Less Than Perfect Kidneys May Help Expand Transplant Access

Bridget M. Kuehn
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Kidneys from donors with acute kidney injury (AKI) are often discarded, but a recent study suggests that transplant patients who receive donor kidneys with AKI do as well as those who receive comparable kidneys without AKI.

The findings are the latest in a growing body of evidence that suggests using more donor kidneys that are less than perfect may help increase access to transplantation. Transplantation is considered the best treatment option for most patients with kidney disease because it can improve their quality of life and help them live longer, according to the National Kidney Foundation. But with about 100,000 patients on the waiting list for transplantation and only about 20,000 kidney transplants completed each year, many patients end up waiting years for a kidney. Currently, about one-third of donor kidneys with AKI are discarded, noted Chirag Parikh, MBBS, PhD, Director of the Division of Nephrology at Johns Hopkins Medicine in Baltimore. Other studies have suggested that donor kidneys that are seropositive for hepatitis C virus (HCV) or kidneys from older donors might also be underutilized options.

“We and other groups are looking at opportunities where there are kidneys in the discard pool [that] can potentially work well and can benefit more people who are on the waiting list,” Parikh said.

Currently, many deceased donor kidneys with AKI are discarded because patients and nephrologists fear they may not last as long, explained Parikh. But some evidence suggests that these fears may be misplaced. With their recent study, Parikh and his colleagues strengthened the case for using donor kidneys with AKI.

In the study, they analyzed data from DonorNet on transplant outcomes in 12, 810 patients who received deceased donor kidneys with AKI and 12,513 patients who received kidneys without AKI from donors with similar characteristics. They found that there wasn’t a significant difference in all-cause graft failure or death-censored graft failure in the two groups. Although more patients who received AKI kidneys experience delayed graft function (29% vs. 22%), Parikh said the rigorous design of the study and the fact that it included all kidneys transplanted between Jan. 1, 2010, and Dec. 31, 2013, bolster the evidence base.

Based on the evidence, Parikh said he thinks between 500 and 700 deceased donor kidneys with AKI could be added to the donor pool each year. This could be beneficial for both patients and society, he said, noting the huge costs of maintaining patients on dialysis.

“Taking these people off dialysis and giving them a meaningful life back makes a huge difference,” he said.

Another potentially underutilized pool of deceased donor kidneys are HCV-positive organs. Until recently, HCV-positive donor kidneys could not be used for transplant because peginterferon plus ribavirin, the gold standard treatment, could cause rejection, said Xingxing Cheng, MD, a transplant nephrologist and clinical assistant professor at Stanford University in California. But the emergence of direct-acting antiviral drugs that have been shown to eliminate the HCV virus in up to 100% of patients after transplant has changed the landscape. The number of HCV seropositive donors has also increased from 181 to 661 per year between 2000 and 2016 as opioid overdose deaths have increased, a recent study co-authored by Cheng showed. The study showed the number of HCV-positive donor kidneys transplanted increased from 165.4 to 334.7. Most are transplanted into HCV-positive patients, but some centers are also transplanting them into patients without HCV, Cheng noted. Both groups of patients are treated with direct-acting antivirals after transplant.

But the use of HCV-positive donor kidneys has lagged behind the use of HCV-positive donor livers, the study found. Cheng said there are several likely explanations for this: Kidney patients can stay on dialysis while they wait for a kidney, while liver transplant patients don’t have such an option. Hepatologists also may be more experienced and comfortable using direct-acting antivirals than their nephrologist counterparts. Another potential concern is whether patients have access to direct-acting antiviral medications, which can cost as much as $94,000 per treatment. Cheng said she and her colleagues seek preapproval for coverage of direct-acting antivirals for prospective kidney transplant patients who are already HCV-positive.

“I think there is a great role for [HCV positive donor kidneys],” she said. The biggest thing that needs to be overcome is the financial hurdle of financing the treatments, so that we don’t create two classes of kidney transplant recipients, ones who have good insurance that can afford the treatment, and ones who can’t.”

Another group of kidneys that may be underutilized are those from older donors, as studies have found that older recipients may benefit from a transplant from older donors. Stephen Pastan, MD, Associate Professor of Medicine and Medical Director of the Kidney and Pancreas Transplant Program at Emory University School of Medicine, explained that a kidney from an older donor may not last as long—perhaps 5 years rather than 8—but getting a transplant from an older donor is still much better than staying on dialysis.

There are several national efforts underway to increase access to transplantation and increase the number of organs available from both deceased and living donors.

Among the aims of the US Department of Health and Human Services Advancing American Kidney Health program launched in 2019 are increasing the number of donor kidneys available, reforming the organ procurement system, and removing financial and other barriers to living organ donation. The United Network for Organ Sharing is developing systems that would more quickly match donor kidneys to centers that will use them in order to decrease discards of donor kidneys that spend too much time on ice during the allocation process.

A report from the National Kidney Foundation’s Consensus Conference to Decrease Kidney Discards highlighted the need to change regulations or payer incentives that may unfairly penalize transplant centers that use lower quality kidneys, Pastan noted.

“We’re trying to identify things that should be done to try to remove those kinds of barriers,” he said. “We do a lot about patient education to make sure that patients are ready and willing to accept whatever kidney comes their way because it would be in their best interest to get a transplant rather than staying on the waiting list.”

Patients and physicians must also weigh the potential benefits and risks of accepting a particular kidney for each patient, Cheng noted. She explained there can be “tension between what is best for the community and what is best for an individual patient.” For example, using an older donor kidney in an older patient may be beneficial, but if it fails, an older patient may be less likely to get a second chance.

“It’s a great idea to try to expand the usage of [marginal] kidneys,” Cheng said. “But there are a lot of just unknowns and ethical questions in finding the proper patients to get these organs to. I’ve personally in my practice seen great successes with these and I’ve also seen some really bad failures.”