Association Between Declined Offers of Deceased Donor Kidney Allograft and Outcomes in Kidney Transplant Candidates

• Published in: JAMA network open 2019-08, Vol.2 (8), p.e1910312-e1910312
• Main Authors: Husain, S Ali, King, Kristen L, Pastan, Stephen, Patzer, Rachel E, Cohen, David J, Radhakrishnan, Jai, Mohan, Sumit
• Format: Article
• Language: English
• Subjects: Adult; Allografts - statistics & numerical data; Allografts - supply & distribution; Allografts - transplantation; Candidates; Case-Control Studies; Female; Health Services Accessibility - ethics; Humans; Kidney Failure, Chronic - epidemiology; Kidney Failure, Chronic - surgery; Kidney Transplantation - adverse effects; Kidney Transplantation - methods; Kidney Transplantation - statistics & numerical data; Kidney transplants; Male; Middle Aged; Nephrology; Online Only; Original Investigation; Outcome Assessment, Health Care; Patient-Centered Care - ethics; Tissue and Organ Procurement - methods; Tissue and Organ Procurement - statistics & numerical data; Tissue Donors - classification; Tissue Donors - statistics & numerical data; Tissue Donors - supply & distribution; Transplant Recipients - statistics & numerical data; United States - epidemiology; Waiting Lists - mortality
• ISSN: 2574-3805; 2574-3805
• DOI: 10.1001/jamanetworkopen.2019.10312

In the United States, substantial disparities in access to kidney transplant exist for wait-listed candidates with end-stage renal disease. The implications of transplant centers' willingness to accept kidney offers for access to transplant and mortality outcomes are unknown. To determine the outcomes for wait-listed kidney transplant candidates after the transplant center's refusal of a deceased donor kidney offer. This cohort study obtained data from the United Network for Organ Sharing Potential Transplant Recipient data set on all deceased donor kidney offers in the United States made between January 1, 2008, and December 31, 2015. The final study cohort included adult patients who were wait-listed for kidney transplant and received at least 1 allograft offer during the study period (N = 280 041). Data analysis was conducted from June 1, 2018, to March 30, 2019. Candidate state of residence. Waiting list outcome event groups included received deceased donor allograft, received living donor allograft, died while on the waiting list, removed from the waiting list without a transplant, or still on the waiting list at the end of follow-up. Among the 280 041 kidney transplant candidates included in the study, the mean (SD) age at wait-listing was 51.1 (13.1) years, and male patients were predominant (171 517 [61.2%]). In this cohort, 81 750 candidates (29.2%) received a deceased donor kidney allograft, 30 870 (11.0%) received a living donor allograft, 25 967 (9.3%) died while on the waiting list, and 59 359 (21.2%) were removed from the waiting list. Overall, 10 candidates with at least 1 previous allograft offer died each day during the study period. Time to first offer was similar for candidates who received deceased donor kidney allograft compared with those who died while waiting (median [interquartile range {IQR}] time, 79 [16-426] days vs 78 [17-401] days, respectively). Deceased donor allograft recipients had a median of 17 offers (IQR, 6-44) over 422 days (IQR, 106-909 days), whereas candidates who died while waiting received a median of 16 offers (IQR, 6-41) over 651 days (IQR, 304-1117 days). Most kidneys (84%) were declined on behalf of at least 1 candidate before being accepted for transplant. As reported by centers, organ or donor quality concerns accounted for 8 416 474 (92.6%) of all declined offers, whereas offers were infrequently refused because of patient-related factors (232 193 [2.6%]), logistical limitations (49 492 [0.5%]), or other c