Impact of the new fast track kidney allocation scheme for declined kidneys in the United Kingdom

In transplant, meaningful international comparisons in organ utilization are needed. This collaborative study between the United Kingdom (UK) and the United States (US) aimed to develop a kidney utilization metric allowing for legitimate intercountry comparisons.Data from the UK and US transplant registries, including all deceased donor kidneys recovered from 2006 to 2017, were analyzed. To identify a potentially comparable kidney utilization rate (UR), several denominators were assessed. We discovered that the proportion of transplanted kidneys from elderly donors in the UK (10.7%) was 18 times greater than that in the US (0.6%). Conversely, en bloc pediatric kidney transplant was more common in the US. Donation after circulatory death utilization has risen in both countries but is twice as prevalent in the UK (39% of transplants) vs the US (20%). In addition, US and UK URs are not directly comparable due to fundamental system differences. However, using a suite of URs revealed practice areas likely to yield the most benefit if improved, such as efforts to increase kidney offer acceptance in the US and to reduce postacceptance discard in the UK. Methods used in this study, including novel intracountry risk-adjusted UR trend logistic regression analyses, can be translated to other international transplant registries in pursuit of further global learning opportunities. K E Y W O R D S clinical research/practice, donors and donation: deceased, donors and donation: donation after brain death (DBD), donors and donation: donation after circulatory death (DCD), kidney transplantation/nephrology, United Network for Organ Sharing (UNOS) S U PP O RTI N G I N FO R M ATI O N Additional supporting information may be found online in the Supporting Information section.

Section: Discussionsupporting

confidence: 65%

An international comparison of deceased donor kidney utilization: What can the United States and the United Kingdom learn from each other?

Ibrahim

Vece²,

Mehew

et al. 2020

“…Future policy refinements aimed at facilitating more dual kidney transplants (36,37)-i.e. two marginal kidneys into the same recipient-and establishing a formal mechanism for OPOs to expedite placement may help avoid unnecessary organ discard (38)(39)(40). In addition, the OPTN is exploring changes to the current paradigm used for monitoring transplant centers' performance to address the long-standing concern about risk aversion to using marginal organs (41,42).…”

Section: Discussionmentioning

confidence: 99%

“…CPRA 98-100%* CPRA 98-100%* CPRA 98-100%* CPRA 98-100%* 0 ABDR mismatch (EPTS 0-20%) 0 ABDR mismatch 0 ABDR mismatch 0 ABDR mismatch Local prior living donors Local prior living donors Local prior living donors Local + regional A2/A2B-->B Local pediatrics Local pediatrics Local A2/A2B-->B Local + regional candidates Local A2/A2B-->B (EPTS 0-20%) Local A2/A2B-->B Local candidates NaƟonal A2/A2B-->B Local EPTS 0-20% Local candidates Regional A2/A2B-->B NaƟonal candidates 0 ABDR mismatch (EPTS 21-100%) Regional pediatrics statistically significant increase was also observed for recipients aged [35][36][37][38][39][40][41][42][43][44][45][46][47][48][49]. Transplants for patients aged 65 or greater, who represented 21.3% of the waiting list pre-KAS, decreased from 22.9% of transplants pre-KAS to 18.1% post-KAS (p < 0.0001).…”

Section: New Kidney Allocaɵon System (Kas) 34 (12/4/2014-present) Kdmentioning

confidence: 93%

Changes in Deceased Donor Kidney Transplantation One Year After KAS Implementation

Stewart¹,

Kucheryavaya²,

Klassen³

et al. 2016

234

248

After over a decade of discussion, analysis, and consensus-building, a new kidney allocation system (KAS) was implemented on December 4, 2014. Key goals included improving longevity matching between donor kidneys and recipients and broadening access for historically disadvantaged subpopulations, in particular highly sensitized patients and those with an extended duration on dialysis but delayed referral for transplantation. To evaluate the early impact of KAS, we compared Organ Procurement and Transplantation Network data 1 year before versus after implementation. The distribution of transplants across many recipient characteristics has changed markedly and suggests that in many ways the new policy is achieving its goals. Transplants in which the donor and recipient age differed by more than 30 years declined by 23%. Initial, sharp increases in transplants were observed for Calculated Panel-Reactive Antibody 99-100% recipients and recipients with at least 10 years on dialysis, with a subsequent tapering of transplants to these groups suggesting bolus effects. Although KAS has arguably increased fairness in allocation, the potential costs of broadening access must be considered. Kidneys are more often being shipped over long distances, leading to increased cold ischemic times. Delayed graft function rates have increased, but 6-month graft survival rates have not changed significantly.

“…This new methodology is designed to help the network monitor system‐level equity, in particular since policy proposals targeting other goals may adversely affect equity. For example, policy ideas such as deceased donor chains and expedited placement are focused on the OPTN's top goal of increasing the number of transplants but could conceivably hinder equity. However, tradeoffs may be tolerable.…”

Section: Discussionmentioning

confidence: 99%

Measuring and monitoring equity in access to deceased donor kidney transplantation

Stewart¹,

Wilk²,

Toll³

et al. 2018

The Organ Procurement and Transplantation Network monitors progress toward strategic goals such as increasing the number of transplants and improving waitlisted patient, living donor, and transplant recipient outcomes. However, a methodology for assessing system performance in providing equity in access to transplants was lacking. We present a novel approach for quantifying the degree of disparity in access to deceased donor kidney transplants among waitlisted patients and determine which factors are most associated with disparities. A Poisson rate regression model was built for each of 29 quarterly, period-prevalent cohorts (January 1, 2010-March 31, 2017; 5 years pre-kidney allocation system [KAS], 2 years post-KAS) of active kidney waiting list registrations. Inequity was quantified as the outlier-robust standard deviation (SD ) of predicted transplant rates (log scale) among registrations, after "discounting" for intentional, policy-induced disparities (eg, pediatric priority) by holding such factors constant. The overall SD declined by 40% after KAS implementation, suggesting substantially increased equity. Risk-adjusted, factor-specific disparities were measured with the SD after holding all other factors constant. Disparities associated with calculated panel-reactive antibodies decreased sharply. Donor service area was the factor most associated with access disparities post-KAS. This methodology will help the transplant community evaluate tradeoffs between equity and utility-centric goals when considering new policies and help monitor equity in access as policies change.