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.