The Paradox of Increasing Waiting List Mortality and Declining Utilization of Deceased Donor Grafts in Kidney Transplant

摘要

Kidney transplant (KTx) is the gold standard treatment for end-stage renal disease because of clear benefits in terms of survival, cost, and quality of life over dialysis.1 However, a recent analysis of the United Network for Organ Sharing database showed that, in the era of organ shortage, transplant candidates receive a large number of viable organ offers that were declined on their behalf by transplant centers.2 Therefore, we analyzed the organ utilization and wait list mortality of KTx candidates in the Eurotransplant database during the period from 2009 to 2018. Over the last decade, there were a consistently high number of patients actively waiting for KTx. Similarly, the number of new registrations, removals, and re-registrations on wait lists remained unchanged, reflecting the persistent high demand for kidney grafts (data not shown). When we assessed the characteristics of KTx candidates on wait lists, we noted a significant increase in the number of patients who are waiting 5 years, are highly sensitized (panel reactive antibodies 85%), and are older than 65 years (Figure 1A; all P .001). More importantly, we also noted a significant increase in mortality for KTx wait list candidates from 4.8% in 2009 to 5.7% in 2018 (P .005). During the same period, the wait list mortality for heart and lung transplant candidates decreased from 20.8% to 11.1% (P = .001) and from 15.8% to 13.4% (P = .001), respectively (Figure 1B). When we evaluated the kidney donation and allocation process, we noted a mild decline in the number of organs transplanted, despite stable offer rates (P = .06). This trend seems to be explained by a significant increase in the number of organs that were discarded (P .001) (Figure 1C). This finding might reflect some deficiencies in the allocation process at the level of the transplant centers. However, this trend was not seen in other solid organs and seems to be organ specific, highlighting the need for better organ utilization in KTx.