Aubert Olivier, Reese Peter P, Audry Benoit, Bouatou Yassine, Raynaud Marc, Viglietti Denis, Legendre Christophe, Glotz Denis, Empana Jean-Phillipe, Jouven Xavier, Lefaucheur Carmen, Jacquelinet Christian, Loupy Alexandre
Paris Translational Research Center for Organ Transplantation, INSERM, UMR-S970, Paris, France.
Department of Kidney Transplantation, Necker Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.
JAMA Intern Med. 2019 Oct 1;179(10):1365-1374. doi: 10.1001/jamainternmed.2019.2322.
Approximately 3500 donated kidneys are discarded in the United States each year, drawing concern from Medicare and advocacy groups.
To estimate the effects of more aggressive allograft acceptance practices on the donor pool and allograft survival for the population of US wait-listed kidney transplant candidates.
DESIGN, SETTING, AND PARTICIPANTS: A nationwide study using validated registries from the United States and France comprising comprehensive cohorts of deceased donors with organs offered to kidney transplant centers between January 1, 2004, and December 31, 2014. Data were analyzed between September 1, 2018, and April 5, 2019.
The primary outcome was kidney allograft discard. The secondary outcome was allograft failure after transplantation. We used logistic regression to model organ acceptance and discard practices in both countries. We then quantified using computer simulation models the number of kidneys discarded in the United States that a more aggressive system would have instead used for transplantation. Finally, based on actual survival data, we quantified the additional years of allograft life that a redesigned US system would have saved.
In the United States, 156 089 kidneys were recovered from deceased donors between 2004 and 2014, of which 128 102 were transplanted, and 27 987 (17.9%) were discarded. In France, among the 29 984 kidneys recovered between 2004 and 2014, 27 252 were transplanted, and 2732 (9.1%, P < .001 vs United States) were discarded. The mean (SD) age of kidneys transplanted in the United States was 36.51 (17.02) years vs 50.91 (17.34) years in France (P < .001). Kidney quality showed little change in the United States over time (mean [SD] kidney donor risk index [KDRI], 1.30 [0.48] in 2004 vs 1.32 [0.46] in 2014), whereas a steadily rising KDRI in France reflected a temporal trend of more aggressive organ use (mean [SD] KDRI, 1.37 [0.47] in 2004 vs 1.74 [0.72] in 2014; P < .001). We applied the French-based allocation model to the population of US deceased donor kidneys and found that 17 435 (62%) of kidneys discarded in the United States would have instead been transplanted under the French system. We further determined that a redesigned system with more aggressive organ acceptance practices would generate an additional 132 445 allograft life-years in the United States over the 10-year observation period.
Greater acceptance of kidneys from deceased donors who are older and have more comorbidities could provide major survival benefits to the population of US wait-listed patients.
ClinicalTrials.gov identifier: NCT03723668.
在美国，每年约有3500个捐赠的肾脏被丢弃，这引起了医疗保险机构和倡导团体的关注。
评估更积极的同种异体移植接受策略对美国等待肾脏移植的候选人群的供体库和同种异体移植存活率的影响。
设计、地点和参与者：一项全国性研究，使用来自美国和法国的经过验证的登记系统，纳入2004年1月1日至2014年12月31日期间提供给肾脏移植中心的已故供体的综合队列。于2018年9月1日至2019年4月5日进行数据分析。
主要结局是肾脏同种异体移植被丢弃。次要结局是移植后同种异体移植失败。我们使用逻辑回归对两国的器官接受和丢弃策略进行建模。然后，我们使用计算机模拟模型量化在美国被丢弃的肾脏数量，而更积极的系统会将这些肾脏用于移植。最后，根据实际存活数据，我们量化了重新设计的美国系统本可节省的同种异体移植存活年数。
在美国，2004年至2014年期间从已故供体获取了156089个肾脏，其中128102个进行了移植，27987个（17.9%）被丢弃。在法国，2004年至2014年期间获取的29984个肾脏中，27252个进行了移植，2732个（9.1%，与美国相比P <.001）被丢弃。在美国移植的肾脏的平均（标准差）年龄为36.51（17.02）岁，而在法国为50.91（17.34）岁（P <.001）。在美国，肾脏质量随时间变化不大（2004年肾脏供体风险指数[KDRI]的平均[标准差]为1.30[0.48]，2014年为1.32[0.46]），而法国KDRI稳步上升反映了更积极使用器官的时间趋势（2004年KDRI的平均[标准差]为1.37[0.47]，2014年为1.74[0.72]；P <.001）。我们将基于法国的分配模型应用于美国已故供体肾脏人群，发现在美国被丢弃的肾脏中有17435个（62%）在法国系统下本可进行移植。我们进一步确定，采用更积极的器官接受策略重新设计的系统在10年观察期内将在美国产生额外的132445个同种异体移植存活年。
更多地接受年龄较大且合并症较多的已故供体的肾脏可为美国等待移植的患者群体带来重大的生存益处。
ClinicalTrials.gov标识符：NCT03723668。
