Has the U.S. Been Too Strict With Kidney Donations?
Posted on: Tuesday, August 27, 2019 By: KorchekStaff
Organ discards twice as common than in France; did this cost American patients' lives?
From 2004 to 2014, the U.S. was twice as likely to discard potential donor kidneys than was France, with researchers suggesting the latter country had the better approach.
In a head-to-head comparison, the U.S. discard rate for deceased-donor kidneys during this period was 17.9% versus 9.1% in France, reported Alexandre Loupy, MD, PhD, of the Paris Translational Research Center for Organ Transplantation, and colleagues.
"This finding indicates that the U.S. kidney transplantation system, which has driven innovations in donor utilization in the domains of kidneys obtained after cardiac death and from hepatitis C virus-infected donors, still has substantial potential for growth by accepting more organs from donors who are older and have comorbidities including diabetes and hypertension," the researchers stated.
This more liberal approach "could provide major survival benefits to the population of U.S. wait-listed patients," they added.
"In the U.S. alone, approximately 95,000 individuals are waiting for a kidney transplant. New, creative solutions to address this concern are needed," co-author Olivier Aubert, MD, PhD, told MedPage Today in 2018 when preliminary findings were presented at Kidney Week. "The French transplant system offers a useful contrast, because French transplant programs face less regulatory scrutiny than U.S. programs and do not use donor kidney biopsies in organ acceptance decisions."
Notably, however, U.S. procedures governing kidney donations were changed in 2012 and again in 2014, introducing use of the Kidney Donor Risk Index (KDRI) and making lower-quality kidneys available to more areas of the country. But the French researchers cited data that suggest no subsequent reduction in the discard rate had occurred by 2016.
The study looked at validated registries of kidneys recovered from donors dying from either circulatory or brain death for the intention of transplantation. Living donor transplants, kidneys offered to transplants centers that were not harvested, and recipients of multi-organ transplants were excluded from the analysis.
During 2004-2014, there were 78,517 deceased U.S. donors, resulting in 156,089 kidneys harvested for potential transplant. Only 128,102 kidneys were actually transplanted, whereas nearly 28,000 kidneys were discarded. During the same period in France, there were 15,500 deceased donors, resulting in nearly 30,000 kidneys recovered, of which 27,252 were eventually transplanted and 2,732 discarded.
Comparing donor kidneys transplanted in the two countries, U.S. donors were significantly younger (mean 37 vs 51 in France over the full study period; 39 vs 56 in 2014) and they were significantly less likely to have hypertension or die from cerebrovascular causes.
Trends in the KDRI -- in which lower numbers reflect higher organ quality -- indicated a steady increase over the 10-year period in France, suggesting a move towards more aggressive donor kidney use (1.37 in 2004 vs 1.74 in 2014). On the other hand, the U.S. didn't show significant change in the KDRI during this time, with values suggesting stricter standards for quality (1.30 in 2004 vs 1.32 in 2014).
In an accompanying commentary, Ryoichi Maenosono, MD, and Stefan Tullius, MD, PhD, both of Brigham and Women's Hospital in Boston, pointed out that population differences could account for the disparity in discard rates.
"The U.S. donor population has a different racial mix, with more African Americans, more donors after circulatory death, and more hepatitis C-positive donors," the commentators noted.
Notably, they pointed out that, due to the 2014 change in U.S. organ allocations, "younger recipients with a longer estimated post-transplant survival have a higher probability of receiving a younger organ, increasing the likelihood that older recipients would receive an older organ."
Maenosono and Tullius also suggested that "regulatory, financial, or medical assessments appear to be the driving force" of this high discard rate in the U.S., as some hospitals may be averse to more aggressive organ use, for fear it could hurt their publicized rankings.
"[W]e should focus more on the needs of the potential recipients and less on the donor kidneys," the pair concluded.