Expanded criteria donors: process and outcomes

Expanded criteria donor (ECD) kidneys are transplantable deceased donor (DD) kidneys for which the average patient, graft survival, and renal function are inferior when compared to standard criteria DD kidneys. Although the term ECD kidneys has been used since the early 1990s to describe kidneys with various characteristics associated with poorer outcomes, the concept has been formally implemented in U.S. organ allocation. A DD kidney is considered to be an ECD organ if the estimated adjusted risk of graft failure is > or = 70% (RR > or = 1.70) compared to DD kidneys with standard characteristics of transplant suitability. The donor characteristics that define an ECD kidney include age > or = 60 years, or age 50-59 years plus two of the following: cerebrovascular accident as the cause of death, preexisting hypertension, or terminal serum creatinine greater than 1.5 mg/dl. In the aggregate, recipients of ECD kidneys have improved survival compared to end-stage renal disease (ESRD) patients on the kidney transplant waiting list. Patient survival is 5% lower at 1 year and 8-12% lower at 3-5 years for ECD kidney recipients. Adjusted graft survival in ECD kidneys is 8% lower at 1 year and 15-20% lower at 3-5 years after transplantation compared to standard criteria donor kidneys. However, patients less than 40 years of age, African Americans, Asians for whom the median waiting time is less than 1350 days receive no survival benefit from ECD kidney transplantation. Informed choice by the potential recipient is a prominent feature of the allocation policy regarding ECD kidneys. Since there are recipient characteristics associated with no survival benefit following ECD transplantation, nephrologists who refer patients for kidney transplantation should be familiar with the combination of donor and recipient factors that are likely to yield detrimental results.     

Enhanced Significance of Donor–Recipient Age Gradient as a Prognostic Factor of Graft Outcome in Living Donor Kidney Transplantation

Background

Successful kidney transplantation (KT) increases survival and improves quality of life for patients with end-stage renal disease. Donor age is an important factor influencing graft outcomes. We evaluated the relationship between the donor–recipient age gradient (DRAG) and graft outcomes after living-donor kidney transplantation (LDKT). Additionally, we analyzed graft survival in patients receiving kidneys from age-mismatched donors.

Methods

From February 1995 to March 2011, a series of 968 consecutive adult LDKT recipients were enrolled in our study. Graft survival and laboratory data for each patient were retrospectively collected. DRAG values were divided into four groups: ≤?21, ?20 to ?1, 0?20, and ≥21 years.

Results

Higher DRAG had negative effects on graft rejection episodes and serum creatinine levels beyond the first month post-transplantation. A DRAG of more than 20 years was significantly correlated with worse 10-year graft survival. Kidneys from donors older than 55 years of age showed significantly compromised graft outcomes when transplanted into recipients younger than 30 years of age, but not in older recipients. Graft survival in transplants using old-to-old allocation was not different from that of young-to-young allocation. In cases of older donors, a lower DRAG between older donors and older recipients showed more favorable graft outcomes than a higher DRAG between older donors and younger recipients.

Conclusions

This study demonstrated that DRAG may serve as a prognostic factor for predicting graft outcomes after LDKT. Additionally, we showed that transplantation of older donor kidneys via living donation is justified in appropriately chosen age-matched recipients.     

Access to quality: evaluation of the allocation of deceased donor kidneys for transplantation

Disparities in both access to the kidney transplant waiting list and waiting times for transplant candidates have been extensively documented with regard to ethnicity, gender, socioeconomic factors, and region. However, the issue of access to equivalent quality organs has garnered less attention. The principal aim of this study was to determine whether certain patient populations were more likely to receive lower quality organs. This was a retrospective cohort study of all deceased-donor adult renal transplant recipients in the United States from 1996 to 2002 (n = 45,832). Using previously reported categorization of donor quality (I to V), the propensity of transplant recipients to receive lower-quality kidneys in a cumulative logit model was evaluated. Older patients were progressively more likely to receive lower-quality organs (age > or = 65 yr, odds ratio [OR] = 2.1, P < 0.01) relative to recipients aged 18 to 24 yr. African American and Asian recipients had a greater likelihood of receiving lower-quality organs relative to non-Hispanic Caucasians. Regional allocation networks were highly variable with regard to donor quality. Neither recipient gender (OR = 1.00, P = 0.81) nor patient's primary diagnosis were associated with donor quality. Findings suggest that disparities in the quality of deceased donor kidneys to transplant recipients exist among certain patient groups that have previously documented access barriers. The extent to which these disparities are in line with broad policies of equity and potentially modifiable will have to be examined in the context of allocation policy.     

Kidneys from Deceased Donors: Maximizing the Value of a Scarce Resource

Donor age is a significant risk factor for graft loss after kidney transplantation. We investigated the question whether significant graft years were being lost through transplantation of younger donor kidneys into older recipients with potentially shorter lifespans than the organs they receive. We examined patient and graft survival for deceased donor kidney transplants performed in the United States between the years 1990 and 2002 by Kaplan-Meier plots. We categorized the distribution of deceased donor kidneys by donor and recipient age. Subsequently, we calculated the actual and projected graft survival of transplanted kidneys from younger donors with the patient survival of transplant recipients of varying ages. Over the study period, 16.4% (9250) transplants from donors aged 15-50 were transplanted to recipients over the age of 60. At the same time, 73.6% of donors above the age of 50 were allocated to recipients under the age of 60. The graft survival of grafts from younger donors significantly exceeded the patient survival of recipients over the age of 60. The overall projected improvement in graft survival, by excluding transplantation of younger kidneys to older recipients, was approximately 3 years per transplant. Avoiding the allocation of young donor kidneys to elderly recipients, could have significantly increased the overall graft life, by a total 27,500 graft years, between 1990 and 2002, with projected cost savings of about 1.5 billion dollars.     

Donor characteristics associated with reduced graft survival: an approach to expanding the pool of kidney donors

BACKGROUND: Availability of cadaveric kidneys for transplantation is far below the growing need, leading to longer waiting time and more deaths while waiting. METHODS: Using national data from 1995 to 2000, we evaluated graft survival by donor characteristics and the rate of discard of retrieved organs, with the goal of increasing use of kidneys that are associated with increased risk of graft failure, that is, expanded donor kidneys. RESULTS: Cox models identified four donor factors that independently predicted significantly higher relative risk of graft loss compared with a low-risk group. These factors included donor age, cerebrovascular accident as the cause of death, renal insufficiency (serum creatinine >1.5 mg/dL), and history of hypertension. Expanded donor kidneys were defined as those with relative risk of graft loss greater than 1.70 and included all donors aged 60 years and older and those aged 50 to 59 years with at least two of the other three conditions (cerebrovascular cause of death, renal insufficiency, hypertension). The expanded donor group accounted for 14.8% of transplanted kidneys. Among organs procured from expanded donors, 38% were discarded versus 9% for all other kidneys. The risk of graft loss of expanded donor kidneys was increased in both older and younger recipients but to a greater extent in those recipients older than 50 years. CONCLUSION: By identifying donor factors associated with graft failure, these analyses may help to expand the number of transplanted kidneys by increasing the utilization of retrieved cadaveric kidneys.     

10 Jahre „Eurotransplant Senior Program“

On 1 January 1999 Eurotransplant started the “Eurotransplant Senior Program” (ESP), the first program worldwide for age-matched kidney allocation and transplantation of expanded criteria donors (ECD). By now more than 4.300 kidneys from donors aged ≥65 were transplanted into recipients ≥65, with local or regional allocation according only to blood group compatibility and waiting time. Compared to ongoing dialysis, renal transplantation in the ESP offers longer patient survival and improved quality of life. The article evaluates the results of the ESP and of other studies dealing with renal transplantation of old donor kidneys into aged recipients. Specific aspects like the unexpectedly high acute rejection rate and ways to assess the residual renal function of aged donor kidneys are covered as well as the specific post-transplant risks of aged recipients.     

Rethinking the advantage of zero‐HLA mismatches in unrelated living donor kidney transplantation: implications on kidney paired donation

The OPTN/UNOS Kidney Paired Donation (KPD) Pilot Program allocates priority to zero‐HLA mismatches. However, in unrelated living donor kidney transplants (LDKT)—the same donor source in KPD—no study has shown whether zero‐HLA mismatches provide any advantage over >0 HLA mismatches. We hypothesize that zero‐HLA mismatches among unrelated LDKT do not benefit graft survival. This retrospective SRTR database study analyzed LDKT recipients from 1987 to 2012. Among unrelated LDKT, subjects with zero‐HLA mismatches were compared to a 1:1–5 matched (by donor age ±1 year and year of transplantation) control cohort with >0 HLA mismatches. The primary endpoint was death‐censored graft survival. Among 32,654 unrelated LDKT recipients, 83 had zero‐HLA mismatches and were matched to 407 controls with >0 HLA mismatches. Kaplan–Meier analyses for death‐censored graft and patient survival showed no difference between study and control cohorts. In multivariate marginal Cox models, zero‐HLA mismatches saw no benefit with death‐censored graft survival (HR = 1.46, 95% CI 0.78–2.73) or patient survival (HR = 1.43, 95% CI 0.68–3.01). Our data suggest that in unrelated LDKT, zero‐HLA mismatches may not offer any survival advantage. Therefore, particular study of zero‐HLA mismatching is needed to validate its place in the OPTN/UNOS KPD Pilot Program allocation algorithm.     

Improving access to kidney transplantation without decreasing graft survival: long-term outcomes of blood group A2/A2B deceased donor kidneys in B recipients

BACKGROUND: The transplantation of blood group A2/A2B deceased donor kidneys into B recipients could improve access to transplantation for blood group B recipients. However, this practice is controversial, and long-term data are lacking. This study analyzed the long-term outcomes of A2/A2B deceased donor kidneys transplanted into selected B recipients. METHODS: We retrospectively assessed the outcomes (graft survival, transplant rates, and acute rejection) of deceased-donor kidneys using an allocation system that transplanted A2/A2B donors into B recipients with low anti-A blood group antibody titers between 1994 and 2003. Patients received conventional immunosuppression without any specific antibody reduction procedures. We further assessed the impact this system had on access to transplantation by blood group. RESULTS: Of 1,400 kidney transplants, 56 (4.0%) were A2/A2B to B recipients. The system reduced waiting time for all B recipients, even shorter than for blood group A recipients (median waiting times of A2/A2B to B transplants=182 days vs. B to B transplants=297 days; and A to A=307 days). Although there was a trend toward increased acute rejection in A2/A2B to B transplants, the actuarial 7-year death censored graft survival was 72% for B recipients regardless of donor type. CONCLUSIONS: Transplanting A2/A2B deceased donor kidneys into B recipients leads to an equalization of waiting time between blood groups with similar patient and graft survival using conventional immunosuppression. This protocol could lead to more equal access to kidney transplantation in blood group B recipients.     

The impact of waiting time and comorbid conditions on the survival benefit of kidney transplantation

BACKGROUND: Longer waiting times may limit the survival benefit of kidney transplantation in older patients or those with a high burden of comorbid disease. METHODS: We performed a longitudinal study of mortality among 63,783 transplant candidates who started dialysis between April 1995 and December 2000. We determined the relative risk (RR) of death and increase in life expectancy among subjects who received a first deceased donor transplant after different waiting times compared to subjects who had equivalent waiting times but remained on dialysis. RESULTS: Transplant recipients had a lower long-term RR of death and the risk reduction was greatest in recipients with longer waiting times (RR of death 12 months after transplantation for recipients with waiting times of 0, 1, 2, 3 years was 0.49, 0.43, 0.38, 0.34, P = 0.0006).The average increase in life expectancy in transplant recipients was 9.8 years and was lower in older recipients and recipients with comorbid conditions. Increased waiting times from 1 to 3 years only moderately decreased the overall survival benefit of transplantation from 7.1 to 5.6 years, and all subjects derived a survival benefit from transplantation with waiting times up to 3 years. CONCLUSION: These findings do not support limiting access to transplantation for otherwise suitable candidates on the basis of longer anticipated waiting times.     

Current Kidney Allocation Rules and Their Impact on a Pediatric Transplant Center

In 2005, kidney allocation rules in the United States were updated to enhance access to kidneys from young adult deceased donors (DDs) for pediatric recipients. We studied how this rule change affected transplant activity at our pediatric center. We retrospectively compared kidney transplant activity at our center since the rule change (until December 31, 2007) to before the change (n = 36 each), focusing on those recipients directly affected by it, that is, younger than 18 years. There were no significant differences in recipients' age, gender or ethnicity before versus after the rule change. Percentages of preemptive transplants and retransplants were similar in both groups, as was the percentage of sensitized patients. There was a significant decrease in overall, but not DD, mean donor age. Mean wait time for DD kidneys decreased for pediatric recipients. Increases were found in percentage of DD transplants and in mean HLA mismatches after the rule change. Patient and short-term graft survival were not significantly different. These data suggest that the allocation rule change was not only followed by improvement in overall access to kidney transplantation for children, but also by decreases in living donor transplants and HLA matching. Larger studies are needed to evaluate the long-term impact of the change.     

Lack of impact of donor age on patient survival for renal transplant recipients ≥60years

There has been an increase in the number of older patients on the transplant waiting list and acceptance of older donor kidneys. Although kidneys from older donors have been associated with poorer graft outcomes, whether there is a differential impact of donor age on outcomes in older recipients remains unclear. The aim of this study was to evaluate the effect of donor age on graft and patient survival in renal transplant (RT) recipients ≥60years. Using the Australia and New Zealand Dialysis and Transplant Registry, outcomes of 1,037 RT recipients ≥60years between 1995 and 2009 were analyzed. Donor age groups were categorized into 0-20, >20-40, >40-60, and >60years. Compared with recipients receiving donor kidneys >60years, those receiving donor kidneys >20-40years had lower risk of acute rejection (odds ratio 0.46, 95% CI 0.27, 0.79; P<0.01) and death-censored graft failure (HR 0.37, 95% CI 0.19, 0.72; P<0.01). There was no association between donor age groups and death. With a corresponding growth in the availability of older donor kidneys and the observed lack of association between donor age and patient survival in RT recipients ≥60years, preferential allocation of older donor kidneys to RT recipients ≥60years may not disadvantage the life expectancy of these patients.     

Underutilization of Hepatitis C‐Positive Kidneys for Hepatitis C‐Positive Recipients

Hepatitis C‐positive (HCV(+)) candidates likely derive survival benefit from transplantation with HCV(+) kidneys, yet evidence remains inconclusive. We hypothesized that lack of good survival benefit data has led to wide practice variation. Our goal was to characterize national utilization of HCV(+) kidneys for HCV(+) recipients, and to quantify the risks/benefits of this practice. Of 93,825 deceased donors between 1995 and 2009, HCV(+) kidneys were 2.60‐times more likely to be discarded (p < 0.001). However, of 6830 HCV(+) recipients, only 29% received HCV(+) kidneys. Patients over 60 relative rate (RR 0.86), women (RR 0.73) and highly sensitized patients (RR 0.42) were less likely to receive HCV(+) kidneys, while African Americans (RR 1.56), diabetics (RR 1.29) and those at centers with long waiting times (RR 1.19) were more likely to receive them. HCV(+) recipients of HCV(+) kidneys waited 310 days less than the average waiting time at their center, and 395 days less than their counterparts at the same center who waited for HCV(?) kidneys, likely offsetting the slightly higher patient (HR 1.29) and graft loss (HR 1.18) associated with HCV(+) kidneys. A better understanding of the risks and benefits of transplanting HCV(+) recipients with HCV(+) kidneys will hopefully improve utilization of these kidneys in an evidence‐based manner.     

Survival in recipients of marginal cadaveric donor kidneys compared with other recipients and wait-listed transplant candidates

An increasing number of cadaveric kidney transplants are now performed with organs from donors who would have been deemed unsuitable in earlier times. Although good allograft outcomes have been obtained with these marginal donor transplants, it is unclear whether recipients of marginal kidney transplants achieve a reduction in long-term mortality as do recipients of "ideal" kidneys. Patients with end-stage renal disease registered on the cadaveric renal transplant waiting list between January 1, 1992, and June 30, 1997, were studied for mortality risks according to three outcomes: wait-listed on dialysis treatment with no transplant (WLD); transplantation with marginal donor kidney (MDK); and "ideal" or optimal donor kidney transplantation (IDK). Thirty-four percent of wait-list registrants had received a cadaveric kidney transplant by June 30, 1998. Of these, 18% received a marginal kidney that had one or more of the following pretransplant factors: donor age >55 yr, non-heartbeating donor, cold ischemia time >36 h, and donor hypertension or diabetes mellitus of > 10 yr duration. Five-year graft and patient survival was 53% and 74% for MDK recipients compared with 67% (P< 0.001) and 80% (P< 0.001) for IDK recipients. Adjusted annual death rate and estimated remaining life time was 6.3%, 4.7%, and 3.3% and 15.3 yr, 20.4 yr, and 28.7 yr for WLD, MDK, and IDK groups, respectively. The average increase in life expectancy for MDK recipients compared with the WLD cohort was 5 yr, although this benefit varied from 3 to 10 yr depending on the recipient's characteristics. It is concluded that transplantation of a marginal kidney is associated with a significant survival benefit when compared with maintenance dialysis.     

Local Expansion of Donation After Circulatory Death Kidney Transplant Activity Improves Waitlisted Outcomes and Addresses Inequities of Access to Transplantation

In the United Kingdom, donation after circulatory death (DCD) kidney transplant activity has increased rapidly, but marked regional variation persists. We report how increased DCD kidney transplant activity influenced waitlisted outcomes for a single center. Between 2002–2003 and 2011–2012, 430 (54%) DCD and 361 (46%) donation after brain death (DBD) kidney‐only transplants were performed at the Cambridge Transplant Centre, with a higher proportion of DCD donors fulfilling expanded criteria status (41% DCD vs. 32% DBD; p = 0.01). Compared with U.K. outcomes, for which the proportion of DCD:DBD kidney transplants performed is lower (25%; p < 0.0001), listed patients at our center waited less time for transplantation (645 vs. 1045 days; p < 0.0001), and our center had higher transplantation rates and lower numbers of waiting list deaths. This was most apparent for older patients (aged >65 years; waiting time 730 vs. 1357 days nationally; p < 0.001), who received predominantly DCD kidneys from older donors (mean donor age 64 years), whereas younger recipients received equal proportions of living donor, DBD and DCD kidney transplants. Death‐censored kidney graft survival was nevertheless comparable for younger and older recipients, although transplantation conferred a survival benefit from listing for only younger recipients. Local expansion in DCD kidney transplant activity improves survival outcomes for younger patients and addresses inequity of access to transplantation for older recipients.     

Experience with deceased donor kidney transplantation in 114 patients over age 60

BACKGROUND: In the recent past, advanced age was a contraindication to kidney transplantation (KT). The purpose of this study was to review retrospectively our single center experience in deceased donor (DD) KT with respect to recipient age. METHODS: From 10/1/01 to 9/1/06, we performed 356 adult DD KTs. Patients received antibody induction in combination with tacrolimus, mycophenolate mofetil, and tapered steroids. RESULTS: A total of 114 (32%) patients were greater than 60 (including 25 >70 years), 186 (52%) were 40-59 years of age, and 56 (16%) were 19-39 years of age. Of the 114 older patients, 61 (54%) received KTs from expanded criteria DDs (ECD), more than the younger age groups (39% ECDs in patients 40-59 years versus 18% ECDs in patients 19-39 years, P < .0001). Mean waiting time (21 mo) was less for patients greater than 60 years compared with the other 2 groups combined (29 mo, P = .06). Patient survival was 91% in recipients greater than 60 years compared with 95% in those less than 60 years of age (P = NS) with a mean follow-up of 27 mo. Graft survival was similar for all 3 age groups (82% >60 years vs 83% in patients 40-59 years vs 87% in patients 19-39 years, P = NS). Initial and subsequent graft function, morbidity, and resource use were similar among groups. Patient survival [93% ECD vs 89% standard criteria DDs (SCD), P = NS) and graft survival (82% ECD vs 81% SCD, P = NS) rates were similar, whereas mean waiting times (18 mo ECD vs 25 mo SCD, P = .04) were less in patients greater than 60 years who received ECD KTs compared with patients greater than 60 years who received SCD KTs. CONCLUSIONS: Patients greater than 60 years account currently for one third of DD KTs performed at our center, and more than half receive kidneys from ECDs. By preferentially directing ECD kidneys to appropriately selected elderly patients, waiting times can be decreased and survival is similar compared with SCD KTs in the elderly. In addition, short-term outcomes can be achieved in patients greater than 60 years that are comparable with those in younger patients.     

Kidney Transplantation in Children and Adolescents: An Analysis of United Network for Organ Sharing Database

Specific pediatric allocation schemes can not only lead to minimization of waiting time, but also to better clinical outcomes for children with end-stage renal disease. The outcome of 4125 deceased donor kidney transplants (DDKT) aged 5-35 years were compared with those of 6456 living donor kidney transplants (LDKT) using univariate and multivariate Cox regression analyses. Unadjusted graft survival rates of DDKT were significantly lower than those of LDKT (hazards ratio [HR] = 1.53; P < .001). Chronic rejection was reported in 416 (10.1%) of 4125 in the DDKT group compared with 537 (8.3%) of 6456 in the LDKT group (P < .001). Among African American recipients, 67 (3.4%) grafts were lost due to noncompliance as a contributory cause of failure compared with 126 (1.5%) among other races (P < .001). A significantly lower incidence of noncompliance was observed in children (0.9%) compared with adolescents (2.2% in ages 10-14; P < .001) and high teens (2.0% in ages 15-20; P < .001). Multivariate analysis showed that adjusted graft survival rates of LDKT were superior to DDKT (HR = 1.22; P < .001) after adjusting for recipient race, recipient age, regraft status, and HLA mismatch. The differences of long-term graft survival rates between DDKT and LDKT have not been reduced (4% at 1 year, 10% at 3 years, and 12% at 5 years for unadjusted survival rates and 3% at 1 year, 6% at 3 years, and 9% at 5 years adjusted survival rates). In our analysis presented here the difference in graft survival between LDKT and DDKT has doubled compared with earlier analysis. Therefore, we recommend LDKT whenever possible as a first choice for pediatric transplant recipients.     

Evolution in allocation rules for renal, hepatic, pancreatic and intestinal grafts

Organ transplantation is the victim of his own success. The results of transplantation are excellent and more patients are activated on the waiting list. The need for organs exceeds the supply. Which criteria are used to allocate available grafts to patients on the waiting list ? Organ allocation and finding the "best match" between donor and recipients, is the goal of Eurotransplant, the organ sharing organization for seven European countries (Austria, Croatia, Germany, Luxemburg, Slovenia, The Netherlands and Belgium). Last decade, the allocation system has switched from a "center-driven" (organ allocated to a center) to a "patient-driven" system (organ allocated to a particular patient). For the allocation of abdominal organs some general allocation rules are followed: blood group compatibility, priority for high urgencies. The allocation of kidneys is based on a point score system based on waiting time, HLA and donor location (to reduce the cold ischemia time). In addition to this standard allocation procedure, there are still specific procedures for pediatric recipients and for candidates > or = 65 year old. There is also an "acceptable" mismatch program for recipients at high immunological risk. The liver allocation system recently changed and is now based on the MELD score, a formula that calculates the probability of death within 3 months on the waiting list. For pancreas and intestine, the system is based on blood group, medical urgency, waiting time, donor region and weight (for intestine).     

Kidney and Pancreas Transplantation in the United States, 1996–2005

Kidney and pancreas transplantation in 2005 improved in quantity and outcome quality, despite the increasing average age of kidney graft recipients, with 56% aged 50 or older. Geography and ABO blood type contribute to the discrepancy in waiting time among the deceased donor (DD) candidates. Allocation policy changes are decreasing the median times to transplant for pediatric recipients. Overall, 6% more DD kidney transplants were performed in 2005 with slight increases in standard criteria donors (SCD) and expanded criteria donors (ECD). The largest increase (39%) was in donation after cardiac death (DCD) from non‐ECD donors. These DCD, non‐ECD kidneys had equivalent outcomes to SCD kidneys. 1‐, 3‐ and 5‐year unadjusted graft survival was 91%, 80% and 70% for non‐ECD‐DD transplants, 82%, 68% and 53% for ECD‐DD grafts, and 95%, 88% and 80% for living donor kidney transplants. In 2005, 27% of patients were discharged without steroids compared to 3% in 1999. Acute rejection decreased to 11% in 2004. There was a slight increase in the number of simultaneous pancreas‐kidney transplants (895), with fewer pancreas after kidney transplants (343 from 419 in 2004), and a stable number of pancreas alone transplants (129). Pancreas underutilization appears to be an ongoing issue.     

An algorithm for cadaver kidney allocation based on a multivariate analysis of factors impacting on cadaver kidney graft survival and function

Abstract The large imbalance between cadaver kidney supply and demand makes the implementation of equitable and effective organ allocation systems an urgent need. This has triggered a revision of the criteria used so far for cadaver kidney allocation within the North Italy Transplant program, not least in the light of the many changes that have occurred recently with respect to broader criteria for admission of patients to the waiting list, donor selection, tissue‐typing methods, organ preservation and immunosuppressive protocols. We based the critical revision of our cadaver kidney allocation algorithm on univariate and multivariate analysis of a number of immunological, clinical, social and administrative factors that impacted on the transplant outcome in 2,917 patients transplanted in the 12 transplant centers operating within our organization from 1 January 1990 to 30 September 1997. This analysis indicated that younger donor age, absence of pretransplant transfusions, patient dialysis center and level of HLA match showed statistically significant positive associations with graft survival. Younger donor age and male donor gender showed a statistically significant association with excellent graft function at 4 years. The results of this analysis were used to develop a new computer‐assisted version of our adult kidney allocation algorithm. It works in two steps (local pool first, then the entire waiting list) and four levels (0‐1 HLA MM, PRA +; 2 HLA MM, PRA +; 0‐1 MM, PRA‐; 2‐4 HLA MM, PRA‐); within each level, selection takes into account waiting time and age difference from donor age. The evaluation of 731 transplants allocated in 19 months with the new algorithm, as against 698 transplants allocated in the preceding 19 months according to the previous algorithm, showed a significantly higher proportion of recipients who had been on the waiting list for more than 3 years (33.2% versus 22.6%). The use of the new algorithm was also associated with a significantly increased number of transplanted alloimmunized patients (18.8% versus 9.2% with the previous algorithm) and recipients with 0‐1 HLA mismatches (22% versus 14.3%). Furthermore, the number of kidneys used locally has steadily increased. Differences in 6‐month graft survival and percentage of patients with excellent function at 6 months were not statistically significant in recipients transplanted with the new versus the previous algorithm. Survivals were 93.7% versus 91.8%. Percentages of patients with excellent renal function were 69.9% and 71.8%, respectively. These preliminary data suggest that the new algorithm improves HLA match and reduces the number of patients on the waiting list for 3 or more years without determining significant modifications of 6‐month graft survival and function. Moreover, it facilitates the achievement of a fair local balance between organs retrieved and transplanted, the compliance of operators with objective allocation rules and the documentation of the whole allocation process.     

Prospective Age-Matching in Elderly Kidney Transplant Recipients—A 5-Year Analysis of the Eurotransplant Senior Program

Renal transplantation faces challenges: the organ shortage resulting in extended waiting times and an aging population resulting in death with a functioning graft. The Eurotransplant Senior Program (ESP) allocates kidneys within a narrow geographic area from donors aged ≥65 years to recipients ≥65 years regardless of HLA. This analysis investigates the impact of the ESP on waiting time, graft and patient survival. The ESP group (n = 1406, old to old) was compared to two groups allocated via the Eurotransplant Kidney Allocation System (ETKAS) with either similar donor age (old to any [O/A], donor age ≥65, n = 446) or recipient age (any to old, [A/O], recipient age 60–64, n = 1687). All patients were transplanted between 1999 and 2004. Since initiation of the ESP (1999), availability of elderly donors doubled and waiting time for ESP patients decreased. Local allocation led to shorter cold ischemia time (11.9 vs. >17.0 h, p < 0.001) and less delayed graft function (DGF, ESP 29.7% vs. O/A 36.2%, p = 0.047) but 5–10% higher rejection rates. Graft and patient survival were not negatively affected by the ESP allocation when compared to the standard allocation. The ESP age matching of elderly donors and recipients is an effective allocation system for organs from elderly donors.