Discarded deceased donor kidneys have increased since 2018
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Key takeaways:
- More deceased donor kidneys have been discarded following the revised allocation system than prior to it.
- The increase was seen across all age groups and most donor profile indexes.
The number of discarded deceased donor kidneys increased in the United States between 2018 and 2022, according to data published in Kidney International Reports.
“Despite a shortage of donated kidneys, the United States has the highest proportion of deceased donor kidneys (DDKs) recovered for transplant that are subsequently discarded, resulting in federal government prioritization of improving organ utilization,” Sumit Mohan, MD, MPH, from Columbia University, and colleagues wrote.
Mohan and colleagues studied the discard rate of DDKs between May 1, 2018, and May 30, 2022. This time period included the revised allocation system (KAS250) in March 2021.
Although this new system removed geographic boundaries for organ allocation to improve transplant equity, according to the researchers, it also increased the complexity of interactions between transplant centers and organ procurement organizations (OPOs).
Analyses revealed a total of 96,834 DDKs were recovered, of which 22% were discarded. Organs discarded prior to KAS250 made up 21% of discarded DDKs, and that percentage increased to 25% following KAS250.
Researchers observed an increase in discarded organs across all adult donor age groups (18 to 60 years: 16% vs. 21%; 60 years: 54% vs. 60%), among DDKs with medium (18% vs. 22%) and high kidney donor profile indexes (64% vs. 68%) and for DDKs from donors after both cardiac death (22% vs. 31%) and brain death (20% vs. 23%).
However, no change was identified among discarded organs with low kidney donor profile indexes.
According to the researchers, the increase in discarded DDKs cannot be attributed to OPOs or geography because the increase has been seen across OPOs of all performance levels. Researchers noted that while “ the absolute number of DDK transplants has increased, over [one in four] DDKs recovered for transplant are not being transplanted, representing missed opportunities for hundreds of patients annually and increased health care system cost,” Mohan and colleagues wrote. “This unintended deleterious consequence of the allocation system change requires urgent intervention to ensure that priceless organs are not wasted and that efforts to improve geographic equity in transplant do not come at a cost of worsening DDK utilization.”
Perspective
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The current state of deceased donor kidney utilization in the United States is undeniably in dire and urgent need of improvement. In the latest report from Mohan and colleagues, the kidney discard rate increased to 25% in 2022 compared with 21% in 2018.
The recent rise in discard rate is thought to be from the increased complexity of organ allocation associated with the United Network for Organ Sharing (UNOS)/Organ Procurement and Transplantation Network (OPTN) 250-nautical mile (NM) circle-based allocation policy implemented in March 2021, which removed donor service areas as geographic boundaries and expanded “local sharing” to a 250-NM radius from a donor hospital. The intent of the policy was to alleviate existing geographic disparities in access to organs. Not surprisingly, since the implementation of the policy, kidneys are now traveling farther with longer cold ischemic times causing concerns for prolonged delayed graft function (DGF), primary nonfunction and overall inferior outcomes, ultimately leading to kidneys being “turned down” by transplant centers and exhaustion of candidates on the match run.
In analyzing the discard problem, it is important to recognize that transplant centers differ greatly as far as which types of kidneys the centers are willing to take. “Marginal” kidneys, such as high kidney donor profile index kidneys, donation after cardiac death kidneys from older donors or kidneys with AKI, are particularly prone to being turned down by some centers yet are considered viable kidneys by others. While it is important to continue educating transplant centers and professionals that these kidneys can in fact work well and benefit recipients, some centers may simply not have the expertise or infrastructure to provide care to patients who end up with prolonged DGF, for example.
And while marginal kidneys may be turned down by these transplant centers, there are certainly “aggressive” transplant centers that are willing to take these kidneys. However, by the time these kidneys are offered to aggressive centers, the cold ischemic times are simply too long, resulting in the match run list being exhausted. And so, to reduce kidney discards, one of the fundamental goals should be to reduce cold ischemic times and to efficiently get a kidney to the center that will use it.
How do we do this? The following are a few thoughts:
On the part of UNOS/OPTN,
- carefully consider the weight of placement efficiency and projected median travel distance as the OPTN finalizes the continuous distribution model of kidney allocation, projected to take in effect in 2024,
- address the inefficiencies of the transportation of kidneys, currently relying on commercial flights and courier services for travel from donor to recipient hospitals,
- standardize pumping criteria; and
- develop tools to allow the electronic transfer of kidney biopsy images such that these can be interpreted remotely by trained renal pathologists.
On the part of transplant centers,
- utilize organ filters,
- utilize predictive analytics tool,
- increase responsiveness to organ offers; and
- utilize “provisional yes” responsibly.
On the part of OPOs,
- ensure timely and responsive communication with transplant centers,
- create relationships with “aggressive centers;” and
- improve infrastructure to increase ability to pump kidneys, among others.
Undoubtedly, organ allocation involves a complex interplay among transplant centers, OPOs and UNOS/OPTN. The recently announced modernization initiative to revamp the organ allocation system by the Health Resources & Service Administration will hopefully help alleviate the problem. Ultimately, it boils down to everyone doing their share and being accountable in fixing the discard problem. Improved partnerships and communication are of utmost importance.
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