Kidney allograft offers: Predictors of turndown and the impact of late organ acceptance on allograft survival

Abstract

There is growing interest in understanding patterns of organ acceptance and reducing discard. Little is known about how donor factors, timing of procurement, and geographic location affect organ offer decisions. We performed a retrospective cohort study of 47 563 deceased donor kidney match-runs from 2007 to 2013. Several characteristics unrelated to allograft quality were independently associated with later acceptance in the match-run: Public Health Service increased-risk donor status (adjusted odds ratio [aOR] 2.49, 95% confidence interval [CI] 2.29-2.69), holiday or weekend procurement (aOR 1.11, 95% CI 1.07-1.16), shorter donor stature (aOR 1.53 for <150 cm vs reference >180 cm, 95% CI 1.28-1.94), and procurement in an area with higher intensity of market competition (aOR 1.71, 95% CI 1.62-1.78) and with the longest waiting times (aOR 1.41, 95% CI 1.34-1.49). Later acceptance in the match-run was associated with delayed graft function but not all-cause allograft failure (adjusted hazard ratio 1.01, 95% CI 0.96-1.07). Study limitations include a lack of match-run data for discarded organs and the possibility of sequence inaccuracies for some nonlocal matches. Interventions are needed to reduce turndowns of viable organs, especially when decisions are driven by infectious risk, weekend or holiday procurement, geography, or other donor characteristics unrelated to allograft quality.

Turn down for what? Patient outcomes associated with declining increased infectious risk kidneys

“…However, we have also shown that IRD kidneys within the low-to-middle range of KDPI (30–50) faced greater scrutiny when considered for transplant and were 2.2-times more likely to be discarded than comparable non-IRD kidneys, while IRD kidneys with higher KDPI (70–100) were only 1.13-times more likely to be discarded than comparable non-IRD kidneys. This analysis indicates that despite the high quality of IRD kidneys, they continue to be regarded with disparate scrutiny for transplantation (22), and it further supports the current discourse on improving utilization of these organs (20, 23–25). …”

Hard-to-place kidney offers: Donor- and system-level predictors of discard

“…Our findings align with other reports wherein system‐level allocation factors have been found to be associated with discard including prolonged cold ischemia, increasing refusal number, nighttime offers, and both kidneys available at the time of offer. Others have postulated that kidney turndown may be reduced with alternative allocation systems to increase early offers of high risk for discard kidneys to centers with and a demonstrated willingness in the past to accept such organs . Given the current paucity of granular donor information available for predictive modeling, our findings suggest that refusal number (a marker of kidneys already in the process of being declined) may be the best candidate to target kidneys for expedited allocation, particularly when both kidneys are still available.…”

Inferior long-term allograft and patient outcomes among recipients of offspring living donor kidneys

“…Our study particularly highlights the significant impact of donor and recipient gender, age, race, and HLA matching on long-term graft survival among LDKT recipients, which previous studies in this area have not thoroughly explored. We also took into careful account body size mismatch between the recipient and donor, which is emerging as an important factor in outcomes for recipients of deceased donor kidneys (42,43). Additionally, understanding that substantial center-specific variability exists with regard to donor and recipient selection criteria and the concerns related to the relationship between the donor and recipient, we used statistical techniques to account for clustering by transplant center.…”