Kidney Transplantation After Rescue Allocation—the Eurotransplant Experience: A Retrospective Multicenter Outcome Analysis

Abstract

Background: At Eurotransplant (ET), kidneys are transferred to 'rescue allocation' (RA), whenever the standard allocation (SA) algorithms Eurotransplant kidney allocation system (ETKAS) and Eurotransplant senior program (ESP) fail. We analyzed the outcome of RA. Methods: Retrospective patient clinical and demographic characteristics association analyses with graft outcomes for 2,421 recipients of a deceased donor renal transplantation (DDRT) after RA versus 25,475 after SA from 71 centers across all ET countries from 2006 to 2018.Results: Numbers of DDRTs after RA increased over the time, especially in Germany. RA played a minor role in ESP vs. ETKAS (2.7% vs. 10.4%). RA recipients and donors were older compared to SA recipients and donors, cold ischemia times were longer, waiting times were shorter, and the incidence of primary non-function was comparable. Among ETKASrecipients, HLA matching was more favorable in SA (mean 3.7 vs. 2.5). In multivariate modeling, the incidence of death with a functioning graft (DwFG) in ETKAS was reduced in RA compared to SA (subdistribution hazard ratio 0.70, 95% confidence interval [0.60-0.81], p<0.001) whereas other outcomes (mortality, graft loss) were not significantly different. None of the three outcomes were significantly different when comparing RA with SA within the ESP program.Conclusions: Facing increased waiting times and mortality on dialysis due to donor shortage, this study reveals encouragingly positive DDRT outcomes following RA. This supports the extension of RA to more patients and as an alternative tool to enable transplantation in patients in countries with prohibitively long waiting times or at risk of deterioration.

Outcomes of DCD kidneys with CIT‐induced delayed graft function

“…Effective strategies to facilitate allocation of unwanted kidneys within a timeframe that minimizes discard and that improves logistical considerations in the United States are desperately needed. Implementation of “expedited” or “rescue” allocation of kidneys at risk for discard that were initiated within the United Kingdom in 2012 15 and Eurotransplant in 2006 16,17 have been shown to reduce CIT 18 and stabilize discard rates at comparable outcomes to standard allocation 15,16 . Other opportunities to reduce CIT, besides allocation offer efficiency, are operational, such as reducing the time required for organ assessment (e.g., biopsy standards and access to pathological interpretation), 19 determination of histocompatibility, 20 organ transportation, and transplant center actions (i.e., operating room availability, pre‐transplant dialysis) 20,21 .…”

The Kidney Donor Profile Index (KDPI) Correlates With Histopathologic Findings in Post-reperfusion Baseline Biopsies and Predicts Kidney Transplant Outcome

“…Thus, a prospective, multicenter study with a higher number of patients performing baseline biopsies is required to clarify, if the combination of the (L)KDPI and histopathological findings can improve the predicted outcome of kidney grafts. This might give clinicians the missing tool to better judge the value of grafts rendered as bad quality by current scores, since evidence proving the need to transplant these organs to improve patient survival accumulates (31,49,50). The overall small predictive value of the currently available tools illustrates the necessity for comprehensive international databases, further research on the predictive value of donor, graft, and transplant specific properties including more variables, and transplant physicians' courage to even accept marginal organs for distinct subgroups in times of growing organ shortage.…”

Kidney utility and futility

“…There are a number of reasons why potentially usable kidneys are refused locally, which results in a subsequent “domino effect” because of a “follow the herd” mentality with respect to organ refusal. The Eurotransplant experience has demonstrated that expedited or “rescue allocation” is successful not only in breaking this cycle of kidney refusal leading either to delayed placement or discard but also achieves acceptable patient and graft outcomes 25 . In 2012, the United Kingdom implemented a fast track kidney allocation scheme for previously declined kidneys in which all registered centers were provided kidney offers simultaneously 26 .…”

“…The Eurotransplant experience has demonstrated that expedited or "rescue allocation" is successful not only in breaking this cycle of kidney refusal leading either to delayed placement or discard but also achieves acceptable patient and graft outcomes. 25 In 2012, the United Kingdom implemented a fast track kidney allocation scheme for previously declined kidneys in which all registered centers were provided kidney offers simultaneously. 26 The new system increased kidney utilization from 39% to 59% with no negative effect on outcomes.…”