Impact of KDPI On Shared Decision-Making.

Abstract

Background: Currently, kidneys are dichotomously classified as either Standard Criteria Donor (SCD) or Extended Criteria Donor (ECD). ECDs account for ˜15% of kidneys. In contrast, the new kidney allocation system will rank all kidneys using a kidney donor risk index modified into a continuous kidney donor profile index (KDPI) with 1 (best) to 100 (worst). Method: Online and paper surveys sent to nephrologists and kidney transplant surgeons regarding KDPI and how they would allocate kidneys using KDPI. Results: 86 of 424 participants (20%) returned partial or complete surveys. Three completed surveys were excluded for not meeting the inclusion criteria. The respondents included 42% nephrologists and 58% transplant surgeons, with approximately half over 50 years of age. 62% of respondents supported the use of KDPI. Respondents were asked to select a KDPI cut-off score for typical candidates (not highly sensitized, doing well on dialysis) of different age ranges. Scores (mean, 25%-75%) for each age group were: < 18 years (39, 25-50), 18-34 years (48, 39-60), 35-49 years (57, 40-74), 50-60 years (66, 50-80), and > 60 years (76, 70-95). 51% (32/63) said that there should not be a KDPI score above which candidates should have to opt-in, and 38% of respondents selected a KDPI opt-in score less than 85, the score currently selected by UNOS. The majority (89.3%) of respondents thought that KDPI alone was inadequate for deciding about whether to accept all kidneys. About half of respondents thought that telling specific KDPI scores to candidates would increase patient autonomy (51%, 34/67), increase shared decision-making (48%, 31/65), and would have no impact on physician autonomy (52%, 34/66). Discussion: The new kidney allocation proposal was developed to increase efficiency and reduce organ waste. Physician preferred KDPI cut-off levels for typical candidates of various ages suggest there will be a high rate of refusal of kidneys with higher KDPI scores. Whether this will result in greater organ wastage or change the demographic profile of deceased donor transplant recipients to an older population with poorer expected survival is not known. Respondents were divided about its impact on patient autonomy, physician autonomy and shared decision-making.