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Kidney allocation system reform necessary, new data suggest
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Due to the implementation of the new kidney allocation system, highly sensitized kidney transplant recipients received more kidneys with lower kidney donor profile indexes. Higher index scores were associated with improved patient survival and graft loss more than calculated panel-reactive antibody level, according to a study.
This type of change in allocation was not the intended result of the kidney allocation system (KAS) and it is unclear whether it has affected the clinical outcomes of kidney transplantation, according to the study.
“We are concerned that the disproportionate utilization of high-quality kidneys in highly sensitized candidates draws these kidneys away from lesser-sensitized candidates, which may have potential ramifications on post-transplant outcomes in the lesser-sensitized,” lead investigator of the study Edmund Huang, MD, said in a National Kidney Foundation press release.
In the observational cohort study, researchers analyzed outcome data of 84,451 adult patients who received a transplant of a deceased donor kidney between Oct. 1, 2009 and Sept. 30, 2017. Predictors in this study included calculated panel-reactive antibody (cPRA) level and kidney donor profile index (KDPI) scores.
Researchers found the transplantation of kidneys with KDPI scores of no more than 20% and between 21% and 85% increased four-fold in patients with cPRA levels of at least 99%. Additionally, patient survival and graft loss showed a strong association with KDPI scores, but not as much with the cPRA scores.
Investigators found no evidence of a differential effect on patient survival or graft loss due to KDPI scores across the range of cPRA levels.
“Our data raise the question of whether the KAS has gone too far in prioritizing highly sensitized candidates,” the authors wrote. “This is a contentious issue because deceased donor transplantation rates (defined as the number of deceased donor transplantations per 100 patient-years of active wait time) among candidates with cPRA levels of 98% to 100% have significantly improved and are now comparable or higher than the rest of the waitlist population after the KAS. Our data suggest that further modifications to policy are warranted to equitably allocate the highest quality organs.”
Among the cPRA groups, survival at 5 years stood between 87.2% and 89.8% for transplant recipients with KDPI scores no more than 20%. Additionally, as KDPI score increased, incidence of graft loss by cPRA level increased; up to 29.7% for scores of greater than 85%.
“This review by Huang and colleagues’ sheds light on the results of the most recent kidney allocation system and the ongoing need to make more efficient use of deceased-donor kidneys and limit deceased-donor kidney discards,” Joseph Vassalotti, MD, chief medical officer of the NKF, said in the release. “As all prior organ allocation systems have demonstrated and current UNOS policy proposals for a new allocation system predict, the continuing shortage of donated organs results in challenging decisions in providing fair access often at the expense of optimal kidney utility and/or kidney survival.” -by Scott Buzby
Disclosures: The authors report no relevant financial disclosures.
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