Public health implications of renal transplant candidates on the Expanded Criteria Donor waiting list

BACKGROUND: A public health organ crisis exists in the United States. To increase the inadequate Deceased Donor kidney pool, Expanded Criteria Donation (ECD) of marginal kidneys for older, sicker patients was instituted. Studies demonstrate improved morbidity and mortality in ECD recipients. Implementation, however, remains highly variable. Our goal was to assess demographics of renal transplant candidates listed for ECD waitlists and the impact on ECD utilization at center, regional, national levels.

METHODS: We conducted a cross-sectional study comparing Rhode Island Hospital (RIH), the regional organ procurement organization (OPO), Organ Procurement and Transplantation Network (OPTN) and Scientific Registry of Transplant Recipients (SRTR) databases. Approximate statistical analysis was performed to calculate crude Odds Ratios and 95% Confidence Intervals. Exposures examined were age, ethnicity, gender, diagnosis, bloodtype. Outcomes were ECD waitlisting, ECD transplantation.

RESULTS: Patients at RIH are less likely to be ECD waitlisted than patients at other centers in the New England OPO (53.1% versus 34.1%) and nationally (14.7%). 15% of both ECD and Standard Criteria Donation (SCD) waitlisted candidates in the nation are transplanted compared to 28% at RIH and 17.8% in New England. Increased likelihood of being waitlisted for ECD was associated with increasing age (OR 14.01), male gender (OR 1.28), diabetes mellitus (OR 1.40), and non-white/non-black ethnicity (OR 1.69) at all sites.

CONCLUSIONS: The utilization of ECD kidneys varies. Efforts to optimize utilization of marginal kidneys should reduce discards, shorten wait times and improve allocation policy based on differences in health outcomes.