A Time-to-Equivalent Risk (TiTER) for decision-making in deceased donor kidney transplant candidates

Area of Science:

• Nephrology
• Transplant Surgery
• Public Health Policy

Background:

• The Time-to-Equivalent Risk (TiTER) tool aids organ acceptance decisions in the US.
• Extreme organ scarcity in Korea may alter TiTER applicability for deceased donor kidney transplantation (DDKT).

Purpose of the Study:

• To estimate the Korean Time-to-Equivalent Risk (K-TiTER) using nationwide data.
• To analyze DDKT versus waitlist mortality patterns in Korea.
• To assess K-TiTER applicability across diverse patient demographics and donor qualities.

Main Methods:

• Nationwide cohort data from 2008-2022 from the Korean Network for Organ Sharing and National Health Insurance.
• Analysis of cumulative incidence and competing risks of DDKT versus waitlist mortality.
• Stratification by recipient age, Korean Estimated Post-Transplant Survival (K-EPTS), blood type, and donor quality.

Main Results:

• Among 51,427 waitlisted patients, 20.6% received DDKT; DDKT incidence was initially lower than mortality.
• K-TiTER was defined as when DDKT probability exceeds waitlist mortality.
• K-TiTER was often not reached for elderly patients, those with high K-EPTS, or blood type O.
• Expanding donor acceptance criteria shortened the time to probability crossover, mitigating waitlist mortality.

Conclusions:

• The K-TiTER framework offers preliminary hypotheses for identifying vulnerable kidney transplant candidates.
• K-TiTER may guide tailored allocation strategies and clinical trial enrollment for high-risk patients.
• Suboptimal donor organs can be strategically used to reduce waitlist mortality.