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Transplant centers routinely reject usable donor kidneys

July 27, 2017

Deceased donor kidneys in the U.S. were refused by transplant centers a median of seven times before finally being accepted, and these refusals may contribute to disparities in access to transplantation, researchers said.

According to an analysis of a national database, the most common reasons for refusal were donor-related factors, such as donor age or the quality of the organ (45% of all refusals), and because the donor organ did not meet a transplant center’s acceptance criteria (44% of refusals), according to investigators led by Anne Huml, MD, of Case Western Reserve University in Cleveland.

For patients on the waiting list, males were less likely than females to receive a kidney (OR 0.93, 95% CI 0.91-0.95), and Hispanics were less likely to receive one than whites (OR 0.96, 95% CI 0.93-0.99), Huml and colleagues reported online in the Clinical Journal of the American Society of Nephrology.

“Our results have implications for patients, providers, researchers, and policy makers,” they wrote. “Waitlisted patients should be aware of how the offer process works and may consider selecting transplant centers based on their acceptance practices. Providers should accurately categorize reasons for refusal and determine if the categories need to be revised. They should also monitor refusals of offers, both among all waitlisted patients and among specific subgroups.

“Our results will allow transplant providers to compare their rates of and reasons for offer refusal with national rates and reasons,” they added. “Researchers should study the impact of the offer process on short- and long-term outcomes of kidney transplantation. Policy makers may be able to develop performance metrics to assess the offer process and disseminate best practices to providers at centers with lower acceptance rates.”

Approximately 600,000 Americans have end-stage renal disease and require dialysis or a kidney transplant, and about two-thirds of kidney transplants come from deceased donor organs, the investigators said. They explained that patients waiting for a donor organ are placed on a national waiting list and typically wait several years to receive a transplant. When a kidney becomes available, a match list is generated that ranks patients in priority order based on a combination of immunologic criteria and waiting time. A transplant center may accept or refuse a kidney that is offered to its patient at the top of the match list. If refused, the kidney is offered to the next patient on the list.

Huml and colleagues analyzed data from the Organ Procurement and Transplantation Network (OPTN), a national database overseen by the Department of Health and Human Services. The study cohort consisted of 178,625 patients on the national waitlist for a kidney and 31,230 deceased donors. The investigators examined all 7 million deceased donor adult kidney offers to transplant centers that eventually led to a transplant during 2007-2012. They looked for associations between transplant centers’ acceptance or refusal of a kidney and characteristics of the potential recipients.

The study found that waitlisted patients with diabetes as the cause of their end-stage renal disease were less likely to be transplanted (OR 0.91, 95% CI 0.88-0.93) as were patients with a body-mass index (BMI) greater than 30 (OR 0.85, 95% CI 0.83-0.87). The investigators also found that waitlisted patients with high panel reactive antibodies were more likely to receive a transplant (OR 2.43, 95% CI 2.33-2.53).

In an accompanying editorial, Sumit Mohan, MD, and Mariana Chiles, MPH, both at Columbia University, said the study “sheds light on an important part of the organ allocation system that is rarely studied — the ability of transplant centers, and providers at these centers, to decline organ offers for their waitlisted patients with no oversight and without the shared decision-making and involvement of the affected patients.”

A third of all refusals in the study were due to to concerns about organ quality, and yet a majority of these organs were eventually transplanted by other centers, suggesting that some centers are more conservative than others or frequently underestimate the quality of donor organs, Mohan and Chiles said.

“There are also implicit biases that appear to inform organ acceptance, many of which are not supported by the evidence,” they added. “For example, kidneys obtained from donors with a history of diabetes or an elevated creatinine have been repeatedly shown to have excellent outcomes post-transplant, and yet, these characteristics continue to be associated with high rates of refusals and eventual discard. These implicit biases and other risk averse behavior are perpetuated by the absence of feedback on these decisions. Informing providers who decline an organ that it was successfully used by another center would potentially lead to a course correction.”

Including patients in the decision-making process may not be feasible or appropriate, Mohan and Chiles said, but “patients deserve to know how ‘aggressive’ their transplant center will be in accepting kidneys for transplantation. Patients should be informed if their wait times are likely to be inflated because of a conservative transplant program philosophy or if there are regulatory pressures or concerns that will impede their ability to get transplanted in a timely manner or at all. Patients who have the ability to choose between transplant centers may find this a more meaningful decision point than other metrics currently being provided.”

An important limitation of the study is that its data pre-dates the new Kidney Allocation System, which was implemented by the OPTN in December 2014, and therefore the study does not account for this change, Mohan and Chiles said. The study authors also noted they didn’t have information on some variables that could have influenced transplant centers’ decisions, such as cold ischemia time.

The study was funded by the National Institutes of Health and the Health Resources and Services Administration.

No study authors reported financial relationships with industry.

Mohan and Chiles reported no financial relationships with industry.

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