• November 2021

    Kidney Transplant Updates – Allocation, Internal Paired Exchange and Transplants in Patients Over Age 70

In March, the Organ Procurement and Transplantation Network (OPTN) launched a new policy for matching kidney transplant candidates with organs from deceased donors. Donated kidneys are now offered first to candidates listed at transplant hospitals within 250 nautical miles of the donor hospital. A kidney that is not accepted for any of these candidates will then be offered to candidates beyond the 250 nautical mile distance.

The new policy eliminates donation service areas and OPTN regions. The goal is to increase geographic equity in accessing transplantation regardless of a candidate’s place of listing, while limiting transportation time and costs, logistical complications, and inefficiencies. For Baylor University Medical Center, part of Baylor Scott & White Health, and Baylor Scott & White All Saints Medical Center – Fort Worth, the new policy provides the opportunity to interact with many more potential donor hospitals that fall into the 250-mile category.

“The new policy centers on a donor hospital, but in essence it delineates large concentric circles around the transplant hospitals where donor organs can potentially come from,” says Eric Martinez, MD, a transplant surgeon on the medical staff at Baylor University Medical Center. “With our locations in Dallas/Fort Worth, there is a large shared area between the two hospitals, but there are also donor hospitals that are unique to each transplant center. For example, Baylor Scott & White – Fort Worth will have access to some cities in West Texas, while the 250-mile circle for Baylor Dallas includes some parts of Arkansas and Louisiana. The new policy gives patients who are higher on the waitlist more and quicker access to organs. Since the new policy went into effect, the number of offers we receive has nearly doubled. While more offers are generally better, the relationship between offers and transplants is not linear, as not all offers are transplantable. Despite this, we have seen our kidney transplant volume increase by approximately 15 to 20 percent.”

Internal paired exchange

The kidney transplant programs at Baylor Dallas, Baylor Scott & White – Fort Worth and Baylor Scott & White Medical Center – Temple are implementing an internal paired exchange utilizing innovative paired donation software. The paired donation software gives clinicians the tools to rapidly and accurately match living organ donors with patients who have willing, healthy, but incompatible donors.

The software was created to optimize the number of transplants for a given pool of donor/recipient pairs and provide the maximum number of transplants in a shorter period of time. It works for simpler 2-way kidney exchanges and also for more complex kidney exchanges involving up to 12 combinations.

“Among our three centers, we perform about 100 living donor kidney transplants each year,” Dr. Martinez says. “With the new internal paired exchange, we will put incompatible pairs into the system to see if the software can facilitate matching between our three centers. This will reduce the time it takes to evaluate offers – we’re all using the same electronic health record – and when it’s time to transplant the organs, the organs will not have to travel too far. In the future, we would like to try to implement a system to offer this to compatible pairs as well in case a recipient may find some benefit from a kidney not donated by his or her originally intended donor while facilitating another transplant.”

More patients over age 70 receive kidney transplants

“With the continued aging of the Baby Boom generation, patients above age 70 are the fastest-growing age group of patients on dialysis. Clinicians generally agree that patients who undergo a successful kidney transplant gain a survival benefit compared to those who remain on dialysis”, says Johanna Bayer, MD, physician on the medical staff and Surgical Director of Transplantation at Baylor Scott & White All Saints Medical Center – Fort Worth.

These older patients are evaluated for frailty. If the patient starts out on the frail side, they may not be able to recover adequately from the transplant surgery. Patients are also monitored more frequently to maintain their candidacy on the waitlist. A patient’s condition five years after listing at age 70 may be far different than a patient listed at age 40.

“Kidneys are a scarce resource that need to be properly allocated. But there are a lot of functional 70-plus-year-olds who could still have a quality-of-life benefit from a kidney transplant. We want to give them a fair shot. Age should not be the only reason someone does or does not get a kidney transplant,” Dr. Bayer says.

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