Declined Offers for Deceased Donor Kidneys Are Not an Independent Reflection of Organ Quality

Abstract

Background: Deceased donor kidney offers are frequently declined multiple times before acceptance for transplantation, despite significant organ shortage and long waiting times. Whether the number of times a kidney has been declined, reflecting cumulative judgments of clinicians, is associated with long-term transplant outcomes remains unclear. Methods: In this national, retrospective cohort study of deceased donor kidney transplants in the United States from 2008 to 2015 (n=78,940), we compared donor and recipient characteristics and short- and long-term graft and patient survival outcomes grouping by the sequence number at which the kidney was accepted for transplantation. We compared outcomes for kidneys accepted within the first 7 offers in the match run, after 8-100 offers, and for hard-to-place kidneys distinguishing those requiring >100 and >1000 offers before acceptance. Results: Harder to place kidneys had lower donor quality and higher rates of delayed graft function (46% among kidneys requiring >1000 offers before acceptance versus 23% among kidneys with ≤7 offers). In unadjusted models, later sequence groups had higher hazard of all-cause graft failure, death-censored graft failure, and patient mortality; however, these associations were attenuated after adjusting for kidney donor risk index (KDRI). After adjusting for donor factors already taken into consideration during allocation and recipient factors associated with long-term outcomes, graft and patient survival outcomes were not significantly different for the hardest-to-place kidneys compared to the easiest-to-place kidneys, with the exception of death-censored graft failure (adjusted hazard ratio: 1.16, 95% CI: 1.05-1.28). Conclusions: Late sequence offers may represent missed opportunities for earlier successful transplant for the higher-priority waitlisted candidates for whom the offers were declined.

Association of transplant center market concentration and local organ availability with deceased donor kidney utilization

“…Kidneys procured for transplant are offered to centers on behalf of their waitlisted candidates, but centers can accept/decline each offer based on criteria of their own choosing. The subjectivity of these decisions appears to be independent of organ quality and leads to considerable practice variations 17,18 . Organs that experience frequent turn‐downs are more likely to be discarded, and this processes has been hypothesized to create a negative feedback loop that discourages OPOs from procuring marginal quality organs.…”

“…The subjectivity of these decisions appears to be independent of organ quality and leads to considerable practice variations. 17,18 Organs that experience frequent turndowns are more likely to be discarded, and this processes has been hypothesized to create a negative feedback loop that discourages OPOs from procuring marginal quality organs. Improving organ procurement and subsequent acceptance is therefore key to expanding kidney transplantation in the United States.…”

Accelerating deceased donor kidney utilization requires more than accelerating placement

“…the waitlist after placement is pervasive as is waitlist mortalityincluding for patients who have had organ offers declined on their behalf. 2,5 As a result, mechanisms to expeditiously match available organs at higher risk for discard with patients that may benefit from these organs is an ongoing challenge with critically important implications. 6 It is with this background that there is an increased focus on organ utilization.…”

“…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 2–4 . Removal of patients from the waitlist after placement is pervasive as is waitlist mortality—including for patients who have had organ offers declined on their behalf 2,5 . As a result, mechanisms to expeditiously match available organs at higher risk for discard with patients that may benefit from these organs is an ongoing challenge with critically important implications 6 …”

Improving the Utilization of Deceased Donor Kidneys by Prioritizing Patient Preferences

“…It is important to remember that studies describing these declined offers have included only organs that were subsequently accepted for a different patient with a lower allocation priority. These declined offers contribute to existing disparities—with little evidence to suggest the organs declined multiple times perform any worse than would be expected for other organs of similar quality (8). In contrast, there is clear evidence that centers are frequently making the wrong choice for their patients, as approximately one third of patients who are waitlisted and receive at least one organ offer are subsequently either delisted without a transplant or die on the waitlist (4).…”