Impact of Extending Eligibility for Reinstatement of Waiting Time After Early Allograft Failure: A Decision Analysis

Abstract

Rationale & objective: The shortage of deceased donor kidneys identified for potential transplantation in the United States is exacerbated by a high proportion of deceased donor kidneys being discarded after procurement. We estimated the impact of a policy proposal aiming to increase organ utilization by extending eligibility for waiting time reinstatement for recipients experiencing early allograft failure after transplantation.

Study design: Decision analysis informed by clinical registry data.

Setting & population: We used Organ Procurement and Transplantation Network data to identify 76,044 deceased-donor kidneys procured in the United States from 2013 to 2017, 80% of which were transplanted and 20% discarded.

Intervention: Extend waiting time reinstatement for recipients experiencing allograft failure from the current 90 days to 1 year after transplantation.

Outcome: Net impact to the waitlist, defined as the estimated number of additional transplants minus estimated increase in waiting list reinstatements.

Model, perspective, & timeframe: We estimated (1) the number of additional deceased donor kidneys that would be transplanted if there was a 5%-25% relative reduction in discards, and (2) the number of recipients who would regain waiting time under a 6-, 12-, 18-, and 24-month reinstatement policy.

Results: Reinstating a waiting time for recipients experiencing allograft failure up to 1 year after transplantation yielded more additional transplants than growth in additions to the waiting list for all model assumptions except the combination of a very low relative reduction in discards (5%) and a very high failure rate of transplanted kidneys that would previously have been discarded (≥5 times the rate of currently transplanted kidneys).

Limitations: Lack of empirical evidence supporting the proposed impact of such a policy change.

Conclusions: A policy change reinstating waiting time for deceased donor kidneys recipients with allograft failure up to 1 year after transplantation should explored as a decision science-based intervention to improve organ utilization.

Keywords: Allograft failure; deceased donor; decision making; end-stage renal disease (ESRD); health policy; kidney transplantation; marginal organs; organ allocation; organ discard; organ utilization; transplant outcomes; waitlist time.