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Patients die on waiting list as US centers reject donor kidney



Numerous options for offering donor kidney dialysis patients when available become missed in the United States every day, as transplant centers often refuse organs show new research.

The results were published online August 30 in the JAMA Open by S. Ali Husain, MD, MPH, from the University of Columbia Medical Center in New York, and colleagues.

In this new analysis of the nation's perceived "shortage of donor organs," investigators report that approximately 10,000 potential applicants each year who received at least one offer for a kidney donor organ have either died or died were removed from the waiting list without receiving a transplant during the period considered, between January 2008 and December 201

5. [19659002] Even worse, those who died while waiting for a kidney to receive a median of 16 offers on their behalf while they were on the waiting list for the median 651 days.

Patients also do not usually know these offers were made on their behalf, as transplant centers do not usually discuss offers for a kidney donor that has been refused with potential recipients, mainly due to time constraints, the report found.

"Honestly, we were surprised by the results of our analysis," senior author Sumit Mohan, MD, associate professor of medicine at Columbia University's Vagelos College of Physicians and Surgeons, New York City, told Medscape Medical News .

"

" Not only are patients spending much longer on the waiting list than necessary, the problem is that a significant proportion of them die in anticipation of an organ, "he complains.

" While transplant centers are working to try to get patients the best organ they can, clearly for patients who have died, getting a kidney that is not perfect would be the right choice, "emphasizes Mohan.

patients had previously offered kidney dying every day

For their study, the University of Colombian gators have begun to see the results for kidney transplant applicants on the waiting list after the transplant center's refusal to accept a kidney donor offer on their behalf.

They used the pooled potential transplant dataset ( UNOS), which includes an orderly list of all proposed kidney transplant candidates and proposed kidney donors.

Importantly, this analysis excludes all kidneys that were eventually discarded. (A French study reported by Medscape Medical News earlier this week shows that kidneys of deceased donors are twice as likely to be dumped in the United States as they are in France.) [19659004] The last cohort included 280,041 adults who were on the waiting list for renal transplant and for whom at least one proposal for allograft was received from the transplant center during the 8-year study interval.

The average time that patients underwent dialysis at the time they were listed for renal transplantation is 1.2 years. The average follow-up was 755 days from the time patients were placed on the waiting list.

"An average of 10 applicants who have previously received an offer [for a donor kidney] die each day during the study period," reported Mohan and his colleagues. [19659016] Over 80% of kidneys initially rejected as centers waiting for "perfect" organ

The average time between centers receiving their first donor organ bid for the next kidney line is only 48 days after the patient is was

Patients who actually received a kidney transplant from a deceased donor had a median of 17 offers while on the waiting list for a median of 422 days before actually receiving the transplant. [19659014] "In the same way … those who were removed from the waiting list received an average of 15 bids … while they were listed," the authors added.

Overall, 84% of deceased donor kidneys were rejected on behalf of one or more potential donor recipients before being variable

and about 27% of all transplanted kidneys were rejected for all potential applicants in the donation area of ​​the center, which leads to their use outside their designated geographical area, the authors add.

Mohan warned, however. that the quality of the data detailing the reasons for the decrease in renal supply is relatively poor.

"As reported by the Centers, concern about the quality of organs or donors represents … 92.6% of all rejected offers," the investigators note, "whereas the offers were rarely refused due to patient-related factors … (2,6%), logistical constraints … (0,5%) or other concerns. "

Importantly, all donor kidneys in the present analysis were eventually transplanted to someone waiting for an allograft somewhere in the United States, he was simply below in the waiting list distribution system.

"These are all kidneys that someone else uses with good results, so we're not talking about kidneys that were defused by grandpa," explained Mohan.

"I think the problem is that transplant centers think they will get a better kidney without considering what the patient is experiencing while undergoing dialysis," he said. [19659014] And, he added, "The likelihood of a patient being dead at the time the center receives an 'ideal' kidney is much higher than some centers realize."

The authors also found significant geographical changes in the risk of death while on the waiting list for a kidney transplant after the centers receive at least one donor kidney offer for the next candidate.

Maine had the best performance at the state level in terms of the lowest risk of death among candidates after the transplant center received a kidney donor offer.

In addition, the average number of offers received by the transplant center before applicants die, while on the waiting list also varies by country, ranging from anywhere from one to 11 offers, to Proposals 11 to 74. [19659029] Decisions taken under pressure but more transparency needed

Mohan emphasized that transplant centers are under intense pressure to make quick decisions whether or not to accept a donor kidney when available.

They only have 60 minutes to decide whether to take a kidney or not, so if they refuse it, the same kidney can be offered to the next patient on the list.

"This means that there really is no time to hold a shared decision-making conversation with the patient," he noted.

However, Mohan still believes that there is an urgent need to increase transparency about what types of donor transplant centers are willing to accept the quality of the donor organs

"I believe patients are entitled to they know this because it can change where they go to be listed as a donor body, "he suggested.

Second, if the center refuses an organ, patients have the right to know about this rejection simply because for them, their primary priority is probably not to get this perfect kidney – as the transplant center might wish – but rather to go out dialysis rather because they have a terrible time with dialysis, he noted.

"Due to the adverse effect of prolonged renal transplant dialysis on post-transplant results, even candidates who eventually received an allograft are likely to experience better life expectancy and quality of life than accepting an earlier bid, "the authors emphasize.

"And these missed opportunities for early transplantation are occurring, despite evidence that obtaining even the highest quality kidneys provides survival and quality of life benefits over current waiting lists for most applicants," they added.
Or as Mohan states again: "It is better to get less – than the perfect kidney earlier, than to wait years for the perfect kidney to appear. "

Mohan announces that he is receiving grants from the National Institutes of Health and personal fees from the Health Services Advisory Group, Centers for Medicare & Medicaid Services, Angion and Kidney International Reports.

JAMA Open. Published online August 30, 2019. Full text

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