Reinstating waiting time after allograft failure will yield more transplants

National Kidney Foundation

Policy analysis shows that reinstating waiting time for recipients experiencing allograft failure up to one year following transplantation would yield higher number of additional transplants compared to a growth in the number of people added to transplant waitlist.

The shortage of deceased donor kidneys (DDKs) identified for potential transplantation in the United States is exacerbated by a high proportion of deceased donor kidneys discarded after procurement. Researchers led by S. Ali Husain propose a simple allocation system change: allowing DDK recipients with early post-transplant allograft failure within an expanded timeframe to regain their waiting time. In a study published in the American Journal of Kidney Diseases (AJKD), they estimate that the proposed policy change would potentially increase access to transplantation at a net benefit to the waiting list (i.e. a greater number of additional transplants performed than excess patients whose waitlist time is reinstated) under almost every combination of assumptions about the failure rates of the DDKs that are “rescued” from discard. The rationale for this policy change is to reduce the perceived patient-level risk of transplanting marginal DDKs, and its rationale is based on the knowledge that humans overweigh the value of a potential loss more than a potential gain of the same value and overvalue temporally proximal gains or losses a hyperbolic manner. Further, we tend to overestimate the probability of rare events. In kidney transplantation, the combination of these cognitive biases favors avoidance of the use of marginal organs through overweighed consideration of poor outcomes even when the most probable outcome is favorable to the patient in the long term. The researchers believe that eliminating a temporally proximal potential adverse effect of early graft failure—loss of waiting time— could therefore potentially significantly improve DDK utilization even though it will only be invoked in a small number of cases. Although these results are theoretical, policies that aim to improve organ utilization by addressing cognitive processes underlying suboptimal organ offer acceptance warrant further study.

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