deceased donor renal transplant have by definition failed to secure a living donor for renal transplantation. Deceased donor candidates are referred for renal transplant and depending upon the transplant center’s evaluation process will undergo a variety of medical tests to determine the patient’s relative fitness for transplantation. See the chapter on recipient selection and the evaluation process for more details. What can patients do to receive a kidney transplant sooner? Kidneys are procured from a variety of donors with a variety of medical backgrounds and social situations. For instance, recently the opioid epidemic has resulted in an increase in drug related deaths and an accompanying increase in the availability of deceased organ donors. Patients on the kidney transplant waiting list may potentially shorten their waiting time by consenting to accept kidneys from a variety of donors. 1. Some deceased donors are designated Public Health Service (PHS) increased risk. PHS increased risk is assigned to donors that have a possible risk of acquiring an infection as a result of their lifestyle or their mechanism of death (e.g., from a drug overdose). Any donor considered to have a risk of infection from hepatitis B, hepatitis C, or HIV will be defined as PHS increased risk. Such donors may have a sexual history that increases their risk of infection, or have been incarcerated, or have used IV drugs. These donors undergo nucleic acid testing to rule out infection with viruses; the tests are not perfect, but they are extremely sensitive. After testing negative, these patients are still at higher risk of transmitting a viral infection than a donor without that history, however the risk of transmitting infection is still extremely low. The infectious risk is much lower than the health risk of staying on dialysis. We encourage patients to consent to receive a PHS increased risk kidney, which may shorten their time on the waitlist. [KIDNEY TRANSPLANT TOOLKIT] May 13, 2019 © Copyright, Forum of ESRD Networks, 2019 Page 11 2. Most kidneys are procured from brain dead donors, but an increasing number are being procured from donors whose heart has stopped beating before procurement, called deceased after cardiac death (DCD) donors. Kidneys from DCD donors have an increased risk of delayed graft function (continuing dialysis within one week after the transplant), but overall have good outcomes. Accepting DCD kidneys can increase the number of patients transplanted. 3. High KDPI kidneys. Although transplant professionals cannot predict with certainty which procured kidneys are likely to do better than others, there are ways to estimate the outcome of patients who receive different kidneys. For instance, we expect a kidney from an 18 year old that died in a car accident is more likely to last longer than a kidney from a 65 year old that died of a stroke. The Kidney Donor Profile Index (KDPI) is a score assigned to each individual kidney that predicts the organ quality. The score ranges from 1% (the best) to 100% (the least good). Factors determining the score include donor age, race, history of hypertension or diabetes, cause of death, creatinine, and if they are a DCD donor. The majority of kidneys with KDPI between 0 and 20% function for over 11 years, with KDPI 21-85% about 9 years, and with KDPI over 85% more than 5 ½ years. For some patients, such as those who are older or who have comorbidities that make them at higher risk for continuing on dialysis, it may be advantageous to consent to accept a high KDPI kidney which will shorten their waiting time and get them off dialysis sooner. It has been shown that receiving a high KDPI kidney confers a survival advantage over staying on dialysis for such patients. Patients will be asked to give consent to receive a transplant with a kidney having a KDPI greater than 85%. 4. Patients with untreated hepatitis C may receive a kidney from a donor who died and also had a hepatitis C infection. The hepatitis C can then be treated after the patient has received a kidney transplant. If a patient’s hepatitis C is treated before transplantation, they are not eligible to receive a hepatitis C positive kidney. It is important that each ESRD patient makes an individualized decision with his nephrologist, liver specialist, and transplant center regarding the decision to treat hepatitis C before or after transplantation. Receiving a hepatitis C positive kidney can shorten a patient’s time on the waiting list, as hepatitis C kidneys may otherwise go unused. 5. Patients with controlled HIV may undergo successful renal transplantation. Some transplant centers are participating in a research study to transplant HIV positive kidneys into HIV positive patients, rather than discarding them. This kind of transplant was legalized by passage of the HIV Organ Policy Equity (HOPE) act in 2013. Receiving an HIV positive kidney can shorten the waiting time for patients with HIV. Organ Acceptance Phase and Pre-Transplant Preparations After a potentially acceptable deceased donor kidney offer is received from the United Network for Organ Sharing (UNOS), the center will enter a provisional “yes” until further information is obtained. There are two categories of deceased donors, those that have undergone brain death but whose hearts are still beating (donation after brain death DBD), and those whose organs are procured only after the heart has stopped beating