Uncontrolled donation after cardiac death kidney transplantation: Opportunity to expand the donor pool?

BACKGROUND: Compared to controlled donation after cardiac death (cDCD), uncontrolled DCD (uDCD) kidney transplantation remains an underutilized resource in the United States. However, it is unclear whether long-term allograft outcomes following uDCD are inferior to that of cDCD kidney transplantation. METHODS: From January 1995 to January 2018, the OPTN/UNOS database was queried to discover all reported cases of uDCD and cDCD kidney transplantation. Primary non-function, delayed graft function, ten-year graft and patient survival were compared among uDCD and cDCD patients. RESULTS: Rates of primary non-function (4.0% [uDCD] vs. 1.8% [cDCD], P < 0.001) and delayed graft function (51.1% [uDCD] vs. 41.7% [cDCD], P < 0.001) were higher following uDCD transplant. However, ten-year graft survival (47.5% [uDCD] vs. 48.4% [cDCD], P = 0.21) and patient survival were similar to cDCD transplantation (59.4% [uDCD] vs. 59.2% [cDCD], P = 0.32). CONCLUSION: Although initial allograft outcomes are inferior following uDCD, long-term durability of uDCD kidney allografts is on par to cDCD transplantation. Kidney allografts derived by uDCD may be a viable and durable option to increase the donor pool.

STEP improves long-term survival for pediatric short bowel syndrome patients: A Markov decision analysis.

INTRODUCTION: Increasingly, for pediatric patients with short bowel syndrome (SBS), intestinal lengthening procedures such as serial transverse enteroplasty (STEP) are being offered with the hope of improving patients' chances for achieving enteral autonomy. However, it remains unclear to what extent STEP reduces the long-term need for intestinal transplant or improves survival. METHODS: Based on existing literature, a decision analytic Markov state transition model was created to simulate the life of 1,000 pediatric SBS patients. Two simulations were modeled: 1) No STEP: patients were listed for transplant once medical management failed and 2) STEP: patients underwent STEP therapy and subsequent transplant listing if enteral autonomy was not achieved. Sensitivity analysis of small bowel length and anatomy was completed. Base case patients were defined as neonates with a small bowel length of 30cm. RESULTS: For base case patients with an ostomy and a NEC SBS etiology, STEP was associated with increased rates of enteral autonomy after 10 years for patients with an ICV (53.9% [STEP] vs. 51.1% [No STEP]) and without an ICV (43.4% [STEP] vs. 36.3% [No STEP]). Transplantation rates were also reduced following STEP therapy for both ICV (17.5% [STEP] vs. 18.2% [No STEP]) and non-ICV patients (20.2% [STEP] vs. 22.1% [No STEP]). 10-year survival was the highest in the (+) STEP and (+) ICV group (85.4%) and lowest in the (-) STEP and (-) ICV group (83.3%). CONCLUSIONS: For SBS patients, according to our model, STEP increases rates of enteral autonomy, reduces need for intestinal transplantation, and improves long-term survival. TYPE OF STUDY: Economic/Decision Analysis or Modeling Studies LEVEL OF EVIDENCE: Level III.

Uncontrolled donation after circulatory death improves access to kidney transplantation: A decision analysis.

AIM: Uncontrolled donation after cardiac death (uDCD) remains an underutilized source of kidney allografts in the United States. The objective of this study was to estimate the impact of the implementation of a uDCD program on transplantation rates and long-term survival for patients with end-stage renal disease (ESRD) in the United States. METHODS: A decision-analytic Markov state transition model was created using medical decision-making software (DATA 3.5; TreeAge Software, Inc) to estimate the impact of an uDCD program on transplantation rates and patient survival. Additionally, sensitivity analysis of uDCD donor pool increase was modeled. All model statistic parameters were extracted from the literature. RESULTS: A uDCD program increased the rate of transplant at 10 years (37.8%, Accept uDCD group, vs 35.9%, Reject uDCD group). At 10 years, overall survival for Accept uDCD was 55.6% compared to 54.8% in the Reject uDCD. CONCLUSIONS: Uncontrolled DCD improves access to transplant for ESRD patients on the kidney transplant waitlist, thereby improving long-term survival.

Sleeve Gastrectomy Compared with Gastric Bypass for Morbidly Obese Patients with End Stage Renal Disease: a Decision Analysis.

INTRODUCTION: The use of bariatric surgery has increased for morbidly obese patients with end stage renal disease (ESRD) for whom listing on the waitlist is often restricted until a certain BMI threshold is achieved. Effective weight loss for this population improves access to life-saving renal transplantation. However, it is unclear whether sleeve gastrectomy (SG) vs Roux-en-Y gastric bypass (RYGB) is a more effective therapy for these patients. METHODS: A decision analytic Markov state transition model was created to simulate the life of morbidly obese patients with ESRD who were deemed ineligible to be waitlisted for renal transplantation unless they achieved a BMI less than 35 kg/m2. Life expectancy following weight management (MWM), RYGB, and SG were estimated. Base case patients were defined as having a pre-intervention BMI of 45 kg/m2. Sensitivity analysis of initial BMI was performed. Markov parameters were extracted from literature review. RESULTS: RYGB improved survival compared with SG and MWM. RYGB patients had higher rates of transplantation, leading to improved mean long-term survival. Base case patients who underwent RYGB gained 1.3 additional years of life compared with patient's who underwent SG and 2.6 additional years of life compared with MWM. CONCLUSIONS: RYGB improves access to renal transplantation and thereby increases long-term survival compared with SG and MWM. The use of SG may be incongruent with the goal of improving access to renal transplantation for morbidly obese patients.

Uncontrolled deceased cardiac donation: An unutilized source for organ transplantation in the United States.

The practice of uncontrolled donation after cardiac death (uDCD) has been met with tepid interest within the United States transplant community. Hesitancy stems largely from fears of eroding public trust due to complex ethical issues involving consent. Beyond ethical concerns, uDCD creates unique logistic challenges to obtain and to preserve organs within a short time frame. This mandates that organ recovery centers be able to rapidly mobilize, and that traditional cold preservation techniques may be inadequate. Proof of effective uDCD organ recovery comes from several European nations, and the frequency of its use is increasing due to early promising results. These scarce resources provide life-saving organs to desperate transplant candidates who otherwise experience high morbidity and mortality on a transplant waitlist. The objective of this review will be to provide an overview of the European experience with uDCD and discuss the unique ethical and logistic challenges associated with its implementation in the United States. Given existing models for it successful use, uDCD remains a poorly utilized source of donors in the United States at this time.