US discards thousands of donor kidneys each year as close to 5,000 Americans die waiting for a transplant
Many of the 90,000 Americans awaiting a kidney transplant could reap significant benefits from a more aggressive approach
Close to 5,000 Americans die waiting for a kidney transplant every year, yet the US is twice as likely to discard potential donor kidneys as compared to France.
French transplant centers would have transplanted an estimated 62%—17,435 kidneys—of the nearly 28,000 deceased-donor kidneys discarded in the US between 2004 and 2014, according to researchers from Penn Medicine and the Paris Transplant Group. They applied the French-based allocation model to the population of US deceased donor kidneys for their analysis.
The researchers found that the US discard rate of these kidneys is nearly twice that of France after analyzing the use of 156,089 deceased donor kidneys in the US and 29,984 in France. The findings highlight the striking disparities in organ acceptance between the two countries and suggest that many of the 90,000 Americans awaiting a kidney transplant could reap significant benefits from a more aggressive approach.
“Analysis shows that the French cohort included 15,500 deceased donors between January 1, 2004, and December 31, 2014, from whom 29,984 kidneys were recovered. Among these recovered kidneys, 27,252 were transplanted, and 2,732 (9.1%) were discarded. The US cohort included 78,517 deceased donors between 2004 and 2014, from whom 156,089 kidneys were recovered for transplantation. Among these recovered kidneys, 128,102 were transplanted, and 27,987 (17.9%) were discarded,” says the study published in JAMA Internal Medicine.
The study further says: “Using real-life survival data from two comprehensive registries, we calculated that elevated kidney discard rates in the US led to the loss of 17,435 kidneys and 132,445 unrealized allograft life years during the observation period.”
According to the researchers, French organ transplant centers are far more likely to accept “lower-rated” kidneys, like those from older organ donors, than centers in the US. If the French approach is adopted, discard rates in the US could decline from 17.9% to 6.8%, says the study. The findings, say the researchers, strongly suggest that patients waitlisted for kidney transplantation would benefit if US transplant programs were more willing to accept lower-quality kidneys, particularly from older deceased donors.
“Our study provides fresh evidence that organs from older deceased donors are a valuable, underused resource, particularly for people on the waitlist who otherwise may not receive a transplant at all,” says study co-author Peter Reese, an associate professor of Medicine and Epidemiology in the Perelman School of Medicine at the University of Pennsylvania.
The lack of organs available for kidney transplantation is a major global health problem. Nearly 5,000 people in the US and more than 3,000 people in Europe die each year while waiting for a kidney transplant. Yet, in the US, over 3,500 donated kidneys are discarded annually. Study co-author Alexandre Loupy says that the findings demonstrate that there is more that the US can do to prevent the deaths of thousands of Americans who are waiting for a transplant. He is a nephrologist at the Department of Nephrology and Kidney Transplantation at Necker Hospital in Paris and head of the Paris Transplant Group.
In the US, an estimated 37 million adults have chronic kidney disease, and more than 720,000 people have end-stage renal disease, meaning their kidneys have failed, and they either require a transplant or dialysis in order to survive. According to the research team, a primary reason behind the high rate of kidney discard includes the intense regulatory scrutiny of US transplant programs, which may lose credentials if their “one-year death and graft failure outcomes exceed predicted outcomes.”
To identify the best practices for kidney allocation and organ use, the research team examined the acceptance and use of deceased-donor kidneys in France and the US between 2004 and 2014. The analysis shows that over the 10-year period, centers in the US discarded about 18% of the 156,089 deceased-donor kidneys recovered - about two times as high as the discard rate in France. During the same period, transplant centers in France addressed the need for organs by accepting lower-rated kidneys, such as those from older donors. For example, the average age of a kidney donor in France was 56-years-old, which is about 17 years older than the average age of a donor in the US.
“The high rate of discard of kidneys recovered for transplantation in the US suggests the potential to gain insight into allocation efficiency from other healthcare systems. In this comparison of kidneys recovered from deceased donors from 2004 through 2014, the age of the donors of transplanted kidneys remained stable in the US. By contrast, transplant practice in France addressed the unmet need for transplantable organs by accepting lower-quality kidneys from older donors, such that by 2014, the mean age of kidney donors was 56 years in France versus 39 years in the US,” say the researchers in their findings.
Although donor age is a risk factor for organ failure, studies have shown that kidneys from donors in their 50s or 60s may extend life for transplant candidates, particularly older recipients. “Previous research found that transplant candidates older than 65 lived longer if they reduced their wait time by accepting kidneys from an “extended criteria” donor - those older than 60, or older than 50 with comorbidities, such as high blood pressure,” the findings state.
There is a significant need for viable kidneys suitable for older adults in America, where the percentage of transplant recipients older than 60 has increased from 22% in 2004 to 32% in 2017. According to the researchers, over 35,000 people older than 60 remain on the waitlist for a kidney in the US. They say that by adopting a model similar to France, the US could potentially provide more than 10,000 years of life with a functioning kidney transplant to its patients each year.
“Our findings reinforce how collaboration between countries can lead to a concrete, new direction on how to help address a global health problem and advance care for waitlisted kidney patients in the US,” says Loupy.
In an invited commentary, published in JAMA Internal Medicine, experts state that it is recognized that the “overly stringent and restrictive process” of monitoring transplant programs in the US has resulted in many transplant programs taking a risk-averse approach, which has led to organs being more frequently discarded in the US.
“Additional research on basic mechanisms of aging may provide other insights for improving organ quality. Until then, we should focus more on the needs of the potential recipients and less on the donor kidneys,” say the experts in the commentary.