Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA.
Am J Transplant. 2010 Dec;10(12):2582-5. doi: 10.1111/j.1600-6143.2010.03320.x.
In the United States, relatively little progress has been made in recent years to improve the efficiency and effectiveness of deceased donor kidney allocation. Despite enactment of the Expanded Criteria Donor (ECD) Policy in 2002, known inequities and suboptimal utility of donated kidneys persist. In contrast with dialysis patients with shorter predicted life expectancies, those with longer predicted lifetimes can often improve their survival by waiting longer for a Standard Criteria Donor (SCD) kidney. Yet, a substantial fraction of these candidates accept ECD kidneys, often poorly HLA matched. Meanwhile, waitlist mortality continues to rise, particularly among older transplant candidates. Despite required consent processes for candidates to list for ECD kidneys, centers appear to interpret and implement ECD policy differently—some list candidates selectively while others list nearly their entire candidate pool. To ensure more efficient and effective implementation of ECD policy across centers, we advocate for (1) more oversight and guidance in directing patients to the ECD list who stand to benefit the most from receipt of an ECD kidney; and (2) enhanced transparency of center-level ECD consent and listing practices. More uniform implementation of ECD policy could improve efficiency and effectiveness of deceased donor kidney allocation without deleteriously impacting equity.
在美国,近年来在提高已故供体肾脏分配的效率和效果方面进展甚微。尽管 2002 年颁布了扩大标准供体(ECD)政策,但仍存在众所周知的不平等和捐赠肾脏利用不足的问题。与预测寿命较短的透析患者相比,预测寿命较长的患者通过等待更长时间获得标准标准供体(SCD)肾脏,通常可以提高其生存率。然而,这些候选人中有相当一部分接受了 ECD 肾脏,通常 HLA 匹配不佳。与此同时,候补名单上的死亡率继续上升,尤其是在年龄较大的移植候选人中。尽管候选人为 ECD 肾脏进行登记需要经过同意程序,但各中心似乎对 ECD 政策的解释和执行存在差异——有些中心有选择地登记候选人,而有些中心则几乎将其全部候选人群登记。为确保 ECD 政策在各中心更有效地实施,我们主张(1)在指导最有可能从 ECD 肾脏中受益的患者登记 ECD 名单方面进行更多监督和指导;(2)增强中心层面 ECD 同意和登记做法的透明度。ECD 政策的更统一实施可以提高已故供体肾脏分配的效率和效果,而不会对公平性产生不利影响。