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.

Among adult first-time kidney transplantation candidates in the United States who were added to the deceased donor kidney transplantation waiting list between 1995 and 2014, disparities in the receipt of live donor kidney transplantation increased from 1995-1999 to 2010-2014. These findings suggest that national strategies for addressing disparities in receipt of live donor kidney transplantation should be revisited.

Studies have estimated the average risk of postdonation ESRD for living kidney donors in the United States, but personalized estimation on the basis of donor characteristics remains unavailable. We studied 133,824 living kidney donors from 1987 to 2015, as reported to the Organ Procurement and Transplantation Network, with ESRD ascertainment Centers for Medicare and Medicaid Services linkage, using Cox regression with late entries. Black race (hazard ratio [HR], 2.96; 95% confidence interval [95% CI], 2.25 to 3.89;<0.001) and male sex (HR, 1.88; 95% CI, 1.50 to 2.35; <0.001) was associated with higher risk of ESRD in donors. Among nonblack donors, older age was associated with greater risk (HR per 10 years, 1.40; 95% CI, 1.23 to 1.59; <0.001). Among black donors, older age was not significantly associated with risk (HR, 0.88; 95% CI, 0.72 to 1.09; =0.3). Greater body mass index was associated with higher risk (HR per 5 kg/m, 1.61; 95% CI, 1.29 to 2.00; <0.001). Donors who had a first-degree biological relationship to the recipient had increased risk (HR, 1.70; 95% CI, 1.24 to 2.34; <0.01). C-statistic of the model was 0.71. Predicted 20-year risk of ESRD for the median donor was only 34 cases per 10,000 donors, but 1% of donors had predicted risk exceeding 256 cases per 10,000 donors. Risk estimation is critical for appropriate informed consent and varies substantially across living kidney donors. Greater permissiveness may be warranted in older black candidate donors; young black candidates should be evaluated carefully.

Choosing between multiple living kidney donors, or evaluating offers in kidney paired donation, can be challenging because no metric currently exists for living donor quality. Furthermore, some deceased donor kidneys can result in better outcomes than some living donor kidneys, yet there is no way to compare them on the same scale. To better inform clinical decision-making, we created a living kidney donor profile index (LKDPI) on the same scale as the deceased donor KDPI, using Cox regression and adjusting for recipient characteristics. Donor age over 50 (HR per 10y = 1.151.241.33), elevated body mass index (BMI) (HR per 10 units = 1.011.091.16), African-American race (HR= 1.151.251.37), cigarette use (HR=1.091.161.23), as well as ABO incompatibility (HR= 1.031.271.58), HLA B (HR= 1.031.081.14) mismatches, and DR (HR= 1.041.091.15) mismatches were associated with greater risk of graft loss after living donor transplantation (all p<0.05). Median (IQR) LKDPI score was 13 (1–27); 24.2% of donors had LKDPI<0 (less risk than any DD kidney), and 4.4% of donors had LKDPI>50 (more risk than the median DD kidney). The LKDPI is a useful tool for comparing living donor kidneys to each other and to deceased donor kidneys.

The impact of interferon (IFN)-free direct acting antiviral (DAA) hepatitis C virus treatments on utilization and outcomes associated with HCV+ deceased-donor liver transplantation (DDLT) is largely unknown. Using SRTR, we identified 25,566 HCV+ DDLT recipients from 2005 to 2015, and compared practices according to the introduction of DAA therapies using modified Poisson regression. The proportion of HCV+ recipients who received HCV+ livers increased from 6.9% in 2010 to 16.9% in 2015. HCV+ recipients were 61% more likely to receive an HCV+ liver after 2010 (early DAA/IFN era) [aRR:1.451.611.79, p<0.001] and almost three times more likely to receive one after 2013 (IFN-free DAA era) [aRR:2.582.853.16, p<0.001]. Compared to HCV− livers, HCV+ livers were 3 times more likely to be discarded from 2005–2010 [aRR:2.692.993.34, p<0.001], 2.2 times more likely after 2010 [aRR:1.802.162.58, p<0.001], and 1.7 times more likely after 2013 [aRR:1.371.682.04, p<0.001]. Donor HCV status was not associated with increased risk of all-cause graft loss (p=0.1), and this did not change over time (p=0.8). Use of HCV+ livers has increased dramatically, coinciding with the advent of DAAs. However, the discard rate remains nearly double that of HCV− livers. Further optimization of HCV+ liver utilization is necessary to improve access for all candidates.

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In recent years, outcomes after the use of technical variant grafts are comparable with whole grafts, and may be superior for LDLT. Greater use of technical variant grafts might provide an opportunity to increase organ supply without compromising post-transplant outcomes.

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.