An International Comparison of Deceased Donor Kidney Utilization

What Can the United States and the United Kingdom Learn From Each Other?

Maria Ibrahim; Gabe Vece; Jenny Mehew; Rachel Johnson; John Forsythe; David Klassen; Chris Callaghan; Darren Stewart


American Journal of Transplantation. 2020;20(5):1309-1322. 

In This Article

Abstract and Introduction


In transplant, meaningful international comparisons in organ utilization are needed. This collaborative study between the United Kingdom (UK) and the United States (US) aimed to develop a kidney utilization metric allowing for legitimate intercountry comparisons. Data from the UK and US transplant registries, including all deceased donor kidneys recovered from 2006 to 2017, were analyzed. To identify a potentially comparable kidney utilization rate (UR), several denominators were assessed. We discovered that the proportion of transplanted kidneys from elderly donors in the UK (10.7%) was 18 times greater than that in the US (0.6%). Conversely, en bloc pediatric kidney transplant was more common in the US. Donation after circulatory death utilization has risen in both countries but is twice as prevalent in the UK (39% of transplants) vs the US (20%). In addition, US and UK URs are not directly comparable due to fundamental system differences. However, using a suite of URs revealed practice areas likely to yield the most benefit if improved, such as efforts to increase kidney offer acceptance in the US and to reduce postacceptance discard in the UK. Methods used in this study, including novel intracountry risk-adjusted UR trend logistic regression analyses, can be translated to other international transplant registries in pursuit of further global learning opportunities.


The benefit of collaborative international evaluations in health care is well recognized. In transplant, the importance of global information sharing has been identified by the World Health Organization as a means of achieving national self-sufficiency in organ donation and transplant.[1] Although numerous consortiums define international standards in various fields,[2–6] there are few relevant worldwide metrics in organ donation and transplant. International transplant activity comparisons are typically limited to basic statistics such as "deceased donor transplants per million population"; however, such rudimentary metrics do not take into account intercountry differences such as variations in national demographics,[7,8] which are likely to affect clinical transplant practice.

Organ shortage in transplant is a global issue. It is essential that organs procured from deceased donors are used as efficiently and effectively as possible. International concerns exist about the discard of potentially transplantable kidneys, especially in the United States (US).[9–11] These concerns have been driven partially by apparent disparities in deceased donor kidney discard rates in the US (18%-20%) and other jurisdictions including the United Kingdom (UK) (10%-12%), and Eurotransplant (8%).[9,11] However, using unadjusted organ discard rates to compare organ utilization practices between countries is flawed if there are significant differences in the distribution of donor type, donor age, or other donor characteristics that may influence utilization rates (URs). To compare "like with like," a detailed understanding of each national transplant system is also required. Development of either a single or a suite of comparable metrics may facilitate fair and insightful intercountry comparisons.

This collaborative initiative between the UK and US national transplant organizations aims to identify comparable metrics for quantifying deceased donor kidney utilization. We also explored intercountry differences in characteristics of recovered and transplanted kidneys, which can enable global discussions and drive shared learning between healthcare professionals in this rapidly advancing field.