US transplant centers frequently refuse deceased donor kidneys

A new study indicates that deceased donor kidneys are typically offered and declined many times before being accepted for transplantation. The study, which appears in an upcoming issue of the Clinical Journal of the American Society of Nephrology (CJASN), also found that such refusals differ by patient and donor characteristics and may contribute to racial and ethnic disparities in access to transplantation.

When a deceased donor kidney becomes available, a list is generated that ranks patients waiting for kidney transplants in priority order based on a combination of immunologic criteria and waiting time. A transplant center may accept or refuse a deceased donor kidney that is offered to its patient at the top of the list; if refused, the kidney is then offered to the next patient on the list.

To determine the outcomes of deceased donor kidney offers and how they relate to characteristics of waitlisted patients and organ donors, Anne Huml, MD (Case Western Reserve University) and her colleagues examined information on all 7 million deceased donor adult kidney offers in the United States from 2007-2012 that led to eventual transplantation. The study included 178,625 patients waitlisted for a deceased donor kidney transplant and 31,230 deceased donors.

The team found that deceased donor kidneys were offered a median of 7 times before being accepted for transplantation. Refusal of an offer was most often due to donor-related factors (such as age or organ quality) or because the minimal acceptable criteria for a transplant center was not met. After adjusting for characteristics of waitlisted patients, organ donors, and transplant centers, male and Hispanic waitlisted patients were 7% and 4% less likely to have kidneys accepted for them for transplant than female and white patients, respectively. The likelihood of offer acceptance varied greatly across transplant centers.

"By recognizing these differences, centers may be able to evaluate their acceptance practices to have the greatest impact on shortening waiting times," said Dr. Huml. "Gaining a better understanding of offer refusals may also allow policy makers to develop and disseminate information about best practices to centers with low acceptance rates." She added that the findings may also help patients who experience long waiting times understand the process involved and encourage people to consider registering as deceased donors.

In an accompanying editorial, Sumit Mohan, MD, MPH and Mariana Chiles, MPH (Columbia University Medical Center) noted that the analysis "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."