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Dealing With the Kidney Discard Problem in the United States—One Potential Solution for a Difficult Problem

Published:January 12, 2022DOI:https://doi.org/10.1053/j.ajkd.2021.09.022
      Related Article, p. ∗∗∗
      In this issue of AJKD, Husain et al

      Husain SA KK, Adler, JT, Mohan S, Perotte R. Impact of extending eligibility for reinstatement of waiting time after early allograft failure: a decision analysis. Am J Kidney Dis. Published online September 17, 2021. https://doi.org/10.1053/j.ajkd.2021.07.023

      examine the persistent problem of deceased donor kidney discards in the United States. While the problem has been highlighted for years, the transplant community has been unable to make a significant impact in reducing organ discards. The authors propose a potential solution: by offering a return of original waiting time to recipients whose allograft fails early after transplant, a major concern of centers and candidates might be alleviated. This policy is already in effect for grafts with primary nonfunction and allows for a return of waiting time if the graft meets a definition of failure in the first 90 days post-transplant. Husain et al posit that by extending that policy out to 6, 12, or 24 months, physicians and candidates would be less risk averse in their kidney acceptance practices and more will be willing to take a chance on a high-risk organ.
      A recent study by Mehrotra et al
      • Mehrotra S.
      • Schantz K.
      • Friedewald J.J.
      • et al.
      Physician and patient acceptance of policies to reduce kidney discard.
      surveyed patients and physicians about their policy preferences, including a policy giving some or all waiting time back to patients who accept an organ with kidney donor profile index (KDPI) >85 and experience graft failure within 1 year. A majority of both patients and physicians supported giving at least 50% of waiting time back (Fig 1). However, physicians commonly suggested that waiting time should be returned when the graft failure was due to donor kidney quality, not in cases when the graft failed due to nonadherence. Patients who provided feedback on the policy commented that returning waiting time would be fair to patients, and suggested that the policy could increase patient willingness to accept high-KDPI kidneys.
      • Mehrotra S.
      • Schantz K.
      • Friedewald J.J.
      • et al.
      Physician and patient acceptance of policies to reduce kidney discard.
      Returning waiting time to patients whose graft fails early after transplant appears to be an acceptable policy solution for both patients and physicians. However, there are many nuances to consider in the implementation of such a policy.
      Figure thumbnail gr1
      Figure 1Responses to a survey from patients and clinicians about the percentage of wait time that should be returned to candidates that have early failed transplants. Adapted from Mehrotra et al
      • Mehrotra S.
      • Schantz K.
      • Friedewald J.J.
      • et al.
      Physician and patient acceptance of policies to reduce kidney discard.
      with permission of the copyright holder; original image ©2020 John Wiley and Sons.
      First, we as a community need to deal with the complexity of our system. Offers are made first to centers and not patients. Given the short timeline and the number of patients on the list for a given organ offer, there is no practical way to have a conversation with enough patients to practice real shared decision-making, particularly because the kidney offers currently being considered often skip far down the list to patients willing to trade waiting time for perceived organ quality. If, thanks to misaligned and imperfect rating systems and outcomes measures, the transplant center has as much to lose as the patients from poor clinical outcomes, centers will continue to make decisions with both their patients and the viability of their center in mind. While in many cases these decisions are synergistic, graft failure of marginal kidneys not only requires additional resources for subsequent care management, but also counts against the transplanting center metrics.
      Although the authors mention this in the discussion, the medical and surgical sequelae of a failed transplant in relation to a second transplant are not trivial. This system would only work if the candidate with a prior failed transplant is able to be successfully retransplanted. Retransplanting a patient sensitized with a prior transplant is significantly more challenging despite the fact that the current kidney allocation policy provides additional calculated panel reactive antibody–based points when prioritizing patients. We think that the additional medical and surgical complexity of a repeat transplant should be considered with more weighting for these factors in the model to ensure the success of proposed policy.
      Another challenge is that identifying kidneys that ultimately get discarded is difficult. There is significant overlap in quality between discarded kidneys and those that are successfully transplanted.
      • Mohan S.
      • Chiles M.C.
      • Patzer R.E.
      • et al.
      Factors leading to the discard of deceased donor kidneys in the United States.
      This is the reason that comparisons with the transplant system in France appear valid.
      • Aubert O.
      • Reese P.P.
      • Audry B.
      • et al.
      Disparities in acceptance of deceased donor kidneys between the United States and France and estimated effects of increased US acceptance.
      However, it also makes designing a prediction system to try to identify and fast-track these organ offers difficult. In daily practice, it is often something not captured by refusal codes and national registries that is ultimately the reason for organ discard, and for many candidates the true reason for discard is likely different than the one appearing in the national registries. Despite these challenges, a recent study by Barah and Mehrotra
      • Barah M.
      • Mehrotra S.
      Predicting kidney discard using machine learning.
      demonstrated that kidneys at risk of discard can be identified at the time of donation as well as upon receiving the biopsy results and pump parameters with high precision using machine learning strategies. Should such a fast-tracking policy be in place, a further consideration might be to differentially adapt the policy of waiting time return in the case of early graft failure only to the subset of kidneys that were identified to be fast-tracked or considered marginal through some predecided criteria, thus promoting consistent evaluation of the transplant programs while not penalizing those receiving transplant of marginal quality and fast-tracked kidneys.
      The authors appropriately highlight the transplant center–specific outcomes reporting that has been shown to push centers towards a risk-averse strategy of organ acceptance. Despite changes to the way the Organ Procurement and Transplant Network Membership and Professional Standards Committee (OPTN MPSC) reviews “underperforming” programs, improvement in organ acceptance has been underwhelming. One important reason for this is that the Scientific Registry for Transplant Recipients stubbornly clings to a 5-tiered public rating system that continues to publicly rank centers with statistically significant but clinically meaningless labels, thus driving risk aversion. Returning to the previous 3-tiered system—with roughly 5% of programs identified as under- or overperforming and the remaining 90% described as adequately performing—would allow programs to focus on more important metrics such as access to transplant and acceptance rates.
      Solving the organ shortage will take effective policy change on several different fronts. With their proposal to remove a disincentive for candidates accepting a high-risk organ offer, Husain et al provide the modeling and an important framework for positive change.

      Article Information

      Authors’ Full Names and Academic Degrees

      John J. Friedewald, MD, Karolina Schantz, MPH, and Sanjay Mehrotra, PhD.

      Support

      None.

      Financial Disclosure

      The authors declare that they have no relevant financial interests.

      Peer Review

      Received September 12, 2012 in response to an invitation from the journal. Direct editorial input from an Associate Editor and a Deputy Editor. Accepted in revised form September 25, 2021.

      References

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