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. 2023 Jun 1;6(6):e2316936.
doi: 10.1001/jamanetworkopen.2023.16936.

Characterization of Transplant Center Decisions to Allocate Kidneys to Candidates With Lower Waiting List Priority

Kristen L King  1   2 , S Ali Husain  1   2 , Miko Yu  1   2 , Joel T Adler  3 , Jesse Schold  4   5 , Sumit Mohan  1   2   6
Affiliations

Characterization of Transplant Center Decisions to Allocate Kidneys to Candidates With Lower Waiting List Priority

Kristen L King et al. JAMA Netw 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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Conflict of interest statement

Conflict of Interest Disclosures: Dr Husain reported receiving grants personal fees from Fresenius outside the submitted work. Dr Mohan reported receiving personal fees from EGenesis and Kidney International Reports, grants from the National Institutes of Health (NIH) and Kidney Transplant Collaborative, serving on a data advisory committee for United Network for Organ Sharing and as faculty cochair for End Stage Renal Disease Treatment Choices Learning Collaborative outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. How Far Down the Match-Run Centers Placed Kidneys When Skipping Their Candidate With the Highest Allocation Priority
Box and whisker plots depict the allocation prioritization rankings for recipients of transplant events at 11 transplant centers with 1-to-1 relationships with their local organ procurement organization when centers skipped their highest-ranked candidate. Bold lines indicate the median position in the local match run where the recipient was ranked or the median proportion of the match run skipped across all events at that center; boxes, IQR; whiskers, upper and lower adjacent values; and dots, outside values in the distributions at each center.
Figure 2.
Figure 2.. Frequency Histogram of the Difference Between the Estimated Posttransplant Survival (EPTS) Scores of the Skipped Candidates and the Ultimate Recipient for Each Declined Offer, by Reason for Organ Offer Decline
Figure 3.
Figure 3.. Frequency Histogram of the Difference Between the Estimated Posttransplant Survival (EPTS) Scores of the Skipped Candidates and the Ultimate Recipient for Each Declined Offer, by Reason for Organ Offer Decline and Kidney Donor Profile Index (KDPI)
See this image and copyright information in PMC

References

    1. 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(6):1593-1602. doi:10.1111/ajt.16967 - DOI - PubMed
    1. Stewart DE, Kucheryavaya AY, Klassen DK, Turgeon NA, Formica RN, Aeder MI. Changes in deceased donor kidney transplantation one year after KAS implementation. Am J Transplant. 2016;16(6):1834-1847. doi:10.1111/ajt.13770 - DOI - PubMed
    1. Israni AK, Salkowski N, Gustafson S, et al. . New national allocation policy for deceased donor kidneys in the United States and possible effect on patient outcomes. J Am Soc Nephrol. 2014;25(8):1842-1848. doi:10.1681/ASN.2013070784 - DOI - PMC - PubMed
    1. Huml AM, Albert JM, Thornton JD, Sehgal AR. Outcomes of deceased donor kidney offers to patients at the top of the waiting list. Clin J Am Soc Nephrol. 2017;12(8):1311-1320. doi:10.2215/CJN.10130916 - DOI - PMC - PubMed
    1. Husain SA, King KL, Pastan S, et al. . Association between declined offers of deceased donor kidney allograft and outcomes in kidney transplant candidates. JAMA Netw Open. 2019;2(8):e1910312. doi:10.1001/jamanetworkopen.2019.10312 - DOI - PMC - PubMed

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