Characterization of Transplant Center Decisions to Allocate Kidneys to Candidates With Lower Waiting List Priority.
Characterization of Transplant Center Decisions to Allocate Kidneys to Candidates With Lower Waiting List Priority.
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DOI：
10.1001/jamanetworkopen.2023.16936
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发表时间：
2023-06-01
影响因子：
13.8
通讯作者：
Mohan, Sumit
中科院分区：
文献类型：
--
作者：
King, Kristen L.;Husain, S. Ali;Yu, Miko;Adler, Joel T.;Schold, Jesse;Mohan, Sumit
肾移植中心有多频繁地跳过具有最高优先级的候选人，而将肾脏放置在具有较低分配优先级的受者身上？这项队列研究从3136名捐赠者到4668名接受者的26579个器官提供发现，在11个地理上隔离的移植中心，肾脏被放置在比具有最高优先级的候选人更低的匹配运行68%的时间。在统计学上，低质量的肾脏比高质量的肾脏更有可能被放置在候选人名单的后面。这些发现表明，移植中心经常跳过候选人，将肾脏与分配优先级较低的受体一起放置，监督和透明度有限。这项队列研究评估了移植中心根据分配算法将已故供体肾脏与优先级较低的候选人进行移植的实践和频率。已故捐赠者肾脏的分配旨在遵循合格候选人的排名匹配运行列表，但与当地器官采购组织具有1对1关系的移植中心有充分的自由裁量权，可以拒绝提供更高优先级的候选人，并接受他们的中心排名较低的候选人。描述移植中心根据分配算法将死亡供体肾脏与其中心排名不是最高的候选人一起放置的实践和频率。这项回顾性队列研究使用了来自美国移植中心的2015年至2019年器官供应数据，这些数据与当地器官采购组织存在1对1的关系，这些数据来自2015年1月至2019年12月的移植事件候选人。参与者是具有单次匹配运行和至少1个本地移植肾的已故肾脏供体，以及首次接受至少1个本地移植已故供体肾脏的成人仅肾脏移植候选人。数据分析时间为2022年3月1日至2023年3月28日。供体和受体的人口统计学和临床特征。感兴趣的结果是肾移植到最高优先级的候选人（定义为在匹配运行中本地候选人的零下降后移植）与排名较低的候选人。这项研究评估了来自3136名捐赠者（中位数[IQR]年龄，38 [25-51]岁; 2903 [62%]男性）的26579个器官提供给4668个受体。移植中心跳过了他们排名最高的候选人，将肾脏放在了3169个肾脏（68%）的匹配运行中。这些肾脏进入第四（第三至第八）排名候选人的中位数（IQR）。较高的肾脏供体特征指数（KDPI;较高的分数表明较低的质量）肾脏不太可能进入排名最高的候选者，24%的KDPI至少为85%的肾脏进入排名最高的候选者，而44%的KDPI为0%至20%的肾脏。当比较跳过的候选人和最终受体之间的估计移植后生存（EPTS）评分时，在所有KDPI风险组中，肾脏被放置在EPTS比跳过的候选人更好和更差的受体中。在这项对孤立移植中心的局部肾脏分配的队列研究中，我们发现中心经常跳过最高优先级的候选人，将肾脏放在分配优先级列表的更低位置，通常引用器官质量问题，但将肾脏与EPTS更好和更差的受体以几乎相同的频率放置。这是在透明度有限的情况下发生的，突出了改进匹配和报价算法以提高分配效率的机会。
How often do kidney transplant centers skip candidates with the highest priority to place kidneys with recipients with lower-ranked allocation prioritization? This cohort study of 26 579 organ offers from 3136 donors to 4668 recipients found that at 11 geographically isolated transplant centers, kidneys were placed further down the match-run than the candidate with the highest priority 68% of the time. Lower-quality kidneys were statistically significantly more likely to be placed with candidates further down the list than higher-quality kidneys. These findings suggest that transplant centers frequently skip over candidates to place kidneys with recipients with lower allocation priority, with limited oversight and transparency. This cohort study assesses the practice and frequency of transplant centers placing deceased donor kidneys with candidates with lower priority over those with higher priority according to the allocation algorithm. Allocation of deceased donor kidneys is meant to follow a ranked match-run list of eligible candidates, but transplant centers with a 1-to-1 relationship with their local organ procurement organization have full discretion to decline offers for higher-priority candidates and accept them for lower-ranked candidates at their center. To describe the practice and frequency of transplant centers placing deceased donor kidneys with candidates who are not the highest rank at their center according to the allocation algorithm. This retrospective cohort study used 2015 to 2019 organ offer data from US transplant centers with a 1-to-1 relationship with their local organ procurement organization, following candidates for transplant events from January 2015 to December 2019. Participants were deceased kidney donors with a single match-run and at least 1 kidney transplanted locally and adult, first-time, kidney-only transplant candidates receiving at least 1 offer for a locally transplanted deceased donor kidney. Data were analyzed from March 1, 2022 to March 28, 2023. Demographic and clinical characteristics of donors and recipients. The outcome of interest was kidney transplantation into the highest-priority candidate (defined as transplanted after zero declines for local candidates in the match-run) vs a lower-ranked candidate. This study assessed 26 579 organ offers from 3136 donors (median [IQR] age, 38 [25-51] years; 2903 [62%] men) to 4668 recipients. Transplant centers skipped their highest-ranked candidate to place kidneys further down the match-run for 3169 kidneys (68%). These kidneys went to a median (IQR) of the fourth- (third- to eighth-) ranked candidate. Higher kidney donor profile index (KDPI; higher score indicates lower quality) kidneys were less likely to go to the highest-ranked candidate, with 24% of kidneys with KDPI of at least 85% going to the top-ranked candidate vs 44% of KDPI 0% to 20% kidneys. When comparing estimated posttransplant survival (EPTS) scores between the skipped candidates and the ultimate recipients, kidneys were placed with recipients with both better and worse EPTS than the skipped candidates, across all KDPI risk groups. In this cohort study of local kidney allocation at isolated transplant centers, we found that centers frequently skipped their highest-priority candidates to place kidneys further down the allocation prioritization list, often citing organ quality concerns but placing kidneys with recipients with both better and worse EPTS with nearly equal frequency. This occurred with limited transparency and highlights the opportunity to improve the matching and offer algorithm to improve allocation efficiency.
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DOI：
10.1111/ajt.16951
发表时间：
2022-05
期刊：
American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons
影响因子：
--
作者：
通讯作者：
--
影响因子：
8.8
作者：
Adler, Joel T.;Husain, Syed A.;Mohan, Sumit
通讯作者：
Mohan, Sumit
影响因子：
6.2
作者：
Jay, Colleen L.;Washburn, Kenneth;Stegall, Mark D.
通讯作者：
Stegall, Mark D.
影响因子：
120.7
作者：
Merion, RM;Ashby, VB;Port, FK
通讯作者：
Port, FK
影响因子：
19.6
作者：
Mohan, Sumit;Chiles, Mariana C.;Cohen, David J.
通讯作者：
Cohen, David J.