Variation in use of procurement biopsies and its implications for discard of deceased donor kidneys recovered for transplantation

Abstract

The use of procurement biopsies in deceased donor kidney acceptance is controversial. We analyzed Scientific Registry of Transplant Recipients data (n = 59 328 allografts, 2014-2018) to describe biopsy practices across US organ procurement organizations (OPOs) and examine relationships with discards, using hierarchical modeling to account for OPO and donor factors. Median odds ratios (MORs) provide the median of the odds that allografts with identical reported traits would be biopsied or discarded from 2 randomly drawn OPOs. Biopsies were obtained for 52.7% of kidneys. Biopsy use rose in a graded manner with kidney donor profile index (KDPI).Biopsy rates differed significantly among OPOs (22.8% to 77.5%), even after adjustment for KDPI and other donor factors. Discard rates also varied from 6.6% to 32.1% across OPOs. After adjustment for donor factors and OPO, biopsy was associated with more than 3 times the likelihood of discard (adjusted odds ratio [ 95%LCL aOR 95%UCL ], 3.29 3.51 3.76 ). This association was most pronounced for low-risk (KDPI <20) kidneys (aOR, 5.45 6.47 7.69 ), with minimal impact at KDPI >85 (aOR, 0.88 1.15 1.51 ). Adjusted MORs for kidney discard and biopsy were greatest for low-risk kidneys. Reducing the rate of unnecessary biopsy and improving the accuracy of histologic assessments in higher KDPI organs may help reduce graft discard rates. K E Y W O R D Sbiopsy, clinical research/practice, donors and donation: deceased, health services and outcomes research, kidney transplantation/nephrology, organ procurement, organ procurement and allocation, Scientific Registry for Transplant Recipients (SRTR)

Can Behavioral Research Improve Transplant Decision-Making? A Mock Offer Study on the Role of Kidney Procurement Biopsies

“…In 16 responses to these kidney offers, participants indicated the organ was "not suitable for any patient, under virtually any circumstance," suggesting belief that such organs should have been discarded rather than transplanted. These results bolster the claim that transplant-quality kidneys are being declined, and possibly discarded, due to the use of procurement biopsies for assessing organ quality (24,31).…”

“…The practice of declining an otherwise clinically acceptable kidney because of arguably "poor" biopsy findings (e.g., glomerulosclerosis [GS] .20%) has been called into question because the evidence for an association between some biopsy results and graft outcomes is suspect (23). Due to the unmistakable link between biopsy findings and kidney discard (24,25), some have proposed eliminating the routine practice of performing a kidney biopsy, citing successful kidney transplantation in Europe without this practice (26). Others insist that the biopsy findings are a vital element of their decision-making process, not only to potentially rule out kidneys for transplantation, but also to rule them in (27).…”

Impacts of center and clinical factors in antihypertensive medication use after kidney transplantation

“…Among patients receiving AHMs, we examined variation in uses of BBs and of ACEi/ARBs as two regimens of key interest given particular focus in JNC‐8, considering clinical factors and center. Bi‐level hierarchical models were constructed to adjust for clustering effects, similar to previous methods . Level 1 comprised patient/donor and transplant (case) factors and level 2 represented centers, wherein use of each regimen (BBs and ACEi/ARBs) was compared with absence of use.…”

Kidney Perfusion as an Organ Quality Assessment Tool—Are We Counting Our Chickens Before They Have Hatched?

“…This evaluation process at time of offer relies on pre-donation review of donor characteristics, donor circumstances and biochemistry, visual appraisal of the organ, and-depending on local practice-results of a zero-time kidney biopsy. Zero-time biopsies are one of the primary reasons of discard in centres relying on these histological findings, while there is a lack of validated scoring systems in combination with poor predictive power [1,15,16]. Considerable effort has gone into the development of risk stratification scores that predict the occurrence of DGF [17][18][19] or graft survival after kidney transplantation [20][21][22][23].…”