Ditching Standard Biopsies Could Provide More Kidneys for Transplant

Pam Harrison

December 22, 2020

Many kidneys from deceased organ donors in the US that are discarded because of procurement biopsy results would function acceptably if transplanted, new research indicates.

Doctors analyzed data on a series of more than 1000 kidneys discarded in the US between 2015 and 2016 and found that 493 of these organs could be matched, in terms of biopsy-evaluated quality and other donor characteristics, to 493 kidneys that were actually transplanted in Europe, where transplant practice is less restrictive.

"Right now in the United States, half of all [donor] kidneys are biopsied to judge their quality," lead author Peter Reese, MD, Perelman School of Medicine, University of Pennsylvania, Philadelphia, told Medscape Medical News. "Unfortunately, 30 to 50% of kidneys that get discarded are thrown away because of biopsy findings."

But "there are some innovations going on in Europe that we can learn from," he explained.

One example is that centers in France and Belgium transplant kidneys from much older donors than American transplant centers do. And while he acknowledges that donor kidneys from older patients are not appropriate for every potential recipient, they could be of use in many older individuals waiting for a transplant.

"We have a lot of elderly patients, so I think we can find patients that these older donor kidneys would benefit because they won't need the kidney for as long [as a younger person]," he explained.

"I think this research should change the default line so that…within a couple of years, a biopsy will not be thought of as standard of care but something that is only done in really special circumstances," Reese emphasized.

The study was published online December 15 in the Journal of the American Society of Nephrology (JASN).

Pretransplant Biopsies Didn't Predict Allograft Survival

The shortage of kidneys for transplantation continues to be a public health crisis in the US. More than 90,000 patients are waiting for kidney transplants, yet only about 20,000 transplants are performed each year. Annually, nearly 5000 people on the transplant waiting list die without getting a transplant. Deceased donors provide roughly two thirds of transplanted kidneys.

Reese and colleagues from France and Belgium set out to see if pretransplant biopsy results improved the prediction of graft survival over other routinely collected donor characteristics.

To do this, they analyzed data from transplant centers in France and Belgium where donor kidneys are not routinely biopsied as part of allocation.

They examined 1629 kidney transplants from two hospitals in France and then validated this using another cohort of 1107 kidney transplant recipients from two hospitals in Belgium.

Patients in both cohorts received a deceased donor kidney and outcomes were compared between some of these organs and donor kidneys from deceased individuals in the US, which were discarded because of histology results.

"We demonstrate that kidney biopsies performed for decision-making in the allocation process did not improve the prediction of allograft survival beyond routinely available clinical attributes of deceased donors and recipients," the authors stress.

They determined that kidneys discarded in the US could have had a graft survival rate of 93.1% at 1 year; 80.7% at 5 years, and 68.9% at 10 years based on their matched comparison of transplanted kidneys in Europe. 

US Has Led the Way in Some Quarters

Reese said that European transplant centers can however learn from some other initiatives in the US, for example the widespread use of kidney paired exchange for living donors.  

"Sometimes you might want to donate a kidney to your sister and I might want to donate a kidney to my wife but if we're incompatible, you might be able to donate your kidney to my wife and I might be able to donate my kidney to your sister."

"The US has really led the way in this paired exchange," he explained.

Furthermore, the US is leading the way in using donor kidneys from deceased individuals with hepatitis C, Reese noted.

Reese also feels that transplant centers in the US can be optimistic about the Advancing American Kidney Health Initiative, which aims to help the US transplant system find strategies to improve its practices.

"I think that organ procurement organizations and transplant centers are under tremendous pressure to respond to our and others' criticisms, so I think this paper might be coming at a good time, in that there is momentum behind the idea that change is needed," he concluded.

This work was supported in part by French national research agency (INSERM) ATIP Avenir, Fondation Bettencourt Schueller, and the National Kidney Foundation. The study authors have disclosed no relevant financial relationships.

JASN. Published online December 15, 2020. Abstract

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