Cooperative kidney paired donation (KPD) networks account for an increasing proportion of all living donor kidney transplants in the United States. There are sparse data on the rate of primary nonfunction (PNF) losses and their consequences within KPD networks. We studied National Kidney Registry (NKR) transplants (February 14, 2009 to December 31, 2017) and quantified PNF, graft loss within 30 days of transplantation, and graft losses in the first-year posttransplant and assessed potential risk factors. Of 2364 transplants, there were 38 grafts (1.6%) lost within the first year, 13 (0.5%) with PNF. When compared to functioning grafts, there were no clinically significant differences in blood type compatibility, degree of HLA mismatch, number of veins/arteries, cold ischemia, and travel times. Of 13 PNF cases, 2 were due to early venous thrombosis, 2 to arterial thrombosis, and 2 to failure of desensitization and development of antibody-mediated rejection (AMR). Given the low rate of PNF, the NKR created a policy to allocate chain-end kidneys to recipients with PNF following event review and attributable to surgical issues of donor nephrectomy. It is expected that demonstration of low incidence of poor early graft outcomes and the presence of a "safety net" would further encourage program participation in national KPD.

This review article provides ethical guidance for determining which kinds of financial benefits provided to living organ donors are ethically appropriate. It does so by way of ethical analysis of a policy case study: the National Kidney Registry (NKR) has implemented a donor insurance program to all its living donors. Is such a policy ethically supportable, or is it an unethical practice? The article proceeds as follows. First, a framework for grounding the ethical commitments of transplant programs is defended. It is argued that this framework can be accepted by all who work in transplant medicine, regardless of differences in ethical theory preference or background. Second, from this framework two ethical principles are formulated. (1) Living donors should, as far as possible, not be worse off for donating. (2) Disincentives towards donation should be removed as much as possible. Third, issues with unethical incentives are explored: undue inducement, commodification of the body, potential decreased organ donation rates, and potential exploitation of vulnerable populations. Lastly, these ethical considerations are applied to the policy change at the NKR, showing that the NKR policy change appears to be ethically supportable. Financial benefits provided to donors are ethically sound if they are in keeping with principles (1) and (2), and do not cause undue inducement, commodification, decreased organ donation, or exploitation. It is ethically appropriate for transplant programs to institute as well as study such programs with the goal of serving the welfare and interests of patients, donors, and the general public.

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation & Vascular Surgery I1 Apr 2018MP61-01 EVALUATING THE FEASIBILITY OF A VOUCHER PROGRAM FOR KIDNEY DONATION Avi Baskin, Patrick Shannon, Rich Marta, Matt Ronin, Garet Hil, and Jeffrey Veale Avi BaskinAvi Baskin More articles by this author , Patrick ShannonPatrick Shannon More articles by this author , Rich MartaRich Marta More articles by this author , Matt RoninMatt Ronin More articles by this author , Garet HilGaret Hil More articles by this author , and Jeffrey VealeJeffrey Veale More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1980AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The donation of a kidney at the optimal time for a living donor can create a ″voucher″ that the donor′s specified recipient can redeem later when medically indicated. However, there is concern that any organization that would take on responsibility for a voucher program would be overwhelmed if the number of vouchers redeemed in any given year outnumbers availability of kidneys. The objective of this study is to estimate how many vouchers would be redeemed per year based various scenarios regarding number of vouchers added per year and health and age status of the voucher recipient at the time the voucher is granted. METHODS A Monte Carlo simulation model was developed to estimate the ability to fulfill voucher requests over time. The simulation model utilizes voucher redemption probability distributions for three groups: healthy voucher recipients, recipients with chronic kidney disease (CKD) and those who had received a prior transplant. The model bases probability of kidney failure and death from data from the National Institute of Digestive Diseases and the United Network of Organ Sharing. The initial scenario tested is based upon the 21 vouchers dispersed thus far by the National Kidney Registry with a recipient mix containing 30% healthy, 35% with CKD (stage 3 or greater) and 35% having had a prior transplant. These 21 recipients form the starting conditions for Year 1 in the model. In this scenario, in each subsequent year (2-50) the number of new vouchers added increases by 2% with the same mix of healthy, CKD, and prior transplanted recipients as in Year 1. RESULTS We ran 1000 independent simulations each lasting 50 years. Of the 1,000 replications, the maximum number of outstanding voucher obligations by Year 50 was 3,390. In this specific scenario the maximum estimated total of vouchers redeemed is 788. Thus, in the most conservative simulation, the number of donors far exceeds the number of vouchers projected to be redeemed. The figure below shows the number of new vouchers donors and the maximum number of vouchers projected to be redeemed each year. CONCLUSIONS At any time the simulation shows that many more donors are contributing kidneys to the system than vouchers are being redeemed. Based on these results, the voucher system is sustainable. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e823-e824 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Avi Baskin More articles by this author Patrick Shannon More articles by this author Rich Marta More articles by this author Matt Ronin More articles by this author Garet Hil More articles by this author Jeffrey Veale More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation, Vascular Surgery II1 Apr 20122280 WAIT-TIME VARIES BY BLOOD-TYPE AND CALCULATED PANEL REACTIVE ANTIBODY FOR INCOMPATIBLE PAIRS IN KIDNEY EXCHANGE Jeff Veale, Marc Melcher, Connie Davis, Elizabeth Berger, Joe Sinacore, Matt Ronin, Garet Hil, and John Milner Jeff VealeJeff Veale LA, CA More articles by this author , Marc MelcherMarc Melcher Stanford, CA More articles by this author , Connie DavisConnie Davis Seattle, WA More articles by this author , Elizabeth BergerElizabeth Berger Maywood, IL More articles by this author , Joe SinacoreJoe Sinacore Babylon, NY More articles by this author , Matt RoninMatt Ronin Babylon, NY More articles by this author , Garet HilGaret Hil Babylon, NY More articles by this author , and John MilnerJohn Milner Maywood, IL More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.2458AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Though important, time waiting to kidney transplant has not been a major focus of transplant centers in regard to a potential kidney transplant recipient waiting with an incompatible living donor. The purpose of this study is to report time-waiting-to-transplant in a large, multi-institutional kidney transplant exchange registry. METHODS A 2-year interval from January 2010 to December 2011 was defined to review time waiting to transplant in a prospectively gathered, multi-institutional registry database created for incompatible living donor-recipient pairs seeking a compatible transplant by exchanging donors. The database was reviewed for recipient wait-time from registration to transplants completed during the interval, and further stratified by the blood types of the incompatible living donor and recipient, and the calculated panel reactive antibody of the recipient assessing how these variables influence wait-time. RESULTS During the interval, a total of 190 transplants were performed, 6 via loops, and 184 via chains. 54 chains were active, 50 eventually closing to the standard wait-list, 2 ongoing, and 2 broken when a bridge donor became unavailable. The average wait-time from registration to transplant was 4 months for recipients with a cPRA of 0 (n=80), 5 months for a cPRA of 0-80% (n=46), 6 months for a cPRA of 80-95% (n=35), and 9 months for a cPRA > 95% (n=29), with an overall wait-time for those transplanted of 6 months (n=190). The average wait-time was 4 months (n=7) for blood type AB recipients, 5 months (n=66) for blood type A recipients, 6 months (n=33) for blood type B recipients, and 8 months (n=84) for blood type O recipients. On the other hand, 212 patients were still awaiting transplant with enrollments continuing throughout the interval, 15% having a cPRA of 0% (n=31), 11% a cPRA of 0-80% (n=24), 8% a cPRA of 80-95% (n=16), and 67% a cPRA of >95% (n=141). A majority of patients still waiting had non-blood type O incompatible donors (n=128), and were sensitized with donor specific antibody (n=181). CONCLUSIONS Wait-time increases with increasing recipient cPRA, and varies by the blood type of the incompatible donor and recipient with blood type O recipients waiting longer on average than blood type B recipients, followed by blood type A recipients, with blood type AB recipients waiting the shortest time to exchange transplant. Sensitized patients who register blood type O incompatible donors, and who register more than one incompatible donor may increase their probability of finding a match more quickly. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e919-e920 Peer Review Report Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jeff Veale LA, CA More articles by this author Marc Melcher Stanford, CA More articles by this author Connie Davis Seattle, WA More articles by this author Elizabeth Berger Maywood, IL More articles by this author Joe Sinacore Babylon, NY More articles by this author Matt Ronin Babylon, NY More articles by this author Garet Hil Babylon, NY More articles by this author John Milner Maywood, IL More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...