Dual Kidney Transplants From Adult Marginal Donors: Double or Nothing.

Abstract

Dual kidney transplantation (DKT) may reduce organ discard and optimize the use of kidneys from adult marginal donors. Methods: We retrospectively reviewed outcomes in DKT; if the donor creatinine clearance was <65 ml/min, then the kidneys were considered for DKT. Low risk patients (pts) were chosen with informed consent; all received either r-ATG or alemtuzumab induction with tacrolimus/mycophenolate ± steroids. Results: From 11/01-3/13, 72 DKTS were performed including 46 from expanded criteria donors (ECDs), 17 (5 ECD) from donation after cardiac death (DCD) donors, and 9 from standard criteria donors (SCD). A total of 31 kidney pairs (43%) were imported from other donor service areas; cold ischemia times were ≥30 hours in 22 cases (31%). Nearly all kidneys were refused by multiple centers and many were targeted for discard. Mean donor and recipient ages were 60 and 59 years, respectively, including 15 donors and recipients ≥70 years of age. Mean pre-KT waiting and dialysis vintage times were 12 months and 24 months, respectively. Pt and graft survival rates were 85% and 71% with a mean follow-up of 4 years. One year and death-censored graft survival rates were 90% and 80%. Outcomes did not differ by donor source or recipient age. 11 pts died at a mean of 36 months post-DKT (8 with functioning grafts) and 13 experienced graft loss at a mean of 34 months. The incidence of delayed graft function (DGF) was 24%; there were 2 cases (2.8%) of primary nonfunction. Mean length of initial hospital stay was 7.6 days. The 12 month incidences of surgical complications, acute rejection (AR), and major infection were each 17%. Mean serum creatinine and aMDRD GFR levels at 24 months were 1.5 mg/dl and 51 ml/min. Graft survival was comparable to concurrent single ECD and graft function comparable to concurrent SCD KTs. In the absence of DGF or AR, the proportionate nephron mass transplanted from donor to DKT recipient was 77% compared to 55-58% for pts receiving single KTs from SCD, ECD, or DCD donors. Conclusions: DKT using kidneys from marginal donors that otherwise might be discarded offer a viable option to counteract the growing shortage of single kidneys. Acceptable medium-term outcomes can be achieved with limited nephron mass donors with appropriate donor and recipient selection.