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Sageshima J, Chandar J, Chen LJ, Shah R, Al Nuss A, Vincenzi P, Morsi M, Figueiro J, Vianna R, Ciancio G, Burke GW. How to Deal With Kidney Retransplantation-Second, Third, Fourth, and Beyond. Transplantation 2022; 106:709-721. [PMID: 34310100 DOI: 10.1097/tp.0000000000003888] [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: 11/25/2022]
Abstract
Kidney transplantation is the best health option for patients with end-stage kidney disease. Ideally, a kidney transplant would last for the lifetime of each recipient. However, depending on the age of the recipient and details of the kidney transplant, there may be a need for a second, third, fourth, or even more kidney transplants. In this overview, the outcome of multiple kidney transplants for an individual is presented. Key issues include surgical approach and immunologic concerns. Included in the surgical approach is an analysis of transplant nephrectomy, with indications, timing, and immunologic impact. Allograft thrombosis, whether related to donor or recipient factors merits investigation to prevent it from happening again. Other posttransplant events such as rejection, viral illness (polyomavirus hominis type I), recurrent disease (focal segmental glomerulosclerosis), and posttransplant lymphoproliferative disease may lead to the need for retransplantation. The pediatric recipient is especially likely to need a subsequent kidney transplant. Finally, noncompliance/nonadherence can affect both adults and children. Innovative approaches may reduce the need for retransplantation in the future.
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Affiliation(s)
- Junichiro Sageshima
- Division of Transplant Surgery, Department of Surgery, University of California Davis School of Medicine, Sacramento, CA
| | - Jayanthi Chandar
- Division of Pediatric Kidney Transplantation, Department of Pediatrics, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Linda J Chen
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Rushi Shah
- Surgical Transplant Fellow, Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Ammar Al Nuss
- Surgical Transplant Fellow, Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Paolo Vincenzi
- Surgical Transplant Fellow, Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Mahmoud Morsi
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Jose Figueiro
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Rodrigo Vianna
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
- Division of Liver and GI Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Gaetano Ciancio
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - George W Burke
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
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Jackson KR, Zhou S, Ruck J, Massie AB, Holscher C, Kernodle A, Glorioso J, Motter J, Neu A, Desai N, Segev DL, Garonzik-Wang J. Pediatric deceased donor kidney transplant outcomes under the Kidney Allocation System. Am J Transplant 2019; 19:3079-3086. [PMID: 31062464 PMCID: PMC6834871 DOI: 10.1111/ajt.15419] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 04/08/2019] [Accepted: 04/26/2019] [Indexed: 01/25/2023]
Abstract
The Kidney Allocation System (KAS) has resulted in fewer pediatric kidneys being allocated to pediatric deceased donor kidney transplant (pDDKT) recipients. This had prompted concerns that post-pDDKT outcomes may worsen. To study this, we used SRTR data to compare the outcomes of 953 pre-KAS pDDKT (age <18 years) recipients (December 4, 2012-December 3, 2014) with the outcomes of 934 post-KAS pDDKT recipients (December 4, 2014-December 3, 2016). We analyzed mortality and graft loss by using Cox regression, delayed graft function (DGF) by using logistic regression, and length of stay (LOS) by using negative binomial regression. Post-KAS recipients had longer pretransplant dialysis times (median 1.26 vs 1.07 years, P = .02) and were more often cPRA 100% (2.0% vs 0.1%, P = .001). Post-KAS recipients had less graft loss than pre-KAS recipients (hazard ratio [HR]: 0.35 0.540.83 , P = .005) but no statistically significant differences in mortality (HR: 0.29 0.721.83 , P = .5), DGF (odds ratio: 0.93 1.321.93 , P = .2), and LOS (LOS ratio: 0.96 1.061.19 , P = .4). After adjusting for donor-recipient characteristics, there were no statistically significant post-KAS differences in mortality (adjusted HR: 0.37 1.042.92 , P = .9), DGF (adjusted odds ratio: 0.94 1.412.13 , P = .1), or LOS (adjusted LOS ratio: 0.93 1.041.16 , P = .5). However, post-KAS pDDKT recipients still had less graft loss (adjusted HR: 0.38 0.590.91 , P = .02). KAS has had a mixed effect on short-term posttransplant outcomes for pDDKT recipients, although our results are limited by only 2 years of posttransplant follow-up.
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Affiliation(s)
- Kyle R. Jackson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sheng Zhou
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jessica Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Allan B. Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Courtenay Holscher
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Amber Kernodle
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jaime Glorioso
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jennifer Motter
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alicia Neu
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Niraj Desai
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland,Scientific Registry of Transplant Recipients, Minneapolis, Minnesota
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Jaramillo A, Reddy KS, Heilman RL. Using the Virtual Crossmatch to Allow for Safer and More Efficient Kidney Transplantation of Highly Sensitized Patients. Transplantation 2019; 104:1121-1122. [PMID: 31449189 DOI: 10.1097/tp.0000000000002925] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Andrés Jaramillo
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Phoenix, AZ
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Sanchez D, Dubay D, Prabhakar B, Taber DJ. Evolving Trends in Racial Disparities for Peri-Operative Outcomes with the New Kidney Allocation System (KAS) Implementation. J Racial Ethn Health Disparities 2018; 5:1171-1179. [PMID: 29557046 DOI: 10.1007/s40615-018-0464-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 01/16/2018] [Accepted: 01/29/2018] [Indexed: 01/08/2023]
Abstract
INTRODUCTION To improve kidney transplant allocation equitability, a new Kidney Allocation System (KAS) was implemented December 4, 2014. The purpose of this study was to determine if the impact of KAS on peri-operative outcomes differed by recipient race/ethnicity. METHODS This was a time series analysis using data aggregated in monthly intervals from October 2012 through September 2015 using the University HealthSystem Consortium (UHC). This includes national data aggregated at the center level of all US kidney transplant centers that participate in the UHC (416 centers). Segmented regression with interaction terms was used to determine the impact of KAS on outcomes and differences by race/ethnicity. RESULTS A total of 28,809 deceased donor kidney transplants were included with 25 months of pre-KAS data and 10 months of post-KAS data. After KAS implementation, the estimated transplant rate per month decreased significantly for Caucasians by 17.6 cases per month (p = 0.0001), and increased significantly for AAs by 37.8 (p = 0.0001), Hispanics by 16.3 (p = 0.0001), and other races by 8.2 cases per month (p = 0.0001). Delayed graft function, 7- and 14-day readmissions significantly increased after KAS, which did not differ by race. Hispanics saw a 7.7% decrease in ICU admissions after KAS, which differed as compared to other racial/ethnic cohorts (p = 0.0026). Costs of kidney transplantation increased significantly after KAS in all groups except Hispanics. Mortality, length of stay, in-hospital complications, and 30-day readmissions were not significantly impacted by KAS, also not differing by race/ethnicity. CONCLUSION KAS had substantial impact on transplant rates by race/ethnicity. KAS also led to increased costs, readmissions, and delayed graft function (DGF) across all racial/ethnic groups. The impact of KAS on ICU cases solely within Hispanics requires further investigation into potential etiologies.
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Affiliation(s)
- Daisy Sanchez
- College of Medicine, MUSC, Charleston, SC, 29425, USA.
| | - Derek Dubay
- Department of Transplant Surgery, MUSC, Charleston, SC, USA
| | | | - David J Taber
- Department of Transplant Surgery, MUSC, Charleston, SC, USA.,Ralph H Johnson, VAMC, Charleston, SC, USA
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Paramesh AS, Neidlinger N, Salvatore M, Smith A, Friedman A, Payne W, Taber T, Wright C. OPO Strategies to Prevent Unintended Use of Kidneys Exported for High PRA (>98% cPRA) Recipients. Am J Transplant 2017; 17:2139-2143. [PMID: 28168823 DOI: 10.1111/ajt.14220] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Revised: 01/26/2017] [Accepted: 01/29/2017] [Indexed: 01/25/2023]
Abstract
Since the advent of the Kidney Allocation System (KAS), matched candidates with high (>98%) panel reactive antibody (hPRA) are given priority over local candidates with lower PRA. This often leads to exporting of kidneys. Data for these kidneys are not detailed on routine reports. Twenty-two organ procurement organizations prospectively submitted data from August 2015 to July 2016, describing allocation practices of kidneys to hPRA patients and outcomes of these kidneys. Five hundred twenty out of 6924 procured kidneys were exported for hPRA recipients. Of these, 402 (77.3%) were transplanted into the intended recipient (IR); 100 (19.2%) were transplanted into unintended recipients (UR), and 18 (3.5%) were discarded. The most common reason for use in an UR was a positive crossmatch (XM) (63%). The most common reasons for discard were donor quality (44%) and ischemic time (39%). Prior to kidney export, when tissue crossmatching was done, 96.2% of the kidneys went to the IR, versus 80.7% following virtual CM, versus 56.7% when no crossmatching was performed (p < 0.0001). A significant number of kidneys exported for hPRA patients are not being used in the IR or are being discarded. The most common reason for this is positive tissue XM. We report that unintended use of the kidney was minimized when tissue was shipped and XM results were known prior to exporting the kidney.
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Affiliation(s)
- A S Paramesh
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA.,Louisiana Organ Procurement Agency, Metairie, LA
| | | | | | - A Smith
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA
| | | | - W Payne
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - T Taber
- Section of Nephrology, Indiana University School of Medicine, Indianapolis, IN
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Diagnostic Contribution of Donor-Specific Antibody Characteristics to Uncover Late Silent Antibody-Mediated Rejection-Results of a Cross-Sectional Screening Study. Transplantation 2017; 101:631-641. [PMID: 27120452 DOI: 10.1097/tp.0000000000001195] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Circulating donor-specific antibodies (DSA) detected on bead arrays may not inevitably indicate ongoing antibody-mediated rejection (AMR). Here, we investigated whether detection of complement-fixation, in parallel to IgG mean fluorescence intensity (MFI), allows for improved prediction of AMR. METHODS Our study included 86 DSA+ kidney transplant recipients subjected to protocol biopsy, who were identified upon cross-sectional antibody screening of 741 recipients with stable graft function at 6 months or longer after transplantation. IgG MFI was analyzed after elimination of prozone effect, and complement-fixation was determined using C1q, C4d, or C3d assays. RESULTS Among DSA+ study patients, 44 recipients (51%) had AMR, 24 of them showing C4d-positive rejection. Although DSA number or HLA class specificity were not different, patients with AMR or C4d + AMR showed significantly higher IgG, C1q, and C3d DSA MFI than nonrejecting or C4d-negative patients, respectively. Overall, the predictive value of DSA characteristics was moderate, whereby the highest accuracy was computed for peak IgG MFI (AMR, 0.73; C4d + AMR, 0.71). Combined analysis of antibody characteristics in multivariate models did not improve AMR prediction. CONCLUSIONS We estimate a 50% prevalence of silent AMR in DSA+ long-term recipients and conclude that assessment of IgG MFI may add predictive accuracy, without an independent diagnostic advantage of detecting complement-fixation.
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Colovai AI, Ajaimy M, Kamal LG, Masiakos P, Chan S, Savchik C, Lubetzky M, de Boccardo G, Courson A, Chokechanachaisakul A, Graham J, Greenstein S, Kinkhabwala M, Rocca J, Akalin E. Increased access to transplantation of highly sensitized patients under the new kidney allocation system. A single center experience. Hum Immunol 2017; 78:257-262. [DOI: 10.1016/j.humimm.2016.12.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 12/06/2016] [Accepted: 12/07/2016] [Indexed: 01/23/2023]
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Jani V, Ingulli E, Mekeel K, Morris GP. Root cause analysis of limitations of virtual crossmatch for kidney allocation to highly-sensitized patients. Hum Immunol 2017; 78:72-79. [DOI: 10.1016/j.humimm.2016.11.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 11/11/2016] [Accepted: 11/14/2016] [Indexed: 10/20/2022]
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Maier M, Takano T, Sapir-Pichhadze R. Changing Paradigms in the Management of Rejection in Kidney Transplantation: Evolving From Protocol-Based Care to the Era of P4 Medicine. Can J Kidney Health Dis 2017; 4:2054358116688227. [PMID: 28270929 PMCID: PMC5308536 DOI: 10.1177/2054358116688227] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 11/17/2016] [Indexed: 12/30/2022] Open
Abstract
PURPOSE OF REVIEW P4 medicine denotes an evolving field of medicine encompassing predictive, preventive, personalized, and participatory medicine. Using the example of kidney allograft rejection because of donor-recipient incompatibility in human leukocyte antigens, this review outlines P4 medicine's relevance to the various stages of the kidney transplant cycle. SOURCES OF INFORMATION A search for English articles was conducted in Medline via OvidSP (up to August 18, 2016) using a combination of subject headings (MeSH) and free text in titles, abstracts, and author keywords for the concepts kidney transplantation and P4 medicine. The electronic database search was expanded further on particular subject headings. FINDINGS Available histocompatibility methods exemplify current applications of the predictive and preventive domains of P4 medicine in kidney transplant recipients' care. Pharmacogenomics are discussed as means to facilitate personalized immunosuppression regimens and promotion of active patient participation as a means to improve adherence. LIMITATIONS For simplicity, this review focuses on rejection. P4 medicine, however, should more broadly address health concerns in kidney transplant recipients, including competing outcomes such as infections, malignancies, and cardiovascular disease. This review highlights how biomarkers to evaluate these competing outcomes warrant validation and standardization prior to their incorporation into clinical practice. IMPLICATIONS Consideration of all 4 domains of the P4 medicine framework when caring for and/or studying kidney transplant recipients has the potential of increasing therapeutic efficiency, minimizing adverse effects, decreasing health care costs, and maximizing wellness. Technologies to gauge immune competency, immunosuppression requirements, and early/reversible immune-mediated injuries are required to optimize kidney transplant care.
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Affiliation(s)
- Mirela Maier
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Metabolic Disorders and Complications, Research Institute of McGill University Health Centre, Montreal, Quebec, Canada
| | - Tomoko Takano
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Metabolic Disorders and Complications, Research Institute of McGill University Health Centre, Montreal, Quebec, Canada
| | - Ruth Sapir-Pichhadze
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Metabolic Disorders and Complications, Research Institute of McGill University Health Centre, Montreal, Quebec, Canada
- Multi-Organ Transplant Program, Royal Victoria Hospital, McGill University Health Centre, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation, McGill University Health Centre, Montreal, Quebec, Canada
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Gebel HM, Kamoun M. The new KAS: It takes a village. Hum Immunol 2016; 78:1-3. [PMID: 27845171 DOI: 10.1016/j.humimm.2016.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 10/31/2016] [Accepted: 10/31/2016] [Indexed: 11/18/2022]
Affiliation(s)
- Howard M Gebel
- Department of Pathology, Emory University Hospital, Atlanta, GA, United States.
| | - Malek Kamoun
- Department of Pathology, University of Pennsylvania, Philadelphia, PA, United States
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11
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Redfield RR, Scalea JR, Zens TJ, Mandelbrot DA, Leverson G, Kaufman DB, Djamali A. The mode of sensitization and its influence on allograft outcomes in highly sensitized kidney transplant recipients. Nephrol Dial Transplant 2016; 31:1746-53. [DOI: 10.1093/ndt/gfw099] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Accepted: 04/05/2016] [Indexed: 11/14/2022] Open
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Cross AR, Lion J, Loiseau P, Charron D, Taupin JL, Glotz D, Mooney N. Donor Specific Antibodies are not only directed against HLA-DR: Minding your Ps and Qs. Hum Immunol 2016; 77:1092-1100. [PMID: 27060781 DOI: 10.1016/j.humimm.2016.04.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 03/08/2016] [Accepted: 04/04/2016] [Indexed: 12/30/2022]
Abstract
During solid organ transplantation, interactions between recipient and donor immune cells occur chiefly in the allograft microvasculature. All three HLA class II antigens, DR, DP and DQ, have been detected on renal EC with a markedly increased expression of HLA class II observed in renal allografts undergoing rejection. Recent studies of donor-specific antibodies (DSA) have exposed the prevalence of de novo DSA directed against HLA-DQ, as well as a strong association between these antibodies and allograft damage. The HLA-DQ molecule can be distinguished from the other class II antigens by its transcription, expression and peptide repertoire. The distinct intragraft expression and immunogenicity of HLA-DQ may contribute to the incidence of HLA-DQ DSA, as well as directing the DSA-mediated damage. The possibility of HLA class II antigen-specific signaling in EC may reveal different mechanisms of allograft damage that act in tandem with complement-dependent injury. This review addresses the features of the HLA-DQ heterodimer that may underlie the high incidence of HLA-DQ directed DSA and their association with allograft damage. We also consider existing data in hematopoietic stem cell transplantation concerning HLA directed DSA.
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Affiliation(s)
- Amy R Cross
- INSERM UMRs 1160, Institut Universitaire d'Hématologie, Université Paris Diderot, Hôpital Saint Louis, Paris 75010, France; LabEx Transplantex, AP-HP, Hôpital Saint-Louis, Paris 75010, France
| | - Julien Lion
- INSERM UMRs 1160, Institut Universitaire d'Hématologie, Université Paris Diderot, Hôpital Saint Louis, Paris 75010, France; LabEx Transplantex, AP-HP, Hôpital Saint-Louis, Paris 75010, France
| | - Pascale Loiseau
- INSERM UMRs 1160, Institut Universitaire d'Hématologie, Université Paris Diderot, Hôpital Saint Louis, Paris 75010, France; LabEx Transplantex, AP-HP, Hôpital Saint-Louis, Paris 75010, France; Laboratoire de Histocompatibilité, Hôpital Saint Louis, Paris 75010, France
| | - Dominique Charron
- Laboratoire de Histocompatibilité, Hôpital Saint Louis, Paris 75010, France; Université Paris Diderot, Sorbonne Paris Cité, F-75013, France
| | - Jean-Luc Taupin
- INSERM UMRs 1160, Institut Universitaire d'Hématologie, Université Paris Diderot, Hôpital Saint Louis, Paris 75010, France; LabEx Transplantex, AP-HP, Hôpital Saint-Louis, Paris 75010, France; Laboratoire de Histocompatibilité, Hôpital Saint Louis, Paris 75010, France; Université Paris Diderot, Sorbonne Paris Cité, F-75013, France
| | - Denis Glotz
- INSERM UMRs 1160, Institut Universitaire d'Hématologie, Université Paris Diderot, Hôpital Saint Louis, Paris 75010, France; LabEx Transplantex, AP-HP, Hôpital Saint-Louis, Paris 75010, France; Service de Néphrologie et Transplantation, Hôpital Saint Louis, Paris 75010, France; Université Paris Diderot, Sorbonne Paris Cité, F-75013, France
| | - Nuala Mooney
- INSERM UMRs 1160, Institut Universitaire d'Hématologie, Université Paris Diderot, Hôpital Saint Louis, Paris 75010, France; LabEx Transplantex, AP-HP, Hôpital Saint-Louis, Paris 75010, France.
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Gebel HM, Kasiske BL, Gustafson SK, Pyke J, Shteyn E, Israni AK, Bray RA, Snyder JJ, Friedewald JJ, Segev DL. Allocating Deceased Donor Kidneys to Candidates with High Panel-Reactive Antibodies. Clin J Am Soc Nephrol 2016; 11:505-11. [PMID: 26839235 DOI: 10.2215/cjn.07720715] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 11/13/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES In December of 2014, the Organ Procurement and Transplant Network implemented a new Kidney Allocation System (KAS) for deceased donor transplant, with increased priority for highly sensitized candidates (calculated panel-reactive antibody [cPRA] >99%). We used a modified version of the new KAS to address issues of access and equity for these candidates. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In a simulation, 10,988 deceased donor kidneys transplanted into waitlisted recipients in 2010 were instead allocated to candidates with cPRA≥80% (n=18,004). Each candidate's unacceptable donor HLA antigens had been entered into the allocation system by the transplant center. In simulated match runs, kidneys were allocated sequentially to adult ABO identical or permissible candidates with cPRA 100%, 99%, 98%, etc. to 80%. Allocations were restricted to donor/recipient pairs with negative virtual crossmatches. RESULTS The simulation indicated that 2111 of 10,988 kidneys (19.2%) would have been allocated to patients with cPRA 100% versus 74 of 10,988 (0.7%) that were actually transplanted. Of cPRA 100% candidates, 74% were predicted to be compatible with an average of six deceased donors; the remaining 26% seemed to be incompatible with every deceased donor organ that entered the system. Of kidneys actually allocated to cPRA 100% candidates in 2010, 66% (49 of 74) were six-antigen HLA matched/zero-antigen mismatched (HLA-A, -B, and -DR) with their recipients versus only 11% (237 of 2111) in the simulation. The simulation predicted that 10,356 of 14,433 (72%) candidates with cPRA 90%-100% could be allocated an organ compared with 7.3% who actually underwent transplant. CONCLUSIONS Data in this simulation are consistent with early results of the new KAS; specifically, nearly 20% of deceased donor kidneys were (virtually) compatible with cPRA 100% candidates. Although most of these candidates were predicted to be compatible with multiple donors, approximately one-quarter are unlikely to receive a single offer.
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Affiliation(s)
- Howard M Gebel
- Department of Pathology, Emory University Hospital, Atlanta, Georgia
| | - Bertram L Kasiske
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota; Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Sally K Gustafson
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Joshua Pyke
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Eugene Shteyn
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Ajay K Israni
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota; Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota; Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota;
| | - Robert A Bray
- Department of Pathology, Emory University Hospital, Atlanta, Georgia
| | - Jon J Snyder
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota; Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - John J Friedewald
- Departments of Medicine and Surgery, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois; and
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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14
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Bringing Rationality to Rationing?--The Challenges of Organ Allocation. Transplantation 2016; 100:708-9. [PMID: 26784115 DOI: 10.1097/tp.0000000000001058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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