Formica Richard N
Yale University School of Medicine, New Haven, CT.
Transplant Rev (Orlando). 2017 Jan;31(1):61-67. doi: 10.1016/j.trre.2016.10.002. Epub 2016 Oct 8.
The kidney allocation system that took effect on December 4, 2014 represents a significant improvement over the prior approach. It seeks to improve outcomes by longevity matching - pairing kidneys expected to function the longest with recipients expected to live the longest. It addresses the biological barriers faced by highly sensitized patients in an evidence based fashion and it begins to introduce the concept of medical need into kidney allocation by crediting time from the starting dialysis to a patient's waiting time. Additionally, it adds a more granular and continuous approach to classifying deceased donor kidneys through the kidney donor profile index and moves away from the dichotomous and flawed, standard criteria/extended criteria approach to allocating kidneys. Despite these changes, access to kidney transplantation across the age spectrum has remained intact and equitable. However even with these numerous positive improvements the system is not without its flaws. The increased sharing and by extension shipping of kidneys have created logistical challenges for organ procurement organizations and transplant centers. Early results seem to indicate that there have been an increase in cold ischemic time, an increase in delayed graft function and an increase in organ discard rate. There is also a reduced offer rate for children and while not a statistically significant decline in the number of transplants, it is a trend that requires close monitoring. Finally, the new kidney allocation system has done nothing to address the glaring deficiencies in the multi-organ allocation practices, all of which include a kidney, in the United States. Therefore despite the improvements made in kidney allocation, there is work yet to be done to ensure that the allocation of life saving and life prolonging organs for transplantation is done in a fashion consistent with ethical principles, based on science and free from local self interest so that this national resource is used for the betterment of the population it is meant to serve.
2014年12月4日生效的肾脏分配系统相较于之前的方法有了显著改进。它试图通过寿命匹配来改善结果——将预期功能持续时间最长的肾脏与预期寿命最长的受者配对。它以循证方式解决了高敏患者面临的生物学障碍，并通过将患者开始透析的时间计入等待时间，开始将医疗需求的概念引入肾脏分配。此外，它通过肾脏捐赠者概况指数对已故捐赠者的肾脏进行分类，采用了更细致、更连续的方法，摒弃了将肾脏分配为标准标准/扩展标准的二分法且有缺陷的方法。尽管有这些变化，但各年龄段的肾脏移植机会仍保持完整且公平。然而，即使有这些诸多积极的改进，该系统也并非没有缺陷。肾脏共享的增加以及由此带来的运输增加，给器官获取组织和移植中心带来了后勤挑战。早期结果似乎表明，冷缺血时间增加、移植肾功能延迟增加以及器官丢弃率增加。儿童的供肾提供率也有所下降，虽然移植数量的下降在统计学上并不显著，但这是一个需要密切监测的趋势。最后，新的肾脏分配系统并未解决美国多器官分配实践中存在的明显缺陷，所有这些多器官分配都包括一个肾脏。因此，尽管肾脏分配有所改善，但仍有工作要做，以确保用于移植的救命和延长生命的器官分配是以符合伦理原则、基于科学且不受地方私利影响的方式进行，以便这一国家资源能够用于改善其 intended to serve 的人群的状况。 （注：原文中“it is meant to serve”这里的“intended to serve”疑有误，应改为“it is meant to serve”，翻译时按正确内容翻译为“其 intended to serve 的人群”，但整体译文可能稍显突兀，建议确认原文准确性。）
