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Fortin MC, Ballesteros Gallego F, Cardinal H, Kaur M, Mainra R, Patoine S, Rosaasen N, Mansell H. Patient and Caregiver Perceptions on the Allocation Process and Waitlist, and Accepting a Less-Than-Ideal Kidney: A Canadian Survey. Can J Kidney Health Dis 2025; 12:20543581251324608. [PMID: 40182648 PMCID: PMC11967212 DOI: 10.1177/20543581251324608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2024] [Accepted: 12/25/2024] [Indexed: 04/05/2025] Open
Abstract
Background Transplanting less-than-ideal (LTI) kidneys could help optimize organ utilization, but little is known about how patients and caregivers perceive the allocation process, waitlist, or LTI kidneys. Objective To explore the perspectives of patients and caregivers on the Canadian kidney transplant allocation process, waitlist, and LTI kidneys. Design Electronic survey. Setting Canada. Patients Transplant recipients, candidates, and caregivers. Methods A bilingual electronic national survey was administered from January to March 2024. The questionnaire contained sections on demographics, perceptions of organ allocation and acceptance, LTI kidneys, and educational preferences. Descriptive analysis was performed. Results Two hundred fifty-one responses were analyzed, including patients (63%, n = 159), and caregivers (37%, n = 92), from 11 provinces and territories. Three-quarters (74%, n = 186) understood how patients are placed on the waiting list, and 65% (n = 162) understood how donor kidneys are allocated, but 72% (n = 181) and 68% (n = 171) wanted more information about the waitlist and donor kidney allocation criteria, respectively. Approximately 20% felt that the waitlist and allocation processes were not transparent. Awareness about the option to refuse a deceased donor kidney offer was high (69%, n = 174), yet nearly half of respondents (46%, n = 115) expressed concern about being disadvantaged if an offer for a deceased donor kidney was refused. One-third of participants (33%, n = 83) were open to accepting an LTI kidney. Limitations Compared to the general population, more study participants were white, and the majority were educated and financially at ease. This limits the generalizability of the results. Conclusion Enhanced communication is required to improve transparency and information about the allocation system and waitlist in Canada.
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Affiliation(s)
| | | | | | - Manpreet Kaur
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Canada
| | - Rahul Mainra
- College of Medicine, University of Saskatchewan, Saskatoon, Canada
| | | | | | - Holly Mansell
- Centre hospitalier de l’Université de Montréal, QC, Canada
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2
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Guerra G, Preczewski L, Gaynor JJ, Morsi M, Tabbara MM, Mattiazzi A, Vianna R, Ciancio G. Multivariable Predictors of Poorer Renal Function Among 1119 Deceased Donor Kidney Transplant Recipients During the First Year Post-Transplant, With a Particular Focus on the Influence of Individual KDRI Components and Donor AKI. Clin Transplant 2025; 39:e70080. [PMID: 40226903 PMCID: PMC11995677 DOI: 10.1111/ctr.70080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2024] [Revised: 12/03/2024] [Accepted: 12/30/2024] [Indexed: 04/15/2025]
Abstract
Given our desire to reduce kidney transplant waiting times by utilizing more difficult-to-place ("higher-risk") DD kidneys, we wanted to better understand post-transplant renal function among 1119 adult DD recipients consecutively transplanted during 2016-2019. Stepwise linear regression of eGFR (CKD-EPI formula) at 3-, 6-, and 12-months post-transplant (considered as biomarkers for longer-term outcomes), respectively, was performed to determine the significant multivariable baseline predictors, using a type I error ≤ 0.01 to avoid spurious/weak associations. Three unfavorable characteristics were selected as highly significant in all three models: Older DonorAge (yr) (p < 0.000001), Longer StaticColdStorage Time (hr) (p < 0.000001), and Higher RecipientBMI (p ≤ 0.00003). Other significantly unfavorable characteristics included: Shorter DonorHeight (cm) (p ≤ 0.00001), Higher Natural Logarithm {Initial DonorCreatinine} (p ≤ 0.001), Longer MachinePerfusion Time (p ≤ 0.003), Greater DR Mismatches (p = 0.01), DonorHypertension (p ≤ 0.004), Recipient HIV+ (p ≤ 0.006), DCD Kidney (p = 0.002), Cerebrovascular DonorDeath (p = 0.01), and DonorDiabetes (p = 0.01). Variables not selected into any model included DonorAKI Stage (p ≥ 0.24), Any DonorAKI (p ≥ 0.04), and five KDRI components: two DonorAge splines at 18 years (p ≥ 0.52) and 50 years (p ≥ 0.28), BlackDonor (p ≥ 0.08), DonorHCV+ (p ≥ 0.06), and DonorWeight spline at 80 kg (p ≥ 0.03), indicating that DonorAKI and the weaker KDRI components have little, if any, prognostic impact on renal function during the first 12 months post-transplant. Additionally, biochemical determinations with skewed distributions such as DonorCreatinine are more accurately represented by natural logarithmic transformed values. In conclusion, one practical takeaway is that donor AKI may be ignored when evaluating DD risk.
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Affiliation(s)
- Giselle Guerra
- Department of MedicineDivision of NephrologyMiami Transplant InstituteUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Luke Preczewski
- Executive Office DepartmentMiami Transplant InstituteJackson Memorial HospitalMiamiFloridaUSA
| | - Jeffrey J. Gaynor
- Department of SurgeryDivision of TransplantationMiami Transplant InstituteUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Mahmoud Morsi
- Department of SurgeryDivision of TransplantationMiami Transplant InstituteUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Marina M. Tabbara
- Department of SurgeryDivision of TransplantationMiami Transplant InstituteUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Adela Mattiazzi
- Department of MedicineDivision of NephrologyMiami Transplant InstituteUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Rodrigo Vianna
- Department of SurgeryDivision of TransplantationMiami Transplant InstituteUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Gaetano Ciancio
- Department of SurgeryDivision of TransplantationMiami Transplant InstituteUniversity of Miami Miller School of MedicineMiamiFloridaUSA
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Romano F, Angelico R, Toti L, Orsi M, Marsella VE, Manzia TM, Emberti Gialloreti L, Tisone G. The Enhanced Recovery After Surgery Pathway Is Safe, Feasible and Cost-Effective in Delayed Graft Function After Kidney Transplant. J Clin Med 2025; 14:2387. [PMID: 40217837 PMCID: PMC11990043 DOI: 10.3390/jcm14072387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2025] [Revised: 03/24/2025] [Accepted: 03/26/2025] [Indexed: 04/14/2025] Open
Abstract
Background/Objectives: Enhanced recovery after surgery (ERAS) pathways are still underutilized in kidney transplantation (KT), and their feasibility after delayed graft function (DGF) is unknown. We aimed to evaluate safety and cost savings after ERAS implementation in KT recipients with DGF. Methods: A retrospective analysis of KT recipients enrolled in the ERAS program with DGF (≥1 dialytic treatment during the first postoperative week or creatinine≥ 2.5 mg/dL on postoperative day 10) between 2010 and 2019 was performed. Recipient, donor, and transplant data, outcomes, and 1-year post-KT costs were collected, comparing recipients within the ERAS target (≤5 days, "early discharge group") to those discharged later (>5 days, "late discharge group"). Results: Out of 170 KT recipients with DGF, 33 (19.4%) were in the "early discharge group" and 137 (80.5%) in the "late discharge group". Recipient, donor, and transplant characteristics were similar in the two groups. The length of hospital stay (LOS) of the "early discharge group" was significantly shorter, with fewer in-hospital dialysis sessions (p < 0.001) compared to the "late discharge group". One year post-KT, no significant differences were observed in postoperative complications, readmissions, or number of outpatient visits. Five-year graft and patient survival along with five-year graft function were similar between the two cohorts. First-year costs were significantly higher in the "late discharge group" (p < 0.001), with a median excess cost (Δ) of EUR 4515.76/patient. Factors influencing first-year costs post-KT were LOS for KT, recipient age, and use of expanded-criteria grafts. Conclusions: The ERAS approach is safe in KT recipients with DGF and allows for economic savings, while its implementation does not cause worse clinical outcomes in recipients.
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Affiliation(s)
- Francesca Romano
- HPB and Transplant Unit, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy; (F.R.); (L.T.); (M.O.); (V.E.M.); (T.M.M.); (G.T.)
| | - Roberta Angelico
- HPB and Transplant Unit, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy; (F.R.); (L.T.); (M.O.); (V.E.M.); (T.M.M.); (G.T.)
| | - Luca Toti
- HPB and Transplant Unit, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy; (F.R.); (L.T.); (M.O.); (V.E.M.); (T.M.M.); (G.T.)
| | - Michela Orsi
- HPB and Transplant Unit, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy; (F.R.); (L.T.); (M.O.); (V.E.M.); (T.M.M.); (G.T.)
| | - Valentina Enrica Marsella
- HPB and Transplant Unit, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy; (F.R.); (L.T.); (M.O.); (V.E.M.); (T.M.M.); (G.T.)
| | - Tommaso Maria Manzia
- HPB and Transplant Unit, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy; (F.R.); (L.T.); (M.O.); (V.E.M.); (T.M.M.); (G.T.)
| | - Leonardo Emberti Gialloreti
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy;
| | - Giuseppe Tisone
- HPB and Transplant Unit, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy; (F.R.); (L.T.); (M.O.); (V.E.M.); (T.M.M.); (G.T.)
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Kujawa-Szewieczek A, Słabiak-Błaż N, Kolonko A, Więcek A, Piecha G. Kidney Donor Risk Index and Cardiovascular Complications in a Long-Term Follow-Up Observation. J Clin Med 2025; 14:2346. [PMID: 40217795 PMCID: PMC11989476 DOI: 10.3390/jcm14072346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2024] [Revised: 03/04/2025] [Accepted: 03/22/2025] [Indexed: 04/14/2025] Open
Abstract
Background: The suitability of the Kidney Donor Risk Index (KDRI) has not been fully validated in the European population. The aim of this study was to evaluate the value of the KDRI in predicting kidney graft function and cardiovascular events (CVEs) in a Polish cohort of kidney transplant recipients (KTRs). Methods: In this retrospective study kidney graft function and CVEs were analyzed among 1420 patients transplanted between 1999 and 2017 and followed until 2021. The KDRI was calculated according to the formula proposed by Rao. Patients were assigned into quartiles (Qs) of KDRI values. Results: Patients in Q4 were older, with higher BMI, longer cold ischemia time (CIT), and a greater rate of ischemic heart disease at the transplantation. The KDRI value determined both early and long-term graft function. During a median follow-up period of 91 months, at least one cardiovascular event was noted in 227 (16.0%) kidney transplant recipients. There was a significant increasing trend for the occurrence of post-transplant CV complications along the consecutive KDRI quartiles (χ2 = 7.3; p < 0.01) among kidney transplant patients younger than 50 years at the time of transplantation. Conclusions: The KDRI is an adequate prognostic tool also for the European population. Despite the KDRI not being used for allocation in Poland we found that kidneys with a higher KDRI are allocated to recipients with worse survival prognosis. The quality of kidneys from a deceased donor may be related to the occurrence of post-transplant cardiovascular complications in recipients younger than 50 years at the transplantation, including those without history of comorbidities such as diabetes or cardiovascular disease.
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Affiliation(s)
- Agata Kujawa-Szewieczek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Francuska 20/24, 40-027 Katowice, Poland; (N.S.-B.); (A.K.); (A.W.); (G.P.)
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Yu M, Husain SA, Adler JT, Maclay LM, King KL, Sahni PV, Cron DC, Schold JD, Mohan S. Decreasing efficiency in deceased donor kidney offer notifications under the new distance-based kidney allocation system. Am J Transplant 2025:S1600-6135(25)00139-X. [PMID: 40107362 DOI: 10.1016/j.ajt.2025.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2024] [Revised: 02/24/2025] [Accepted: 03/07/2025] [Indexed: 03/22/2025]
Abstract
Organ Procurement Organizations (OPOs) recover deceased donor kidneys and place them with matched recipients according to ranked match runs of patients, but offer notification practices differ across the OPOs and have changed following updates to allocation policy (kidney allocation system 250 [KAS250]). This national registry study used batch notification data to quantify time spent on kidney allocation and identify variations in batch notification practices across OPOs before and after the KAS250 allocation system era. Overall allocation time between the first and last offer notifications increased from a median of 1 to 7 hours under the KAS250 allocation system. For match runs of unplaced kidneys, allocation time increased from a median of 18 to 28 hours. Out-of-sequence (OOS) allocation, used by OPOs to limit nonutilization due to excess cold ischemia time, more than doubled in frequency between 2018 and 2022, with median time from first offer to initiation of OOS varying across OPOs from 0 to 47 hours. Increasing rates of organ nonutilization and the observed allocation practice differences based on organ quality demonstrate the urgent need for new approaches to achieve more efficient placement of hard-to-place kidneys. Data-driven approaches to optimize kidney allocation efforts will help ensure fairness in a system that currently allows for wide practice variation and frequent OOS allocation.
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Affiliation(s)
- Miko Yu
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA; Columbia University Renal Epidemiology Group, New York, New York, USA
| | - Syed Ali Husain
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA; Columbia University Renal Epidemiology Group, New York, New York, USA
| | - Joel T Adler
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Lindsey M Maclay
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA; Columbia University Renal Epidemiology Group, New York, New York, USA
| | - Kristen L King
- Columbia University Renal Epidemiology Group, New York, New York, USA
| | - Prateek V Sahni
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA; Columbia University Renal Epidemiology Group, New York, New York, USA
| | - David C Cron
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jesse D Schold
- Department of Surgery, University of Colorado-Anschutz Medical Campus, Aurora, Colorado, USA; Department of Epidemiology, School of Public Health, University of Colorado-Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA; Columbia University Renal Epidemiology Group, New York, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA.
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6
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Yatim K, Ribas GT, Elton DC, Rockenbach MABC, Al Jurdi A, Pickhardt PJ, Garrett JW, Dreyer KJ, Bizzo BC, Riella LV. Applying Artificial Intelligence to Quantify Body Composition on Abdominal CTs and Better Predict Kidney Transplantation Wait-List Mortality. J Am Coll Radiol 2025; 22:332-341. [PMID: 40044312 DOI: 10.1016/j.jacr.2025.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2024] [Revised: 01/06/2025] [Accepted: 01/06/2025] [Indexed: 05/13/2025]
Abstract
BACKGROUND Prekidney transplant evaluation routinely includes abdominal CT for presurgical vascular assessment. A wealth of body composition data are available from these CT examinations, but they remain an underused source of data, often missing from prognostication models, as these measurements require organ segmentation not routinely performed clinically by radiologists. We hypothesize that artificial intelligence facilitates accurate extraction of abdominal CT body composition data, allowing better prediction of outcomes. METHODS We conducted a retrospective, single-center observational study of kidney transplant candidates wait-listed between January 1, 2007, and December 31, 2017, with available CT data. Validated deep learning models quantified body composition including fat, aortic calcification, bone density, and muscle mass. Logistic regression was used to compare body composition data to Expected Post-Transplant Survival Score (EPTS) as a predictor of 5-year wait-list mortality. RESULTS In all, 899 patients were followed for a median 943 days (interquartile range 320-1,697). Of 899, 589 (65.5%) were men and 680 of 899 (75.6%) were White, non-Hispanic. Of 899, 167 patients (18.6%) died while on the waiting list. Myosteatosis (defined as the lowest tertile of muscle attenuation) and increased total aortic and abdominal calcification were associated with increased 5-year wait-list mortality. Logistic regression showed that imaging parameters performed similarly to EPTS at predicting 5-year wait-list mortality (area under receiver operating characteristic curve 0.70 [0.64-0.75] versus 0.67 [0.62-0.72], respectively), and combining body composition parameters with EPTS led to a slight improved survival prediction (area under receiver operating characteristic curve = 0.72, 95% confidence interval 0.66-0.76). CONCLUSIONS Fully automated quantification of body composition in kidney transplant candidates is feasible. Myosteatosis and atherosclerosis are associated with 5-year wait-list mortality.
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Affiliation(s)
- Karim Yatim
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts
| | - Guilherme T Ribas
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel C Elton
- Mass General Brigham AI, Mass General Brigham, Boston, Massachusetts
| | - Marcio A B C Rockenbach
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Mass General Brigham AI, Mass General Brigham, Boston, Massachusetts
| | - Ayman Al Jurdi
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Perry J Pickhardt
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - John W Garrett
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Department of Medical Physics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Keith J Dreyer
- Mass General Brigham AI, Mass General Brigham, Boston, Massachusetts
| | - Bernardo C Bizzo
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Mass General Brigham AI, Mass General Brigham, Boston, Massachusetts
| | - Leonardo V Riella
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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7
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Bradbrook K, Klassen D, Massie AB, Stewart DE. Does a changing donor pool explain the recent rise in the United States kidney nonuse rate? Am J Transplant 2025:S1600-6135(25)00080-2. [PMID: 39947400 DOI: 10.1016/j.ajt.2025.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2024] [Revised: 01/13/2025] [Accepted: 02/09/2025] [Indexed: 03/14/2025]
Abstract
The proportion of deceased donor kidneys recovered for transplantation that are not transplanted reached 28% in 2023. Past research demonstrated that >90% of the nonuse rate (NUR) increase in the 2000s could be explained by the broadening donor pool. We used the Organ Procurement and Transplantation Network data to study kidneys recovered from 2010-2023, applying causal inference methods to assess the degree to which the recent, sharp rise in the NUR could be explained by changes in donor clinical characteristics. Unadjusted odds of kidney nonuse were 63% higher (95% CI: 56%, 70%) in 2023 vs 2018. After adjusting for donor factors, the odds of nonuse were only 12% (9%, 15%) higher in 2023. Both regression and propensity weighting demonstrated that 75% to 80% of the recent NUR increase can be explained by a rapidly expanding donor pool. Encouragingly, the NUR has not increased and remains low for above-average quality kidneys. However, the unexplained risk of nonuse for kidneys in the highest kidney donor risk index quartile increased by ∼ 30%, potentially due to residual confounding and/or system-level, exogenous factors such as allocation policy changes. To improve placement efficiency, allocation policy should adapt to the increasingly heterogeneous donor pool by allocating kidneys differently along the donor quality spectrum.
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Affiliation(s)
| | - David Klassen
- United Network for Organ Sharing, Richmond, Virginia, USA
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8
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Liyanage LN, Akizhanov D, Patel SS, Segev DL, Massie AB, Stewart DE, Gentry SE. Contemporary prevalence and practice patterns of out-of-sequence kidney allocation. Am J Transplant 2025; 25:343-354. [PMID: 39182614 PMCID: PMC11772121 DOI: 10.1016/j.ajt.2024.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 08/01/2024] [Accepted: 08/14/2024] [Indexed: 08/27/2024]
Abstract
Since 2021, the Organ Procurement and Transplantation Network has reported a nearly 10-fold rise in out-of-sequence (OOS) kidney allocation, generating concern and halting development of continuous distribution policies. We report contemporary (2022-2023) practice patterns in OOS allocation using Organ Procurement and Transplantation Network data. We examined in sequence vs OOS donors with multivariable logistic regression and skipped vs OOS-accepting recipients with conditional logistic regression. Nearly 20% of kidney placements were OOS, varying from 0% to 43% acsoss organ procurement organizations; the 5 highest OOS-organ procurement organizations accounted for 29% of all OOS. Of OOS kidneys, 33% were declined ≥100 times in the standard allocation sequence and 51% were declined by ≥10 centers before OOS allocation began; 4.5% were made without any in-sequence declines. Nearly, all OOS offers were open offers. OOS kidneys were more likely to be from female, Black, older, donation after cardiac death, hypertensive, diabetic, and elevated creatinine donors. Candidates receiving OOS kidneys were more likely female, Asian, and older than skipped candidates. Higher-volume centers and centers with more White, fewer Hispanic, and more educated waiting list patients underwent transplantation disproportionately with more OOS kidneys. These findings suggest that the current, highly variable, discretionary use of OOS might exacerbate disparities, yet the impact of OOS on organ utilization cannot be determined with data now collected.
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Affiliation(s)
| | | | - Suhani S Patel
- Department of Surgery, NYU Langone, New York, New York, USA
| | - Dorry L Segev
- Department of Surgery, NYU Langone, New York, New York, USA; Scientific Registry of Transplant Recipients, Minneapolis, Minnesota, USA
| | - Allan B Massie
- Department of Surgery, NYU Langone, New York, New York, USA
| | | | - Sommer E Gentry
- Department of Surgery, NYU Langone, New York, New York, USA; Scientific Registry of Transplant Recipients, Minneapolis, Minnesota, USA
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9
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Oh S, Kim K, Na O, Ha J, Koo TY, Yang J. Evaluating non-utilization of deceased donor kidneys in Korea. Sci Rep 2025; 15:2588. [PMID: 39833548 PMCID: PMC11746993 DOI: 10.1038/s41598-025-86998-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2024] [Accepted: 01/15/2025] [Indexed: 01/22/2025] Open
Abstract
Considering the low deceased donation rates despite increasing rates of end-stage kidney disease in Asia, minimizing donor kidney discard is important. This study aimed to investigate the current situation of donor kidney discard in Korea. This nationwide study included deceased donor kidneys of candidates for kidney transplantation (KT) between 2013 and 2018 in Korea. Kidney discard was defined as no procurement or discarding after procurement of kidneys. Among 5592 deceased donor kidneys, no-procurement, single-procurement, and double-procurement were 385, 63, and 5144, respectively. All unilaterally procured kidneys, except for one, were transplanted. Bilaterally procured kidneys were accompanied by two KT (n = 5058), one KT with the other kidney discarded (n = 33), or both kidneys discarded (n = 20). The overall kidney discard rate was 7.9%. The cause of non-procurement was universally organ damage, and the common causes of kidney discard after procurement were organ damage, absence of available candidates, and malignancy. While the kidney donor profile index was higher in the discarded group than in the KT group, a large overlap was observed. The risk factors for kidney non-utilization were old age, hypertension, diabetes mellitus, high serum creatinine levels, low hemoglobin levels, and non-cerebrovascular causes of death. KT using contralateral kidney in the discard group showed graft failure and mortality rates comparable to those of KT in the no-discard group. The discard rate of deceased donor kidneys was low, and the discard of one kidney does not necessarily rule out the utilization of contralateral kidney, especially in Korea with a long waiting time.
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Affiliation(s)
- Suhyun Oh
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Yonsei University Severance Hospital, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Keonhwa Kim
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Yonsei University Severance Hospital, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Omi Na
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Yonsei University Severance Hospital, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Juhyung Ha
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Yonsei University Severance Hospital, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Tai Yeon Koo
- Department of Nephrology, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Jaeseok Yang
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Yonsei University Severance Hospital, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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10
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Kim JH, Lee SH, Kim JS, Hwang HS, Ko H, Jung CW, Kim DG, Kim YH, Yang J, Ahn C, Jeong KH. Clinical significance of the living kidney donor profile index for predicting long-term posttransplant outcomes: results from the Korean Organ Transplantation Registry. Kidney Res Clin Pract 2025; 44:189-199. [PMID: 37885175 PMCID: PMC11838853 DOI: 10.23876/j.krcp.22.266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 02/07/2023] [Accepted: 03/11/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND The usefulness of the living kidney donor profile index (LKDPI) has not been widely demonstrated; therefore, it requires verification before clinical application. We analyzed the LKDPI using data from the Korean Organ Transplantation Registry (KOTRY) to confirm whether the LKDPI can be used to predict the survival of allografts in living donor kidney transplantation (LDKT) patients in Korea. METHODS The study population was obtained from the KOTRY database. A total of 2,598 kidney recipients registered in the KOTRY database were enrolled between May 2014 and December 2020. Donor and recipient information was observed, and the LKDPI was measured. RESULTS Median LKDPI score was 15.5 with a follow-up duration of 33.7 ± 16.1 months. According to LKDPI scores (group 1, <0; group 2, 0-20; group 3, 20-40; and group 4, >40), LKDPI group 4 had significantly higher death-censored graft loss than LKDPI group 1 (hazard ratio [HR], 1.89; 95% confidence interval [CI], 1.06- 3.40; p = 0.03). When divided based on the cutoff value (LKDPI, 36.6), the high LKDPI group had higher graft loss than the low LKDPI group (HR, 2.14; 95% CI, 1.37-3.34; p < 0.001). When follow-up was repeated after transplantation, it was confirmed that the higher the LKDPI value was, the lower the average estimated glomerular filtration rate (p < 0.001). CONCLUSION This study confirmed that LKDPI can serve as an independent predictor for assessing the risk of allograft failure and transplant outcomes in Korean LDKT patients.
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Affiliation(s)
- Jong Ho Kim
- Department of Nephrology, Kyung Hee University College of Medicine, Seoul, Republic of Korea
| | - Sang Ho Lee
- Department of Nephrology, Kyung Hee University College of Medicine, Seoul, Republic of Korea
| | - Jin Sug Kim
- Department of Nephrology, Kyung Hee University College of Medicine, Seoul, Republic of Korea
| | - Hyeon Seok Hwang
- Department of Nephrology, Kyung Hee University College of Medicine, Seoul, Republic of Korea
| | - Hyunmin Ko
- Department of Surgery, Kyung Hee University College of Medicine, Seoul, Republic of Korea
| | - Cheol-Woong Jung
- Department of Transplantation and Vascular Surgery, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Deok Gie Kim
- Department of Surgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Yeong Hoon Kim
- Department of Internal Medicine, Inje University Busan Paik Hospital, Busan, Republic of Korea
| | - Jaeseok Yang
- Department of Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Curie Ahn
- Department of Nephrology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyung Hwan Jeong
- Department of Nephrology, Kyung Hee University College of Medicine, Seoul, Republic of Korea
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11
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Koo TY, Lee J, Na O, Lee Y, Jeong JC, Yang J. A Prognostic Index for Deceased Donor Kidneys and Criteria for Identifying Suitable Candidates for Kidney Transplantation from Expanded Criteria Donors with Prolonged Waiting Times. KIDNEY DISEASES (BASEL, SWITZERLAND) 2025; 11:143-153. [PMID: 40160491 PMCID: PMC11952819 DOI: 10.1159/000544792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2024] [Accepted: 02/14/2025] [Indexed: 04/02/2025]
Abstract
Introduction The kidney donor profile index (KDPI) is a valuable prognostic tool in deceased donor kidney transplantation (DDKT), while its optimization for each country using local data is essential. It remains unclear which patients derive survival benefits from expanded criteria donor (ECD) DDKT compared to waitlist or standard criteria donor (SCD) DDKT, particularly in the context of long waiting times. This study aimed to develop a prognostic index for donor kidneys and propose criteria to identify suitable candidates for ECD DDKT in Korea. Methods Two prediction models were developed using data from two cohorts based on national databases (the Korean Network for Organ Sharing and the National Health Insurance Data Sharing Service): cohort for the prediction of graft prognosis (n = 6,272) and cohort for the prediction of suitable candidates for ECD DDKT (n = 30,183). Results The Korean KDPI (K-KDPI) comprises five donor factors (age, height, diabetes mellitus, serum creatinine levels, and hepatitis C virus), associated with graft failure. The discriminatory ability of the K-KDPI for graft outcomes surpassed that of the US KDPI and dichotomous ECD criteria. ECD kidneys (K-KDPI ≥70%) showed worse allograft survival compared to SCD kidneys (K-KDPI <70%). Candidates aged ≥40 years, with negative panel reactive antibody, and without diabetes mellitus had a significantly lower mortality risk with ECD DDKT than with waitlist-or-SCD DDKT, making them suitable for ECD DDKT. Conclusion The K-KDPI and criteria for identifying suitable ECD recipients are expected to improve the quality assessment and efficient utilization of ECD kidneys in Korea with long waiting times.
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Affiliation(s)
- Tai Yeon Koo
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Joongyub Lee
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Institute of Health Policy and Management, Medical Research Center, Seoul National University, Seoul, Republic of Korea
| | - Omi Na
- Department of Internal Medicine, Yonsei University College of Medicine, Severance Hospital, Seoul, Republic of Korea
| | - Yonggu Lee
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Republic of Korea
| | - Jong Cheol Jeong
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jaeseok Yang
- Department of Internal Medicine, Yonsei University College of Medicine, Severance Hospital, Seoul, Republic of Korea
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12
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Goussous N, De Leon F, Alghannam K, Howard BC, Than PA, Wang AX, Sageshima J, Perez RV. Outcomes Using High KDPI Kidneys in Recipients Over 65 y of Age. Transplant Direct 2024; 10:e1738. [PMID: 39563722 PMCID: PMC11575968 DOI: 10.1097/txd.0000000000001738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2024] [Revised: 09/30/2024] [Accepted: 10/01/2024] [Indexed: 11/21/2024] Open
Abstract
BACKGROUND Kidney transplantation has been shown to improve life expectancy when compared with remaining on dialysis. However, there is an ever-expanding shortage of available organs for transplantation. The use of high kidney donor profile index (KDPI; >85) kidneys is 1 strategy to address this shortage. The current study aims to evaluate the advantage of accepting a high KDPI versus a low KDPI kidney (KDPI ≤85) in patients 65 y or older. METHODS A single-center retrospective review of all patients, ages 65 y or older, who underwent deceased donor kidney transplantation between 2010 and 2020 was performed. Outcomes and wait times of recipients undergoing low KDPI (KDPI ≤85) versus high KDPI (KDPI >85) kidney transplantation were compared. Significance was defined as P < 0.05. RESULTS Four hundred ninety-two patients were identified; 317 (64.4%) were men with a median age at transplantation of 69 y. Four hundred five patients received low KDPI kidneys, whereas the remaining received high KDPI grafts. High KDPI kidneys were procured from older donors (60 versus 47, P < 0.001) and had shorter cold ischemic time (25.0 versus 28.3 h, P = 0.01) compared with low KDPI kidneys. There was no significant difference in graft and patient survival between low and high KDPI recipients, with 85.1% and 86.2% grafts functioning at a follow-up of 4.85 (2.9-7.0) y, respectively. Pretransplant wait time was significantly shorter in the high KDPI group (2.7 [1.8-4.1] versus 3.5 [2.3-4.8] y; P = 0.004). CONCLUSIONS In patients 65 y or older undergoing deceased donor kidney transplantation, high KDPI kidneys may offer shorter pretransplant waiting times without compromising graft or patient survival.
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Affiliation(s)
- Naeem Goussous
- Division of Transplant Surgery, Department of Surgery, University of California Davis, Sacramento, CA
| | - Fransia De Leon
- Division of Transplant Surgery, Department of Surgery, University of California Davis, Sacramento, CA
| | - Karima Alghannam
- Division of Transplant Surgery, Department of Surgery, University of California Davis, Sacramento, CA
| | - Brian C. Howard
- Division of Transplant Surgery, Department of Surgery, University of California Davis, Sacramento, CA
| | - Peter A. Than
- Division of Transplant and Hepatobiliary Surgery, Department of Surgery, University of California San Diego, San Diego, CA
| | - Aileen X Wang
- Division of Transplant Nephrology, Department of Medicine, University of California Davis, Sacramento, CA
| | - Junichiro Sageshima
- Division of Transplant Surgery, Department of Surgery, University of California Davis, Sacramento, CA
| | - Richard V. Perez
- Division of Transplant Surgery, Department of Surgery, University of California Davis, Sacramento, CA
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13
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Giorgakis E, Hardgrave H, Callais N, Wells A. Machine learning-driven virtual biopsy system may increase organ discards at aggressive kidney transplant centers. Nat Commun 2024; 15:10323. [PMID: 39614083 DOI: 10.1038/s41467-024-53702-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 10/18/2024] [Indexed: 12/01/2024] Open
Affiliation(s)
- Emmanouil Giorgakis
- Division of Abdominal Transplantation, Department of Surgery, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA.
- Division of Solid Organ Transplant, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Hailey Hardgrave
- Division of Solid Organ Transplant, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Nicholas Callais
- Division of Solid Organ Transplant, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Allison Wells
- Division of Solid Organ Transplant, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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14
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Hardgrave H, Jeon H, Wells A, Burdine M, Giorgakis E, Bhusal S, Khan N, Patel RB, Estrada M, Sharma A, Manchala V, Roll GR, Burdine LJ. Kidney Utilization in the Context of a Shifting Donor Landscape in the United States. Transplantation 2024:00007890-990000000-00935. [PMID: 40101109 DOI: 10.1097/tp.0000000000005229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2025]
Abstract
BACKGROUND In 2021, 24.6% of kidneys procured in the United States were not utilized. This study examines trends in kidney graft nonutilization within the context of shifting donor demographics and procurement practices. METHODS We analyzed data from the Standard Transplant Analysis and Research data set, spanning deceased donors from 1988 to the present, provided by the Organ Procurement and Transplantation Network. Linear regression was used to estimate changes in organ utilization over time. RESULTS During the past 40 y, the quality of donor kidneys decreased as measured by the mean Kidney Donor Risk Index (KDRI), which increased from 1.20 to 1.43. Currently, 13% of kidneys procured have a KDRI >2, with an 81% nonutilization rate. Despite the increase in high-risk graft procurement, the overall growth in kidney recoveries and utilization has increased. CONCLUSIONS The volume of kidney transplants has grown alongside an increasing KDRI in the donor population, which led to a concurrent rise in nonutilization rates. Nevertheless, transplant volumes and 1-y graft outcomes have shown continuous improvement, underscoring the resilience of the transplantation system despite the evolving donor landscape.
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Affiliation(s)
- Hailey Hardgrave
- Division of Solid Organ Transplant, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Helen Jeon
- Division of Solid Organ Transplant, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Allison Wells
- Division of Solid Organ Transplant, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Marie Burdine
- Division of Solid Organ Transplant, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Emmanouill Giorgakis
- Division of Solid Organ Transplant, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Sushma Bhusal
- Division of Solid Organ Transplant, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Nasir Khan
- Division of Solid Organ Transplant, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Raj B Patel
- Division of Solid Organ Transplant, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Michelle Estrada
- Division of Solid Organ Transplant, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Aparna Sharma
- Division of Solid Organ Transplant, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Venkata Manchala
- Division of Solid Organ Transplant, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Garrett R Roll
- Division of Transplant, Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Lyle J Burdine
- Division of Solid Organ Transplant, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
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15
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Gentry SE, Stewart DE, Massie AB, Segev DL. Mitigating the Disparate Impacts of Longevity Matching of Kidney Transplants. Am J Kidney Dis 2024; 84:397-399. [PMID: 38970578 PMCID: PMC11578229 DOI: 10.1053/j.ajkd.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Accepted: 06/04/2024] [Indexed: 07/08/2024]
Affiliation(s)
- Sommer E Gentry
- Department of Surgery, NYU Langone, New York, New York; Scientific Registry of Transplant Recipients.
| | | | | | - Dorry L Segev
- Department of Surgery, NYU Langone, New York, New York; Scientific Registry of Transplant Recipients
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16
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Ma X, Moradi M, Ma X, Tang Q, Levi M, Chen Y, Zhang HK. Large area kidney imaging for pre-transplant evaluation using real-time robotic optical coherence tomography. COMMUNICATIONS ENGINEERING 2024; 3:122. [PMID: 39223332 PMCID: PMC11368928 DOI: 10.1038/s44172-024-00264-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 08/07/2024] [Indexed: 09/04/2024]
Abstract
Optical coherence tomography (OCT) can be used to image microstructures of human kidneys. However, current OCT probes exhibit inadequate field-of-view, leading to potentially biased kidney assessment. Here we present a robotic OCT system where the probe is integrated to a robot manipulator, enabling wider area (covers an area of 106.39 mm by 37.70 mm) spatially-resolved imaging. Our system comprehensively scans the kidney surface at the optimal altitude with preoperative path planning and OCT image-based feedback control scheme. It further parameterizes and visualizes microstructures of large area. We verified the system positioning accuracy on a phantom as 0.0762 ± 0.0727 mm and showed the clinical feasibility by scanning ex vivo kidneys. The parameterization reveals vasculatures beneath the kidney surface. Quantification on the proximal convoluted tubule of a human kidney yields clinical-relevant information. The system promises to assess kidney viability for transplantation after collecting a vast amount of whole-organ parameterization and patient outcomes data.
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Affiliation(s)
- Xihan Ma
- Department of Robotics Engineering, Worcester Polytechnic Institute, Worcester, MA, USA
| | - Mousa Moradi
- Department of Biomedical Engineering, University of Massachusetts, Amherst, MA, USA
| | - Xiaoyu Ma
- Department of Biomedical Engineering, University of Massachusetts, Amherst, MA, USA
| | - Qinggong Tang
- The Stephenson School of Biomedical Engineering, University of Oklahoma, Norman, OK, USA
| | - Moshe Levi
- Department of Biochemistry and Molecular & Cellular Biology, Georgetown University, Washington, DC, USA
| | - Yu Chen
- Department of Biomedical Engineering, University of Massachusetts, Amherst, MA, USA.
- College of Photonic and Electronic Engineering, Fujian Normal University, Fuzhou, Fujian, PR China.
| | - Haichong K Zhang
- Department of Robotics Engineering, Worcester Polytechnic Institute, Worcester, MA, USA.
- Department of Biomedical Engineering, Worcester Polytechnic Institute, Worcester, MA, USA.
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17
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Wang Y, Nan B, Kalbfleisch JD. BIVARIATE FUNCTIONAL PATTERNS OF LIFETIME MEDICARE COSTS AMONG ESRD PATIENTS. Ann Appl Stat 2024; 18:2596-2614. [PMID: 39431171 PMCID: PMC11488692 DOI: 10.1214/24-aoas1897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2024]
Abstract
In this work we study the lifetime Medicare spending patterns of patients with end-stage renal disease (ESRD). We extract the information of patients who started their ESRD services in 2007-2011 from the United States Renal Data System (USRDS). Patients are partitioned into three groups based on their kidney transplant status: 1-unwaitlisted and never transplanted, 2-waitlisted but never transplanted, and 3-waitlisted and then transplanted. To study their Medicare cost trajectories, we use a semiparametric regression model with both fixed and bivariate time-varying coefficients to compare groups 1 and 2, and a bivariate time-varying coefficient model with different starting times (time since the first ESRD service and time since the kidney transplant) to compare groups 2 and 3. In addition to demographics and other medical conditions, these regression models are conditional on the survival time, which ideally depict the lifetime Medicare spending patterns. For estimation, we extend the profile weighted least squares (PWLS) estimator to longitudinal data for the first comparison and propose a two-stage estimating method for the second comparison. We use sandwich variance estimators to construct confidence intervals and validate inference procedures through simulations. Our analysis of the Medicare claims data reveals that waitlisting is associated with a lower daily medical cost at the beginning of ESRD service among waitlisted patients which gradually increases over time. Averaging over lifespan, however, there is no difference between waitlisted and unwaitlisted groups. A kidney transplant, on the other hand, reduces the medical cost significantly after an initial spike.
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Affiliation(s)
- Yue Wang
- University of California, Irvine
| | - Bin Nan
- University of California, Irvine
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18
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Kolbrink B, Kakavand N, Voran JC, Zacharias HU, Rahmel A, Vogelaar S, Schicktanz S, Braun F, Schmitt R, von Samson-Himmelstjerna FA, Schulte K. Allocation Rules and Age-Dependent Waiting Times for Kidney Transplantation. DEUTSCHES ARZTEBLATT INTERNATIONAL 2024; 121:559-565. [PMID: 39115277 PMCID: PMC11551543 DOI: 10.3238/arztebl.m2024.0137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 06/21/2024] [Accepted: 06/21/2024] [Indexed: 10/26/2024]
Abstract
BACKGROUND Rigid age limits in the current allocation system for post-mortem donor kidneys in Germany may have problematic effects. The new German national transplantion registry enables data analysis with respect to this question. METHODS Using anonymized data from the German national transplantion registry, we extracted and evaluated information on the recipients and postmortem donors of kidneys that were allocated in Germany through Eurotransplant over the period 2006-2020. RESULTS Data on 19 664 kidney transplantations in Germany from 2006 to 2020 were analyzed. The median waiting time for kidney transplantation was 5.8 years. Persons under age 18 waited a median of 1.7 years; persons aged 18 to 64, 7.0 years; and persons aged 65 and older, 3.8 years. Over the period of observation, postmortem kidneys were transplanted into 401 people of age 64 (2.0% of all organ recipients) and 1,393 people of age 65 (7.1% of all organ recipients). The difference in waiting times between allocation programs for persons under age 65 (ETKAS, "Eurotransplant Kidney Allocation System") and those aged 65 and older (ESP, "Eurotransplant Senior Program") increased over the period of observation, from 2.6 years in 2006-2010 to 4.1 years in 2017-2020. CONCLUSION The rigid age limits in the current allocation rules for post-mortem kidney donations in Germany are prolonging the waiting times for transplants among patients aged 18 to 64. We think these rules need to be fundamentally reassessed.
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Affiliation(s)
- Benedikt Kolbrink
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Nassim Kakavand
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Jakob C. Voran
- Department of Internal Medicine III, Cardiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
- German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Germany
| | - Helena U. Zacharias
- Peter L. Reichertz Institute for Medical Informatics (PLTI), TU Braunschweig and Hannover Medical School, Hannover, Germany
| | - Axel Rahmel
- German Organ Procurement Organization (DSO), Frankfurt am Main, Germany
| | - Serge Vogelaar
- Eurotransplant International Foundation, Leiden,Netherlands
| | - Silke Schicktanz
- Institute of Ethics and History of Medicine, University Medicine Göttingen, Göttingen, Germany
| | - Felix Braun
- Division of Clinical Transplantation Medicine, Department of General, Visceral, Thoracic, Transplantation and Pediatric Surgery, University Hospital Schleswig Holstein Campus Kiel, Kiel, Germany
| | - Roland Schmitt
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | | | - Kevin Schulte
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
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19
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Sancho C, Affdal A, Ballesteros Gallego FA, Malo MF, Cochran-Mavrikakis SL, Cardinal H, Gill JS, Fortin MC. The Use of Kidneys With Lower Longevity From Deceased Donors to Improve Access to Preemptive Renal Transplantation for Elderly Patients: A Qualitative Study. Can J Kidney Health Dis 2024; 11:20543581241267165. [PMID: 39091638 PMCID: PMC11292676 DOI: 10.1177/20543581241267165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 06/04/2024] [Indexed: 08/04/2024] Open
Abstract
Background There is a gap between the number of patients waiting for a transplant and the number of kidneys available. Some deceased donor kidneys are currently nonutilized, as medical teams fear that they will experience suboptimal graft survival. However, these organs could provide an acceptable therapeutic option if they were allocated for preemptive kidney transplantation in elderly candidates. Objective This project aims to gather patients' perspectives on the allocation of kidneys with lower longevity for preemptive kidney transplantation in elderly patients. Design Individual interviews. Setting The Center hospitalier de l'Université de Montréal (CHUM) chronic kidney disease (CKD) clinic. Participants Patients aged between 64 and 75 years with CKD G4-5 ND, followed at the CHUM and who have not initiated dialysis yet. Methods Between March and July 2023, we conducted 14 individual interviews with patients aged between 64 and 75 years who had CKD G4-5 ND and were followed at the CHUM. The interviews were digitally recorded and transcribed. Thematic analysis was conducted. Results Most participants were in favor of using kidneys with lower longevity to increase their access to transplantation, improve their quality of life, enable accelerated transplantation, and avoid dialysis. Patients also wanted to be engaged in the decision-making process, underlining the importance of informed consent. Although the use of kidneys with lower longevity offers the hope of returning to "normal" life, some patients were concerned about the risk of reduced graft survival and the need for a subsequent kidney transplant. In these cases, patients were interested in using mitigation strategies, such as prioritization for kidney transplantation from standard donors in case of early graft loss associated with receiving kidneys with lower longevity. They also recommended the development of a separate waiting list for patients consenting to preemptive transplantation with kidneys with lower longevity. Limitations This study was conducted in only 1 nephrology clinic in the province of Quebec with French-speaking patients. Consequently, the results may not be generalizable to other populations, including ethnic minorities. Conclusion The use of kidneys with lower longevity for preemptive kidney transplantation appears to be an interesting option for elderly kidney transplant candidates. However, patient information and participation in the decision-making process are essential. Moreover, organ donation organizations and transplant programs should develop a separate waitlist for transplant candidates who have preconsented to receive organ offers of deceased donor kidneys with lower longevity. Trial registration Not registered.
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Affiliation(s)
- Carina Sancho
- Bioethics Program, École de santé publique de l’Université de Montréal, Québec, Canada
| | - Aliya Affdal
- Bioethics Program, École de santé publique de l’Université de Montréal, Québec, Canada
- Centre de recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Québec, Canada
| | | | - Marie-Françoise Malo
- Bioethics Program, École de santé publique de l’Université de Montréal, Québec, Canada
| | | | - Héloise Cardinal
- Centre de recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Québec, Canada
- Faculté de médecine de l’Université de Montréal, Québec, Canada
- Centre hospitalier de l’Université de Montréal, Québec, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - John S. Gill
- Division of Nephrology, Faculty of Medicine, The University of British Columbia, Vancouver, Canada
| | - Marie-Chantal Fortin
- Centre de recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Québec, Canada
- Faculté de médecine de l’Université de Montréal, Québec, Canada
- Centre hospitalier de l’Université de Montréal, Québec, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
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20
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Eerola V, Sallinen V, Lyden G, Snyder J, Lempinen M, Helanterä I. Preoperative Risk Assessment of Early Kidney Graft Loss. Transplant Direct 2024; 10:e1636. [PMID: 38769983 PMCID: PMC11104730 DOI: 10.1097/txd.0000000000001636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 03/05/2024] [Indexed: 05/22/2024] Open
Abstract
Background A large proportion of potential organ donors are not utilized for kidney transplantation out of risk of early allograft loss because of donor-related characteristics. These can be summarized using kidney donor profile index (KDPI). Because KDPI affects the choice of the recipient, the predictive ability of KDPI is tied to recipient attributes. These have been questioned to explain most of the predictive ability of KDPI. This study aims to quantify the effect of the donor on early graft loss (EGL) by accounting for nonrandom allocation. Methods This study included patients undergoing kidney transplantation from deceased donors between 2014 and 2020 from the Scientific Registry of Transplantation Recipients. EGL, defined as a return to dialysis or retransplantation during the first posttransplant year, was the primary endpoint. Nonrandom allocation and donor-recipient matching by KDPI necessitated the use of inverse probability treatment weighting, which served to assess the effect of KDPI and mitigate selection bias in a weighted Cox regression model. Results The study comprised 89 290 transplantations in 88 720 individual patients. Inverse probability treatment weighting resulted in a good balance of recipient covariates across values of continuous KDPI. Weighted analysis showed KDPI to be a significant predictor for short-term outcomes. A comparable (in terms of age, time on dialysis, previous transplants, gender, diabetes status, computed panel-reactive antibodies, and HLA mismatches) average recipient, receiving a kidney from a donor with KDPI 40-60 had a 3.5% risk of EGL increased to a risk of 7.5% if received a kidney from a KDPI >95 donor (hazard ratio, 2.3; 95% confidence interval, 1.9-2.7). However, for all-cause survival KDPI was less influential. Conclusions The predictive ability of KDPI does not stem from recipient confounding alone. In this large sample-sized study, modeling methods accounting for nonindependence of recipient selection verify graft quality to effectively predict short-term transplantation outcomes.
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Affiliation(s)
- Verner Eerola
- Department of Transplantation and Liver Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Ville Sallinen
- Department of Transplantation and Liver Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Grace Lyden
- Department of Health Services and Organ Transplantation, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - Jon Snyder
- Department of Health Services and Organ Transplantation, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - Marko Lempinen
- Department of Transplantation and Liver Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Ilkka Helanterä
- Department of Transplantation and Liver Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
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21
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Bamforth RJ, Trachtenberg A, Ho J, Wiebe C, Ferguson TW, Rigatto C, Forget E, Dodd N, Tangri N. Expanding Access to High KDPI Kidney Transplant for Recipients Aged 60 y and Older: Cost Utility and Survival. Transplant Direct 2024; 10:e1629. [PMID: 38757046 PMCID: PMC11098249 DOI: 10.1097/txd.0000000000001629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/05/2024] [Accepted: 02/21/2024] [Indexed: 05/18/2024] Open
Abstract
Background Modern organ allocation systems are tasked with equitably maximizing the utility of transplanted organs. Increasing the use of deceased donor organs at risk of discard may be a cost-effective strategy to improve overall transplant benefit. We determined the survival implications and cost utility of increasing the use of marginal kidneys in an older adult Canadian population of patients with end-stage kidney disease. Methods We constructed a cost-utility model with microsimulation from the perspective of the Canadian single-payer health system for incident transplant waitlisted patients aged 60 y and older. A kidney donor profile index score of ≥86 was considered a marginal kidney. Donor- and recipient-level characteristics encompassed in the kidney donor profile index and estimated posttransplant survival scores were used to derive survival posttransplant. Patients were followed up for 10 y from the date of waitlist initiation. Our analysis compared the routine use of marginal kidneys (marginal kidney scenario) with the current practice of limited use (status quo scenario). Results The 10-y mean cost and quality-adjusted life-years per patient in the marginal kidney scenario were estimated at $379 485.33 (SD: $156 872.49) and 4.77 (SD: 1.87). In the status quo scenario, the mean cost and quality-adjusted life-years per patient were $402 937.68 (SD: $168 508.85) and 4.37 (SD: 1.87); thus, the intervention was considered dominant. At 10 y, 62.8% and 57.0% of the respective cohorts in the marginal kidney and status quo scenarios remained alive. Conclusions Increasing the use of marginal kidneys in patients with end-stage kidney disease aged 60 y and older may offer cost savings, improved quality of life, and greater patient survival in comparison with usual care.
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Affiliation(s)
- Ryan J. Bamforth
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
| | - Aaron Trachtenberg
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
- Transplant Manitoba Adult Kidney Program, Winnipeg, MB, Canada
| | - Julie Ho
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
- Transplant Manitoba Adult Kidney Program, Winnipeg, MB, Canada
| | - Chris Wiebe
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
- Transplant Manitoba Adult Kidney Program, Winnipeg, MB, Canada
| | - Thomas W. Ferguson
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
| | - Claudio Rigatto
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Evelyn Forget
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Nancy Dodd
- Transplant Manitoba Adult Kidney Program, Winnipeg, MB, Canada
| | - Navdeep Tangri
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
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22
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Wisel SA, Borja-Cacho D, Megna D, Adjei M, Kim IK, Steggerda JA. Organ Utilization Rates from Non-Ideal Donors for Solid Organ Transplant in the United States. J Clin Med 2024; 13:3271. [PMID: 38892982 PMCID: PMC11172619 DOI: 10.3390/jcm13113271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 05/16/2024] [Accepted: 05/25/2024] [Indexed: 06/21/2024] Open
Abstract
Background: Non-ideal donors provide acceptable allografts and may expand the donor pool. This study evaluates donor utilization across solid organs over 15-years in the United States. Methods: We analyzed the OPTN STAR database to identify potential donors across three donor eras: 2005-2009, 2010-2014, and 2015-2019. Donors were analyzed by a composite Donor Utilization Score (DUS), comprised of donor age and comorbidities. Outcomes of interest were overall and organ-specific donor utilization. Descriptive analyses and multivariable logistic regression modeling were performed. p-values < 0.01 considered significant. Results: Of 132,465 donors, 32,710 (24.7%) were identified as non-ideal donors (NID), based on a DUS ≥ 3. Compared to ideal donors (ID), NID were older (median 56 years, IQR 51-64 years vs. 35 years, 22-48 years, p < 0.001) and more frequently female (44.3% vs. 39.1%, p < 0.001), Black (22.1% vs. 14.6%, p < 0.001) and obese (60.7% vs. 19.6%, p < 0.001). The likelihood of overall DBD utilization from NID increased from Era 1 to Era 2 (OR 1.227, 95% CI 1.123-1.341, p < 0.001) and Era 3 (OR 1.504, 1.376-1.643, p < 0.001), while DCD donor utilization in NID was not statistically different across Eras. Compared to Era 1, the likelihood of DBD utilization from NID for kidney transplantation was lower in Era 2 (OR 0.882, 0.822-0.946) and Era 3 (OR 0.938, 0.876-1.004, p = 0.002). The likelihood of NID utilization increased in Era 3 compared to Era 1 for livers (OR 1.511, 1.411-1.618, p < 0.001), hearts (OR 1.623, 1.415-1.862, p < 0.001), and lungs (OR 2.251, 2.011-2.520, p < 0.001). Conclusions: Using a universal definition of NID across organs, NID donor utilization is increasing; however, use of DUS may improve resource utilization in identifying donors at highest likelihood for multi-organ donation.
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Affiliation(s)
- Steven A. Wisel
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (S.A.W.); (M.A.); (I.K.K.)
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Daniel Borja-Cacho
- Division of Transplant Surgery, Department of Surgery, Northwestern Memorial Hospital, Chicago, IL 60611, USA
| | - Dominick Megna
- Division of Cardiothoracic Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Michie Adjei
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (S.A.W.); (M.A.); (I.K.K.)
| | - Irene K. Kim
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (S.A.W.); (M.A.); (I.K.K.)
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Justin A. Steggerda
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (S.A.W.); (M.A.); (I.K.K.)
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
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23
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Schold JD, Conzen KD, Cooper J, Arrigain S, Lopez R, Mohan S, Husain SA, Huml AM, Kennealey PT, Kaplan B, Pomfret EA. Quantifying the Effect of Consent for High-Kidney Donor Profile Index Deceased Donor Transplants in the United States. J Am Soc Nephrol 2024; 35:630-641. [PMID: 38347668 PMCID: PMC11149032 DOI: 10.1681/asn.0000000000000318] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 02/06/2024] [Indexed: 03/09/2024] Open
Abstract
Key Points Nationally, 41% of kidney transplant candidates consented to receive high–Kidney Donor Profile Index (KDPI) donor offers in the United States. There was wide variation in consent proportion for high-KDPI donors on the basis of individual characteristics and transplant centers. Consent for high-KDPI kidneys was associated with 15% higher adjusted rates of deceased donor transplantation. Background Despite known benefits of kidney transplantation, including transplantation from donors with increased risk factors, many waitlisted candidates die before transplantation. Consent to receive donor kidneys with lower expected survival (e.g ., Kidney Donor Profile Index [KDPI] >85%) is typically obtained at waitlist placement. The presumed benefit of consent to receive high-KDPI donor kidneys is higher likelihood and timeliness of donor offers for transplantation. However, the specific effect of consent on access to transplantation is unclear. Our aims were to evaluate the characteristics of candidates consenting to high-KDPI donor kidneys and the likelihood of receiving a deceased donor transplant over time on the basis of consent. Methods We used national Scientific Registry of Transplant Recipients data between 2015 and 2022 (n =213,364). We evaluated the likelihood of consent using multivariable logistic models and time to deceased donor transplant with cumulative incidence plots accounting for competing risks and multivariable Cox models. Results Overall, high-KDPI consent was 41%, which was higher among candidates who were older, were Black or Hispanic, had higher body mass index, had diabetes, had vascular disease, and had 12–48 months prelisting dialysis time, with significant center-level variation. High-KDPI consent was associated with higher rates of deceased donor transplant (adjusted hazard ratio=1.15; 95% confidence interval, 1.13 to 1.17) with no difference in likelihood of deceased donor transplant from donors with KDPI <85%. The effect of high-KDPI consent on higher rates of deceased donor transplantation was higher among candidates older than 60 years and candidates with diabetes and variable on the basis of center characteristics. Conclusions There is significant variation of consent for high-KDPI donor kidneys and higher likelihood of transplantation associated with consent.
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Affiliation(s)
- Jesse D. Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Epidemiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kendra D. Conzen
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - James Cooper
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Susana Arrigain
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Rocio Lopez
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Sumit Mohan
- Department of Medicine, Columbia University, New York, New York
- Department of Epidemiology, Columbia University, New York, New York
| | - Syed Ali Husain
- Department of Medicine, Columbia University, New York, New York
| | - Anne M. Huml
- Department of Kidney Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Peter T. Kennealey
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Bruce Kaplan
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Elizabeth A. Pomfret
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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24
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Subramanian HV, Canfield C, Shank DB. Designing explainable AI to improve human-AI team performance: A medical stakeholder-driven scoping review. Artif Intell Med 2024; 149:102780. [PMID: 38462282 DOI: 10.1016/j.artmed.2024.102780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 12/20/2023] [Accepted: 01/14/2024] [Indexed: 03/12/2024]
Abstract
The rise of complex AI systems in healthcare and other sectors has led to a growing area of research called Explainable AI (XAI) designed to increase transparency. In this area, quantitative and qualitative studies focus on improving user trust and task performance by providing system- and prediction-level XAI features. We analyze stakeholder engagement events (interviews and workshops) on the use of AI for kidney transplantation. From this we identify themes which we use to frame a scoping literature review on current XAI features. The stakeholder engagement process lasted over nine months covering three stakeholder group's workflows, determining where AI could intervene and assessing a mock XAI decision support system. Based on the stakeholder engagement, we identify four major themes relevant to designing XAI systems - 1) use of AI predictions, 2) information included in AI predictions, 3) personalization of AI predictions for individual differences, and 4) customizing AI predictions for specific cases. Using these themes, our scoping literature review finds that providing AI predictions before, during, or after decision-making could be beneficial depending on the complexity of the stakeholder's task. Additionally, expert stakeholders like surgeons prefer minimal to no XAI features, AI prediction, and uncertainty estimates for easy use cases. However, almost all stakeholders prefer to have optional XAI features to review when needed, especially in hard-to-predict cases. The literature also suggests that providing both system- and prediction-level information is necessary to build the user's mental model of the system appropriately. Although XAI features improve users' trust in the system, human-AI team performance is not always enhanced. Overall, stakeholders prefer to have agency over the XAI interface to control the level of information based on their needs and task complexity. We conclude with suggestions for future research, especially on customizing XAI features based on preferences and tasks.
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Affiliation(s)
- Harishankar V Subramanian
- Engineering Management & Systems Engineering, Missouri University of Science and Technology, 600 W 14(th) Street, Rolla, MO 65409, United States of America
| | - Casey Canfield
- Engineering Management & Systems Engineering, Missouri University of Science and Technology, 600 W 14(th) Street, Rolla, MO 65409, United States of America.
| | - Daniel B Shank
- Psychological Science, Missouri University of Science and Technology, 500 W 14(th) Street, Rolla, MO 65409, United States of America
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25
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Pérez Valdivia MÁ, Calvillo Arbizu J, Portero Barreña D, Castro de la Nuez P, López Jiménez V, Rodríguez Benot A, Mazuecos Blanca A, de Gracia Guindo MC, Bernal Blanco G, Gentil Govantes MÁ, Bedoya Pérez R, Rocha Castilla JL. Predicting Kidney Transplantation Outcomes from Donor and Recipient Characteristics at Time Zero: Development of a Mobile Application for Nephrologists. J Clin Med 2024; 13:1270. [PMID: 38592072 PMCID: PMC10932177 DOI: 10.3390/jcm13051270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 02/14/2024] [Accepted: 02/21/2024] [Indexed: 04/10/2024] Open
Abstract
(1) Background: We report on the development of a predictive tool that can estimate kidney transplant survival at time zero. (2) Methods: This was an observational, retrospective study including 5078 transplants. Death-censored graft and patient survivals were calculated. (3) Results: Graft loss was associated with donor age (hazard ratio [HR], 1.021, 95% confidence interval [CI] 1.018-1.024, p < 0.001), uncontrolled donation after circulatory death (DCD) (HR 1.576, 95% CI 1.241-2.047, p < 0.001) and controlled DCD (HR 1.567, 95% CI 1.372-1.812, p < 0.001), panel reactive antibody percentage (HR 1.009, 95% CI 1.007-1.011, p < 0.001), and previous transplants (HR 1.494, 95% CI 1.367-1.634, p < 0.001). Patient survival was associated with recipient age (> 60 years, HR 5.507, 95% CI 4.524-6.704, p < 0.001 vs. < 40 years), donor age (HR 1.019, 95% CI 1.016-1.023, p < 0.001), dialysis vintage (HR 1.0000263, 95% CI 1.000225-1.000301, p < 0.01), and male sex (HR 1.229, 95% CI 1.135-1.332, p < 0.001). The C-statistics for graft and patient survival were 0.666 (95% CI: 0.646, 0.686) and 0.726 (95% CI: 0.710-0.742), respectively. (4) Conclusions: We developed a mobile app to estimate survival at time zero, which can guide decisions for organ allocation.
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Affiliation(s)
| | - Jorge Calvillo Arbizu
- Biomedical Engineering Group, University of Sevilla, 41092 Sevilla, Spain;
- Department of Telematics Engineering, University of Sevilla, 41092 Sevilla, Spain;
| | | | | | | | | | | | | | - Gabriel Bernal Blanco
- Nephrology Service, Hospital Virgen del Rocío, 41013 Sevilla, Spain; (G.B.B.); (M.Á.G.G.); (J.L.R.C.)
| | | | - Rafael Bedoya Pérez
- Pediatric Nephrology Service, Hospital Virgen del Rocío, 41013 Sevilla, Spain;
| | - José Luis Rocha Castilla
- Nephrology Service, Hospital Virgen del Rocío, 41013 Sevilla, Spain; (G.B.B.); (M.Á.G.G.); (J.L.R.C.)
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26
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Yu B, Liu Y, Wang T, Zhang Y, Guo J, Kong C, Chen Z, Ma X, Zhou J, Qiu T. Validation of the kidney donor profile index (KDPI) for deceased donor kidney transplants in China. Transpl Immunol 2024; 82:101961. [PMID: 38184216 DOI: 10.1016/j.trim.2023.101961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 11/16/2023] [Accepted: 11/17/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND The kidney donor profile index (KDPI) evaluates kidney donor's age, height, weight, ethnicity, cause of death, high blood pressure, diabetes, exposure to hepatitis C and estimated glomerular filtration (eGFR). Kidneys with lower KDPI scores are expected to function longer that those with higher KPDI values. The applicability of KDPI score in Chinese kidney transplant donation has not yet been validated. This study evaluated the prognostic value of KDPI score in Chinese kidney transplant patients. METHODS A retrospective analysis was conducted on 184 deceased donors and 353 corresponding kidney transplant patients at the Organ Transplantation Department of Renmin Hospital of Wuhan University between 2018 and 2021. The donors and recipients were stratified into four groups based on their KDPI score: KDPI 85-100, KDPI 60-84, KDPI 21-59, and KDPI 0-20. RESULTS As expected, the KDPI 85-100 group was associated with a poor short-term renal function (both postoperative creatinine and eGFR with P > 0.05), a higher incidence of delayed graft function (DGF; 25.5% for KDPI 85-100 group vs. 10.2% for KDPI 60-84 group vs. 5.4% for KDPI 21-59 group vs. 0 for KDPI 0-20 group, all P > 0.05). Furthermore, the same groups showed worse 3-year patient survival rate: 86.3% for KDPI 85-100 group vs. 97.01% for KDPI 60-84 group vs. 97.83% for KDPI 21-59 group vs. 100% for KDPI 0-20 group, all P > 0.05); and renal survival rate: 82.6% for KDPI 85-100 group vs. 92.99% KDPI 60-84 group vs.97.83% for KDPI 21-59 group vs. 100% for KDPI 0-20 group, all P > 0.05). Our analysis showed that the KDPI score had a good predictive value for the survival of kidney transplants and patients in our center (area under the curve: 0.728 and 0.76, P > 0.05). CONCLUSION We recommend that the KDPI scoring system can be employed as an effective tool to predict kidney transplantation outcomes in deceased donation in China.
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Affiliation(s)
- Bo Yu
- The Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei, PR China; Department of Urology, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei, PR China
| | - Yiting Liu
- The Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei, PR China; Department of Urology, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei, PR China
| | - Tianyu Wang
- The Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei, PR China; Department of Urology, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei, PR China
| | - Yalong Zhang
- The Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei, PR China; Department of Urology, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei, PR China
| | - Jiayu Guo
- The Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei, PR China; Department of Urology, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei, PR China
| | - Chenyang Kong
- The Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei, PR China; Department of Urology, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei, PR China
| | - Zhongbao Chen
- The Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei, PR China; Department of Urology, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei, PR China
| | - Xiaoxiong Ma
- The Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei, PR China; Department of Urology, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei, PR China
| | - Jiangqiao Zhou
- The Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei, PR China; Department of Urology, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei, PR China.
| | - Tao Qiu
- The Department of Organ Transplantation, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei, PR China; Department of Urology, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei, PR China.
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27
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Ellison TA, Bae S, Chow EKH, Massie AB, Kucirka LM, Van Arendonk KJ, Segev DL. Evaluating Cost-Effectiveness in Using High-Kidney Donor Profile Index Organs. Transplant Proc 2023; 55:2333-2344. [PMID: 37925233 PMCID: PMC10841655 DOI: 10.1016/j.transproceed.2023.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/22/2023] [Indexed: 11/06/2023]
Abstract
A more granular donor kidney grading scale, the kidney donor profile index (KDPI), has recently emerged in contradistinction to the standard criteria donor/expanded criteria donor framework. In this paper, we built a Markov decision process model to evaluate the survival, quality-adjusted life years (QALY), and cost advantages of using high-KDPI kidneys based on multiple KDPI strata over a 60-month time horizon as opposed to remaining on the waiting list waiting for a lower-KDPI kidney. Data for the model were gathered from the Scientific Registry of Transplant Recipients and the United States Renal Data System Medicare parts A, B, and D databases. Of the 129,024 phenotypes delineated in this model, 65% of them would experience a survival benefit, 81% would experience an increase in QALYs, 87% would see cost-savings, and 76% would experience cost-savings per QALY from accepting a high-KDPI kidney rather than remaining on the waiting list waiting for a kidney of lower-KDPI. Classification and regression tree analysis (CART) revealed the main drivers of increased survival in accepting high-KDPI kidneys were wait time ≥30 months, panel reactive antibody (PRA) <90, age ≥45 to 65, diagnosis leading to renal failure, and prior transplantation. The CART analysis showed the main drivers of increased QALYs in accepting high-kidneys were wait time ≥30 months, PRA <90, and age ≥55 to 65.
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Affiliation(s)
- Trevor A Ellison
- Department of Cardiothoracic Surgery, Genesis Healthcare, Zanesville, OH.
| | - Sunjae Bae
- Department of Surgery, NYU Grossman School of Medicine, NY; Department of Population Health, NYU Grossman School of Medicine, NY
| | - Eric K H Chow
- Rosalind Franklin University of Medicine and Science, North Chicago, IL
| | - Allan B Massie
- Department of Surgery, NYU Grossman School of Medicine, NY; Department of Population Health, NYU Grossman School of Medicine, NY
| | - Lauren M Kucirka
- Department of Obstetrics and Gynecology, University of North Carolina, NC
| | - Kyle J Van Arendonk
- Department of Surgery, Division of Pediatric Surgery, Medical College of Wisconsin, WI
| | - Dorry L Segev
- Department of Surgery, NYU Grossman School of Medicine, NY; Department of Population Health, NYU Grossman School of Medicine, NY
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28
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Gonzalez Sepulveda JM, Mehrotra S, Yang JC, Schantz KJ, Becker Y, Formica R, Ladner DP, Kaufman D, Friedewald J. Physician Preferences when Selecting Candidates for Lower-Quality Kidney Offers. Clin J Am Soc Nephrol 2023; 18:1599-1609. [PMID: 37729938 PMCID: PMC10723918 DOI: 10.2215/cjn.0000000000000302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 09/14/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND In the United States, more than 50% of kidneys in the lowest 15% quality range (those with Kidney Donor Profile Index >85) are discarded. Studies suggest that using more of these kidneys could benefit patients waiting for a transplant. This study assesses the trade-offs physicians make when selecting recipients for lower-quality kidneys. METHODS A discrete choice experiment (DCE) was administered to surgeons and nephrologists in the United States who are involved in kidney acceptance decisions. The DCE presented kidneys that varied in terms of Kidney Donor Profile Index, expected cold ischemia time, donor age, pump parameters, serum creatinine levels, glomerulosclerosis, donor diabetes status, and whether donation was made after circulatory death. Candidate characteristics included recipients' age, diabetes history, time on dialysis, ejection fraction, HLA mismatch, calculated panel reactive antibody, and Karnofsky performance score. Regression analysis was used to estimate acceptability weights associated with kidney and recipient characteristics. RESULTS A total of 108 physicians completed the DCE. The likelihood of acceptance was significantly lower with deterioration of kidney quality, expected cold ischemia time at transplantation, and missing biopsy and pump information. Acceptance was prioritized for patients who were higher on the waiting list, younger recipients, those who have spent less time on dialysis, and those without a history of diabetes. Performance status (Karnofsky score) and calculated panel reactive antibody also had a statistically significant but smaller association. Finally, ejection fraction had a marginally significant association, and HLA match had no significant association with the acceptance of marginal kidneys. A group of respondents were found to be primarily concerned about cold ischemia time. CONCLUSIONS In this DCE, physicians considered the recipient characteristics that inform expected post-transplant survival score when they decided whether to accept a marginal kidney for a given recipient.
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Affiliation(s)
- Juan M. Gonzalez Sepulveda
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Sanjay Mehrotra
- Industrial Engineering and Management Sciences, McCormick School of Engineering, Northwestern University, Evanston, Illinois
| | - Jui-Chen Yang
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | - Yolanda Becker
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - Richard Formica
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Daniela P. Ladner
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Dixon Kaufman
- University of Wisconsin School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - John Friedewald
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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29
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Caldwell JS, Cheng XS. Maximizing Utility of Deceased Donor Kidney Offers. Clin J Am Soc Nephrol 2023; 18:1521-1523. [PMID: 38064304 PMCID: PMC10723914 DOI: 10.2215/cjn.0000000000000349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
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30
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Ma X, Moradi M, Ma X, Tang Q, Levi M, Chen Y, Zhang HK. Large Area Kidney Imaging for Pre-transplant Evaluation using Real-Time Robotic Optical Coherence Tomography. RESEARCH SQUARE 2023:rs.3.rs-3385622. [PMID: 37886456 PMCID: PMC10602184 DOI: 10.21203/rs.3.rs-3385622/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
Optical coherence tomography (OCT) is a high-resolution imaging modality that can be used to image microstructures of human kidneys. These images can be analyzed to evaluate the viability of the organ for transplantation. However, current OCT devices suffer from insufficient field-of-view, leading to biased examination outcomes when only small portions of the kidney can be assessed. Here we present a robotic OCT system where an OCT probe is integrated with a robotic manipulator, enabling wider area spatially-resolved imaging. With the proposed system, it becomes possible to comprehensively scan the kidney surface and provide large area parameterization of the microstructures. We verified the probe tracking accuracy with a phantom as 0.0762±0.0727 mm and demonstrated its clinical feasibility by scanning ex vivo kidneys. The parametric map exhibits fine vasculatures beneath the kidney surface. Quantitative analysis on the proximal convoluted tubule from the ex vivo human kidney yields highly clinical-relevant information.
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Affiliation(s)
- Xihan Ma
- Department of Robotics Engineering, Worcester Polytechnic Institute, MA 01609, USA
| | - Mousa Moradi
- Department of Biomedical Engineering, University of Massachusetts, Amherst, MA 01003, USA
| | - Xiaoyu Ma
- Department of Biomedical Engineering, University of Massachusetts, Amherst, MA 01003, USA
| | - Qinggong Tang
- The Stephenson School of Biomedical Engineering, University of Oklahoma, Norman, OK 73019, USA
| | - Moshe Levi
- Department of Biochemistry and Molecular & Cellular Biology, Georgetown University, Washington, DC 20057, USA
| | - Yu Chen
- Department of Biomedical Engineering, University of Massachusetts, Amherst, MA 01003, USA
| | - Haichong K Zhang
- Department of Robotics Engineering, Worcester Polytechnic Institute, MA 01609, USA
- Department of Biomedical Engineering, Worcester Polytechnic Institute, MA 01609, USA
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Abstract
PURPOSE OF REVIEW Optimizing deceased donor organ utilization is gaining recognition as a topical and important issue, both in the United Kingdom (UK) and globally. This review discusses pertinent issues in the field of organ utilization, with specific reference to UK data and recent developments within the UK. RECENT FINDINGS A multifaceted approach is likely required in order to improve organ utilization. Having a solid evidence-base upon which transplant clinicians and patients on national waiting lists can base decisions regarding organ utilization is imperative in order to bridge gaps in knowledge regarding the optimal use of each donated organ. A better understanding of the risks and benefits of the uses of higher risk organs, along with innovations such as novel machine perfusion technologies, can help clinician decision-making and may ultimately reduce the unnecessary discard of precious deceased donor organs. SUMMARY The issues facing the UK with regards to organ utilization are likely to be similar to those in many other developed countries. Discussions around these issues within organ donation and transplantation communities may help facilitate shared learning, lead to improvements in the usage of scarce deceased donor organs, and enable better outcomes for patients waiting for transplants.
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Affiliation(s)
- Maria Ibrahim
- Department of Nephrology and Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester
| | - Chris J Callaghan
- Department of Nephrology and Transplantation, Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London
- NHS Blood and Transplant, Bristol, UK
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32
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Ibrahim M, Mehew J, Martin K, Forsythe J, Johnson RJ, Callaghan C. Outcomes of Declined Deceased Donor Kidney Offers That Are Subsequently Implanted: A UK Registry Study. Transplantation 2023; 107:1348-1358. [PMID: 36706063 DOI: 10.1097/tp.0000000000004467] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Deceased donor kidneys are often declined for ≥1 patients but then implanted into another. Studies are needed to guide transplant clinicians and patients, especially given the increasing age and comorbidity of donors. This study compares outcomes of recipients of transplanted kidneys that were initially declined with outcomes of patients who remained on the waiting list. METHODS This UK Transplant Registry study examined named-patient, adult donation after brain death donor single kidney-only offers that were declined for donor- or organ-related reasons (DORRs), in which the kidney was subsequently transplanted from January 1, 2010, to December 31, 2018. Outcomes included graft function and survival of kidneys transplanted following DORR decline, survival and transplant status of patients who had a kidney declined, and intercenter decline rates. RESULTS A total of 4722 kidneys declined for DORRs, which eventually resulted in single kidney-only transplants, were examined. One year after the offer decline, 35% of patients for whom the organ was declined remained on the list, 55% received a deceased donor transplant at a median of 174 d after the initial offer decline, and 4% had been removed or died. For patients transplanted following offer decline, there was no significant difference in 5-y graft survival when comparing the outcomes to those recipients who received the declined kidney. There was significant variation in DORR decline rates between UK transplant units (17%-54%). CONCLUSIONS This study shows reasonable outcomes of kidneys previously declined for DORRs and supports the utilization of those considered to be of higher risk for carefully selected recipients.
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Affiliation(s)
- Maria Ibrahim
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- NHS Blood and Transplant, Stoke Gifford, Bristol, United Kingdom
| | - Jennifer Mehew
- NHS Blood and Transplant, Stoke Gifford, Bristol, United Kingdom
| | - Kate Martin
- NHS Blood and Transplant, Stoke Gifford, Bristol, United Kingdom
| | - John Forsythe
- NHS Blood and Transplant, Stoke Gifford, Bristol, United Kingdom
| | - Rachel J Johnson
- NHS Blood and Transplant, Stoke Gifford, Bristol, United Kingdom
| | - Chris Callaghan
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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33
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McDonald SP, Irish GL. Should You Accept What Others Reject? Transplantation 2023; 107:1244-1245. [PMID: 36582018 DOI: 10.1097/tp.0000000000004468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Stephen P McDonald
- Australia and New Zealand Dialysis and Transplant Registry, SA Health and Medical Research Institute, Adelaide, SA, Australia
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34
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Shi B, Ying T, Xu J, Wyburn K, Laurence J, Chadban SJ. Obesity is Associated With Delayed Graft Function in Kidney Transplant Recipients: A Paired Kidney Analysis. Transpl Int 2023; 36:11107. [PMID: 37324221 PMCID: PMC10261700 DOI: 10.3389/ti.2023.11107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 05/11/2023] [Indexed: 06/17/2023]
Abstract
Obesity is increasingly prevalent among candidates for kidney transplantation. Existing studies have shown conflicting post-transplant outcomes for obese patients which may relate to confounding bias from donor-related characteristics that were unaccounted for. We used ANZDATA Registry data to compare graft and patient survival between obese (BMI >27.5 kg/m2 Asians; >30 kg/m2 non-Asians) and non-obese kidney transplant recipients, while controlling for donor characteristics by comparing recipients of paired kidneys. We selected transplant pairs (2000-2020) where a deceased donor supplied one kidney to an obese candidate and the other to a non-obese candidate. We compared the incidence of delayed graft function (DGF), graft failure and death by multivariable models. We identified 1,522 pairs. Obesity was associated with an increased risk of DGF (aRR = 1.26, 95% CI 1.11-1.44, p < 0.001). Obese recipients were more likely to experience death-censored graft failure (aHR = 1.25, 95% CI 1.05-1.49, p = 0.012), and more likely to die with function (aHR = 1.32, 95% CI 1.15-1.56, p = 0.001), versus non-obese recipients. Long-term patient survival was significantly worse in obese patients with 10- and 15-year survival of 71% and 56% compared to 77% and 63% in non-obese patients. Addressing obesity is an unmet clinical need in kidney transplantation.
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Affiliation(s)
- Bree Shi
- Charles Perkins Centre, The University of Sydney, Camperdown, NSW, Australia
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australia Health and Medicine Research Institute, Adelaide, SA, Australia
| | - Tracey Ying
- Charles Perkins Centre, The University of Sydney, Camperdown, NSW, Australia
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australia Health and Medicine Research Institute, Adelaide, SA, Australia
- Renal Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Josephine Xu
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australia Health and Medicine Research Institute, Adelaide, SA, Australia
- Department of Transplant Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Kate Wyburn
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australia Health and Medicine Research Institute, Adelaide, SA, Australia
- Renal Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Jerome Laurence
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australia Health and Medicine Research Institute, Adelaide, SA, Australia
- Department of Transplant Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Steven J Chadban
- Charles Perkins Centre, The University of Sydney, Camperdown, NSW, Australia
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australia Health and Medicine Research Institute, Adelaide, SA, Australia
- Renal Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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35
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Kadatz MJ, Gill J, Gill J, Lan JH, McMichael LC, Chang DT, Gill JS. The Benefits of Preemptive Transplantation Using High-Kidney Donor Profile Index Kidneys. Clin J Am Soc Nephrol 2023; 18:634-643. [PMID: 37027505 PMCID: PMC10278842 DOI: 10.2215/cjn.0000000000000134] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 02/16/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND The Kidney Donor Profile Index (KDPI) is a percentile score summarizing the likelihood of allograft failure: A KDPI ≥85% is associated with shorter allograft survival, and 50% of these donated kidneys are not currently used for transplantation. Preemptive transplantation (transplantation without prior maintenance dialysis) is associated with longer allograft survival than transplantation after dialysis; however, it is unknown whether this benefit extends to high-KDPI transplants. The objective of this analysis was to determine whether the benefit of preemptive transplantation extends to recipients of transplants with a KDPI ≥85%. METHODS This retrospective cohort study compared the post-transplant outcomes of preemptive and nonpreemptive deceased donor kidney transplants using data from the Scientific Registry of Transplant Recipients. 120,091 patients who received their first, kidney-only transplant between January 1, 2005, and December 31, 2017, were studied, including 23,211 with KDPI ≥85%. Of this cohort, 12,331 patients received a transplant preemptively. Time-to-event models for the outcomes of allograft loss from any cause, death-censored graft loss, and death with a functioning transplant were performed. RESULTS Compared with recipients of nonpreemptive transplants with a KDPI of 0%-20% as the reference group, the risk of allograft loss from any cause in recipients of a preemptive transplant with KDPI ≥85% (hazard ratio [HR], 1.51; 95% confidence interval [CI], 1.39 to 1.64) was lower than that in recipients of nonpreemptive transplant with a KDPI ≥85% (HR, 2.39; 95% CI, 2.21 to 2.58) and similar to that of recipients of a nonpreemptive transplant with a KDPI of 51%-84% (HR, 1.61; 95% CI, 1.52 to 1.70). CONCLUSIONS Preemptive transplantation is associated with a lower risk of allograft failure, irrespective of KDPI, and preemptive transplants with KDPI ≥85% have comparable outcomes with nonpreemptive transplants with KDPI 51%-84%.
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Affiliation(s)
- Matthew J. Kadatz
- Kidney Transplant Program, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
- Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Jagbir Gill
- Kidney Transplant Program, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
- Providence Health Research Institute, Vancouver, British Columbia, Canada
- Centre for Health Evaluation and Outcomes Sciences, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Justin Gill
- Kidney Transplant Program, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - James H. Lan
- Kidney Transplant Program, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
- Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lachlan C. McMichael
- Kidney Transplant Program, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Doris T. Chang
- Providence Health Research Institute, Vancouver, British Columbia, Canada
| | - John S. Gill
- Kidney Transplant Program, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
- Providence Health Research Institute, Vancouver, British Columbia, Canada
- Centre for Health Evaluation and Outcomes Sciences, Vancouver, British Columbia, Canada
- Tufts-New England Medical Center, Boston, Massachusetts
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36
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Formica RN. The National Organ Transplant Act Must Be Updated to Meet the Demands of Transplantation's Future. Clin J Am Soc Nephrol 2023; 18:554-556. [PMID: 37016475 PMCID: PMC10278798 DOI: 10.2215/cjn.0000000000000139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Affiliation(s)
- Richard N Formica
- Yale University School of Medicine Department of Medicine/Section of Nephrology, New Haven, Connecticut
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37
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Friedewald JJ, Schantz K, Mehrotra S. Kidney organ allocation: reducing discards. Curr Opin Organ Transplant 2023; 28:145-148. [PMID: 36696090 DOI: 10.1097/mot.0000000000001049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE OF REVIEW The donation and kidney transplant system in the United States is challenged with reducing the number of kidneys that are procured for transplant but ultimately discarded. That number can reach 20% of donated kidneys each year. RECENT FINDINGS The reasons for these discards, in the face of overwhelming demand, are multiple. SUMMARY The authors review the data supporting a number of potential causes for high discard rates as well as provide potential solutions to the problem.
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Affiliation(s)
| | - Karolina Schantz
- Northwestern University Industrial Engineering and Management Sciences, Evanston, Illinois, USA
| | - Sanjay Mehrotra
- Northwestern University Industrial Engineering and Management Sciences, Evanston, Illinois, USA
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38
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Gill JS, Kelly B, Tonelli M. Time to Abolish Metrics That Sustain Systemic Racism in Kidney Allocation. JAMA 2023; 329:879-880. [PMID: 36848169 DOI: 10.1001/jama.2023.1076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
This Viewpoint discusses how the Kidney Donor Profile Index (KDPI) in its current form is not fit to guide kidney allocation because it devalues organ donation by Black donors based on a weak association between donor race and kidney transplant failure.
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Affiliation(s)
- John S Gill
- Kidney Transplant Program, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Marcello Tonelli
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
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39
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Gaynor JJ, Tabbara MM, Ciancio G, Selvaggi G, Garcia J, Tekin A, Vianna R. The Importance Of Avoiding Time-Dependent Bias When Testing The Prognostic Value Of An Intervening Event - Two Acute Cellular Rejection Examples In Intestinal Transplantation. Am J Transplant 2023:S1600-6135(23)00308-8. [PMID: 36871628 DOI: 10.1016/j.ajt.2023.02.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/24/2023] [Indexed: 03/07/2023]
Abstract
In testing the prognostic value of the occurrence of an intervening event (clinical event that occurs post-transplant), 3 proper statistical methodologies for testing its prognostic value exist (time dependent covariate, landmark, and semi-Markov modelling methods). However, time-dependent bias has appeared in many clinical reports, whereby the intervening event is statistically treated as a baseline variable (as if it occurred at transplant). Using a single-center cohort of 445 intestinal transplant cases to test the prognostic value of 1st acute cellular rejection (ACR) and severe (grade of) ACR on the hazard rate of developing graft loss, we demonstrate how the inclusion of such time-dependent bias can lead to severe underestimation of the true hazard ratio (HR). The (statistically more powerful) time dependent covariate method in Cox's multivariable model yielded significantly unfavorable effects of 1st ACR (P<.0001; HR=2.492) and severe ACR (P<.0001; HR=4.531). In contrast, when using the time-dependent biased approach, multivariable analysis yielded an incorrect conclusion for the prognostic value of 1st ACR (P=.31, HR=0.877, 35.2% of 2.492) and a much smaller estimated effect of severe ACR (P=.0008; HR=1.589; 35.1% of 4.531). In conclusion, this study demonstrates the importance of avoiding time-dependent bias when testing the prognostic value of an intervening event.
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Affiliation(s)
- Jeffrey J Gaynor
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL.
| | - Marina M Tabbara
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL
| | - Gaetano Ciancio
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL
| | - Gennaro Selvaggi
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL
| | - Jennifer Garcia
- Miami Transplant Institute, Department of Pediatrics, University of Miami Miller School of Medicine; Miami, FL
| | - Akin Tekin
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL
| | - Rodrigo Vianna
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL
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40
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Wang CJ, Wetmore JB, Wey A, Miller J, Snyder JJ, Israni AK. Impact of donor kidney biopsy on kidney yield and posttransplant outcomes. Am J Transplant 2023; 23:387-392. [PMID: 36695677 DOI: 10.1016/j.ajt.2022.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 11/10/2022] [Accepted: 11/17/2022] [Indexed: 01/03/2023]
Abstract
Procurement biopsy is performed to determine kidney quality, but evidence supporting such association is poor. We investigated the impact of glomerulosclerosis percentage (GS%) on kidney yield and patient outcomes. Information on deceased kidney donors from July 1, 2017, to June 30, 2019, was collected. Association between GS% and kidney yield (number of kidneys procured per donor) and posttransplant graft and patient outcomes were studied. Maximal GS% and minimal GS% were calculated to determine the relationship between GS% and kidney yield; minimal GS% only for correlation with posttransplant outcomes. Multinomial logistic regression and Cox models with least absolute shrinkage and selection operator were used to analyze the association of GS% with kidney yield and posttransplant outcomes, respectively. The kidney yield was 1.63 when maximal GS% and minimal GS% were <5%, but was 0.88 when both GS% were >20%. The hazard ratio for graft failure 1 year after transplant was 1.05 when minimal GS% was 16% to 20%, but was 1.3 for GS% of >20%. The hazard ratio for mortality increased from 1 to 1.2 when minimal GS% reached >20%. In summary, higher GS% was associated with lower kidney yield and inferior posttransplant outcomes. Incorporation of GS% into Scientific Registry of Transplant Recipients models may reassure organ procurement organizations and transplant centers pursuing kidneys with relatively high GS% levels, thereby reducing kidney discard rates.
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Affiliation(s)
- Connie J Wang
- Division of Nephrology, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - James B Wetmore
- Division of Nephrology, Hennepin Healthcare, Minneapolis, Minnesota, USA; Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Andrew Wey
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Jonathan Miller
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Jon J Snyder
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Ajay K Israni
- Division of Nephrology, Hennepin Healthcare, Minneapolis, Minnesota, USA; Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA.
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41
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Maldonado AQ, Bradbrook K, Sjöholm K, Kjellman C, Lee J, Stewart D. The real unmet need: A multifactorial approach for identifying sensitized kidney candidates with low access to transplant. Clin Transplant 2023; 37:e14946. [PMID: 36841966 DOI: 10.1111/ctr.14946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 01/30/2023] [Accepted: 02/08/2023] [Indexed: 02/27/2023]
Abstract
BACKGROUND At the start of 2020, the kidney waiting list consisted of 2526 candidates with a calculated panel reactive antibody (CPRA) of 99.9% or greater, a cohort demonstrated in published research to have meaningfully lower than average access to transplantation even under the revised kidney allocation system (KAS). METHODS This was a retrospective analysis of US kidney registrations using data from the OPTN [Reference (https://optn.transplant.hrsa.gov/data/about-data/)]. The period-prevalent study cohort consisted of US kidney-alone registrations who waited at least 1 day between April 1, 2016, when HLA DQ-Alpha and DP-Beta unacceptable antigen data became available in OPTN data collection, to December 31, 2019. Poisson rate regression was used to model deceased donor kidney transplant rates per active year waiting and using an offset term to account for differential at-risk periods. Median time to transplant was estimated for each IRR group using the Kaplan-Meier method. Sensitivity analyses were included to address geographic variation in supply-to-demand ratios and differences in dialysis time or waiting time. RESULTS In this study, we found 1597 additional sensitized (CPRA 50-<99.9%) candidates with meaningfully lower than average access to transplant when simultaneously taking into account CPRA and other factors. In combination with CPRA, candidate blood type, Estimated Post-Transplant Survival Score (EPTS), and presence of other antibody specificities beyond those in the current, 5-locus CPRA were found to influence the likelihood of transplant. CONCLUSION In total, this suggests approximately 4100 sensitized candidates are on the waiting list who represent a community of disadvantaged patients who may benefit from progressive therapies and interventions to facilitate incompatible transplantation. Though associated with higher risks, such interventions may nevertheless be more attractive than remaining on dialysis with the associated accumulation of mortality risk over time.
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Affiliation(s)
| | | | | | | | | | - Darren Stewart
- United Network for Organ Sharing, Richmond, Virginia, USA.,NYU Langone Transplant Institute, New York, USA
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42
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Vinson AJ, Cardinal H, Parsons C, Tennankore KK, Mainra R, Maru K, Treleaven D, Gill J. Disparities in Deceased Donor Kidney Offer Acceptance: A Survey of Canadian Transplant Nephrologists, General Surgeons and Urologists. Can J Kidney Health Dis 2023; 10:20543581231156855. [PMID: 36861114 PMCID: PMC9969426 DOI: 10.1177/20543581231156855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 12/19/2022] [Indexed: 02/26/2023] Open
Abstract
Background Significant variability in organ acceptance thresholds have been demonstrated across the United States, but data regarding the rate and rationale for kidney donor organ decline in Canada are lacking. Objective To examine decision making regarding deceased kidney donor acceptance and non-acceptance in a population of Canadian transplant professionals. Design A survey study of theoretical deceased donor kidney cases of increasing complexity. Setting Canadian transplant nephrologists, urologists, and surgeons making donor call decisions responding to an electronic survey between July 22 and October 4, 2022. Participants Invitations to participate were distributed to 179 Canadian transplant nephrologists, surgeons, and urologists through e-mail. Participants were identified by contacting each transplant program and requesting a list of physicians who take donor call. Measurements Survey respondents were asked whether they would accept or decline a given donor, assuming there was a suitable recipient. They were also asked to cite reasons for donor non-acceptance. Methods Donor scenario-specific acceptance rates (total acceptance divided by total number of respondents for a given scenario and overall) and reasons for decline were determined and presented as a percentage of the total cases declined. Results In all, 72 respondents from 7 provinces completed at least one question of the survey, with considerable variability between acceptance rates for centers; the most conservative center declined 60.9% of donor cases, whereas the most aggressive center declined only 28.1%, P-value < .001. There was an increased risk of non-acceptance with advancing age, donation after cardiac death, acute kidney injury, chronic kidney disease, and comorbidities. Limitations As with any survey, there is the potential for participation bias. In addition, this study examines donor characteristics in isolation, however, asks respondent to assume there is a suitable candidate available. In reality, whenever donor quality is considered, it should be considered in the context of the intended recipient. Conclusion In a survey of increasingly medically complex deceased kidney donor cases, there was significant variability in donor decline among Canadian transplant specialists. Given relatively high rates of donor decline and apparent heterogeneity in acceptance decisions, Canadian transplant specialists may benefit from additional education regarding the benefits achieved from even medically complex kidney donors for appropriate candidates relative to remaining on dialysis on the transplant waitlist.
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Affiliation(s)
- A. J. Vinson
- Nova Scotia Health Authority, Halifax,
Canada,Division of Nephrology, Department of
Medicine, Dalhousie University, Halifax, NS, Canada,A. J. Vinson, Division of Nephrology,
Department of Medicine, Dalhousie University, Room 5081, 5th Floor Dickson
Building, Victoria General Hospital, 5820 University Ave, Halifax, NS B3H 1V8,
Canada.
| | - H. Cardinal
- Centre de recherche du Centre
hospitalier de l’Université de Montréal, QC, Canada
| | - C. Parsons
- Organ and Tissue Donation and
Transplantation, Canadian Blood Services, Ottawa, ON, Canada
| | - K. K. Tennankore
- Nova Scotia Health Authority, Halifax,
Canada,Division of Nephrology, Department of
Medicine, Dalhousie University, Halifax, NS, Canada
| | - R. Mainra
- Division of Nephrology, Department of
Medicine, University of Saskatchewan, Regina, Canada
| | - K. Maru
- Canadian Blood Services, Ottawa, ON,
Canada
| | - D. Treleaven
- Division of Nephrology, Department of
Medicine, McMaster University, Hamilton, ON, Canada
| | - J. Gill
- Division of Nephrology, Department of
Medicine, The University of British Columbia, Vancouver, Canada
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43
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Martin P, Gupta D, Pruett T. Predicting older-donor kidneys' post-transplant renal function using pre-transplant data. NAVAL RESEARCH LOGISTICS 2023; 70:21-33. [PMID: 37082424 PMCID: PMC10108525 DOI: 10.1002/nav.22083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 08/29/2022] [Accepted: 09/15/2022] [Indexed: 05/03/2023]
Abstract
This paper provides a methodology for predicting post-transplant kidney function, that is, the 1-year post-transplant estimated Glomerular Filtration Rate (eGFR-1) for each donor-candidate pair. We apply customized machine-learning algorithms to pre-transplant donor and recipient data to determine the probability of achieving an eGFR-1 of at least 30 ml/min. This threshold was chosen because there is insufficient survival benefit if the kidney fails to generate an eGFR-1 ≥ 30 ml/min. For some donor-candidate pairs, the developed algorithm provides highly accurate predictions. For others, limitations of previous transplants' data results in noisier predictions. However, because the same kidney is offered to many candidates, we identify those pairs for whom the predictions are highly accurate. Out of 6977 discarded older-donor kidneys that were a match with at least one transplanted kidney, 5282 had one or more identified candidate, who were offered that kidney, did not accept any other offer, and would have had ≥80% chance of achieving eGFR-1 ≥ 30 ml/min, had the kidney been transplanted. We also show that transplants with ≥80% chance of achieving eGFR-1 ≥ 30 ml/min and that survive 1 year have higher 10-year death-censored graft survival probabilities than all older-donor transplants that survive 1 year (73.61% vs. 70.48%, respectively).
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Affiliation(s)
- Paola Martin
- Kelley School of BusinessIndiana UniversityBloomingtonIndianaUSA
| | - Diwakar Gupta
- McCombs School of BusinessUniversity of TexasAustinTexasUSA
| | - Timothy Pruett
- Department of SurgeryUniversity of MinnesotaMinneapolisMinnesotaUSA
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Albert C, Harris M, DiRito J, Shi A, Edwards C, Harkins L, Lysyy T, Kulkarni S, Mulligan DC, Hosgood SA, Watson CJE, Friend PJ, Nicholson ML, Haakinson D, Saeb-Parsy K, Tietjen GT. Honoring the gift: The transformative potential of transplant-declined human organs. Am J Transplant 2023; 23:165-170. [PMID: 36695696 DOI: 10.1016/j.ajt.2022.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 10/24/2022] [Accepted: 11/13/2022] [Indexed: 01/09/2023]
Abstract
For decades, transplantation has been a life-saving treatment for those fortunate enough to gain access. Nevertheless, many patients die waiting for an organ and countless more never make it onto the waitlist because of a shortage of donor organs. Concurrently, thousands of donated organs are declined for transplant each year because of concerns about poor outcomes post-transplant. The decline of any donated organ-even if medically justified-is tragic for both the donor family and potential recipients. In this Personal Viewpoint, we discuss the need for a new mindset in how we honor the gift of organ donation. We believe that the use of transplant-declined human organs in translational research has the potential to hasten breakthrough discoveries in a multitude of scientific and medical areas. More importantly, such breakthroughs will allow us to properly value every donated organ. We further discuss the many practical challenges that such research presents and offer some possible solutions based on experiences in our own research laboratories. Finally, we share our perspective on what we believe are the necessary next steps to ensure a future where every donated organ realizes its full potential to impact the lives of current and future patients.
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Affiliation(s)
- Claire Albert
- Yale University, Department of Biomedical Engineering, New Haven, Connecticut, USA
| | - Matthew Harris
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut, USA
| | - Jenna DiRito
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut, USA
| | - Audrey Shi
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut, USA
| | | | - Lauren Harkins
- Yale University, Department of Biomedical Engineering, New Haven, Connecticut, USA
| | - Taras Lysyy
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut, USA
| | - Sanjay Kulkarni
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut, USA
| | - David C Mulligan
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut, USA
| | - Sarah A Hosgood
- Department of Surgery, University of Cambridge, and Cambridge NIHR Biomedical Research Centre, Cambridge, UK
| | - Christopher J E Watson
- Department of Surgery, University of Cambridge, and Cambridge NIHR Biomedical Research Centre, Cambridge, UK
| | - Peter J Friend
- University of Oxford, Nuffield Department of Surgical Sciences and the Oxford Transplant Centre, Oxford, UK
| | - Michael L Nicholson
- Department of Surgery, University of Cambridge, and Cambridge NIHR Biomedical Research Centre, Cambridge, UK
| | - Danielle Haakinson
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut, USA
| | - Kourosh Saeb-Parsy
- Department of Surgery, University of Cambridge, and Cambridge NIHR Biomedical Research Centre, Cambridge, UK.
| | - Gregory T Tietjen
- Yale University, Department of Biomedical Engineering, New Haven, Connecticut, USA; Yale School of Medicine, Department of Surgery, New Haven, Connecticut, USA.
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Stewart D, Mupfudze T, Klassen D. Does anybody really know what (the kidney median waiting) time is? Am J Transplant 2023; 23:223-231. [PMID: 36695688 DOI: 10.1016/j.ajt.2022.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/10/2022] [Accepted: 12/05/2022] [Indexed: 01/13/2023]
Abstract
The median waiting time (MWT) to deceased donor kidney transplant is of interest to patients, clinicians, and the media but remains elusive due to both methodological and philosophical challenges. We used Organ Procurement and Transplantation Network data from January 2003 to March 2022 to estimate MWTs using various methods and timescales, applied overall, by era, and by candidate demographics. After rising for a decade, the overall MWT fell to 5.19 years between 2015 and 2018 and declined again to 4.05 years (April 2021 to March 2022), based on the Kaplan-Meier method applied to period-prevalent cohorts. MWTs differed markedly by blood type, donor service area, and pediatric vs adult status, but to a lesser degree by race/ethnicity. Choice of methodology affected the magnitude of these differences. Instead of waiting years for an answer, reliable kidney MWT estimates can be obtained shortly after a policy is implemented using the period-prevalent Kaplan-Meier approach, a theoretical but useful construct for which we found no evidence of bias compared with using incident cohorts. We recommend this method be used complementary to the competing risks approach, under which MWT is often inestimable, to fill the present information void concerning the seemingly simple question of how long it takes to get a kidney transplant in the United States.
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Affiliation(s)
| | | | - David Klassen
- Office of the Chief Medical Officer, United Network for Organ Sharing
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Miller G, Ankerst DP, Kattan MW, Hüser N, Vogelaar S, Tieken I, Heemann U, Assfalg V. Kidney Transplantation Outcome Predictions (KTOP): A Risk Prediction Tool for Kidney Transplants from Brain-dead Deceased Donors Based on a Large European Cohort. Eur Urol 2023; 83:173-179. [PMID: 35000822 DOI: 10.1016/j.eururo.2021.12.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 11/24/2021] [Accepted: 12/02/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND European kidney donation shortages mandate efficient organ allocation by optimizing the prediction of success for individual recipients. OBJECTIVE To develop the first European online risk tool for kidney transplant outcomes on the basis of recipient-only and recipient plus donor characteristics. DESIGN, SETTING, AND PARTICIPANTS We used individual recipient and donor risk factors and three outcomes (death, death with functioning graft [DWFG], and graft loss) for 32 958 transplants within the Eurotransplant kidney allocation system and the Eurotransplant senior program between January 2006 and May 2018 in eight European countries to develop and validate a risk tool. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Cox proportional-hazards models were used to analyze the association of risk factors with overall patient mortality, and proportional subdistribution hazard regression models for their association with graft loss and DWFG. Prediction models were developed with recipient-only and recipient-donor risk factors. Sensitivity analyses based on time-specific area under the receiver operating characteristic curve (AUC) with leave-one-country-out validation were performed and calibration plots were generated. RESULTS AND LIMITATIONS The 10-yr cumulative incidence rate was 37% for mortality, 12% for DWFG, and 41% for graft loss. In recipient-donor models the leading risk factors for mortality were recipient diabetes (hazard ratio [HR] 10.73), retransplantation (HR 3.08 per transplant), and recipient age (HR 1.08). Effects were similar for DWFG. For graft loss, diabetes (subdistributional HR [SHR] 1.32), increased donor age (SHR 1.02), and prolonged cold ischemia time (SHR 1.02) had increased SHRs. All p values were <0.001. CONCLUSIONS Previously identified risk factors for outcomes following kidney transplants allow for outcome prediction with 10-yr AUC values of up to 0.81. PATIENT SUMMARY Using European data, we estimated individual risks to predict the success of kidney transplants and support physicians in decision-making. An online tool is now available (https://riskcalc.org/ktop/) for predicting kidney transplant outcomes both before and after a donor has been identified.
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Affiliation(s)
- Gregor Miller
- Department of Mathematics, Technical University of Munich, Garching, Germany.
| | - Donna P Ankerst
- Department of Mathematics, Technical University of Munich, Garching, Germany; Department of Life Science Systems, Munich Data Science Institute, Technical University of Munich, Freising, Germany
| | - Michael W Kattan
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Norbert Hüser
- TransplanTUM - Munich Transplant Center, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany; Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Serge Vogelaar
- Eurotransplant International Foundation, Leiden, The Netherlands
| | - Ineke Tieken
- Eurotransplant International Foundation, Leiden, The Netherlands
| | - Uwe Heemann
- TransplanTUM - Munich Transplant Center, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany; Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Volker Assfalg
- TransplanTUM - Munich Transplant Center, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany; Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
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Nair SS, Thorp AN, Hanna W, Johnson BK, Smith B, Iyengar S, Howe EA, Mour GK. Effectiveness of education and attitudes toward different types of deceased donor kidneys: Survey analysis of single-center experience. Front Public Health 2023; 11:1116823. [PMID: 37064665 PMCID: PMC10090271 DOI: 10.3389/fpubh.2023.1116823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/02/2023] [Indexed: 04/18/2023] Open
Abstract
Background We lack data on the effectiveness of education and the patient's attitude toward different deceased donor kidney types. A prospective study was performed to evaluate patient attitudes, baseline knowledge, and effectiveness of our kidney transplant education process. We also analyzed the knowledge retention of our waitlist patients. Design We prospectively surveyed a patient cohort using a paired analysis pre and post education with initial evaluation visit. Knowledge retention among waitlist patients was assessed with annual waitlist visit. Results One hundred four patients received paired surveys to assess the baseline knowledge and effectiveness of education. Forty-three patients received a single survey with their annual waitlist evaluation to assess knowledge retention. Paired survey showed mixed results, with no statistically significant improvement in the kidney donor profile index domain. Significant improvement was seen in the hepatitis C virus-positive donor domain and the Public Health Service (PHS) increased-risk donor domain. For the waitlist cohort, overall knowledge retention ranged from excellent to fair, with a decline in knowledge for the PHS increased-risk donor domain. Conclusion Our study suggests that the education intervention regarding different deceased donor kidney types is effective overall and transplant candidates retain the knowledge while waiting for transplant.
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Affiliation(s)
- Sumi S. Nair
- Division of Nephrology, Mayo Clinic, Phoenix, AZ, United States
| | - Andrea N. Thorp
- Department of Nursing, Mayo Clinic, Phoenix, AZ, United States
| | - Wael Hanna
- Dallas Nephrology Associates, Dallas, TX, United States
| | - Bradley K. Johnson
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, United States
| | - Byron Smith
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, United States
| | - Savitha Iyengar
- Manager Transplant Quality and Compliance, Mayo Clinic, Rochester, MN, United States
| | | | - Girish K. Mour
- Division of Nephrology, Mayo Clinic, Phoenix, AZ, United States
- *Correspondence: Girish K. Mour
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48
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Stratta RJ. Kidney utility and futility. Clin Transplant 2022; 36:e14847. [PMID: 36321653 DOI: 10.1111/ctr.14847] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/01/2022] [Accepted: 10/29/2022] [Indexed: 11/25/2022]
Abstract
Changes in kidney allocation coupled with the COVID-19 pandemic have placed tremendous strain on current systems of organ distribution and logistics. Although the number of deceased donors continues to rise annually in the United States, the proportion of marginal deceased donors (MDDs) is disproportionately growing. Cold ischemia times and kidney discard rates are rising in part related to inadequate planning, resources, and shortages. Complexity in kidney allocation and distribution has contributed to this dilemma. Logistical issues and the ability to reperfuse the kidney within acceptable time constraints increasingly determine clinical decision-making for organ acceptance. We have a good understanding of the phenotype of "hard to place" MDD kidneys, yet continue to promote a "one size fits all" approach to organ allocation. Allocation and transportation systems need to be agile, mobile, and flexible in order to accommodate the expanding numbers of MDD organs. By identifying "hard to place" MDD kidneys early and implementing a "fast-track" or open offer policy to expedite placement, the utilization rate of MDDs would improve dramatically. Organ allocation and distribution based on location, motivation, and innovation must lead the way. In the absence of change, we are sacrificing utility for futility and discard rates will continue to escalate.
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Affiliation(s)
- Robert J Stratta
- Department of Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
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Angelico R, Romano F, Riccetti C, Pellicciaro M, Toti L, Favi E, Cacciola R, Manzia TM, Tisone G. The Enhanced Recovery after Surgery (ERAS) Pathway Is a Safe Journey for Kidney Transplant Recipients during the "Extended Criteria Donor" Era. Pathogens 2022; 11:1193. [PMID: 36297249 PMCID: PMC9610733 DOI: 10.3390/pathogens11101193] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/30/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) protocols are still underused in kidney transplantation (KT) due to recipients’ “frailty” and risk of postoperative complications. We aimed to evaluate the feasibility and safety of ERAS in KT during the “extended-criteria donor” era, and to identify the predictive factors of prolonged hospitalization. In 2010−2019, all patients receiving KT were included in ERAS program targeting a discharge home within 5 days of surgery. Recipient, transplant, and outcomes data were analyzed. Of 454 KT [male: 280, 63.9%; age: 57 (19−77) years], 212 (46.7%) recipients were discharged within the ERAS target (≤5 days), while 242 (53.3%) were discharged later. Patients within the ERAS target (≤5 days) had comparable recipient and transplant characteristics to those with longer hospital stays, and they had similar post-operative complications, readmission rates, and 5 year graft/patient survival. In the multivariate analysis, DGF (HR: 2.16, 95% CI: 1.08−4.34, p < 0.030) and in-hospital dialysis (HR: 3.68, 95% CI: 1.73−7.85, p < 0.001) were the only predictive factors for late discharge. The ERAS approach is feasible and safe in all KT candidates, and its failure is primarily related to the postoperative graft function, rather than the recipient’s clinical status. ERAS pathways, integrated with strict collaboration with local nephrologists, allow early discharge after KT, with clinical benefits.
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Affiliation(s)
- Roberta Angelico
- Transplant and HPB Unit, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Francesca Romano
- Transplant and HPB Unit, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Camilla Riccetti
- Transplant and HPB Unit, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Marco Pellicciaro
- Transplant and HPB Unit, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Luca Toti
- Transplant and HPB Unit, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Evaldo Favi
- Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20126 Milan, Italy
| | - Roberto Cacciola
- Transplant and HPB Unit, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy
- King Salman Armed Forces Hospital, Tabuk 47512, Saudi Arabia
| | - Tommaso Maria Manzia
- Transplant and HPB Unit, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Giuseppe Tisone
- Transplant and HPB Unit, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy
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50
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Stewart D, Tanriover B, Gupta G. Oversimplification and Misplaced Blame Will Not Solve the Complex Kidney Underutilization Problem. KIDNEY360 2022; 3:2143-2147. [PMID: 36591359 PMCID: PMC9802557 DOI: 10.34067/kid.0005402022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 09/27/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Darren Stewart
- Department of Surgery, New York University Langone Health, New York, New York
| | - Bekir Tanriover
- Division of Nephrology, The University of Arizona, Tucson, Arizona
| | - Gaurav Gupta
- Division of Nephrology, School of Medicine, Virginia Commonwealth University, Richmond, Virginia,Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, Virginia
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