Kidney utility and futility.

Area of Science:

• Nephrology
• Transplantation
• Organ Logistics

Background:

• Kidney allocation systems face significant strain due to changes in allocation policies and the COVID-19 pandemic.
• The proportion of marginal deceased donors (MDDs) is increasing, leading to challenges in organ utilization.
• Rising cold ischemia times and kidney discard rates are linked to inadequate planning, resources, and logistical complexities.

Purpose of the Study:

• To address the growing challenge of utilizing marginal deceased donor kidneys.
• To propose improvements in organ allocation and distribution systems for increased kidney utilization.
• To highlight the need for agile and flexible systems to accommodate a rising number of MDDs.

Main Methods:

• Analysis of current kidney allocation and distribution systems.
• Identification of factors contributing to the rising discard rates of MDDs.
• Review of logistical challenges and clinical decision-making in organ acceptance.

Main Results:

• Current "one size fits all" allocation approaches are insufficient for the increasing number of MDDs.
• Logistical issues and reperfusion time constraints heavily influence organ acceptance decisions.
• A significant proportion of MDD kidneys are considered "hard to place" despite understanding their phenotype.

Conclusions:

• Current organ allocation and distribution systems require significant adaptation to handle the increasing volume of MDDs.
• Implementing "fast-track" or open offer policies for "hard to place" MDDs can dramatically improve utilization rates.
• A shift towards location, motivation, and innovation-based organ allocation is necessary to prevent escalating discard rates and improve utility.