Policy change for graft failure in deceased-donor kidney recipients may benefit waitlist
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Restoring pre-transplant waiting time for deceased-donor kidney recipients with allograft failure within 1 year of transplant may benefit the kidney waitlist through decrease in proportion of deceased-donor kidneys discarded.
“Current rules allow recipients to regain their pre-transplant waiting time only in the case of primary allograft non-function (PNF), defined as allograft nephrectomy, allograft failure, or persistent [eGFR]/creatinine clearance equal to or greater than 20 mL/min within 90 days of transplantation,” S. Ali Husain, MD, MPH, FASN, of the division of nephrology at Columbia University Medical Center and the Columbia University Renal Epidemiology Group, and colleagues wrote in American Journal of Kidney Diseases. “However, the incidence of PNF in the U.S. is less than 3% and true primary nonfunction is largely attributable to vascular catastrophes rather than poor donor quality. We therefore predict that implementing a policy change extending the period during which recipients with graft failure can reclaim waiting time can improve [deceased-donor kidney (DDK)] utilization by decreasing the cognitive weighting of an uncommon, temporally proximal loss and therefore reduce the perceived patient-level impact of early graft failure.”
Husain and colleagues retrospectively analyzed 2020 Organ Procurement and Transplantation Network Standard Transplant Analysis and Research data available for deceased kidney donors in the U.S. donating at least one kidney between Jan. 1, 2013, and Dec. 31, 2017, which allowed at least 2 years of follow-up for DDK recipients.
They identified 76,044 DDKs, 80% of which were transplanted and 20% discarded; an average of 4,045 DDKs were discarded annually. A relative reduction of the current discard rate (R) by 5%, 10%, 15%, 20% or 25%, would mean an estimated 202, 405, 607, 809 or 1,011 additional DDKs would be transplanted annually, respectively.
DDK transplantations had a failure rate of 1.3% to 3.9% at 3 months, 1.5% to 5.4% at 6 months, 1.9% to 7.5% at 12 months, 2.6% to 9.3% at 18 months and 3.5% to 10.7% at 24 months; 410 transplants per year failed within in 1 year, 150 of which were between 3 months and 1 year.
If additional transplants were expected to fail at the same rate within 1 year, 838 net additional DDKs would be transplanted for R = 25%, 641 for R = 20%, 443 for R = 15%, 245 for R = 10% and 47 for R = 5%.
Additionally, if currently discarded kidneys were expected to fail at two, three, four or five times the rate of currently transplanted kidneys, more additional transplants than excess would return to the waitlist at 6, 12, 18 and 24 months for reductions of 15%, 20% and 25%; at 10 times the failure rate, this was not the case.
“At this high expected failure rate, however, a net benefit to the waitlist would still be seen at a [time] up to 12 months except in a scenario where only a 5% relative reduction in discards is achieved,” Husain and colleagues wrote.
Based on their findings, they noted that extending the waitlist reinstatement policy would increase transplantation access, reduce net waitlist size and increase the perception of fairness in transplant allocation among patients.
Limitations included computation methods, perceived risks of DDKs and not accounting for dual transplantation or patient-level consequences of graft failure.
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