In the Journals

Centers decline 15 to 17 donor kidney offers before transplant, removal from waitlist or death

A recently published study found transplant centers refuse many deceased donor kidney offers — over periods of several years in some cases — prior to candidates either receiving the transplant, being removed from the waitlist or dying.

“A center has the ability to decline the offer on the candidate’s behalf without informing the candidate of the offer or the reason it was declined,” S. Ali Husain, MD, MPH, of Columbia University Medical Center, and colleagues wrote. “Despite the advantages of earlier transplant for patients with end-stage renal disease, deceased donor kidneys are offered to a median of seven different candidates before being accepted for transplant, with one-quarter of transplanted deceased donor kidneys offered first to at least 73 candidates. Organ offers are often declined on the basis of center-level organ selection practices rather than a detailed assessment of the advantages to each individual candidate of receiving that kidney allograft, including a shorter time receiving dialysis.”

To determine how this process impacts patients, researchers conducted a cohort study of 280,041 kidney transplant candidates who received one or more deceased donor kidney offers from January 2008 to December 2015 (mean age at time of waitlist placement, 51.1 years; 61.2% were men; median time on dialysis 1.2 years). Primary outcomes included whether the candidate received a deceased or living donor allograft, died while on the waitlist, were removed from the waitlist without a transplant or were still on the waitlist at the end of follow-up.

Starting from when they were listed, patients were followed for a mean of 755 days.

During this time, 29.2% of the cohort received a deceased donor kidney allograft, 11% received a living donor kidney allograft, 9.3% died while on the waitlist and 21.2% were removed from the waitlist.

Researchers found candidates received their first offer of an organ a median of 48 days after being placed on the waitlist. Candidates who eventually underwent a deceased donor transplant received a median of 17 offers during a median of 422 days before the transplant, while those who underwent a living donor transplant received a median of seven offers during a median of 188 days. Candidates who were removed from the waitlist received a median of 15 offers, while waitlisted and candidates who died on the waitlist received a median of 16 offers during a median of 651 days before death.

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Transplant centers refuse many deceased donor kidney offers — over periods of several years in some cases — prior to candidates either receiving the transplant, being removed from the waitlist or dying.
Source: Adobe Stock

Researchers also found a mean of 10 candidates died each day during the study period and that those who died while on the waitlist were more likely to be older and have diabetes or vascular disease and less likely to be wait-listed before dialysis initiation.

In addition, 84% of deceased donor kidneys were declined on behalf of one or more candidates before being accepted for transplant.

Centers reported that concerns related to organ or donor quality accounted for 92.6% of all declined offers (compared with 2.6% declined due to patient-related factors). Researchers noted the odds of death after an offer and the median number of offers received before death varied by state.

“This study found that kidney transplant candidates received a large number of deceased donor kidney offers that were refused on their behalf but subsequently accepted and transplanted into patients with lower priority on the match run,” the researchers wrote. “A death while on the waiting list was frequently preceded by multiple missed opportunities to accept an organ for transplant, which raises important questions about the current organ allocation process. Policy interventions that increase the transparency of these decisions may help maintain the objective nature of the allocation system, improve patient-centered care and increase transplant rates in the United States. – by Melissa J. Webb

Disclosures: Husain reports grants from the National Kidney Foundation. Please see the study for all other authors’ relevant financial disclosures.

A recently published study found transplant centers refuse many deceased donor kidney offers — over periods of several years in some cases — prior to candidates either receiving the transplant, being removed from the waitlist or dying.

“A center has the ability to decline the offer on the candidate’s behalf without informing the candidate of the offer or the reason it was declined,” S. Ali Husain, MD, MPH, of Columbia University Medical Center, and colleagues wrote. “Despite the advantages of earlier transplant for patients with end-stage renal disease, deceased donor kidneys are offered to a median of seven different candidates before being accepted for transplant, with one-quarter of transplanted deceased donor kidneys offered first to at least 73 candidates. Organ offers are often declined on the basis of center-level organ selection practices rather than a detailed assessment of the advantages to each individual candidate of receiving that kidney allograft, including a shorter time receiving dialysis.”

To determine how this process impacts patients, researchers conducted a cohort study of 280,041 kidney transplant candidates who received one or more deceased donor kidney offers from January 2008 to December 2015 (mean age at time of waitlist placement, 51.1 years; 61.2% were men; median time on dialysis 1.2 years). Primary outcomes included whether the candidate received a deceased or living donor allograft, died while on the waitlist, were removed from the waitlist without a transplant or were still on the waitlist at the end of follow-up.

Starting from when they were listed, patients were followed for a mean of 755 days.

During this time, 29.2% of the cohort received a deceased donor kidney allograft, 11% received a living donor kidney allograft, 9.3% died while on the waitlist and 21.2% were removed from the waitlist.

Researchers found candidates received their first offer of an organ a median of 48 days after being placed on the waitlist. Candidates who eventually underwent a deceased donor transplant received a median of 17 offers during a median of 422 days before the transplant, while those who underwent a living donor transplant received a median of seven offers during a median of 188 days. Candidates who were removed from the waitlist received a median of 15 offers, while waitlisted and candidates who died on the waitlist received a median of 16 offers during a median of 651 days before death.

#
Transplant centers refuse many deceased donor kidney offers — over periods of several years in some cases — prior to candidates either receiving the transplant, being removed from the waitlist or dying.
Source: Adobe Stock

Researchers also found a mean of 10 candidates died each day during the study period and that those who died while on the waitlist were more likely to be older and have diabetes or vascular disease and less likely to be wait-listed before dialysis initiation.

In addition, 84% of deceased donor kidneys were declined on behalf of one or more candidates before being accepted for transplant.

Centers reported that concerns related to organ or donor quality accounted for 92.6% of all declined offers (compared with 2.6% declined due to patient-related factors). Researchers noted the odds of death after an offer and the median number of offers received before death varied by state.

“This study found that kidney transplant candidates received a large number of deceased donor kidney offers that were refused on their behalf but subsequently accepted and transplanted into patients with lower priority on the match run,” the researchers wrote. “A death while on the waiting list was frequently preceded by multiple missed opportunities to accept an organ for transplant, which raises important questions about the current organ allocation process. Policy interventions that increase the transparency of these decisions may help maintain the objective nature of the allocation system, improve patient-centered care and increase transplant rates in the United States. – by Melissa J. Webb

Disclosures: Husain reports grants from the National Kidney Foundation. Please see the study for all other authors’ relevant financial disclosures.