The weekend effect alters the procurement and discard rates of deceased donor kidneys in the United States

Abstract

Factors contributing to the high rate of discard among deceased donor kidneys remain poorly understood and the influence of resource limitations of weekends on kidney transplantation is unknown. To quantify this we used data from the Scientific Registry of Transplant Recipients and assembled a retrospective cohort of 181,799 deceased donor kidneys recovered for transplantation from 2000-2013. We identified the impact of the day of the week on the procurement and subsequent utilization or discard of deceased donor kidneys in the United States, as well as report the geographic variation on the impact of weekends on transplantation. Compared to weekday kidneys, organs procured on weekends were significantly more likely to be discarded than transplanted (odds ratio: 1.16; 95% confidence interval 1.13 – 1.19), even after adjusting for organ quality (adjusted odds ratio: 1.13; 95% confidence interval 1.10 – 1.17). Weekend discards were of a significantly higher quality than weekday discards (kidney donor profile index: 76.5 vs 77.3%). Considerable geographic variation was noted in the proportion of transplants that occurred over the weekend. Kidneys available for transplant over the weekend were significantly more likely to be used at larger transplant centers, be shared without payback, and experienced shorter cold ischemia times. Thus, factors other than kidney quality are contributing to the discard of deceased donor kidneys, particularly during weekends. Policy prescriptions, administrative or organizational solutions within transplant programs may potentially mitigate against the recent increase in kidney discards.

Is prolonged cold ischemia a contraindication to using kidneys from acute kidney injury donors?

“…Recent expansion of deceased donors have been due to increased utilization of “marginal” kidneys procured from ECD, DCD, and AKI donors . Unfortunately, with liberalization of deceased donor criteria, the number of kidneys recovered with the intent to transplant and then ultimately discarded each year has nearly doubled . Reasons for discard are myriad and include poor organ function and extended ischemia.…”

“…Future work will determine whether criteria for successful utilization within the AKI donor kidney category can be further expanded to maximize the use of available allografts. In fact, it is estimated that up to 500 recovered kidneys per year in the United States are discarded because of either poor organ function or AKI irrespective of CIT . In our opinion, when pre‐existing renal function is believed to be suboptimal or an accurate estimate of baseline renal function cannot be defined, dual kidney transplantation may represent another option …”

“…Commensurate with efforts to enlarge the donor pool and with changes in the Kidney Allocation System (KAS) including implementation of the Kidney Donor Profile Index (KDPI), the kidney discard rate increased from 10% in 1998 to 20% in 2015 . Deceased donors with an elevated terminal serum creatinine (SCr) level and/or cases with prolonged CIT represent a significant proportion of kidneys that are doomed to discard because of a lack of acceptance by multiple centers …”

Analysis of local versus imported expanded criteria donor kidneys: A single‐center experience with 497 ECD kidney transplants

“…These efforts resulted in increase in the number of marginal donors such as ECDs. Unfortunately, with liberalization of selection criteria to older deceased donors, the kidney discard rate in the United States nearly doubled as the value of transplanting ECD kidneys was questioned because of concerns over diminished graft function, survival, and longevity . The total proportion of recovered deceased donor kidneys that were subsequently discarded increased from 10% in 1998 to 19% in 2015.…”

Maximizing donors with viral hepatitis in the current era

“…In addition, fear of regulatory oversight with negative consequences for poor outcomes may inhibit transplant centers from exploring expansion of the donor pool. It is clear that many factors lead to the choice of whether to accept or decline an offer including potentially the day of the week . It is important to note that more recent data do not support a significant reduction in either patient or graft survival for HCV‐positive recipients of either an HCV‐positive kidney or liver.…”