Kidney Nonprocurement in Solid Organ Donors in the United States

Kathleen Yu; Kristen King; Syed A. Husain; Geoffrey K. Dube; Jacob S. Stevens; Lloyd E. Ratner; Matthew Cooper; Chirag R. Parikh; Sumit Mohan

Disclosures

American Journal of Transplantation. 2020;20(12):3413-3425. 

In This Article

Abstract and Introduction

Abstract

There are limited data on the nonprocurement of kidneys from solid organ donors. Analysis of Standard Transplant Analysis and Research files was undertaken on all deceased donors in the United States with at least 1 solid organ recovered. From 2000 to 2018, 21 731 deceased donor kidneys (averaging 1144 kidneys per year) were not procured. No kidneys were procured from 8% of liver donors, 3% of heart donors, and 3% of lung donors. Compared to donors with all kidneys procured, those with none procured were older and more likely obese, black, hypertensive, diabetic, hepatitis C positive, smokers, Public Health Service – Increased Risk designated, deceased after cardiac death, or deceased after cerebrovascular accident. Although these donors had lower quality kidneys (median Kidney Donor Risk Index (interquartile range) 1.9 (1.0) vs 1.2 (0.7)), there was substantial overlap in quality between nonprocured and procured kidneys. Nearly one third of nonprocurements were attributed to donor history. Donors with elevated terminal creatinine likely resulting from acute kidney injury (AKI) had higher odds of kidney nonprocurement. Nonprocurement odds varied widely across Organ Procurement and Transplantation Network regions, with a positive correlation between donor kidney nonprocurements and kidney discards at the donation service area level. These findings suggest current discard rates underestimate the underutilization of deceased donor kidneys and more research is needed to optimize safe procurement and utilization of kidneys from donors with AKI.

Introduction

Kidney transplantation is the treatment of choice for end-stage kidney disease (ESKD) and is associated with improved survival, quality of life, and long-term cost compared to dialysis.[1,2] However, access to transplantation in the United States is limited by the shortage of available organs. Recent efforts to expand the organ donor pool have identified suboptimal deceased donor kidney utilization and concerns about the adequacy of procurement efforts.[3]

Although there remains debate over how to identify the true number of eligible deaths in order to determine the full extent of available organs in the United States, the number of solid organ donors—and in particular, the number of donors from whom a kidney was not procured—is known. Kidneys are the most commonly procured organs from deceased donors and tend to have less stringent criteria for acceptance than the heart or lungs.[4] Organ procurement organizations (OPOs) attempt to be appropriately selective in organ procurement to optimize their efforts to obtain the largest number of organs that are going to be transplanted and avoid procuring organs that will subsequently be discarded. For example, organs with tumors and those with significant anatomical abnormalities that would preclude transplantation are usually not procured.[5] However, it is surprising that in some donation service areas (DSAs), over 10% of deceased donors who have given other solid organs were not also kidney donors.[6,7] There remains limited information on the extent of kidney nonprocurement in donors who have given at least 1 other solid organ for transplant, that is, a heart, lung, and/or liver, or the factors that contribute to this phenomenon.[8] We attempt to measure the extent of kidney nonprocurement from deceased solid organ donors, identify factors associated with nonprocurement, and analyze variations in procurement practices across OPOs.

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