Kidney utility and futility

Abstract

Changes in kidney allocation coupled with the COVID‐19 pandemic have placed tremendous strain on current systems of organ distribution and logistics. Although the number of deceased donors continues to rise annually in the United States, the proportion of marginal deceased donors (MDDs) is disproportionately growing. Cold ischemia times and kidney discard rates are rising in part related to inadequate planning, resources, and shortages. Complexity in kidney allocation and distribution has contributed to this dilemma. Logistical issues and the ability to reperfuse the kidney within acceptable time constraints increasingly determine clinical decision‐making for organ acceptance. We have a good understanding of the phenotype of “hard to place” MDD kidneys, yet continue to promote a “one size fits all” approach to organ allocation. Allocation and transportation systems need to be agile, mobile, and flexible in order to accommodate the expanding numbers of MDD organs. By identifying “hard to place” MDD kidneys early and implementing a “fast‐track” or open offer policy to expedite placement, the utilization rate of MDDs would improve dramatically. Organ allocation and distribution based on location, motivation, and innovation must lead the way. In the absence of change, we are sacrificing utility for futility and discard rates will continue to escalate.

Single center experience and literature review of kidney transplantation from non‐ideal donors with acute kidney injury: Risk and reward

“…In one study, AKI in the setting of a high KDPI donor kidney doubled the risk of graft failure 65 . As a result, many AKI donor kidneys are declined by local centers, which results in delays in placement and increases in CIT 20,66–69 . Complicated logistics and transportation barriers further prolong CIT leading to non‐utilization even though there are studies to suggest that longer CIT may have a minimal effect on outcomes in the setting of a previous ischemic donor event 20,43,70–72 .…”

“…For example, the KDPI classifies all donors who are hepatitis C virus antibody or nucleic acid test positive as a higher risk even though donor hepatitis C virus seropositive status is no longer associated with an increased risk of graft failure in the era of highly effective direct‐acting antiviral therapy 16,17 . The KDPI is also not applicable for patients receiving either dual adult or pediatric en bloc kidney transplants 18–20 . In addition, DCD is one of 10 donor factors used in calculating the KDPI, but the risk coefficient and effect of DCD date back to a period in which relatively few DCD donor kidney transplants were being performed in the United States.…”

“…16,17 The KDPI is also not applicable for patients receiving either dual adult or pediatric en bloc kidney transplants. [18][19][20] In addition, DCD is one of 10 donor factors used in calculating the KDPI, but the risk coefficient and effect of DCD date back to a period in which relatively few DCD donor kidney transplants were being performed in the United States. For these reasons, we still find that the ECD designation is useful in our practice irrespective of the KDPI score because it influences decision-making pursuant to acceptance of kidney offers and appropriate recipient selection.…”

Beyond donation to organ utilization in the USA

“…Placement inefficiency takes two primary forms: the increased costs, logistical complexity and resource utilization associated with transporting organs over greater distances; and the underutilization of organs mediated by increased offer refusals and ensuing increases in cold ischemia time (CIT). In substantially altering the role of the recipient's proximity to the donor in all allocation policies, the emphasis of recent policy projects has been on fostering geographic equity, and evidence suggests these changes have sacrificed placement efficiency [20,21,24 ▪ ,41,42].…”

Renal transplantation: the last iteration of the rest of the world

“…In addition to the aforementioned approaches, developing criteria for placing more challenging kidneys, expediting placement of harder to place kidneys, more detailed data collection for understanding discard reasons, and improved measures of kidney quality and estimated posttransplant survival are among the other parking lot ideas [22 ▪▪ ]. The United States system, like others across the world, seeks to improve kidney allocation by continuously bringing innovative approaches to the table.…”