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Tucker EG, Yu ME, Adler JT, Cron DC, Sahni PV, Schold JD, Mohan S, Husain SA. Underrecognition of deceased donor kidney out-of-sequence allocation due to increasing use of free-text coding. Am J Transplant 2025:S1600-6135(25)00173-X. [PMID: 40209903 DOI: 10.1016/j.ajt.2025.04.002] [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: 09/24/2024] [Revised: 04/01/2025] [Accepted: 04/02/2025] [Indexed: 04/12/2025]
Abstract
Out-of-sequence (OOS) allocation, the process by which organ procurement organizations (OPOs) can deviate from standard rank lists of potential recipients to expeditiously allocate deceased-donor kidneys, is increasing in the United States. We aimed to determine whether current OPO reporting practices obscure the extent of OOS allocation. Using match-run data for all US deceased-donor kidney transplants from 2021-2023, we defined miscoded OOS (mOOS) allocation transplants as those with use of the 799 or 898 OPO-initiated refusal codes (other, specify) with free-text responses clearly indicating OOS allocation and compared them with explicit OOS allocation, in which OOS transplants are appropriately coded using refusal codes 861 to 863. We found that the prevalence of mOOS allocation increased from 2021 (122 transplants) to 2023 (430 transplants) and accounted for 12% of all OOS transplants by 2023. Organs allocated via mOOS had a lower median kidney donor profile index than those allocated via explicit OOS (51% vs 55%, P < .01). While an increasing number of OPOs used mOOS throughout the study period, the practice remained concentrated overall, with 5 high-frequency OPOs performing 66% of mOOS allocations in 2023. These findings highlight the need for stricter oversight of organ allocation and underscore the responsibility of the Organ Procurement and Transplant Network to ensure proper data reporting.
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Affiliation(s)
- Emma G Tucker
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York, USA; Columbia University Renal Epidemiology Group, New York, New York, USA
| | - Miko E Yu
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, 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
| | - David C Cron
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Prateek V Sahni
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York, USA; Columbia University Renal Epidemiology Group, New York, New York, USA
| | - Jesse D Schold
- Department of Epidemiology, School of Public Health, University of Colorado-Anschutz Medical Campus, Aurora, Colorado, USA; Department of Surgery, University of Colorado-Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, 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.
| | - Syed Ali Husain
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York, USA; Columbia University Renal Epidemiology Group, New York, New York, USA
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Mohan S, Yu M, Maclay LM, Adler JT, Huml AM, Schold JD, Husain SA. Outcomes for Patients With a Deceased Donor Kidney Offer in the New Allocation System. Kidney Int Rep 2025; 10:1111-1121. [PMID: 40303214 PMCID: PMC12034855 DOI: 10.1016/j.ekir.2025.01.021] [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: 09/04/2024] [Revised: 01/13/2025] [Accepted: 01/13/2025] [Indexed: 05/02/2025] Open
Abstract
Introduction In the United States (US), disparities in access to kidney transplantation exist for waitlisted candidates with end-stage kidney disease. Meanwhile, changes in kidney allocation policy have been associated with a dramatic increase in the number of organ offers declined before an organ is successfully placed. Methods We describe transplant and mortality rates for waitlisted candidates from 2015 to 2022 following these allocation changes. Results Among 249,145 incident waitlisted adults, 180,039 received at least 1 offer and were included in the study. Of these, 37.7% received a deceased donor kidney allograft, 14.7% received a living donor allograft, 7.4% died while on the waiting list, 12.7% were removed, and 27.5% were still waitlisted by the study end period. Overall, candidates' median number of days to receiving their first offer declined from 20 (7-48) in 2015 to 5 (2-13) in 2022. Candidates who died while on the waiting list received a median of 25 (9-56) offers and candidates who were removed received a median of 22 (8-53) offers during the study period. The total number of offers generated by the match-run algorithm, including those from nonutilized kidneys, increased sharply from 7,911,688 offers in 2015 to 13,682,914 in 2019, and to 29,332,516 in 2022. Conclusion These findings emphasize the inefficiencies inherent in our current allocation algorithms and the need to rethink how waitlisted patients are prioritized for a given deceased donor organ in order to maximize the probability of appropriate utilization of lifesaving organs .
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Affiliation(s)
- 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
| | - 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
| | - 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
| | - Joel T. Adler
- Division of Transplantation, Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas, USA
| | - Anne M. Huml
- Department of Kidney Medicine, Cleveland Clinic, Cleveland, Ohio, 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
| | - S. 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
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Mohan S, Yu M, Husain SA. Equity and the operational considerations of the kidney transplant allocation system. Curr Opin Organ Transplant 2025; 30:146-151. [PMID: 39760137 PMCID: PMC11962740 DOI: 10.1097/mot.0000000000001201] [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] [Indexed: 01/07/2025]
Abstract
PURPOSE OF REVIEW Demonstrate the impact of allocation system design on access to the waitlist and transplantation for patients with end-stage kidney disease (ESKD). RECENT FINDINGS Minoritized groups are more likely to be declined from transplant listing owing to psychosocial criteria. Lack of consistent definitions, screening tools with differential subgroup validity, and insufficient evidence-base contribute to concerns about reliance on psychosocial factors in transplant listing decisions. SUMMARY Although kidney transplantation is the preferred treatment choice, a shrinking proportion of prevalent patients are waitlisted for this option in the United States, even among our youngest ESKD patients. Recent HRSA proposals to expand data collection to encompass the prewaitlisting process suggest a timely need to capture additional data on transplant referrals to improve access to transplantation. In 2021, KAS250 was implemented in response to concerns of geographic inequities in transplant rates. However, updates to this system have also resulted in a dramatic rise in organ offers, the number of offers needed to successfully place an organ and lowered utilization rates. Since KAS250, the use of alternative pathways to improve organ utilization rates, such as out-of-sequence placements has increased dramatically across the organ quality spectrum and risk exacerbating disparities in access to transplant. Additionally, the current absence of meaningful oversight risks undermining the perception of the transplant system as an objective process. SUMMARY There is a need for a more robust evaluation of recent iterative changes in waitlist and organ allocation practices to ensure equity in access for our most vulnerable patients.
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Affiliation(s)
- Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos
College of Physicians & Surgeons, Columbia University, New York, NY
- Department of Epidemiology, Mailman School of Public
Health, Columbia University, New York, NY
- Columbia University Renal Epidemiology Group, New York,
NY
| | - Miko Yu
- Division of Nephrology, Department of Medicine, Vagelos
College of Physicians & Surgeons, Columbia University, New York, NY
- Department of Epidemiology, Mailman School of Public
Health, Columbia University, New York, NY
| | - S Ali Husain
- Division of Nephrology, Department of Medicine, Vagelos
College of Physicians & Surgeons, Columbia University, New York, NY
- Department of Epidemiology, Mailman School of Public
Health, Columbia University, New York, NY
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Symeou S, Avramidou E, Papalois V, Tsoulfas G. Global transplantation: Lessons from organ transplantation organizations worldwide. World J Transplant 2025; 15:99683. [PMID: 40104190 PMCID: PMC11612884 DOI: 10.5500/wjt.v15.i1.99683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2024] [Revised: 08/30/2024] [Accepted: 09/13/2024] [Indexed: 11/26/2024] Open
Abstract
Although national transplant organizations share common visions and goals, the creation of a unified global organization remains impractical. Differences in ethnicity, culture, religion, and education shape local practices and infrastructure, making the establishment of a single global entity unfeasible. Even with these social disparities aside, logistical factors such as time and distance between organ procurement and transplantation sites pose significant challenges. While technological advancements have extended organ preservation times, they have yet to support the demands of transcontinental transplantations effectively. This review presents a comparative analysis of the structures, operational frameworks, policies, and legislation governing various transplant organizations around the world. Key differences pertain to the administration of these organizations, trends in organ donation, and organ allocation policies, which reflect the financial, cultural, and religious diversity across different regions. While a global transplant organization may be out of reach, agreeing on best practices for the benefit of patients is essential.
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Affiliation(s)
- Solonas Symeou
- Medical School, University of Ioannina, Ioannina 45110, Greece
| | - Eleni Avramidou
- Department of Transplantation Surgery, Center for Research and Innovation in Solid Organ Transplantation, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Vassilios Papalois
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W120HS, United Kingdom
- Department of Surgery and Cancer, Imperial College London, London SW72AZ, United Kingdom
| | - Georgios Tsoulfas
- Department of Transplantation Surgery, Center for Research and Innovation in Solid Organ Transplantation, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
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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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Wood NL, VanDerwerken DN, Massie AB, Segev DL, Snyder JJ, Gentry SE. Diagnosing the Recent Decrease in Utilization of Deceased Donor Kidneys. Transplantation 2025; 109:496-503. [PMID: 39976985 PMCID: PMC11862262 DOI: 10.1097/tp.0000000000005178] [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] [Indexed: 09/19/2024]
Abstract
BACKGROUND The number of deceased donor kidney transplants has been increasing and is at a record high, yet nonuse of kidneys recovered for transplantation has risen to 25.8% following circular kidney allocation system based on 250-nautical-mile circles implemented on March 15, 2021 (KAS250). METHODS Using Scientific Registry of Transplant Recipients data, we studied all deceased donor kidneys recovered for transplant from March 15, 2019, to January 31, 2023. We calculated the association of multiple factors with kidney nonuse, including increasing recovery of kidneys from nonideal donors, delays in offer acceptance observed under KAS250, and impacts of COVID-19. RESULTS In the 2 y before KAS250, the nonuse rate was 21.2%. Had this rate continued, 2334 more kidneys would have been transplanted through January 2023. We estimated that about 769 of these nonused kidneys (33%) were associated with offer acceptance delays under KAS250; about 994 of these nonused kidneys (43%) were associated with increased prevalence of nonideal donors: donation after circulatory death donors, older donors, and donors with elevated peak serum creatinine; and about 542 of these nonused kidneys (23%) were associated with an otherwise unexplained gradual upward trend in nonuse of recovered kidneys across the pre-KAS250 and KAS250 eras. The overall impact of COVID-19 on the nonuse rate was not significant. CONCLUSIONS The rise in kidney nonuse rate was significantly associated with both increased recovery of nonideal donors, and with KAS250 allocation complexity and delays. Increasing recovery of kidneys from nonideal donors benefits patients because recovering more kidneys increases the number of kidneys available for transplant.
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Affiliation(s)
- Nicholas L. Wood
- Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | | | - Allan B. Massie
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Dorry L. Segev
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Jon J. Snyder
- Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
- Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Sommer E. Gentry
- Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
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Tucker EG, Yu ME, Adler JT, Cron DC, Sahni PV, Schold JD, Mohan S, Husain SA. Nonstandard coding of deceased-donor kidney out-of-sequence allocation leads to underrecognition of allocation deviations. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2025:2025.02.24.25322786. [PMID: 40061353 PMCID: PMC11888527 DOI: 10.1101/2025.02.24.25322786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/23/2025]
Abstract
Out-of-sequence (OOS) allocation, the process by which organ procurement organizations (OPOs) can deviate from standard rank lists of potential recipients to expeditiously allocate deceased-donor kidneys, is rising in the U.S. We aimed to determine whether current OPO reporting practices obscure the extent of OOS allocation. Using match-run data for all U.S. deceased-donor kidney transplants from 2021-2023, we defined "miscoded" OOS (mOOS) allocation transplants as those with use of the 799 or 898 OPO- initiated refusal codes ("other, specify") with free text responses clearly indicating OOS allocation, and compared these to "explicit" OOS (eOOS) allocation, wherein OOS transplants are appropriately coded using refusal codes 861-863. We found that the prevalence of mOOS allocation increased from 2021 (122 transplants) to 2023 (430 transplants) and accounted for 12% of all OOS transplants by 2023. Organs allocated via mOOS had a lower median KDPI than those allocated via eOOS (51% vs 55%, p <0.01). While an increasing number of OPOs used mOOS throughout the study period, the practice remained concentrated overall, with 5 "outlier" OPOs performing 66% of mOOS allocations in 2023. These findings highlight the need for stricter oversight of organ allocation and underscore the responsibility of the OPTN to ensure proper data reporting.
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Adler JT, Cron DC, Kuk AE, Yu M, Mohan S, Husain SA, Parast L. Association between out-of-sequence allocation and deceased donor kidney nonuse across organ procurement organizations. Am J Transplant 2025:S1600-6135(25)00081-4. [PMID: 39971132 DOI: 10.1016/j.ajt.2025.02.005] [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: 10/25/2024] [Revised: 01/31/2025] [Accepted: 02/10/2025] [Indexed: 02/21/2025]
Abstract
Out-of-sequence (OOS) kidney allocation has become increasingly prevalent since 2021. We examined the relationship between organ procurement organization (OPO) OOS allocation frequency and kidney nonuse rates. Among 57 OPOs between March 2021 and December 2023, we analyzed trends in OOS utilization and its association with kidney nonuse rates. There was significant variability in OOS use across OPOs, with some allocating over 20% of kidneys out-of-sequence over the entire period. An absolute increase of 1 SD (12.8%) of OOS allocation was modestly associated with a reduction in kidney nonuse rates (incidence risk ratio = 0.98; P = .04). Donor characteristics, particularly older age, donation after circulatory death, and high kidney donor profile index, were the strongest predictors of nonuse. While OOS allocation may mitigate logistical challenges, other strategies may be more effective at reducing the nonuse rate.
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Affiliation(s)
- Joel T Adler
- Division of Transplantation, Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas, USA.
| | - David C Cron
- Center for Surgery and Public Health at Brigham and Women's Hospital, Boston, Massachusetts, USA; Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Arnold E Kuk
- Department of Statistics and Data Science, University of Texas at Austin, Austin, Texas, USA
| | - Miko Yu
- Columbia University Renal Epidemiology (CURE) Group, Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Sumit Mohan
- Columbia University Renal Epidemiology (CURE) Group, Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA; Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - S Ali Husain
- Columbia University Renal Epidemiology (CURE) Group, Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA; Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Layla Parast
- Biomedical Data Sciences Hub, Dell Medical School at the University of Texas at Austin, Austin, Texas, USA
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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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Cron DC, Kuk AE, Parast L, Husain SA, King KL, Yu M, Mohan S, Adler JT. Associations Among Circle-Based Kidney Allocation, Center Waiting Time, and Likelihood of Deceased-Donor Kidney Transplantation. Am J Kidney Dis 2025; 85:187-195. [PMID: 39366540 PMCID: PMC11930355 DOI: 10.1053/j.ajkd.2024.07.014] [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: 03/28/2024] [Revised: 06/27/2024] [Accepted: 07/16/2024] [Indexed: 10/06/2024]
Abstract
RATIONALE & OBJECTIVE The kidney allocation system (KAS250), using circle-based distribution, attempts to address geographic disparities through broader sharing of deceased-donor kidney allografts. This study evaluated the association between KAS250 and likelihood of deceased-donor kidney transplantation (DDKT) among wait-listed candidates, and whether the policy has differentially affected centers with shorter versus longer waiting time. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS 160,941 candidates waitlisted at 176 transplant centers between March 2017 and March 2024. EXPOSURE KAS250 allocation policy. OUTCOME Rate of DDKT. ANALYTICAL APPROACH Multivariable Cox regression, modeling KAS250 as a time-dependent variable. RESULTS KAS250 was not independently associated with likelihood of DDKT overall (HR, 1.01 vs pre-KAS250 [95% CI, 0.97-1.04]). KAS250's association with likelihood of DDKT varied across centers from HR, 0.18 (DDKT less likely after KAS250), to HR, 17.12 (DDKT more likely) and varied even among neighboring centers. KAS250 was associated with decreased DDKT at 25.6% and increased DDKT at 18.2% of centers. Centers with previously long median waiting times (57+months) experienced increased likelihood of DDKT after KAS250 (HR, 1.20 [95% CI, 1.15-1.26]) whereas centers with previously short median waiting times (6-24 months; HR, 0.88 [95% CI, 0.84-0.92]) experienced decreased likelihood of DDKT. LIMITATIONS Retrospective study of allocation policy changes, confounded by multiple changes over the study time frame. CONCLUSIONS Association between KAS250 and DDKT varied across centers. For 1 in 4 centers, DDKT was less likely after KAS250 relative to pre-KAS250 trends. Candidates at centers with previously long waiting times experienced an increased likelihood of DDKT after KAS250. Thus, broader distribution of kidneys may be associated with improved equity in access to DDKT, but additional strategies may be needed to minimize disparities between centers. PLAIN-LANGUAGE SUMMARY This study examines how a recent policy change, KAS250, aimed at broadening the geographic sharing of deceased-donor kidneys, has impacted likelihood of kidney transplantation in the United States. Historically, kidney allocation occurred within local geographic boundaries, leading to unequal rates of transplantation across regions. KAS250, implemented in March 2021, replaced this system with a broader allocation radius of 250 miles around the donor hospital. Using national registry data, the study found that while there was no overall significant increase in the likelihood of transplantation nationally under KAS250, the policy's effect varied widely even among neighboring transplant centers. One quarter of centers experienced a decrease in the likelihood of DDKT after KAS250. In contrast, centers with longer pre-KAS250 waiting times experienced an increased likelihood of transplantation, suggesting some success in reducing disparities between centers. Ongoing surveillance will be needed to ensure KAS250 is meeting the intended aim of more equitably distributing organs.
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Affiliation(s)
- David C Cron
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Arnold E Kuk
- Biomedical Data Sciences Hub, University of Texas, Austin, Texas
| | - Layla Parast
- Dell Medical School, and Department of Statistics and Data Science, University of Texas, Austin, Texas
| | - S Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York; Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Kristen L King
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York; Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Miko Yu
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York; Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York; Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Joel T Adler
- Division of Transplantation, Department of Surgery and Perioperative Care, University of Texas, Austin, Texas.
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Cron DC, Husain SA, Kuk AE, Mohan S, Adler JT. Increasing Incidence of Out-of-Sequence Allocation of Deceased Donor Kidneys. KIDNEY360 2025; 6:145-149. [PMID: 39760230 PMCID: PMC11793170 DOI: 10.34067/kid.0000000640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2024] [Accepted: 11/07/2024] [Indexed: 01/07/2025]
Affiliation(s)
- David C. Cron
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - S. Ali Husain
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Arnold E. Kuk
- Biomedical Data Sciences Hub, Dell Medical School at the University of Texas at Austin, Austin, Texas
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Joel T. Adler
- Division of Transplantation, Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas
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12
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Syed FJ, Bekbolsynov D, Green RC, Kaur D, Ekwenna O, Sindhwani P, Rees M, Stepkowski S. Potential of new 250-nautical mile concentric circle allocation system for improving the donor/recipient HLA matching: Development of new matching algorithm. Transpl Immunol 2024; 87:102146. [PMID: 39537113 DOI: 10.1016/j.trim.2024.102146] [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: 04/13/2024] [Revised: 11/06/2024] [Accepted: 11/06/2024] [Indexed: 11/16/2024]
Abstract
BACKGROUND High-resolution typing of human leukocyte antigen (HLA) may revolutionize the field of kidney transplantation by selection of low immunogenic grafts. The new 250-nautical mile circle allocation system offers a unique opportunity to find low HLA immunogenic donors for eligible recipients. METHODS 501 transplant candidates from the University of Toledo Medical Center (UTMC) between 2015 and 2019, registered at the Scientific Registry of Transplant Recipients (SRTR) were virtually matched to 4812 donors procured within 250-nautical miles using an in-house-developed simulation algorithm. Immunogenicity of HMS (hydrophobic mismatch score) ≤10 was measured based on imputed high-resolution HLAs. Simulated "optimal" matches with a KDPI≤50 % were compared with the transplant cohort between 2000 and 2010 with their kidney allograft survivals. RESULTS Out of 501 recipients 500 (99.8 %) were matched with donors ≤10 HMS and KDPI ≤50 %. The average HMS value for simulated transplants was 1.4 (range 0-10) versus 6.3 (range 0-75) in the retrospective cohort (p < 0.001). The simulated model had a median mismatch number of 3/6, while the reference cohort 4/6 among HLA-A/B/DR antigens (p < 0.001). The estimated median graft survival was 18.2 years for the simulated cohort vs. 13.4 years in the real-life cohort (p < 0.001), gaining 4.9 years per transplant and 2450 survival years for all patients. For year 2014, out of 98 patients and 659 donors, each recipient had a median number of 141 donors (HMS < 10; range 8-378). Similar values were found for patients between 2015 and 2019. CONCLUSION Donors within 250-nautical miles proffers excellent and multiple options for finding well-matched low immunogenic HLA kidney donors for UTMC patients, thus significantly improving their chances for long-term allograft survival.
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Affiliation(s)
- Fayeq Jeelani Syed
- Electrical Engineering and Computer Science Department, University of Toledo, 2801 W Bancroft St., Toledo 43606, OH, USA
| | - Dulat Bekbolsynov
- Department of Medical Microbiology and Immunology, University of Toledo Medical Center, 3000 Arlington Ave., Toledo 43614, OH, USA.
| | - Robert C Green
- Department of Computer Science, Bowling Green State University, 1001 E Wooster St., Bowling Green 43403, OH, USA
| | - Devinder Kaur
- Electrical Engineering and Computer Science Department, University of Toledo, 2801 W Bancroft St., Toledo 43606, OH, USA
| | - Obi Ekwenna
- Department of Urology, University of Toledo Medical Center, 3000 Arlington Ave., Toledo 43614, OH, USA
| | - Puneet Sindhwani
- Department of Urology, University of Toledo Medical Center, 3000 Arlington Ave., Toledo 43614, OH, USA
| | - Michael Rees
- Department of Urology, University of Toledo Medical Center, 3000 Arlington Ave., Toledo 43614, OH, USA
| | - Stanislaw Stepkowski
- Department of Medical Microbiology and Immunology, University of Toledo Medical Center, 3000 Arlington Ave., Toledo 43614, OH, USA
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13
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Cutrone AM, Rega SA, Feurer ID, Karp SJ. Effects of the March 2021 Allocation Policy Change on Key Deceased-donor Kidney Transplant Metrics. Transplantation 2024; 108:e376-e381. [PMID: 38831485 DOI: 10.1097/tp.0000000000005044] [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: 06/05/2024]
Abstract
BACKGROUND A major change to deceased-donor kidney allocation in the United States, Kidney Allocation System 250 (KAS250), was implemented on March 15, 2021. Evaluating the consequences of this policy on critical system performance metrics is critical to determining its success. METHODS We performed a retrospective analysis of critical performance measures of the kidney transplant system by reviewing all organs procured during a 4-y period in the United States. To mitigate against possible effects of the COVID-19 pandemic, Scientific Registry of Transplant Recipients records were stratified into 2 pre- and 2 post-KAS250 eras: (1) 2019; (2) January 1, 2020-March14, 2021; (3) March 15, 2021-December 31, 2021; and (4) 2022. Between-era differences in rates of key metrics were analyzed using chi-square tests with pairwise z -tests. Multivariable logistic regression and analysis of variations methods were used to evaluate the effects of the policy on rural and urban centers. RESULTS Over the period examined, among kidneys recovered for transplant, nonuse increased from 19.7% to 26.4% (all between-era P < 0.05) and among all Kidney Donor Profile Index strata. Cold ischemia times increased ( P < 0.001); however, the distance between donor and recipient hospitals decreased ( P < 0.05). Kidneys from small-metropolitan or nonmetropolitan hospitals were more likely to not be used over all times ( P < 0.05). CONCLUSIONS Implementation of KAS250 was associated with increased nonuse rates across all Kidney Donor Profile Index strata, increased cold ischemic times, and shorter distance traveled.
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Affiliation(s)
- Alissa M Cutrone
- Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA
| | - Scott A Rega
- Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, TN
| | - Irene D Feurer
- Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, TN
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Seth J Karp
- Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, TN
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
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14
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Cron DC, Kuk AE, Parast L, Husain SA, Welten VM, Yu M, Mohan S, Adler JT. Variation Across Organ Procurement Organizations in Deceased-Donor Kidney Offer Notification Practices. Clin Transplant 2024; 38:e70024. [PMID: 39543973 PMCID: PMC11573248 DOI: 10.1111/ctr.70024] [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: 04/05/2024] [Revised: 10/25/2024] [Accepted: 10/28/2024] [Indexed: 11/17/2024]
Abstract
INTRODUCTION How offer notifications are distributed early in the kidney allocation timeline, including how widely they are offered, is unclear. A better understanding of offer notification practices across organ procurement organizations (OPOs) may identify opportunities for more efficient allocation. METHODS We merged the Scientific Registry of Transplant Recipients potential transplant recipient file with additional offer notification time stamps to identify 54 631 deceased-donor kidney match runs from 2017 to 2023. Offer notifications for a given match run are sent to candidates/centers in "batches." We quantified the number of offers in the initial batch-which theoretically reflects the OPO's initial estimate of how widely a kidney should be offered-and compared this metric across OPOs. RESULTS Kidneys were offered to a median of 14 candidates (IQR 9-38) in the first batch of notifications, and this varied across OPOs from 3 to 746 candidates per initial batch. Batch size at the OPO-level did not correlate with rank at kidney placement or OPO nonuse rate. OPOs in the highest quartile of batch size sent more offers (median 100) than presumably necessary to place kidneys (median rank at placement 21), and OPOs in the lowest quartile of batch size sent fewer offers (6) than needed to place kidneys (rank at placement 19). CONCLUSIONS Offer notification practices vary widely across OPOs, and many OPOs offer kidneys far more widely than necessary for placement. Optimization of offer notification practices may reduce unnecessary communications. Further research into allocation processes is needed to identify opportunities to improve efficiency of allocation for OPOs and transplant centers.
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Affiliation(s)
- David C. Cron
- Department of Surgery, Massachusetts General Hospital, Boston, MA
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA
| | - Arnold E. Kuk
- Biomedical Data Sciences Hub, Dell Medical School at the University of Texas at Austin, Austin, TX
| | - Layla Parast
- Department of Statistics and Data Science, University of Texas at Austin, Austin, TX
| | - S. Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Vanessa M. Welten
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA
| | - Miko Yu
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Joel T. Adler
- Division of Transplantation, Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, TX
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15
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Stratta RJ, Jay CL. Equity in Kidney Allocation and Optimizing Utilization: Are These Goals Mutually Exclusive? Transplantation 2024; 108:2162-2163. [PMID: 38831491 DOI: 10.1097/tp.0000000000005054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Affiliation(s)
- Robert J Stratta
- Department of Surgery, Section of Abdominal Organ Transplantation, Atrium Health Wake Forest Baptist, Winston-Salem, NC
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16
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Husain SA, Khanna S, Yu M, Adler JT, Cron DC, King KL, Schold JD, Mohan S. Cold Ischemia Time and Delayed Graft Function in Kidney Transplantation: A Paired Kidney Analysis. Transplantation 2024; 108:e245-e253. [PMID: 38557641 PMCID: PMC11338744 DOI: 10.1097/tp.0000000000005006] [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] [Indexed: 04/04/2024]
Abstract
BACKGROUND We aimed to understand the association between cold ischemia time (CIT) and delayed graft function (DGF) after kidney transplantation and the impact of organ pumping on that association. METHODS Retrospective cohort study using US registry data. We identified kidney pairs from the same donor where both kidneys were transplanted but had a CIT difference >0 and ≤20 h. We determined the frequency of concordant (both kidneys with/without DGF) or discordant (only 1 kidney DGF) DGF outcomes. Among discordant pairs, we computed unadjusted and adjusted relative risk of DGF associated with longer-CIT status, when then repeated this analysis restricted to pairs where only the longer-CIT kidney was pumped. RESULTS Among 25 831 kidney pairs included, 71% had concordant DGF outcomes, 16% had only the longer-CIT kidney with DGF, and 13% had only the shorter-CIT kidney with DGF. Among discordant pairs, longer-CIT status was associated with a higher risk of DGF in unadjusted and adjusted models. Among pairs where only the longer-CIT kidney was pumped, longer-CIT kidneys that were pumped had a lower risk of DGF than their contralateral shorter-CIT kidneys that were not pumped regardless of the size of the CIT difference. CONCLUSIONS Most kidney pairs have concordant DGF outcomes regardless of CIT difference, but even small increases in CIT raise the risk of DGF. Organ pumping may mitigate and even overcome the adverse consequences of prolonged CIT on the risk of DGF, but prospective studies are needed to better understand this relationship.
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Affiliation(s)
- Syed Ali Husain
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY
- The Columbia University Renal Epidemiology Group, New York, NY
| | - Sohil Khanna
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY
| | - Miko Yu
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY
- The Columbia University Renal Epidemiology Group, New York, NY
| | - Joel T Adler
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX
| | - David C Cron
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Kristen L King
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY
- The Columbia University Renal Epidemiology Group, New York, NY
| | - Jesse D Schold
- Department of Surgery, University of Colorado-Anschutz Medical Campus, Aurora, CO
- Department of Epidemiology, School of Public Health, University of Colorado-Anschutz Medical Campus, Aurora, CO
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY
- The Columbia University Renal Epidemiology Group, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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17
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Schold JD, Tambur AR, Mohan S, Kaplan B. Calibration of Priority Points for Sensitization Status of Kidney Transplant Candidates in the United States. Clin J Am Soc Nephrol 2024; 19:767-777. [PMID: 38509037 PMCID: PMC11168827 DOI: 10.2215/cjn.0000000000000449] [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: 09/28/2023] [Accepted: 03/14/2024] [Indexed: 03/22/2024]
Abstract
Key Points There are multiple factors associated with high sensitization levels among kidney transplant candidates, which differ by candidate sex. Since the initiation of the kidney allocation system, candidates with higher sensitization have higher rates of deceased donor transplantation. Priority points assigned to candidates associated with sensitization have led to inequities in access to deceased donor transplantation. Background A primary change to the national organ allocation system in 2014 for deceased donor kidney offers was to weight candidate priority on the basis of sensitization (i.e ., calculated panel reactive antibody percentage [cPRA%]) using a sliding scale. Increased priority for sensitized patients could improve equity in access to transplantation for disadvantaged candidates. We sought to evaluate the effect of these weights using a contemporary cohort of adult US kidney transplant candidates. Methods We used the national Scientific Registry of Transplant Recipients to evaluate factors associated with sensitization using multivariable logistic models and rates of deceased donor transplantation using cumulative incidence models accounting for competing risks and multivariable Cox models. Results We examined 270,912 adult candidates placed on the waiting list between January 2016 and September 2023. Six-year cumulative incidence of deceased donor transplantation for candidates with cPRA%=80–85 and 90–95 was 48% and 53%, respectively, as compared with 37% for candidates with cPRA%=0–20. In multivariable models, candidates with high cPRA% had the highest adjusted hazards for deceased donor transplantation. There was significant effect modification such that the association of high cPRA% with adjusted rates of deceased donor transplantation varied by region of the country, sex, race and ethnicity, prior dialysis time, and blood type. Conclusions The results indicate that the weighting algorithm for highly sensitized candidates may overinflate the need for prioritization and lead to higher rates of transplantation. Findings suggest recalibration of priority weights for allocation is needed to facilitate overall equity in access to transplantation for prospective kidney transplant candidates. However, priority points should also account for subgroups of candidates who are disadvantaged for access to donor offers.
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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
| | - Anat R Tambur
- Department of Surgery, Northwestern University, Chicago, Illinois
| | - Sumit Mohan
- Department of Medicine, Columbia University, New York, New York
- Department of Epidemiology, Columbia University, New York, New York
| | - Bruce Kaplan
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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18
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Yu M, King KL, Husain SA, Schold JD, Mohan S. Use of Offer Bypass Filters under the Circular Kidney Allocation System. KIDNEY360 2024; 5:756-758. [PMID: 38568866 PMCID: PMC11146644 DOI: 10.34067/kid.0000000000000423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 03/19/2024] [Indexed: 04/05/2024]
Affiliation(s)
- Miko Yu
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
| | - Kristen L. King
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
| | - S. Ali Husain
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
| | - Jesse D. Schold
- Department of Surgery, University of Colorado – Anschutz Medical Campus, Aurora, Colorado
- Department of Epidemiology, School of Public Health, University of Colorado – Anschutz Medical Campus, Aurora, Colorado
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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19
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McCracken EK, Jay CL, Garner M, Webb C, Farney AC, Orlando G, Reeves-Daniel A, Mena-Gutierrez A, Sakhovskaya N, Stratta RJ. The Kidney Not Taken: Single-Kidney Use in Deceased Donors. J Am Coll Surg 2024; 238:492-504. [PMID: 38224100 DOI: 10.1097/xcs.0000000000000968] [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: 01/16/2024]
Abstract
BACKGROUND The nonuse rate for kidneys recovered from deceased donors is increasing, rising to 27% in 2023. In 10% of these cases, 1 kidney is transplanted but the mate kidney is not. STUDY DESIGN We conducted a retrospective, single-center cohort study from December 2001 to May 2023 comparing single kidneys transplanted at our center (where the contralateral kidney was not used) to kidneys where both were transplanted separately, at least 1 of which was at our center. RESULTS We performed 395 single deceased-donor kidney transplants in which the mate kidney was not transplanted. Primary reasons for mate kidney nonuse were as follows: no recipient located or list exhausted (33.4%), kidney trauma or injury or anatomic abnormalities (18.7%), biopsy findings (16.7%), and poor renal function (13.7%). Mean donor and recipient ages were 51.5 ± 14.2 and 60 ± 12.6 years, respectively. Mean kidney donor profile index was 73% ± 22%, and 104 donors (26.3%) had kidney donor profile index >85%. Mean cold ischemia was 25.6 ± 7.4 hours, and 280 kidneys (70.7%) were imported. Compared with 2,303 concurrent control transplants performed at our center, primary nonfunction or thrombosis (5.1% single vs 2.8% control) and delayed graft function (35.4% single vs 30.1% control) were greater with single-kidney use (both p < 0.05). Median patient and death-censored graft survival were shorter in the single group (11.6 vs 13.5 years, p = 0.03 and 11.6 vs 19 years, p = 0.003), although the former was at least double median survival on the waiting list. In patients with functioning grafts in the single-kidney group, 1-year mean serum creatinine was 1.77 ± 0.8 mg/dL and estimated glomerular filtration rate was 44.8 ± 20 mL/min/1.73 m 2 . CONCLUSIONS These findings suggest that many mate kidneys are being inappropriately rejected, given the acceptable outcomes that can be achieved by transplanting the single kidney in appropriately selected recipients.
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Affiliation(s)
- Emily Ke McCracken
- From the Department of Surgery, Section of Transplantation (McCracken, Jay, Garner, Webb, Farney, Orlando, Stratta)
| | - Colleen L Jay
- From the Department of Surgery, Section of Transplantation (McCracken, Jay, Garner, Webb, Farney, Orlando, Stratta)
| | - Matthew Garner
- From the Department of Surgery, Section of Transplantation (McCracken, Jay, Garner, Webb, Farney, Orlando, Stratta)
| | - Christopher Webb
- From the Department of Surgery, Section of Transplantation (McCracken, Jay, Garner, Webb, Farney, Orlando, Stratta)
| | - Alan C Farney
- From the Department of Surgery, Section of Transplantation (McCracken, Jay, Garner, Webb, Farney, Orlando, Stratta)
| | - Giuseppe Orlando
- From the Department of Surgery, Section of Transplantation (McCracken, Jay, Garner, Webb, Farney, Orlando, Stratta)
| | - Amber Reeves-Daniel
- Department of Internal Medicine, Section of Nephrology (Reeves-Daniel, Mena-Gutierrez, Sakhovskaya), Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Alejandra Mena-Gutierrez
- Department of Internal Medicine, Section of Nephrology (Reeves-Daniel, Mena-Gutierrez, Sakhovskaya), Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Natalia Sakhovskaya
- Department of Internal Medicine, Section of Nephrology (Reeves-Daniel, Mena-Gutierrez, Sakhovskaya), Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Robert J Stratta
- From the Department of Surgery, Section of Transplantation (McCracken, Jay, Garner, Webb, Farney, Orlando, Stratta)
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20
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Woelfel I, Schenk A, Limkemann A, Huang E, Syed S. Missing the Match: A National Survey Investigating Education in Renal Donor-Recipient Matching. Transplant Proc 2024; 56:267-277. [PMID: 38341297 DOI: 10.1016/j.transproceed.2024.01.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 10/07/2023] [Accepted: 01/16/2024] [Indexed: 02/12/2024]
Abstract
PURPOSE Clinical judgment in renal donor organ and recipient selection is gained through fellowship and mentorship in early career. We aim to understand the past and current state of organ acceptance education. METHODS We developed and distributed an anonymous, national survey to American Society of Transplant Surgeons faculty members and transplant surgery fellows in 2022. Survey questions explored in detail the evaluation of organ offers, the extent of formal education in organ evaluation, and attitudes regarding training adequacy. FINDINGS Ninety-eight attending surgeons (65 men, 25 women, and 3 nonbinary) and 38 fellows (25 men, 6 women, and 2 nonbinary) responded. Seventy-eight percent of attending surgeons and 6% of fellows take primary organ offers. Forty-four percent of fellows report no didactic education in donor evaluation and recipient selection. Fellows report that discussion with attending surgeons (37.2%) and independent study of the literature (35.4%) are their primary modes of learning. Fellows call for additional clinical decision-making experience (47.3%), further didactic sessions (44.7%), and additional discussions with faculty (44.7%). Sixty-four percent of fellows and 55% of attendings felt their training provided adequate education about donor selection. CONCLUSION Our responses suggest gaps in education regarding donor and recipient selection. Increased clinical experience and standardized education at the national level represent opportunities for improvement.
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Affiliation(s)
- Ingrid Woelfel
- Ohio State University, Department of Surgery, Columbus, Ohio.
| | - Austin Schenk
- Ohio State University, Department of Surgery, Columbus, Ohio
| | | | - Emily Huang
- Ohio State University, Department of Surgery, Columbus, Ohio
| | - Shareef Syed
- University of California San Francisco, Department of Surgery, Division of Transplantation, San Francisco, California
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21
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Kilambi V, Barah M, Formica RN, Friedewald JJ, Mehrotra S. Evaluation of Opening Offers Early for Deceased Donor Kidneys at Risk of Nonutilization. Clin J Am Soc Nephrol 2024; 19:233-240. [PMID: 37943856 PMCID: PMC10861110 DOI: 10.2215/cjn.0000000000000346] [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: 04/24/2023] [Accepted: 10/30/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Reducing nonutilization of kidneys recovered from deceased donors is a current policy concern for kidney allocation in the United States. The likelihood of nonutilization is greater with a higher kidney donor risk index (KDRI) offer. We examine how opening offers for organs with KDRI >1.75 to the broader waitlist at varying points of time affects usage rates. METHODS We simulate kidney allocation using data for January 2018 to June 2019 from Organ Procurement and Transplantation Network. For the simulation experiment, allocation policy is modified so that KDRI >1.75 organs are offered to all local candidates (same donation service area) after a set amount of cold time simultaneously. Open offers to candidates nationally are similarly examined. RESULTS Simulation results ( n =50 replications) estimate that opening offers locally for KDRI >1.75 after 10 hours yields a nonutilization rate of 38% (range: 35%-42%), less than the prevailing rate of 55% of KDRI >1.75 kidneys. Opening offers after 5 hours yields 30% (range: 26%-34%), reducing the prevailing nonutilization rate by 45%. Opening offers nationally after 10 and 5 hours yields nonutilization rates of 11% (range: 8%-15%) and 6% (range: 4%-9%) for KDRI >1.75 kidneys, respectively. CONCLUSIONS Simulation findings indicate that opening offers and adjusting their timing can significantly reduce nonutilization of high-KDRI kidneys.
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Affiliation(s)
- Vikram Kilambi
- Department of Engineering and Applied Sciences, RAND Corporation, Arlington, Virginia
- RAND Health Care, Access and Delivery Program, RAND Corporation, Arlington, Virginia
| | - Masoud Barah
- Department of Industrial Engineering and Management Sciences, Northwestern University, Evanston, Illinois
| | - Richard N. Formica
- Department of Nephrology, Yale School of Medicine, New Haven, Connecticut
| | - John J. Friedewald
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Nephrology, Department of Medicine, Northwestern University, Chicago, Illinois
- Center for Engineering and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sanjay Mehrotra
- Department of Industrial Engineering and Management Sciences, Northwestern University, Evanston, Illinois
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Nephrology, Department of Medicine, Northwestern University, Chicago, Illinois
- Center for Engineering and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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22
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Ross-Driscoll K, McElroy LM, Adler JT. Geography, inequities, and the social determinants of health in transplantation. Front Public Health 2023; 11:1286810. [PMID: 38146478 PMCID: PMC10749310 DOI: 10.3389/fpubh.2023.1286810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/07/2023] [Indexed: 12/27/2023] Open
Abstract
Among the causes of inequity in organ transplantation, geography is oft-cited but rarely defined with precision. Traditionally, geographic inequity has been characterized by variation in distance to transplant centers, availability of deceased organ donors, or the consequences of allocation systems that are inherently geographically based. Recent research has begun to explore the use of measures at various geographic levels to better understand how characteristics of a patient's geographic surroundings contribute to a broad range of transplant inequities. Within, we first explore the relationship between geography, inequities, and the social determinants of health. Next, we review methodologic considerations essential to geographic health research, and critically appraise how these techniques have been applied. Finally, we propose how to use geography to improve access to and outcomes of transplantation.
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Affiliation(s)
- Katherine Ross-Driscoll
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, United States
- Center for Health Services Research, Regenstrief Institute, Indianapolis, IN, United States
| | - Lisa M. McElroy
- Department of Surgery, Duke University School of Medicine, Durham, NC, United States
| | - Joel T. Adler
- Division of Abdominal Transplant Surgery, Department of Surgery and Perioperative Care, Dell Medical at the University of Texas at Austin, Austin, TX, United States
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Webb CJ, McCracken E, Jay CL, Sharda B, Garner M, Farney AC, Orlando G, Reeves-Daniel A, Mena-Gutierrez A, Sakhovskaya N, Stratta B, Stratta RJ. Single center experience and literature review of kidney transplantation from non-ideal donors with acute kidney injury: Risk and reward. Clin Transplant 2023; 37:e15115. [PMID: 37646473 DOI: 10.1111/ctr.15115] [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: 06/13/2023] [Revised: 08/18/2023] [Accepted: 08/22/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION There is limited experience transplanting kidneys from either expanded criteria donors (ECD) or donation after circulatory death (DCD) deceased donors with terminal acute kidney injury (AKI). METHODS AKI kidneys were defined by a donor terminal serum creatinine level >2.0 mg/dL whereas non-ideal deceased donor (NIDD) kidneys were defined as AKI/DCD or AKI/ECDs. RESULTS From February 2007 to March 2023, we transplanted 266 single AKI donor kidneys including 29 from ECDs, 29 from DCDs (n = 58 NIDDs), and 208 from brain-dead standard criteria donors (SCDs). Mean donor age (43.7 NIDD vs. 33.5 years SCD), KDPI (66% NIDD vs. 45% SCD), and recipient age (57 NIDD vs. 51 years SCD) were higher in the NIDD group (all p < .01). Mean waiting times (17.8 NIDD vs. 24.2 months SCD) and dialysis duration (34 NIDD vs. 47 months SCD) were shorter in the NIDD group (p < .05). Delayed graft function (DGF, 48%) and 1-year graft survival (92.7% NIDD vs. 95.9% SCD) was similar in both groups. Five-year patient and kidney graft survival rates were 82.1% versus 89.9% and 82.1% versus 75.2% (both p = NS) in the NIDD versus SCD groups, respectively. CONCLUSIONS The use of kidneys from AKI donors can be safely liberalized to include selected ECD and DCD donors.
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Affiliation(s)
- Christopher J Webb
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Emily McCracken
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Colleen L Jay
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Berjesh Sharda
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Matthew Garner
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Alan C Farney
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Giuseppe Orlando
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Amber Reeves-Daniel
- Department of Medicine, Section of Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Alejandra Mena-Gutierrez
- Department of Medicine, Section of Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Natalia Sakhovskaya
- Department of Medicine, Section of Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Bobby Stratta
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Robert J Stratta
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
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Hod-Dvorai R, Philogene MC, Timofeeva O, Gimferrer I, Dunckley H, Greenshields A, Jindra P. Utilizing proficiency testing survey data to create advanced educational content: the virtual crossmatch challenge model. Front Genet 2023; 14:1256498. [PMID: 37811147 PMCID: PMC10552184 DOI: 10.3389/fgene.2023.1256498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/11/2023] [Indexed: 10/10/2023] Open
Abstract
Proficiency testing (PT) surveys include data from laboratories across the world and are ideal for creating advanced educational content, beyond just consensus grading. Educational challenges provide a unique opportunity to probe common laboratory practices and risk assessment, especially in cases where there is no "analyte" tested. Human leukocyte antigen (HLA) compatibility evaluation between donor and recipient pairs has been traditionally assessed using T-cell and B-cell physical crossmatches. However, advancements in our ability to identify and characterize HLA antibodies using solid phase assays, in combination with changing deceased donor allocation schemes and improved HLA typing, have shifted the paradigm from performing physical crossmatches to the use of the virtual crossmatch (VXM). VXM is a compatibility assessment relying on the interpretation of pre-transplant HLA laboratory data and as such, it is not an "analyte". However, VXM results are used in clinical decision-making. The VXM assessment depends on patient characteristics as well as laboratory and transplant center practices but must ensure safe transplantation outcomes while maintaining equity in access to transplantation. In this manuscript, we describe the American Society for Histocompatibility and Immunogenetics (ASHI) PT Educational VXM Challenge, as a model for creating educational content using PT survey data. We discuss the different components of the VXM Challenge and highlight major findings and learning points acquired from ASHI VXM Challenges performed between 2018-2022, such as the lack of correlation between the VXM and the physical crossmatch in the presence of low level donor-specific antibodies (DSA), or when the DSA were aimed against donor alleles that are not present on the antibody panel, and in the presence of an antibody to a shared eplet. Finally, we show that the VXM Educational Challenge serves as a valuable tool to highlight the strengths and pitfalls of the VXM assessment and reveals differences in testing and result interpretation among participating HLA laboratories.
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Affiliation(s)
- Reut Hod-Dvorai
- Department of Pathology, SUNY Upstate Medical University, Syracuse, NY, United States
| | - Mary Carmelle Philogene
- Department of Surgery, Virginia Commonwealth University Medical Center, Richmond, VA, United States
| | - Olga Timofeeva
- Department of Pathology, MedStar Georgetown University Hospital, Georgetown University Medical Center, Washington, DC, United States
| | - Idoia Gimferrer
- Department of Immunogenetics/HLA, BloodworksNW, Seattle, WA, United States
| | - Heather Dunckley
- New Zealand Transplantation and Immunogenetics Laboratory, New Zealand Blood Service, Auckland, New Zealand
| | | | - Peter Jindra
- Immune Evaluation Laboratory, Department of Surgery, Baylor College of Medicine, Houston, TX, United States
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Cron DC, Husain SA, King KL, Mohan S, Adler JT. Increased volume of organ offers and decreased efficiency of kidney placement under circle-based kidney allocation. Am J Transplant 2023; 23:1209-1220. [PMID: 37196709 PMCID: PMC10527286 DOI: 10.1016/j.ajt.2023.05.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 04/19/2023] [Accepted: 05/07/2023] [Indexed: 05/19/2023]
Abstract
The newest kidney allocation policy kidney allocation system 250 (KAS250) broadened geographic distribution while increasing allocation system complexity. We studied the volume of kidney offers received by transplant centers and the efficiency of kidney placement since KAS250. We identified deceased-donor kidney offers (N = 907,848; N = 36,226 donors) to 185 US transplant centers from January 1, 2019, to December 31, 2021 (policy implemented March 15, 2021). Each unique donor offered to a center was considered a single offer. We compared the monthly volume of offers received by centers and the number of centers offered before the first acceptance using an interrupted time series approach (pre-/post-KAS250). Post-KAS250, transplant centers received more kidney offers (level change: 32.5 offers/center/mo, P < .001; slope change: 3.9 offers/center/mo, P = .003). The median monthly offer volume post-/pre-KAS250 was 195 (interquartile range 137-253) vs. 115 (76-151). There was no significant increase in deceased-donor transplant volume at the center level after KAS250, and center-specific changes in offer volume did not correlate with changes in transplant volume (r = -0.001). Post-KAS250, the number of centers to whom a kidney was offered before acceptance increased significantly (level change: 1.7 centers/donor, P < .001; slope change: 0.1 centers/donor/mo, P = .014). These findings demonstrate the logistical burden of broader organ sharing, and future allocation policy changes will need to balance equity in transplant access with the operational efficiency of the allocation system.
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Affiliation(s)
- David C Cron
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Syed A Husain
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA; The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - Kristen L King
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA; The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA; The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Joel T Adler
- Division of Transplantation, Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA.
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26
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King KL, Husain SA, Yu M, Adler JT, Schold J, Mohan S. Characterization of Transplant Center Decisions to Allocate Kidneys to Candidates With Lower Waiting List Priority. JAMA Netw Open 2023; 6:e2316936. [PMID: 37273203 PMCID: PMC10242426 DOI: 10.1001/jamanetworkopen.2023.16936] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 04/21/2023] [Indexed: 06/06/2023] Open
Abstract
Importance Allocation of deceased donor kidneys is meant to follow a ranked match-run list of eligible candidates, but transplant centers with a 1-to-1 relationship with their local organ procurement organization have full discretion to decline offers for higher-priority candidates and accept them for lower-ranked candidates at their center. Objective To describe the practice and frequency of transplant centers placing deceased donor kidneys with candidates who are not the highest rank at their center according to the allocation algorithm. Design, Setting, and Participants This retrospective cohort study used 2015 to 2019 organ offer data from US transplant centers with a 1-to-1 relationship with their local organ procurement organization, following candidates for transplant events from January 2015 to December 2019. Participants were deceased kidney donors with a single match-run and at least 1 kidney transplanted locally and adult, first-time, kidney-only transplant candidates receiving at least 1 offer for a locally transplanted deceased donor kidney. Data were analyzed from March 1, 2022 to March 28, 2023. Exposure Demographic and clinical characteristics of donors and recipients. Main Outcomes and Measures The outcome of interest was kidney transplantation into the highest-priority candidate (defined as transplanted after zero declines for local candidates in the match-run) vs a lower-ranked candidate. Results This study assessed 26 579 organ offers from 3136 donors (median [IQR] age, 38 [25-51] years; 2903 [62%] men) to 4668 recipients. Transplant centers skipped their highest-ranked candidate to place kidneys further down the match-run for 3169 kidneys (68%). These kidneys went to a median (IQR) of the fourth- (third- to eighth-) ranked candidate. Higher kidney donor profile index (KDPI; higher score indicates lower quality) kidneys were less likely to go to the highest-ranked candidate, with 24% of kidneys with KDPI of at least 85% going to the top-ranked candidate vs 44% of KDPI 0% to 20% kidneys. When comparing estimated posttransplant survival (EPTS) scores between the skipped candidates and the ultimate recipients, kidneys were placed with recipients with both better and worse EPTS than the skipped candidates, across all KDPI risk groups. Conclusions and Relevance In this cohort study of local kidney allocation at isolated transplant centers, we found that centers frequently skipped their highest-priority candidates to place kidneys further down the allocation prioritization list, often citing organ quality concerns but placing kidneys with recipients with both better and worse EPTS with nearly equal frequency. This occurred with limited transparency and highlights the opportunity to improve the matching and offer algorithm to improve allocation efficiency.
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Affiliation(s)
- Kristen L. King
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
| | - S. Ali Husain
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
| | - Miko Yu
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
| | - Joel T. Adler
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin
| | - Jesse Schold
- Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora
- Department of Epidemiology, School of Public Health, University of Colorado, Anschutz Medical Campus, Aurora
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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27
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Mohan S, Yu M, King KL, Husain SA. Increasing Discards as an Unintended Consequence of Recent Changes in United States Kidney Allocation Policy. Kidney Int Rep 2023; 8:1109-1111. [PMID: 37180509 PMCID: PMC10166727 DOI: 10.1016/j.ekir.2023.02.1081] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/25/2023] [Accepted: 02/19/2023] [Indexed: 02/27/2023] Open
Affiliation(s)
- 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
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - 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
| | - Kristen L. King
- 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
| | - S. 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
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28
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Liu RX, Koyawala N, Thiessen-Philbrook HR, Doshi MD, Reese PP, Hall IE, Mohan S, Parikh CR. Untargeted metabolomics of perfusate and their association with hypothermic machine perfusion and allograft failure. Kidney Int 2023; 103:762-771. [PMID: 36549364 DOI: 10.1016/j.kint.2022.11.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/28/2022] [Accepted: 11/14/2022] [Indexed: 12/24/2022]
Abstract
Although hypothermic machine perfusion (HMP) is associated with improved kidney graft viability and function, the underlying biological mechanisms are unknown. Untargeted metabolomic profiling may identify potential metabolites and pathways that can help assess allograft viability and contribute to organ preservation. Therefore, in this multicenter study, we measured all detectable metabolites in perfusate collected at the beginning and end of deceased-donor kidney perfusion and evaluated their associations with graft failure. In our cohort of 190 kidney transplants, 33 (17%) had death-censored graft failure over a median follow-up of 5.0 years (IQR 3.0-6.1 years). We identified 553 known metabolites in perfusate and characterized their experimental and biological consistency through duplicate samples and unsupervised clustering. After perfusion-time adjustment and false discovery correction, six metabolites in post-HMP perfusate were significantly associated with death-censored graft failure, including alpha-ketoglutarate, 3-carboxy-4-methyl-5-propyl-2-furanpropanoate, 1-carboxyethylphenylalanine, and three glycerol-phosphatidylcholines. All six metabolites were associated with an increased risk of graft failure (Hazard Ratio per median absolute deviation range 1.04-1.45). Four of six metabolites also demonstrated significant interaction with donation after cardiac death with notably greater risk in the donation after cardiac death group (Hazard Ratios up to 1.69). Discarded kidneys did not have significantly different levels of any death-censored graft failure-associated metabolites. On interrogation of pathway analysis, production of reactive oxygen species and increased metabolism of fatty acids were upregulated in kidneys that subsequently developed death-censored graft failure. Thus, further understanding the role of these metabolites may inform the HMP process and help improve the objective evaluation of allograft offers, thereby reducing the discard of potentially viable organs.
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Affiliation(s)
- Richard X Liu
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Neel Koyawala
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Mona D Doshi
- Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Isaac E Hall
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Sumit Mohan
- Department of Medicine, Vagelos College of Physicians and Surgeons, New York, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Chirag R Parikh
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Garner M, Jay CL, Sharda B, Webb C, Farney AC, Orlando G, Rogers J, Reeves-Daniel A, Mena-Gutierrez A, Sakhovskaya N, Stratta B, Stratta RJ. Long-term outcomes of kidney transplantation from deceased donors with terminal acute kidney injury: Single center experience and literature review. Clin Transplant 2023; 37:e14886. [PMID: 36524320 DOI: 10.1111/ctr.14886] [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: 09/07/2022] [Revised: 11/05/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Long-term outcomes of kidney transplantation from deceased donors (DDKTs) with terminal acute kidney injury (AKI) are not well defined. METHODS Single center retrospective review of DDKTs from 1/31/07-12/31/19. AKI kidneys were defined by a doubling of the donor's admission serum creatinine (SCr) level AND a terminal SCr ≥2.0 mg/dl. RESULTS A total of 188 AKI DDKTs were performed, including 154 from brain-dead standard criteria donors (SCD). Mean donor age was 36 years and mean Kidney Donor Profile Index was 50%; mean admission and terminal SCr levels were 1.3 and 3.1 mg/dl, respectively. With a mean follow-up of 94 months (median 89 months), overall patient (both 71.3%) and graft survival (54% AKI vs. 57% non-AKI) rates were comparable to concurrent DDKTs from brain-dead non-AKI SCDs (n = 769). Delayed graft function (DGF) was higher in AKI kidney recipients (47% vs. 20% non-AKI DDKTs, p < .0001). DGF was associated with lower graft survival in recipients of both AKI and non-AKI SCD kidneys but the impact was earlier and more pronounced in non-AKI recipients. CONCLUSIONS Despite having more than twice the incidence of DGF, kidneys from deceased donors with terminal AKI have long-term outcomes comparable to non-AKI SCD kidneys and represent a safe and effective method to expand the donor pool.
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Affiliation(s)
- Matthew Garner
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Colleen L Jay
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Berjesh Sharda
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Christopher Webb
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Alan C Farney
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Giuseppe Orlando
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jeffrey Rogers
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Amber Reeves-Daniel
- Department of Medicine, Section of Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Alejandra Mena-Gutierrez
- Department of Medicine, Section of Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Natalia Sakhovskaya
- Department of Medicine, Section of Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Bobby Stratta
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Robert J Stratta
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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Puttarajappa CM, Tevar AD, Hoffman W, Degenholtz H, Schinstock CA, Gunabushanam V, Zeevi A, Xu Q, Hariharan S. Virtual crossmatch for deceased donor kidney transplantation in the United States: A survey of histocompatibility lab directors and transplant surgeons. Hum Immunol 2023; 84:214-223. [PMID: 36581507 PMCID: PMC9991979 DOI: 10.1016/j.humimm.2022.12.001] [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: 09/02/2022] [Revised: 11/22/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022]
Abstract
Virtual crossmatch (VXM) is used as an alternative to or in conjunction with a cell-based physical crossmatch (PXM) for assessing HLA (human leukocyte antigen) compatibility prior to deceased donor kidney transplantation (DDKT). Data on practice patterns and perceptions regarding VXM use in the US are limited. We performed a survey of US HLA directors and transplant surgeons regarding HLA testing and crossmatch strategies. 53 (56 %) HLA directors and 68 surgeons (representing ∼ 23 % of US transplant centers) completed the survey. Both groups agreed that VXM could reduce cold ischemia time (CIT), costs and improve allocation efficiency. VXM use increased following the 2021 kidney allocation change. Reducing CIT was the primary reason for favoring VXM over PXM. Preference for VXM reduced as candidates' panel reactive antibodies increased. Regulations, program policies and limitations of HLA technology were cited as important reasons for preferring PXM over VXM. Surgeons reported similar perceptions, but findings are limited by the low response rate. Finally, half the labs reported lacking specific protocols for VXM use. In conclusion, improved HLA technology and protocols along with changes to institutional procedures and policy regulations are needed for safer expansion of VXM in DDKT.
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Affiliation(s)
- Chethan M Puttarajappa
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, USA.
| | - Amit D Tevar
- Department of Surgery, University of Pittsburgh, Pittsburgh, USA
| | | | - Howard Degenholtz
- Department of Health Policy and Management, University of Pittsburgh, Pittsburgh, USA
| | | | | | - Adriana Zeevi
- Department of Pathology, University of Pittsburgh, Pittsburgh, USA
| | - Qingyong Xu
- Department of Pathology, University of Pittsburgh, Pittsburgh, USA
| | - Sundaram Hariharan
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, USA
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Achieving Equity in Organ Transplantation: Recommendations for Action Based on the National Academies of Sciences, Engineering, and Medicine Report. Transplantation 2023; 107:291-296. [PMID: 36584378 DOI: 10.1097/tp.0000000000004464] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The United States organ transplantation system has recently reached a historic milestone of a cumulative 1 million transplants. Despite this considerable success in providing life-saving organ transplants to patients with end organ failure, there are ample opportunities for improvement, particularly with regard to achieving equity. Recognizing this, Congress directed the National Institutes of Health to fund the National Academies of Sciences, Engineering, and Medicine in conducting a study on deceased donor organ procurement, allocation, and distribution, recommending ways to improve equity and accountability. The National Academies of Sciences, Engineering, and Medicine study committee's report, Realizing the Promise of Equity in the Organ Transplantation System , reached multiple conclusions and agreed on 14 recommendations for action that can be grouped into 3 areas: (1) achieving equity, (2) improving system performance, and (3) increasing the utilization of available organs. Here, we review overarching areas for improvement, highlighting key recommendations, and suggest implementing actions.
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Wood NL, VanDerwerken DN, Segev DL, Gentry SE. Logistical burden of offers and allocation inefficiency in circle-based liver allocation. Liver Transpl 2023; 29:26-33. [PMID: 35696252 PMCID: PMC11561902 DOI: 10.1002/lt.26527] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 05/13/2022] [Accepted: 06/08/2022] [Indexed: 01/14/2023]
Abstract
Recent changes to liver allocation replaced donor service areas with circles as the geographic unit of allocation. Circle-based allocation might increase the number of transplantation centers and candidates required to place a liver, thereby increasing the logistical burden of making and responding to offers on organ procurement organizations and transplantation centers. Circle-based allocation might also increase distribution time and cold ischemia time (CIT), particularly in densely populated areas of the country, thereby decreasing allocation efficiency. Using Scientific Registry of Transplant Recipient data from 2019 to 2021, we evaluated the number of transplantation centers and candidates required to place livers in the precircles and postcircles eras, nationally and by donor region. Compared with the precircles era, livers were offered to more candidates (5 vs. 9; p < 0.001) and centers (3 vs. 5; p < 0.001) before being accepted; more centers were involved in the match run by offer number 50 (9 vs. 14; p < 0.001); CIT increased by 0.2 h (5.9 h vs. 6.1 h; p < 0.001); and distribution time increased by 2.0 h (30.6 h vs. 32.6 h; p < 0.001). Increased burden varied geographically by donor region; livers recovered in Region 9 were offered to many more candidates (4 vs. 12; p < 0.001) and centers (3 vs. 8; p < 0.001) before being accepted, resulting in the largest increase in CIT (5.4 h vs. 6.0 h; p < 0.001). Circle-based allocation is associated with increased logistical burdens that are geographically heterogeneous. Continuous distribution systems will have to be carefully designed to avoid exacerbating this problem.
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Affiliation(s)
- Nicholas L. Wood
- Department of Mathematics, United States Naval Academy, Annapolis, MD
| | | | - Dorry L. Segev
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Sommer E. Gentry
- Department of Mathematics, United States Naval Academy, Annapolis, MD
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Puttarajappa CM, Hariharan S, Zhang X, Tevar A, Mehta R, Gunabushanam V, Sood P, Hoffman W, Mohan S. Early Effect of the Circular Model of Kidney Allocation in the United States. J Am Soc Nephrol 2023; 34:26-39. [PMID: 36302599 PMCID: PMC10101588 DOI: 10.1681/asn.2022040471] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 07/21/2022] [Accepted: 08/16/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND In March 2021, the United States implemented a new kidney allocation system (KAS250) for deceased donor kidney transplantation (DDKT), which eliminated the donation service area-based allocation and replaced it with a system on the basis of distance from donor hospital to transplant center within/outside a radius of 250 nautical miles. The effect of this policy on kidney discards and logistics is unknown. METHODS We examined discards, donor-recipient characteristics, cold ischemia time (CIT), and delayed graft function (DGF) during the first 9 months of KAS250 compared with a pre-KAS250 cohort from the preceding 2 years. Changes in discards and CIT after the onset of COVID-19 and the implementation of KAS250 were evaluated using an interrupted time-series model. Changes in allocation practices (biopsy, machine perfusion, and virtual cross-match) were also evaluated. RESULTS Post-KAS250 saw a two-fold increase in kidneys imported from nonlocal organ procurement organizations (OPO) and a higher proportion of recipients with calculated panel reactive antibody (cPRA) 81%-98% (12% versus 8%; P <0.001) and those with >5 years of pretransplant dialysis (35% versus 33%; P <0.001). CIT increased (mean 2 hours), including among local OPO kidneys. DGF was similar on adjusted analysis. Discards after KAS250 did not immediately change, but we observed a statistically significant increase over time that was independent of donor quality. Machine perfusion use decreased, whereas reliance on virtual cross-match increased, which was associated with shorter CIT. CONCLUSIONS Early trends after KAS250 show an increase in transplant access to patients with cPRA>80% and those with longer dialysis duration, but this was accompanied by an increase in CIT and a suggestion of worsening kidney discards.
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Affiliation(s)
- Chethan M. Puttarajappa
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sundaram Hariharan
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Xingyu Zhang
- Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Amit Tevar
- Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Rajil Mehta
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Vikraman Gunabushanam
- Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Puneet Sood
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - William Hoffman
- Transplant Nephrology, UPMC Pinnacle, Harrisburg, Pennsylvania
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians and Surgeons and Department of Medicine, Mailman School of Public Health, Columbia University, New York, New York
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Alhamad T, Marklin G, Ji M, Rothweiler R, Chang SH, Wellen J. One-Year Experience With the New Kidney Allocation Policy at a Single Center and an OPO in the Midwestern United States. Transpl Int 2022; 35:10798. [PMID: 36568140 PMCID: PMC9767943 DOI: 10.3389/ti.2022.10798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Tarek Alhamad
- Division of Nephrology, School of Medicine, Washington University in St. Louis, St. Louis, MO, United States,*Correspondence: Tarek Alhamad,
| | - Gary Marklin
- Mid-America Transplant Organ Procurement Organization, St. Louis, MO, United States
| | - Mengmeng Ji
- Division of Nephrology, School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Richard Rothweiler
- Mid-America Transplant Organ Procurement Organization, St. Louis, MO, United States
| | - Su-Hsin Chang
- Division of Public Health Sciences, Department of Surgery, School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Jason Wellen
- Department of Surgery, School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
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35
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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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36
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Reddy V, da Graca B, Martinez E, Ruiz R, Asrani SK, Testa G, Wall A. Single-center analysis of organ offers and workload for liver and kidney allocation. Am J Transplant 2022; 22:2661-2667. [PMID: 35822324 DOI: 10.1111/ajt.17144] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 07/06/2022] [Accepted: 07/08/2022] [Indexed: 01/25/2023]
Abstract
The volume of abdominal organ offers received by the Baylor Simmons Transplant Institute has increased over time, resulting in a higher workload for our donor call team. To quantify the increase in organ offers, determine the characteristics of these offers, and estimate the impact on our transplant center workload, we collected center-specific organ offer data from May 2019 to July 2021 using the UNOS Center Acceptance and Refusal Evaluation Report and performed a time study that collected the number of communications and time spent on communications for organ offers made during a typical week. The total offers per month increased by 140% (270/month to 648/month), while the number of transplanted organs remained stable. In addition, the percentage of offers for organs that were never transplanted increased from 54% to 75%. In a representative week-long time study, surgeons made 505, center coordinators 590, and answering service coordinators 318 distinct communications, averaging 3, 4, and 2 communications/hour. Between November 2019 and July 2021, offer-related workload increased by an estimated 97%. These results demonstrate a sizeable inefficiency in abdominal organ allocation associated with a nonrecoverable cost to our transplant center.
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Affiliation(s)
- Vikrant Reddy
- Division of Abdominal Transplantation, Baylor University Medical Center, Dallas, Texas, USA
| | | | - Eric Martinez
- Division of Abdominal Transplantation, Baylor University Medical Center, Dallas, Texas, USA
| | - Richard Ruiz
- Division of Abdominal Transplantation, Baylor University Medical Center, Dallas, Texas, USA
| | - Sumeet K Asrani
- Division of Abdominal Transplantation, Baylor University Medical Center, Dallas, Texas, USA
| | - Giuliano Testa
- Division of Abdominal Transplantation, Baylor University Medical Center, Dallas, Texas, USA
| | - Anji Wall
- Division of Abdominal Transplantation, Baylor University Medical Center, Dallas, Texas, USA
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Adler JT, Husain SA. More is better … until it is worse: Can organ placement processes scale to an increasingly complex system? Am J Transplant 2022; 22:2499-2501. [PMID: 35951475 DOI: 10.1111/ajt.17168] [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] [Received: 07/17/2022] [Accepted: 08/09/2022] [Indexed: 01/25/2023]
Affiliation(s)
- Joel T Adler
- Division of Transplantation, Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Syed A Husain
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians & Surgeons, New York, New York, USA
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Cron DC, Husain SA, Adler JT. The New Distance-Based Kidney Allocation System: Implications for Patients, Transplant Centers, and Organ Procurement Organizations. CURRENT TRANSPLANTATION REPORTS 2022; 9:302-307. [PMID: 36254174 PMCID: PMC9558035 DOI: 10.1007/s40472-022-00384-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2022] [Indexed: 11/12/2022]
Abstract
Purpose of Review The goal of deceased donor kidney allocation policy is to provide objective prioritization for donated kidneys, and policy has undergone a series of revisions in the past decade in attempt to achieve equity and utility in access to kidney transplantation. Most recently, to address geographic disparities in access to kidney transplantation, the Kidney Allocation System changed to a distance-based allocation system—colloquially termed “KAS 250”—moving away from donor service areas as the geographic basis of allocation. We review the early impact of this policy change on access to transplant for patients, and on complexity of organ allocation and transplantation for transplant centers and organ procurement organizations. Recent Findings Broader sharing of kidneys has increased complexity of the allocation system, as transplant centers and OPOs now interact in larger networks. The increased competition resulting from this system, and the increased operational burden on centers and OPOs resulting from greater numbers of organ offers, may adversely affect organ utilization. Preliminary results suggest an increase in transplant rate overall but a trend toward higher kidney discard and increased cold ischemia time. Summary The KAS 250 allocation policy changed the geographic basis of deceased donor kidney distribution in a manner that is intended to reduce geographic disparities in access to kidney transplantation. Close monitoring of this policy’s impact on patients, transplant center behavior, and process measures is critical to the aim of maximizing access to transplant while achieving transplant equity.
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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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40
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Wood NL, VanDerwerken DN, Segev DL, Gentry SE. Increased Logistical Burden in Circle-based Kidney Allocation. Transplantation 2022; 106:1885-1887. [PMID: 36173652 PMCID: PMC11561894 DOI: 10.1097/tp.0000000000004127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Nicholas L. Wood
- Department of Mathematics, United States Naval Academy, Annapolis, MD
| | | | - Dorry L. Segev
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
- Department of Surgery, New York University Grossman School of Medicine, New York, NY
| | - Sommer E. Gentry
- Department of Mathematics, United States Naval Academy, Annapolis, MD
- Department of Surgery, New York University Grossman School of Medicine, New York, NY
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41
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Tandukar S, Tandukar Z. Dual impact of donor service area removal from kidney allocation system and Coronavirus Disease 2019 pandemic on access to transplantation. Clin Transplant 2022; 36:e14797. [PMID: 35988050 PMCID: PMC9538084 DOI: 10.1111/ctr.14797] [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: 05/03/2022] [Revised: 07/06/2022] [Accepted: 08/16/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Donor service area was removed from kidney and pancreas allocation system in the United States on March 15, 2021 in favor of a distance based policy to provide geographic equity to access to transplantation. The policy change was introduced at a time when ongoing Coronavirus Disease 2019 (COVID-19) pandemic cases were declining following the first delta wave. METHODS In this Scientific Registry of Transplant Recipients based study, deceased donor kidney transplant recipients between March 15 and December 2 of 2019, 2020 and 2021 were compared representing pre-policy change, pre-COVID cohort; pre-policy change, early COVID cohort; and post-policy change, late COVID cohort. RESULTS There were 11336, 11808, and 12914 kidney transplants in the 2019, 2020, and 2021 cohorts, respectively. Proportion of kidney transplants increased from 8798 (78%) to 9496 (80%) to 11152 (86%), and decreased from 2538 (22%) to 2312 (20%) to 1762 (14%) within and beyond 250 nautical miles in subsequent years. Median distance between donor and transplant hospital increased (73 vs. 63 vs. 119 nautical miles, P < .001) and mean cold ischemia time increased (18.1 vs. 17.8 vs. 19.9 h, P < .001). Access to transplantation did not change for various racial groups (P = .07), pediatric patients (P = .29), dialysis vintage of >5 years (P = .21), veterans (P = .07) and decreased for those with calculated PRA of 99% and 100% (P < .001). Rate of kidney discard (19.6% vs. 20.4% vs. 24%) remained high. Although there were numerical increases in transplants from donors with donation after circulatory death, donor acute kidney injury, kidney donor profile index >85% and donor age >60 years in successive years, rates of kidney discard also increased proportionally. CONCLUSION Improvement in the access to transplantation following the policy change was attenuated by the concurrent prevalence of the COVID-19 pandemic.
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Affiliation(s)
- Srijan Tandukar
- John C. McDonald Regional Transplant Center, Willis‐Knighton Medical CenterShreveportLouisianaUSA
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Barah M, Kilambi V, Friedewald JJ, Mehrotra S. Implications of Accumulated Cold Time for US Kidney Transplantation Offer Acceptance. Clin J Am Soc Nephrol 2022; 17:1353-1362. [PMID: 35868843 PMCID: PMC9625102 DOI: 10.2215/cjn.01600222] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 07/12/2022] [Accepted: 07/16/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND OBJECTIVES Reducing discard is important for the US transplantation system because nearly 20% of the deceased donor kidneys are discarded. One cause for the discards is the avoidance of protracted cold ischemia times. Extended cold ischemia times at transplant are associated with additional risk of graft failure and patient mortality. A preference for local (within the same donor service area) or low-Kidney Donor Risk Index organs, the endogeneity of cold ischemia time during organ allocation, and the use of provisional offers all complicate the analysis of cold ischemia times' influence on kidney acceptance decision making. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using January 2018 to June 2019 Organ Procurement and Transplantation Network data, we modeled the probability of accepting an offer for a kidney after provisional acceptance. We use logistic regression that includes cold ischemia time, Kidney Donor Risk Index, and other covariates selected from literature. Endogeneity of cold ischemia time was treated by a two-stage instrumental variables approach. RESULTS Logistic regression results for 3.33 million provisional acceptances from 12,369 donors and 108,313 candidates quantify trade-offs between cold ischemia time at the time of offer acceptance and donor-recipient characteristics. Overall, each additional 2 hours of cold ischemia time affected acceptance for nonlocal and local recipients (odds ratio, 0.75; 95% confidence interval, 0.73 to 0.77, odds ratio, 0.88; 95% confidence interval, 0.86 to 0.91; P<0.001). For Kidney Donor Risk Index >1.75 (Kidney Donor Profile Index >85) kidneys, an additional 2 hours of cold ischemia time for nonlocal and local recipients was associated with acceptance with odds ratio, 0.58; 95% confidence interval, 0.54 to 0.63 (nonlocal) and odds ratio, 0.65; 95% confidence interval, 0.6 to 0.7 (local); P<0.001. The effect of an additional 2 hours of cold ischemia time on acceptance of kidneys with Kidney Donor Risk Index ≤1.75 (Kidney Donor Profile Index ≤85) was less pronounced for nonlocal offers (odds ratio, 0.82; 95% confidence interval, 0.80 to 0.85; P<0.001) and not significant for local offers. CONCLUSIONS The acceptability of marginal organs was higher when placements were nearer to the donor and when cold ischemia time was shorter.
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Affiliation(s)
- Masoud Barah
- Department of Industrial Engineering and Management Sciences, Northwestern University, Evanston, Illinois
| | - Vikram Kilambi
- Department of Engineering and Applied Sciences, RAND Corporation, Arlington, Virginia
- RAND Health Care, Access and Delivery Program, RAND Corporation, Arlington, Virginia
| | - John J Friedewald
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Nephrology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Sanjay Mehrotra
- Department of Industrial Engineering and Management Sciences, Northwestern University, Evanston, Illinois
- Center for Engineering and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Fletchinger T, Jensen HK, Wells A, Giorgakis E, Patel RB, Barone GW, Khan N, Burdine M, Sharma A, Bhusal S, Burdine L. Impact of Prolonged Cold Ischemia Time on One Year Kidney Transplant Outcomes. Transplant Proc 2022; 54:2170-2173. [DOI: 10.1016/j.transproceed.2022.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 08/08/2022] [Accepted: 08/26/2022] [Indexed: 10/14/2022]
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Mohan S, Husain SA. Improving the Utilization of Deceased Donor Kidneys by Prioritizing Patient Preferences. Clin J Am Soc Nephrol 2022; 17:1278-1280. [PMID: 35985701 PMCID: PMC9625108 DOI: 10.2215/cjn.08500722] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - S. Ali Husain
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
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45
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Increased Rates of Kidney Discard in the Era of COVID-19 and Recent KAS Policy Implementation. Transplantation 2022; 106:e503-e506. [PMID: 35939384 DOI: 10.1097/tp.0000000000004321] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Transplantation is a life-saving medical intervention that unfortunately is constrained by scarcity of available organs. An ideal system for allocating organs should seek to achieve the greatest good for the greatest number of people. It also must be fair and not disadvantage certain populations. However, policies aimed at reducing disparities also must be balanced with considerations of utility (graft outcomes), cost, efficiency, and any adverse effects on organ utilization. Here, we discuss the ethical challenges of creating a fair and equitable organ allocation system, focusing on the principles governing deceased donor kidney transplant waitlists around the world. The kidney organ allocation systems in the United States, Australia, and Hong Kong are used as illustrations.
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King KL, Husain SA, Cohen DJ, Schold JD, Mohan S. The role of bypass filters in deceased donor kidney allocation in the United States. Am J Transplant 2022; 22:1593-1602. [PMID: 35090080 DOI: 10.1111/ajt.16967] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 01/25/2023]
Abstract
Kidney transplant centers set organ offer filters enabling all candidates at their center to be bypassed during allocation of deceased donor kidneys from the UNOS Organ Center. These filters aim to increase allocation efficiency by preemptively screening out offers unlikely to be accepted. National data were used to compare filter settings of 175 centers in 2007 and in 2019. We examined characteristics of centers whose settings became increasingly restrictive over time, and associations between filter settings and organ offer acceptance. Overall, centers became more open to receiving offers over time, from a median 62% of filters open to receiving national offers in 2007 to 73% in 2019. Intravenous drug use filter settings changed most, from 63 to 153 willing centers. Centers with more open filter settings had higher transplant volume and offer acceptance ratios across all risk categories despite preemptively screening out fewer offers compared to centers with less open settings, but similar transplant rates. There was significant geographic heterogeneity in the distribution of centers with more open filter settings. Current center bypass filters may impact patients' access to transplantation without achieving their full potential for improving allocation efficiency.
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Affiliation(s)
- Kristen L King
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - S Ali Husain
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - David J Cohen
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Jesse D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
- The Columbia University Renal Epidemiology (CURE) 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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Husain SA, King KL, Cron DC, Neidlinger NA, Ng H, Mohan S, Adler JT. Association of transplant center market concentration and local organ availability with deceased donor kidney utilization. Am J Transplant 2022; 22:1603-1613. [PMID: 35213789 PMCID: PMC9177771 DOI: 10.1111/ajt.17010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/30/2022] [Accepted: 02/20/2022] [Indexed: 01/25/2023]
Abstract
Although there is a shortage of kidneys available for transplantation, many transplantable kidneys are not procured or are discarded after procurement. We investigated whether local market competition and/or organ availability impact kidney procurement/utilization. We calculated the Herfindahl-Hirschman Index (HHI) for deceased donor kidney transplants (2015-2019) for 58 US donation service areas (DSAs) and defined 4 groups: HHI ≤ 0.32 (high competition), HHI = 0.33-0.51 (medium), HHI = 0.53-0.99 (low), and HHI = 1 (monopoly). We calculated organ availability for each DSA as the number kidneys procured per incident waitlisted candidate, grouped as: <0.42, 0.42-0.69, >0.69. Characteristics of procured organs were similar across groups. In adjusted logistic regression, the HHI group was inconsistently associated with composite export/discard (reference: high competition; medium: OR 1.16, 95% CI 1.11-1.20; low 1.01, 0.96-1.06; monopoly 1.19, 1.13-1.26) and increasing organ availability was associated with export/discard (reference: availability <0.42; 0.42-0.69: OR 1.35, 95% CI 1.30-1.40; >0.69: OR 1.83, 95% CI 1.73-1.93). When analyzing each endpoint separately, lower competition was associated with higher export and only market monopoly was weakly associated with lower discard, whereas higher organ availability was associated with export and discard. These results indicate that local organ utilization is more strongly influenced by the relative intensity of the organ shortage than by market competition between centers.
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Affiliation(s)
- Syed A. Husain
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York,The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Kristen L. King
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York,The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - David C. Cron
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Han Ng
- Department of Economics, Pennsylvania State University, State College, Pennsylvania
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York,The Columbia University Renal Epidemiology (CURE) Group, New York, New York,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Joel T. Adler
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas
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Saunders M, Simpson D. “Can i donate a kidney?” Common questions and simplified answers to the prospective kidney donor. J Natl Med Assoc 2022; 114:S56-S61. [DOI: 10.1016/j.jnma.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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50
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Do Organizational Characteristics of Lung Procurement Operations Matter: The Association Between Transplant Center Centrality and Volume With Total Ischemic Time. Transplantation 2022; 106:657-665. [PMID: 33831940 DOI: 10.1097/tp.0000000000003781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND To understand the association of 2 organizational characteristics of transplant center (TXC), volume and closeness centrality, with total ischemic time for deceased donor lung transplants in conjunction with the removal of donation service area (DSA) lung allocation policy. The organization of donor procurements has received increased attention since DSA was removed from allocation policy. Consistent with network theories of organization, organizational characteristics of a TXC could affect procurement efficiency, as volume and closeness centrality (measuring how connected a TXC is within the Organ Procurement and Transplantation Network) could be associated with total ischemic time. These associations could have changed because of the removal of DSA from allocation policy. METHODS We conducted a retrospective, pooled cross-sectional study of total ischemic time for nonperfused deceased donor lung transplants (n = 9281) between 2015 and 2019, using within-between regression. RESULTS Higher volume TXCs exhibited lower total ischemic times after the removal of DSA from lung allocation policy (P = 0.011); however, all TXCs that had increased volumes, after the removal of DSA from lung allocation policy, exhibited higher levels of total ischemic time (P ≤ 0.001). Before the removal of DSA, TXCs that had increased volumes exhibited lower levels of ischemic time (P ≤ 0.001). Both within and between closeness centrality exhibited u-shaped associations with total ischemic time (P = 0.012; P = 0.006) and the effect of closeness centrality on total ischemic time was different after DSA removal (P < 0.001). CONCLUSIONS Organizational characteristics were associated with the efficiency of deceased organ procurements. The effects on total ischemic time were dependent on whether DSA was used for lung allocation.
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