Clinician-to-Clinician Update Clinician-to-Clinician Update

Novel Approaches to Improving Access to Donor Kidneys

March 2018

Kidney transplantation is the preferred treatment for patients with end-stage renal disease, yet the number of patients on dialysis and transplant waiting lists far exceeds the number of available donor kidneys. As a result, approximately 30 patients die each day while awaiting a kidney transplant.1 Improvements in histocompatibility testing and immunosuppression therapies have facilitated donor-recipient matches and successful transplants. Paired exchange programs, which place willing but incompatible donor-recipient pairs in a database of similarly incompatible pairs, have also helped identify matches2 and supported living-donor kidney transplants. Kidneys from living donors have been shown to provide overall better function and longevity than kidneys from deceased donors (82% vs. 74% 10 year death-censored graft survival).1

Despite these developments and education efforts on transplant and donation, there is growing recognition that new approaches are needed. In 2016, the Collaborative Innovation and Improvement Network (COIIN), a study assessing transplant performance monitoring, was launched. With the goal of improving access to transplant, the project studies the use of expanded donor-organ criteria and enables a collaborative approach to transplant practice improvement.

Adult-Spec-SOT-March-2018-Feature-Article-Main-Image
— Transplant surgeons Ty B. Dunn, MD, MS, and Timothy Pruett, MD, confer in the University of Minnesota Health Clinics and Surgery Center.

A main COIIN project goal is reassessing use of deceased-donor kidneys with a kidney donor profile index (KDPI) score of above 50%.3 Kidneys with a KDPI score above 50% have an increased risk of graft failure when compared to all donor kidneys recovered in the previous year. Nevertheless, for patients who do not have access to a living-donor kidney, deceased-donor kidneys offer good graft survival. (All-cause graft failure at 1 year was 4.8% for these kidney transplant recipients, and 51.6% at 10 years.1) Deceased-donor kidneys from high KDPI donors are highly viable when properly screened and matched with the correct recipient.1 Survival rates are also better with these donor organs than they are with long-term dialysis. For example, a kidney that is expected to function for 5 years may be appropriate for a patient whose average risk of death from end-stage renal disease after 1 year on dialysis exceeds 20%.4 For patients 65 years and older, transplantation on average provides about 2.5 times the survival rate that dialysis does.5

The University of Minnesota Health Transplant Program, by virtue of its extensive experience in complex and high-risk transplants, was selected to join the first cohort of hospitals participating in COIIN. Along with testing the use of expanded donor-organ criteria, COIIN hospitals place an emphasis on new approaches to matching deceased-donor kidneys to appropriate recipients. The University of Minnesota Health Transplant Program is now working to adopt new protocols developed during COIIN participation. One such protocol activates the transplant team early on to identify a potential recipient further down the list who could benefit from the donor kidney with a KDPI score above 85% in case a patient at another hospital who is higher on the transplant list turns down the offer. This approach allows patients to be transplanted much earlier, reducing time on dialysis. Proactive planning for this type of situation also helps to reduce the cold ischemic time, which helps reduce the risk of delayed graft function.

Efforts to expand access to transplantation through increased use of deceased-donor kidneys appear to be working. From 2015 to 2016, the increase in the number of kidney transplants in the United States was entirely attributable to an increase in deceased-donor organs.

References

  1. Hart A, Smith JM, Skeans MA, et al. OPTN/SRTR 2016 annual data report: kidney. Am J Transplant. 2018;18(Suppl 1):18-113. doi: 10.1111/ajt.14557.
  2. Maggiore U, Oberbauer R, Pascual J, et al. Strategies to increase the donor pool and access to kidney transplantation: an international perspective. Nephrol Dial Transpl. 2015;30:217-22.
  3. U.S. Department of Health and Human Services. Organ Procurement and Transplantation Network. COIIN. Oct. 18, 2016. https://optn.transplant.hrsa.gov/resources/coiin/ Accessed February 16, 2018.
  4. Neovius M, Jacobson SH, Eriksson J, et al. Mortality in chronic kidney disease and renal replacement therapy: a population-based cohort study. BMJ Open. 2014;4(2):e004251.
  5. United States Renal Data System. Mortality. In: 2017 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2017:347. https://www.usrds.org/2017/download/v2_c05_Mortali...

When to refer

University of Minnesota Health transplant providers have extensive experience with patients requiring organ transplant resulting from conditions such as diabetes, lung disease, or heart, intestinal, kidney, or liver failure. Our surgeons are part of a long tradition of innovative leadership in transplant care in the United States. University of Minnesota Health providers established the world’s first nondirected living kidney donor program, wherein anonymous altruistic donors can be evaluated for kidney donation.

Multidisciplinary, Collaborative Care

University of Minnesota Health clinicians provide stateof-the-art care to patients seeking an organ transplant. We perform over 200 kidney transplants per year, with statistically better than expected 1-year graft survival outcomes after living-kidney donation. Overall, 96.9% of our program recipients of living- or deceased-donor kidney transplants are alive with a functioning kidney at 1 year after transplant. We participate in research collaborations designed to improve access to donor kidneys and enhance transplant care team performance. Our teams strive to provide comprehensive patient education and to maintain streamlined communication with patients and their referring providers. Patients are educated about the benefits and risks associated with transplant with living- or deceased-donor kidneys and learn about histocompatibility testing and immunosuppressive medications.

Patients in need of an organ transplant often have coexisting health conditions, such as diabetes, heart disease, and hypertension. Our clinicians work closely with cardiologists, hepatologists, nephrologists, pulmonologists, and other specialists to provide comprehensive, collaborative care. We coordinate with nurse practitioners and pharmacists to help patients manage medications and post-transplant rehabilitation.

Our goal is to provide unmatched care and leading-edge interventions for patients in need of solid organ transplant.

To request a free copy of the 2017 University of Minnesota Health Adult Specialty Directory, visit mhealth.org/for-medical-professionals/adult-specialty-directory

To find current clinical trials available through M Health providers, visit studyfinder.umn.edu.

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