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      Report of National Kidney Foundation Consensus Conference to Decrease Kidney Discards

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          Abstract

          The organ shortage is one of the major challenges in the field of organ transplantation, yet the percentage of kidneys procured and discarded prior to transplantation has continued to rise to twenty percent. The causes of organ discard are complex, yet an urgent need exists for collaborative efforts to maximize the utilization of all potentially transplantable renal allografts. The National Kidney Foundation convened a meeting of experts to identify factors contributing to reduced organ utilization, and to propose actionable solutions to decrease the rate of kidney discards.

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          Deceased-donor characteristics and the survival benefit of kidney transplantation.

          Joseph Ojo, T Hulbert-Shearon, Friedrich Port … (2005)
          Transplantation using kidneys from deceased donors who meet the expanded criteria donor (ECD) definition (age > or =60 years or 50 to 59 years with at least 2 of the following: history of hypertension, serum creatinine level >1.5 mg/dL [132.6 micromol/L], and cerebrovascular cause of death) is associated with 70% higher risk of graft failure compared with non-ECD transplants. However, if ECD transplants offer improved overall patient survival, inferior graft outcome may represent an acceptable trade-off. To compare mortality after ECD kidney transplantation vs that in a combined standard-therapy group of non-ECD recipients and those still receiving dialysis. Retrospective cohort study using data from a US national registry of mortality and graft outcomes among kidney transplant candidates and recipients. The cohort included 109,127 patients receiving dialysis and added to the kidney waiting list between January 1, 1995, and December 31, 2002, and followed up through July 31, 2004. Long-term (3-year) relative risk of mortality for ECD kidney recipients vs those receiving standard therapy, estimated using time-dependent Cox regression models. By end of follow-up, 7790 ECD kidney transplants were performed. Because of excess ECD recipient mortality in the perioperative period, cumulative survival did not equal that of standard-therapy patients until 3.5 years posttransplantation. Long-term relative mortality risk was 17% lower for ECD recipients (relative risk, 0.83; 95% confidence interval, 0.77-0.90; P 1350 days), ECD recipients had a 27% lower risk of death (relative risk, 0.73; 95% confidence interval, 0.64-0.83; P<.001). In areas with shorter waiting times, only recipients with diabetes demonstrated an ECD survival benefit. ECD kidney transplants should be offered principally to candidates older than 40 years in OPOs with long waiting times. In OPOs with shorter waiting times, in which non-ECD kidney transplant availability is higher, candidates should be counseled that ECD survival benefit is observed only for patients with diabetes.
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            The Donor Kidney Biopsy and Its Implications in Predicting Graft Outcomes: A Systematic Review

            B Kasiske, G S Crary, J. B. Wetmore … (2015)
            Despite a growing organ shortage in the United States, many deceased donor kidneys removed for transplantation are discarded. Kidney biopsy findings often play a role in these discards, although it is not clear whether biopsies reliably inform acceptance decisions. Therefore, we carried out a systematic review of the medical literature on the utility of both procurement and implantation biopsies for predicting posttransplant outcomes. Between January 1, 1994 and July 1, 2014, 47 studies were published in the English language literature that examined the association between pretransplant donor biopsy findings from 50 or more donors (with more than half being from deceased donors) and either posttransplant graft failure, delayed graft function, or graft function. In general, study quality was poor. All were retrospective or did not indicate if they were prospective. Results were heterogeneous, with authors as often as not concluding that biopsy results did not predict posttransplant outcomes. The percent glomerular sclerosis was most often examined, and failed to predict graft failure in 7 of 14 studies. Of 15 semiquantitative scoring systems proposed, none consistently predicted posttransplant outcomes across studies. Routine use of biopsies to help determine whether or not to transplant a kidney should be reexamined.
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              The reproducibility and predictive value on outcome of renal biopsies from expanded criteria donors.

              M Azancot, Francesc Moreso, Maite Salcedo-Allende … (2014)
              Reproducibility and predictive value on outcome are the main criteria to evaluate the utility of histological scores. Here we analyze the reproducibility of donor biopsy assessment by different on-call pathologists and the retrospective evaluation by a single renal pathologist blinded to clinical outcomes. We also evaluate the predictive value on graft outcome of both evaluations. A biopsy was performed in donors with any of the following: age≥55 years, hypertension, diabetes, creatinine>1.5 mg/dl, or stroke. Glomerulosclerosis, interstitial fibrosis, tubular atrophy, intimal thickening, and arteriolar hyalinosis evaluated according to the Banff criteria were added to obtain a chronic score. Biopsies were classified as mild (≥3), intermediate (4-5), or advanced (6-7) damage, and unacceptable (≥8) for transplantation of 127 kidneys biopsied. Weighted κ value between both readings was 0.41 (95% CI: 0.28-0.54). Evaluation of biopsies by the renal pathologist was significantly and independently associated with estimated 12-month glomerular filtration rate and a significant composite outcome variable, including death-censored graft survival and time to reach an estimated glomerular filtration rate<30 ml/min per 1.73 m2. Thus, there was no association between readings of on-call pathologists and outcome. The lack of association between histological scores obtained by the on-call pathologists and graft outcome suggests that a specific training on renal pathology is recommended to optimize the use of kidneys retrieved from expanded criteria donors.
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                Author and article information

                Journal
                Title: Clinical Transplantation
                Abbreviated Title: Clin Transplant
                Publisher: Wiley
                ISSN: 09020063
                Publication date (Electronic): October 21 2018
                Page: e13419
                Affiliations
                [1 ]Medstar Georgetown Transplant Institute; Georgetown University; Washington District of Columbia
                [2 ]Department of Medicine, Section of Nephrology; Yale School of Medicine; New Haven Connecticut
                [3 ]Northwestern University Comprehensive Transplant Center; Chicago Illinois
                [4 ]Department of Surgery; University of California San Francisco; San Francisco California
                [5 ]LifeCenter Northwest; Bellevue Washington
                [6 ]Division of Nephrology, Department of Medicine; Vagelos College of Physicians & Surgeons, Columbia University; New York New York
                [7 ]Department of Epidemiology, Mailman School of Public Health; Columbia University; New York New York
                [8 ]Department of Quantitative Health Sciences; Cleveland Clinic; Cleveland Ohio
                [9 ]Department of Surgery; Lahey Hospital and Medical Center; Burlington Massachusetts
                [10 ]Renal Division, Department of Medicine; Emory University School of Medicine; Atlanta Georgia
                Article
                DOI: 10.1111/ctr.13419
                PubMed ID: 30345720
                SO-VID: ade42748-acb7-45d1-b005-1ed479d55676
                Copyright © © 2018
                License:

                http://doi.wiley.com/10.1002/tdm_license_1.1

                http://onlinelibrary.wiley.com/termsAndConditions#vor

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