Improving utilization of deceased donor kidneys has been a major focus of the Organ Procurement and Transplantation Network and is one consideration driving an overhaul of the US transplant system. High–Kidney Donor Profile Index (KDPI) deceased donor kidneys (>85%) are at a higher risk for nonutilization,1 and one strategy for increasing the use of these kidneys includes educating both providers and candidates regarding risks and benefits of consenting for these kidneys. Along these lines, in this issue of JASN, Schold et al. provide valuable data highlighting the merits of consenting to receive a high-KDPI kidney that could be used to facilitate patient education and potentially expand the number of waitlisted candidates with consent.2 The article has several important findings that warrant further commentary, including the following: (1) High-KDPI consent was associated with higher rates of deceased donor transplantation, without affecting the likelihood of receiving a deceased donor with a KDPI <85%; (2) the overall high-KDPI consent rate was 41%, with higher rates in older, Black, or Hispanic candidates and candidates with high body mass index, diabetes, and vascular disease; and (3) there was significant center variation in consent rates, with both largest and smallest centers having a relatively lower proportion of candidates consent for high-KDPI donor organs.2
The key finding of their report is that patients who are consented for high-KDPI kidney transplants are 15% more likely to receive a deceased donor transplantation. Given the well-established lower risk of death with transplantation over remaining on dialysis and the accompanying quality-of-life benefits,3 increasing the rate of transplantation through better utilization of high-KDPI kidneys could be a significant benefit for the entire population of patients waiting for kidney transplantation. Importantly, Schold et al. found that consenting patients for high-KDPI kidneys did not impede access to the remaining pool of available kidneys. In fact, the high-KDPI–consented patients had a slightly higher rate of transplant for the lower-KDPI kidneys (hazard ratio, 1.05).2 This suggests that patients being consented for high-KDPI kidneys may constitute a subset of patients who are highly motivated to get transplanted and expedite the completion of the extensive workup required to become a transplant-ready candidate. In the same way, it is likely that the educational process that resulted in acceptance of a high-KDPI kidney also extended to acceptance of kidneys from higher infectious risk donors. Nonetheless, this small increase in transplants from lower-KDPI kidneys cannot account for the overall increased rate of transplants, supporting the benefit of access to high-KDPI kidneys. Future work examining associations of consenting for high-KDPI kidneys with patient and graft survival is needed to inform patients, clinicians, and policy makers of the outcome implications of willingness to accept these organs.
While an understandable conclusion from the data could be that we need to greatly increase the number of patients who are being consented for high-KDPI kidneys, there are important considerations. The pool of high-KDPI kidneys is a great resource, and we should use the organs, when possible, to both help patients in need of transplant and to better honor the wishes of the donors and donor families. The decision to use these organs, though, must be carefully implemented and each organ offer must be carefully evaluated. In other words, no two high-KDPI kidney offers are the same. The overall risks of a high-KDPI kidney must be carefully weighed against the goals for the specific recipient. The short-term consequences of delayed graft function and possible primary nonfunction and the overall shorter graft survival must be in keeping with the goals for a patient, and simply getting a patient transplanted cannot be the only marker of success.4
Beyond these key details highlighting higher rates of transplant, the article uncovers interesting trends in consenting for high-KDPI kidneys and provides important insights into some of the challenges that still exist for access to transplantation. Notably, the finding that Black and Hispanic populations are more often consented for expanded criteria donors raises questions about how we, as a field, approach consent for populations that have been historically underserved. Are we more aggressive in looking to use high-KDPI kidneys in these populations because of a perceived lack of overall access? Is this of benefit to these patient populations? The article suggests that our overall consenting process varies, in part, by the race and background of the patient, and this finding should be carefully evaluated and scrutinized. It will be interesting to see if future studies can evaluate not just who is consenting to high-KDPI kidneys but also who is being offered consent and if there are differences among potential candidate populations regarding willingness to consent.
In addition, it is striking that there are such differences in approaches to consenting candidates for high-KDPI donors between individual transplant centers. The interesting finding that small-volume and very large–volume centers consent patients at lower rates (37%–38%) suggests that there are multiple reasons why some centers do not consent for these kidneys. Smaller centers will have shorter lists and may not have the impetus to accept the higher-KDPI kidneys. In addition, there may be a higher concern about poor outcomes and the disproportionate impact that poorer outcomes could have on the overall evaluation of the program. It should be emphasized that this concern is unfounded based on the risk stratification that is used in the calculations for center-specific results. For large centers, it may be challenging for coordinators to have sufficient time to adequately consent candidates for higher-KDPI kidneys and have potential candidates for high-KDPI kidney transplant ready when the offers occur. The recently available UNet Predictive Analytics Tool aids clinicians who are considering an organ offer by providing important information on the likelihood of obtaining future offers for a specific patient.5 This tool is currently limited to predicting offers with a KDPI cutoff of 30% or 50%. We envision that this tool could be expanded to highlight the benefits and risks of a high-KDPI kidney, helping to make these important, life-saving offer decisions.
This article should be a reminder for high-volume and low-volume programs to re-evaluate how they consent candidates for kidney transplantation and whether there are opportunities to improve this process, enabling more patients to have access to the pool of high-KDPI donors. If there had been uniform consent practices among transplant centers and the rates were approximately 45% (the rate of the middle-volume centers), there would have been an additional 1200 candidates consented in 2021 alone. The differences in practice patterns between transplant centers further highlight that much of what determines which organs are used (and therefore how efficiently organs are used) is dependent on decisions made at the transplant center level and not dictated by policies or practices at the national level. United Network for Organ Sharing and other governing bodies can provide significant information and access to donor organs, but how those organs are used will largely be dictated by the tendencies of the individual surgeons and the practice patterns of the individual transplant centers.
The findings from Schold et al. provide important contextual information to share with kidney transplant candidates during the discussion about donor types.2 The data will help candidates better understand the consequences of consenting for high-KDPI kidneys and aid in the shared decision making that is central to transplantation. Undoubtedly, these better-informed discussions will lead to better outcomes for patients and better use of the precious resource of donor organs. At a time when there is a high level of scrutiny on modifiable, system-level, practice and education factors across the transplant ecosystem that may increase organ utilization, it is important to recognize the critical responsibility of transplant centers and their efficiency in accepting the right kidney, for the right patient, at the right time.6
Supplementary Material
Acknowledgments
The content of this article reflects the personal experience and views of the authors and should not be considered medical advice or recommendation. The content does not reflect the views or opinions of the American Society of Nephrology (ASN) or JASN. Responsibility for the information and views expressed herein lies entirely with the authors.
Footnotes
See related article, “Quantifying the Effect of Consent for High–Kidney Donor Profile Index Deceased Donor Transplants in the United States,” on pages 630–641.
Disclosures
Disclosure forms, as provided by each author, are available with the online version of the article at http://links.lww.com/JSN/E606.
Funding
None.
Author Contributions
Conceptualization: Charles Gerard Rickert, Peter Stock.
Project administration: Charles Gerard Rickert, Peter Stock.
Supervision: Peter Stock.
Writing – original draft: Charles Gerard Rickert, Peter Stock.
Writing – review & editing: Charles Gerard Rickert, Peter Stock.
References
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