Categories
Deceased Organ Donation Organ Allocation

Older Kidneys Are A Good Alternative For Older Recipients

“[Deceased donor] organs from older donors are often discarded due to the macroscopic appearance of the parenchyma or major vessels. On the other hand, a large number of elderly patients are potential candidates for kidney transplantation, while many kidneys from elderly deceased donors are discarded due to a lack of age-matched recipients. In addition, a large number are often discarded due to the lack of compatible recipients among elderly patients undergoing chronic dialysis.”

“From 2007 to 2012, we performed a prospective observational study comparing 26 elderly patients receiving PKT with a control group of 26 elderly patients receiving a first transplant after prior dialysis.”

 

“Mean age of recipients was 74.3 ± 2.9 years and mean age of donors was 73.8 ± 4.1 years.”

 

“Death-censored graft survival was 96% in the PKT pre-emptive kidney group; prior to dialysis] group and 68% in the control group, at 5 years after transplantation. Immediate and delayed graft function occurred in 92% and 3.8%, respectively, of patients in the PKT group and 53% and 34.6% of patients in the control group . Acute rejection was significantly more frequent in PKT patients (23.1% vs 3.8%).

At the end of follow-up time 35.5 ± 20.1 months, the glomerular filtration rate GFR] was similar in both groups (42.2 ± 11.7 vs 41.7 ± 11.2 ml/min, p-value = 0.72). Patient survival was similar in the two groups.”

 

Morales, E., Gutiérrez, E., Hernández, A., Rojas-Rivera, J., Gonzalez, E., Hernández, E., Polanco, N., Praga, M., & Andrés, A. (2015). Preemptive kidney transplantation in elderly recipients with kidneys discarded of very old donors: A good alternative Nefrología (English Edition), 35 (3), 246-255 DOI: 10.1016/j.nefroe.2015.07.003

Categories
OPTN Organ Allocation

OPTN new kidney allocation policy

Here’s OPTN’s new kidney allocation policy: http://optn.transplant.hrsa.gov/ContentDocuments/Policy8_Update_KAS_12-2014.pdf

If adopted by the Executive Committee, it will go into effect the end of 2014.

This new policy is an attempt at wider sharing of organs, and a move toward a true national system (as federal law requires). The regions that have benefited from the prior system aren’t happy about these changes. OPTN will probably apply this same idea to liver allocation, which is why articles have already begun appearing from hospitals whining about the possibility.

This new policy affects prior living donors who need a transplant, but it’s unclear how, specifically. See section 8.5.F for more.

 

Categories
OPTN Organ Allocation

My Only Post on Lung Transplants in Children

Only because there’s so much bad information floating around about this.

Development of the New Lung Allocation System in the United States” by Egan et al. From 2006 regarding 2004 allocation changes. 

(emphasis mine)

Pediatric candidates for lung transplantation pose vexing challenges. In young patients, there are serious size constraints for thoracic organs in general and lungs in particular, because of the effect of age and height on the volume of the chest cavity that must accommodate the graft. Fortunately, the incidence of life-limiting lung disease in very young patients is quite low, making the demand for pediatric lungs much less than that seen for adults with end-stage lung diseases. However, the number of sudden deaths leading to organ donation in children is also low, making the number of potential lung donors in this segment of the population also low, and inadequate to meet the demands of lung transplant programs.

Based on analysis of the distribution of diagnoses of waitlisted and transplanted pediatric candidates and recipients, it appeared that there was a difference in diagnosis patterns and incidence of diagnoses among children younger than 10 or 11 years, and among teenagers, whose incidence of certain diagnoses for end-stage lung disease resembled that of a cohort of adults in the third decade of life. Additional analyses of waiting list and post-transplant survival by age for patients younger than 18 years (summarized partially in data tables of the OPTN/SRTR Annual Report) led the Subcommittee to conclude that there appeared to be a ‘break point’ at the age of 12 years. Adolescent and teenage lung transplant recipients aged 12 years and older had similar incidence of diagnoses and waiting list and posttransplant survival to young adults, while children younger than 12 years old had different diagnoses and survival probabilities. Thus, the Subcommittee decided to group all potential recipients younger than 12 years together as a separate group (Group E), place all patients aged 12 years and older in Groups A through D, and repeat the analyses to identify predictors of waiting list and post-transplant survival.

Because of the small number of potential recipients younger than 12 years, risk factors for death cannot be reliably calculated with the available data. After consultation with large-volume pediatric lung transplant programs at Children’s Hospital of Philadelphia and St. Louis Children’s Hospital, Washington University, it was decided that, until sufficient data become available, time on the waiting list remained the most appropriate way to allocate lungs to this small group of patients.

 

The policy is not “arbitrary” nor “not based in science” or not “data supported”. And neither is it a product of the ACA  (aka Obamacare). Any questions?

 

Full article: http://onlinelibrary.wiley.com/doi/10.1111/j.1600-6143.2006.01276.x/full

Categories
Deceased Organ Donation Liver Donor Organ Allocation

No Reason Not to Use Deceased Liver Donors Over 60 Years Old

As OPTN has admitted, organs from deceased donors over the age of 50 are often discarded despite being viable. A recent study compared patient and graft (transplanted organ) survival rates in liver transplant recipients given livers from deceased donors younger than 60, 60-70 years of age, and older than 70 years old.

Summary results are as follows:

 

Patient survival 1-year 3 year 5-year
<60yoa   (n=226) 81% 76.1% 71%
60-70yoa    (n=75) 83.8% 74% 72.2%
>70yoa   (n=25) 76% 70% 64.1%

 

Graft Survival 1-year 3-year 5 year
<60yoa   (n=226) 74.8% 69% 64.1%
60-70yoa    (n=75) 82.7% 71.4% 69.6%
>70yoa   (n=25) 71.4% 64.8% 58.3%

 

Conclusion;

Because patient and graft survival rates are not affected by donor age, well-selected older donor livers can be safely used if they show good function and preharvesting conditions.

 

Read full abstract here: http://link.springer.com/article/10.1007/s00268-013-2085-7

Categories
Advocacy Ethical Considerations Living Donor Protections Living Kidney Donor OPTN Organ Allocation

Proposed Kidney Allocation and Independent Donor Advocate Policies Detrimental to Living Donors

Today we have a guest post by Jane Zill, LICSW on OPTN’s proposed policies now up for public comment:

 

The Board of the OPTN will vote on new allocation principles for deceased donor kidneys in June. These allocation principles will definitely impact living organ donors. I am very concerned about this and believe that we should reach out to OPTN Board members immediately and to the Kidney Committee that sponsored this proposal. We don’t have much information about living donors who develop end stage renal disease. A few years ago it was thought to be only 56 but now a new tally is 324*. Because systematic data collection has never been required we do not have an accurate count or an understanding of the factors that led to organ failure in these people.

 

Also, public comment closes in June on a proposal for Independent Donor Advocacy. While the proposal represents hard work and good faith of the members of the Living Donor Committee, it falls far short of what is considered to be best practice. I believe that the wisest and safest route to go would be to ask HRSA to reverse its 2006 decision that gave the OPTN authority (thus the transplant surgical community) to make policy about living organ donation. The transplant surgical community has a conflict of interest regarding living donors that should preclude them from the ability to make their own policy about how they will care for living donors. Since 2006 their efforts have been very unproductive, while KPD [kidney paired donation] that requires the use of living donors, is gaining traction.

 

We need a National Center for the Independent Care and Advocacy for Living Organ Donors, which is totally apart from the purview of the OPTN or the transplant community. Public comment closes on the proposal about Independent Donor Advocacy in June.

 

PLEASE ADDRESS THESE VERY IMPORTANT ISSUE THROUGH THE PUBLIC COMMENT PROCESS OR BY WRITING TO THE KIDNEY COMMITTEE OF MEMBERS OF THE BOARD. IF ANY WOULD LIKE HELP WRITING THEIR COMMENT, PLEASE LET ME KNOW. IF ANYONE WOULD LIKE TO COLLABORATE TO CREATE A DRAFT DOCUMENT(S) FOR OTHERS TO USE TO MAKE PUBLIC COMMENT, PLEASE LET ME KNOW.

 

Jane

Here is a .pdf of Jane’s public comment  at the OPTN Region 1 meeting in Worcester, MA. –   Public comment; Region 1, 4-13; IDA -1

 

(Check OPTN’s calendar; your regional meeting may be upcoming. They are open to the public)

 

Table that compares models of Independent Donor Advocacy: Best Practices, CMS Final Rule 2007 and OPTN’s current policy: Models of Independent Living Donor Advocacy

 

To submit your own public comment on the OPTN proposals: http://optn.transplant.hrsa.gov/policiesAndBylaws/publicComment/proposals.asp

Also, you can feel free to contact Jane directly, leave a comment here or email me if you’d like more information or to receive a template to submit to OPTN.

 

 

*note: I’ll be posting the most recent living kidney donors waitlisted numbers soon.