Global trends and challenges in deceased donor kidney allocation

Abstract

Worldwide, the number of patients able to benefit from kidney transplantation is greatly restricted by the severe shortage of deceased donor organs. Allocation of this scarce resource is increasingly challenging and complex. Striking an acceptable balance between efficient use of (utility) and fair access to (equity) the limited supply of donated kidneys raises controversial but important debates at ethical, medical, and social levels. There is no international consensus on the recipient and donor factors that should be considered in the kidney allocation process. There is a general trend toward a reduction in the influence of human leukocyte antigen mismatch and an increase in the importance of other factors shown to affect posttransplant outcomes, such as cold ischemia, duration of dialysis, donor and recipient age, and comorbidity. Increased consideration of equity has led to improved access to transplantation for disadvantaged patient groups. There has been an overall improvement in the transparency and accountability of allocation policies. Novel and contentious approaches in kidney allocation include the use of survival prediction scores as a criterion for accessing the waiting list and at the point of organ offering with matching of predicted graft and recipient survival. This review compares the diverse international approaches to deceased donor kidney allocation and their evolution over the last decade.

Racial/ethnic disparities in waitlisting for deceased donor kidney transplantation 1 year after implementation of the new national kidney allocation system

“…(1) However, there is a severe shortage of organs for transplantation, forcing organ allocation policies to balance both equity and utility in their design (2). Many countries established their own deceased kidney organ allocation system to strike a balance between efficient use of and equal access to the deceased organs for deceased donor transplantation (2). In the United States, only ~15% of ESRD patients were waitlisted for kidney transplantation, and ~19,000 patients received a transplant in 2016 among the 103,114 people currently on the waitlist.…”

“…The aims of this study were (1) to assess the impact of the 2014 KAS policy change on waitlisting overall, and (2) to evaluate whether racial/ethnic disparities in waitlisting in the United States changed following the policy’s implementation. We performed two types of analyses to achieve these aims: (1) a time-to-event analysis to examine how KAS affected time from dialysis start to waitlisting among the incident ESRD population, and (2) a trend analysis to examine how the new KAS policy affected monthly waitlisting rates among prevalent (existing) dialysis patients not already on the waiting list.…”

Minding the Missing Link

“…However, not all HLA MM has an equal effect on transplant outcomes, and with the advent and uptake of safer and more potent immunosuppression, the benefit of HLA matching has been questioned. Despite this, many centers continue to prioritize zero HLA MM for kidney transplantation (8).…”

Successful development of vitrified embryonic kidney after laparoscopy transplantation into non-immunosuppressed hosts

“…Paradoxically, for these reasons that evidence the superior benefits of kidney transplantation over dialysis and the growing incidence of end-stage renal disease have led to an exponential increase in the need for kidney transplantation worldwide [19]. In addition, it is known that five-year survival was considerably better after living-donor kidney transplantation (94%) or after cadaveric-kidney transplantation (76%) than on chronic dialysis (60%) [20].…”

“…In 2014, only 17.814 kidneys were transplanted, being 12.279 from deceased donors and 5535 from living donors [22]. Thus, as long as the patient does not get an organ it will be dependent on dialysis, which have a higher risk for morbidity and mortality [19], dying nearly 5000 patients every year in this country [21]. In fact, the long-term mortality risk was 68% lower in the case of the patient receives a transplant when compared with patients remaining on the waiting list [23].…”