Abstract
The use of kidneys donated after circulatory death (DCD) remains controversial due to concerns with regard to high incidences of early graft loss, delayed graft function (DGF), and impaired graft survival. As these concerns are mainly based on data from historical cohorts, they are prone to time-related effects and may therefore not apply to the current timeframe. To assess the impact of time on outcomes, we performed a time-dependent comparative analysis of outcomes of DCD and donation after brain death (DBD) kidney transplantations. Data of all 11,415 deceased-donor kidney transplantations performed in The Netherlands between 1990-2018 were collected. Based on the incidences of early graft loss, two eras were defined (1998-2008 [n = 3,499] and 2008-2018 [n = 3,781]), and potential time-related effects on outcomes evaluated. Multivariate analyses were applied to examine associations between donor type and outcomes. Interaction tests were used to explore presence of effect modification. Results show clear time-related effects on posttransplant outcomes. The 1998-2008 interval showed compromised outcomes for DCD procedures (higher incidences of DGF and early graft loss, impaired 1-year renal function, and inferior graft survival), whereas DBD and DCD outcome equivalence was observed for the 2008-2018 interval. This occurred despite persistently high incidences of DGF in DCD grafts, and more adverse recipient and donor risk profiles (recipients were 6 years older and the KDRI increased from 1.23 to 1.39 and from 1.35 to 1.49 for DBD and DCD donors). In contrast, the median cold ischaemic period decreased from 20 to 15 hours. This national study shows major improvements in outcomes of transplanted DCD kidneys over time. The time-dependent shift underpins that kidney transplantation has come of age and DCD results are nowadays comparable to DBD transplants. It also calls for careful interpretation of conclusions based on historical cohorts, and emphasises that retrospective studies should correct for time-related effects.
Highlights
In the past decades, organs retrieved from donation after brain death (DBD) donors have provided the majority of solid organ transplants globally
While for some countries reasons to not or only slowly allow donated after circulatory death (DCD) programmes relate to ethical issues, legal restrictions or logistical concerns [9], for the majority of countries the reticent attitude generally reflects medical concerns that are based on reported high incidences of early graft loss, delayed graft function (DGF), and an assumed impaired graft survival for DCD kidneys
Analyses of 5,895 DBD and 2,616 DCD primary kidney transplants performed in this period indicated clear time-related effects with 1998 (DBD) and 2008 (DCD) as clear transition years, after which the incidence of early graft loss dropped and stabilized at an incidence of approximately 6% (Fig 1)
Summary
Organs retrieved from donation after brain death (DBD) donors have provided the majority of solid organ transplants globally. Due to the medical success of transplantation as an effective therapy for patients with end stage organ failure, the increased need of donor organs created a persistent shortage which has resulted in the death of many patients while waiting for a transplant. While for some countries reasons to not or only slowly allow DCD programmes relate to ethical issues, legal restrictions or logistical concerns [9], for the majority of countries the reticent attitude generally reflects medical concerns that are based on reported high incidences of early graft loss, delayed graft function (DGF), and an assumed impaired graft survival for DCD kidneys
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