Impact of Geographic Boundaries on Deceased Donor Kidney Discard, Allocation, and Outcomes

项目摘要 对于目前等待肾移植的近95，000人来说，他们的地理居住地有一个 这对他们是否会接受移植有很大的影响。器官分配是基于地理边界的 捐助者服务区是人为的。美国有58个DSA，它们的大小差别很大 和人口，这就解释了在获得移植方面的一些差异。地理边界 的DSA从未被设计用于优化器官分配，也没有考虑到人口、 肾脏疾病或器官捐赠率。这些地理边界也可能有助于另一个 重要问题-捐赠肾脏不必要的丢弃。在美国，近20%的肾脏捐赠是 丢弃。改善移植的可及性和减少肾脏丢弃是国家的优先事项， “推进美国肾脏健康倡议”。新的肾脏分配政策，不使用任何固定的 地理边界计划于2020年12月实施。然而，新的器官分配 政策可能会对器官结果产生意想不到的影响，并加剧获得移植的差距。 这项拨款将研究肾脏分配的三个时代，揭示如何使用地理位置， 边界影响了终末期肾病患者的移植获益和公平性：1）历史 分配时间：2014年12月4日之前进行的移植，当时分配了在DSA内获得的肾脏 主要用于同一DSA内的接受者; 2）肾脏分配系统时代（分为两个子时代）：肾脏 在2019年9月5日之前，在更广泛的区域内共享了被认为是“质量较低”的信息，随后该政策被 由于肾脏丢弃率高而逆转; 3）同心圆时代：该系统计划于 2020年12月15日实施，取消了DSA边界，并使用250海里半径 捐赠医院分配肾脏这项科学建议的总体目标是确定 在肾脏丢弃的具体结果方面，死亡供体肾脏的地理共享范围更广， 获得移植和受体结果。我的中心假设是， 死亡的供体肾脏可能会减少居住在等待时间长的地区的患者的地理不平等， 但它会加重器官丢弃，不能提高肾移植存活率。这些新颖的见解， 地理位置和肾脏分配之间的关系最终可以推动主要的公共卫生收益， 通过展示肾脏如何分配来改善公平性， 移植数量。 申请人在宾夕法尼亚大学有一个初级教师的任命。与 一个经验丰富的导师团队的支持和充足的资源，在大学 宾夕法尼亚州，他的目标是培养一个持久的研究作为R 01资助的独立医生的职业生涯 科学家，并成为肾脏病学和肾移植领域的领导者。

PROJECT SUMMARY For the nearly 95,000 people currently waiting for a kidney transplant, their geographic residence has a major impact on whether they will get a transplant. Organ allocation is based on geographic boundaries of donor service areas (DSA) that are artificial. There are 58 DSA in the US, and they vary tremendously in size and population, which explains some of the variation in access to transplantation. The geographic boundaries of DSAs were never designed to optimize organ allocation, and do not account for population, prevalence of kidney disease, or organ donation rates. These geographic boundaries might also contribute to another important problem – unnecessary discard of donated kidneys. Nearly 20% of all kidneys donated in the US are discarded. Improving access to transplant and reducing kidney discard are national priorities under the “Advancing American Kidney Health Initiative.” A new kidney allocation policy that does not use any fixed geographic boundaries is scheduled for implementation in December 2020. However, the new organ allocation policy may have unintended effects on organ outcomes and worsen disparities in access to transplant. This grant will examine three eras of kidney allocation that reveal how the use of geographic boundaries has affected transplant benefits and equity for patients with end-stage kidney disease: 1) Historical Allocation Era: Transplants performed before 12/4/2014, when kidneys procured within a DSA were allocated primarily to recipients within the same DSA; 2) Kidney Allocation System Era (split into two sub eras): Kidneys considered “lower quality” were shared over a wider region until 9/5/2019, and this policy was subsequently reversed due to high kidney discard rates; 3) Concentric Circle Era: This system is scheduled for implementation on 12/15/2020 and eliminates DSA boundaries, and uses a 250-nautical mile radius around donor hospital to allocate kidneys. The overall objective of this scientific proposal is to determine the effects of wider geographic sharing of deceased donor kidneys on the specific outcomes of kidney discard, disparities in access to transplant, and recipient outcomes. My central hypothesis is that systems with wider sharing of deceased donor kidneys might reduce geographic inequities for patients living in areas with high wait-times, but it will worsen organ discard and fail to improve kidney allograft survival. These novel insights into the relationship between geography and kidney allocation could ultimately drive major public health gains for patients with kidney disease by showing how kidneys can be allocated to improve fairness and increase the number of transplants. The applicant has an appointment on the junior faculty at the University of Pennsylvania. With the support of a highly experienced mentorship team and the ample resources available at the University of Pennsylvania, his goal is to foster a career of enduring research as an R01 funded independent physician scientist, and to become a leader in the field of nephrology and kidney transplantation.