Arika Hoffman

While there has been an appropriate focus on characterizing the risks associated with living kidney donation, little attention has been paid to the potential benefit to the donor of undergoing the living donor evaluation. This review highlights four studies from the United States and Europe across 30 years demonstrating that the living donor evaluation leads to the detection of previously undiagnosed medical problems in potential donors, including serious cancers. Potential donors should be counseled on the possible benefit of undergoing evaluation.

Introduction: OPTN Policy 3.7D, implemented January 5, 2023, mandates that all kidney transplant programs modify waiting time for candidates affected by race‐inclusive eGFR calculations. We report the early impact of this policy change.Methods: Our transplant program reviewed all listed transplant candidates and identified patients potentially eligible for waiting time modification. Eligible candidates received waiting time modification after submission of supporting evidence to the OPTN. We reviewed the impact on waiting time and transplant activity through October 1, 2023.Results: Forty‐six adult patients on our center's active waiting list self‐identified as Black/African American. 25 (54.3%) candidates qualified for waiting time modification. A median 451 (321, 1543.5) additional days of waiting time was added for qualifying patients. Of the 25 patients who qualified for waiting time modification, 11 patients received a deceased donor kidney in the early period following waiting time modification, including 5 patients transplanted within 1 month after modification.Conclusions: Policy 3.7D is one of few national mandates to address specifically structural racism within transplantation. Implementation has yielded near immediate effects with greater than 40% of time‐adjusted patients at our center receiving a deceased donor kidney transplant in the initial months after policy enactment. Early assessment demonstrates great potential impact for this policy.

Background: Kidney transplant is the best treatment for end‐stage renal disease (ESRD); however, access is limited by severe organ shortage. Public Health Service increased risk donors (PHS‐IRD) represent a significant portion of available organs which are discarded at disproportional rates.Methods: Pediatric nephrologists were surveyed regarding PHS‐IRD kidneys to understand attitudes and perceived barriers to the use of these grafts in children. We sought to elucidate what methods may help increase the likelihood of PHS‐IRD acceptance.Results: Twenty‐two responses were received from United States pediatric nephrologists representing 11 UNOS regions (response rate 5.9%). Of respondents, 50% had been practicing for 20+ years, 77% in academic hospitals, and 63% in cities with over 1 000 000 people. All respondents worked in an institution with a kidney transplant program. 41% reported that they would not accept PHS‐IRD kidneys under any circumstance, 45% would accept depending on the candidate's medical status, and 14% routinely accepted PHS‐IRD kidneys. Infectious transmission was the biggest disincentive reported (59%), with only 55% of respondents feeling comfortable counseling families on the associated risks. 82% of respondents did not perceive all PHS‐IRD as the same, and 90% supported stratifying PHS‐IRD into tiers based on risk, which would increase the likelihood of organ acceptance (82%) and assist in counseling families (91%).Conclusions: With improved utilization, PHS‐IRD kidneys offer a step toward decreasing the organ shortage. These findings suggest hesitance in use of PHS‐IRD kidneys for pediatric recipients. Further stratification of risk could aid in provider organ acceptance and counseling patients.

Background: All living kidney donors are counseled about the possible surgical and medical risks associated with donation. Only a minority of transplant centers discuss the potential benefit of discovering undiagnosed medical conditions in the donor during evaluation, as part of their consent process.Methods: We retrospectively investigated all potential living kidney donors evaluated over a 10‐year period at a single center to characterize incidentally diagnosed serious medical conditions.Results: Sixty‐five of the 762 potential donors (8.5%) were not approved for donation because of a newly diagnosed serious medical condition discovered during their evaluation. This included six patients diagnosed with malignancies, five of which required operative intervention, six patients diagnosed with transmittable diseases requiring follow‐up and treatment, four patients were found to have bilateral renal stones with significant stone burden, and two patients diagnosed with IgA nephropathy. Additionally, four patients were diagnosed with significant heart disease, and one of those patients subsequently required a coronary artery bypass surgery.Conclusions: The evaluation process can diagnose serious medical conditions in a significant minority of donors that would have otherwise been unrecognized. The benefit associated with the donor evaluation should be considered an important part of the consent process.