Since 3/26/2012, the Kidney Donor Profile Index (KDPI) has been provided with all deceased-donor kidney offers, with the goal of improving the ECD indicator. Although an improved risk index may facilitate identification and transplantation of marginal yet viable kidneys, a granular percentile system may reduce provider-patient communication flexibility, paradoxically leading to more discards (“labeling effect”). We studied the discard rates of the kidneys recovered for transplantation between 3/26/2010-3/25/2012 (“ECD era”, N=28,636) and 3/26/2012-3/25/2014 (“KDPI era”, N=29,021) using SRTR data. There was no significant change in discard rate from ECD era (18.1%) to KDPI era (18.3%) among the entire population (aOR=0.971.041.10, p=0.3), or in any KDPI stratum. However, among kidneys in which ECD and KDPI indicators were discordant, “high risk” SCD kidneys (with KDPI>85) were at increased risk of discard in the KDPI era (aOR=1.071.421.89, p=0.02). Yet, recipients of these kidneys were at much lower risk of death (aRR=0.560.770.94 at 2 years post-transplant) compared to those remaining on dialysis waiting for low-KDPI kidneys. Our findings suggest that there might be an unexpected, harmful labeling effect of reporting a high KDPI for SCD kidneys, without the expected advantage of providing a more granular risk index.

Inferences about late risk of end-stage renal disease (ESRD) in live kidney donors have been extrapolated from studies averaging <10 years of follow-up. Since early postdonation ESRD (<10 years postdonation) and late postdonation ESRD (10+ years postdonation) may differ by causal mechanism, it is possible that extrapolations are misleading. To better understand postdonation ESRD, we studied patterns of common etiologies including diabetes, hypertension, and glomerulonephritis (GN)(as reported by providers) using donor-registry data linked to ESRD-registry data. Overall, 125,427 donors were observed for a median of 11.0 years (interquartile range 5.3–15.7; maximum 25). The cumulative incidence of ESRD increased from 10 events per 10,000 at 10 years postdonation to 85 events per 10,000 at 25 years postdonation (incidence rate ratio [IRR] for late vs. early ESRD [adjusted for age, race, and sex]: 1.31.72.3 [subscripts are 95% confidence intervals]). Early postdonation ESRD was predominantly reported as GN-ESRD; however, late postdonation ESRD was more frequently reported as diabetic-ESRD and hypertensive-ESRD (IRR 2.37.725.2 and 1.42.64.6). These time-dependent patterns were not seen with GN-ESRD (IRR 0.40.71.2). Since ESRD in live kidney donors has traditionally been reported in studies averaging <10 years of follow-up, our findings suggest caution in extrapolating such results over much longer intervals.

Many of the PLWH surveyed expressed willingness to be organ donors. However, knowledge about the HOPE Act and donor registration was low, highlighting a need to increase outreach.

Background Kidney donors can develop ESRD after donation, but the outcomes of those who do remain poorly characterized. Methods Using USRDS and SRTR data, we compared access to kidney transplantation (KT), time from ESRD to listing, time from listing to KT, and post-KT graft failure and death between donors and matched nondonors with ESRD. Results Among 99 donors between April 1994 and November 2011 who developed ESRD, 78 initially received dialysis (of whom 37 listed for KT, 2 received live donor KT without listing, and 39 never listed for or received a KT), 20 listed preemptively (of whom 19 were subsequently transplanted), and 1 received a preemptive live donor KT without listing or ever receiving dialysis. Donors were listed earlier (median time-to-listing 17 months versus 120 for nondonors; p<0.001), received KT earlier (median waiting-time 2.8 months versus 21.5 for nondonors; p<0.001), and received 13% live donor, 87% standard criteria, and 0% expanded criteria deceased donor KT (39%, 50%, and 11% in nondonors). Post-KT graft failure (adjusted hazard ratio [HR], 1.9; 95% confidence interval [CI], 0.9 to 4.1; p=0.1) and patient mortality (HR, 0.7; 95% CI, 0.2 to 2.4; p=0.5) were comparable in donors and nondonors. Conclusions Our finding that 39 of 99 donors who developed ESRD never listed for a transplant warrants further study to ascertain why these donors with ESRD never gained access to the waiting list.

The Open Payments Program (OPP) was recently implemented to publicly disclose industry payments to physicians, with the goal of enabling patient awareness of potential conflicts-of-interests. Awareness of OPP, its data, and its implications for transplantation are critical. We used the first wave of OPP data to describe industry payments made to transplant surgeons. Transplant surgeons (N=297) received a total of $759,654. The median (IQR) payment to a transplant surgeon was $125 ($39–1018), and the highest payment to an individual surgeon was $83,520; 122 surgeons received <$100, and 17 received >$10,000. A higher h-index was associated with 30% higher chance of receiving >$1000 (RR/10 unit h-index increase= 1.181.301.44, p<0.001). The highest payment category was consulting fees, with a total of $314,448 paid in this reported category. Recipients of consulting fees had higher h-indices, median (IQR) of 20 (10–35) vs. 9 (3–17) (p<0.001). Ten of 122 companies accounted for 62% of all payments. Kidney transplant (KT) and liver transplant (LT) centers that received >$1,000 had higher center volumes (p<0.001). LT centers that received payments of >$1,000 had a higher percentage of private-insurance/self-pay patients (p<0.01). Continued surveillance of industry payments may further elucidate the relationship between industry payments and physician practices.

Live kidney donors have an increased risk of ESRD compared with nondonors; however, it is unknown whether undetected, subclinical kidney disease exists at donation that subsequently contributes to this risk. To indirectly test this hypothesis, we followed the donated kidneys themselves, by comparing outcomes of 257 recipients whose donors subsequently developed ESRD with a matched cohort whose donors remained ESRD-free. The compared recipients were matched on donor (age, sex, race/ethnicity, donor/recipient relationship), transplant (HLA mismatch, peak-PRA, previous transplant, year-of-transplant), and recipient risk factors (age, sex, race/ethnicity, body-mass index, cause of ESRD, and time-on-dialysis). Median recipient follow-up was 12.5 years (interquartile range 7.4–17.9, maximum 20 years). Recipients of allografts from donors who developed ESRD had increased death-censored graft loss (74% vs. 56% at 20 years; adjusted hazard ratio [aHR] 1.7; 95% confidence interval [CI] 1.5–2.0; p<0.001) and mortality (61% vs. 46% at 20 years; aHR 1.5; 95% CI 1.2–1.8; p<0.001) compared with matched recipients of allografts from donors who did not develop ESRD. This association was similar among related, spousal, and unrelated nonspousal donors. These findings support a novel view of the mechanisms underlying donor ESRD: that of pre-donation kidney disease. However, biopsy data may be required to confirm this hypothesis.

Background: HIV-infected (HIV+) donor to HIV+ recipient (HIV D+/R+) transplantation might improve access to transplantation for people living with HIV. However, it remains unknown whether transplant candidates living with HIV will accept the currently unknown risks of HIV D+/R+ transplantation. Methods: We surveyed transplant candidates living with HIV from 9 US transplant centers regarding willingness to accept HIV+ donor organs. Results: Among 116 participants, the median age was 55 years, 68% were men, and 78% were African American. Most were willing to accept HIV+ living donor organs (87%), HIV+ deceased donor organs (84%), and increased infectious risk donor organs (70%). Some (30%) were concerned about HIV superinfection; even among these respondents, 71% were willing to accept an HIV D+ organ. Respondents from centers that had already performed a transplant under an HIV D+/R+ transplantation research protocol were more willing to accept HIV+ deceased donor organs (89% vs. 71%, P = 0.04). Respondents who chose not to enroll in an HIV D+/R+ transplantation research protocol were less likely to believe that HIV D+/R+ transplantation was safe (45% vs. 77%, P = 0.02), and that HIV D+ organs would work similar to HIV D− organs (55% vs. 77%, P = 0.04), but more likely to believe they would receive an infection other than HIV from an HIV D+ organ (64% vs. 13%, P < 0.01). Conclusions: Willingness to accept HIV D+ organs among transplant candidates living with HIV does not seem to be a major barrier to HIV D+/R+ transplantation and may increase with growing HIV D+/R+ transplantation experience.

Background Recent evidence suggests that living kidney donors are at an increased risk of end-stage renal disease. However, predicting which donors will have renal dysfunction remains challenging, particularly among those with no clinical evidence of disease at the time of donation. Although renal biopsies are not routinely performed as part of the donor evaluation process, they may yield valuable information that improves the ability to predict renal function in donors. Methods We used implantation protocol biopsies to evaluate the association between histological abnormalities in the donated kidney and postdonation renal function (estimated glomerular filtration rate, eGFR) of the remaining kidney in living kidney donors. Longitudinal analysis using mixed-effects linear regression was used to account for multiple eGFR measures per donor. Results Among 310 donors between 1997 and 2012, median (IQR) follow-up was 6.2 (2.5–8.7; maximum 14.0) years. In this cohort, the overall prevalence of histological abnormalities was 65.8% (19.7% abnormal glomerulosclerosis, 23.9% abnormal interstitial fibrosis and tubular atrophy (IFTA), 4.8% abnormal mesangial matrix increase, 32.0% abnormal arteriolar hyalinosis, and 32.9% abnormal vascular intimal thickening). IFTA was associated with a 5-mL/min/1.73m2 decrease of postdonation eGFR after adjusting for donor age at donation, sex, race, preoperative systolic blood pressure, preoperative eGFR, and time since donation (p<0.01). Conclusions In this single-center study, among healthy individuals cleared for living donation, IFTA was associated with decreased postdonation eGFR, while no other subclinical histological abnormalities provided additional information.