Deceased donor kidney transplantation in candidates with pre-transplant hematological malignancies: a literature review and recipient allocation proposal in Singapore

TL;DR

This paper reviews kidney transplant allocation for cancer survivors in Singapore, where donor organs are scarce, and proposes guidelines for fair and efficient allocation.

Contribution

The paper proposes a tailored allocation framework for deceased donor kidney transplants in Singapore, considering local organ scarcity and cancer survivor outcomes.

Findings

Patients with pre-transplant hematological malignancies have higher mortality risks but improved survival with modern therapies.

Allocation of scarce donor kidneys to these patients requires careful evaluation to balance justice and utilitarianism.

The proposed framework is specific to Singapore's context and may not apply universally.

Abstract

Deceased donor kidneys are a scarce national resource, and principles of utilitarianism and justice govern allocation. Kidney transplant recipients with a prior history of cancer show an increased risk of malignancy- and non-malignancy-related mortality compared to their counterparts without a previous history of malignancy. The inferior survival of a recipient with pre-transplant malignancy questions the allocation of a scarce resource to a population at anticipated poorer patient and graft survival. However, patient survival has significantly improved with advances in therapeutics for hematological malignancies, which led to an updated consensus expert opinion by the American Society of Transplantation in 2019. Nevertheless, the candidacy of patients with pre-transplant hematological malignancies in countries with a scarcity of deceased donor kidneys and a prolonged wait time may warrant specific considerations. This review details the basis for evaluation and candidacy recommendations for patients with a history of hematological malignancy for waitlist placement for deceased donor kidney transplantation, while optimizing scarce deceased donor organ supply in  Singapore. It considers the available evidence in countries where organ scarcity is a distinct challenge; thus, this consensus report is tailored to these constraints and may not be fully generalizable to other countries or transplant allocation algorithms.

The online version contains supplementary material available at 10.1007/s40620-025-02381-8.

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