Article Figures & Data
Figures
- Figure 1.
The kidney discard rate has remained high over time, especially for kidneys with KDPI >85. KDPI, kidney donor profile index.
- Figure 2.
A substantial percentage of kidneys transplanted in 2013 were not from standard criteria donors. Top panel: KDPI >85%; Lower panel: KDPI <85%. KDPI, kidney donor profile index; PHS, public health service; HCV, hepatitis C virus; DCDD, donation after circulatory determination of death.
- Figure 3.
Increasing Probability of Discard as the KDPI Rises, with 95% CI. KDPI, kidney donor profile index; 95% CI, 95% confidence interval.
- Figure 4.
Geographic variation in discard rate by organ quality in 2013 (top panel: KDPI >85%; lower panel: KDPI <85%). KDPI, kidney donor profile index.
Tables
Primary Reasonsa KDPI<85 N=1206 KDPI≥85 N=1440 n % n % Biopsy findings 335 28 559 39 No recipient located 263 22 417 29 Prior organ function 122 10 110 8 Anatomic abnormalities 92 8 80 6 Organ trauma 68 6 15 1 Diseased organ 32 3 30 2 Donor medical history 4 0.3 11 0.8 Donor infection 15 1.2 13 0.9 Organ too old 23 2 9 0.6 Donor social history 7 0.6 0 0 Recipient unsuitable 7 0.6 6 0.4 Long warm ischemia 5 0.4 3 0.2 Organ not as described 7 0.6 1 0.1 Otherb 236 20 186 13 - Table 2.
Proposed policies to incentivize transplant centers to accept kidneys with a high KDPI or designated by the PHS as increased risk for blood-borne viral infection
Current Barrier New Incentives Challenges to Successful Implementation Acceptance of high KDPI kidneys imposes additional costs for centers, such as perioperative complications requiring treatment and longer length of stay. Medicare and other payers should reimburse at higher rates for higher-risk kidneys. Payers have not historically embraced risk-adjusted payment structures. Kidney allocation rules should be changed so that centers that achieve good outcomes with higher-risk kidneys subsequently get priority for higher-risk kidneys. This approach would require new changes to the national allocation system. Kidney allocation rules should be changed across all organ procurement organizations so that when a donor is identified whose kidneys are at highest risk for discard, centers can use the pair of kidneys for one recipient. If kidneys at risk for discard are not accurately identified, one patient may get two kidneys where two patients might have instead benefitted. Transplant centers are penalized for worse-than-expected patient and allograft survival after transplantation. Calculation of center survival outcomes should exclude patients who received the lowest-quality kidneys. Potentially valuable information about center performance would not be included in the survival statistics. Report cards should include an “organ acceptance metric” which would reward centers for accepting higher-risk organs. The organ acceptance metric would require careful risk adjustment for organ quality and the center population. Each year, regulatory organizations should recognize and/or reward centers that aggressively accepted organs. The organ acceptance metric might put pressure on centers to accept lower-quality kidneys for patients that would be better served by waiting longer for a higher-quality organ. It is unknown how to optimally design this recognition or reward to change center behavior. High KDPI and PHS infectious risk kidneys are often turned down by many patients, leading to prolonged cold storage and eventual discard. Novel methods for prospective informed consent should be developed, such that patients are consented on the waiting list for lower-quality organs and minimal additional consent is required at the organ offer; kidneys are accepted quickly. Transplant clinicians may feel that obtaining a second consent at the time that an organ is offered is necessary to protect them from subsequent liability. Note that higher KDPI kidneys have an elevated estimated rate of graft failure. PHS infectious-risk kidneys, such as a kidney donated by an individual with an injection drug-use history, pose slightly higher risks of viral transmission (such as HIV) compared with other kidneys).
In this issue
New Solutions to Reduce Discard of Kidneys Donated for Transplantation
Jump to section
- Article
- Abstract
- The Lost Opportunity: Many Available Kidneys are from Nonstandard Donors
- Our Toolbox to Assess the Future Function of Donated Kidneys has Major Shortcomings
- Organ Acceptance and Risks of Disease Transmission
- Evidence That Some Discarded Kidneys Would Provide a Survival Benefit If Transplanted
- Center Report Cards: A Disincentive to use Higher-Risk but Viable Kidneys?
- Potential Remedies to Improve Organ Acceptance Rates
- The Role of Referring Nephrologists in Reducing Kidney Discard
- Conclusions
- Disclosures
- Acknowledgments
- Footnotes
- References
- Figures & Data Supps
- Info & Metrics
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Up Front Matters
Cited By...
- Assessment of the Utility of Kidney Histology as a Basis for Discarding Organs in the United States: A Comparison of International Transplant Practices and Outcomes
- Major Variation across Local Transplant Centers in Probability of Kidney Transplant for Wait-Listed Patients
- Can Behavioral Research Improve Transplant Decision-Making? A Mock Offer Study on the Role of Kidney Procurement Biopsies
- Quantifying Donor Effects on Transplant Outcomes Using Kidney Pairs from Deceased Donors
- A Donor Utilization Index to Assess the Utilization and Discard of Deceased Donor Kidneys Perceived as High Risk
- No Time to Wait: Optimizing Use of Deceased Donor Kidneys
- Compelling Evidence of the Need for Policy Change to Decrease Deceased Donor Kidney Discard in the United States: Waste Not Want Less
- Characteristics and Performance of Unilateral Kidney Transplants from Deceased Donors
- Use and Outcomes of Kidneys from Donation after Circulatory Death Donors in the United States
- Survival Benefit of Transplantation with a Deceased Diabetic Donor Kidney Compared with Remaining on the Waitlist