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

Abstract

Transplant candidates who accept a kidney labeled increased risk for disease transmission (IRD) accept a low risk of window period infection, yet those who decline must wait for another offer that might harbor other risks or never even come. To characterize survival benefit of accepting IRD kidneys, we used 2010-2014 Scientific Registry of Transplant Recipients data to identify 104 998 adult transplant candidates who were offered IRD kidneys that were eventually accepted by someone; the median (interquartile range) Kidney Donor Profile Index (KDPI) of these kidneys was 30 (16-49). We followed patients from the offer decision until death or end-of-study. After 5 years, only 31.0% of candidates who declined IRDs later received non-IRD deceased donor kidney transplants; the median KDPI of these non-IRD kidneys was 52, compared to 21 of the IRDs they had declined. After a brief risk period in the first 30 days following IRD acceptance (adjusted hazard ratio [aHR] accept vs decline: 2.06 , P = .008) (absolute mortality 0.8% vs. 0.4%), those who accepted IRDs were at 33% lower risk of death 1-6 months postdecision (aHR 0.67 , P = .006), and at 48% lower risk of death beyond 6 months postdecision (aHR 0.52 , P < .001). Accepting an IRD kidney was associated with substantial long-term survival benefit; providers should consider this benefit when counseling patients on IRD offer acceptance.

The Drug Overdose Epidemic and Deceased-Donor Transplantation in the United States

“…However, with viral nucleic acid and antibody testing, the true risk for a window-period infection for IRD organ recipients is extremely low (<1 in 1000 for HCV and <1 in 10 000 for HIV) (29, 30). Furthermore, candidates who accept IRD kidneys have better survival than those who wait for another organ (12). Despite this survival benefit, IRD kidneys continue to be discarded (12); this may be driven by administrative burdens of specialized consent (31), medical-legal concerns, or stigma associated with the IRD designation (32, 33).…”

“…Furthermore, candidates who accept IRD kidneys have better survival than those who wait for another organ (12). Despite this survival benefit, IRD kidneys continue to be discarded (12); this may be driven by administrative burdens of specialized consent (31), medical-legal concerns, or stigma associated with the IRD designation (32, 33). Our findings of elevated discard associated with the IRD designation are consistent with these prior studies and suggest that these organs might be unnecessarily discarded in the context of an organ shortage.…”

“…However, ODDs might be designated as increased- infectious risk donors (IRDs) due to behaviors that increase risk for HIV, hepatitis B virus (HBV), or hepatitis C virus (HCV) infection (10, 11). The IRD label might reduce use of ODD organs because it is associated with organ discard (surgical recovery without subsequent use for transplant) (12). Moreover, ODDs are increasingly positive for HCV antibodies (10, 11), and inferior outcomes might be expected due to HCV infection (13–16).…”

Trends in utilization of deceased donor kidneys based on hepatitis C virus status and impact of public health service labeling on discard

“…Decision to discard a deceased donor kidney is influenced by several factors including variability in regional/OPO/center wait time and wait‐list size, center transplant rates/aggressiveness, KDPI score, CIT, decision to biopsy and biopsy findings, pump parameters, regional and national share, living donation access, PHS designation, HCV status, perceived risk/benefit ratio, recipients socioeconomic status. Accepting a PHS‐IR organ offers survival benefit to recipients compared to those who declined it and are waiting for a PHS‐IR donor offer and staying on dialysis . There exist a notion that a disproportionate number of discarded kidneys originate from PHS‐IR donors .…”

Center-level trends in utilization of HCV-exposed donors for HCV-uninfected kidney and liver transplant recipients in the United States

“…1 These HCV Ab+ donors (746 recovered in 2017 alone) might present a viable option for many of the 95 221 kidney and 13 698 liver candidates who currently await transplantation, based on Organ Procurement and Transplantation Network (OPTN) data as of October 2018. [1][2][3][4][5] In light of these factors and the persistent organ shortage, transplant centers have reported increasing willingness to use HCV Ab+ donors for HCV-uninfected (HCV-) recipients, and there is some evidence that this practice is growing. In the DAA era, HCV Ab+ recipients were two to three times more likely to receive HCV Ab+ organs, and the increased utilization was not associated with worse posttransplant outcomes.…”