Despite existing interprovincial organ sharing policies and local allocation practices, programs often find themselves with an organ that cannot be allocated to their provincial lists. In general, programs will offer organs first to a national program, followed by their local transplant waitlist. Once both of these avenues have been exhausted, there is a lack of consistency and clear direction on how to allocate these organs to their peer organizations inside the country.
This project was launched in September 2017 at the Canadian Society of Transplantation (CST) meeting in Halifax, NS. This leading practice engaged members from deceased donation, transplantation, Laboratory (HLA/Histocompatibility), ethics, and ODO administration, with the goal of producing guiding principles, recommendations, and eventually policies to guide the allocation of organs that are difficult to place locally. Kidneys will be the initial organ of focus with the intention of engaging the heart and liver communities in subsequent phases.
Meeting Objectives and Process
Webinars were held October 14 and 15, 2021 to provide attendees with necessary background information to assist in forum discussions. The forum took place virtually on October 21 and 28, 2021, engaging pan-Canadian representatives from ethics, legal, critical care, donation, as well as adult and pediatric transplant programs.
Objectives of the forum included:
- Review current organ utilization and best practice research; review clinical/administrative allocation and assessment practices in Canada/internationally.
- Consult with patients, donation/transplantation nephrologists, surgeons, and others.
- Build a national consensus on the criteria for and tracking of hard to place kidneys and recipients who accept these.
- Develop final consensus recommendations for Canadian listing and allocation policies for hard to place kidneys.
- Achieve understanding of how the outputs of this meeting align with the broader Interprovincial Organ Sharing Programs strategy of Canadian Blood Services
Forum attendees participated in both small group and plenary discussions to provide recommendations on the following topics:
- Characteristics of donors whose organ are at risk of not being utilized
- Donor data required at time of kidney offer
- Accountability processes to maximize utilization of these organs
- Communication of risk and benefit to recipients
- Principles that guide the allocation of these organs
- System responsibilities in case of early graft loss
- Recipients that are likely to have improved outcomes with these organs versus staying on dialysis
- Processes to use to maximize outcomes of these organs
- Required post-transplant outcome data
The forum was rated highly by all participants and was felt to be a valuable use of time. Several attendees commented that more time for discussions and a process to ensure all voices were heard would have been helpful. Attendees found the information provided very helpful and are eager to begin the process of influencing local practices.
Based on the information presented and preliminary discussions at the forum, the following preliminary outputs were established:
- Potential term to use to describe deceased kidney donors at increased risk of organ discard as well as phenotype characteristics to define this group of donors.
- A list of donor data required for initial offer screening. Further input will be sought from critical care and organ donation organizations regarding these.
- Proposed processes to use to ensure communication of risks and benefits to candidates prior to offer and to ensure every offer is properly evaluated.
- A list of proposed principles to guide allocation of these kidneys.
- An extensive list of data elements to consider for improved performance measurement, professional education needs, as well as knowledge gaps and research opportunities.
The planning committee will oversee the following next steps:
- Development of a comprehensive meeting report based on the recommendations resulting from the forum. Participants will be invited to review prior to finalization and participant feedback will be assembled and incorporated. Transplant candidates and recipients will also be engaged to provide feedback on recommendations.
- The guidance for policy development will be submitted to a peer-reviewed journal for publication.
- The final report and peer-reviewed publication will be disseminated to all forum participants and community stakeholders to improve practice and patient and family experience.
- Canadian Blood Services’ Kidney Transplant Advisory Committee will consider development of interprovincial sharing policies to establish a national program to allocate these kidneys.
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