Equity in Kidney Allocation and Optimizing Utilization: Are These Goals Mutually Exclusive?
2024; Wolters Kluwer; Linguagem: Inglês
10.1097/tp.0000000000005054
ISSN1534-6080
AutoresRobert J. Stratta, Colleen L. Jay,
Tópico(s)Organ Transplantation Techniques and Outcomes
ResumoEvery time you make a choice, it has unintended consequences. —Stone Gossard On March 15, 2021, in response to a Health Resources and Services Administration mandate, the new Kidney Allocation System (KAS) based on 250 nautical mile radius circles around the donor hospital replaced donor service areas as the basis for local allocation priority aiming to provide more equitable distribution of organs and alleviate access disparities based on perceived arbitrary geographic boundaries.1 Unfortunately, the change to circle-based allocation has led to greater complexity of interactions between multiple organ procurement organizations (OPOs) and transplant centers resulting in increased offer burden and kidney nonutilization rates while unmasking and worsening allocation and logistical inefficiencies.2,3 In the retrospective study of Scientific Registry of Transplant Recipients data spanning 4 y by Cutrone et al,4 key performance indicators of KAS were analyzed across 2 eras preallocation and 2 eras postallocation change. In addition to analyzing data according to the Kidney Donor Profile Index (KDPI), cold ischemia time (CIT), and recipient race, the authors considered distance between the donor and recipient hospitals and introduced the novel concept of "urbanicity" based on metropolitan size. The article contains excellent data, and the findings are provocative particularly in the context of ensuring that allocation follows the directives of the Final Rule. During the study period, major findings were that kidney nonutilization increased from 19.7% to 26.4%, which occurred across all KDPI strata and was positively correlated with increasing KDPI. Most compelling is that CIT increased although the distance between donor and recipient hospitals decreased suggesting that allocation inefficiency is the cardinal and growing shortcoming of the KAS250 policy. This disturbing development is consistent with prior evidence that showed an 11% increase in CIT following KAS250 concurrent with a 6% decrease in mean distance between donor and recipient hospital.3 These findings highlight critical concerns about KAS250 upholding tenets of the Final Rule as noted by the authors including "best use of donated organs, to avoid wasting organs, to avoid futile transplants, and to promote patient access and the efficient management of organ placement." Finally, the authors reported that kidneys from small or nonmetropolitan areas had a higher nonutilization rate compared with large metropolitan areas.4 In their concluding paragraph, they state "A strong argument could be made to abandon KAS250 and move to a system that improves equity but not at such a high cost of utility." With any system of "allocation" (aka "rationing" given the large disparity between supply and demand), there are always going to be groups that are either "advantaged" or "disadvantaged." True equity cannot be achieved in the absence of an adequate supply of organs. In the interim, we must strive to mitigate large disparities and systematic barriers to transplant while not sacrificing utility in lieu of equity. Trying to remove or minimize local geography from the allocation formula for the sake of equity and ignoring the impact on allocation efficiency and organ utilization is proving to be an unwise endeavor. Many have suggested that OPO and transplant center metrics need better alignment to optimize utilization. We would add that it is essential to have allocation policy in alignment with OPO and transplant center behavior and capabilities to promote utilization and efficient placement of organs. It is important to note that changes in OPO behavior (pursuing more nonideal donors) plays a role in the rising nonutilization rate. However, in 10% of cases of kidney nonuse, one kidney from the donor is successfully transplanted and the major reason for mate kidney nonuse is prolonged CIT and logistics.5 In addition to longer CITs, the number of donation after circulatory death donors is rising out of proportion to other types of deceased donors.6 We have previously shown that the rates of early graft loss and primary nonfunction are increased 2–3-fold with high KDPI and donation after circulatory death donor kidneys if CITs are >24 h.7 Because the annual number of deceased donors is steadily increasing, the total number of kidney transplants performed do not reflect the missed opportunities to improve utilization.6 We as a community have a good understanding of the phenotype of "hard to place" deceased donor kidneys, yet we continue to promote a "one size fits all" approach to organ allocation and distribution by failing to implement a meaningful expedited allocation system to direct nonideal donor kidneys to transplant centers with an "aggressive center" phenotype and make it possible for centers to allocate these organs to an appropriate individual who may be "far down the list."8 The Eurotransplant experience has demonstrated that expedited or "rescue allocation" is successful not only in placing nonideal kidneys efficiently but also achieves acceptable patient and graft outcomes. Recently, Eurotransplant has implemented 2 procedurally different modes of rescue allocation: recipient-oriented extended allocation and competitive rescue allocation to further reduce CIT and improve kidney utilization.9 In the United States, the United Network for Organ Sharing Center Kidney Accelerated Placement project concluded that "waiting to accelerate placement after kidneys have been declined by multiple transplant programs locally and regionally is an intervention that may come too late to effectively increase utilization."10 It is evident that potentially usable kidneys are not transplanted because they are not offered to the "right recipient" or the "right transplant center" at the right time. Complicated logistics with a projected long CIT has become one of the primary reasons for kidney refusal and subsequent nonutilization. Based on the findings of this and other recent studies, Health Resources and Services Administration's patient-centric approach to modernizing the US transplant system is headed in the wrong direction and the kidney nonutilization rate will continue to climb. As a community, we need to be vigilant in surveilling the impact of any policy changes and pivot when needed to ensure equity, fairness, justice, access, utility, and excellent posttransplant outcomes for all patients. In the words of Voltaire, "The enemy of good is better." Changes to allocation policy must be carefully crafted to protect us from "throwing the baby out with the bathwater" as we strive to address inefficiencies in our current system of allocating scarce resources.
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