Old versus new: Progress in reaching the goals of the new kidney allocation system

As demand for kidney transplant continues to grow faster than organ availability, appropriate allocation of deceased donor kidneys is an acute priority. Increased longevity matching is central to this effort. To foster equitable and efficient utilization of deceased donor kidneys, a new kidney allocation system (KAS) was introduced in December 2014. Major achievements in the 1 year after its implementation include a reduction in age-mismatch and an increase in access to transplant for historically disadvantaged candidates, such as those with very high levels of panel-reactive antibodies or long dialysis duration. However, the rate of discarded kidneys has not decreased, and an increase in A2/A2B transplants has yet to be realized. Organs are now shared more often at the regional and national levels, with some regions experiencing an increase in transplants and other a decrease. While implementation of the KAS has been associated with the attainment of key goals, the kidney transplant community must remain vigilant about potential untoward consequences, including reductions in transplant rates for specific groups such as pediatric patients. More time is required before firm conclusions about the long-term effects of the new KAS can be rendered.     

A call to action: Feasible strategies to reduce the discard of transplantable kidneys in the United States

Changes to the United States kidney allocation system targeted at reducing organ discard have failed to improve organ utilization. High Kidney Donor Profile Index kidneys continue to be discarded at high rates as a result of the regulatory and financial barriers to widespread utilization of these organs. However, there are potential changes to clinical practice that could improve organ utilization. Expediting the time from initial offer to final organ acceptance would reduce cold ischemic time and should improve utilization. Implementation of procurement biopsy standards to avoid biopsy of low risk organs may prevent organ discards due to inaccurate data or excessive cold ischemia time. Further, standardization of procurement biopsy pathological interpretation coupled with electronic accessibility would enable early acceptance of difficult to transplant organs. These changes to allocation practice patterns are vital given proposals to expand the geographic sharing of deceased donor kidneys. Implementation of new allocation policies must be evaluated to ensure they result in higher transplant rates and acceptable post-transplant outcomes.     

¿Predice el Kidney Donor Profile Index (KDPI) la supervivencia del injerto y del paciente en una población española?

Background and objective

The Kidney Donor Profile Index (KDPI), together with other donor and recipient variables, can optimise the organ allocation process. This study aims to check the feasibility of the KDPI for a Spanish population and its predictive ability of graft and patient survival.

Donor acute kidney injury and its effect on 1-year post-transplant kidney allograft fibrosis

Transplantation of kidneys from deceased donors with acute kidney injury (AKI) can expand the donor pool. We investigated the effect of donor AKI on renal function and chronic changes on protocol biopsies at 1-year post-transplant. Donor AKI was defined according to Acute Kidney Injury Network (AKIN) criteria. Between 2013 and 2017, 333 kidneys were transplanted and subsequently biopsied after 1 year. Fifty-three kidneys from AKI donors (AKIN stage I n = 42, stage II n = 8, stage III n = 3) were compared to 280 kidneys from non-AKI donors. At 1-year follow-up, patient and graft survival were comparable. Donor AKI was not predictive of IFTA (Banff interstitial fibrosis plus tubular atrophy scores) at 1-year post-transplant biopsy (2.10 ± 1.28 in AKI, 2.09 ± 1.22 in non-AKI, P = .95). Donor AKI was also not associated with progression of IFTA from 3 to 12 months (P = .69), or inferior glomerular filtration rate (eGFR, P = .94). In a multivariate analysis, the odds of IFTA >2 were comparable between AKI and non-AKI groups. In conclusion, the transplantation of kidneys from donors with predominantly stage I AKI results in comparable function and degree of fibrosis on protocol biopsies 1-year post-transplant. Selected grafts from donors with AKI are a valuable tool for expanding the donor pool for kidney transplantation.     

Transplantation of Kidneys From Hepatitis C Virus-Infected Donors to Hepatitis C Virus-Negative Recipients: One-Year Kidney Allograft Outcomes

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