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Wisel SA, Borja-Cacho D, Megna D, Adjei M, Kim IK, Steggerda JA. Organ Utilization Rates from Non-Ideal Donors for Solid Organ Transplant in the United States. J Clin Med 2024; 13:3271. [PMID: 38892982 PMCID: PMC11172619 DOI: 10.3390/jcm13113271] [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: 04/03/2024] [Revised: 05/16/2024] [Accepted: 05/25/2024] [Indexed: 06/21/2024] Open
Abstract
Background: Non-ideal donors provide acceptable allografts and may expand the donor pool. This study evaluates donor utilization across solid organs over 15-years in the United States. Methods: We analyzed the OPTN STAR database to identify potential donors across three donor eras: 2005-2009, 2010-2014, and 2015-2019. Donors were analyzed by a composite Donor Utilization Score (DUS), comprised of donor age and comorbidities. Outcomes of interest were overall and organ-specific donor utilization. Descriptive analyses and multivariable logistic regression modeling were performed. p-values < 0.01 considered significant. Results: Of 132,465 donors, 32,710 (24.7%) were identified as non-ideal donors (NID), based on a DUS ≥ 3. Compared to ideal donors (ID), NID were older (median 56 years, IQR 51-64 years vs. 35 years, 22-48 years, p < 0.001) and more frequently female (44.3% vs. 39.1%, p < 0.001), Black (22.1% vs. 14.6%, p < 0.001) and obese (60.7% vs. 19.6%, p < 0.001). The likelihood of overall DBD utilization from NID increased from Era 1 to Era 2 (OR 1.227, 95% CI 1.123-1.341, p < 0.001) and Era 3 (OR 1.504, 1.376-1.643, p < 0.001), while DCD donor utilization in NID was not statistically different across Eras. Compared to Era 1, the likelihood of DBD utilization from NID for kidney transplantation was lower in Era 2 (OR 0.882, 0.822-0.946) and Era 3 (OR 0.938, 0.876-1.004, p = 0.002). The likelihood of NID utilization increased in Era 3 compared to Era 1 for livers (OR 1.511, 1.411-1.618, p < 0.001), hearts (OR 1.623, 1.415-1.862, p < 0.001), and lungs (OR 2.251, 2.011-2.520, p < 0.001). Conclusions: Using a universal definition of NID across organs, NID donor utilization is increasing; however, use of DUS may improve resource utilization in identifying donors at highest likelihood for multi-organ donation.
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Affiliation(s)
- Steven A. Wisel
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (S.A.W.); (M.A.); (I.K.K.)
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Daniel Borja-Cacho
- Division of Transplant Surgery, Department of Surgery, Northwestern Memorial Hospital, Chicago, IL 60611, USA
| | - Dominick Megna
- Division of Cardiothoracic Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Michie Adjei
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (S.A.W.); (M.A.); (I.K.K.)
| | - Irene K. Kim
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (S.A.W.); (M.A.); (I.K.K.)
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Justin A. Steggerda
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (S.A.W.); (M.A.); (I.K.K.)
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
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2
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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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3
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Bhattarai D, Lee SO, Joshi N, Jun SR, Lo S, Jiang L, Gokden N, Parajuli N. Cold Storage Followed by Transplantation Induces Immunoproteasome in Rat Kidney Allografts: Inhibition of Immunoproteasome Does Not Improve Function. KIDNEY360 2024; 5:743-752. [PMID: 38303110 PMCID: PMC11146655 DOI: 10.34067/kid.0000000000000368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 01/12/2024] [Indexed: 02/03/2024]
Abstract
Key Points Cold storage (CS) increases the severity of graft dysfunction in a time-dependent manner, and prolonged CS decreases animal survival. CS plus transplant increases iproeasome levels/assembly in renal allografts; IFN-γ is a potential inducer of the iproteasome. Inhibiting iproteasome ex vivo during renal CS did not confer graft protection after transplantation. Background It is a major clinical challenge to ensure the long-term function of transplanted kidneys. Specifically, the injury associated with cold storage (CS) of kidneys compromises the long-term function of the grafts after transplantation. Therefore, the molecular mechanisms underlying CS-related kidney injury are attractive therapeutic targets to prevent injury and improve long-term graft function. Previously, we found that constitutive proteasome function was compromised in rat kidneys after CS followed by transplantation. Here, we evaluated the role of the immunoproteasome (i proteasome), a proteasome variant, during CS followed by transplantation. Methods Established in vivo rat kidney transplant model with or without CS containing vehicle or iproteasome inhibitor (ONX 0914) was used in this study. The i proteasome function was performed using rat kidney homogenates and fluorescent-based peptide substrate specific to β 5i subunit. Western blotting and quantitative RT-PCR were used to assess the subunit expression/level of the i proteasome (β 5i) subunit. Results We demonstrated a decrease in the abundance of the β 5i subunit of the i proteasome in kidneys during CS, but β 5i levels increased in kidneys after CS and transplant. Despite the increase in β 5i levels and its peptidase activity within kidneys, inhibiting β 5i during CS did not improve graft function after transplantation. Summary These results suggest that the pharmacologic inhibition of immunoproteasome function during CS does not improve graft function or outcome. In light of these findings, future studies targeting immunoproteasomes during both CS and transplantation may define the role of immunoproteasomes on short-term and long-term kidney transplant outcomes.
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Affiliation(s)
- Dinesh Bhattarai
- Department of Pharmacology and Toxicology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Seong-Ok Lee
- Department of Pharmacology and Toxicology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Neelam Joshi
- Department of Pharmacology and Toxicology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Se-Ran Jun
- Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Sorena Lo
- Department of Pharmacology and Toxicology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Li Jiang
- Department of Pharmacology and Toxicology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Neriman Gokden
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Nirmala Parajuli
- Department of Pharmacology and Toxicology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
- Division of Nephrology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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4
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McCracken EK, Jay CL, Garner M, Webb C, Farney AC, Orlando G, Reeves-Daniel A, Mena-Gutierrez A, Sakhovskaya N, Stratta RJ. The Kidney Not Taken: Single-Kidney Use in Deceased Donors. J Am Coll Surg 2024; 238:492-504. [PMID: 38224100 DOI: 10.1097/xcs.0000000000000968] [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: 01/16/2024]
Abstract
BACKGROUND The nonuse rate for kidneys recovered from deceased donors is increasing, rising to 27% in 2023. In 10% of these cases, 1 kidney is transplanted but the mate kidney is not. STUDY DESIGN We conducted a retrospective, single-center cohort study from December 2001 to May 2023 comparing single kidneys transplanted at our center (where the contralateral kidney was not used) to kidneys where both were transplanted separately, at least 1 of which was at our center. RESULTS We performed 395 single deceased-donor kidney transplants in which the mate kidney was not transplanted. Primary reasons for mate kidney nonuse were as follows: no recipient located or list exhausted (33.4%), kidney trauma or injury or anatomic abnormalities (18.7%), biopsy findings (16.7%), and poor renal function (13.7%). Mean donor and recipient ages were 51.5 ± 14.2 and 60 ± 12.6 years, respectively. Mean kidney donor profile index was 73% ± 22%, and 104 donors (26.3%) had kidney donor profile index >85%. Mean cold ischemia was 25.6 ± 7.4 hours, and 280 kidneys (70.7%) were imported. Compared with 2,303 concurrent control transplants performed at our center, primary nonfunction or thrombosis (5.1% single vs 2.8% control) and delayed graft function (35.4% single vs 30.1% control) were greater with single-kidney use (both p < 0.05). Median patient and death-censored graft survival were shorter in the single group (11.6 vs 13.5 years, p = 0.03 and 11.6 vs 19 years, p = 0.003), although the former was at least double median survival on the waiting list. In patients with functioning grafts in the single-kidney group, 1-year mean serum creatinine was 1.77 ± 0.8 mg/dL and estimated glomerular filtration rate was 44.8 ± 20 mL/min/1.73 m 2 . CONCLUSIONS These findings suggest that many mate kidneys are being inappropriately rejected, given the acceptable outcomes that can be achieved by transplanting the single kidney in appropriately selected recipients.
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Affiliation(s)
- Emily Ke McCracken
- From the Department of Surgery, Section of Transplantation (McCracken, Jay, Garner, Webb, Farney, Orlando, Stratta)
| | - Colleen L Jay
- From the Department of Surgery, Section of Transplantation (McCracken, Jay, Garner, Webb, Farney, Orlando, Stratta)
| | - Matthew Garner
- From the Department of Surgery, Section of Transplantation (McCracken, Jay, Garner, Webb, Farney, Orlando, Stratta)
| | - Christopher Webb
- From the Department of Surgery, Section of Transplantation (McCracken, Jay, Garner, Webb, Farney, Orlando, Stratta)
| | - Alan C Farney
- From the Department of Surgery, Section of Transplantation (McCracken, Jay, Garner, Webb, Farney, Orlando, Stratta)
| | - Giuseppe Orlando
- From the Department of Surgery, Section of Transplantation (McCracken, Jay, Garner, Webb, Farney, Orlando, Stratta)
| | - Amber Reeves-Daniel
- Department of Internal Medicine, Section of Nephrology (Reeves-Daniel, Mena-Gutierrez, Sakhovskaya), Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Alejandra Mena-Gutierrez
- Department of Internal Medicine, Section of Nephrology (Reeves-Daniel, Mena-Gutierrez, Sakhovskaya), Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Natalia Sakhovskaya
- Department of Internal Medicine, Section of Nephrology (Reeves-Daniel, Mena-Gutierrez, Sakhovskaya), Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Robert J Stratta
- From the Department of Surgery, Section of Transplantation (McCracken, Jay, Garner, Webb, Farney, Orlando, Stratta)
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5
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Cruz Mususú W, García-Lopez A, Lozano-Suarez N, Gómez-Montero A, Orellano-Salas M, Vargas-Pérez L, Escobar-Chaves X, Girón-Luque F. Understanding the dynamics of deceased organ donation and utilization in Colombia. Rev Panam Salud Publica 2024; 48:e24. [PMID: 38464873 PMCID: PMC10921909 DOI: 10.26633/rpsp.2024.24] [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] [Received: 11/01/2023] [Accepted: 12/19/2023] [Indexed: 03/12/2024] Open
Abstract
Objective To obtain a comprehensive overview of organ donation, organ utilization, and discard in the entire donation process in Colombia. Methods A retrospective study of 1 451 possible donors, distributed in three regions of Colombia, evaluated in 2022. The general characteristics, diagnosis, and causes of contraindication for potential donors were described. Results Among the 1 451 possible donors, 441 (30.4%) fulfilled brain death criteria, constituting the potential donor pool. Families consented to organ donation in 141 medically suitable cases, while 60 instances utilized legal presumption, leading to 201 eligible donors (13.9%). Of those, 160 (11.0%) were actual donors (in whom operative incision was made with the intent of organ recovery or who had at least one organ recovered). Finally, we identified 147 utilized donors (10.1%) (from whom at least one organ was transplanted). Statistically significant differences were found between age, sex, diagnosis of brain death, and donor critical pathway between regions. A total of 411 organs were transplanted from 147 utilized donors, with kidneys being the most frequently procured and transplanted organs, accounting for 280 (68.1%) of the total. This was followed by 85 livers (20.7%), 31 hearts (7.5%), 14 lungs (3.4%), and 1 pancreas (0.2%). The discard rate of procured deceased donors was 8.1%. Conclusions About one-tenth of donors are effectively used for transplantation purposes. Our findings highlight areas of success and challenges, providing a basis for future improvements in Colombia.
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Affiliation(s)
| | - Andrea García-Lopez
- Colombiana de TrasplantesBogotáColombiaColombiana de Trasplantes, Bogotá, Colombia
| | | | - Andrea Gómez-Montero
- Colombiana de TrasplantesBogotáColombiaColombiana de Trasplantes, Bogotá, Colombia
| | | | | | | | - Fernando Girón-Luque
- Colombiana de TrasplantesBogotáColombiaColombiana de Trasplantes, Bogotá, Colombia
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6
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Mella A, Calvetti R, Barreca A, Congiu G, Biancone L. Kidney transplants from elderly donors: what we have learned 20 years after the Crystal City consensus criteria meeting. J Nephrol 2024:10.1007/s40620-024-01888-w. [PMID: 38446386 DOI: 10.1007/s40620-024-01888-w] [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: 05/26/2022] [Accepted: 01/03/2024] [Indexed: 03/07/2024]
Abstract
Based on the current projection of the general population and the combined increase in end-stage kidney disease with age, the number of elderly donors and recipients is increasing, raising crucial questions about how to minimize the discard rate of organs from elderly donors and improve graft and patient outcomes. In 2002, extended criteria donors were the focus of a meeting in Crystal City (VA, USA), with a goal of maximizing the use of organs from deceased donors. Since then, extended criteria donors have progressively contributed to a large number of transplanted grafts worldwide, posing specific issues for allocation systems, recipient management, and therapeutic approaches. This review analyzes what we have learned in the last 20 years about extended criteria donor utilization, the promising innovations in immunosuppressive management, and the molecular pathways involved in the aging process, which constitute potential targets for novel therapies.
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Affiliation(s)
- Alberto Mella
- Renal Transplant Center" A. Vercellone," Nephrology, Dialysis, and Renal Transplant Division, "Città Della Salute e Della Scienza" Hospital, Department of Medical Sciences, University of Turin, Corso Bramante, 88, 10126, Turin, Italy
| | - Ruggero Calvetti
- Renal Transplant Center" A. Vercellone," Nephrology, Dialysis, and Renal Transplant Division, "Città Della Salute e Della Scienza" Hospital, Department of Medical Sciences, University of Turin, Corso Bramante, 88, 10126, Turin, Italy
| | - Antonella Barreca
- Division of Pathology, "Città Della Salute e Della Scienza" Hospital, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Giovanni Congiu
- Renal Transplant Center" A. Vercellone," Nephrology, Dialysis, and Renal Transplant Division, "Città Della Salute e Della Scienza" Hospital, Department of Medical Sciences, University of Turin, Corso Bramante, 88, 10126, Turin, Italy
| | - Luigi Biancone
- Renal Transplant Center" A. Vercellone," Nephrology, Dialysis, and Renal Transplant Division, "Città Della Salute e Della Scienza" Hospital, Department of Medical Sciences, University of Turin, Corso Bramante, 88, 10126, Turin, Italy.
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7
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Pruett TL, Martin P, Gupta D. Outcomes of kidneys used for transplantation: an analysis of survival and function. FRONTIERS IN TRANSPLANTATION 2024; 3:1335999. [PMID: 38993770 PMCID: PMC11235350 DOI: 10.3389/frtra.2024.1335999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/19/2024] [Indexed: 07/13/2024]
Abstract
Introduction Kidney transplant recipients expect to survive the procedure with sufficient renal function for reliable dialysis freedom. Methods Transplant outcomes (survival and estimated renal function) were assessed after live and deceased donor transplantation from the US national database. Outcomes were stratified by age (donor and recipient) and donor type. Results Aggregate recipient outcomes were better transplanting living vs deceased donated kidneys. However, when stratified by the one-year renal function (within KDIGO CKD stage stratifications), surviving recipients had clinically similar dialysis-freedom, irrespective of donor type or age. The major outcome differences for recipients of age-stratified live and deceased kidneys was 1) the increasing frequency of one-year graft failures and 2) the increasing likelihood of severely limited renal function (CKD 4/5) with advancing donor age. Over 30% of recipients of deceased kidneys >65 years had either one-year graft failure or severely limited renal function contrasted to less than 15% of recipients of live kidneys aged >65 years. Conclusions Evolving techniques to reduce adverse events after urgent vs elective procedures, plus improved transplant outcome predictability with increased-age deceased donor kidneys using advanced predictive analytics (using age-stratified live kidney transplantation outcomes as a relevant reference point) should facilitate similar kidney transplant outcomes, irrespective of donor type.
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Affiliation(s)
- Timothy L. Pruett
- Division of Transplantation, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Paola Martin
- ODT, Kelley School of Business, Indiana University, Bloomington, IN, United States
| | - Diwakar Gupta
- IROM, The McCombs School of Business at University of Texas (Austin), Austin, TX, United States
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8
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Munjal RS, Munjal J, Dhillon G, Buddhavarapu VS, Grewal H, Sharma P, Verma RK, Lee R, Kashyap R. Dialyzing a Brain-Dead Individual for Organ Procurement. Cureus 2024; 16:e56960. [PMID: 38665738 PMCID: PMC11044104 DOI: 10.7759/cureus.56960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
Many patients are unable to receive organ transplantation as there is an expanding gap between the number of patients waiting for an organ and the number who receive it. Organ procurement from the brain-dead can address this expanding gap, especially because one brain-dead patient can potentially donate multiple organs to several recipients. Here, we describe a rare case of a previously healthy 26-year-old male who was declared brain dead after a motor vehicle accident but underwent hemodialysis to treat his acute kidney injury and hyperkalemia before successfully donating his heart and left kidney.
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Affiliation(s)
| | - Jaskaran Munjal
- Internal Medicine, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, IND
| | - Gagandeep Dhillon
- Internal Medicine, University of Maryland Medical Center, Glen Burnie, USA
| | | | - Harpreet Grewal
- Radiology, Florida State University College of Medicine, Pensacola, USA
| | - Pranjal Sharma
- Clinical Research, Global Remote Research Scholars Program, St Paul, USA
- Nephrology, Premier Renal Care Associates, Cuyahoga Falls, USA
- Internal Medicine/Nephrology, Northeast Ohio Medical University, Rootstown, USA
| | - Ram K Verma
- Sleep Medicine, Parkview Health System, Fort Wayne, USA
| | - Ruth Lee
- Nephrology, University of California, Davis, Davis, USA
| | - Rahul Kashyap
- Research, Global Remote Research Scholars Program, St Paul, USA
- Research, WellSpan Health, York, USA
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9
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Kilambi V, Barah M, Formica RN, Friedewald JJ, Mehrotra S. Evaluation of Opening Offers Early for Deceased Donor Kidneys at Risk of Nonutilization. Clin J Am Soc Nephrol 2024; 19:233-240. [PMID: 37943856 PMCID: PMC10861110 DOI: 10.2215/cjn.0000000000000346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 10/30/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Reducing nonutilization of kidneys recovered from deceased donors is a current policy concern for kidney allocation in the United States. The likelihood of nonutilization is greater with a higher kidney donor risk index (KDRI) offer. We examine how opening offers for organs with KDRI >1.75 to the broader waitlist at varying points of time affects usage rates. METHODS We simulate kidney allocation using data for January 2018 to June 2019 from Organ Procurement and Transplantation Network. For the simulation experiment, allocation policy is modified so that KDRI >1.75 organs are offered to all local candidates (same donation service area) after a set amount of cold time simultaneously. Open offers to candidates nationally are similarly examined. RESULTS Simulation results ( n =50 replications) estimate that opening offers locally for KDRI >1.75 after 10 hours yields a nonutilization rate of 38% (range: 35%-42%), less than the prevailing rate of 55% of KDRI >1.75 kidneys. Opening offers after 5 hours yields 30% (range: 26%-34%), reducing the prevailing nonutilization rate by 45%. Opening offers nationally after 10 and 5 hours yields nonutilization rates of 11% (range: 8%-15%) and 6% (range: 4%-9%) for KDRI >1.75 kidneys, respectively. CONCLUSIONS Simulation findings indicate that opening offers and adjusting their timing can significantly reduce nonutilization of high-KDRI kidneys.
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Affiliation(s)
- Vikram Kilambi
- Department of Engineering and Applied Sciences, RAND Corporation, Arlington, Virginia
- RAND Health Care, Access and Delivery Program, RAND Corporation, Arlington, Virginia
| | - Masoud Barah
- Department of Industrial Engineering and Management Sciences, Northwestern University, Evanston, Illinois
| | - Richard N. Formica
- Department of Nephrology, Yale School of Medicine, New Haven, Connecticut
| | - John J. Friedewald
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Nephrology, Department of Medicine, Northwestern University, Chicago, Illinois
- Center for Engineering and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sanjay Mehrotra
- Department of Industrial Engineering and Management Sciences, Northwestern University, Evanston, Illinois
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Nephrology, Department of Medicine, Northwestern University, Chicago, Illinois
- Center for Engineering and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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10
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Scurt FG, Fischer-Fröhlich CL, Wassermann T, Ernst A, Schwarz A, Becker JU, Chatzikyrkou C. Histological and clinical evaluation of discarded kidneys in a European cohort of deceased brain death donor kidneys of marginal quality. J Nephrol 2023; 36:2587-2600. [PMID: 37856068 DOI: 10.1007/s40620-023-01785-8] [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] [Accepted: 09/04/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Despite organ shortages, the discard rate of deceased donor kidneys is high. Risk factors for this trend warrant further study. METHODS We investigated reasons for discard in a cohort of brain death donors with marginal kidneys and procurement biopsies. Paraffin embedded procurement biopsies were systematically reevaluated and graded for the purpose of the study. Assessment included percentage of global glomerulosclerosis, Banff Lesion scores and tubular epithelial damage. Donor-, transplant process-, perfusion quality-, histopathology-, and recipient-related parameters were compared between discarded and transplanted organs. RESULTS Although most clinical characteristics were similar between donors whose kidneys were transplanted and those whose kidneys were procured but discarded, discarded kidneys were more likely to be from donors with hepatitis C, to have undergone wedge biopsies, to show changes of acute and chronic injury and to be deemed poor quality. Except for obvious anatomic abnormalities, kidneys were often discarded due to the findings of procurement biopsies. Donors of kidneys discarded for histologic reasons more often had hypertension, coronary artery disease, stroke, and increased serum creatinine. The reason for discard was unknown in 20% of cases. Discarded kidneys came from donors who appeared to be clinically similar to donors whose kidneys were utilized for transplant. CONCLUSION A considerable proportion of discarded kidneys were of acceptable quality. The analysis of the outcome of every recovered organ could help to overcome this problem. Procurement biopsies more often lead to discard than to transplantation of recovered organs. Proper handling during allocation has to be determined.
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Affiliation(s)
- Florian G Scurt
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, Otto-von Guericke University, Magdeburg, Germany
| | | | - Tamara Wassermann
- Otto-von Guericke University, Magdeburg, Germany
- Department of Nephrology and Hypertension, Hannover Medical School, Carl-Neuberg Str. 1, 30655, Hannover, Germany
| | - Angela Ernst
- Institute of Medical Statistics and Bioinformatics, University of Cologne, Cologne, Germany
| | - Anke Schwarz
- Department of Nephrology and Hypertension, Hannover Medical School, Carl-Neuberg Str. 1, 30655, Hannover, Germany
| | - Jan U Becker
- Institute of Pathology, University Hospital of Cologne, Cologne, Germany
| | - Christos Chatzikyrkou
- Department of Nephrology and Hypertension, Hannover Medical School, Carl-Neuberg Str. 1, 30655, Hannover, Germany.
- Institute of Medical Statistics and Bioinformatics, University of Cologne, Cologne, Germany.
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11
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Schold JD, Huml AM, Husain SA, Poggio ED, Buchalter RB, Lopez R, Kaplan B, Mohan S. Deceased donor kidneys from higher distressed communities are significantly less likely to be utilized for transplantation. Am J Transplant 2023; 23:1723-1732. [PMID: 37001643 DOI: 10.1016/j.ajt.2023.03.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 03/20/2023] [Accepted: 03/22/2023] [Indexed: 03/31/2023]
Abstract
The proportion of kidneys procured for transplantation but not utilized exceeds 20% in the United States. Factors associated with nonutilization are complex, and further understanding of novel causes are critically important. We used the national Scientific Registry of Transplant Recipients data (2010-2022) to evaluate associations of Distressed Community Index (DCI) of deceased donor residence and likelihood of kidney nonutilization (n = 209 413). Deceased donors from higher distressed communities were younger, had an increased history of hypertension and diabetes, were CDC high-risk, and had higher terminal creatinine and donation after brain death. Mechanisms and circumstances of death varied significantly by DCI. The proportion of kidney nonutilization was 19.9%, which increased by DCI quintile (Q1 = 18.1% to Q5 = 21.6%). The adjusted odds ratio of nonutilization from the highest quintile DCI communities was 1.22 (95% CI = 1.16-1.28; reference = lowest DCI), which persisted stratified by donor race. Donors from highly distressed communities were highly variable by the donor service area (range: 1%-51%; median = 21%). There was no increased risk for delayed graft function or death-censored graft loss by donor DCI but modest increased adjusted hazard for overall graft loss (high DCI = 1.05; 95% CI = 1.01-1.10; reference = lowest DCI). Results indicate that donor residential distress is associated with significantly higher rates of donor kidney nonutilization with notable regional variation and minimal impact on recipient outcomes.
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Affiliation(s)
- Jesse D Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Department of Epidemiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
| | - Anne M Huml
- Department of Kidney Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - S Ali Husain
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Emilio D Poggio
- Department of Kidney Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - R Blake Buchalter
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rocio Lopez
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Bruce Kaplan
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sumit Mohan
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA; Department of Epidemiology, Columbia University, New York, New York, USA
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12
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Webb CJ, McCracken E, Jay CL, Sharda B, Garner M, Farney AC, Orlando G, Reeves-Daniel A, Mena-Gutierrez A, Sakhovskaya N, Stratta B, Stratta RJ. Single center experience and literature review of kidney transplantation from non-ideal donors with acute kidney injury: Risk and reward. Clin Transplant 2023; 37:e15115. [PMID: 37646473 DOI: 10.1111/ctr.15115] [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: 06/13/2023] [Revised: 08/18/2023] [Accepted: 08/22/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION There is limited experience transplanting kidneys from either expanded criteria donors (ECD) or donation after circulatory death (DCD) deceased donors with terminal acute kidney injury (AKI). METHODS AKI kidneys were defined by a donor terminal serum creatinine level >2.0 mg/dL whereas non-ideal deceased donor (NIDD) kidneys were defined as AKI/DCD or AKI/ECDs. RESULTS From February 2007 to March 2023, we transplanted 266 single AKI donor kidneys including 29 from ECDs, 29 from DCDs (n = 58 NIDDs), and 208 from brain-dead standard criteria donors (SCDs). Mean donor age (43.7 NIDD vs. 33.5 years SCD), KDPI (66% NIDD vs. 45% SCD), and recipient age (57 NIDD vs. 51 years SCD) were higher in the NIDD group (all p < .01). Mean waiting times (17.8 NIDD vs. 24.2 months SCD) and dialysis duration (34 NIDD vs. 47 months SCD) were shorter in the NIDD group (p < .05). Delayed graft function (DGF, 48%) and 1-year graft survival (92.7% NIDD vs. 95.9% SCD) was similar in both groups. Five-year patient and kidney graft survival rates were 82.1% versus 89.9% and 82.1% versus 75.2% (both p = NS) in the NIDD versus SCD groups, respectively. CONCLUSIONS The use of kidneys from AKI donors can be safely liberalized to include selected ECD and DCD donors.
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Affiliation(s)
- Christopher J Webb
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Emily McCracken
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Colleen L Jay
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Berjesh Sharda
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Matthew Garner
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Alan C Farney
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Giuseppe Orlando
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Amber Reeves-Daniel
- Department of Medicine, Section of Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Alejandra Mena-Gutierrez
- Department of Medicine, Section of Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Natalia Sakhovskaya
- Department of Medicine, Section of Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Bobby Stratta
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Robert J Stratta
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
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13
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Bakhtiyar SS, Sakowitz S, Verma A, Richardson S, Curry J, Chervu NL, Blumberg J, Benharash P. Postoperative length of stay following kidney transplantation in patients without delayed graft function-An analysis of center-level variation and patient outcomes. Clin Transplant 2023; 37:e15000. [PMID: 37126410 DOI: 10.1111/ctr.15000] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 04/04/2023] [Accepted: 04/13/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Early discharge after surgical procedures has been proposed as a novel strategy to reduce healthcare expenditures. However, national analyses of the association between discharge timing and post-transplant outcomes following kidney transplantation are lacking. METHODS This was a retrospective cohort study of all adult kidney transplant recipients without delayed graft function from 2014 to 2019 in the Organ Procurement and Transplantation Network and Nationwide Readmissions Databases. Recipients were divided into Early (LOS ≤ 4 days), Routine (LOS 5-7), and Delayed (LOS > 7) cohorts. RESULTS Of 61 798 kidney transplant recipients, 26 821 (43%) were discharged Early and 23 279 (38%) Routine. Compared to Routine, patients discharged Early were younger (52 [41-61] vs. 54 [43-62] years, p < .001), less commonly Black (33% vs. 34%, p < .001), and more frequently had private insurance (41% vs. 35%, p < .001). After adjustment, Early discharge was not associated with inferior 1-year patient survival (Hazard Ratio [HR] .74, 95% Confidence Interval [CI] 0.66-0.84) or increased likelihood of nonelective readmission at 90-days (HR .93, CI .89-.97), relative to Routine discharge. Discharging all Routine patients as Early would result in an estimated cost saving of ∼$40 million per year. Multi-level modeling of post-transplantation LOS revealed that 28.8% of the variation in LOS was attributable to interhospital differences rather than patient factors. CONCLUSIONS Early discharge after kidney transplantation appears to be cost-efficient and not associated with inferior post-transplant survival or increased readmission at 90 days. Future work should elucidate the benefits of early discharge and develop standardized enhanced recovery protocols to be implemented across transplant centers.
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Affiliation(s)
- Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, California, USA
- Department of Surgery, University of Colorado Anschutz Medical, Center, Denver, Colorado, USA
| | - Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, California, USA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, California, USA
| | - Shannon Richardson
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, California, USA
| | - Joanna Curry
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, California, USA
| | - Nikhil L Chervu
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, California, USA
| | - Jeremy Blumberg
- Division of Urology, Department of Surgery, University of California, Los Angeles, California, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, California, USA
- Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, California, USA
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14
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Tanriover B, Stewart D, Kamal L, Saeed M, Cooper M, Foutz J, McGehee H, Gupta G. The Independent Effects of Kidney Length and Vascular Plaque on Ten-Year Outcomes of Extended Criteria Donor Kidney Transplants. Transpl Int 2023; 36:11373. [PMID: 37519905 PMCID: PMC10379651 DOI: 10.3389/ti.2023.11373] [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: 03/19/2023] [Accepted: 07/05/2023] [Indexed: 08/01/2023]
Abstract
The independent effects of deceased donor kidney length and vascular plaque on long-term graft survival are not established. Utilizing DonorNet attachments from 4,480 expanded criteria donors (ECD) recovered between 2008 and 2012 in the United States with at least one kidney biopsied and transplanted, we analyzed the relationship between kidney length and vascular plaques and 10-year hazard of all-cause graft failure (ACGF) using causal inference methods in a Cox regression framework. The composite plaque score (range 0-4) and the presence of any plaque (yes, no) was also analyzed. Kidney length was modeled both categorically (<10, 10-12, >12 cm) as well as numerically, using a restricted cubic spline to capture nonlinearity. Effects of a novel composite plaque score 4 vs. 0 (HR 1.08; 95% CI: 0.96, 1.23) and the presence of any vascular plaque (HR 1.08; 95% CI: 0.98, 1.20) were attenuated after adjustment. Likewise, we identified a potential nonlinear relationship between kidney length and the 10-year hazard of ACGF, however the strength of the relationship was attenuated after adjusting for other donor factors. The independent effects of vascular plaque and kidney length on long-term ECD graft survival were found to be minimal and should not play a significant role in utilization.
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Affiliation(s)
- Bekir Tanriover
- Division of Nephrology, University of Arizona, Tucson, AZ, United States
| | - Darren Stewart
- Department of Surgery, New York University Langone Health, New York City, NY, United States
| | - Layla Kamal
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, United States
| | - Muhammad Saeed
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, United States
| | - Matthew Cooper
- Medical College of Wisconsin, Milwaukee, WI, United States
| | - Julia Foutz
- United Network for Organ Sharing, Richmond, VA, United States
| | | | - Gaurav Gupta
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA, United States
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15
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Ibrahim M, Callaghan CJ. Beyond donation to organ utilization in the UK. Curr Opin Organ Transplant 2023; 28:212-221. [PMID: 37040628 DOI: 10.1097/mot.0000000000001071] [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: 04/13/2023]
Abstract
PURPOSE OF REVIEW Optimizing deceased donor organ utilization is gaining recognition as a topical and important issue, both in the United Kingdom (UK) and globally. This review discusses pertinent issues in the field of organ utilization, with specific reference to UK data and recent developments within the UK. RECENT FINDINGS A multifaceted approach is likely required in order to improve organ utilization. Having a solid evidence-base upon which transplant clinicians and patients on national waiting lists can base decisions regarding organ utilization is imperative in order to bridge gaps in knowledge regarding the optimal use of each donated organ. A better understanding of the risks and benefits of the uses of higher risk organs, along with innovations such as novel machine perfusion technologies, can help clinician decision-making and may ultimately reduce the unnecessary discard of precious deceased donor organs. SUMMARY The issues facing the UK with regards to organ utilization are likely to be similar to those in many other developed countries. Discussions around these issues within organ donation and transplantation communities may help facilitate shared learning, lead to improvements in the usage of scarce deceased donor organs, and enable better outcomes for patients waiting for transplants.
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Affiliation(s)
- Maria Ibrahim
- Department of Nephrology and Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester
| | - Chris J Callaghan
- Department of Nephrology and Transplantation, Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London
- NHS Blood and Transplant, Bristol, UK
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16
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King KL, Husain SA, Yu M, Adler JT, Schold J, Mohan S. Characterization of Transplant Center Decisions to Allocate Kidneys to Candidates With Lower Waiting List Priority. JAMA Netw Open 2023; 6:e2316936. [PMID: 37273203 PMCID: PMC10242426 DOI: 10.1001/jamanetworkopen.2023.16936] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 04/21/2023] [Indexed: 06/06/2023] Open
Abstract
Importance Allocation of deceased donor kidneys is meant to follow a ranked match-run list of eligible candidates, but transplant centers with a 1-to-1 relationship with their local organ procurement organization have full discretion to decline offers for higher-priority candidates and accept them for lower-ranked candidates at their center. Objective To describe the practice and frequency of transplant centers placing deceased donor kidneys with candidates who are not the highest rank at their center according to the allocation algorithm. Design, Setting, and Participants This retrospective cohort study used 2015 to 2019 organ offer data from US transplant centers with a 1-to-1 relationship with their local organ procurement organization, following candidates for transplant events from January 2015 to December 2019. Participants were deceased kidney donors with a single match-run and at least 1 kidney transplanted locally and adult, first-time, kidney-only transplant candidates receiving at least 1 offer for a locally transplanted deceased donor kidney. Data were analyzed from March 1, 2022 to March 28, 2023. Exposure Demographic and clinical characteristics of donors and recipients. Main Outcomes and Measures The outcome of interest was kidney transplantation into the highest-priority candidate (defined as transplanted after zero declines for local candidates in the match-run) vs a lower-ranked candidate. Results This study assessed 26 579 organ offers from 3136 donors (median [IQR] age, 38 [25-51] years; 2903 [62%] men) to 4668 recipients. Transplant centers skipped their highest-ranked candidate to place kidneys further down the match-run for 3169 kidneys (68%). These kidneys went to a median (IQR) of the fourth- (third- to eighth-) ranked candidate. Higher kidney donor profile index (KDPI; higher score indicates lower quality) kidneys were less likely to go to the highest-ranked candidate, with 24% of kidneys with KDPI of at least 85% going to the top-ranked candidate vs 44% of KDPI 0% to 20% kidneys. When comparing estimated posttransplant survival (EPTS) scores between the skipped candidates and the ultimate recipients, kidneys were placed with recipients with both better and worse EPTS than the skipped candidates, across all KDPI risk groups. Conclusions and Relevance In this cohort study of local kidney allocation at isolated transplant centers, we found that centers frequently skipped their highest-priority candidates to place kidneys further down the allocation prioritization list, often citing organ quality concerns but placing kidneys with recipients with both better and worse EPTS with nearly equal frequency. This occurred with limited transparency and highlights the opportunity to improve the matching and offer algorithm to improve allocation efficiency.
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Affiliation(s)
- Kristen L. King
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
| | - S. Ali Husain
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
| | - Miko Yu
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
| | - Joel T. Adler
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin
| | - Jesse Schold
- Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora
- Department of Epidemiology, School of Public Health, University of Colorado, Anschutz Medical Campus, Aurora
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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17
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Bunnapradist S, Rosenthal JT, Huang E, Dafoe D, Seto T, Cohen A, Danovitch G. Deceased Donor Kidney Nonuse: A Systematic Approach to Improvement. Transplant Direct 2023; 9:e1491. [PMID: 37250491 PMCID: PMC10219747 DOI: 10.1097/txd.0000000000001491] [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: 09/26/2022] [Revised: 03/09/2023] [Accepted: 03/14/2023] [Indexed: 05/31/2023] Open
Abstract
A large number of procured kidneys continue not to be transplanted, while the waiting list remains high. Methods We analyzed donor characteristics for unutilized kidneys in our large organ procurement organization (OPO) service area in a single year to determine the reasonableness of their nonuse and to identify how we might increase the transplant rate of these kidneys. Five experienced local transplant physicians independently reviewed unutilized kidneys to identify which kidneys they would consider transplanting in the future. Biopsy results, donor age, kidney donor profile index, positive serologies, diabetes, and hypertension were risk factors for nonuse. Results Two-thirds of nonused kidneys had biopsies with high degree of glomerulosclerosis and interstitial fibrosis. Reviewers identified 33 kidneys as potentially transplantable (12%). Conclusions Reducing the rate of unutilized kidneys in this OPO service area will be achieved by setting acceptable expanded donor characteristics, identifying suitable well-informed recipients, defining acceptable outcomes, and systematically evaluating the results of these transplants. Because the improvement opportunity will vary by region, to achieve a significant impact on improving the national nonuse rate, it would be useful for all OPOs, in collaboration with their transplant centers, to conduct a similar analysis.
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Affiliation(s)
- Suphamai Bunnapradist
- David Geffen School of Mesdicine, University of California Los Angeles, Los Angeles, CA
| | - J. Thomas Rosenthal
- David Geffen School of Mesdicine, University of California Los Angeles, Los Angeles, CA
| | - Edmund Huang
- Department of Medicine, Cedars Sinai Medical Center, Los Angeles, CA
| | - Donald Dafoe
- Department of Surgery, University of California Irvine, Irvine, CA
| | | | | | - Gabriel Danovitch
- David Geffen School of Mesdicine, University of California Los Angeles, Los Angeles, CA
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18
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Ibrahim M, Mehew J, Martin K, Forsythe J, Johnson RJ, Callaghan C. Outcomes of Declined Deceased Donor Kidney Offers That Are Subsequently Implanted: A UK Registry Study. Transplantation 2023; 107:1348-1358. [PMID: 36706063 DOI: 10.1097/tp.0000000000004467] [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: 01/28/2023]
Abstract
BACKGROUND Deceased donor kidneys are often declined for ≥1 patients but then implanted into another. Studies are needed to guide transplant clinicians and patients, especially given the increasing age and comorbidity of donors. This study compares outcomes of recipients of transplanted kidneys that were initially declined with outcomes of patients who remained on the waiting list. METHODS This UK Transplant Registry study examined named-patient, adult donation after brain death donor single kidney-only offers that were declined for donor- or organ-related reasons (DORRs), in which the kidney was subsequently transplanted from January 1, 2010, to December 31, 2018. Outcomes included graft function and survival of kidneys transplanted following DORR decline, survival and transplant status of patients who had a kidney declined, and intercenter decline rates. RESULTS A total of 4722 kidneys declined for DORRs, which eventually resulted in single kidney-only transplants, were examined. One year after the offer decline, 35% of patients for whom the organ was declined remained on the list, 55% received a deceased donor transplant at a median of 174 d after the initial offer decline, and 4% had been removed or died. For patients transplanted following offer decline, there was no significant difference in 5-y graft survival when comparing the outcomes to those recipients who received the declined kidney. There was significant variation in DORR decline rates between UK transplant units (17%-54%). CONCLUSIONS This study shows reasonable outcomes of kidneys previously declined for DORRs and supports the utilization of those considered to be of higher risk for carefully selected recipients.
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Affiliation(s)
- Maria Ibrahim
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- NHS Blood and Transplant, Stoke Gifford, Bristol, United Kingdom
| | - Jennifer Mehew
- NHS Blood and Transplant, Stoke Gifford, Bristol, United Kingdom
| | - Kate Martin
- NHS Blood and Transplant, Stoke Gifford, Bristol, United Kingdom
| | - John Forsythe
- NHS Blood and Transplant, Stoke Gifford, Bristol, United Kingdom
| | - Rachel J Johnson
- NHS Blood and Transplant, Stoke Gifford, Bristol, United Kingdom
| | - Chris Callaghan
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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19
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Kadatz MJ, Gill J, Gill J, Lan JH, McMichael LC, Chang DT, Gill JS. The Benefits of Preemptive Transplantation Using High-Kidney Donor Profile Index Kidneys. Clin J Am Soc Nephrol 2023; 18:634-643. [PMID: 37027505 PMCID: PMC10278842 DOI: 10.2215/cjn.0000000000000134] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 02/16/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND The Kidney Donor Profile Index (KDPI) is a percentile score summarizing the likelihood of allograft failure: A KDPI ≥85% is associated with shorter allograft survival, and 50% of these donated kidneys are not currently used for transplantation. Preemptive transplantation (transplantation without prior maintenance dialysis) is associated with longer allograft survival than transplantation after dialysis; however, it is unknown whether this benefit extends to high-KDPI transplants. The objective of this analysis was to determine whether the benefit of preemptive transplantation extends to recipients of transplants with a KDPI ≥85%. METHODS This retrospective cohort study compared the post-transplant outcomes of preemptive and nonpreemptive deceased donor kidney transplants using data from the Scientific Registry of Transplant Recipients. 120,091 patients who received their first, kidney-only transplant between January 1, 2005, and December 31, 2017, were studied, including 23,211 with KDPI ≥85%. Of this cohort, 12,331 patients received a transplant preemptively. Time-to-event models for the outcomes of allograft loss from any cause, death-censored graft loss, and death with a functioning transplant were performed. RESULTS Compared with recipients of nonpreemptive transplants with a KDPI of 0%-20% as the reference group, the risk of allograft loss from any cause in recipients of a preemptive transplant with KDPI ≥85% (hazard ratio [HR], 1.51; 95% confidence interval [CI], 1.39 to 1.64) was lower than that in recipients of nonpreemptive transplant with a KDPI ≥85% (HR, 2.39; 95% CI, 2.21 to 2.58) and similar to that of recipients of a nonpreemptive transplant with a KDPI of 51%-84% (HR, 1.61; 95% CI, 1.52 to 1.70). CONCLUSIONS Preemptive transplantation is associated with a lower risk of allograft failure, irrespective of KDPI, and preemptive transplants with KDPI ≥85% have comparable outcomes with nonpreemptive transplants with KDPI 51%-84%.
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Affiliation(s)
- Matthew J. Kadatz
- Kidney Transplant Program, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
- Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Jagbir Gill
- Kidney Transplant Program, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
- Providence Health Research Institute, Vancouver, British Columbia, Canada
- Centre for Health Evaluation and Outcomes Sciences, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Justin Gill
- Kidney Transplant Program, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - James H. Lan
- Kidney Transplant Program, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
- Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lachlan C. McMichael
- Kidney Transplant Program, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Doris T. Chang
- Providence Health Research Institute, Vancouver, British Columbia, Canada
| | - John S. Gill
- Kidney Transplant Program, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
- Providence Health Research Institute, Vancouver, British Columbia, Canada
- Centre for Health Evaluation and Outcomes Sciences, Vancouver, British Columbia, Canada
- Tufts-New England Medical Center, Boston, Massachusetts
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20
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Garner M, Jay CL, Sharda B, Webb C, Farney AC, Orlando G, Rogers J, Reeves-Daniel A, Mena-Gutierrez A, Sakhovskaya N, Stratta B, Stratta RJ. Long-term outcomes of kidney transplantation from deceased donors with terminal acute kidney injury: Single center experience and literature review. Clin Transplant 2023; 37:e14886. [PMID: 36524320 DOI: 10.1111/ctr.14886] [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: 09/07/2022] [Revised: 11/05/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Long-term outcomes of kidney transplantation from deceased donors (DDKTs) with terminal acute kidney injury (AKI) are not well defined. METHODS Single center retrospective review of DDKTs from 1/31/07-12/31/19. AKI kidneys were defined by a doubling of the donor's admission serum creatinine (SCr) level AND a terminal SCr ≥2.0 mg/dl. RESULTS A total of 188 AKI DDKTs were performed, including 154 from brain-dead standard criteria donors (SCD). Mean donor age was 36 years and mean Kidney Donor Profile Index was 50%; mean admission and terminal SCr levels were 1.3 and 3.1 mg/dl, respectively. With a mean follow-up of 94 months (median 89 months), overall patient (both 71.3%) and graft survival (54% AKI vs. 57% non-AKI) rates were comparable to concurrent DDKTs from brain-dead non-AKI SCDs (n = 769). Delayed graft function (DGF) was higher in AKI kidney recipients (47% vs. 20% non-AKI DDKTs, p < .0001). DGF was associated with lower graft survival in recipients of both AKI and non-AKI SCD kidneys but the impact was earlier and more pronounced in non-AKI recipients. CONCLUSIONS Despite having more than twice the incidence of DGF, kidneys from deceased donors with terminal AKI have long-term outcomes comparable to non-AKI SCD kidneys and represent a safe and effective method to expand the donor pool.
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Affiliation(s)
- Matthew Garner
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Colleen L Jay
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Berjesh Sharda
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Christopher Webb
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Alan C Farney
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Giuseppe Orlando
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jeffrey Rogers
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Amber Reeves-Daniel
- Department of Medicine, Section of Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Alejandra Mena-Gutierrez
- Department of Medicine, Section of Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Natalia Sakhovskaya
- Department of Medicine, Section of Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Bobby Stratta
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Robert J Stratta
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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21
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Wang CJ, Wetmore JB, Wey A, Miller J, Snyder JJ, Israni AK. Impact of donor kidney biopsy on kidney yield and posttransplant outcomes. Am J Transplant 2023; 23:387-392. [PMID: 36695677 DOI: 10.1016/j.ajt.2022.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 11/10/2022] [Accepted: 11/17/2022] [Indexed: 01/03/2023]
Abstract
Procurement biopsy is performed to determine kidney quality, but evidence supporting such association is poor. We investigated the impact of glomerulosclerosis percentage (GS%) on kidney yield and patient outcomes. Information on deceased kidney donors from July 1, 2017, to June 30, 2019, was collected. Association between GS% and kidney yield (number of kidneys procured per donor) and posttransplant graft and patient outcomes were studied. Maximal GS% and minimal GS% were calculated to determine the relationship between GS% and kidney yield; minimal GS% only for correlation with posttransplant outcomes. Multinomial logistic regression and Cox models with least absolute shrinkage and selection operator were used to analyze the association of GS% with kidney yield and posttransplant outcomes, respectively. The kidney yield was 1.63 when maximal GS% and minimal GS% were <5%, but was 0.88 when both GS% were >20%. The hazard ratio for graft failure 1 year after transplant was 1.05 when minimal GS% was 16% to 20%, but was 1.3 for GS% of >20%. The hazard ratio for mortality increased from 1 to 1.2 when minimal GS% reached >20%. In summary, higher GS% was associated with lower kidney yield and inferior posttransplant outcomes. Incorporation of GS% into Scientific Registry of Transplant Recipients models may reassure organ procurement organizations and transplant centers pursuing kidneys with relatively high GS% levels, thereby reducing kidney discard rates.
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Affiliation(s)
- Connie J Wang
- Division of Nephrology, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - James B Wetmore
- Division of Nephrology, Hennepin Healthcare, Minneapolis, Minnesota, USA; Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Andrew Wey
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Jonathan Miller
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Jon J Snyder
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Ajay K Israni
- Division of Nephrology, Hennepin Healthcare, Minneapolis, Minnesota, USA; Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA.
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22
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Puttarajappa CM, Tevar AD, Hoffman W, Degenholtz H, Schinstock CA, Gunabushanam V, Zeevi A, Xu Q, Hariharan S. Virtual crossmatch for deceased donor kidney transplantation in the United States: A survey of histocompatibility lab directors and transplant surgeons. Hum Immunol 2023; 84:214-223. [PMID: 36581507 PMCID: PMC9991979 DOI: 10.1016/j.humimm.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 11/22/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022]
Abstract
Virtual crossmatch (VXM) is used as an alternative to or in conjunction with a cell-based physical crossmatch (PXM) for assessing HLA (human leukocyte antigen) compatibility prior to deceased donor kidney transplantation (DDKT). Data on practice patterns and perceptions regarding VXM use in the US are limited. We performed a survey of US HLA directors and transplant surgeons regarding HLA testing and crossmatch strategies. 53 (56 %) HLA directors and 68 surgeons (representing ∼ 23 % of US transplant centers) completed the survey. Both groups agreed that VXM could reduce cold ischemia time (CIT), costs and improve allocation efficiency. VXM use increased following the 2021 kidney allocation change. Reducing CIT was the primary reason for favoring VXM over PXM. Preference for VXM reduced as candidates' panel reactive antibodies increased. Regulations, program policies and limitations of HLA technology were cited as important reasons for preferring PXM over VXM. Surgeons reported similar perceptions, but findings are limited by the low response rate. Finally, half the labs reported lacking specific protocols for VXM use. In conclusion, improved HLA technology and protocols along with changes to institutional procedures and policy regulations are needed for safer expansion of VXM in DDKT.
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Affiliation(s)
- Chethan M Puttarajappa
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, USA.
| | - Amit D Tevar
- Department of Surgery, University of Pittsburgh, Pittsburgh, USA
| | | | - Howard Degenholtz
- Department of Health Policy and Management, University of Pittsburgh, Pittsburgh, USA
| | | | | | - Adriana Zeevi
- Department of Pathology, University of Pittsburgh, Pittsburgh, USA
| | - Qingyong Xu
- Department of Pathology, University of Pittsburgh, Pittsburgh, USA
| | - Sundaram Hariharan
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, USA
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23
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Akalay S, Hosgood SA. How to Best Protect Kidneys for Transplantation-Mechanistic Target. J Clin Med 2023; 12:jcm12051787. [PMID: 36902572 PMCID: PMC10003664 DOI: 10.3390/jcm12051787] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 02/15/2023] [Accepted: 02/17/2023] [Indexed: 02/25/2023] Open
Abstract
The increasing number of patients on the kidney transplant waiting list underlines the need to expand the donor pool and improve kidney graft utilization. By protecting kidney grafts adequately from the initial ischemic and subsequent reperfusion injury occurring during transplantation, both the number and quality of kidney grafts could be improved. The last few years have seen the emergence of many new technologies to abrogate ischemia-reperfusion (I/R) injury, including dynamic organ preservation through machine perfusion and organ reconditioning therapies. Although machine perfusion is gradually making the transition to clinical practice, reconditioning therapies have not yet progressed from the experimental setting, pointing towards a translational gap. In this review, we discuss the current knowledge on the biological processes implicated in I/R injury and explore the strategies and interventions that are being proposed to either prevent I/R injury, treat its deleterious consequences, or support the reparative response of the kidney. Prospects to improve the clinical translation of these therapies are discussed with a particular focus on the need to address multiple aspects of I/R injury to achieve robust and long-lasting protective effects on the kidney graft.
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Affiliation(s)
- Sara Akalay
- Department of Development and Regeneration, Laboratory of Pediatric Nephrology, KU Leuven, 3000 Leuven, Belgium
| | - Sarah A. Hosgood
- Department of Surgery, University of Cambridge, Cambridge CB2 0QQ, UK
- Correspondence:
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24
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Vinson AJ, Cardinal H, Parsons C, Tennankore KK, Mainra R, Maru K, Treleaven D, Gill J. Disparities in Deceased Donor Kidney Offer Acceptance: A Survey of Canadian Transplant Nephrologists, General Surgeons and Urologists. Can J Kidney Health Dis 2023; 10:20543581231156855. [PMID: 36861114 PMCID: PMC9969426 DOI: 10.1177/20543581231156855] [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] [Received: 09/09/2022] [Accepted: 12/19/2022] [Indexed: 02/26/2023] Open
Abstract
Background Significant variability in organ acceptance thresholds have been demonstrated across the United States, but data regarding the rate and rationale for kidney donor organ decline in Canada are lacking. Objective To examine decision making regarding deceased kidney donor acceptance and non-acceptance in a population of Canadian transplant professionals. Design A survey study of theoretical deceased donor kidney cases of increasing complexity. Setting Canadian transplant nephrologists, urologists, and surgeons making donor call decisions responding to an electronic survey between July 22 and October 4, 2022. Participants Invitations to participate were distributed to 179 Canadian transplant nephrologists, surgeons, and urologists through e-mail. Participants were identified by contacting each transplant program and requesting a list of physicians who take donor call. Measurements Survey respondents were asked whether they would accept or decline a given donor, assuming there was a suitable recipient. They were also asked to cite reasons for donor non-acceptance. Methods Donor scenario-specific acceptance rates (total acceptance divided by total number of respondents for a given scenario and overall) and reasons for decline were determined and presented as a percentage of the total cases declined. Results In all, 72 respondents from 7 provinces completed at least one question of the survey, with considerable variability between acceptance rates for centers; the most conservative center declined 60.9% of donor cases, whereas the most aggressive center declined only 28.1%, P-value < .001. There was an increased risk of non-acceptance with advancing age, donation after cardiac death, acute kidney injury, chronic kidney disease, and comorbidities. Limitations As with any survey, there is the potential for participation bias. In addition, this study examines donor characteristics in isolation, however, asks respondent to assume there is a suitable candidate available. In reality, whenever donor quality is considered, it should be considered in the context of the intended recipient. Conclusion In a survey of increasingly medically complex deceased kidney donor cases, there was significant variability in donor decline among Canadian transplant specialists. Given relatively high rates of donor decline and apparent heterogeneity in acceptance decisions, Canadian transplant specialists may benefit from additional education regarding the benefits achieved from even medically complex kidney donors for appropriate candidates relative to remaining on dialysis on the transplant waitlist.
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Affiliation(s)
- A. J. Vinson
- Nova Scotia Health Authority, Halifax,
Canada,Division of Nephrology, Department of
Medicine, Dalhousie University, Halifax, NS, Canada,A. J. Vinson, Division of Nephrology,
Department of Medicine, Dalhousie University, Room 5081, 5th Floor Dickson
Building, Victoria General Hospital, 5820 University Ave, Halifax, NS B3H 1V8,
Canada.
| | - H. Cardinal
- Centre de recherche du Centre
hospitalier de l’Université de Montréal, QC, Canada
| | - C. Parsons
- Organ and Tissue Donation and
Transplantation, Canadian Blood Services, Ottawa, ON, Canada
| | - K. K. Tennankore
- Nova Scotia Health Authority, Halifax,
Canada,Division of Nephrology, Department of
Medicine, Dalhousie University, Halifax, NS, Canada
| | - R. Mainra
- Division of Nephrology, Department of
Medicine, University of Saskatchewan, Regina, Canada
| | - K. Maru
- Canadian Blood Services, Ottawa, ON,
Canada
| | - D. Treleaven
- Division of Nephrology, Department of
Medicine, McMaster University, Hamilton, ON, Canada
| | - J. Gill
- Division of Nephrology, Department of
Medicine, The University of British Columbia, Vancouver, Canada
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25
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Martin P, Gupta D, Pruett T. Predicting older-donor kidneys' post-transplant renal function using pre-transplant data. NAVAL RESEARCH LOGISTICS 2023; 70:21-33. [PMID: 37082424 PMCID: PMC10108525 DOI: 10.1002/nav.22083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 08/29/2022] [Accepted: 09/15/2022] [Indexed: 05/03/2023]
Abstract
This paper provides a methodology for predicting post-transplant kidney function, that is, the 1-year post-transplant estimated Glomerular Filtration Rate (eGFR-1) for each donor-candidate pair. We apply customized machine-learning algorithms to pre-transplant donor and recipient data to determine the probability of achieving an eGFR-1 of at least 30 ml/min. This threshold was chosen because there is insufficient survival benefit if the kidney fails to generate an eGFR-1 ≥ 30 ml/min. For some donor-candidate pairs, the developed algorithm provides highly accurate predictions. For others, limitations of previous transplants' data results in noisier predictions. However, because the same kidney is offered to many candidates, we identify those pairs for whom the predictions are highly accurate. Out of 6977 discarded older-donor kidneys that were a match with at least one transplanted kidney, 5282 had one or more identified candidate, who were offered that kidney, did not accept any other offer, and would have had ≥80% chance of achieving eGFR-1 ≥ 30 ml/min, had the kidney been transplanted. We also show that transplants with ≥80% chance of achieving eGFR-1 ≥ 30 ml/min and that survive 1 year have higher 10-year death-censored graft survival probabilities than all older-donor transplants that survive 1 year (73.61% vs. 70.48%, respectively).
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Affiliation(s)
- Paola Martin
- Kelley School of BusinessIndiana UniversityBloomingtonIndianaUSA
| | - Diwakar Gupta
- McCombs School of BusinessUniversity of TexasAustinTexasUSA
| | - Timothy Pruett
- Department of SurgeryUniversity of MinnesotaMinneapolisMinnesotaUSA
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26
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Albert C, Harris M, DiRito J, Shi A, Edwards C, Harkins L, Lysyy T, Kulkarni S, Mulligan DC, Hosgood SA, Watson CJE, Friend PJ, Nicholson ML, Haakinson D, Saeb-Parsy K, Tietjen GT. Honoring the gift: The transformative potential of transplant-declined human organs. Am J Transplant 2023; 23:165-170. [PMID: 36695696 DOI: 10.1016/j.ajt.2022.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 10/24/2022] [Accepted: 11/13/2022] [Indexed: 01/09/2023]
Abstract
For decades, transplantation has been a life-saving treatment for those fortunate enough to gain access. Nevertheless, many patients die waiting for an organ and countless more never make it onto the waitlist because of a shortage of donor organs. Concurrently, thousands of donated organs are declined for transplant each year because of concerns about poor outcomes post-transplant. The decline of any donated organ-even if medically justified-is tragic for both the donor family and potential recipients. In this Personal Viewpoint, we discuss the need for a new mindset in how we honor the gift of organ donation. We believe that the use of transplant-declined human organs in translational research has the potential to hasten breakthrough discoveries in a multitude of scientific and medical areas. More importantly, such breakthroughs will allow us to properly value every donated organ. We further discuss the many practical challenges that such research presents and offer some possible solutions based on experiences in our own research laboratories. Finally, we share our perspective on what we believe are the necessary next steps to ensure a future where every donated organ realizes its full potential to impact the lives of current and future patients.
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Affiliation(s)
- Claire Albert
- Yale University, Department of Biomedical Engineering, New Haven, Connecticut, USA
| | - Matthew Harris
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut, USA
| | - Jenna DiRito
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut, USA
| | - Audrey Shi
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut, USA
| | | | - Lauren Harkins
- Yale University, Department of Biomedical Engineering, New Haven, Connecticut, USA
| | - Taras Lysyy
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut, USA
| | - Sanjay Kulkarni
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut, USA
| | - David C Mulligan
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut, USA
| | - Sarah A Hosgood
- Department of Surgery, University of Cambridge, and Cambridge NIHR Biomedical Research Centre, Cambridge, UK
| | - Christopher J E Watson
- Department of Surgery, University of Cambridge, and Cambridge NIHR Biomedical Research Centre, Cambridge, UK
| | - Peter J Friend
- University of Oxford, Nuffield Department of Surgical Sciences and the Oxford Transplant Centre, Oxford, UK
| | - Michael L Nicholson
- Department of Surgery, University of Cambridge, and Cambridge NIHR Biomedical Research Centre, Cambridge, UK
| | - Danielle Haakinson
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut, USA
| | - Kourosh Saeb-Parsy
- Department of Surgery, University of Cambridge, and Cambridge NIHR Biomedical Research Centre, Cambridge, UK.
| | - Gregory T Tietjen
- Yale University, Department of Biomedical Engineering, New Haven, Connecticut, USA; Yale School of Medicine, Department of Surgery, New Haven, Connecticut, USA.
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27
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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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28
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Schutter R, Vrijlandt WAL, Weima GM, Pol RA, Sanders JSF, Crop MJ, Leuvenink HGD, Moers C. Kidney utilization in the Netherlands - do we optimally use our donor organs? Nephrol Dial Transplant 2022; 38:787-796. [PMID: 36318454 PMCID: PMC9976738 DOI: 10.1093/ndt/gfac300] [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] [Received: 07/15/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND To ensure optimal utilization of deceased donor kidneys, it is important to understand the precise reasons why kidneys are discarded. In this study we aimed to obtain a comprehensive overview of kidney utilization and discard during the entire donation process in the Netherlands. METHODS In this retrospective cohort study we analysed kidney utilization of 3856 kidneys in the Netherlands between 1 January 2015 and 31 December 2020. For every kidney that was not transplanted, we determined the moment of and reason for discard through a unique case-by-case assessment. RESULTS Kidney discard according to the traditional definition (procured but not transplanted) was 7.8%. However, when kidneys that seemed medically suitable at the beginning of the donation process were also included, many more potential donor kidneys were lost and the total non-utilization was 24.4%. Subjectively presumed impaired organ quality was responsible for 34.2% of all discarded kidneys. Two-thirds of kidneys discarded due to acute kidney injury (AKI) had only AKI stage 1 or 2. CONCLUSION The classical definition of organ discard underestimates the non-utilization of deceased donor kidneys. Strategies to improve kidney utilization could be a revision of the maximum allowed agonal time in donation after circulatory death, careful consideration in reporting and accepting kidneys from donors with AKI and a prospectively filled registry of detailed organ discard reasons, including the 'silent' non-utilization before procurement.
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Affiliation(s)
| | | | | | - Robert A Pol
- Department of Surgery – Organ Donation and Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan-Stephan F Sanders
- Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Meindert J Crop
- Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Henri G D Leuvenink
- Department of Surgery – Organ Donation and Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Cyril Moers
- Department of Surgery – Organ Donation and Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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29
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Stewart D, Tanriover B, Gupta G. Oversimplification and Misplaced Blame Will Not Solve the Complex Kidney Underutilization Problem. KIDNEY360 2022; 3:2143-2147. [PMID: 36591359 PMCID: PMC9802557 DOI: 10.34067/kid.0005402022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 09/27/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Darren Stewart
- Department of Surgery, New York University Langone Health, New York, New York
| | - Bekir Tanriover
- Division of Nephrology, The University of Arizona, Tucson, Arizona
| | - Gaurav Gupta
- Division of Nephrology, School of Medicine, Virginia Commonwealth University, Richmond, Virginia,Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, Virginia
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30
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Barah M, Kilambi V, Friedewald JJ, Mehrotra S. Implications of Accumulated Cold Time for US Kidney Transplantation Offer Acceptance. Clin J Am Soc Nephrol 2022; 17:1353-1362. [PMID: 35868843 PMCID: PMC9625102 DOI: 10.2215/cjn.01600222] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 07/12/2022] [Accepted: 07/16/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND OBJECTIVES Reducing discard is important for the US transplantation system because nearly 20% of the deceased donor kidneys are discarded. One cause for the discards is the avoidance of protracted cold ischemia times. Extended cold ischemia times at transplant are associated with additional risk of graft failure and patient mortality. A preference for local (within the same donor service area) or low-Kidney Donor Risk Index organs, the endogeneity of cold ischemia time during organ allocation, and the use of provisional offers all complicate the analysis of cold ischemia times' influence on kidney acceptance decision making. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using January 2018 to June 2019 Organ Procurement and Transplantation Network data, we modeled the probability of accepting an offer for a kidney after provisional acceptance. We use logistic regression that includes cold ischemia time, Kidney Donor Risk Index, and other covariates selected from literature. Endogeneity of cold ischemia time was treated by a two-stage instrumental variables approach. RESULTS Logistic regression results for 3.33 million provisional acceptances from 12,369 donors and 108,313 candidates quantify trade-offs between cold ischemia time at the time of offer acceptance and donor-recipient characteristics. Overall, each additional 2 hours of cold ischemia time affected acceptance for nonlocal and local recipients (odds ratio, 0.75; 95% confidence interval, 0.73 to 0.77, odds ratio, 0.88; 95% confidence interval, 0.86 to 0.91; P<0.001). For Kidney Donor Risk Index >1.75 (Kidney Donor Profile Index >85) kidneys, an additional 2 hours of cold ischemia time for nonlocal and local recipients was associated with acceptance with odds ratio, 0.58; 95% confidence interval, 0.54 to 0.63 (nonlocal) and odds ratio, 0.65; 95% confidence interval, 0.6 to 0.7 (local); P<0.001. The effect of an additional 2 hours of cold ischemia time on acceptance of kidneys with Kidney Donor Risk Index ≤1.75 (Kidney Donor Profile Index ≤85) was less pronounced for nonlocal offers (odds ratio, 0.82; 95% confidence interval, 0.80 to 0.85; P<0.001) and not significant for local offers. CONCLUSIONS The acceptability of marginal organs was higher when placements were nearer to the donor and when cold ischemia time was shorter.
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Affiliation(s)
- Masoud Barah
- Department of Industrial Engineering and Management Sciences, Northwestern University, Evanston, Illinois
| | - Vikram Kilambi
- Department of Engineering and Applied Sciences, RAND Corporation, Arlington, Virginia
- RAND Health Care, Access and Delivery Program, RAND Corporation, Arlington, Virginia
| | - John J Friedewald
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Nephrology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Sanjay Mehrotra
- Department of Industrial Engineering and Management Sciences, Northwestern University, Evanston, Illinois
- Center for Engineering and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Sharif A. Deceased Donor Characteristics and Kidney Transplant Outcomes. Transpl Int 2022; 35:10482. [PMID: 36090778 PMCID: PMC9452640 DOI: 10.3389/ti.2022.10482] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 07/25/2022] [Indexed: 11/25/2022]
Abstract
Kidney transplantation is the therapy of choice for people living with kidney failure who are suitable for surgery. However, the disparity between supply versus demand for organs means many either die or are removed from the waiting-list before receiving a kidney allograft. Reducing unnecessary discard of deceased donor kidneys is important to maximize utilization of a scarce and valuable resource but requires nuanced decision-making. Accepting kidneys from deceased donors with heterogenous characteristics for waitlisted kidney transplant candidates, often in the context of time-pressured decision-making, requires an understanding of the association between donor characteristics and kidney transplant outcomes. Deceased donor clinical factors can impact patient and/or kidney allograft survival but risk-versus-benefit deliberation must be balanced against the morbidity and mortality associated with remaining on the waiting-list. In this article, the association between deceased kidney donor characteristics and post kidney transplant outcomes for the recipient are reviewed. While translating this evidence to individual kidney transplant candidates is a challenge, emerging strategies to improve this process will be discussed. Fundamentally, tools and guidelines to inform decision-making when considering deceased donor kidney offers will be valuable to both professionals and patients.
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Affiliation(s)
- Adnan Sharif
- Department of Nephrology and Transplantation, University Hospitals Birmingham, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
- *Correspondence: Adnan Sharif,
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Increased Rates of Kidney Discard in the Era of COVID-19 and Recent KAS Policy Implementation. Transplantation 2022; 106:e503-e506. [PMID: 35939384 DOI: 10.1097/tp.0000000000004321] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Schaapherder AF, Kaisar M, Mumford L, Robb M, Johnson R, de Kok MJ, Bemelman FJ, van de Wetering J, van Zuilen AD, Christiaans MH, Baas MC, Nurmohamed AS, Berger SP, Bastiaannet E, de Vries AP, Sharples E, Ploeg RJ, Lindeman JH. Donor characteristics and their impact on kidney transplantation outcomes: Results from two nationwide instrumental variable analyses based on outcomes of donor kidney pairs accepted for transplantation. EClinicalMedicine 2022; 50:101516. [PMID: 35784435 PMCID: PMC9240982 DOI: 10.1016/j.eclinm.2022.101516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 05/22/2022] [Accepted: 05/27/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Donor-characteristics and donor characteristics-based decision algorithms are being progressively used in the decision process whether or not to accept an available donor kidney graft for transplantation. While this may improve outcomes, the performance characteristics of the algorithms remains moderate. To estimate the impact of donor factors of grafts accepted for transplantation on transplant outcomes, and to test whether implementation of donor-characteristics-based algorithms in clinical decision-making is justified, we applied an instrumental variable analysis to outcomes for kidney donor pairs transplanted in different individuals. METHODS This analysis used (dis)congruent outcomes of kidney donor pairs as an instrument and was based on national transplantation registry data for all donor kidney pairs transplanted in separate individuals in the Netherlands (1990-2018, 2,845 donor pairs), and the United Kingdom (UK, 2000-2018, 11,450 pairs). Incident early graft loss (EGL) was used as the primary discriminatory factor. It was reasoned that a scenario with a dominant impact of donor variables on transplantation outcomes would result in high concordance of EGL in both recipients, whilst dominance of asymmetrical outcomes could indicate a more complex scenario, involving an interaction of donor, procedural and recipient factors. FINDINGS Incidences of congruent EGL (Netherlands: 1·2%, UK: 0·7%) were slightly lower than the arithmetical (stochastic) incidences, suggesting that once a graft has been accepted for transplantation, donor factors minimally contribute to incident EGL. A long-term impact of donor factors was explored by comparing outcomes for functional grafts from donor pairs with asymmetrical vs. symmetrical outcomes. Recipient survival was similar for both groups, but a slightly compromised graft survival was observed for grafts with asymmetrical outcomes in the UK cohort: (10-years Hazard Ratio for graft loss: 1·18 [1·03-1·35] p<0·018); and 5 years eGFR (48·6 [48·3-49·0] vs. 46·0 [44·5-47·6] ml/min in the symmetrical outcome group, p<0·001). INTERPRETATION Our results suggest that donor factors for kidney grafts deemed acceptable for transplantation impact minimally on transplantation outcomes. A strong reliance on donor factors and/or donor-characteristics-based decision algorithms could result in unjustified rejection of grafts. Future efforts to optimize transplant outcomes should focus on a better understanding of the recipient factors underlying transplant outcomes. FUNDING None.
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Affiliation(s)
- Alexander F. Schaapherder
- Department of Surgery and Leiden Transplant Center, Leiden University Medical Center, Leiden, the Netherlands
| | - Maria Kaisar
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
- Research and Development, NHS Blood and Transplant, Bristol & Oxford, United Kingdom
| | - Lisa Mumford
- Statistics and Clinical Studies, NHS Blood and Transplant, Bristol, United Kingdom
| | - Matthew Robb
- Statistics and Clinical Studies, NHS Blood and Transplant, Bristol, United Kingdom
| | - Rachel Johnson
- Statistics and Clinical Studies, NHS Blood and Transplant, Bristol, United Kingdom
| | - Michèle J.C. de Kok
- Department of Surgery and Leiden Transplant Center, Leiden University Medical Center, Leiden, the Netherlands
| | - Frederike J. Bemelman
- Department of Internal Medicine (Nephrology), Amsterdam UMC, Academic Medical Center, Amsterdam, the Netherlands
| | - Jacqueline van de Wetering
- Department of Internal Medicine (Nephrology), Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Arjan D. van Zuilen
- Department of Internal Medicine (Nephrology), University Medical Center Utrecht, Utrecht, the Netherlands
| | - Maarten H.L. Christiaans
- Department of Internal Medicine (Nephrology), Maastricht University Medical Center, Maastricht, the Netherlands
| | - Marije C. Baas
- Department of Internal Medicine (Nephrology), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Azam S. Nurmohamed
- Department of Internal Medicine (Nephrology), Amsterdam UMC, VU Medical Center, Amsterdam, the Netherlands
| | - Stefan P. Berger
- Department of Internal Medicine (Nephrology), University Medical Center Groningen, Groningen, the Netherlands
| | - Esther Bastiaannet
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands. Current address: Dept. Epidemiology, UZH, Zurich, Switzerland
| | - Aiko P.J. de Vries
- Division of Nephrology, Department of Internal Medicine and Leiden Transplant Center, Leiden University Medical Center, Leiden, the Netherlands
| | - Edward Sharples
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Rutger J. Ploeg
- Department of Surgery and Leiden Transplant Center, Leiden University Medical Center, Leiden, the Netherlands
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Jan H.N. Lindeman
- Department of Surgery and Leiden Transplant Center, Leiden University Medical Center, Leiden, the Netherlands
- Corresponding author at: Department of Surgery, Leiden University Medical Center, PObox 9600, 2300 RC Leiden, the Netherlands.
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Gonzalez-Viedma A, Van Dyck R, De Beule J, Ghesquière B, Jochmans I. Unraveling metabolism during kidney perfusion using tracer studies, a systematic review. Artif Organs 2022; 46:2118-2134. [PMID: 35848397 DOI: 10.1111/aor.14355] [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: 03/29/2022] [Revised: 06/02/2022] [Accepted: 07/03/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Understanding kidney metabolism during perfusion is vital to further develop the technology as a preservation, viability assessment, and resuscitation platform. We reviewed the evidence on the use of labeled metabolites (tracers) to understand "on-pump" kidney behavior. METHODS PubMed, Embase, Web of Science, and Cochrane databases were systematically searched for studies evaluating metabolism of (non)radioactively labeled endogenous compounds during kidney perfusion. RESULTS Of 5899 articles, 30 were included. All were animal studies [rat (70%), dog (13%), pig (10%), rabbit (7%)] perfusing but not transplanting kidneys. Perfusion took place at hypothermic (4-12°C) (20%), normothermic (35-40°C) (77%), or undefined temperatures (3%). Hypothermic perfusion used albumin or a clinical kidney preservation solution, mostly in the presence of oxygen. Normothermic perfusion was mostly performed with oxygenated crystalloids often containing glucose and amino acids with unclear partial oxygen tensions. Active metabolism of carbohydrate, amino acid, lipids, and large molecules was shown in hypothermic and normothermic perfusion. Production of macromolecules, such as prostaglandin, thromboxane, and vitamin D, takes place during normothermic perfusion. No experiments compared differences in metabolic activity between hypothermic and normothermic perfusion. One conference abstract showed increased anaerobic metabolism in kidneys donated after circulatory death by adding labeled glucose to hypothermically perfused human kidneys. CONCLUSIONS Tracer studies during kidney perfusion contribute to unraveling kidney metabolic behavior in pre-clinical models. Whether findings are truly translational needs further investigation in large animal models of human kidneys. Furthermore, it is essential to better understand how ischemia changes this metabolic behavior.
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Affiliation(s)
- Arantxa Gonzalez-Viedma
- Department of Microbiology, Immunology, and Transplantation, Transplantation Research Group, Lab of Abdominal Transplantation, KU Leuven, Leuven, Belgium
| | - Robbe Van Dyck
- Department of Microbiology, Immunology, and Transplantation, Transplantation Research Group, Lab of Abdominal Transplantation, KU Leuven, Leuven, Belgium
| | - Julie De Beule
- Department of Microbiology, Immunology, and Transplantation, Transplantation Research Group, Lab of Abdominal Transplantation, KU Leuven, Leuven, Belgium
| | - Bart Ghesquière
- Metabolomics Expertise Center, Center for Cancer Biology, VIB Center for Cancer Biology, Leuven, Belgium.,Metabolomics Expertise Center, Department of Oncology, KU Leuven, Leuven, Belgium
| | - Ina Jochmans
- Department of Microbiology, Immunology, and Transplantation, Transplantation Research Group, Lab of Abdominal Transplantation, KU Leuven, Leuven, Belgium.,Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
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Husain SA, King KL, Cron DC, Neidlinger NA, Ng H, Mohan S, Adler JT. Association of transplant center market concentration and local organ availability with deceased donor kidney utilization. Am J Transplant 2022; 22:1603-1613. [PMID: 35213789 PMCID: PMC9177771 DOI: 10.1111/ajt.17010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/30/2022] [Accepted: 02/20/2022] [Indexed: 01/25/2023]
Abstract
Although there is a shortage of kidneys available for transplantation, many transplantable kidneys are not procured or are discarded after procurement. We investigated whether local market competition and/or organ availability impact kidney procurement/utilization. We calculated the Herfindahl-Hirschman Index (HHI) for deceased donor kidney transplants (2015-2019) for 58 US donation service areas (DSAs) and defined 4 groups: HHI ≤ 0.32 (high competition), HHI = 0.33-0.51 (medium), HHI = 0.53-0.99 (low), and HHI = 1 (monopoly). We calculated organ availability for each DSA as the number kidneys procured per incident waitlisted candidate, grouped as: <0.42, 0.42-0.69, >0.69. Characteristics of procured organs were similar across groups. In adjusted logistic regression, the HHI group was inconsistently associated with composite export/discard (reference: high competition; medium: OR 1.16, 95% CI 1.11-1.20; low 1.01, 0.96-1.06; monopoly 1.19, 1.13-1.26) and increasing organ availability was associated with export/discard (reference: availability <0.42; 0.42-0.69: OR 1.35, 95% CI 1.30-1.40; >0.69: OR 1.83, 95% CI 1.73-1.93). When analyzing each endpoint separately, lower competition was associated with higher export and only market monopoly was weakly associated with lower discard, whereas higher organ availability was associated with export and discard. These results indicate that local organ utilization is more strongly influenced by the relative intensity of the organ shortage than by market competition between centers.
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Affiliation(s)
- Syed A. Husain
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York,The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Kristen L. King
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York,The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - David C. Cron
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Han Ng
- Department of Economics, Pennsylvania State University, State College, Pennsylvania
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York,The Columbia University Renal Epidemiology (CURE) Group, New York, New York,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Joel T. Adler
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas
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King KL, Husain SA, Perotte A, Adler JT, Schold JD, Mohan S. Deceased donor kidneys allocated out of sequence by organ procurement organizations. Am J Transplant 2022; 22:1372-1381. [PMID: 35000284 PMCID: PMC9081167 DOI: 10.1111/ajt.16951] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/20/2021] [Accepted: 01/03/2022] [Indexed: 01/25/2023]
Abstract
Deceased donor kidney allocation follows a ranked match-run of potential recipients. Organ procurement organizations (OPOs) are permitted to deviate from the mandated match-run in exceptional circumstances. Using match-run data for all deceased donor kidney transplants (Ktx) in the US between 2015 and 2019, we identified 1544 kidneys transplanted from 933 donors with an OPO-initiated allocation exception. Most OPOs (55/58) used this process at least once, but 3 OPOs performed 64% of the exceptions and just 2 transplant centers received 25% of allocation exception Ktx. At 2 of 3 outlier OPOs these transplants increased 136% and 141% between 2015 and 2019 compared to only a 35% increase in all Ktx. Allocation exception donors had less favorable characteristics (median KDPI 70, 41% with history of hypertension), but only 29% had KDPI ≥ 85% and the majority did not meet the traditional threshold for marginal kidneys. Allocation exception kidneys went to larger centers with higher offer acceptance ratios and to recipients with 2 fewer priority points-equivalent to 2 less years of waiting time. OPO-initiated exceptions for kidney allocation are growing increasingly frequent and more concentrated at a few outlier centers. Increasing pressure to improve organ utilization risks increasing out-of-sequence allocations, potentially exacerbating disparities in access to transplantation.
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Affiliation(s)
- Kristen L King
- Department of Medicine, Division of Nephrology, Columbia University Vagelos College of Physicians & Surgeons, New York, NY
- The Columbia University Renal Epidemiology (CURE) Group, New York, NY
| | - S Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University Vagelos College of Physicians & Surgeons, New York, NY
- The Columbia University Renal Epidemiology (CURE) Group, New York, NY
| | - Adler Perotte
- Department of Biomedical Informatics, Columbia University, New York, NY
| | - Joel T. Adler
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, TX
| | - Jesse D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Vagelos College of Physicians & Surgeons, New York, NY
- The Columbia University Renal Epidemiology (CURE) Group, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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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: 10] [Impact Index Per Article: 5.0] [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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Sharif A. Risk Aversion, Organ Utilization and Changing Behavior. Transpl Int 2022; 35:10339. [PMID: 35462791 PMCID: PMC9021374 DOI: 10.3389/ti.2022.10339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 03/18/2022] [Indexed: 01/20/2023]
Abstract
Improving organ acceptance and utilization rates is critical to ensure we maximize usage of donated organs as a scarce resource. Many factors underlie unnecessary discard of viable organs. Declined transplantation opportunities for candidates is associated with increased wait-list mortality. Technological advancements in organ preservation may help bridge the gap between donation and utilization, but an overlooked obstacle is the practice of risk aversion by transplant professionals when decision-making under risk. Lessons from behavioral economics, where experimental work has outlined the impact of loss or risk aversion on decision-making, have not been translated to transplantation. Many external factors can influence decision-making when accepting or utilizing organs, which are potentially amendable if external conditions are improved. However, attitudes and perceptions to risk for transplant professionals can pervade decision-making and influence behaviour. If we wish to change this behavior, then the underlying nature of decision-making under risk when accepting or utilizing organs must be studied to facilitate the design of targeted behavior change interventions to convert risk aversion to risk tolerance. To ensure optimal use of donated organs, we need more research into decision-making under risk.
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Affiliation(s)
- Adnan Sharif
- Department of Nephrology and Transplantation, University Hospitals Birmingham, Birmingham, United Kingdom
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
- *Correspondence: Adnan Sharif, , orcid.org/0000-0002-7586-9136
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Fazal MS, Gordon EJ, Humbyrd CJ. Current Bioethical Issues in Geriatric Organ Transplantation. CURRENT TRANSPLANTATION REPORTS 2022. [DOI: 10.1007/s40472-022-00364-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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40
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Donnelly CV, Keller M, Kayler L. Kidney Transplant Outcomes after Prolonged Delayed Graft Function. J Clin Med 2022; 11:jcm11061535. [PMID: 35329861 PMCID: PMC8954343 DOI: 10.3390/jcm11061535] [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] [Received: 01/18/2022] [Revised: 02/22/2022] [Accepted: 03/01/2022] [Indexed: 11/16/2022] Open
Abstract
Background: The protracted recovery of renal function may be an actionable marker of post-transplant adverse events, but a paucity of data are available to determine if the duration of graft recovery serves to stratify risk. Materials and Methods: Single-center data of adult-isolated deceased-donor kidney transplant (KTX) recipients between 1 July 2015 and 31 December 2018 were stratified by delayed graft function (DGF) duration, defined as time to serum creatinine < 3.0 mg/dL. Results: Of 355 kidney transplants, the time to creatinine < 3.0 mg/dL was 0−3 days among 96 cases (DGF ≤ 3), 4−10 days among 85 cases (DGF4-10), 11−20 days among 93 cases (DGF11-20), and ≥21 days for 81 cases (DGF ≥ 21). DGF ≥ 21 recipients were significantly more likely to be male, non-sensitized, and receive kidneys from donors that were older, with donation after circulatory death, non-mandatory share, hypertensive, higher KDPI, higher terminal creatinine, and longer cold and warm ischemia time. On multivariate analysis, DGF ≥ 21 was associated with a 5.73-fold increased odds of 12-month eGFR < 40 mL/min compared to DGF ≤ 3. Lesser degrees of DGF had similar outcomes. Conclusions: Prolonged DGF lasting over 20 days signifies a substantially higher risk for reduced eGFR at 1 year compared to lesser degrees of DGF, thus serving as a threshold indicator of increased risk.
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Affiliation(s)
- Cullan V. Donnelly
- Jacobs School of Medicine and Biomedical Sciences, SUNY-University at Buffalo, 955 Main Street, Buffalo, NY 14203, USA;
- Department of Surgery, SUNY-University at Buffalo, 100 High Street, Buffalo, NY 14203, USA;
- Transplant and Kidney Care Regional Center of Excellence, Erie County Medical Center, 462 Grider Street, Buffalo, NY 14215, USA
| | - Maria Keller
- Department of Surgery, SUNY-University at Buffalo, 100 High Street, Buffalo, NY 14203, USA;
- Transplant and Kidney Care Regional Center of Excellence, Erie County Medical Center, 462 Grider Street, Buffalo, NY 14215, USA
| | - Liise Kayler
- Jacobs School of Medicine and Biomedical Sciences, SUNY-University at Buffalo, 955 Main Street, Buffalo, NY 14203, USA;
- Department of Surgery, SUNY-University at Buffalo, 100 High Street, Buffalo, NY 14203, USA;
- Transplant and Kidney Care Regional Center of Excellence, Erie County Medical Center, 462 Grider Street, Buffalo, NY 14215, USA
- Correspondence: ; Tel.: +1-17-16-289-8255
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Husain SA, King KL, Adler JT, Mohan S, Perotte R. Impact of Extending Eligibility for Reinstatement of Waiting Time After Early Allograft Failure: A Decision Analysis. Am J Kidney Dis 2022; 79:354-361. [PMID: 34562524 PMCID: PMC8881308 DOI: 10.1053/j.ajkd.2021.07.023] [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: 02/24/2021] [Accepted: 07/31/2021] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE The shortage of deceased donor kidneys identified for potential transplantation in the United States is exacerbated by a high proportion of deceased donor kidneys being discarded after procurement. We estimated the impact of a policy proposal aiming to increase organ utilization by extending eligibility for waiting time reinstatement for recipients experiencing early allograft failure after transplantation. STUDY DESIGN Decision analysis informed by clinical registry data. SETTING & POPULATION We used Organ Procurement and Transplantation Network data to identify 76,044 deceased-donor kidneys procured in the United States from 2013 to 2017, 80% of which were transplanted and 20% discarded. INTERVENTION Extend waiting time reinstatement for recipients experiencing allograft failure from the current 90 days to 1 year after transplantation. OUTCOME Net impact to the waitlist, defined as the estimated number of additional transplants minus estimated increase in waiting list reinstatements. MODEL, PERSPECTIVE, & TIMEFRAME We estimated (1) the number of additional deceased donor kidneys that would be transplanted if there was a 5%-25% relative reduction in discards, and (2) the number of recipients who would regain waiting time under a 6-, 12-, 18-, and 24-month reinstatement policy. RESULTS Reinstating a waiting time for recipients experiencing allograft failure up to 1 year after transplantation yielded more additional transplants than growth in additions to the waiting list for all model assumptions except the combination of a very low relative reduction in discards (5%) and a very high failure rate of transplanted kidneys that would previously have been discarded (≥5 times the rate of currently transplanted kidneys). LIMITATIONS Lack of empirical evidence supporting the proposed impact of such a policy change. CONCLUSIONS A policy change reinstating waiting time for deceased donor kidneys recipients with allograft failure up to 1 year after transplantation should explored as a decision science-based intervention to improve organ utilization.
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Affiliation(s)
- S. Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY,The Columbia University Renal Epidemiology (CURE) Group, New York, NY
| | - Kristen L. King
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY,The Columbia University Renal Epidemiology (CURE) Group, New York, NY
| | - Joel T. Adler
- Department of Surgery, Division of Transplant Surgery, Brigham and Women’s Hospital, Boston, MA,Center for Surgery and Public Health at Brigham and Women’s Hospital, Boston, MA
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY,The Columbia University Renal Epidemiology (CURE) Group, New York, NY,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Rimma Perotte
- Department of Emergency Medicine, Hackensack University Medical Center, Hackensack, NJ,Department of Biomedical Informatics, Columbia University Medical Center, New York, NY
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Liu C, Alasfar S, Reese PP, Mohan S, Doshi MD, Hall IE, Thiessen Philbrook H, Jia Y, Stewart D, Parikh CR. Trends in the procurement and discard of kidneys from deceased donors with acute kidney injury. Am J Transplant 2022; 22:898-908. [PMID: 34897982 DOI: 10.1111/ajt.16920] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 11/11/2021] [Accepted: 12/02/2021] [Indexed: 01/25/2023]
Abstract
Kidney allocation trends from deceased donors with acute kidney injury (AKI) have not been characterized since initial Kidney Donor Profile Index reporting in 2012 and its use under the revised Kidney Allocation System (KAS) in 2014. We conducted a retrospective analysis of US registry data to characterize kidney procurement and discard trends in deceased donors with AKI, defined by ≥50% or ≥0.3 mg/dl (≥4.0 mg/dl or ≥200% for stage 3) increase in terminal serum creatinine from admission. From 2010 to 2020, 172 410 kidneys were procured from 93 341 deceased donors 16 years or older; 34 984 kidneys were discarded (17 559 from AKI donors). The proportion of stage 3 AKI donors doubled from 6% (412/6841) in 2010 to 12% (1365/11493) in 2020. Procurement of stage 3 AKI kidneys increased from 51% (423/824) to 80% (2183/2730). While discard of stage 3 AKI kidneys increased from 41% (175/423) in 2010 to 44% (960/2183) in 2020, this increase was not statistically significant in interrupted time-series analysis following KAS implementation (slope difference -0.41 [-3.22, 2.4], and level change 3.09 [-6.4, 12.6]). In conclusion, the absolute number of stage 3 AKI kidneys transplanted has increased. Ongoing high discard rates of these kidneys suggest opportunities for improved utilization.
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Affiliation(s)
- Caroline Liu
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sami Alasfar
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Peter P Reese
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Mona D Doshi
- Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Isaac E Hall
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Heather Thiessen Philbrook
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yaqi Jia
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Darren Stewart
- Research Department, United Network for Organ Sharing, Richmond, Virginia
| | - Chirag R Parikh
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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43
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Calderon E, Chang YH, Chang JM, Velazco CS, Giorgakis E, Srinivasan A, Moss AA, Khamash H, Heilman R, Reddy KS, Mathur AK. Outcomes and Health Care Utilization After Early Hospital Dismissal in Kidney Transplantation: An Analysis of 1001 Consecutive Cases. Ann Surg 2022; 275:e511-e519. [PMID: 32516231 DOI: 10.1097/sla.0000000000003948] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To understand whether reduced lengths of stay after kidney transplantation were associated with excess health care utilization in the first 90 days or long-term graft and patient survival outcomes. BACKGROUND Reducing length of stay after kidney transplant has an unknown effect on post-transplant health care utilization. We studied this association in a cohort of 1001 consecutive kidney transplants. METHODS We retrospectively reviewed 2011-2015 data from a prospectively-maintained kidney transplant database from a single center. RESULTS A total of 1001 patients underwent kidney transplant, and were dismissed from the hospital in 3 groups: Early [≤2 days] (19.8%), Normal [3-7 days] (79.4%) and Late [>7 days] (3.8%). 34.8% of patients had living donor transplants (Early 51%, Normal 31.4%, Late 18.4%, P < 0.001). Early patients had lower delayed graft function rates (Early 19.2%, Normal 32%, Late73.7%, P = 0.001). By the hospital dismissal group, there were no differences in readmissions or emergency room visits at 30 or 90 days. Glomerular filtration rate at 12 months and rates of biopsy-proven acute rejection were also similar between groups. The timing of hospital dismissal was not associated with the risk-adjusted likelihood of readmission. Early and Normal patients had similar graft and patient survival. Late dismissal patients, who had higher rates of cardiovascular complications, had significantly higher late mortality versus Normal dismissal patients in unadjusted and risk-adjusted models. CONCLUSION Dismissing patients from the hospital 2 days after kidney transplant is safe, feasible, and improves value. It is not associated with excess health care utilization or worse short or long-term transplant outcomes.
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Affiliation(s)
| | - Yu-Hui Chang
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Phoenix, Arizona
| | - James M Chang
- Department of Surgery, Mayo Clinic, Phoenix, Arizona
| | | | | | | | - Adyr A Moss
- Department of Surgery, Mayo Clinic, Phoenix, Arizona
| | - Hasan Khamash
- Department of Nephrology, Mayo Clinic, Phoenix, Arizona
| | | | - Kunam S Reddy
- Department of Surgery, Mayo Clinic, Phoenix, Arizona
| | - Amit K Mathur
- Department of Surgery, Mayo Clinic, Phoenix, Arizona
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Phoenix, Arizona
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44
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Stratta RJ, Harriman D, Gurram V, Gurung K, Sharda B. The use of marginal kidneys in dual kidney transplantation to expand kidney graft utilization. Curr Opin Organ Transplant 2022; 27:75-85. [PMID: 34939967 DOI: 10.1097/mot.0000000000000946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to chronicle the history of dual kidney transplantation (DKT) and identify opportunities to improve utilization of marginal deceased donor (MDD) kidneys through DKT. RECENT FINDINGS The practice of DKT from adult MDDs dates back to the mid-1990s, at which time the primary indication was projected insufficient nephron mass from older donors. Multiple subsequent studies of short- and long-term success have been reported focusing on three major aspects: Identifying appropriate selection criteria/scoring systems based on pre- and postdonation factors; refining technical aspects; and analyzing longer-term outcomes. The number of adult DKTs performed in the United States has declined in the past decade and only about 60 are performed annually. For adult deceased donor kidneys meeting double allocation criteria, >60% are ultimately not transplanted. MDDs with limited renal functional capacity represent a large proportion of potential kidneys doomed to either discard or nonrecovery. SUMMARY DKT may reduce organ discard and optimize the use of kidneys from MDDs. New and innovative technologies targeting ex vivo organ assessment, repair, and regeneration may have a major impact on the decision whether or not to use recovered kidneys for single or DKT.
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Affiliation(s)
- Robert J Stratta
- The Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - David Harriman
- The Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Venkat Gurram
- The Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Komal Gurung
- The Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Berjesh Sharda
- The Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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45
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Stratta RJ, Harriman D, Gurram V, Gurung K, Sharda B. Dual kidney transplants from adult marginal donors: Review and perspective. Clin Transplant 2021; 36:e14566. [PMID: 34936135 DOI: 10.1111/ctr.14566] [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: 08/27/2021] [Revised: 10/08/2021] [Accepted: 12/13/2021] [Indexed: 11/28/2022]
Abstract
The practice of dual kidney transplantation (DKT) from adult marginal deceased donors (MDDs) dates back to the mid-1990s with initial pioneering experiences reported by the Stanford and Maryland groups, at which time the primary indication was estimated insufficient nephron mass from older donors. Multiple subsequent studies of short and long-term success have been reported focusing on three major aspects of DKT: Identifying appropriate selection criteria and developing scoring systems based on pre- and post-donation factors; refining technical aspects; and analyzing mid-term outcomes. The number of adult DKTs performed in the United States has declined in the past decade and only about 60 are performed annually. For adult deceased donor kidneys meeting double allocation criteria, >60% are ultimately not transplanted. Deceased donors with limited renal functional capacity represent a large proportion of potential kidneys doomed to either discard or non-recovery. However, DKT may reduce organ discard and optimize the use of kidneys from MDDs. In an attempt to promote utilization of MDD kidneys, the United Network for Organ Sharing introduced new allocation guidelines pursuant to DKT in 2019. The purpose of this review is to chronicle the history of DKT and identify opportunities to improve utilization of MDD kidneys through DKT. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Robert J Stratta
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, One Medical Center Blvd., Winston-Salem, NC, 27157, United States
| | - David Harriman
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, V5Z1M9, Canada
| | - Venkat Gurram
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, One Medical Center Blvd., Winston-Salem, NC, 27157, United States
| | - Komal Gurung
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, One Medical Center Blvd., Winston-Salem, NC, 27157, United States
| | - Berjesh Sharda
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, One Medical Center Blvd., Winston-Salem, NC, 27157, United States
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46
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Husain SA, King KL, Robbins-Juarez S, Adler JT, McCune KR, Mohan S. Number of Donor Renal Arteries and Early Outcomes after Deceased Donor Kidney Transplantation. KIDNEY360 2021; 2:1819-1826. [PMID: 35373010 PMCID: PMC8785844 DOI: 10.34067/kid.0005152021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/07/2021] [Indexed: 02/07/2023]
Abstract
Background Anatomic abnormalities increase the risk of deceased donor kidney discard, but their effect on transplant outcomes is understudied. We sought to determine the effect of multiple donor renal arteries on early outcomes after deceased donor kidney transplantation. Methods For this retrospective cohort study, we identified 1443 kidneys from 832 deceased donors with ≥1 kidney transplanted at our center (2006-2016). We compared the odds of delayed graft function and 90-day graft failure using logistic regression. To reduce potential selection bias, we then repeated the analysis using a paired-kidney cohort, including kidney pairs from 162 donors with one single-artery kidney and one multiartery kidney. Results Of 1443 kidneys included, 319 (22%) had multiple arteries. Multiartery kidneys experienced longer cold ischemia time, but other characteristics were similar between groups. Delayed graft function (50% multiartery versus 45% one artery, P=0.07) and 90-day graft failure (3% versus 3%, P=0.83) were similar between groups before and after adjusting for donor and recipient characteristics. In the paired kidney analysis, cold ischemia time was significantly longer for multiartery kidneys compared with single-artery kidneys from the same donor (33.5 versus 26.1 hours, P<0.001), but delayed graft function and 90-day graft failure were again similar between groups. Conclusions Compared with single-artery deceased donor kidneys, those with multiple renal arteries are harder to place, but experience similar delayed graft function and early graft failure.
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Affiliation(s)
- S Ali Husain
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, New York.,The Columbia University Renal Epidemiology Group, New York, New York
| | - Kristen L King
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, New York.,The Columbia University Renal Epidemiology Group, New York, New York
| | - Shelief Robbins-Juarez
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, New York
| | - Joel T Adler
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Center for Surgery and Public Health at Brigham and Women's Hospital, Boston, Massachusetts
| | - Kasi R McCune
- Department of Surgery, Kidney and Pancreas Transplant Program, Columbia University College of Physicians & Surgeons, New York, New York
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, New York.,The Columbia University Renal Epidemiology Group, New York, New York.,Department of Epidemiology, Mailman School of Public Health, New York, New York
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47
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Benoit T, Prudhomme T, Adypagavane A, Malavaud B, Soulié M, Gamé X, Kamar N, Dariane C, Legendre C, Méjean A, Roumiguié M, Timsit MO. External Validation of a Predictive Model to Estimate Renal Function After Living Donor Nephrectomy. Transplantation 2021; 105:2445-2450. [PMID: 33496555 DOI: 10.1097/tp.0000000000003643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Transplantation from living donor nephrectomy (LDN) is the best treatment for end-stage renal disease but observed decrease in donor renal function is a major concern. The aim of this study was to externally validate a predictive model to estimate 1-y postdonation estimated glomerular filtration rate (eGFR) and risk of chronic kidney disease (CKD) in living donors. METHODS All LDN performed at Necker Hospital from January 2006 to May 2018 were retrospectively included. Observed eGFR (using CKD-EPI formula) at 1-y post LDN was compared with the predicted eGFR calculated with a formula developed at Toulouse-Rangueil and based on predonation eGFR and age. Pearson correlation, receiver operating characteristics curve (ROC curve), and calibration curve were used to assess external validity of the proposed prognostic model to predict postoperative eGFR and occurrence of CKD in donors. RESULTS Four hundred donors were evaluated with a mean postoperative eGFR of 62.1 ± 14 mL/min/1.73m2. Significant correlation (Pearson r = 0.66; P < 0.001) and concordance (Bradley-Blackwood F = 49.189; P < 0.001) were observed between predicted and observed 1-y eGFR. Area under the receiver operating characteristic curve of the model relevant accuracy was 0.86 (95% CI, 0.82-0.89). CONCLUSIONS This study externally validated the formula to predict 1-y postdonation eGFR. The calculator could be an accurate tool to improve the selection of living kidney donor candidate.
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Affiliation(s)
- Thibaut Benoit
- Department of Urology, Clinique Pasteur, Toulouse, France
| | - Thomas Prudhomme
- Department of Urology, Kidney Transplantation and Andrology, Toulouse Rangueil University Hospital, Toulouse, France
| | - Aurélien Adypagavane
- Department of Urology and Renal Transplantation, Hôpital Necker and Hôpital européen Georges-Pompidou (HEGP), AP-HP, Paris, France
| | - Bernard Malavaud
- Department of Urology, Institut Universitaire du Cancer, Toulouse, France
| | - Michel Soulié
- Department of Urology, Kidney Transplantation and Andrology, Toulouse Rangueil University Hospital, Toulouse, France
| | - Xavier Gamé
- Department of Urology, Kidney Transplantation and Andrology, Toulouse Rangueil University Hospital, Toulouse, France
| | - Nassim Kamar
- Université de Paris, PARCC, INSERM, Paris, France
| | - Charles Dariane
- Department of Urology and Renal Transplantation, Hôpital Necker and Hôpital européen Georges-Pompidou (HEGP), AP-HP, Paris, France
| | - Christophe Legendre
- Department of Nephrology and Organ Transplantation, Toulouse Rangueil University Hospital, Toulouse, France
| | - Arnaud Méjean
- Department of Urology and Renal Transplantation, Hôpital Necker and Hôpital européen Georges-Pompidou (HEGP), AP-HP, Paris, France
| | - Mathieu Roumiguié
- Department of Urology, Kidney Transplantation and Andrology, Toulouse Rangueil University Hospital, Toulouse, France
| | - Marc Olivier Timsit
- Department of Urology and Renal Transplantation, Hôpital Necker and Hôpital européen Georges-Pompidou (HEGP), AP-HP, Paris, France
- Université de Paris, PARCC, INSERM, Paris, France
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48
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Kayler LK, Nie J, Noyes K. Hardest-to-place kidney transplant outcomes in the United States. Am J Transplant 2021; 21:3663-3672. [PMID: 34212471 DOI: 10.1111/ajt.16739] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 06/22/2021] [Accepted: 06/27/2021] [Indexed: 01/25/2023]
Abstract
The outcomes of hardest-to-place kidney transplants-accepted last in the entire match run after being refused by previous centers-are unclear, potentially translating to risk aversion and unnecessary organ discard. We aimed to determine the outcomes of hardest-to-place kidney transplants and whether the organ acceptance position on the match run sufficiently captures the risk. This is a cohort study of the United Network for Organ Sharing data of all adult kidney-only transplant recipients from deceased donors between 2007 and 2018. Multiple regression models assessed delayed graft function, graft survival, and patient survival stratified by share type: local versus shared kidney acceptance position scaled by tertile. Among 127 028 kidney transplant recipients, 92 855 received local kidneys. The remaining received shared kidneys at sequence number 1-4 (n = 12 322), 5-164 (n = 10 485) and >164 (n = 11 366). Hardest-to-place kidneys, defined as the latest acceptance group in the match-run, were associated with delayed graft function (adjusted odds ratio 1.83, 95% confidence interval [CI] 1.74-1.92) and all-cause allograft failure (adjusted hazard ratio [aHR] 1.11, 95% CI 1.04-1.17). Results of this IRB-approved study were robust to the exclusion of operational allocation bypass and mandatory shares. The hardest-to-place kidneys accepted later in the match run were associated with higher graft failure and delayed graft function.
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Affiliation(s)
- Liise K Kayler
- Department of Surgery, University at Buffalo, Buffalo, New York, USA.,Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Transplant and Kidney Care Regional Center of Excellence, Erie County Medical Center, Buffalo, New York, USA
| | - Jing Nie
- Department of Epidemiology and Environmental Health, University at Buffalo School of Public Health and Health Professions, Buffalo, New York, USA
| | - Katia Noyes
- Department of Epidemiology and Environmental Health, University at Buffalo School of Public Health and Health Professions, Buffalo, New York, USA
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49
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Emmons BR, Husain SA, King KL, Adler JT, Mohan S. Variations in deceased donor kidney procurement biopsy practice patterns: A survey of U.S. organ procurement organizations. Clin Transplant 2021; 35:e14411. [PMID: 34196034 PMCID: PMC8556234 DOI: 10.1111/ctr.14411] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 06/22/2021] [Accepted: 06/23/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Procurement biopsies have become a common practice in the evaluation and allocation of deceased donor kidneys in the United States despite questions about their value and reproducibility. We sought to determine the extent of OPO-level differences in criteria used to decide which deceased donor kidneys undergo a procurement biopsy and to assess the degree of variability in procurement biopsy technique and interpretation across OPOs. METHODS Each of the country's 58 OPOs were invited to participate in the survey. OPOs were divided into two groups based on organ availability ratio and deceased donor kidney discard rate. RESULTS AND CONCLUSIONS Fifty-out-of-fifty-eight invited OPOs (86% response rate) responded to the survey between November 2020 and December 2020. Thirty (60%) OPOs reported that they have formal criteria for performing kidney procurement biopsy, but for 29 of these OPOs, transplant centers can request biopsy on kidneys that do not meet criteria. OPOs used a total of seven different variables and 12 different numerical thresholds to define impaired kidney function that would prompt a procurement biopsy. Additionally, wide variability was seen in biopsy technique and procedures for biopsy interpretation and reporting of findings to transplant programs. These findings identify a clear opportunity for standardization of procurement biopsies to best practices.
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Affiliation(s)
- Brendan R. Emmons
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY
| | - S. Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY
- The Columbia University Renal Epidemiology (CURE) Group, New York, NY
| | - Kristen L. King
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY
- The Columbia University Renal Epidemiology (CURE) Group, New York, NY
| | - Joel T. Adler
- Department of Surgery, Division of Transplant Surgery, Brigham and Women’s Hospital, Boston, MA
- Center for Surgery and Public Health at Brigham and Women’s Hospital, Boston, MA
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY
- The Columbia University Renal Epidemiology (CURE) Group, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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50
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Schutter R, Lantinga VA, Hamelink TL, Pool MBF, van Varsseveld OC, Potze JH, Hillebrands JL, van den Heuvel MC, Dierckx RAJO, Leuvenink HGD, Moers C, Borra RJH. Magnetic resonance imaging assessment of renal flow distribution patterns during ex vivo normothermic machine perfusion in porcine and human kidneys. Transpl Int 2021; 34:1643-1655. [PMID: 34448269 PMCID: PMC9290094 DOI: 10.1111/tri.13991] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 07/13/2021] [Accepted: 07/14/2021] [Indexed: 02/06/2023]
Abstract
Acceptance criteria of deceased donor organs have gradually been extended toward suboptimal quality, posing an urgent need for more objective pre‐transplant organ assessment. Ex vivo normothermic machine perfusion (NMP) combined with magnetic resonance imaging (MRI) could assist clinicians in deciding whether a donor kidney is suitable for transplantation. Aim of this study was to characterize the regional distribution of perfusate flow during NMP, to better understand how ex vivo kidney assessment protocols should eventually be designed. Nine porcine and 4 human discarded kidneys underwent 3 h of NMP in an MRI‐compatible perfusion setup. Arterial spin labeling scans were performed every 15 min, resulting in perfusion‐weighted images that visualize intrarenal flow distribution. At the start of NMP, all kidneys were mainly centrally perfused and it took time for the outer cortex to reach its physiological dominant perfusion state. Calculated corticomedullary ratios based on the perfusion maps reached a physiological range comparable to in vivo observations, but only after 1 to 2 h after the start of NMP. Before that, the functionally important renal cortex appeared severely underperfused. Our findings suggest that early functional NMP quality assessment markers may not reflect actual physiology and should therefore be interpreted with caution.
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Affiliation(s)
- Rianne Schutter
- Department of Surgery - Organ Donation and Transplantation, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Veerle A Lantinga
- Department of Surgery - Organ Donation and Transplantation, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Tim L Hamelink
- Department of Surgery - Organ Donation and Transplantation, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Merel B F Pool
- Department of Surgery - Organ Donation and Transplantation, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Otis C van Varsseveld
- Department of Surgery - Organ Donation and Transplantation, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Jan Hendrik Potze
- Department of Radiology, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Jan-Luuk Hillebrands
- Department of Pathology & Medical Biology, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Marius C van den Heuvel
- Department of Pathology & Medical Biology, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Rudi A J O Dierckx
- Department of Radiology, University of Groningen, University Medical Center, Groningen, The Netherlands.,Department of Nuclear Medicine, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Henri G D Leuvenink
- Department of Surgery - Organ Donation and Transplantation, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Cyril Moers
- Department of Surgery - Organ Donation and Transplantation, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Ronald J H Borra
- Department of Radiology, University of Groningen, University Medical Center, Groningen, The Netherlands.,Department of Nuclear Medicine, University of Groningen, University Medical Center, Groningen, The Netherlands
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