Identifying Appropriate Recipients for CDC Infectious Risk Donor Kidneys

Abstract

yBoth authors contributed equally.Over 10% of deceased donors in 2011 met PHS/CDC criteria for infectious risk donor (IRD), and discard rates are significantly higher for kidneys from these donors. We hypothesized that patient phenotypes exist for whom the survival benefit outweighs the infectious risk associated with IRDs. A patient-oriented Markov decision process model was developed and validated, based on SRTR data and meta-analyses of window period risks among persons with IRD behaviors. The Markov model allows patients to see, for their phenotype, their estimated survival after accepting versus declining an IRD offer, graphed over a 5-year horizon. Estimated 5-year survival differences associated with accepting IRDs ranged from À6.4% to þ67.3% for a variety of patient phenotypes. Factors most predictive of the survival difference with IRD transplantation were age, PRA, previous transplant, and the expected time until the next non-IRD deceased donor offer. This study suggests that survival benefit derived from IRD kidneys varies widely by patient phenotype. Furthermore, within the inherent limitations of modelbased prediction, this study demonstrates that it is possible to identify those predicted to benefit from IRD kidneys, and illustrates how estimated survival curves based on a clinical decision can be presented to better inform patient and provider decision-making.

Landscape of Deceased Donors Labeled Increased Risk for Disease Transmission Under New Guidelines

“…Data show that for almost all patients, an IRD transplant would significantly improve survival compared to remaining on the waitlist (6). However, regardless of the low absolute risks, patients may be reluctant to accept an organ specifically labeled as imparting any increased risk of stigmatized diseases such as HIV and hepatitis, and may instead choose to wait for a “risk-free” organ (8, 9).…”

“…While the risk that an IRD is infected during the WP is higher relative to a non-IRD, the absolute risk is still very low (published risks ranging from < 1 in 1000 for hepatitis C to <1 in 10,000 for HIV) (4, 5), and many patients are predicted to derive substantial survival benefit (6). While the IRD label is intended to reduce infectious transmission, there are potential downsides.…”

New Solutions to Reduce Discard of Kidneys Donated for Transplantation

“…The survival benefit of accepting a PHS infectious-risk kidney was most evident for patients in regions with longer waiting times, older patients, patients with diabetes, and those with elevated panel reactive antibody. 29 These simulations did not take into account quality of life, but most studies have demonstrated that kidney transplantation improves quality of life versus dialysis. 30 …”

Cultural competency of a mobile, customized patient education tool for improving potential kidney transplant recipients’ knowledge and decision-making

“…Survival with US PHS increased-risk kidneys was assumed to be the similar to the non US-PHS high risk kidneys with average KDPI scores based on national data. [16] Data presentation: MTC includes 3 analyses for patients. First, patients are provided with 5-year survival estimates for individuals with comparable risk who either remain on dialysis, are waitlisted for a DDKT, or immediately receive a LDKT ( Figure 1A).…”