It is time to re-think 'extended criteria'

With respect to elderly patients: finding kidneys in the context of new allocation concepts

The elderly have benefited from increased access to renal transplantation in recent years. New allocation concepts would shift distribution of kidneys to younger recipients, making expanded criteria and living donor kidneys more relevant for seniors. Current issues impacting expanded criteria donor kidney availability and living donor transplant opportunities for the elderly are explored. It is hoped that the kidney donor profile index will improve risk assessment and utilization of marginal kidneys. The usefulness of procurement biopsy remains controversial. Dual kidney transplantation and machine perfusion appear to be effective mechanisms to increase organ availability. "Old-for-old" allocation systems, donation service area variation and regulatory and reimbursement issues highlight disparities and disincentives affecting expanded criteria donor organ utilization, and considerations for the way forward are discussed. Living donor transplantation, even with older donors, may provide the best option for elderly recipients, and careful expansion of the living donor pool appears appropriate. In light of new allocation concepts, it will be important to understand issues pertinent to seniors and develop effective strategies to maintain or improve their access to the benefits of transplantation.

Efficient utilization of the expanded criteria donor (ECD) deceased donor kidney pool: an analysis of the effect of labeling

We investigated the effect of the expanded criteria donor (ECD) label on (i) recovery of kidneys and (ii) acceptance for transplantation given recovery. An ECD is age > or = 60, or age 50-59 with > or = 2 of 3 specified comorbidities. Using data from the Scientific Registry of Transplant Recipients from 1999 to 2005, we modeled recovery rates through linear regression and transplantation probabilities via logistic regression, focusing on organs from donors just-younger versus just-older than the ECD age thresholds. We split the sample at July 1, 2002 to determine how decisions changed at the approximate time of implementation of the ECD definition. Before July 2002, the number of recovered kidneys with 0-1 comorbidities dropped at age 60, but transplantation probabilities given recovery did not. After July 2002, the number of recovered kidneys with 0-1 comorbidities rose at age 60, but transplantation probabilities contingent on recovery declined. No similar trends were observed at donor age 50 among donors with > or = 2 comorbidities. Overall, implementation of the ECD definition coincided with a reversal of an apparent reluctance to recover kidneys from donors over age 59, but increased selectiveness on the part of surgeons/centers with respect to these kidneys.

Acceptable outcome after kidney transplantation using "expanded criteria donor" grafts

INTRODUCTION

With the worldwide shortage of donors, extra lengths are ongoing to enlarge the donor pool. One means has been a greater use of "expanded criteria donor" (ECD) grafts. A major concern regarding ECD kidneys is poor long-term graft survival. The aims of this study were to determine whether ECD grafts, as defined by the United Network for Organ Sharing, had a negative impact on graft survival and to identify the principle donor and recipient factors that influenced graft survival in our patient cohort.

METHODS

We analyzed all deceased donor renal transplants in our unit from January 1995 to October 2005, in total 1,053 transplants.

RESULTS

ECD grafts (United Network for Organ Sharing criteria) demonstrated higher rates of delayed graft function and higher early mean creatinine levels. However, there was no significant difference in 5-year graft survival. Multivariate analysis of our patient group identified donor hypertension and ischemic heart disease (IHD) as independent predictors of poor graft survival. Recipient age was significant on univariate but not on multivariate analysis. However, although younger recipients maintained acceptable 5-year graft survival despite donor hypertension, IHD, or a combination of both, these factors significantly reduced graft survival in older recipients.

CONCLUSION

Although ECD grafts had slightly worse function, 5-year survival was comparable with standard grafts in all recipients. Donor hypertension, IHD, or a combination of both significantly reduced graft survival in older recipients, not evident in younger patients. We discuss the possible factors for improved outcome with ECD grafts in our patients and the implications of our patient analysis.

Immunosuppression in high-risk transplantation

PURPOSE OF REVIEW

Increasingly, transplant clinicians are faced with providing candidates with increased risks for poorer outcome with donor grafts that also carry higher risks of failure. Understanding the role of immunosuppressive management in these combinations of higher risks remains important for optimizing results.

RECENT FINDINGS

Few immunosuppressive protocols have been rigorously tested in the high-risk renal transplant setting. The two main risk categories accounted for in the trials are those ones that confer increased risks to renal function, usually carried by the donor organs, and those protocols defined by increased risk for immunological failure, mostly determined by recipient characteristics. The studied protocols generally involve reduction or avoidance of nephrotoxic drugs in the first case and use of lymphocyte-depleting agents in the case of increased immunological risk. In both scenarios, acceptable short-term results have been achieved. However, long-term results for high-risk transplants defined either by donor or recipient factors have yet to be reported.

SUMMARY

The lack of long-term data for optimizing the right immunosuppressive regimen for a given donor/recipient risk profile remains an ongoing challenge for researchers and clinicians alike.

Moving kidney allocation forward: the ASTS perspective

In 2008, the United Network for Organ Sharing issued a request for information regarding a proposed revision to kidney allocation policy. This plan described combining dialysis time, donor characteristics and the estimated life years from transplant (LYFT) each candidate would gain in an allocation score that would rank waiting candidates. Though there were some advantages of this plan, the inclusion of LYFT raised many questions. Foremost, there was no clear agreement that LYFT should be the main criterion by which patients should be ranked. Moreover, to rank waiting candidates with this metric, long-term survival models were required in which there was no incorporation of patient preference or discounting for long survival times and for which the predictive accuracy did not achieve accepted standards. The American Society of Transplant Surgeons was pleased to participate in the evaluation of the proposal. Ultimately, the membership did not favor this proposal, because we felt that it was too complicated and that the projected slight increase in overall utility was not justified by the compromise in individual justice that was required. We offer alternative policy options to address some of the unmet needs and issues that were brought to light during this interesting process.