Wait-listed kidney transplant candidates receive a large number of viable deceased donor (DD) kidney offers that transplant centers refuse to accept on their behalf, according to new data published in JAMA Network Open. Each DD kidney is eventually transplanted in another patient with a lower priority on the list of matched candidates representing many missed opportunities for earlier transplantation.

According to United Network for Organ Sharing (UNOS) Potential Transplant Recipient data, 280,041 candidates (mean age 51 years; 61% male) received at least 1 DD kidney offer during 2008 to 2015. Of these, 29.2% eventually received a DD kidney allograft, 11.0% received a living donor allograft, 21.2% left the waiting list, and 9.3% died while waiting.

Ten candidates with a previous allograft offer died each day, Sumit Mohan, MD, MPH, of Columbia University Medical Center in New York, and colleagues reported. Yet recipients and candidates who died had similar median times to first offer (79 vs 78 days, respectively). DD kidney recipients had a median of 17 offers over 422 days compared with 16 offers over 651 days for candidates who died while on the waiting list. The odds of death after an offer varied considerably by state, with the highest death risks observed in New York, Connecticut, California, Texas, Hawaii, Illinois, Louisiana, New Mexico, Alabama, and Mississippi, compared with the reference state of Maine.

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Most kidneys (84%) were declined at least once before being accepted for transplant. Organ or donor quality concerns by the transplant center were the major cause by far (92.6%) of all declined offers. Patient-related factors, logistical limitations, and immunologic or other concerns accounted for just 2.6%, 0.5%, and 4.3% of refusals, respectively.

“Although organ or donor quality concerns were the primary reason for refusing offers, these missed opportunities for an earlier transplant occur despite evidence that receiving even marginal-quality kidneys provides survival and quality-of-life advantages over ongoing wait-listing for most candidates,” Dr Mohan’s team stated. “Making the adverse consequences of declining offers more evident to all parties is likely necessary in order to change clinician and patient behavior.”

Transplant centers may decline a DD kidney offer because they expect to receive a superior offer in the short term, the investigators pointed out. But centers often make broad decisions about an organ’s suitability for transplant instead of weighing the advantages for each candidate, they said. The team encouraged policy changes toward a patient-centered organ offer process, disincentivized offer declines, and reduced organ discards.

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Husain SA, King KL, Pastan S, et al. Association between declined offers of deceased donor kidney allograft and outcomes in kidney transplant candidates. JAMA Network Open. 2019;2(8):e1910312. doi:10.1001/jamanetworkopen.2019.10312