Hospitals less finicky about kidneys

Hospitals less finicky about kidneys
Broader donor criteria save lives

Mar 02, 2008
Jean P. Fisher, Staff Writer

Deaths among patients awaiting lifesaving kidney transplants fell nationally last year amid rising organ donation and broader use of kidneys that would once have been discarded.

Patients who would otherwise face long waits for a kidney are now often encouraged to consider organs from deceased donors older than age 60 or from younger patients who died of stroke or suffered from high blood pressure. Many transplant centers will now give a patient two low-functioning kidneys instead of one higher-functioning organ, as is customary.

"In a perfect world, it would be nice to get everyone a kidney from a younger donor," said Dr. Robert Stratta, director of transplants at Wake Forest Baptist University Medical Center in Winston-Salem since 2001. "But we don't live in a perfect world. Getting a kidney is better than not getting a kidney."

So-called expanded-criteria donor organs are more likely to fail than kidneys from younger, healthier donors. Traditionally, such organs were considered unsuitable for transplant. But as the gap continues to widen between the number of patients seeking transplants and the number of organs available to them, Stratta and other transplant experts increasingly see them as an untapped resource.

The use of expanded criteria donor kidneys has increased about 30 percent since 2002, when the United Network for Organ Sharing (UNOS) set criteria for their use. These kidneys now account for nearly 11 percent of all kidney transplants.

The number of patients seeking kidney transplants is rising by an average of 7 percent to 10 percent a year, in part because of rising rates of Type 2 diabetes, which damages the kidneys. Meanwhile, as the number of organs from both living and deceased donors has increased modestly, the supply of kidneys available for transplant has only inched up. According to UNOS, only about a quarter of patients waiting for kidneys nationally got a transplant last year.

"Hardly a week goes by that I'm not notified that someone on our waiting list has died," Stratta said.

To cut such losses, Stratta has led Wake Forest Baptist to become one of the nation's most active kidney transplant programs and one of the most daring in its use of higher-risk kidneys.

High-mileage kidneys

Aggressive use of expanded criteria donor kidneys has helped Wake Forest Baptist shorten the wait for kidney transplants. Stratta said agreeing to an extended criteria kidney typically shaves a year off a patient's wait. Higher-risk kidneys do tend to wear out sooner, lasting no more than eight years on average. A standard kidney transplant lasts an average of about 12 years.

A 2005 study sponsored by the Scientific Registry of Transplant Recipients found that patients who took less-than-optimal organs were less likely to die than patients who remained on dialysis. Older recipients were particularly likely to benefit.

"It's a little bit like buying a used car -- there are some high-mileage cars that are good cars," Stratta says of selecting expanded criteria kidneys for transplant. "If we don't think it's a good kidney, we don't offer it."

But higher-risk kidneys aren't a good option for all patients. Younger patients are still best served by holding out for a healthy organ from a younger donor, Stratta said. So closing the gap between demand and supply also depends on getting more kidneys from healthy donors.

To that end, Wake Forest Baptist and other busy transplant programs, such as those at Duke University Medical Center in Durham and UNC Hospitals in Chapel Hill, have joined forces in recent years with organ procurement agencies and the federal government. A Duke transplant surgeon is co-leader of a 2002 national effort, called the Organ Donation Breakthrough Collaborative.

Raising donation rates

When the project started, only about 40 percent of families eligible to donate a loved one's organs did so. Today the average consent rate is about 60 percent, and many hospitals have maintained consent rates of 75 percent or better. Rex Healthcare in Raleigh and Wake Forest Baptist are two North Carolina hospitals that have kept organ donations at or above 75 percent.

"We're recovering organs that we wouldn't have recovered five years ago," said Dr. Janet E. Tuttle-Newhall, a Duke transplant surgeon and co-leader of the national organ donation collaborative.

The project emphasizes practices proven to achieve high levels of organ donation. For example, families with a loved one near death in the hospital are now routinely assigned a contact from an organ procurement organization. He or she helps the family through the grieving process to ensure the approach is made with sensitivity, said Burt Mattice, vice president and chief operating officer of Carolina Donor Services. The Durham organ procurement agency works with hospitals in 79 North Carolina counties to recover and preserve organs for transplant.

The supply of kidneys available for transplant has increased nearly 15 percent since the U.S. Department of Health and Human Services established the national collaborative. And experts see signs that increasing the supply of organs is helping save lives.

Many states have also passed laws that allow hospitals to treat the organ donation symbol on a person's driver's license as legal consent to donate. North Carolina enacted such a law in October. Before it took effect, families did not always honor loved ones' wishes to donate organs, Mattice said.

He said Carolina Donor Services and other procurement agencies are also preserving more donated kidneys with mechanical pumps instead of keeping them in cold storage. Pumped kidneys are more likely to begin functioning quickly after transplant, studies show. They can also be preserved longer, allowing more patients on the waiting list to be considered and more time to transport the organs.

A happy surprise

Penny Poston of Raleigh considers herself one of the beneficiaries of efforts to increase the supply of donor kidneys.

When Poston, 34, was added to the waiting list at Duke more than a year ago, hoping to receive what would be her third transplant, she was told to expect a wait of up to seven years. Patients who have had previous transplants develop antibodies that make them particularly hard to match to donor kidneys. But to Poston's relief, she received a kidney transplant Feb. 19.

"When they called to say they might have a match, I was just shocked," Poston said. She had her first transplant at age 6 after a strep throat turned into a systemic infection that caused permanent kidney damage.

A second transplant in 1998 turned out to be a bad match, and that kidney had to be taken out in 2002. Poston had been on dialysis since then, going to a center three days a week to have up to eight pounds of fluid drained off. She moved to Raleigh in 2007 to live with her mother and sought care at Duke shortly after.

"If there are more kidneys," Poston said, "then there was a better chance for me to match."

jean.fisher@newsobserver.com or (919) 829-4753

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