Volker Assfalg1,2, Gregor Miller3, Felix Stocker1,2, Marieke van Meel4, Tiny Groenevelt4, Ineke Tieken4, Donna Ankerst3, Lutz Renders1,5, Alexander Novotny1,2, Daniel Hartmann1,2, Alissa Jell1,2, Axel Rahmel4, Roger Wahba6, Anja Mühlfeld7, Antonia Bouts8, Dirk Ysebaert9, Brigitta Globke10, Daniel Jacobs-Tulleneers-Thevissen11, László Piros12, Dirk Stippel6, Katharina Heller13, Ute Eisenberger14, Steven van Laecke15, Rolf Weimer16, Alexander R Rosenkranz17, Stefan Berger18, Lutz Fischer19, Volker Kliem20, Florian Vondran21, Urban Sester22, Stefan Schneeberger23, Ana Harth24, Dirk Kuypers25, Reinhold Függer26, Miha Arnol27, Maarten Christiaans28, Julia Weinmann-Menke29, Bernd Krüger30, Luuk Hilbrands31, Bernhard Banas32, Oliver Hakenberg33, Robert Minnee34, Vedat Schwenger35, Nils Heyne36, Arjan van Zuilen37, Roman Reindl-Schwaighofer38, Kai Lopau39, Norbert Hüser1,2, Uwe Heemann1,5. 1. TransplanTUM Munich Transplant Center, Interdisciplinary Transplant Center, Technical University of Munich, TUM School of Medicine, München, Germany. 2. Department of Surgery, Technical University of Munich, TUM School of Medicine, Klinikum rechts der Isar, München, Germany. 3. Department of Mathematics, Technical University of Munich, Garching, Germany. 4. Eurotransplant International Foundation, Leiden, The Netherlands. 5. Department of Nephrology, Technical University of Munich, TUM School of Medicine, Klinikum rechts der Isar, München, Germany. 6. Department of General Visceral Cancer and Transplant Surgery, Transplant Center Cologne, University of Cologne Faculty of Medicine and University Hospital of Cologne, Cologne, Germany. 7. Department of Nephrology, Universitätsklinikum Aachen, Aachen, Germany. 8. Department of Pediatric Nephrology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, The Netherlands. 9. Department of Surgery, Antwerp University Hospital & University of Antwerp, Edegem, Antwerpen, Belgium. 10. Department of Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany. 11. Department of Surgery, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium. 12. Department of Transplantation and Surgery, School of Medicine, Semmelweis University, Budapest, Hungary. 13. Medizinische Klinik 4, Universitätsklinikum Erlangen-Nürnberg, Transplantation szentrum Erlangen-Nürnberg, Erlangen, Germany. 14. Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany. 15. Renal Department, University Hospital Gent, Gent, Belgium. 16. Department of Internal Medicine, Nephrology and Renal Transplantation, University Clinic of Giessen and Marburg (UKGM), Giessen, Germany. 17. Universitätsklinik für Innere Medizin, Nephrologie, Medizinische Universität Graz, Graz, Austria. 18. Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands. 19. Department of Visceral Transplant Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. 20. Division of Nephrology, Department of Internal Medicine, Transplantationszentrum Hannoversch Münden, Münden, Germany. 21. Department for General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany. 22. Department of Internal Medicine IV, Nephrology and Hypertension, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany. 23. Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria. 24. Medizinische Klinik I, Kliniken der Stadt Köln gGmbH, Lehrstuhl für Innere Medizin II, Nephrologie, Uniklinik Witten/Herdecke, Köln, Germany. 25. Department of Nephrology, University Hospitals Leuven, Leuven, Belgium. 26. Department of Surgery, Ordensklinikum Elisabethinen Linz, Linz, Austria. 27. Department of Nephrology and Renal Transplantation, University Medical Centre Ljubljana, Ljubljana, Slovenia. 28. Division of Nephrology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands. 29. Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Schwerpunkt Nephrologie und Nierentransplantation, Mainz, Germany. 30. Department of Nephrology, Universitätsmedizin Mannheim, Medizinische Fakultät Mannheim der Universität Heidelberg, Mannheim, Germany. 31. Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands. 32. Department of Nephrology, Universitätsklinikum Regensburg, Universitäres Transplantationszentrum, Regensburg, Germany. 33. Department of Urology, University Hospital Rostock, Rostock, Germany. 34. Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC Transplant Institute, Rotterdam, The Netherlands. 35. Department of Nephrology, Klinikum der Landeshauptstadt Stuttgart, Katharinenhospital, Stuttgart, Germany. 36. Department of Internal Medicine IV, Section of Nephrology and Hypertension, Tübingen University Hospital, Tübingen, Germany. 37. Department of Nephrology, University Medical Center Utrecht, Utrecht, The Netherlands. 38. Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Wien, Austria. 39. Division of Nephrology, Department of Internal Medicine 1, University hospital Wuerzburg, Würzburg, Germany.
Abstract
BACKGROUND: At Eurotransplant (ET), kidneys are transferred to "rescue allocation" (RA), whenever the standard allocation (SA) algorithms Eurotransplant Kidney Allocation System (ETKAS) and Eurotransplant Senior Program (ESP) fail. We analyzed the outcome of RA. METHODS: Retrospective patient clinical and demographic characteristics association analyses were performed with graft outcomes for 2422 recipients of a deceased donor renal transplantation (DDRT) after RA versus 25 481 after SA from 71 centers across all ET countries from 2006 to 2018. RESULTS: Numbers of DDRTs after RA increased over the time, especially in Germany. RA played a minor role in ESP versus ETKAS (2.7% versus 10.4%). RA recipients and donors were older compared with SA recipients and donors, cold ischemia times were longer, waiting times were shorter, and the incidence of primary nonfunction was comparable. Among ETKAS recipients, HLA matching was more favorable in SA (mean 3.7 versus 2.5). In multivariate modeling, the incidence of graft loss in ETKAS recipients was reduced in RA compared with SA (subdistribution hazard ratio, 0.80; 95% confidence interval [0.70-0.91], P < 0.001), whereas other outcomes (mortality, death with functioning graft (DwFG)) were not significantly different. None of the 3 outcomes were significantly different when comparing RA with SA within the ESP program. CONCLUSIONS: Facing increased waiting times and mortality on dialysis due to donor shortage, this study reveals encouragingly positive DDRT outcomes following RA. This supports the extension of RA to more patients and as an alternative tool to enable transplantation in patients in countries with prohibitively long waiting times or at risk of deterioration.
BACKGROUND: At Eurotransplant (ET), kidneys are transferred to "rescue allocation" (RA), whenever the standard allocation (SA) algorithms Eurotransplant Kidney Allocation System (ETKAS) and Eurotransplant Senior Program (ESP) fail. We analyzed the outcome of RA. METHODS: Retrospective patient clinical and demographic characteristics association analyses were performed with graft outcomes for 2422 recipients of a deceased donor renal transplantation (DDRT) after RA versus 25 481 after SA from 71 centers across all ET countries from 2006 to 2018. RESULTS: Numbers of DDRTs after RA increased over the time, especially in Germany. RA played a minor role in ESP versus ETKAS (2.7% versus 10.4%). RA recipients and donors were older compared with SA recipients and donors, cold ischemia times were longer, waiting times were shorter, and the incidence of primary nonfunction was comparable. Among ETKAS recipients, HLA matching was more favorable in SA (mean 3.7 versus 2.5). In multivariate modeling, the incidence of graft loss in ETKAS recipients was reduced in RA compared with SA (subdistribution hazard ratio, 0.80; 95% confidence interval [0.70-0.91], P < 0.001), whereas other outcomes (mortality, death with functioning graft (DwFG)) were not significantly different. None of the 3 outcomes were significantly different when comparing RA with SA within the ESP program. CONCLUSIONS: Facing increased waiting times and mortality on dialysis due to donor shortage, this study reveals encouragingly positive DDRT outcomes following RA. This supports the extension of RA to more patients and as an alternative tool to enable transplantation in patients in countries with prohibitively long waiting times or at risk of deterioration.
Authors: Quirin Bachmann; Flora Haberfellner; Maike Büttner-Herold; Carlos Torrez; Bernhard Haller; Volker Assfalg; Lutz Renders; Kerstin Amann; Uwe Heemann; Christoph Schmaderer; Stephan Kemmner Journal: Front Med (Lausanne) Date: 2022-04-29