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

Peter P. Reese; Olivier Aubert; Maarten Naesens; Edmund Huang; Vishnu Potluri; Dirk Kuypers; Antoine Bouquegneau; Gillian Divard; Marc Raynaud; Yassine Bouatou; Ashley Vo; Denis Glotz; Christophe Legendre; Carmen Lefaucheur; Stanley Jordan; Jean-Philippe Empana; Xavier Jouven; Alexandre Loupy

doi:10.1681/ASN.2020040464

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Visual Abstract

Significance Statement

Many kidneys donated for transplantation are discarded because of abnormal histology, but it is unknown whether preimplantation kidney biopsies that are routinely performed in the United States add incremental value beyond usual donor attributes in predicting allograft survival. The investigators analyzed detailed data from transplant centers in France and Belgium, where pretransplant biopsies are prospectively performed as standard practice but do not guide decision making for organ allocation. They found that transplant histology did not improve the prediction of allograft failure beyond a robust baseline set of donor and recipient characteristics. They also studied donor kidneys from deceased United States donors—specifically, organs discarded because of abnormal histology—and matched them with similar kidneys transplanted in Europe. The matched kidneys had acceptable allograft survival, illustrating lost transplant opportunities in the United States.

Abstract

Background Many kidneys donated for transplant in the United States are discarded because of abnormal histology. Whether histology adds incremental value beyond usual donor attributes in assessing allograft quality is unknown.

Methods This population-based study included patients who received a deceased donor kidney that had been biopsied before implantation according to a prespecified protocol in France and Belgium, where preimplantation biopsy findings are generally not used for decision making in the allocation process. We also studied kidneys that had been acquired from deceased United States donors for transplantation that were biopsied during allocation and discarded because of low organ quality. Using donor and recipient characteristics, we fit multivariable Cox models for death-censored graft failure and examined whether predictive accuracy (C index) improved after adding donor histology. We matched the discarded United States kidneys to similar kidneys transplanted in Europe and calculated predicted allograft survival.

Results In the development cohort of 1629 kidney recipients at two French centers, adding donor histology to the model did not significantly improve prediction of long-term allograft failure. Analyses using an external validation cohort from two Belgian centers confirmed the lack of improved accuracy from adding histology. About 45% of 1103 United States kidneys discarded because of histologic findings could be accurately matched to very similar kidneys that had been transplanted in France; these discarded kidneys would be expected to have allograft survival of 93.1% at 1 year, 80.7% at 5 years, and 68.9% at 10 years.

Conclusions In this multicenter study, donor kidney histology assessment during allocation did not provide substantial incremental value in ascertaining organ quality. Many kidneys discarded on the basis of biopsy findings would likely benefit United States patients who are wait listed.

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