economics, MIT and NBER. Ashlagi: Management Science and Engineering, Stanford University. Rees: Department of Urology, University of Toledo Medical Center. Somaini: Stanford Graduate School of Business and NBER. Waldinger: Department of Economics, New York University
| | - Itai Ashlagi
- Agarwal: Department of Economics, MIT and NBER. Ashlagi: Management Science and Engineering, Stanford University. Rees: Department of Urology, University of Toledo Medical Center. Somaini: Stanford Graduate School of Business and NBER. Waldinger: Department of Economics, New York University
| | - Michael Rees
- Agarwal: Department of Economics, MIT and NBER. Ashlagi: Management Science and Engineering, Stanford University. Rees: Department of Urology, University of Toledo Medical Center. Somaini: Stanford Graduate School of Business and NBER. Waldinger: Department of Economics, New York University
| | - Paulo Somaini
- Agarwal: Department of Economics, MIT and NBER. Ashlagi: Management Science and Engineering, Stanford University. Rees: Department of Urology, University of Toledo Medical Center. Somaini: Stanford Graduate School of Business and NBER. Waldinger: Department of Economics, New York University
| | - Daniel Waldinger
- Agarwal: Department of Economics, MIT and NBER. Ashlagi: Management Science and Engineering, Stanford University. Rees: Department of Urology, University of Toledo Medical Center. Somaini: Stanford Graduate School of Business and NBER. Waldinger: Department of Economics, New York University
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