The use of marginal kidneys in dual kidney transplantation to expand kidney graft utilization

Abstract

Purpose of reviewThe purpose of this review is to chronicle the history of dual kidney transplantation (DKT) and identify opportunities to improve utilization of marginal deceased donor (MDD) kidneys through DKT. Recent findingsThe practice of DKT from adult MDDs dates back to the mid-1990s, at which time the primary indication was projected insufficient nephron mass from older donors. Multiple subsequent studies of short-and longterm success have been reported focusing on three major aspects: Identifying appropriate selection criteria/scoring systems based on pre-and postdonation factors; refining technical aspects; and analyzing longer-term outcomes. The number of adult DKTs performed in the United States has declined in the past decade and only about 60 are performed annually. For adult deceased donor kidneys meeting double allocation criteria, >60% are ultimately not transplanted. MDDs with limited renal functional capacity represent a large proportion of potential kidneys doomed to either discard or nonrecovery. SummaryDKT may reduce organ discard and optimize the use of kidneys from MDDs. New and innovative technologies targeting ex vivo organ assessment, repair, and regeneration may have a major impact on the decision whether or not to use recovered kidneys for single or DKT.

Implementation of Blockchain Technology Could Increase Equity and Transparency in Organ Transplantation: A Narrative Review of an Emergent Tool

“…Despite the application of expanded criteria, deceased donors or marginal kidneys in dual kidney procedures (36 , 37) , it has been calculated that fewer than 25% of the waitlisted patients are transplanted because of organ shortage ( 38 ). To overcome the chronic organ shortage, kidney donation is routinely performed in one-third of patients from living donors.…”

Mitochondria Transplantation Mitigates Damage in an In Vitro Model of Renal Tubular Injury and in an Ex Vivo Model of DCD Renal Transplantation

“…Finally, as 40% of the renal transplants performed in the Unite States are DCD renal transplants, alternative, more effective approaches that may improve the function and the overall outcome of "less than optimal graft" are urgently needed. Our transplant program has a broad, longstanding experience in the use of such allografts including DCD kidneys [40][41][42][43][44][45][46][47][48][49][50][51][52][53][54][55] and our patients would see potential benefit from treatments that mitigate DCD kidney damage. Overall, our ex vivo data confirmed the beneficial effects of MITO observed in vitro.…”

Kidney utility and futility

“…We as a community have a good understanding of the phenotype of “hard to place” deceased donor kidneys (Table 1), yet we continue to promote a “one size fits all” approach to organ allocation and distribution 17–19 . For example, when the “new” UNOS dual kidney allocation policy was implemented in September 2019, the data demonstrated that when either the donor age was ≥68 years or the KDPI was ≥92%, then the kidney discard rate surpassed the rate of single kidney utilization 20 . We are also aware of the “aggressive center” phenotype (or donor utilization index) and those centers that are most likely to import and utilize MDD kidneys provided they receive the offer in a timely fashion and the offer is an “open” offer (to anyone on the center's waiting list) 17,19,21,22 …”

“…[17][18][19] For example, when the "new" UNOS dual kidney allocation policy was implemented in September 2019, the data demonstrated that when either the donor age was ≥68 years or the KDPI was ≥92%, then the kidney discard rate surpassed the rate of single kidney utilization. 20 We are also aware of the "aggressive center" phenotype (or donor utilization index) and those centers that are most likely to import and utilize MDD kidneys provided they receive the offer in a timely TA B L E 1 Defining criteria for marginal deceased donor (MDD)/hard to place deceased donor kidneys Pre-recovery criteria:…”