Increased risk organ transplantation in the pediatric population

Abstract

IRD organs are classified by the Public Health Service to be at above-average risk for harboring human immunodeficiency virus, hepatitis C, and hepatitis B. Traditionally underutilized, there exists even greater reluctance for their use in pediatric patients. We performed a retrospective analysis via the United Network for Organ Sharing database of all pediatric renal and hepatic transplants performed from 2004 to 2008 in the United States. Primary outcomes were patient and graft survival. Proportional hazards regression was performed to control for potentially confounding factors. Waitlist time, organ acceptance rates, and infectious transmissions were analyzed. There were 1830 SRD renal, 92 IRD renal, 1695 SRD hepatic, and 59 IRD hepatic transplants. There were no statistically significant differences in allograft or patient survival in either group. Acceptance rates of IRD organs were lower for kidney (1.5% IRD vs 4.82% SRD) and liver (1.99% IRD vs 4.51% SRD). One transmission of a bloodborne pathogen involving a pediatric recipient out of 7797 unique transplants was reported from 2008 to 2015. IRD organs appear to have equivalent outcomes. Increasing their utilization may improve access to transplant while decreasing wait times and circumventing waitlist morbidity and mortality.

The impact of public health service increased risk donors in pediatric liver transplantation

“…Therefore, patients and/or providers might be making a decision to wait for the “ideal donor” rather than using a donor labeled as increased risk that, in reality, has a very low risk of infectious transmission 16 . Previous studies have demonstrated equivalent outcomes to standard criteria organs with the use of livers from increased risk donors in adults and pediatrics 3,20 . In our analysis, we also demonstrated no difference in patient or allograft survival between recipients receiving PHS increased risk donors and non‐increased risk donors.…”

“…There is controversy regarding the use of donors who are considered “PHS increased risk.” 3 In 2004, the UNOS adopted the label “high risk donor” to identify donors that met the CDC 1994 criteria for high risk behavior for infection. In 2013, the PHS published updated guidelines for reducing HIV, HBV, and HCV transmission through organ transplantation 4 .…”

Use of public health service increased risk kidneys in pediatric renal transplant recipients

“…Although an extensive body of work has evaluated utilization of organs from IR donors among adults, little data exist in the context of pediatric patients. Wrenn et al examined utilization of IR kidneys for pediatric recipients in the early IR period (2004‐2008) showing no significant difference in allograft or patient survival, but lower acceptance rates for IR kidneys . Recent data have demonstrated that transplant outcomes using organs from IR donors are not different than standard donors for adults, yet organs from these donors are discarded at higher rates .…”

“…The impact of the opioid epidemic on organ transplantation has received significant attention, with a focus on the markedly increased 23 Recent data have demonstrated that transplant outcomes using organs from IR donors are not different than standard donors for adults, yet organs from these donors are discarded at higher rates. 4,24,25 Recent work has demonstrated pediatric recipients' decreasing access to high quality deceased donor kidneys post-Kidney Allocation System's transition to a KDPI-based allocation system.…”

Expanding deceased donor kidney transplantation

“…In fact, one study found that 42% of kidney transplant candidates would reject IRD kidneys under all circumstances (38). The reluctance to use IRD organs is perhaps even greater when treating pediatric transplant candidates, despite the fact that IRD kidneys are associated with similar allograft and patient survival and that only one unintended bloodborne pathogen transmission occurred in 8,000 unique pediatric transplants from 2008-2015 (39).…”