Do factors like race and gender come into play, consciously or unconsciously, when transplant centers are offered donor kidneys? It looks that way, according to the results of a study published in the July 2017 Clinical Journal of the American Society of Nephrology (CJASN). The research analyzed deceased donor adult kidney offers to patients at the top of wait lists spanning 2007-2012 to see how often the kidneys were accepted or rejected. They then looked at these acceptance rates to discover any discrepancies between groups. In total, 7 million offers were analyzed. Kidneys were offered a median of seven times before finally being accepted for transplantation.
So, why all the rejections for such a seemingly in-demand organ? To lay people, the process of matching a donor kidney with a recipient seems pretty cut and dried. However, pairing an organ that's likely to work given a patient's specific circumstances is complex, to say the least. "We found that transplant centers largely pass on organ offers based upon certain donor, recipient and their center characteristics. These characteristics include donors with high blood pressure, a history of diabetes, reduced kidney function or death from cardiac reasons," explains lead researcher and nephrologist, Anne Huml, M.D., with Case Western Reserve University in an email interview.
Why Some Centers Accept Kidneys Others Reject
Although there are plenty of legitimate medical reasons to decline a kidney, the complexity of this process is compounded by any number of other factors like human error, biases and individual transplant program policy. The data examined uncovered some unsettling trends.
"Waitlisted patients who are male, Hispanic, have high blood pressure as cause of kidney failure or high body mass indexes (BMI) are less likely to have kidneys accepted for them for transplant," Huml says. "High volume transplant centers are more likely to accept organ offers while those with a higher percentage of minorities on their waiting list were less likely to accept organ offers."
Sometimes a kidney comes along that could be a perfectly good match for the patient, but thee transplant center itself declines use of the organ for reasons that another program might not. "A third of all refusals in the analysis were related to concerns about organ quality and yet a majority of these organs were eventually transplanted by other centers," write Sumit Mohan, M.D. and Mariana Chiles, Ph.D. in an editorial accompanying the article publication. "The initial refusal, but eventual acceptance, of the majority of deceased donor kidneys suggests: (1) that underestimating the quality of an organ is a common and recurring problem; and (2) there are external factors that influence clinician behavior such as center philosophy/culture and risk aversion that occurs in response to the current regulatory monitoring/reporting of transplant outcomes."
The findings have some pretty big implications for patients on the wait list, who typically spend long periods of time on dialysis waiting for a match. "Annually, about 8,000 patients die or become too ill and are removed from the list before getting a transplant," Huml says, noting that gender, race and socioeconomic disparities in access to kidney transplantation are nothing new. This study is the first to look at the refusal codes for deceased donor kidneys.
Often, patients don't even know that kidneys are being offered and declined on their behalf. According to the editorial authors, although it's probably not logistically feasible or ethical for programs to loop patients in on the process (the decision must be made to accept or reject very quickly and with great clinical care), awareness of a particular transplant center's practices can help a patient decide whether to pursue care there, or seek out a more aggressive program. "Patients should be informed if their wait times are likely to be inflated because of a conservative transplant program philosophy or if there are regulatory pressures or concerns that will impede their ability to get transplanted in a timely manner or at all," the editorial authors note.
Researchers are hoping that, by shedding light on organ acceptance disparities, that transplant centers will take a long, hard look at their own acceptance habits and practices. For instance, the editorial authors point out that kidneys from donors with diabetes have consistently been shown to have excellent post-transplant outcomes. Yet they are often rejected.
"Transplant centers may also strategize how to change their acceptance practices to optimize acceptances by monitoring refusals of offers, both among all waitlisted patients and among specific subgroups," Huml says.
Turning the tide on this practice could be as simple as informing transplant centers of outcomes. Indeed, some programs may be unaware that kidneys they deemed unusable turn out to be more than viable. "Informing providers who decline an organ, that it was successfully used by another center would potentially lead to a course correction," the editorial authors note. "Closing the feedback loop would encourage providers to re-examine their decisions and by extension, their biases and preferences."