Strategies to increase the donor pool and access to kidney transplantation: an international perspective

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Abstract

In this position article, DESCARTES (Developing Education Science and Care for Renal Transplantation in European States) board members describe the current strategies aimed at expanding living and deceased donor kidney pools. The article focuses on the recent progress in desensitization and kidney paired exchange programmes and on the expanded criteria for the use of donor kidneys and organs from donors after circulatory death. It also highlights differences in policies and practices across different regions with special regard to European Union countries. Living donor kidney paired exchange, the deceased donor Acceptable Mismatch Programme and kidneys from donors after circulatory death are probably the most promising innovations for expanding kidney transplantation in Europe over the coming decade. To maximize success, an effort is needed to standardize transplant strategies, policies and legislation across European countries.

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Desensitization in HLA-incompatible kidney recipients and survival.

Robert Montgomery, Bonnie Lonze, Karen E. King … (2011)

More than 20,000 candidates for kidney transplantation in the United States are sensitized to HLA and may have a prolonged wait for a transplant, with a reduced transplantation rate and an increased rate of death. One solution is to perform live-donor renal transplantation after the depletion of donor-specific anti-HLA antibodies. Whether such antibody depletion results in a survival benefit as compared with waiting for an HLA-compatible kidney is unknown. We used a protocol that included plasmapheresis and the administration of low-dose intravenous immune globulin to desensitize 211 HLA-sensitized patients who subsequently underwent renal transplantation (treatment group). We compared rates of death between the group undergoing desensitization treatment and two carefully matched control groups of patients on a waiting list for kidney transplantation who continued to undergo dialysis (dialysis-only group) or who underwent either dialysis or HLA-compatible transplantation (dialysis-or-transplantation group). In the treatment group, Kaplan-Meier estimates of patient survival were 90.6% at 1 year, 85.7% at 3 years, 80.6% at 5 years, and 80.6% at 8 years, as compared with rates of 91.1%, 67.2%, 51.5%, and 30.5%, respectively, for patients in the dialysis-only group and rates of 93.1%, 77.0%, 65.6%, and 49.1%, respectively, for patients in the dialysis-or-transplantation group (P<0.001 for both comparisons). Live-donor transplantation after desensitization provided a significant survival benefit for patients with HLA sensitization, as compared with waiting for a compatible organ. By 8 years, this survival advantage more than doubled. These data provide evidence that desensitization protocols may help overcome incompatibility barriers in live-donor renal transplantation. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and the Charles T. Bauer Foundation.).

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Donation after circulatory death: current practices, ongoing challenges, and potential improvements.

Paul E Morrissey, Anthony Monaco (2014)

Organ donation after circulatory death (DCD) has been endorsed by the World Health Organization and is practiced worldwide. This overview examines current DCD practices, identifies problems and challenges, and suggests clinical strategies for possible improvement. Although there is uniform agreement on DCD donor candidacy (ventilator-dependent individuals with nonrecoverable or irreversible neurologic injury not meeting brain death criteria), there are variations in all aspects of DCD practice. Utilization of DCD organs is limited by hypoxia, hypotension, reduced--then absent--organ perfusion, and ischemia/reperfusion syndrome. Nevertheless, DCD kidneys exhibit comparable function and survival to donors with brain death kidneys, although they have higher rates of primary graft nonfunction, delayed graft function, discard, and retrieval associated injury. Concern over ischemic organ injury underscores the reluctance to recover extrarenal DCD organs since lack of medical therapy to support inadequate allograft function limits their acceptability. Nevertheless, limited results with DCD pancreas, liver, and lung allografts (but not heart) are now approaching that of donors with brain death organs. Pretransplant machine perfusion of DCD kidneys (vs. static storage) may reduce delayed graft function but has no effect on long-term organ function and survival. Normothermic regional perfusion used during DCD abdominal organ retrieval may reduce ischemic organ injury and increase the number of usable organs, although critical confirmative studies have yet to be done. Minor increases in usable DCD kidneys could accrue from increased use of pediatric DCD kidneys and from selective use of DCD/ECD kidneys, whereas a modest increase could result through utilization of donors declared dead beyond 1 hr from withdrawal of life support therapy. A significant increase in transplantable kidneys could be achieved by extension of the concept of living kidney donation in relation to imminent death of potential DCD donors. Progress in research to identify, prevent, and repair DCD-associated organ retrieval injury should improve utilization of DCD organs. Recent results using ex situ pretransplant organ perfusion of DCD organs has been encouraging in this regard.

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Mortality among hemodialysis patients in Europe, Japan, and the United States: case-mix effects.

Karl Prütz, Nathan W. Levin, Jock W. Young … (2004)

The Dialysis Outcomes and Practice Patterns Study is well suited to identify case-mix effects, given its extensive data set. The data set was used to examine the influence of case-mix variables on mortality and the extent to which these variables account for differences in mortality across regions, as well as the prevalence and incidence of hepatitis B and hepatitis C. Demographic and comorbid disease features were determined for 8,615 patients internationally; mortality was recorded for this cohort, plus replacement patients (total n = 16,720), from 1996 to 2002. Mortality was associated with increasing age, nonblack race, coronary artery disease, congestive heart failure, other cardiac disease, diabetes mellitus, peripheral vascular disease, cerebrovascular disease, absence of hypertension, lung disease, cancer, human immunodeficiency virus infection, gastrointestinal bleeding, neurologic disease, psychiatric disease, cellulitis/gangrene, hepatitis C, and smoking. US patients were slightly older than those in Europe or Japan and had the highest prevalence of diabetes, coronary artery disease, congestive heart failure, peripheral vascular disease, and cerebrovascular disease. Upon adjusting for case-mix to assess mortality across facilities, it was found that regional differences in mortality (highest in the United States and lowest in Japan) and differences across facilities within nations remain after such corrections. It is likely that practice patterns account for some of this variation. Prevalence of hepatitis B virus (HBV) across facilities increased as the number of dialyzing patients per facility increased; risk of HBV seroconversion decreased among facilities using protocols for treatment of patients with HBV infection. Greater employment of staff with at least 2 years of formal nursing training was associated with lower prevalence of hepatitis C virus infection and lower seroconversion risk.

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Author and article information

Journal

Journal ID (nlm-ta): Nephrol Dial Transplant

Journal ID (iso-abbrev): Nephrol. Dial. Transplant

Journal ID (publisher-id): ndt

Journal ID (hwp): ndt

Title: Nephrology Dialysis Transplantation

Publisher: Oxford University Press

ISSN (Print): 0931-0509

ISSN (Electronic): 1460-2385

Publication date (Print): February 2015

Publication date (Electronic): 06 June 2014

Publication date PMC-release: 06 June 2014

Volume: 30

Issue: 2

Pages: 217-222

Affiliations

[1 ]Department of Nephrology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy

[2 ]KH Elisabethinen Linz and Department of Nephrology, Medical University of Vienna , Vienna, Austria

[3 ]Department of Nephrology, Hospital del Mar , Barcelona, Spain

[4 ]Department of Nephrology, Institute for Clinical and Experimental Medicine , Prague, Czech Republic

[5 ]Richard Bright Renal Unit, Bristol, UK

[6 ]Department of Nephrology, Charité Medical University Berlin , Berlin, Germany

[7 ]Department of Nephrology P, Rigshospitalet, University of Copenhagen , Copenhagen, Denmark

[8 ]Service de Néphrologie, Univ Lille Nord de France , Lille, France

[9 ]Department of Nephrology and Transplantation Medicine, Wroclaw Medical University , Wroclaw, Poland

[10 ]Department of Nephrology, Antwerp University Hospital , Antwerp, Belgium

Author notes

Correspondence and offprint requests to: Umberto Maggiore; E-mail: umberto_maggiore@ 123456hotmail.com

Article

Publisher ID: gfu212

DOI: 10.1093/ndt/gfu212

PMC ID: 4309190

PubMed ID: 24907023

SO-VID: b8502950-9566-4a6d-8c66-c04c2a52f2b1

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This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

History

Date received : 6 May 2014

Date accepted : 7 May 2014

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Strategies to increase the donor pool and access to kidney transplantation: an international perspective

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Most cited references 43

Desensitization in HLA-incompatible kidney recipients and survival.

Donation after circulatory death: current practices, ongoing challenges, and potential improvements.

Mortality among hemodialysis patients in Europe, Japan, and the United States: case-mix effects.

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