High-Urgency Kidney Transplantation in the Eurotransplant Kidney Allocation System

Success or Waste of Organs? The Eurotransplant 15-year All-Centre Survey

Volker Assfalg; Norbert Hüser; Marieke van Meel; Bernhard Haller; Axel Rahmel; Jan de Boer; Edouard Matevossian; Alexander Novotny; Noël Knops; Laurent Weekers; Helmut Friess; Johann Pratschke; Reinhold Függer; Otmar Janko; Susanne Rasoul-Rockenschaub; Jean-Louis Bosmans; Nilufer Broeders; Patrick Peeters; Michel Mourad; Dirk Kuypers; Jasna Slaviček; Anja Muehlfeld; Florian Sommer; Richard Viebahn; Andreas Pascher; Markus van der Giet; Frans Zantvoort; Rainer P. Woitas; Juliane Putz; Klaus Grabitz; Andreas Kribben; Ingeborg Hauser; Przemyslaw Pisarski; Rolf Weimer; Thomas Lorf; Paola Fornara; Christian Morath; Björn Nashan; Frank Lehner; Volker Kliem; Urban Sester; Marc-Oliver Grimm; Thorsten Feldkamp; Robert Kleinert; Wolfgang Arns; Christian Mönch; Markus Bo Schoenberg; Martin Nitschke; Bernd Krüger; Stefan Thorban; Helmut P. Arbogast; Heiner H. Wolters; Tanja Maier; Jens Lutz; Katharina Heller; Bernhard Banas; Oliver Hakenberg; Martin Kalus; Silvio Nadalin; Frieder Keller; Kai Lopau; Frederike José Bemelman; Shaikh Nurmohamed; Jan-Stephan Sanders; Johan W. de Fijter; Maarten Christiaans; Luuk Hilbrands; Michiel Betjes; Arjan van Zuilen; Uwe Heemann


Nephrol Dial Transplant. 2016;31(9):1515-1522. 

In This Article

Abstract and Introduction


Background. In the Eurotransplant Kidney Allocation System (ETKAS), transplant candidates can be considered for high-urgency (HU) status in case of life-threatening inability to undergo renal replacement therapy. Data on the outcomes of HU transplantation are sparse and the benefit is controversial.

Methods. We systematically analysed data from 898 ET HU kidney transplant recipients from 61 transplant centres between 1996 and 2010 and investigated the 5-year patient and graft outcomes and differences between relevant subgroups.

Results. Kidney recipients with an HU status were younger (median 43 versus 55 years) and spent less time on the waiting list compared with non-HU recipients (34 versus 54 months). They received grafts with significantly more mismatches (mean 3.79 versus 2.42; P < 0.001) and the percentage of retransplantations was remarkably higher (37.5 versus 16.7%). Patient survival (P = 0.0053) and death with a functioning graft (DwFG; P < 0.0001) after HU transplantation were significantly worse than in non-HU recipients, whereas graft outcome was comparable (P = 0.094). Analysis according to the different HU indications revealed that recipients listed HU because of an imminent lack of access for dialysis had a significantly worse patient survival (P = 0.0053) and DwFG (P = 0.0462) compared with recipients with psychological problems and suicidality because of dialysis. In addition, retransplantation had a negative impact on patient and graft outcome.

Conclusions. Facing organ shortages, increasing wait times and considerable mortality on dialysis, we question the current policy of HU allocation and propose more restrictive criteria with regard to individuals with vascular complications or repeated retransplantations in order to support patients on the non-HU waiting list with a much better long-term prognosis.


In times of a shortage of donor organs, long-term success and outcome of deceased donor renal transplantation (DDRT) gain crucial importance. The Eurotransplant Kidney Allocation System (ETKAS) was first introduced in 1996[1] and thereafter continuously refined to improve patient and graft survival, guarantee objective recipient selection system based on medical and immunological criteria and streamline the use of available donor organs. The allocation is based on histocompatibility, waiting time, sensitization, logistic aspects and medical urgency.[2,3] Patients waiting for a kidney graft can be granted high medical urgency (HU) status on condition that distinct criteria are fulfilled:[4]

  • imminent lack of access for haemodialysis and peritoneal dialysis,

  • high risk for suicide due to psychological inability to cope with dialysis,

  • severe (uraemic) polyneuropathy (not applicable in all member countries) or

  • severe bladder problems (haematuria, cystitis, etc.) due to kidney graft failure after simultaneous kidney and pancreas transplantation, provided that the pancreas graft is bladder-drained and functioning adequately.

The request for 'HU status' in Eurotransplant (ET) organ allocation reaches back to the early 1970s.[5] Exceptional near-term rescue DDRT intends to save the recipient's life, who otherwise would presumably die within a short period of time. Despite of marked advances in dialysis treatment, HU requests represent a consistent part of kidney allocation in the ETKAS.

After passing the HU audit, candidates receive a bonus of 500 additional points in the ETKAS[4,5] to accelerate allocation of a graft. Currently, regular ETKAS DDRT allocation occurs when a recipient candidate accumulates between 850 and 900 points.

In contrast, the United Network for Organ Sharing (UNOS) together with the Organ Procurement and Transplantation Network (OPTN) in the USA has organized the allocation of kidneys based on medical urgency regionally. If there is only one regional renal transplant centre, the candidate's centre has the authority to use medical assessment in the allocation of medical urgency points. When there is more than one regional transplant centre, cooperative medical decision-making is required prior to assignment of medical urgency points.[6,7] In other countries, such as the UK,[8] Canada,[9] Spain,[10] Portugal,[11] Brazil[12] and Turkey,[13] urgency priority kidney transplant allocation is possible after an audit by independent nephrologists in case of an absolute absence of access for renal replacement therapy or severe complications despite or due to dialysis, such as uraemic cardiomyopathy or neuropathy.

The HU option for kidney allocation is controversial, as mortality on the HU kidney waiting list diminished towards nil during the past decades.[14] Critics state that in DDRT, the HU status lost its 'life-saving' intention compared with rescuing indications in heart, lung and liver transplantations. However, proponents feel vindicated in the success of HU allocation in the ETKAS. Regardless, factors such as optimal human leucocyte antigen (HLA) matching,[15] younger recipient age, better physical condition and higher quality of transplanted organs[16–18] are associated with a better outcome of both patient and graft survival.

Due to the proportionally small number of HU renal transplant recipients compared with all kidney transplantations and the exceptional disease structure, which leads to an HU request in each individual case, data from these patients are very inhomogeneous. Until now, there have been no comprehensive data comparing patient and graft survival under HU conditions with those following standard ETKAS allocation.

This study surveys the available information on priority (HU) DDRT in the literature, compares the insights with the results from all kidney transplant centres within the ET area for the first 15 years since introduction of the new ETKAS, outlines the outcome of HU DDRT compared with standard ETKAS allocated deceased donor transplantation and then comprehensively discusses the findings with regard to benefit and necessity.