The effect of altering eligibility criteria for entry onto a kidney transplant waiting list

Trends in Patient Characteristics on the Japanese Waiting Lists for Deceased-Donor Kidney Transplantation. Are There no Eligibility or Ineligibility Criteria for Registration and Renewal?

BACKGROUND

Controversial issues in registering candidates for deceased-donor kidney transplantation (DDKT) comprise various factors, including age, life expectancy, and dialysis duration. We investigated patient characteristics on the waiting list and discussed suitable criteria in Japan, which has a long waiting period.

METHODS

This study included 592 patients on the waiting list for DDKT at our institute between 1982 and 2023. We retrospectively reviewed patients' medical charts and obtained their clinical information. Patient characteristics according to outcomes and eligibility criteria for applying for or renewing registration were investigated. No prisoners were used in the study, and the participants were neither coerced nor paid.

RESULTS

Approximately 70%, 45%, and 14.5% of the registered patients were aged >60, >70, and 80 years, respectively. The number of patients aged ≥70 years gradually decreased over time. The median waiting periods of patients who underwent and interrupted DDKT were 13 and 7 years, respectively. Patients in their 70s with a >15-year dialysis period tended to have opportunities for DDKT. Living-donor kidney transplantation was performed in patients aged <60 years. Waiting patients were significantly younger and had a shorter dialysis duration. Advanced age at registration was associated with a significantly high risk of interruption.

CONCLUSIONS

Advanced age and longer dialysis periods were considered at registration because patients with these factors tended to experience interruptions despite the long waiting period and high cost. Although older patients can undergo DDKT, factors including surgical cost and risks are considered. Eligibility/ineligibility criteria should be established for DDKT waiting lists in Japan.

Kidney allocation rules simulator

The greatest challenge of any kidney transplant program lies in finding enough organ donors (in number and quality) for all waitlisted transplant candidates. Unfortunately, we must resign ourselves to a manifestly insufficient supply of organs for the current demand. Furthermore we must be able to predict kidney transplant success at organ allocation if we want to minimize the number of patients who return to an already overcrowded waiting list for transplantation. Therefore, the definition of deceased donors' kidney allocation rules on transplantation must be supported by simulations that allow foreseeing, as much as possible, the consequences of these rules. Here we present the Kidney Allocation Rules Simulator (KARS) application that enables testing different kidney transplant allocation' systems with different donors and transplant candidates' datasets. In this application, it is possible to simulate allocation rules implemented in Portugal, in the United Kingdom, in countries within Eurtotransplant, and a previously suggested color priority system. As inputs, this application needs three data files: a file with transplant candidates' information, a file with candidates' anti-HLA antibodies, and a file with donors' information. As output, we will have a file with donor-recipient pairs selected according to the kidney allocation system simulated. When seeking waste reduction while ensuring a fair distribution of organs from deceased donors, the definition of rules selecting donor-recipient pairs in renal transplantation must be based on evidence supported by data. On the continuously changing process for a better distribution of an increasingly scarce resource must, we must be able to predict transplant outcomes when defining the best allocation rules.

Clinical practice guidelines on wait-listing for kidney transplantation: consistent and equitable?

BACKGROUND

Apparent variability in wait-listing criteria globally has raised concern about inequitable access to kidney transplantation. This study aimed to compare the quality, the scope, and the consistency of international guidelines on wait-listing for kidney transplantation.

METHODS

Electronic databases and guideline registries were searched to December 2011. The Appraisal of Guidelines for Research and Evaluation II instrument and textual synthesis was used to assess and compare recommendations.

RESULTS

Fifteen guidelines published from 2001 to 2011 were included. Methodological rigor and scope were variable. We identified 4 major criteria across guidelines: recipient age and life expectancy, medical criteria, social and lifestyle circumstances, and psychosocial considerations. Whereas some recommendations were consistent, there were differences in age cutoffs, estimated life expectancy (2-5 years), and glomerular filtration rate at listing (15-20 mL/min/1.73 m). Cardiovascular contraindications were broadly defined. Recommended cancer-free periods also varied substantially, and whereas uncontrolled infections were universally contraindicated, human immunodeficiency virus thresholds and adherence to highly active antiretroviral therapy were inconsistent. Most guidelines recommended psychological screening but were not augmented with specific clinical assessment tools.

CONCLUSIONS

Wait-listing recommendations in current guidelines are based on life expectancy, comorbidities, lifestyle, and psychosocial factors. Some recommendations are different across guidelines or broadly defined. There is a case for developing comprehensive, methodologically robust, and regularly updated guidelines on wait-listing for kidney transplantation.

Pretransplant physical functioning and kidney patients' risk for posttransplantation hospitalization/death: evidence from a national cohort

Patient physical functioning level is an indicator of medical fitness that may predict outcomes after kidney transplantation. A small study of patients at a single center found a correlation between patient-rated physical functioning pretransplantation and the number of emergency hospital visits posttransplantation. In a national multicenter cohort, the association of incident dialysis patients' physical functioning scores with their risk for posttransplantation all-cause hospitalization/death was investigated using Cox proportional hazards analysis. The study cohort included patients who participated in the Dialysis Morbidity and Mortality Study (DMMS) Wave 2 and received a first transplant no more than 24 mo after treatment start. Updated patient information was available in the 2004 United States Renal Data System Standard Analysis Files. Higher pretransplantation physical functioning score was found to be a significant predictor of transplant recipients' reduced risk for hospitalization/death. Patients in the Cox model who were aged 55+ had increased risk for hospitalization/death. Gender, race, diabetic ESRD, and cardiovascular comorbidity were NS predictors. A potential explanation for the ability of the Medical Outcomes Study Short-Form 36 physical functioning measure to predict risk for posttransplantation morbidity/mortality is that physical activity/exercise behavior is likely to be closely associated with an individual's physical functioning level, and pretransplantation activity levels may be indicative of lifestyle habits that continue to influence patient behavior posttransplantation. More research investigating patients' pre- and posttransplantation physical functioning levels in relation to transplant outcomes would be valuable.

Efficacy of an educational programme for secondary school students on opinions on renal transplantation and organ donation: a randomized controlled trial

CONTEXT

Organ shortage for transplantation is a crucial problem; educational interventions may increase donations and decrease opposition.

OBJECTIVE

To test the efficacy of an educational programme on opinions on organ transplantation and kidney donation.

DESIGN AND PARTICIPANTS

Cluster Randomized Controlled Trial: eight intervention and eight control schools were randomly selected from the 33 public schools that agreed to participate. Targets: students in the last 2 years of secondary school (17-18 years); seven schools per group completed the study. EDUCATIONAL PROGRAMME:

INTERVENTION

first questionnaire (anonymous); 2 h lesson in each class; 2 h general session with patients and experts; second questionnaire.

CONTROL

questionnaires.

MAIN OUTCOME MEASURES

Differences between questionnaires (comparative analysis); interest; satisfaction with the programme; (cross-sectional analysis).

RESULTS

1776 first, 1467 second questionnaires were retrieved. Living kidney donation: at baseline 78.8% of students would donate a kidney to a relative/friend in need. The answers were unaffected by type of school but depended on sex (females more prone to donate, P<0.001); the answers did not change after the lessons. Cadaveric kidney donation: baseline opinions were mixed (intervention schools: 31.5% yes, 33.7% no, 34.8% uncertain), depending on type of school (classical-scientific high schools more positive than technical institutes, P<0.001), sex (males more prone to donate, P<0.001). Answers on living and cadaveric donation were correlated (P<0.001). The educational intervention increased favourable (31.5 to 42.9%) and uncertain (34.8 to 41.1%) opinions and decreased negative ones (33.7 to 16%) (P<0.001).

CONCLUSIONS

Educational interventions are effective in increasing interest and improving opinions about cadaveric organ donation.

The heart-allocation simulation model: a tool for comparison of transplantation allocation policies1

BACKGROUND

Numerous studies have investigated prognostic factors for the survival of transplant candidates waiting for a donor organ, but little is known about the impact of allocation policies on waiting list outcome. Simulation models would allow a comparison of different policies for allocating donor hearts on pretransplant outcome.

METHODS

A model was built for the Eurotransplant waiting list for heart transplantation. Survival and delisting distributions were estimated from the Eurotransplant transplant candidate inflow between 1995 and 2000 (n=7,142). Other characteristics were obtained directly from the transplant candidate inflow of 1999 and 2000 (n=2,097) and the donor organs of 1998 and 1999 (n=1,520). Overall and subgroup waiting list mortality were estimated for allocation policies differing by ABO blood group, border, and clinical profile rules.

RESULTS

The model estimated that international organ exchange reduces waiting list mortality in the different countries by 1.9% to 12.4%. An allocation policy incorporating the initial clinical profile of the transplant candidates further reduced waiting list mortality by 1.7%. Changing ABO rules toward identical matching yielded a slightly more equitable survival for the different groups, without an overall effect on mortality. The best possible allocation policy is the policy where organs are allocated to patients that are at highest risk of dying, and withholding organs from patients that would eventually delist because of improvement.

CONCLUSIONS

Patients benefit from international organ exchange and by a heart allocation scheme based on clinical profiles. Timely delisting of patients who are-temporarily-too well for transplantation is the best waiting list policy.

Impact of nephrology referral on early and midterm outcomes in ESRD: EPidémiologie de l'Insuffisance REnale chronique terminale en Lorraine (EPIREL): results of a 2-year, prospective, community-based study

BACKGROUND

Most studies looking at how the outcome of end-stage renal disease (ESRD) is affected by the timing and quality of the care received before initiation of renal replacement therapy (RRT) are inconclusive.

METHODS

Five hundred and two adult French patients (age, 62.8 +/- 16 years) receiving their first RRT were enrolled in a 2-year, community-based, prospective study. Subjects were assigned to 1 of 5 groups depending on the time between their first serum creatinine reading above 2 mg/dL (177 micromol/L): chronic renal failure (CRF) and nephrology referral (NR) and RRT. Multivariate logistic regression was used to analyze 90-day survival data, and data concerning long-term survival and inclusion on the waiting list for renal transplantation were analyzed using Cox proportional hazards regression.

RESULTS

Overall survival rates were 88% at 90 days, 77.2% at 1 year, 65.2% at 2 years, and 54.2% at 3 years. The nephrology referral pattern was associated with age and systolic blood pressure, and independently predicted early death. Compared with group 1 (NR > 12 months), odds ratios (confidence interval 95%) were 2.7 (1.2 to 6.3) for group 2 (NR < or = 12 months or >4 months), 2.8 (1.0 to 8.0) for group 3 (NR < or = 4 months or >1 month), 4.9 (2.2 to 11.0) for group 4 (NR < or = 1 month; CRF > 1 month), and 5.2 (2.2 to 12.3) for group 5 (NR < or = 1 month; CRF < or = 1 month). Independent predictors of death in 90-day survivors were age, cardiac disease with previous episodes of heart failure, vascular disease, low diastolic blood pressure, and group 3 referral pattern. Not being entered on the waiting list for renal transplantation was predicted by age, diabetes, vascular disease, and nonelective first dialysis.

CONCLUSION

Late nephrology referral is strongly associated with early death. Emergency first dialysis is an independent risk factor for not being placed on the waiting list for transplantation. Among 90-day survivors, referral pattern has little influence on mortality, which is mainly determined by cardiovascular complications at initiation of RRT.

Subjective and quantitative assessment of patient fitness for cadaveric kidney transplantation: the "equity penalty"

BACKGROUND

Patient fitness at the time of organ allocation has an impact on graft survival equivalent to the effect of human leukocyte antigen (HLA) matching. The variation between institutions in assessment of fitness is not known, nor is the potential impact on mean graft survival of incorporating patient fitness into local adult cadaveric-kidney transplant-allocation algorithms.

METHODS

Data from the Collaborative Transplant Study (CTS, 1985-2000) were reviewed. Quantitative criteria (QC) of patient fitness based on national transplant society guidelines were compared with subjective categorization (SC) of each patient on the current local transplant waiting list (n=109) determined by their supervising nephrologist.

RESULTS

Five-year cadaveric graft survival was 70%, 61%, and 53% for good-, moderate-, and poor-risk patients in the CTS data set (n=102, 612), equivalent to half lives of 12.7, 9.8, and 8.7 years, respectively, with similar results from the local program. The distribution of local waiting-list patients into fitness categories A (good), B (moderate), C (poor), and D (unacceptable) was 51%:31%:13%:5% by SC and 25%:40%:27%:8% by QC. At one hospital, 61% (n=51) of patients were classified category A by SC, and falling to 16% by QC (P<.0001). Compared with preferential category A recipient allocation, an unrestricted allocation policy was estimated to sacrifice 1.5 years of overall program-mean graft survival.

CONCLUSIONS

Use of QC may reduce the variation in subjective patient assessment seen between institutions. Any proposed changes in organ allocation methods should address the "equity versus efficiency" balance in an open fashion and predict the impact on the overall graft survival for the program by quantifying the "equity penalty."