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What's New

                                                                                Kidney Transplantation: Version 7.0

What’s New?

In spite of initiatives like the HRSA/Institute for Healthcare Improvement collaborative effort of all 58 Donation Service Areas to increase deceased donation so that the kidney waiting list could be eliminated by 2015, the waiting time for potential kidney recipients is still very long and growing. Furthermore, questions around equal access to donor organs and questions of utility has led to a profound change in the algorithm determining kidney allocation. The new kidney allocation system (KAS) went into effect December 4, 2014.

Key Goals of the new KAS-which only impacts cadaveric transplants

        1-Make better use of available kidneys
        2-Increase transplant opportunities for difficult-to-match patients (increased equity)
        3-Increase fairness by awarding waiting time points based on dialysis start date
        4-Have minimal impact on most candidates

Now, these goals are achieved by developing two novel algorithms. The first is called the Kidney Donor Profile Index (KDPI) and estimates (using 10 variables) how long the kidney is likely to function. The second algorithm is called the Estimated Post-Transplant Survival Score (EPTS) and is associated with how long the candidate will need a functioning kidney transplant when compared with other candidates. This may seem odd or almost inhumane but it is important to understand that death with a functioning graft is one of the main causes of kidney transplant graft loss. The diseases that lead to ESRD are usually systemic diseases that impact the cardiac and vascular systems of a patient. A young patient with Polycystic Disease certainly has a much longer life expectancy than a 60 year old diabetic with renal failure. Transplant is the preferred option for both patients but donor quality can be different and yet still meet the patients’ lifetime needs.

In addition to factoring in KDPI and EPTS, the new system will also change the way highly sensitized candidates get priority for kidneys through additional sharing of organs beyond former boundaries. Also added is a sliding scale points system for calculated panel reactive antibody of CPRA scores. There will be greater access to deceased donor kidneys for blood type B candidates who can safely accept a kidney from an A2 or A2B blood type donor. Finally, priority for pediatric candidates will be based on the donor’s KDPI instead of the donor’s age.

These changes were extensive and we now have 18 month data on how these changes have impacted the system.

Highlights: First 18 months of KAS:

        •    Many very highly sensitized and high dialysis time patients
              have been transplanted
        •    Deceased donor transplant volume has increased 17%
        •    However, utilization of recovered kidneys has not improved
        •    Largest impact on pediatric transplants was observed in Region 5 (California)
        •    Delayed Graft Function has increased
        •    Post-KAS, 6-month graft (95.3%) and recipient (97.6%) survival are
              excellent, though slightly lower than pre-KAS. OPTN

1. Updated first year billed charges from Milliman:
See tables at the end of this Quick Reference Guide.

2. Paired Kidney Donation (PKD)

Another process, logistically difficult, but rapidly gaining in popularity around the country is the notion of paired donation. The idea is based on the relatively common occurrence of a potential recipient having a willing living donor, but that donor is not a match for the intended recipient. It may be that another person needing a kidney has a similar situation, either known to that center, or somewhere else the USA. If each of the donors is a good match for the other person, it is possible for the donors to donate their kidney to the (usually) unknown other person.

As can be imagined, the organization of the time of transplant, the donor operation, transport of the donated organ, the work-ups done before hand can be a laborious undertaking. However, paired exchanges extending to chains as involving as many as 8 different donor-recipient pairs, transplanted over many months, have been reported. Currently, UNOS is in the process of formalizing the matching process and grants are being awarded to several of the paired-exchange networks developed cooperatively by major kidney transplant centers. The plan is to develop a computerized matching process that will streamline the exchange process and open the door to many more of these types of exchanges. There are strong proponents for a local or regional system, a single national system, or some combination of the two. It is uncertain now which of these designs may predominate, although many of these smaller paired donation programs are now also participating with the UNOS national plan.

3. Desensitization

Several centers developed methods for treating patients highly sensitized to donor-specific antigens, making locating an appropriate donor organ a much lesser challenge. Many other programs are now participating. In some centers those patients constitute the majority of their kidney transplant volume. The fairly complex regimen, including plasmapheresis or immunoadsorption to remove anti-HLA or ABO group antibodies with the subsequent use of intravenous immunoglobulin, has proven to be quite successful. Centers willing to undertake this treatment find mixing both paired donation and desensitization the most prudent approach. Patients with ABO incompatibilities used to have splenectomies as well, although rituxan, a monoclonal antibody against B lymphocytes, (Rituximab) use has substantially eliminated that procedure.
As expensive and time consuming as desensitization protocols are, they still allow those who are highly sensitized from long-time dialysis, to be transplanted with living donors and with a low-to-moderate risk of acute rejection. Recent actions of Medicare to require outcomes from desensitization transplants to be in the range of those who are not sensitized may have a dampening effect on the further expansion of this technique, although recent reports suggest the improvement in overall survival for desensitized patients is close to that of traditional deceased-donor transplants. Living donor kidneys still have the best graft survival outcomes.

4. ABO Incompatible Donors:

This is another area at the forefront of our knowledge of the immune system.  There are centers where patients will be offered blood-type-incompatible kidneys.  These centers have specific expertise in managing this ABO immune incompatibility. It is managed in much the same way as the highly sensitized recipient is managed: IVIG and plasmapheresis in preparation for the transplant and intensive immunosuppression throughout the transplant period. While the failure rate is higher than normal, the results are surprisingly good. This is a technique that offers hope to patients with ESRD who could not otherwise benefit from a transplant.  ABO incompatible kidney transplants should not be done casually, but should only be done at centers where the transplant team has the necessary experience. Managing ABO incompatible transplants will add as much as $50,000 over and above the expected expense of the transplant episode of care.

5. Steroid Avoidance Protocols:

There has been a lot of interest, now waning somewhat, in avoiding the use of prednisone in kidney transplantation.  Many of the long-term issues faced by transplant recipients (obesity, diabetes, hypertension and hyperlipidemia) are associated with the use of long-term steroids.  In theory, anything that can be done to avoid their use should be beneficial for the transplant recipient.  But, the evidence is conflicting.  If steroids are avoided, it is almost certainly going to be necessary to increase the doses of other immunosuppressives and use induction (broad immunosuppression delivered just prior to surgery) in all patients. These strategies are not without risk. Among these risks are the possible increased incidence of kidney failure as a consequence of increased doses of calcineurin inhibitors or the immediate and long-term consequences, which can include higher incidences of new cancers and opportunistic infections, of the intense immune suppression associated with induction and the uses of higher than otherwise used doses of other immunosuppressives.