Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York.
Columbia University Renal Epidemiology Group, New York, New York.
JAMA Netw Open. 2023 Jun 1;6(6):e2316936. doi: 10.1001/jamanetworkopen.2023.16936.
Allocation of deceased donor kidneys is meant to follow a ranked match-run list of eligible candidates, but transplant centers with a 1-to-1 relationship with their local organ procurement organization have full discretion to decline offers for higher-priority candidates and accept them for lower-ranked candidates at their center.
To describe the practice and frequency of transplant centers placing deceased donor kidneys with candidates who are not the highest rank at their center according to the allocation algorithm.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used 2015 to 2019 organ offer data from US transplant centers with a 1-to-1 relationship with their local organ procurement organization, following candidates for transplant events from January 2015 to December 2019. Participants were deceased kidney donors with a single match-run and at least 1 kidney transplanted locally and adult, first-time, kidney-only transplant candidates receiving at least 1 offer for a locally transplanted deceased donor kidney. Data were analyzed from March 1, 2022 to March 28, 2023.
Demographic and clinical characteristics of donors and recipients.
The outcome of interest was kidney transplantation into the highest-priority candidate (defined as transplanted after zero declines for local candidates in the match-run) vs a lower-ranked candidate.
This study assessed 26 579 organ offers from 3136 donors (median [IQR] age, 38 [25-51] years; 2903 [62%] men) to 4668 recipients. Transplant centers skipped their highest-ranked candidate to place kidneys further down the match-run for 3169 kidneys (68%). These kidneys went to a median (IQR) of the fourth- (third- to eighth-) ranked candidate. Higher kidney donor profile index (KDPI; higher score indicates lower quality) kidneys were less likely to go to the highest-ranked candidate, with 24% of kidneys with KDPI of at least 85% going to the top-ranked candidate vs 44% of KDPI 0% to 20% kidneys. When comparing estimated posttransplant survival (EPTS) scores between the skipped candidates and the ultimate recipients, kidneys were placed with recipients with both better and worse EPTS than the skipped candidates, across all KDPI risk groups.
In this cohort study of local kidney allocation at isolated transplant centers, we found that centers frequently skipped their highest-priority candidates to place kidneys further down the allocation prioritization list, often citing organ quality concerns but placing kidneys with recipients with both better and worse EPTS with nearly equal frequency. This occurred with limited transparency and highlights the opportunity to improve the matching and offer algorithm to improve allocation efficiency.
已故供体肾脏的分配旨在遵循符合条件的候选者的排名匹配列表，但与当地器官采购组织有 1 对 1 关系的移植中心完全可以自行决定拒绝为优先级更高的候选者提供器官，并为其中心的排名较低的候选者接受这些器官。
描述移植中心将已故供体肾脏分配给不符合分配算法中心内最高优先级的候选者的做法和频率。
设计、设置和参与者： 这项回顾性队列研究使用了 2015 年至 2019 年美国移植中心的器官提供数据，这些中心与当地器官采购组织有 1 对 1 的关系，并从 2015 年 1 月至 2019 年 12 月对移植候选者进行了随访。参与者为具有单一匹配运行且至少有 1 个本地移植的已故肾脏供体，以及接受至少 1 个本地移植的已故供体肾脏提供的移植候选者。数据于 2023 年 3 月 1 日至 2023 年 3 月 28 日进行分析。
供体和受体的人口统计学和临床特征。
主要结局是将肾脏移植给最高优先级的候选者（定义为在匹配运行中本地候选者没有零次拒绝后进行移植）与较低优先级的候选者。
本研究评估了 26579 个器官供体来自 3136 个供体（中位数[IQR]年龄为 38 [25-51]岁；2903[62%]为男性），分配给 4668 个受体。移植中心为了将肾脏放置在匹配运行中更靠后的位置，跳过了自己的最高优先级候选者，这种情况发生了 3169 次（68%）。这些肾脏被分配给中位数（IQR）排名第四（第三到第八）的候选者。肾脏质量更高（KDPI 评分越高表示质量越低）的供体肾脏不太可能被分配给最高优先级的候选者，KDPI 评分至少为 85%的供体肾脏中，有 24%被分配给了排名最高的候选者，而 KDPI 评分 0%至 20%的供体肾脏中，这一比例为 44%。当比较跳过的候选者和最终接受者之间的移植后估计生存率（EPTS）评分时，在所有 KDPI 风险组中，肾脏被分配给了 EPTS 评分比跳过的候选者更好和更差的接受者。
在这项对孤立移植中心的本地肾脏分配的队列研究中，我们发现中心经常跳过自己的最高优先级候选者，将肾脏放置在分配优先级列表中更靠后的位置，这通常是因为器官质量问题，但几乎以相同的频率将肾脏分配给 EPTS 评分更好和更差的接受者。这种情况发生在透明度有限的情况下，突出了有机会改进匹配和提供算法以提高分配效率。
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