Renal transplantation remains the undisputed best treatment for most patients suffering from end-stage renal disease. The nephrology community continues to drive toward expanding the pool of available allografts, from both deceased and living donors. Therefore, data that shed light on the allograft decision process may ultimately better help transplant teams navigate their expanding waiting lists.

An observational study published in July in the Clinical Journal of the American Society of Nephrology reviewed 7 million deceased-donor adult kidney offers over 5 years to evaluate donor kidney acceptance rates across transplant centers. This publication highlights variables that affect organ acceptance and denials based upon donor-specific characteristics, waitlist-recipient patient characteristics, and transplant center-specific policies that potentially contribute to the variance.  

Notably, the authors found significant variation in deceased-donor kidney acceptance rates. Similarly, organs were routinely refused multiple times before ultimately being accepted for transplantation. The acceptance rate varied significantly between centers and recipient/donor clinical criteria. Specifically, the investigators cited a median of 7 offers per allograft before acceptance for transplantation. Reasons for rejecting an organ included donor-related factors, such as patient age or organ quality, and transplant center bypass, such as the minimum acceptance criteria were not met

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After adjusting for the above-listed characteristics, male and Hispanic waitlisted patients were more likely to experience a transplant offer rejection than female and white patients. On the basis of these findings, variables, including race, gender, donor characteristics and transplant center policies, may explain some of the differences in the acceptance rate for deceased-donor kidney offers. The authors of this study also note their “findings on organ acceptance may be due to clinical appropriateness, biologic factors or subconscious biases.”

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While this study doesn’t necessarily offer solutions, the authors correctly state that their “results have implications for patients, providers, researchers and policy makers.” Further evaluation of the organ allocation and acceptance process with an intent to improve efficiency and increase organ availability is warranted. In the meantime, DaVita continues to invest in supporting people with kidney disease to fully evaluate and understand their treatment options, including transplantation. DaVita uses one of the most robust, systematic data systems of dialysis providers to track the education and transplant status of end stage renal disease patients. Through these data, we are able to set goals around transplants, understand reasons for refusing referral to transplants and better tailor education and resources for patients.

In addition, Transplant Smart, a new element within DaVita’s educational programs, will launch in 2018 to provide micro-learning educational modules that leverage principles of adult learning and specific work-flow triggers. The goals of Transplant Smart are to increase the number of patients referred to transplants and to increase the number who remain active on the waitlist and ultimately receive a transplant.

Jeffrey Giuillian, MD

Jeffrey Giuillian, MD, is chief medical officer, hospital services, vice president of medical affairs, and national group medical director at DaVita Kidney Care in Denver.