Subjective and quantitative assessment of patient fitness for cadaveric kidney transplantation: the "equity penalty".
BACKGROUND
Patient fitness at the time of organ allocation has an impact on graft survival equivalent to the effect of human leukocyte antigen (HLA) matching. The variation between institutions in assessment of fitness is not known, nor is the potential impact on mean graft survival of incorporating patient fitness into local adult cadaveric-kidney transplant-allocation algorithms.


METHODS
Data from the Collaborative Transplant Study (CTS, 1985-2000) were reviewed. Quantitative criteria (QC) of patient fitness based on national transplant society guidelines were compared with subjective categorization (SC) of each patient on the current local transplant waiting list (n=109) determined by their supervising nephrologist.


RESULTS
Five-year cadaveric graft survival was 70%, 61%, and 53% for good-, moderate-, and poor-risk patients in the CTS data set (n=102, 612), equivalent to half lives of 12.7, 9.8, and 8.7 years, respectively, with similar results from the local program. The distribution of local waiting-list patients into fitness categories A (good), B (moderate), C (poor), and D (unacceptable) was 51%:31%:13%:5% by SC and 25%:40%:27%:8% by QC. At one hospital, 61% (n=51) of patients were classified category A by SC, and falling to 16% by QC (P<.0001). Compared with preferential category A recipient allocation, an unrestricted allocation policy was estimated to sacrifice 1.5 years of overall program-mean graft survival.


CONCLUSIONS
Use of QC may reduce the variation in subjective patient assessment seen between institutions. Any proposed changes in organ allocation methods should address the "equity versus efficiency" balance in an open fashion and predict the impact on the overall graft survival for the program by quantifying the "equity penalty."
Thomas
Mark A B
MA
Department of Nephrology, Royal Perth Hospital, PO Box X2213, Perth, WA 6001, Australia. mark.thomas@health.wa.gov.au
Luxton
Grant
G
Moody
Henry R
HR
Woodroffe
Andrew J
AJ
Kulkarni
Hemant
H
Lim
Wai
W
Christiansen
Frank T
FT
Opelz
Gerhard
G
D000293:Adolescent; D000328:Adult; D000368:Aged; D002102:Cadaver; D002648:Child; D002675:Child, Preschool; D006085:Graft Survival; D006801:Humans; D007223:Infant; D007674:Kidney Diseases / Q000503:physiopathology* / Q000601:surgery*; D016030:Kidney Transplantation; D008875:Middle Aged; D010809:Physical Fitness; D016019:Survival Analysis