Efforts to reduce organ discard rate face regulatory challenges
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Even with a waitlist close to 100,000 individuals seeking a kidney transplant, approximately 20% of organs procured are discarded each year.
Reducing that rate will require elimination of regulatory changes that punish transplant centers for taking risks on using marginal donors, a speaker said at the American Nephrology Nurses Association’s Nephrology Nursing Practice, Management & Leadership Conference.
“Why are there so many organ discards yet we have a long waiting time for a kidney?” Kenneth Andreoni, MD, professor of surgery at the University Hospitals of Cleveland Medical Center-Case Western Reserve University, asked attendees.
There are pros and cons to using poor-quality or compromised organs, Andreoni said, noting that not all organs are the same. “When my mother was having hip surgery, I wasn’t worried about the prosthesis. They all look the same; they function the same.
“With transplant, all the kidneys are different. We are not getting the perfect replacement aortic value or cochlear implant,” Andreoni said. “We want to be able to just pull [a kidney] ‘off the shelf’ and transplant it like other devices.”
Transplant centers, like many health care entities, are evaluated by organizations like the Joint Commission on Accreditation of Healthcare Organizations, the Organ Procurement and Transplant Network and CMS, Andreoni said.
Failure to meet performance measures could result in transplant centers losing their certification. “These performance measures are based on outcomes. So if a transplant center accepts a marginal organ that has complications or has a lower graft survival, that could impact their performance score,” Andreoni said.
Approaches to procurement
In December 2014, the Organ Procurement and Transplant Network implemented the new kidney allocation system. In the new system, each kidney is allocated a kidney donor profile index (KDPI) based on 10 donor variables. KDPI scores range from 0%-100%, with higher scores meaning lower quality kidneys.
Deceased donor kidneys with higher KDPI scores “can be offered to older patients, sometimes with the implantation of both kidneys,” Andreoni said. “We need to address the reality of organs that are useable vs. the number of organs that are procured and educate patients on what these offers of deceased donor kidneys are about. Accepting two organs that are compromised is OK; make it clear about the limitations.”
Nationally, there was a 6% increase in deceased donor kidneys procured between 2019 to 2020, according to Andreoni — the 10th consecutive year for increases in donation. But “donor age is up,” he said, meaning that more compromised organs are being accepted for donation.
NKF Report
The NKF Consensus Conference to Decrease Kidney Discards released a report in October 2018 estimating that approximately 12 people die each day waiting for a kidney transplant, while about 10 kidneys are discarded, Andreoni said. “The reasons cited for discarded organs was poor organ quality, abnormal biopsy findings, prolonged cold ischemic time, anatomy, punitive regulatory and payer sanctions due to poor clinical outcomes, and the increased costs associated with the use of higher KDPI grafts,” he said. "Discard rates also vary upon geography, leading experts to believe that the variation may be based on a subjective view of organ viability by an individual transplant team.”
The panel of transplant experts agreed that to reduce the discard rate, CMS and other monitoring agencies should not penalize transplant centers for using more difficult deceased donor kidneys; change allocation for kidneys that are predictably hard to place for transplant, including two organ placements in place of one and educate patients on various organ offers early.
Patients on dialysis should be referred for a transplant workup when they still have residual renal function — “around CKD 3, when the eGFR is 20 or 19, instead of waiting longer,” Andreoni said. “Someone who is 75 and on dialysis doesn’t need a kidney for 30 years.”
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Andreoni K. Decreasing discard rates in transplantation. Presented at: American Nephrology Nurses Association’s Nephrology Nursing Practice, Management & Leadership Conference. Sept. 16-19, 2021.
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