Accelerating deceased donor kidney utilization requires more than accelerating placement

Abstract

The probability of kidney transplantation for waitlisted candidates varies widely in the United States. The 3-year probability of deceased donor transplantation ranges from 4% to 64.2%-representing a 16fold variation. 1 This variation is often attributed to geographical differences in the underlying organ supply but instead appears to be primarily driven by the willingness of transplant programs to accept organ offers as evidenced by the fact that in some instances there is nearly a 10-fold difference in the adjusted probability of transplantation within a single donation service area. 1 The reluctance to accept an organ that is eventually discarded may, in part, represent careful organ assessment. However, evidence that 84% of all kidneys are declined at least once as well as the abrupt rise in discards on the weekend and frequent incidence of unilateral discards raises important questions about the high level of variation in organ assessment and additional factors contributing to organ discard. [2][3][4] Removal of patients from

Early Effect of the Circular Model of Kidney Allocation in the United States

“…This would suggest that the introduction of more centers at the top of the match run is increasing the operational inefficiency in allocation. 22,23 For example, multiple centers with patients at the top of the match run creates the need for donor samples to be sent to more centers when a physical cross-match is desired. Also, local centers are potentially receiving offers late in the allocation process compared with the pre-KAS250 period.…”

Deceased donor kidneys allocated out of sequence by organ procurement organizations

“…With increasing attention on the rising national discard rate and greater system complexity introduced under KAS250 that appears to have increased CIT even for local kidneys and may have worsened the discard rate, pressure to invoke allocation exceptions for challenging kidneys may increase with the move toward continuous distribution. This is of particular concern given recent evidence that accelerating placement alone is insufficient for improved organ utilization 21,22 . It should also be noted that the OPO‐initiated out‐of‐sequence allocations in our study are occurring as exceptions with an unclear amount of oversight.…”

“…This is of particular concern given recent evidence that accelerating placement alone is insufficient for improved organ utilization. 21,22 It should also be noted that the OPO-initiated out-ofsequence allocations in our study are occurring as exceptions with an unclear amount of oversight. Lack of transparency around this process and the increase in frequency at only a couple centers risks undercutting the principles that allocation system design attempts to balance.…”

The role of bypass filters in deceased donor kidney allocation in the United States

“…Bypass filters examined in this study only apply to national offers from the UNOS Organ Center, which facilitates organ placements between different parts of the country. However, given the current capacity of the organ center, many OPOs place organs directly with non‐local centers, thereby avoiding engagement with the organ center and limiting the impact of these filters 29 . Centers unwilling to use kidneys with certain characteristics would presumably decline them regardless of where they originate.…”