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LETTER TO EDITOR
The Paradox of Increasing Waiting List Mortality and Declining Utilization of Deceased Donor Grafts in Kidney Transplant

Dear Editor:

Kidney transplant (KTx) is the gold standard treatment for end-stage renal disease because of clear benefits in terms of survival, cost, and quality of life over dialysis.1 However, a recent analysis of the United Network for Organ Sharing database showed that, in the era of organ shortage, transplant candidates receive a large number of viable organ offers that were declined on their behalf by transplant centers.2 Therefore, we analyzed the organ utilization and wait list mortality of KTx candidates in the Eurotransplant database during the period from 2009 to 2018.

Over the last decade, there were a consistently high number of patients actively waiting for KTx. Similarly, the number of new registrations, removals, and re-registrations on wait lists remained unchanged, reflecting the persistent high demand for kidney grafts (data not shown). When we assessed the characteristics of KTx candidates on wait lists, we noted a significant increase in the number of patients who are waiting > 5 years, are highly sensitized (panel reactive antibodies > 85%), and are older than 65 years (Figure 1A; all P < .001). More importantly, we also noted a significant increase in mortality for KTx wait list candidates from 4.8% in 2009 to 5.7% in 2018 (P < .005). During the same period, the wait list mortality for heart and lung transplant candidates decreased from 20.8% to 11.1% (P = .001) and from 15.8% to 13.4% (P = .001), respectively (Figure 1B). When we evaluated the kidney donation and allocation process, we noted a mild decline in the number of organs transplanted, despite stable offer rates (P = .06). This trend seems to be explained by a significant increase in the number of organs that were discarded (P < .001) (Figure 1C). This finding might reflect some deficiencies in the allocation process at the level of the transplant centers. However, this trend was not seen in other solid organs and seems to be organ specific, highlighting the need for better organ utilization in KTx.

Despite the limited data granularity of this analysis, we were able to show that mortality is increasing for KTx wait list candidates. At the same time, organ utilization is declining, with increasing numbers of kidney grafts not being accepted or not used for transplant after initial acceptance. The Eurotransplant database does not provide information on the reasons for decreasing organ utilization. Also, the data set does not capture information regarding specific characteristics such as cold ischemia time. If this information were available, it could provide explanations for the cases in which of organ donation had declined, in that there was a decision to avoid the potential for worse posttransplant outcomes.3 Overall, the reasons for declining an organ offer are multifactorial,4,5 but data have shown that there is room for improvement by increasing the pool of potential donors,6 as well as by enhancing organ acceptance behavior.7,8 For this reason, we believe that future efforts should focus on the more vigorous assessment of organs prior to KTx.8 The Pre-Implantation Trial of Histopathology in Renal Allografts (PITHIA; trial number ISRCTN11708741) aims to evaluate preimplantation kidney biopsies as a tool to help increase the number and quality of kidneys transplanted.9 Beyond that, ex vivo machine perfusion has shown great potential for assessment of extended criteria organs and improvements in organ utilization.10 The Consortium for Organ Preservation in Europe and Cold Oxygenated Machine Perfusion of Aged Renal Grafts (COPE-COMPARE) trial (trial number ISRCTN32967929) will test the effect of supplemental oxygen to hypothermic machine perfusion of organs donated after circulatory death. We believe that these efforts will be the key in turning around the described negative trend, and the transplant community should initiate more similar efforts.


References:

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  2. Husain SA, King KL, Pastan S, et al. Association between declined offers of deceased donor kidney allograft and outcomes in kidney transplant candidates. JAMA Netw Open. 2019;2(8):e1910312.
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  6. Moris D, Tsilimigras DI, Bokos J, Vernadakis S. Organ donation after circulatory death in Greece: time to consider. Exp Clin Transplant. Published online August 19, 2019. doi: 10.6002/ect.2019.0100
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  7. Akyuz Ozdemir A, Sayin CB, Erdal R, Ozcan C, Haberal M. Influence of social, economic, familial, marital status, and disease adaptation on the physical and mental health dimensions of patients who are candidates for renal transplant. Exp Clin Transplant. 2018;16 Suppl 1(Suppl 1):112-116.
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  8. Altinors N, Haberal M. Donor safety, risks, and complications in solid-organ transplant. Exp Clin Transplant. 2020;18(Suppl 1):55-59.
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  9. Ayorinde JO, Summers DM, Pankhurst L, et al. PreImplantation Trial of Histopathology In renal Allografts (PITHIA): a stepped-wedge Cluster Randomised Controlled Trial Protocol. BMJ Open. 2019;9(1):e026166.
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  10. Hosgood SA, Thompson E, Moore T, Wilson CH, Nicholson ML. Normothermic machine perfusion for the assessment and transplantation of declined human kidneys from donation after circulatory death donors. Br J Surg. 2018;105(4):388-394.
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DOI : 10.6002/ect.2019.0427


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From the 1Duke Surgery, Duke University Medical Center, Durham, North Carolina, USA; the 2Transplant Unit, Laikon General Hospital, Athens, Greece; the 3Department of General, Visceral and Transplant Surgery, University Hospital of Heidelberg, Heidelberg, Germany; and the Hepato-Pancreato-Biliary and Liver Transplant Unit, Royal Free Hospital, London, United Kingdom
Acknowledgements: The authors have no sources of funding for this study and have no conflicts of interest to declare
Corresponding author: Dimitrios Moris, Department of Surgery, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710, USA
E-mail: Dimitrios.moris@duke.edu