Nav: Home

Many who die waiting for a kidney had multiple offers, new study finds

August 30, 2019

Patients who die waiting for a kidney, or who are removed from the transplant waitlist for poor health, are usually considered unfortunate victims of the ever-growing shortage of available organs.

Yet a new study has found that most candidates have had multiple opportunities to receive a transplant, but the offered organs were declined by their transplant team and subsequently transplanted in someone lower on the waitlist.

Among the candidates who received at least one offer during the study period, nearly one-third (approximately 10,000 people per year) died or were removed from the list without receiving a transplant.

Candidates who died without a transplant received a median of 16 offers (over 651 days) while waitlisted.

"Presumably, these offers were declined primarily because centers were expecting patients to get a better offer in a timely manner," says study leader Sumit Mohan, MD, associate professor of medicine at Columbia University Vagelos College of Physicians and Surgeons and of epidemiology at the Mailman School of Public Health.

"In some cases, a decline may have been the right decision, but our data suggest that many others probably would have been better served if their transplant center had accepted one of the offers."

76% of candidates receive at least one offer

With colleagues from Columbia University Irving Medical Center and Emory University, Mohan examined all 14 million kidney offers made between 2008 and 2015 to more than 350,000 waitlisted patients in the United States. The data came from the United Network for Organ Sharing.

The analysis revealed that most waitlisted patients--76%--received at least one viable offer of a kidney.

Kidney offers that were automatically declined due to a center's minimum acceptance criteria were counted as viable offers, but offers of kidneys that were eventually discarded and never transplanted were not.

Each year, thousands receive multiple offers, but no transplant

Of the 280,041 patients who received at least one offer, 30% (approximately 85,000 people) either died on the waitlist or were removed from the waitlist before receiving a kidney.

For candidates who received at least one offer but died without a transplant, the first offer arrived a median of just 78 days after a candidate joined the list.

The vast majority of organs, 84%, were declined at least once, including organs that appeared to be an ideal immunological match.

Concern about organ quality was the reason most often provided by the transplant team for declining the kidney. "But clearly these organs were transplantable, because all of them were eventually transplanted," Mohan says. "We know 93% of transplanted kidneys are still working after one year and 75% are still working after five years, which calls into question the validity of these decisions to decline offers of a kidney."

Patients unaware of declined offers

For the most part, Mohan says, patients are unaware of declined offers.

The transplant team has just 60 minutes to accept or decline an organ offer, and often patients are not told when an organ is declined on their behalf, even after the fact.

"While the time constraints preclude real time shared decision-making, making patients aware of these organ offers subsequently will potentially improve patient engagement resulting in a process that prioritizes stated patient preference of shorter time to transplant," Mohan says.

"It's better to get a less-than-perfect kidney sooner than to wait years for the perfect kidney to come along. Better communication between patients and transplant centers may prompt a reconsideration of how and when to decline offers."

Executive order

"The vast majority of kidneys are not going to the first matched candidate on the list," Mohan says.

"The current system, which allows centers to decline offers without patient involvement or awareness, appears to make an otherwise objective allocation system more subjective than intended."

The recent executive order directing the Secretary of Health and Human Services to improve the allocation and utilization of deceased-donor kidneys may create an opportunity for change.
The study, "Association of declining deceased donor kidney offers and outcomes in kidney transplant candidates," was published Aug. 30 in JAMA Network Open.

Other authors: S. Ali Husain, MD, MPH (Columbia University Irving Medical Center); Kristen L. King, MPH (CUIMC); Stephen Pastan, MD (Emory University School of Medicine, Atlanta, Georgia); Rachel E. Patzer, PhD (Emory); David J. Cohen, MD (CUIMC); and Jai Radhakrishnan, MD (CUIMC).

The research was supported by a Young Investigator Grant from the National Kidney Foundation, the National Center for Advancing Translational Sciences (KL2TR001874), the National Institutes of Health (R01DK114893 and U01DK116066), and the Laura and John Arnold Foundation.

The authors declare that they have no financial conflicts of interest to disclose.

Columbia University Irving Medical Center

Related Transplant Articles:

Researchers standardise test for predicting transplant rejection
Researchers from The Westmead Institute for Medical Research have developed a standardised method of measuring the immune response in islet transplant recipients, helping predict patient outcomes.
Measuring quality of life after pediatric kidney transplant
After receiving a kidney transplant, children may experience worrisome quality-of-life changes that underscore the importance of screening transplant recipients for psychosocial function, according to Children's research presented during the 10th Congress of the International Pediatric Transplant Association.
Kidney transplant patients need even better aftercare!
Kidney transplantation is the best renal replacement therapy available. Although survival and quality of life are significantly better compared to dialysis patients, transplant recipients nevertheless have a significantly higher cardiovascular morbidity and mortality than healthy people.
First birth after robot-assisted uterus transplant
A boy 48 centimeters long, weighing 2900 grams, is the first baby born after the technological shift in the Swedish world-leading research on uterine transplantation.
New clues discovered to lung transplant rejection
Researchers at Washington University School of Medicine in St. Louis have discovered clues to a particularly deadly form of rejection that can follow lung transplantation.
First pregnancy after robot-assisted uterus transplant
The well-known research on uterine transplantation in Gothenburg is now supported by robotic surgery.
Marijuana use has no effect on kidney transplant outcomes
A new study published in Clinical Kidney Journal indicates that the usage of marijuana by kidney donors has no measurable effect upon the outcomes of kidney transplants for donors or recipients.
Does obesity have an impact on kidney transplant outcomes?
In a study of kidney transplant recipients, those with ideal BMI (18-25) had the best organ survival.
New insights into what drives organ transplant rejection
Investigators from Brigham and Women's Hospital set out to understand why skin grafts have such a high rate of rejection, hoping to capitalize on new biological insights to not only explain why skin transplants provoke the immune system but also what treatments can be given to an organ prior to transplantation to decrease the likelihood of rejection.
Transplant-damaging virus comes into focus
Researchers from the University of Leeds have revealed the structure of a virus which affects kidney and bone marrow transplant patients in near-atomic levels of detail for the first time.
More Transplant News and Transplant Current Events

Best Science Podcasts 2019

We have hand picked the best science podcasts for 2019. Sit back and enjoy new science podcasts updated daily from your favorite science news services and scientists.
Now Playing: TED Radio Hour

Rethinking Anger
Anger is universal and complex: it can be quiet, festering, justified, vengeful, and destructive. This hour, TED speakers explore the many sides of anger, why we need it, and who's allowed to feel it. Guests include psychologists Ryan Martin and Russell Kolts, writer Soraya Chemaly, former talk radio host Lisa Fritsch, and business professor Dan Moshavi.
Now Playing: Science for the People

#538 Nobels and Astrophysics
This week we start with this year's physics Nobel Prize awarded to Jim Peebles, Michel Mayor, and Didier Queloz and finish with a discussion of the Nobel Prizes as a way to award and highlight important science. Are they still relevant? When science breakthroughs are built on the backs of hundreds -- and sometimes thousands -- of people's hard work, how do you pick just three to highlight? Join host Rachelle Saunders and astrophysicist, author, and science communicator Ethan Siegel for their chat about astrophysics and Nobel Prizes.