ECD Kidneys Research Articles

Recipients of Kidneys from Expanded Criteria Donors Whose eGFR Does not Drop >30% Between 1-12 Months after Transplantation Have Excellent Long-Term Graft Survival

Purpose: To determine the impact of eGFR drop lower or greater than 30% during the first yr post-kidney transplantation (KTx) on long-term death censored graft survival (DCGS). Methods: We studied 471 KTx recipients of deceased donor kidneys between 1/1990 and 12/2006. 253 pts (53.7%, 82 women, 171 men, 49±12 yrs) received standard criteria donor (SCD) kidneys, and 218 pts (46.3%, 73 women, 145 men, 52±13 yrs) received ECD kidneys. Immunosuppression consisted of ATG induction, CNI and an antimetabolite. CIT was 15.4±8.4 hr. We analyzed an eGFR drop lower or greater than 30% between 1-3, 1-12 and 3-12 months in recipients of SCD and ECD kidneys, with immediate (IGF, Scr decreased ≥20% within 24 hrs post-KTx), slow (SGF, Scr decreased < 20% within 24 hrs post-KTx and no need for dialysis) or delayed graft function (DGF, need for dialysis during the first week post-KTx), on long-term DCGS in pts whose graft survived >1 yr post-KTx. 55 recipients of SCD and 34 recipients of ECD were excluded because of graft loss, death or loss to follow-up during the first yr. Results: The impact of eGFR drop on long-term DCGS is depicted in Figures 1 and 2. There was no difference in pts with SGF. eGFR (mL/min/1.73m2) at 1, 5 and 10 yrs was 71±22, 66±22 and 57±22 respectively, in recipients of SCD and 56±18, 49±23 and 41±20 respectively, in recipients of ECD (P=0.001). An eGFR drop between 1-12 months was associated with lower DCGS (HR 2.16, P=0.02).Figure: [*P=0.002 and **P=0.01 vs. ECD Drop >30%]Figure: [P<0.0001 and **P=0.0003 vs. ECD Drop >30%]Conclusion: Recipients of ECD kidneys without an eGFR drop >30% between 1-12 months post-KTx have excellent long-term DCGS, equivalent to recipients of SCD kidneys.

Recipients of Kidneys from Expanded Criteria Donors Whose eGFR Does not Drop >30% Between 1-12 Months after Transplantation Have Excellent Long-Term Graft Survival

Purpose: To determine the impact of eGFR drop lower or greater than 30% during the first yr post-kidney transplantation (KTx) on long-term death censored graft survival (DCGS). Methods: We studied 471 KTx recipients of deceased donor kidneys between 1/1990 and 12/2006. 253 pts (53.7%, 82 women, 171 men, 49±12 yrs) received standard criteria donor (SCD) kidneys, and 218 pts (46.3%, 73 women, 145 men, 52±13 yrs) received ECD kidneys. Immunosuppression consisted of ATG induction, CNI and an antimetabolite. CIT was 15.4±8.4 hr. We analyzed an eGFR drop lower or greater than 30% between 1-3, 1-12 and 3-12 months in recipients of SCD and ECD kidneys, with immediate (IGF, Scr decreased ≥20% within 24 hrs post-KTx), slow (SGF, Scr decreased < 20% within 24 hrs post-KTx and no need for dialysis) or delayed graft function (DGF, need for dialysis during the first week post-KTx), on long-term DCGS in pts whose graft survived >1 yr post-KTx. 55 recipients of SCD and 34 recipients of ECD were excluded because of graft loss, death or loss to follow-up during the first yr. Results: The impact of eGFR drop on long-term DCGS is depicted in Figures 1 and 2. There was no difference in pts with SGF. eGFR (mL/min/1.73m2) at 1, 5 and 10 yrs was 71±22, 66±22 and 57±22 respectively, in recipients of SCD and 56±18, 49±23 and 41±20 respectively, in recipients of ECD (P=0.001). An eGFR drop between 1-12 months was associated with lower DCGS (HR 2.16, P=0.02).Figure: [*P=0.002 and **P=0.01 vs. ECD Drop >30%]Figure: [*P<0.0001 and **P=0.0003 vs. ECD Drop >30%]Conclusion: Recipients of ECD kidneys without an eGFR drop >30% between 1-12 months post-KTx have excellent long-term DCGS, equivalent to recipients of SCD kidneys.

Risk Factors for Devlopment of BK Virus Infection

Intoduction: The only known risk factor for the development of BK viral infection (BKV) post-transplantation is overall immunosuppression. Early detection of BKV may provide opportunity for intervention and help prevent renal allograft loss. Identification of recipients at increased risk for development of BKV would allow for more targeted screening and possible avoidance of BKV nephropathy and allograft loss Methods: Since 2004 we have prospectively screened urine and plasma on renal transplant recipients at 6 weeks, 3 months, and 1 year. Demographics and post transplant factors were analyzed. Incidence of significant BK Viruria (BKVu) (>10 million copies/ml) was the outcome of interest. Results: 849 recipients of a renal transplant between 2005 and 2011 were included in the study. 102 (12%) of recipients developed BKVu, 28 (3%) developed BK viremia, and 2 (0.2%) lost their graft to BKV. Recipients of a living donor transplant were less likely to develop BKVu (80% BKVu-free survival at 3 years vs 79% for deceased donors, p=0.003). Recipients on prednisone were more likely to develop BKVu (74% BKVu-free survival at 3 years vs 86% for those not on prednisone, p=0.003). Older recipients were more likely to develop BKVu (recipients >60 yrs of age had 78% BKVu-free survival at 3 years vs 87% for those < 60 years of age, p=0.001). Factors associated with increased risk for BKVu in multivariate analysis were deceased donor (adjusted-HR 1.85; 1.14-3.0; p=0.012), use of prednisone (adj-HR 2.1; 1.34-3.3; p=0.001), older recipient (adj-HR 1.7;1.14-2.56; p=0.01), and diabetes (adj-HR 1.5;1-2.26; p=0.051). Within the deceased-donor stratum, factors associated with the development of BKVu were: use of prednisone (adj-HR 2.4;1.44-3.98; p=0.001), ECD kidneys (adj-HR1.8;1.02-3.04; p=0.043), and diabetes (adj-HR 1.7;1.06-2.63; p=0.028). Pediatric en-bloc appears to be protective for development of BKVu (adj-HR 0.14; 0.02-1.03; p=0.054), though this did not reach statistical significance. For the living donor recipient stratum: recipient > 60 yr was associated with an increased risk of BKVu (adj-HR 2.9; 1.28-6.83; p=0.011)Figure: [BKV free survival Living Donor vs Deceased Donor]Conclusion: Kidney transplant recipients of deceased donors, recipients over the age of 60 years, those on prednisone, and recipients who are diabetic appear to be at greater risk for development of BKVu. Recipients of pediatric en-bloc kidneys may be somewhat protected from development of BKVu, though this did not reach statistical significance.

Optimising expanded donor organs through dual kidney transplantation: a case-control study.

In order to take full advantage of ECD kidneys, which may not provide sufficient renal mass if used individually, it has been suggested that such organs be used in dual or bilateral kidney transplantation (DTx). We analysed the experience in a single hospital between May 2007 and March 2011 in a case-control study. Criteria for determining whether to perform single or dual Tx were defined in a protocol in which the biopsy score was important, but not the only factor. Donor's age, medical history, kidney size and creatinine clearance were also considered. During this time period, 80 kidneys from donors over age 65 were transplanted. Single transplants (STx) accounted for 40 of the organs, and another 40 were used in DTx. Mean donor age for STx was 68.7 ± 3.0 years; for DTx, it was 74.2 ± 4.3 years (P<.001), with more female donors for DTx (75%) than for STx (40%) (P<.001). There were no differences between groups with regard to glomerular filtration rate or proteinuria. Kidneys assigned to DTx received higher biopsy scores than those assigned to STx (2.95 ± 1.01 vs 1.8 ± 1.04; P<.001). DTx recipients were older than STx recipients. There were no differences between the groups regarding cold ischaemia time, delayed graft function, haemorrhagic complications or re-surgeries. However, DTx recipients achieved better creatinine clearance at 1, 3, 6 and 12 months, although the difference was only statistically significant at 6 months (53.4 ± 19.5ml/min vs 44.5 ± 15.6ml/min; P<.05). Renal artery thrombosis appeared in 2 STx patients and in both kidneys of 1 DTx patient. Another 2 patients in the DTx group each lost 1 kidney due to thrombosis and ureteral necrosis respectively, but were able to remain dialysis-free. Graft survival at 3 years was 90% for both groups. During the study period 3 patients died (2 in the STx group and 1 in the DTx group). Our preliminary experience indicates that DTx provides good results in terms of survival and renal function data, despite surgery being more complicated and the organs having characteristics that probably make them unsuitable for STx. The decision to perform DTx makes using ECD kidneys easier, and it should be based on a combination of pre-transplant histological criteria and the donor's clinical characteristics.

Response: DonorNet and the Potential Effects on Organ Utilization

To the Editor: We read the article by Gerber and colleagues (1) with particular interest in the placement of locally rejected kidneys, because facilitating kidney placement at this juncture has the greatest potential to reduce the likelihood of discard and extended cold ischemic times (CIT) for transplanted kidneys. The authors suggested that their data ‘demonstrates improvements in the efficiencies of organ placement, including a decrease in the accepted organ offer for select kidney match runs’. They did not point out that for other select kidney match runs, the 90th, 95th and 99th percentiles, acceptor sequence numbers were higher in the post-DonorNet (DN) cohorts compared to pre-DN, indicating that for difficult-to-place kidneys, more offer rejections occurred under DN before finding an acceptor, signifying decreased efficiency of kidney placements. The interpretation of these data is also compromised by the absence of testing for proportional differences in the completion of kidney runs by era. This is a barrier for understanding the impact of DN since any era with proportionately more early closures of the match run would be biased toward lower acceptance sequence numbers. Similarly, another means of addressing efficiency of kidney placement would be to determine how often the match run was closed early because center minimal renal acceptance criteria for CIT had been exceeded. The authors found that the 90th, 95th and 99th percentiles of center number also increased under DN for ECD and DCD kidneys and state that this data suggests ‘an increase in efficiency of placement …’ More likely, this data indicates that more centers were offered and declined difficult-to-place kidneys under DN. Although offering kidneys to more centers may demonstrate improved justice-based allocation, by enforcing allocation rules and reducing offers to aggressive centers lower on the list, it does not appear to represent ‘increased efficiency’. It is stated that ‘for kidney … no significant changes in CIT were observed at any level of sharing’; however, it appears that the asterisk in Figure 2 indicates a significantly longer mean CIT in the later-DN compared to the pre-DN era for national transplants. This provides additional evidence of decreased efficiency in national placement. Unfortunately, CIT is a suboptimal surrogate to evaluate the efficacy of kidney placement because other factors such as the availability of commercial flights and center specific practices, also impact CIT. A potentially better surrogate, if available, would be duration of cold ischemia at the time of offer. Finally, based on the finding of similar kidney discard rates between eras, the authors state that historic arguments suggesting that ‘aggressive’ centers drove organ utilization in the pre-DN period is not supported by their data. However, this conclusion may not be supported by the results since the authors did not investigate which centers were accepting these organs in each era. It may be that the same ‘aggressive’ centers are still driving organ utilization; a concept that is supported by a recent analysis that found the cumulative distribution of imports by center were similar before and after DN (2).

HLA matching for organ transplantation… Why not?

HLA matching for organ transplantation… Why not?

Acceptable Outcome After Kidney Transplantation Using “Expanded Criteria Donor” Grafts

With the worldwide shortage of donors, extra lengths are ongoing to enlarge the donor pool. One means has been a greater use of "expanded criteria donor" (ECD) grafts. A major concern regarding ECD kidneys is poor long-term graft survival. The aims of this study were to determine whether ECD grafts, as defined by the United Network for Organ Sharing, had a negative impact on graft survival and to identify the principle donor and recipient factors that influenced graft survival in our patient cohort. We analyzed all deceased donor renal transplants in our unit from January 1995 to October 2005, in total 1,053 transplants. ECD grafts (United Network for Organ Sharing criteria) demonstrated higher rates of delayed graft function and higher early mean creatinine levels. However, there was no significant difference in 5-year graft survival. Multivariate analysis of our patient group identified donor hypertension and ischemic heart disease (IHD) as independent predictors of poor graft survival. Recipient age was significant on univariate but not on multivariate analysis. However, although younger recipients maintained acceptable 5-year graft survival despite donor hypertension, IHD, or a combination of both, these factors significantly reduced graft survival in older recipients. Although ECD grafts had slightly worse function, 5-year survival was comparable with standard grafts in all recipients. Donor hypertension, IHD, or a combination of both significantly reduced graft survival in older recipients, not evident in younger patients. We discuss the possible factors for improved outcome with ECD grafts in our patients and the implications of our patient analysis.

Use of marginal organs in kidney transplantation for marginal recipients: too close to the margins of safety?

ObjectiveDue to organ shortage, average waiting time for a kidney in Germany is about 4 years after start of dialysis. Number of kidney grafts recovered can only be maintained by accepting older and expanded criteria donors. The aim of this study was to analyse the impact of donor and recipient risk on kidney long-term function.MethodsAll deceased kidney transplantations were considered. We retrospectively studied 332 patients between 2002 and 2006; divided in 4 groups reflecting donor and recipient risk.ResultsNon-marginal recipients were less likely to receive a marginal organ (69 of 207, 33%) as compared to marginal recipients, of whom two-thirds received a marginal organ (p < 0.0001). Graft function significantly differed between the groups, but detrimental effect of marginal recipient status on eGFR after 12 months (-6 ml/min/1.73 qm, 95% CI -2 to -9) was clearly smaller than the effect of marginal donor status (-10 ml/min/1.73 qm, 95% CI -7 to -14).ConclusionsAs we were able to show expanded criteria donor has a far bigger effect on long-term graft function than the "extra risk" recipient. Although there have been attempts to define groups of recipients who should be offered ECD kidneys primarily the discussion is still ongoing.

In ECD Kidney Recipients, Renal Function Superior with Belatacept

In ECD Kidney Recipients, Renal Function Superior with Belatacept

Renal transplantation in the elderly

Elderly patients are increasingly being considered for kidney transplantation due to a global explosion of the aging population with end-stage renal disease (ESRD). However, mounting scarcity of available organs for transplant has led to a wider disparity between organ supply and demand. Consequently, the criteria for accepting kidneys for transplantation have been extended in an attempt to allow the use of organs from elderly donors or those with significant co-morbidities, so-called "expanded criteria donor" (ECD) kidneys. Excellent outcomes have been achieved from ECD kidneys with appropriate donor and recipient profiling and selection. With increasing recovery efforts directed at older donors, the concept of age-matching is becoming more accepted as a method of optimizing utilization of organs in elderly donors and recipients. Utilization of pulsatile perfusion has further improved ECD outcomes and helped the decision-making process for the UNOS (United Network for Organ Sharing) offer. However, age-related immune dysfunction and associated co-morbidities make the elderly transplant recipients ever more susceptible to complications associated with immunosuppressive agents. Consequently, the elderly population is at a higher risk to develop infections and malignancy in the post-transplant period notwithstanding improved transplant outcomes. Appropriate immunosuppressive agents and dosages should be selected to minimize adverse events while reducing the risk of acute rejections and maximizing patient and renal allograft survival.

The Effects of Donor and Recipient Practices on Transplant Center Finances

Over the past several years we have noted a marked decrease in this profitability of our kidney transplant program. Our hypothesis is that this reduction in kidney transplant institutional profitability is related to aggressive donor and recipient practices. The study population included all adults with Medicare insurance who received a kidney transplant at our center between 1999 and 2005. Adopting the hospital perspective, multi-variate linear regression models to determine the independent effects of donor and recipient characteristics and era effects on total reimbursements and total hospital margin. We note statistically significant decreased medical center incremental margins in cases with ECDs (-$5887) and in cases of DGF (-4937). We also note an annual change in the medical center margin is independently associated with year and changes at a rate of -$5278 per year, related to both increasing costs and decreasing Medicare reimbursements. The financial loss associated with patient DGF and the use of ECD kidneys may resonate with other centers, and could hinder efforts to expand kidney transplantation within the United States. The Centers for Medicare and Medicaid Services (CMS) should consider risk-adjusted reimbursement for kidney transplantation.

The improvement in survival of expanded criteria donor kidneys with transplantation era

To compensate for the shortage of donor kidneys, use of expanded donor criteria (ECD) has been adopted by many transplant centres. Multiple criteria on which to score such kidneys have been proposed but the evidence base for the definitions is derived from retrospective and registry data only. We aimed to see if analysis of ECD in our population would indicate the need to change our donor selection process. Data on primary kidney transplants (minimum follow-up two yr) from 1989 to 2004 were reviewed (n = 635). The primary study endpoint was overall graft survival. Published ECD, including the United Network for Organ Sharing (UNOS) ECD criteria were assessed as potential prognostic variables, in a multivariable Cox proportional hazards model. Patients transplanted after 1996 had improved graft survival compared to those transplanted pre-1996 HR = 0.51 (0.35-0.76), p = 0.0001. Pre-1996 UNOS defined ECD kidneys had a markedly increased risk of graft failure compared to live donor kidneys HR = 3.52 (1.9-6.35), p < 0.001. Post-1996 ECD kidneys had similar prognosis compared to live donor kidneys HR 0.38 (0.1-1.59), p = 0.184. The observed improvement in graft survival was not explained by changes in donor source, cause of end stage renal failure (ESRF), human leukocyte antigen mismatch, recipient age or any histological parameter on implantation biopsy. The explanation for improved overall graft survival and marked improved survival of ECD kidneys is unclear, but introduction of mycophenolate and subsequent falls in calcineurin inhibitor doses over the study period could be potential factors. These results provide some justification for our current selection and management of ECD kidneys.

Selective Use of Expanded Criteria Donors for Renal Transplantation With Good Results

Increasing demand for renal transplants has stimulated expanded criteria for the use of deceased donors. Recently an official category of “Expanded Criteria Donors” (ECD) was designated by UNOS. This category included any deceased donor (1) greater than age 60 years or (2) age 50 to 59 years with any two of: (a) creatinine greater than 1.5 mg/dL (b) cerebrovascular accident cause of death, or (c) hypertension history. It has been anticipated that at 3 years, 70% of ECD kidneys with serum creatinine greater than 1.5 would be lost. We reviewed our experience with the use of this type of kidney prior to the era of officially designated ECD. Survival rates and serum creatinines were compared to standard criteria donor recipients for the same time period whose donor was greater than 50 years of age and correlated with biopsies. From 1996 to 2003, 341 deceased donor kidneys were transplanted at our center. Of these, 37 were ECD kidneys and 46 were standard criteria donors kidneys. Four pretransplant biopsies had greater than 20% sclerosed glomeruli. Four donors had 0% to 25% arteriosclerosis pretransplant; on postperfusion biopsy, eight had 0% to 25% arteriosclerosis, while three had 25% to 50%. The mean donor age was 61 years; mean recipient age was 54 years; recipient sex was 57% male, and 54% of the recipients were African-American. At 1, 2, and 3 years posttransplant, there was no significant difference between the two groups in serum creatinine, graft survival, or patient survival. Despite using ECD donors, good long-term function can be obtained, particularly if selectivity is exercised.

Intermediate-Term Outcomes With Expanded Criteria Deceased Donors in Kidney Transplantation

To compare intermediate-term outcomes in adult recipients of expanded criteria (ECD) versus concurrent standard criteria (SCD) deceased donor kidney transplants at a single center using a standardized approach. Expanded criteria donors (ECDs) are a source of kidneys that increase the donor organ pool, but the value of transplanting these kidneys has been questioned because of concerns regarding diminished survival and predicted poorer intermediate-term outcomes. Over a 47-month period, we performed 244 deceased donor kidney transplants into adult recipients, including 143 from SCDs and 101 from ECDs. Management algorithms were implemented to preserve nephron function, and recipient selection for an ECD kidney transplant was based on low immunologic risk. All patients received depleting antibody induction in combination with tacrolimus and mycophenolate mofetil. A total of 188 patients (77%) had at least a 1-year follow-up. ECDs were older, had a higher BMI, had an increased incidence of cerebrovascular brain death and preexisting donor hypertension, and had a lower estimated creatinine clearance (CrCl, all P < 0.01) compared with SCDs. Cold ischemic times were similar between groups, but more ECD kidneys were preserved with pulsatile perfusion (P < 0.01). ECD kidney recipients were older, less sensitized, had a lower BMI, had fewer 0-antigen mismatches, and had a shorter waiting time (all P < 0.01) compared with SCD kidney recipients. Actual patient (93%) and kidney graft (83%) survival rates were similar between groups with a mean follow-up of 24 months. The rates of delayed graft function (DGF), acute rejection, readmissions, operative complications, major infections, and resource utilization were comparable between groups. Renal function followed longitudinally was consistently better in SCD patients (P < 0.05). Black recipients had higher rates of DGF, acute rejection, and graft loss (P < 0.05), but the effects were less pronounced in the ECD group. By appropriate donor and recipient profiling and the use of management algorithms to project and protect renal function, excellent intermediate-term outcomes can be achieved with ECD kidney transplants that are comparable to SCD kidney transplants.

Use of perfusion parameters in predicting outcomes of machine-preserved kidneys

Perfusion parameters (PP) and early transplant outcome data from 332 consecutive ECD type kidneys machine preserved on the Waters RM-3 apparatus were reviewed and analyzed to examine the validity of using suboptimal PPs (renal resistance of .41–.60) as a criterion for discarding kidneys. Overall discard rate was 23.5%, with 55% of these having “poor” PP as part of reason for discard. PP analysis after 4 hours on the RM-3 is presented. This encompasses 280 kidneys with renal resistance ≤ .60. Sixty-six kidneys were discarded (23.5%). Of the 214 transplanted kidneys, 146 had immediate function (IF; 68%), 63 had delayed function (DGF; 29%), and 5 never functioned (PNF; 2%). Of the 30 transplanted kidneys with renal resistance .40 to .60, 16 (53%) had IF versus 58% in kidneys with renal resistance ≤ .40 ( P = .125). Two of the five PNF kidney had renal resistance > .40. The PP-related discard rate in the renal resistance .41 to .60 kidneys was 51% versus 17% in the renal resistance ≤ .40 ( P ≤ .01). Based on our observations kidneys with renal resistance ≤ .60 should not be discarded strictly based on “suboptimal perfusion parameters.” This presents an opportunity for a decrease in discard rates of ECD kidneys.

KIDNEY TRANSPLANTATION IN THE ELDERLY: VARIATIONS OF THE “MATCH-GAME”

P99 Aims: Introduction: The aging donor (D) and recipient (R) population has led to new challenges in kidney transplantation (KT). Controversy exists regarding the optimal approach to the elderly D or R. A number of strategies have been proposed including matching by age, medical risk, serology, HLA, size, or nephron mass. The purpose of this study was to retrospectively review our single center experience in deceased donor (DD) KT with respect to age. Methods: From 10/1/01 through 11/15/03, we performed a total of 129 DD KTs, including 33 (26%) in Rs ≥60 years and 96 (74%) in Rs 19-59 years of age. The DD pool included 51 expanded criteria donors (ECD; defined and allocated according to UNOS policy) and 78 standard criteria donors (SCD; defined as non-ECD). ECD kidneys were utilized by matching estimated renal functional mass to recipient size (BMI <25 kg/m2), including the use of dual KTs (N=8). ECD kidney Rs were further selected based on age >40 and low immunologic risk. Rs received rATG or alemtuzumab induction in combination with tacrolimus, MMF, and steroids; those ≥60 had lower tacrolimus targets and MMF doses. Results: The mean age differed significantly between R groups (65 vs 46 years, p<.001), including 7 patients >70. In Rs ≥60, 22 (67%) received KTs from ECDs compared to 29 from ECDs (30%, p<.001) in Rs <60. Other demographic and transplant characteristics were similar among groups. Patient survival is 97% in Rs ≥60 compared to 99% in Rs <60 (p=NS) with a mean follow-up of 12 months. Kidney graft survival rates are 94% in Rs ≥60 vs 89% in Rs <60, p=NS. Initial and subsequent graft function, rejection, infection, re-operations, length of stay, re-admissions, and resource utilization were similar among groups. Nine patients had opportunistic viral infections (5 CMV, 3 polyomavirus nephropathy, 1 EBV-associated PTLD), including 4 (12.5%) in Rs ≥60 compared to 5 (5%, p=NS) in Rs <60. However, all 9 cases occurred in ECD Rs (18% ECD vs 0 SCD Rs, p<.001). Conclusions: By matching nephron mass with R size and avoiding the use of ECD kidneys in high immunologic risk Rs, short-term outcomes that are comparable to SCD kidneys in younger patients can be achieved with either older Ds or Rs, regardless of age. However, the risk of viral infection is higher in ECD Rs, and long-term follow-up is needed to ultimately determine the risks and benefits of KT in this setting.

Economic impact of delayed graft function and suboptimal kidneys

Renal transplantation remains the cost-effective treatment of choice for end-stage renal disease. However, the gap between supply and demand for cadaveric kidneys only continues to widen. To expand the donor pool, many transplant centers now accept organs from donors that only a few years ago would have been rejected. The use of kidneys from ECDs and those with a high likelihood of DGF can have a significant impact on graft survival and cost. The average cost of initial hospitalization for patients undergoing cadaveric renal transplant in which there is DGF is approximately $25,000 higher per patient than when there is no DGF. Moreover, the use of an ECD kidney increases the average cost by $12,000 per patient. When the clinical manifestations of DGF and ECD kidneys, such as increased rate of acute rejection and worse graft survival, are taken into account the economic impact is expanded. In the past decade, pharmaceutical companies have focused their resources far more on new immunosuppressive agents rather than treatments to improve early graft function or reduce alloantigen independent injury and inflammation. As the negative economic and clinical impacts of DGF and ECD kidney become clearer, there may be more incentive for scientific and clinical research in this area to improve long-term and short-term graft survival.