DECISION SUPPORT TOOL TO AID RISK ASSESSMENT OF ACCEPTING VERSUS DECLINING A KIDNEY OFFER FROM A DONOR WITH A RISK OF DISEASE TRANSMISSION
Mr James Hedley1, Sarah White1, Danielle Muscat1, Kate Wyburn1,2, Angela Webster1,3,4
1Sydney School of Public Health, Faculty of Medicine and Health, University Of Sydney, Sydney, Australia, 2Renal Unit, Royal Prince Alfred Hospital, Sydney, Australia, 3NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia, 4Centre for Renal and Transplant Research, Westmead Hospital, Sydney, Australia
Aim: To develop a decision support tool for patients and clinicians comparing consequences of accepting versus declining a kidney offer from a deceased donor with cancer or blood-borne virus (BBV) transmission risk.
Background: The decision to accept a kidney from a donor with history of cancer/BBV involves complex assessment of the risk of acceptance versus remaining on dialysis. Transplant clinicians and patients would benefit from tools to aid this decision-making.
Methods: Transmission risks by cancer type and BBV serology were based on TSANZ guidelines and published literature. We supplemented the NSW biovigilance register (SAFEBOD) with Australia-wide data from ANZDATA/ANZOD to model outcomes from declining a kidney offer including time to next/better offer and waitlist suspension. Models were adjusted for age, sex, blood-group, sensitisation, state/territory, previous transplants, comorbidities, kidney disease, dialysis time, and kidney failure time. Time to cancer and death were based on AIHW cancer data, ABS life tables, and published standardised cancer incidence and mortality ratios in kidney failure. A tool interface was developed using the R package ‘shiny’.
Results: A web-app visualising expected outcomes, available here: http://tiny.cc/pr12yz. For example, for a hypothetical patient (50y, male, blood-group B, sensitisation 80%, NSW resident, glomerular disease, transplant-naive, 2-years dialysis) offered a kidney from a 45y male DBD donor (KDPI 31%, glioblastoma), cancer transmission risk is 2%. If declined, median waiting time is 1.6 months (any offer) or 7.2 months (KDPI <31%), with chance of waitlist suspension (20%), cancer (0.4%) or death (3.4%) while waiting.
Conclusions: A bespoke visualisation of expected outcomes and risks of remaining on dialysis may enable informed decision-making and better patient outcomes.