Department of Medicine, Columbia University Irving Medical Center, New York, New York.
The Columbia University Renal Epidemiology Group, New York, New York.
Kidney360. 2021 Aug 24;2(11):1807-1818. doi: 10.34067/KID.0004052021. eCollection 2021 Nov 25.
Deceased donor kidney offers are frequently declined multiple times before acceptance for transplantation, despite significant organ shortage and long waiting times. Whether the number of times a kidney has been declined, reflecting cumulative judgments of clinicians, is associated with long-term transplant outcomes remains unclear.
In this national, retrospective cohort study of deceased donor kidney transplants in the United States from 2008 to 2015 (=78,940), we compared donor and recipient characteristics and short- and long-term graft and patient survival outcomes grouping by the sequence number at which the kidney was accepted for transplantation. We compared outcomes for kidneys accepted within the first seven offers in the match-run, after 8-100 offers, and for hard-to-place kidneys distinguishing those requiring >100 and >1000 offers before acceptance.
Harder-to-place kidneys had lower donor quality and higher rates of delayed graft function (46% among kidneys requiring >1000 offers before acceptance versus 23% among kidneys with ≤7 offers). In unadjusted models, later sequence groups had higher hazard of all-cause graft failure, death-censored graft failure, and patient mortality; however, these associations were attenuated after adjusting for Kidney Donor Risk Index (KDRI). After adjusting for donor factors already taken into consideration during allocation, and recipient factors associated with long-term outcomes, graft, and patient survival outcomes were not significantly different for the hardest-to-place kidneys compared with the easiest-to-place kidneys, with the exception of death-censored graft failure (adjusted hazard ratio, 1.16, 95% CI, 1.05 to 1.28).
Late sequence offers may represent missed opportunities for earlier successful transplant for the higher-priority waitlisted candidates for whom the offers were declined.
尽管器官短缺严重且等待时间长，但在接受移植之前，供体肾脏通常会被多次拒绝。尽管一个肾脏被拒绝的次数（反映了临床医生的综合判断）与长期移植结果相关，但目前尚不清楚这是否有关。
本项在美国进行的全国性、回顾性队列研究，纳入了 2008 年至 2015 年期间接受的供体肾脏移植患者（共 78940 例）。我们根据肾脏被接受移植的顺序号对供体和受者特征以及短期和长期移植物和患者存活率进行分组。我们比较了在匹配运行中前 7 次接受的供体肾脏、8-100 次接受的供体肾脏和难以放置的供体肾脏的结果，后两者还区分了需要>100 次和>1000 次接受才能被放置的供体肾脏。
更难放置的供体肾脏的供体质量较低，延迟移植物功能的发生率较高（在需要>1000 次接受才能被放置的供体肾脏中为 46%，而在接受≤7 次接受的供体肾脏中为 23%）。在未调整模型中，较晚的顺序组全因移植物失败、死亡相关移植物失败和患者死亡率的风险更高；然而，这些关联在调整了肾供体风险指数（KDRI）后减弱。在调整了已经在分配中考虑到的供体因素以及与长期结果相关的受者因素后，与最容易放置的供体肾脏相比，最难放置的供体肾脏的移植物和患者存活率结果没有显著差异，除了死亡相关移植物失败（调整后的危险比，1.16；95%CI，1.05 至 1.28）。
对于被拒绝的优先级较高的候补患者来说，较晚的顺序可能代表着错失了更早成功移植的机会。
