Improving the Utilization of Deceased Donor Kidneys by Prioritizing Patient Preferences

Mohan, Sumit; Husain, S. Ali

doi:10.2215/cjn.08500722

Cited by 2 publications

(4 citation statements)

References 11 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Future allocation policies need to take into consideration potential recipients’ characteristics and preferences in a manner that results in match runs that are viewed by clinicians as providing more appropriate organ offers for their patients. This would ideally lower or eliminate declined offers (and out-of-sequence offers) by reducing or eliminating inappropriate offers for given recipients, thus dramatically improving allocation efficiency and organ placement in a patient-centered manner . Increased transparency for declined offers is an essential guardrail to ensure that the allocation system remains objective, accountable, and patient-centered and does not inadvertently increase disparities in access to transplantation …”

Section: Discussionmentioning

confidence: 99%

“…This would ideally lower or eliminate declined offers (and out-of-sequence offers) by reducing or eliminating inappropriate offers for given recipients, thus dramatically improving allocation efficiency and organ placement in a patient-centered manner. 7 , 27 Increased transparency for declined offers is an essential guardrail to ensure that the allocation system remains objective, accountable, and patient-centered and does not inadvertently increase disparities in access to transplantation. 5 , 8 , 15 , 28 …”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Characterization of Transplant Center Decisions to Allocate Kidneys to Candidates With Lower Waiting List Priority

King

Husain

et al. 2023

JAMA Netw Open

Self Cite

View full text Add to dashboard Cite

ImportanceAllocation of deceased donor kidneys is meant to follow a ranked match-run list of eligible candidates, but transplant centers with a 1-to-1 relationship with their local organ procurement organization have full discretion to decline offers for higher-priority candidates and accept them for lower-ranked candidates at their center.ObjectiveTo describe the practice and frequency of transplant centers placing deceased donor kidneys with candidates who are not the highest rank at their center according to the allocation algorithm.Design, Setting, and ParticipantsThis retrospective cohort study used 2015 to 2019 organ offer data from US transplant centers with a 1-to-1 relationship with their local organ procurement organization, following candidates for transplant events from January 2015 to December 2019. Participants were deceased kidney donors with a single match-run and at least 1 kidney transplanted locally and adult, first-time, kidney-only transplant candidates receiving at least 1 offer for a locally transplanted deceased donor kidney. Data were analyzed from March 1, 2022 to March 28, 2023.ExposureDemographic and clinical characteristics of donors and recipients.Main Outcomes and MeasuresThe outcome of interest was kidney transplantation into the highest-priority candidate (defined as transplanted after zero declines for local candidates in the match-run) vs a lower-ranked candidate.ResultsThis study assessed 26 579 organ offers from 3136 donors (median [IQR] age, 38 [25-51] years; 2903 [62%] men) to 4668 recipients. Transplant centers skipped their highest-ranked candidate to place kidneys further down the match-run for 3169 kidneys (68%). These kidneys went to a median (IQR) of the fourth- (third- to eighth-) ranked candidate. Higher kidney donor profile index (KDPI; higher score indicates lower quality) kidneys were less likely to go to the highest-ranked candidate, with 24% of kidneys with KDPI of at least 85% going to the top-ranked candidate vs 44% of KDPI 0% to 20% kidneys. When comparing estimated posttransplant survival (EPTS) scores between the skipped candidates and the ultimate recipients, kidneys were placed with recipients with both better and worse EPTS than the skipped candidates, across all KDPI risk groups.Conclusions and RelevanceIn this cohort study of local kidney allocation at isolated transplant centers, we found that centers frequently skipped their highest-priority candidates to place kidneys further down the allocation prioritization list, often citing organ quality concerns but placing kidneys with recipients with both better and worse EPTS with nearly equal frequency. This occurred with limited transparency and highlights the opportunity to improve the matching and offer algorithm to improve allocation efficiency.

show abstract

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Characterization of Transplant Center Decisions to Allocate Kidneys to Candidates With Lower Waiting List Priority

King

Husain

et al. 2023

JAMA Netw Open

Self Cite

View full text Add to dashboard Cite

show abstract

Section: Discussionmentioning

confidence: 99%

“…The complex process of getting onto the waitlist has many steps, and single-center analyses have identified disparities in attrition and rate of progression between each of these steps . However, our ability to assess which stages of this process act as the largest barriers to waitlisting or are responsible for waitlist disparities is limited by the absence of this information at the national level . There is no mandate for transplant centers to report which patients have been referred to them for transplant evaluation, which candidates do not complete a transplant workup, or which patients are deemed unsuitable for waitlisting and the reasons for these denials.…”

Section: Discussionmentioning

confidence: 99%

Disparities in Kidney Transplant Waitlisting Among Young Patients Without Medical Comorbidities

Husain,

Yu,

King

et al. 2023

JAMA Intern Med

Self Cite

View full text Add to dashboard Cite

ImportanceDisparities in kidney transplant referral and waitlisting contribute to disparities in kidney disease outcomes. Whether these differences are rooted in population differences in comorbidity burden is unclear.ObjectiveTo examine whether disparities in kidney transplant waitlisting were present among a young, relatively healthy cohort of patients unlikely to have medical contraindications to kidney transplant.Design, Setting, and ParticipantsThis retrospective cohort study used the US Renal Data System Registry to identify patients with end-stage kidney disease who initiated dialysis between January 1, 2005, and December 31, 2019. Patients who were older than 40 years, received a preemptive transplant, were preemptively waitlisted, or had documented medical comorbidities other than hypertension or smoking were excluded, yielding an analytic cohort of 52 902 patients. Data were analyzed between March 1, 2022, and February 1, 2023.Main Outcome(s) and Measure(s)Kidney transplant waitlisting after dialysis initiation.ResultsOf 52 902 patients (mean [SD] age, 31 [5] years; 31 132 [59%] male; 3547 [7%] Asian/Pacific Islander, 20 782 [39%] Black/African American, and 28 006 [53%] White) included in the analysis, 15 840 (30%) were waitlisted for a kidney transplant within 1 year of dialysis initiation, 11 122 (21%) were waitlisted between 1 and 5 years after dialysis initiation, and 25 940 (49%) were not waitlisted by 5 years. Patients waitlisted within 1 year of dialysis initiation were more likely to be male, to be White, to be employed full time, and to have had predialysis nephrology care. There were large state-level differences in the proportion of patients waitlisted within 1 year (median, 33%; range, 15%-58%). In competing risk regression, female sex (adjusted subhazard ratio [SHR], 0.92; 95% CI, 0.90-0.94), Hispanic ethnicity (SHR, 0.77; 95% CI, 0.75-0.80), and Black race (SHR, 0.66; 95% CI, 0.64-0.68) were all associated with lower waitlisting after dialysis initiation. Unemployment (SHR, 0.47; 95% CI, 0.45-0.48) and part-time employment (SHR, 0.74; 95% CI, 0.70-0.77) were associated with lower waitlisting compared with full-time employment, and more than 1 year of predialysis nephrology care, compared with none, was associated with greater waitlisting (SHR, 1.51; 95% CI, 1.46-1.56).Conclusions and RelevanceThis retrospective cohort study found that fewer than one-third of patients without major medical comorbidities were waitlisted for a kidney transplant within 1 year of dialysis initiation, with sociodemographic disparities in waitlisting even in this cohort of young, relatively healthy patients unlikely to have a medical contraindication to transplantation. Transplant policy changes are needed to increase transparency and address structural barriers to waitlist access.

show abstract

Improving the Utilization of Deceased Donor Kidneys by Prioritizing Patient Preferences

Cited by 2 publications

References 11 publications

Characterization of Transplant Center Decisions to Allocate Kidneys to Candidates With Lower Waiting List Priority

Characterization of Transplant Center Decisions to Allocate Kidneys to Candidates With Lower Waiting List Priority

Disparities in Kidney Transplant Waitlisting Among Young Patients Without Medical Comorbidities

Contact Info

Product

Resources

About