Increasing kidney transplants with stratified kidney allocation: acceptability and impacts

About This Grant

In 2023, about 4750 Americans died while awaiting a kidney transplant (KT), but over 8,500 kidneys were recovered and not transplanted. The National Academies of Sciences, Engineering, and Medicine (NASEM) declared kidney non-utilization a critical problem that mandates immediate attention and remedy. Highly prioritized candidates receive many offers for superior kidneys, but also receive offers for many non-ideal kidneys that they refuse sequentially while the clock counts down to kidney non-use. Many candidates with low priority would benefit from receiving a non-ideal kidney quickly but rarely get these offers. Stratified kidney allocation is a proposed system under which patients would make an obligatory but modifiable choice between receiving a superior kidney after a longer wait or a non-ideal kidney sooner. Stratified kidney allocation might increase organ utilization while shortening wait times and improving transplant outcomes for selected patients. Prior work has shown that patients have misperceptions about the dimensions of kidney quality, underestimate the survival benefit of transplant with non-ideal kidneys, and alarmingly, are given a very limited role in decisions about offer quality. While stratified allocation might expedite and increase the use of non-ideal kidneys, impacts are unknown because myriad and sundry details such as which deceased donor kidneys would be categorized as non-ideal, which candidates would select which quality category, etc., have never been specified, nor have patient perceptions about acceptability been investigated. We will build expert consensus on the design of stratified kidney allocation, estimate the impact of stratified allocation to assist policymakers, and investigate attitudes and perceptions of patients, care partners, and providers on shared decision making about kidney offer acceptance, and on making a choice to receive either superior or non-ideal kidneys. Our aims are (1) To understand patient and care partner attitudes, perceptions, and preferences about stratified allocation, shared decision-making, and needs for transparency around organ offers and declines, (2) to assess transplant provider attitudes, perceptions, and preferences about a stratified allocation system, and (3) to estimate the impact of stratified allocation on kidney utilization, and to estimate waiting time for KT candidates choosing either to receive either superior or non-ideal offers. This research will take stratified allocation from a speculative proposal to a concrete policy design that supports deliberation and possible adoption, informed by the judgements of transplant experts, by patient and caregiver perceptions, and by numerical estimates of its impacts. Whether or not stratified allocation succeeds, we will, as advocated in NASEM’s 2022 report, investigate approaches for increasing transparency around offer declines, and involving patients in shared decision making about the kidney quality vs. wait time tradeoff.