The impact of multi-organ transplant allocation priority on waitlisted kidney transplant candidates

Abstract

Kidney‐alone transplant (KAT) candidates may be disadvantaged by the allocation priority given to multi‐organ transplant (MOT) candidates. This study identified potential KAT candidates not receiving a given kidney offer due to its allocation for MOT. Using the Organ Procurement and Transplant Network (OPTN) database, we identified deceased donors from 2002 to 2017 who had one kidney allocated for MOT and the other kidney allocated for KAT or simultaneous pancreas–kidney transplant (SPK) (n = 7,378). Potential transplant recipient data were used to identify the “next‐sequential KAT candidate” who would have received a given kidney offer had it not been allocated to a higher prioritized MOT candidate. In this analysis, next‐sequential KAT candidates were younger (p < .001), more likely to be racial/ethnic minorities (p < .001), and more highly sensitized than MOT recipients (p < .001). A total of 2,113 (28.6%) next‐sequential KAT candidates subsequently either died or were removed from the waiting list without receiving a transplant. In a multivariable model, despite adjacent position on the kidney match‐run, mortality risk was significantly higher for next‐sequential KAT candidates compared to KAT/SPK recipients (hazard ratio 1.55, 95% confidence interval 1.44, 1.66). These results highlight implications of MOT allocation prioritization, and potential consequences to KAT candidates prioritized below MOT candidates.

First World Consensus Conference on pancreas transplantation: Part II – recommendations

“…Preferential graft allocation to SPK could not be recommended in case of competition with highly sensitized recipients of a kidney alone transplantation with a negative crossmatch, because of lack of supporting evidence showing which transplant candidate could benefit most from that specific renal graft. 64 …”

“…[61][62][63] This is a key issue, considering donor shortage and the need to maintain a balance between equity and efficacy in graft allocation policy. 64,65 While preemptive SPK transplant seems to be an excellent option in | 21 AJT BOGGI et al…”

Developing simultaneous liver-kidney transplant medical eligibility criteria while providing a safety net: A 2-year review of the OPTN’s allocation policy

“…SLK candidates were prioritized over kidney-alone candidates who may have strong stronger medical urgency claims for priority, such as pediatric age, high levels of sensitization, or long waiting times. [1][2][3] Moreover, after the 2014 implementation of the kidney allocation system, it becomes evident that SLK transplantation was disproportionately utilizing high-longevity kidneys, which are generally prioritized for the pediatric population and adults with the longest estimated posttransplant survival (EPTS). 4 Finally, SLK transplantation was occurring in a manner inconsistent with the OPTN Final Rule due to a lack of standardized rules and medical eligibility criteria.…”

A deeper dive into the impact of multiple-organ transplant policy on kidney transplant candidate prognoses

“…Rigorous analysis of these policies must consider intended aims with resulting system performance in a context with organ scarcity, dynamic decision‐making, secular trends, heterogeneous practice patterns, and patient populations and variation in individual behavior. In this issue, Westphal et al report unique insights about the impact of MOT on outcomes for kidney transplant candidates in the United States 2 . The authors evaluated the outcomes of kidney transplant candidates that would have received the offer that ultimately resulted in a MOT.…”