Hospitals less finicky about kidneys

Broader donor criteria save lives

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.