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• W2026127504 abstract "All donation and transplantation programs must have mechanisms to determine when a donated organ is suitable for transplantation. An essential starting point is routine assessment of transmissible disease risk, but the important task of determining the physiological suitability of a particular kidney is, at best, still an inexact science. Guidelines on issues such as the upper age limit of the donor have been both written and ignored. Donor organizations focused, by their funding sources and transplant programs, on increasing the number of donors, seek to improve the donation rate amongst older and more marginally acceptable donors who had perhaps been missed in previous years. Cecka et al. have identified that the transplant unit's response to being presented with increasingly elderly and clinically marginal donor kidneys has been to reconsider the value of transplanting them (5,466 discarded kidneys in the United States during 2000 to 2003). The discard rate from donor programs could thus be interpreted as a modulator for the donor organization's enthusiasm to accept and retrieve unsuitable kidneys. Cecka et al. have shown that discard rates in the United States are nearly three times the rate in the Eurotransplant region, suggesting that there must be factors driving an unnecessarily high discard rate. The transplant recipient would like to die of old age with a perfectly functioning kidney. Maximizing the community benefits of each donation, on the other hand, would imply that every kidney would be transplanted into a patient who had a longer prognosis than the kidney. Two examples of how this problem has been addressed, are the “old for old” Eurotransplant Seniors Program (1) and the Expanded Criteria Donor program of UNOS (2). The supposition is essentially the same—that specific recipients accept, ahead of time, a kidney that will have a worse long-term prognosis in exchange for more rapid access to that kidney. In doing so, they are reducing short-term excess mortality in exchange for higher long-term mortality when the kidney transplant fails (3). The cry from Cecka et al. is the cry from the “community” perspective: why waste functioning transplant life years by discarding donated kidneys? The reasons are of course complex and the report analyses some of the potential causes for the high discard rate in the United States. If more kidneys are retrieved per million population in one country than another, it is possible that the donor organizations are simply being too enthusiastic, for one reason or another, and the high discard rate is telling them they should tighten their donor criteria. The discard rate for only one kidney from a donor was 6% in both services, suggesting that surgeons have very similar thresholds for discarding a damaged kidney. On the other hand there is a much higher discard rate of both kidneys from one donor in the United States, suggesting that there must be an explanation based upon local factors. Biopsy of the kidney has been used to help decide when a particular kidney and donor are likely to yield satisfactory results after transplantation. A figure of 20% of sclerosed glomeruli in the biopsy has been used by many centers to determine a threshold for discard. Surgeons tend to biopsy areas of a kidney over which they have concerns, whereas physicians want to know how good or bad the majority of the kidney looks. Biopsy technique has not yet been standardized with respect to site (one or both kidneys, macroscopically scarred or nonscarred areas), type (needle core versus wedge), adequacy (20% of 5 glomeruli or 20% of 100 glomeruli) or predictive criteria (glomerular, interstitial, vascular damage), and yet pathology is the most frequently quoted reason for discard. Increasing the rate of biopsy could be an explanation for increasing discard and is one of the striking differences between the UNOS and Eurotransplant experiences, with biopsies only rarely performed in Europe but in 85% of over 65-year-old donors in the United States. Increasing the rate of biopsy does not always lead to increased discard rates, as shown in an Australian experience when a biopsy protocol was introduced (4). The biopsy rate rose from 0.8% to 15.5% of potential kidney donors, with little change in the discard rate (4.9% to 5.7%, P=NS). Perhaps other indices such as pulsatile pump perfusion pressure will help better predict outcome in the future, but for the moment—in the middle of the night—the tendency will be to stick to biopsy. This analysis of the high discard rate in the United States challenges the OPTN and the transplant centers to answer a number of questions: Are donor procurement agencies being too aggressive in retrieving kidneys from unsuitable donors, perhaps because this assists funding of the overall retrieval program? Are kidneys being discarded by transplant units that could be transplanted successfully, either singly or as double kidney transplants in one recipient? Does the allocation system adequately support rapid transplantation of such kidneys, to avoid adding long ischemia times to already marginal kidneys? Should a surgeon retrieve kidneys that they are not prepared to transplant? Are transplant units being driven to make decisions on the basis of predicted excess cost of transplantation of an initially non-functioning kidney, or because of concerns about impairing the overall unit success rates from accepting more marginal kidneys? It would be reasonable to seek answers to these questions, on behalf of the tax payer who is funding discarded kidneys, the donors and their families whose donations are of no avail, and finally on behalf of the potential recipients who languish on the waiting lists." @default.
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• W2026127504 date "2006-04-01" @default.
• W2026127504 modified "2023-10-16" @default.
• W2026127504 title "Not All Donors Are Equal" @default.
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• W2026127504 doi "https://doi.org/10.1097/01.tp.0000216308.00684.a7" @default.
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