Can Behavioral Research Improve Transplant Decision-Making? A Mock Offer Study on the Role of Kidney Procurement Biopsies

Abstract

Background The use of procurement biopsies for assessing kidney quality has been implicated as a driver of the nearly 20% kidney discard rate in the United States. Yet in some contexts, biopsies may boost clinical confidence, enabling acceptance of kidneys that would otherwise be discarded. We leveraged a novel organ offer simulation platform to conduct a controlled experiment isolating biopsy effects on offer acceptance decisions. Methods Between November 26 and December 14, 2018, 41 kidney transplant surgeons and 27 transplant nephrologists each received the same 20 hypothetical kidney offers using a crossover design with weekend "washout" periods. Mini-study 1 included four, low serum creatinine (,1.5 mg/dl) donor offers with arguably "poor" biopsy findings that were based on real offers that were accepted with successful 3-year recipient outcome. For each of the four offers, two experimental variants-no biopsy and "good" biopsy-were also sent. Mini-study 2 included four AKI offers with no biopsy, each having an offer variant with "good" biopsy findings. Results Among low serum creatinine donor offers, we found approximately threefold higher odds of acceptance when arguably poor biopsy findings were hidden or replaced with good biopsy findings. Among AKI donor offers, we found nearly fourfold higher odds of acceptance with good biopsy findings compared with no biopsy. Biopsy information had profound but variable effects on decision making: more participants appeared to have been influenced by biopsies to rule out, versus rule in, transplantable kidneys. Conclusions The current use of biopsies in the United States appears skewed toward inducing kidney discard. Several areas for improvement, including reducing variation in offer acceptance decisions and more accurate interpretation of findings, have the potential to make better use of scarce, donated organs. Offer simulation studies are a viable research tool for understanding decision making and identifying ways to improve the transplant system.

Deceased Donor Procurement Biopsy Practices, Interpretation, and Histology-Based Decision-Making: A Survey of US Kidney Transplant Centers

“… 38 However, the biopsy was impactful to many of the survey respondents: >60% of respondents reported that they would decline a marginal kidney and 46% that they would decline a standard criteria kidney with “bad” histology. The standard criteria donor responses are consistent with a case-based study 39 wherein respondents were provided with a variety of simulated organ offers accompanied by no biopsy, a “poor” biopsy, or a “good” biopsy. The odds of declining an otherwise acceptable kidney from a donor with low serum creatinine but with a “bad” biopsy were 2.5 times that faced by a similar kidney with a “good” biopsy; 31% of the respondents reported that the biopsy prompted them to decline in this situation.…”

“…The odds of declining an otherwise acceptable kidney from a donor with low serum creatinine but with a “bad” biopsy were 2.5 times that faced by a similar kidney with a “good” biopsy; 31% of the respondents reported that the biopsy prompted them to decline in this situation. 39 Similarly, in a national US registry analysis, Lentine et al. 2 found that low-KDPI (<20%) donor organs which were biopsied were >6 times (odds ratio, 6.47) as likely to be discarded as kidneys that were not biopsied.…”

Variations in deceased donor kidney procurement biopsy practice patterns: A survey of U.S. organ procurement organizations

“…27 A recent mock offer study on the role of procurement biopsy in acceptance decisions found that offer acceptance rates were significantly influenced by percentage glomerulosclerosis when all other aspects of the biopsy and donor history remained the same. 28 We should also note that while centers continue to use percentage glomerulosclerosis as part of the kidney acceptance decision, the percentage glomerulosclerosis ought to be interpreted within the context of other aspects of donor history, including donor age. A biopsy with 20% glomeruli sclerosed in a kidney from a 20-year-old donor as opposed to a 65-year-old donor have very different prognostic implications, as in the latter instance, the sclerosis may simply reflect age related changes.…”

The Independent Effects of Procurement Biopsy Findings on 10-Year Outcomes of Extended Criteria Donor Kidney Transplants

“…All else equal, offer acceptance rates were found to be 37% lower when interstitial fibrosis was reported as mild-moderate compared with absent in a controlled experiment. 21 Our study found that the apparent increased risk associated with interstitial fibrosis is largely, if not entirely, accounted for by other factors. Clinical prediction models statistically adjust for such correlations to avoid the double counting trap.…”