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Trends in Usage and Outcomes for Expanded Criteria Donor Kidney Transplantation in the United States Characterized by Kidney Donor Profile Index



Abstract

There has been increasing concern in the kidney transplant community about the declining use of expanded criteria donors (ECD) despite improvement in survival and quality of life. The recent introduction of the Kidney Donor Profile Index (KDPI), which provides a more granular characterization of donor quality, was expected to increase utilization of marginal kidneys and decrease the discard rates. However, trends and practice patterns of ECD kidney utilization on a national level based on donor organ quality as per KDPI are not well known. We, therefore, performed a trend analysis of all ECD recipients in the United Network for Organ Sharing (UNOS) registry between 2002 and 2012, after calculating the corresponding KDPI, to enable understanding the trends of usage and outcomes based on the KDPI characterization. High-risk recipient characteristics (diabetes, body mass index ≥30 kg/m2, hypertension, and age ≥60 years) increased over the period of the study (trend test p<0.001 for all). The proportion of ECD transplants increased from 18% in 2003 to a peak of 20.4% in 2008 and then declined thereafter to 17.3% in 2012. Using the KDPI >85% definition, the proportion increased from 9.4% in 2003 to a peak of 12.1% in 2008 and declined to 9.7% in 2012. Overall, although this represents a significant utilization of kidneys with KDPI >85% over time (p<0.001), recent years have seen a decline in usage, probably related to regulations imposed by Centers for Medicare & Medicaid Services (CMS).

When comparing the hazards of graft failure by KDPI, ECD kidneys with KDPI >85% have a slightly lower risk of graft failure compared to standard criteria donor (SCD) kidneys with KDPI >85%, with a hazard ratio (HR) of 0.95, a confidence interval (CI) of 0.94-0.96, and statistical significance of p<0.001. This indicates that some SCD kidneys may actually have a lower estimated quality, with a higher Kidney Donor Risk Index (KDRI), than some ECDs. The incidence of delayed graft function (DGF) in ECD recipients has significantly decreased over time from 35.2% in 2003 to 29.6% in 2011 (p=0.007), probably related to better understanding of the donor risk profile along with increased use of hypothermic machine perfusion and pretransplant biopsy to aid in optimal allograft selection.

The recent decline in transplantation of KDPI >85% kidneys probably reflects risk-averse transplant center behavior. Whether discard of discordant SCD kidneys with KDPI >85% has contributed to this decline remains to be studied.



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Original article
peer-reviewed

Trends in Usage and Outcomes for Expanded Criteria Donor Kidney Transplantation in the United States Characterized by Kidney Donor Profile Index


Author Information

Aparna Rege

Surgery, Duke University Medical Center

Bill Irish

Health Outcomes Research & Biostatistics, CTI Clinical Trial and Consulting

Anthony Castleberry

Surgery, Duke University Medical Center

Deepak Vikraman

Surgery, Duke University Medical Center

Division of Abdominal Transplantation, Duke University Medical Center

Scott Sanoff

Transplant Nephrology, Duke University Medical Center

Kadiyala Ravindra

Surgery, Duke University Medical Center

Division of Abdominal Transplantation, Duke University Medical Center

Bradley Collins Corresponding Author

Surgery, Duke University Medical Center

Debra Sudan

Surgery, Duke University Medical Center

Division of Abdominal Transplantation, Duke University Medical Center


Ethics Statement and Conflict of Interest Disclosures

Human subjects: This study did not involve human participants or tissue. Animal subjects: This study did not involve animal subjects or tissue. Conflicts of interest: The authors have declared that no conflicts of interest exist.


Original article
peer-reviewed

Trends in Usage and Outcomes for Expanded Criteria Donor Kidney Transplantation in the United States Characterized by Kidney Donor Profile Index


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Original article
peer-reviewed
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Optimization Strategies for Organ Donation and Utilization

Trends in Usage and Outcomes for Expanded Criteria Donor Kidney Transplantation in the United States Characterized by Kidney Donor Profile Index

  • Author Information
    Aparna Rege

    Surgery, Duke University Medical Center

    Bill Irish

    Health Outcomes Research & Biostatistics, CTI Clinical Trial and Consulting

    Anthony Castleberry

    Surgery, Duke University Medical Center

    Deepak Vikraman

    Surgery, Duke University Medical Center

    Division of Abdominal Transplantation, Duke University Medical Center

    Scott Sanoff

    Transplant Nephrology, Duke University Medical Center

    Kadiyala Ravindra

    Surgery, Duke University Medical Center

    Division of Abdominal Transplantation, Duke University Medical Center

    Bradley Collins Corresponding Author

    Surgery, Duke University Medical Center

    Debra Sudan

    Surgery, Duke University Medical Center

    Division of Abdominal Transplantation, Duke University Medical Center


    Ethics Statement and Conflict of Interest Disclosures

    Human subjects: This study did not involve human participants or tissue. Animal subjects: This study did not involve animal subjects or tissue. Conflicts of interest: The authors have declared that no conflicts of interest exist.

    Acknowledgements


    Article Information

    Published: November 22, 2016

    DOI

    10.7759/cureus.887

    Cite this article as:

    Rege A, Irish B, Castleberry A, et al. (November 22, 2016) Trends in Usage and Outcomes for Expanded Criteria Donor Kidney Transplantation in the United States Characterized by Kidney Donor Profile Index. Cureus 8(11): e887. doi:10.7759/cureus.887

    Publication history

    Received by Cureus: September 27, 2016
    Peer review began: October 09, 2016
    Peer review concluded: November 13, 2016
    Published: November 22, 2016

    Copyright

    © Copyright 2016
    Rege et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 3.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

    License

    This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

There has been increasing concern in the kidney transplant community about the declining use of expanded criteria donors (ECD) despite improvement in survival and quality of life. The recent introduction of the Kidney Donor Profile Index (KDPI), which provides a more granular characterization of donor quality, was expected to increase utilization of marginal kidneys and decrease the discard rates. However, trends and practice patterns of ECD kidney utilization on a national level based on donor organ quality as per KDPI are not well known. We, therefore, performed a trend analysis of all ECD recipients in the United Network for Organ Sharing (UNOS) registry between 2002 and 2012, after calculating the corresponding KDPI, to enable understanding the trends of usage and outcomes based on the KDPI characterization. High-risk recipient characteristics (diabetes, body mass index ≥30 kg/m2, hypertension, and age ≥60 years) increased over the period of the study (trend test p<0.001 for all). The proportion of ECD transplants increased from 18% in 2003 to a peak of 20.4% in 2008 and then declined thereafter to 17.3% in 2012. Using the KDPI >85% definition, the proportion increased from 9.4% in 2003 to a peak of 12.1% in 2008 and declined to 9.7% in 2012. Overall, although this represents a significant utilization of kidneys with KDPI >85% over time (p<0.001), recent years have seen a decline in usage, probably related to regulations imposed by Centers for Medicare & Medicaid Services (CMS).

When comparing the hazards of graft failure by KDPI, ECD kidneys with KDPI >85% have a slightly lower risk of graft failure compared to standard criteria donor (SCD) kidneys with KDPI >85%, with a hazard ratio (HR) of 0.95, a confidence interval (CI) of 0.94-0.96, and statistical significance of p<0.001. This indicates that some SCD kidneys may actually have a lower estimated quality, with a higher Kidney Donor Risk Index (KDRI), than some ECDs. The incidence of delayed graft function (DGF) in ECD recipients has significantly decreased over time from 35.2% in 2003 to 29.6% in 2011 (p=0.007), probably related to better understanding of the donor risk profile along with increased use of hypothermic machine perfusion and pretransplant biopsy to aid in optimal allograft selection.

The recent decline in transplantation of KDPI >85% kidneys probably reflects risk-averse transplant center behavior. Whether discard of discordant SCD kidneys with KDPI >85% has contributed to this decline remains to be studied.



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Aparna Rege

Surgery, Duke University Medical Center

Bill Irish

Health Outcomes Research & Biostatistics, CTI Clinical Trial and Consulting

Anthony Castleberry

Surgery, Duke University Medical Center

Deepak Vikraman

Surgery, Duke University Medical Center

Scott Sanoff

Transplant Nephrology, Duke University Medical Center

Kadiyala Ravindra

Surgery, Duke University Medical Center

Bradley Collins

Surgery, Duke University Medical Center

For correspondence:
bradley.collins@duke.edu

Debra Sudan

Surgery, Duke University Medical Center

Aparna Rege

Surgery, Duke University Medical Center

Bill Irish

Health Outcomes Research & Biostatistics, CTI Clinical Trial and Consulting

Anthony Castleberry

Surgery, Duke University Medical Center

Deepak Vikraman

Surgery, Duke University Medical Center

Scott Sanoff

Transplant Nephrology, Duke University Medical Center

Kadiyala Ravindra

Surgery, Duke University Medical Center

Bradley Collins

Surgery, Duke University Medical Center

For correspondence:
bradley.collins@duke.edu

Debra Sudan

Surgery, Duke University Medical Center