The New Kidney Donor Allocation System and Implications for Anesthesiologists

Abstract

Given potential disparity and limited allocation of deceased donor kidneys for transplantation, a new federal kidney allocation system was implemented in 2014. Donor organ function and estimated recipient survival in this system has implications for perioperative management of kidney transplant recipients. Early analysis suggests that many of the anticipated goals are being attained. For anesthesiologists, implications of increased dialysis duration and burdens of end-stage renal disease include increased cardiopulmonary disease, challenging fluid, hemodynamic management, and central vein access. With no recent evidence to guide anesthesia care within this new system, we describe the kidney allocation system, summarize initial data, and briefly review organ systems of interest to anesthesiologists. As additional invasive and echocardiographic monitoring may be indicated, one consideration may be development of a dedicated anesthesiology team experienced in management and monitoring of complex patients, in a similar manner as has been done for liver transplant recipients.

Abdominal Organ Transplantation: Noteworthy Literature in 2018

“…A lower KDPI score is associated with better posttransplant graft survival. [35][36][37] Similarly, transplant candidates are risk stratified based on recipient factors, including age, time on dialysis, and diabetes, and are assigned an estimated posttransplant survival score. The goal of combining the KDPI and estimated posttransplant survival scores was to match younger patients with kidneys with low KDPI scores to improve matching organs with long survival potential to the patients who would gain the greatest survival benefit.…”

“…11,39,40 With the changes to organ allocation, anesthesiologists can expect to care for kidney transplant recipients with more significant comorbidities because time on hemodialysis correlates to patients with more CV comorbidities such as CAD, pulmonary HTN, and more challenging vascular access. 37 In their excellent review of donor allocation in the New England Journal of Medicine , Tullius and Rabb 36 argue that for the new KAS to reach its full potential of organ utilization in the United States, regulatory changes may be necessary because many centers may be hesitant to use organs with high KDPI scores for fear of suboptimal outcomes. 36 Access to kidney transplantation can improve with better utilization of donation after cardiac death (DCD) donors.…”

An Update in Abdominal Organ Transplantation Anesthesia in 2018: Society for the Advancement of Transplant Anesthesia (SATA)

“…Sridhar and associates provide the reader with up-to-date information about the new federal kidney allocation system implemented in 2014. 13 They provide scientific rationale for the choice of invasive monitors, and the designation of dedicated anesthesiology teams to care for kidney transplant patients. This section concludes with a review by West discussing the challenging role of anesthesiologists in handling ethical dilemmas inherent to transplant medicine.…”