Eurotransplant Senior Program Research Articles

Old for young kidney transplantation: a responsible option for our patients to reduce waiting time?

PurposeThe Eurotransplant Senior program allocating grafts from donors ≥ 65 years to recipients aged ≥ 65 years has proven good results within the last 20 years. However, “old” grafts are also allocated to younger recipients < 65 years, and this outcome of “old for young” kidney transplantations (KT) still lacks detailed investigations.MethodsAll “old for young” KT performed at four tertiary referral centers were retrospectively compared including a recent follow-up, stratifying for “old for young” (donor ≥ 65 years to recipient < 65 years) vs. “very old for young” KT (donor ≥ 70 years to recipient < 65 years).ResultsOverall, 99 patients were included with 56 (56.6%) “old for young” and 43 (43.4%) “very old for young” KT. The median waiting time did not differ (60.7 vs. 45.8 months, respectively) at comparable living donation rates (57.1% vs. 44.2%) as well as intra- and postoperative results. At a median follow-up of 44 months (range 1; 133), the 3-year graft survival of 91% vs. 87% did not significantly vary. In subgroup analyses assessing living donation or donation after brain death (DBD) KT only, the graft survival was significantly longer for “old for young” KT within the living donation subgroup. In multivariate Cox regression analyses, the presence of panel-reactive antibodies was the only significant impact factor on graft survival (HR 8.32, p = 0.001).ConclusionThis analysis clearly demonstrates the effectiveness of the "old for young" approach, enabling favorable perioperative results as well as comparable data of graft- and overall survival, while reducing waiting time for eligible patients.

Rescue Allocation Modes in Eurotransplant Kidney Transplantation: Recipient Oriented Extended Allocation Versus Competitive Rescue Allocation-A Retrospective Multicenter Outcome Analysis.

Whenever the kidney standard allocation (SA) algorithms according to the Eurotransplant (ET) Kidney Allocation System or the Eurotransplant Senior Program fail, rescue allocation (RA) is initiated. There are 2 procedurally different modes of RA: recipient oriented extended allocation (REAL) and competitive rescue allocation (CRA). The objective of this study was to evaluate the association of patient survival and graft failure with RA mode and whether or not it varied across the different ET countries. The ET database was retrospectively analyzed for donor and recipient clinical and demographic characteristics in association with graft outcomes of deceased donor renal transplantation (DDRT) across all ET countries and centers from 2014 to 2021 using Cox proportional hazards methods. Seventeen thousand six hundred seventy-nine renal transplantations were included (SA 15 658 [89%], REAL 860 [4.9%], and CRA 1161 [6.6%]). In CRA, donors were older, cold ischemia times were longer, and HLA matches were worse in comparison with REAL and especially SA. Multivariable analyses showed comparable graft and recipient survival between SA and REAL; however, CRA was associated with shorter graft survival. Germany performed 76% of all DDRTs after REAL and CRA and the latter mode reduced waiting times by up to 2.9 y. REAL and CRA are used differently in the ET countries according to national donor rates. Both RA schemes optimize graft utilization, lead to acceptable outcomes, and help to stabilize national DDRT programs, especially in Germany.

A paired-kidney allocation study found superior survival with HLA-DR compatible kidney transplants in the Eurotransplant Senior Program

The Eurotransplant Senior Program (ESP) has expedited the chance for elderly patients with kidney failure to receive a timely transplant. This current study evaluated survival parameters of kidneys donated after brain death with or without matching for HLA-DR antigens. This cohort study evaluated the period within ESP with paired allocation of kidneys from 675 donors 65 years and older to transplant candidates 65 years and older, the first 341 patients within the Eurotransplant Senior DR-compatible Program and 334 contralateral kidneys without (ESP) HLA-DR antigen matching. We used Kaplan-Meier estimates and competing risk analysis to assess all cause mortality and kidney graft failure, respectively. The log-rank test and Cox proportional hazards regression were used for comparisons. Within ESP, matching for HLA-DR antigens was associated with a significantly lower five-year risk of mortality (hazard ratio 0.71; 95% confidence interval 0.53-0.95) and significantly lower cause-specific hazards for kidney graft failure and return to dialysis at one year (0.55; 0.35-0.87) and five years (0.73; 0.53-0.99) post-transplant. Allocation based on HLA-DR matching resulted in longer cold ischemia (mean difference 1.00 hours; 95% confidence interval: 0.32-1.68) and kidney offers with a significantly shorter median dialysis vintage of 2.4 versus 4.1 yrs. in ESP without matching. Thus, our allocation based on HLA-DR matching improved five-year patient and kidney allograft survival. Hence, our paired allocation study suggests a superior outcome of HLA-DR matching in the context of old-for-old kidney transplantation.

Regional Differences in Waiting Times Before Kidney Transplantation in Germany.

In order to achieve short ischemia times between organ donation and transplantation, regional organ allocation has been assigned priority in the development of allocation rules for kidney transplantation. It is unclear whether this leads to differences in regional waiting times in Germany. A retrospective cohort study over a 24-month observation period was conducted, including all patients who received a kidney-only graft allocated via the standard Eurotransplant Kidney Allocation System (ETKAS) (n = 1487) or the Eurotransplant Senior Program (ESP) (n = 566). Multiple linear regression analyses were performed to investigate differences in waiting times across the regions (ETKAS) or subregions (ESP) as defined by the German Organ Procurement Organization (DSO). Associations between the number of regionally procured kidneys (n = 1444) and regional waiting times were investigated. In ETKAS, the median waiting time was 8.9 years (interquartile range [IQR] 6.7-10.6); in ESP, it was 3.9 (2.4 -5.3) years. Compared with the reference region with the shortest waiting time, waiting times in other regions were 0.6 to 1.7 years longer in ETKAS and 1.3 to 4.4 years longer in ESP. The ratio of the number of patients on the waiting list for a particular region to the number of organs donated in that region was associated with the waiting time in ETKAS (R2 = 0.70). In ESP, this association was markedly less pronounced (R2 = 0.45). In Germany, waiting times depend strongly on the region where a patient is listed for kidney transplantation, especially in ESP. These findings call the current allocation algorithms into question and imply a need for suitable modification.

Human Leucocyte Antigen–Matching Can Improve Long Term Outcome of Renal Allografts from Donors Older Than 75 Years

BackgroundRenal transplantation is the therapy of choice for kidney failure. The Eurotransplant Senior Program (ESP) has been established to allocate kidneys ≥65 years to recipients of the same age group considered a regional allocation with short cold ischemia (CIT) but not human-leukocyte-antigen (HLA)-matching. The acceptance of organs aged ≥75 years is also still controversial within the ESP. MethodsIn a multicenter approach, 179 kidney grafts ≥75 years (mean donor age 78 years) that were transplanted in 174 patients in 5 German transplant centers were analyzed. The primary focus of the analysis was long-term outcome of the grafts and the impact of CIT, HLA matching, and recipient related risk factors. ResultsThe mean graft survival was 59 months (median 67 months) with a mean donor age of 78.3 ± 2.9 years. Grafts with 0 to 3 HLA-mismatches had a significantly better overall graft survival compared to grafts with ≥4 mismatches (69 months vs 54 months; P = .008). The mean CIT was short (11.9 ± 5.3 hours) and had no impact on graft survival. ConclusionRecipients receiving a kidney graft from donors aged ≥75 years can benefit from nearly 5 years of survival with a functioning graft. Even minimal HLA matching may improve long term allograft survival.

Allokation von Nieren im Zeitalter des Organmangels in Deutschland

Due to the opt-in solution currently in place in Germany, there is a substantial shortage of deceased organ donors. Therefore, it is critical that the allocation of available organs follows an optimized algorithm and that the potential of living donations is maximized; however, in this respect the current German legislation has major shortcomings. The human leukocyte antigen (HLA) matching system has a large impact on the standard kidney allocation (Eurotransplant kidney allocation system, ETKAS), that is no longer necessary to this extent in the era of modern immunosuppression but continues to put patients with rare HLA types at a disadvantage. As most points are effectively awarded for the accrual of waiting time, kidneys are often awarded to recipients with poor perspectives for organ survival. The aim of the Eurotransplant Senior Program (ESP) is primarily to minimize the cold ischemia time (CIT) even though it has been shown that CIT can be increased to up to 18 h without impairing allograft survival, also for high-risk organs from ≥ 70-year-old donors. At the same time, the preferential allocation of ESP organs within one subregion results in greatly different waiting times within Germany. Also, the only inclusion criterion for the ESP is recipient age, whereas other medical conditions and thus other recipient risk groups (e.g., diabetics) are disadvantaged. The ban on altruistic living kidney donations in Germany impairs the implementation of modern strategies, such as crossover donations, that have become standard internationally. In turn, the full potential of living kidney donations cannot currently be exploited in Germany. The allocation system should be modernized by incorporating new advances from transplantation research, e.g., by allocation according to life years gained.

Impact of Sensitization on Waiting Time Prior to Kidney Transplantation in Germany.

Assignment of unacceptable HLA mismatches (UAMs) prevents transplantation of incompatible grafts but potentially prolongs waiting time. Whether this is true in the Eurotransplant Kidney Allocation System (ETKAS) and the Eurotransplant Senior Program in Germany is highly debated and relevant for UAM policies. Donor pool restriction due to UAM was expressed as percent virtual panel-reactive antibodies (vPRAs). Kaplan-Meier estimates and multivariable Cox regression models were used to analyze the impact of vPRA levels on waiting time and transplant probability during a period of 2 y in all patients eligible for a kidney graft unter standard circumstances in Germany on February 1, 2019 (n = 6533). Utility of the mismatch probability score to compensate for sensitization in ETKAS was also investigated. In ETKAS, donor pool restriction resulted in significant prolongation of waiting time and reduction in transplant probability only in patients with vPRA levels above 85%. This was most evident in patients with vPRA levels above 95%, whereas patients in the acceptable mismatch program had significantly shorter waiting times and higher chances for transplantation than nonsensitized patients. In the Eurotransplant Senior Program, vPRA levels above 50% resulted in significantly longer waiting times and markedly reduced the chance for transplantation. Compensation for sensitization by the mismatch probability score was insufficient. Donor pool restriction had no significant impact on waiting time in most sensitized patients. However, despite the existence of the acceptable mismatch program, the majority of highly sensitized patients is currently disadvantaged and would benefit from better compensation mechanisms.

Evaluation of Deceased Donor Kidney Transplantation in the Eurotransplant Senior Program in Comparison to Standard Allocation.

BackgroundThe organ shortage and long waiting times have dramatically increased the age of potential kidney transplant recipients. The Eurotransplant Senior Program (ESP) was initiated to allocate kidneys from deceased donors aged ≥65 years to recipients with a comparable age independent of pre-transplant human leucocyte antigen (HLA) matching; however, parameters affecting the long-term benefits of this strategy remain poorly defined.Material/MethodsWe retrospectively evaluated outcome and risk factors for mortality in kidney recipients aged ≥65 years that were transplanted according to the ESP protocol relative to patients aged >50 years transplanted according to the Eurotransplant kidney allocation system (ETKAS) criteria at the University Freiburg Medical Center, Germany, between 2008 and 2018.ResultsGraft survival, graft function, the maintenance immunosuppressive therapy, and the incidence of rejections and infections did not differ between groups. Infectious diseases were the main cause of death in both groups; however, infection-associated mortality was more than double in the ESP group, and 5-year patient survival was 61.4% in the ESP group compared to 83.2% in the ETKAS group. Multivariate analysis identified age, the number of HLA mismatches, and the CMV serostatus with a seropositive donor and negative recipient as the main risk factors for mortality.ConclusionsA comparable immunosuppressive regimen used in ESP and ETKAS patients was associated with similar rejection rates and infectious disease complications, and infections were the most common cause of death in both groups. CMV-negative patients receiving an organ from a CMV-positive donor and patients with a high number of HLA mismatches require close follow-up to reduce mortality.

Kidney Transplantation After Rescue Allocation-the Eurotransplant Experience: A Retrospective Multicenter Outcome Analysis.

At Eurotransplant (ET), kidneys are transferred to "rescue allocation" (RA), whenever the standard allocation (SA) algorithms Eurotransplant Kidney Allocation System (ETKAS) and Eurotransplant Senior Program (ESP) fail. We analyzed the outcome of RA. Retrospective patient clinical and demographic characteristics association analyses were performed with graft outcomes for 2422 recipients of a deceased donor renal transplantation (DDRT) after RA versus 25 481 after SA from 71 centers across all ET countries from 2006 to 2018. Numbers of DDRTs after RA increased over the time, especially in Germany. RA played a minor role in ESP versus ETKAS (2.7% versus 10.4%). RA recipients and donors were older compared with SA recipients and donors, cold ischemia times were longer, waiting times were shorter, and the incidence of primary nonfunction was comparable. Among ETKAS recipients, HLA matching was more favorable in SA (mean 3.7 versus 2.5). In multivariate modeling, the incidence of graft loss in ETKAS recipients was reduced in RA compared with SA (subdistribution hazard ratio, 0.80; 95% confidence interval [0.70-0.91], P < 0.001), whereas other outcomes (mortality, death with functioning graft (DwFG)) were not significantly different. None of the 3 outcomes were significantly different when comparing RA with SA within the ESP program. Facing increased waiting times and mortality on dialysis due to donor shortage, this study reveals encouragingly positive DDRT outcomes following RA. This supports the extension of RA to more patients and as an alternative tool to enable transplantation in patients in countries with prohibitively long waiting times or at risk of deterioration.

Effects of Artificial Intelligence-Derived Body Composition on Kidney Graft and Patient Survival in the Eurotransplant Senior Program.

The Eurotransplant Senior Program allocates kidneys to elderly transplant patients. The aim of this retrospective study is to investigate the use of computed tomography (CT) body composition using artificial intelligence (AI)-based tissue segmentation to predict patient and kidney transplant survival. Body composition at the third lumbar vertebra level was analyzed in 42 kidney transplant recipients. Cox regression analysis of 1-year, 3-year and 5-year patient survival, 1-year, 3-year and 5-year censored kidney transplant survival, and 1-year, 3-year and 5-year uncensored kidney transplant survival was performed. First, the body mass index (BMI), psoas muscle index (PMI), skeletal muscle index (SMI), visceral adipose tissue (VAT), and subcutaneous adipose tissue (SAT) served as independent variates. Second, the cut-off values for sarcopenia and obesity served as independent variates. The 1-year uncensored and censored kidney transplant survival was influenced by reduced PMI (p = 0.02 and p = 0.03, respectively) and reduced SMI (p = 0.01 and p = 0.03, respectively); 3-year uncensored kidney transplant survival was influenced by increased VAT (p = 0.04); and 3-year censored kidney transplant survival was influenced by reduced SMI (p = 0.05). Additionally, sarcopenia influenced 1-year uncensored kidney transplant survival (p = 0.05), whereas obesity influenced 3-year and 5-year uncensored kidney transplant survival. In summary, AI-based body composition analysis may aid in predicting short- and long-term kidney transplant survival.

Kidney Transplantation Outcome Predictions (KTOP): A Risk Prediction Tool for Kidney Transplants from Brain-dead Deceased Donors Based on a Large European Cohort

BackgroundEuropean kidney donation shortages mandate efficient organ allocation by optimizing the prediction of success for individual recipients. ObjectiveTo develop the first European online risk tool for kidney transplant outcomes on the basis of recipient-only and recipient plus donor characteristics. Design, setting, and participantsWe used individual recipient and donor risk factors and three outcomes (death, death with functioning graft [DWFG], and graft loss) for 32 958 transplants within the Eurotransplant kidney allocation system and the Eurotransplant senior program between January 2006 and May 2018 in eight European countries to develop and validate a risk tool. Outcome measurements and statistical analysisCox proportional-hazards models were used to analyze the association of risk factors with overall patient mortality, and proportional subdistribution hazard regression models for their association with graft loss and DWFG. Prediction models were developed with recipient-only and recipient-donor risk factors. Sensitivity analyses based on time-specific area under the receiver operating characteristic curve (AUC) with leave-one-country-out validation were performed and calibration plots were generated. Results and limitationsThe 10-yr cumulative incidence rate was 37% for mortality, 12% for DWFG, and 41% for graft loss. In recipient-donor models the leading risk factors for mortality were recipient diabetes (hazard ratio [HR] 10.73), retransplantation (HR 3.08 per transplant), and recipient age (HR 1.08). Effects were similar for DWFG. For graft loss, diabetes (subdistributional HR [SHR] 1.32), increased donor age (SHR 1.02), and prolonged cold ischemia time (SHR 1.02) had increased SHRs. All p values were <0.001. ConclusionsPreviously identified risk factors for outcomes following kidney transplants allow for outcome prediction with 10-yr AUC values of up to 0.81. Patient summaryUsing European data, we estimated individual risks to predict the success of kidney transplants and support physicians in decision-making. An online tool is now available (https://riskcalc.org/ktop/) for predicting kidney transplant outcomes both before and after a donor has been identified.

Outcomes of Deceased Donor Kidney Transplantation in the Eurotransplant Senior Program with A Focus on Recipients ≥75 Years.

To evaluate the outcomes of kidney transplantations (KTs) in the Eurotransplant Senior Program (ESP) with a focus on the very old, defined as recipients ≥75 years. This retrospective clinical study included 85 patients, who under the ESP protocol underwent deceased donor kidney transplantation from January 2010 to July 2018 at the Charité–Universitätsmedizin Berlin in Germany. Recipients were divided in three age groups, i.e., Group 65–69, Group 70–74, Group ≥75, and compared. Prognostic risk factors for short and long-term outcomes of kidney transplantations were investigated. Graft survival at 1 and 5 years were respectively 90.7% and 68.0% for group 65–69, 88.9% and 76.2% for Group 70–74, and 100% and 71.4% for Group ≥75. Patient survival at 1 and 5 years were respectively 92.9% and 68.0% for Group 65–69, 85.7% and 61.5% for Group 70–74 and 100% and 62.5% for Group ≥75. Serum creatinine did not significantly differ between the three groups, with the exception of serum creatinine at 1 year. Increased recipient age and prolonged time on dialysis correlated with increased occurrence of postoperative complication. An increase in BMI, pretransplant diabetes mellitus and prolonged time on dialysis correlated with the occurrence of delayed graft function (DGF). History of smoking was identified as an independent risk factor for events of rejection. Increased human leukocyte antigen mismatches (HLA-MM) and prolonged cold ischemia time (CIT) correlated with higher rates of intensive care unit (ICU) treatment. This study supports kidney transplantations for the very old. End-stage renal disease (ESRD) patients ≥75 years of age who underwent kidney transplantation experienced comparable results to their younger counterparts. A comprehensive evaluation of ESRD patients with consideration of prognostic risk factor is the most suitable mean of identifying adequate kidney transplant candidates.

Comparative survival of elderly renal transplant recipients with a living donor versus a deceased donor: A retrospective single center observational study.

SummaryIncreasing numbers of elderly (≥65 years) patients are listed for kidney transplantation. This study compares the survival outcome between living (LDK), regularly allocated (ETKAS), and Eurotransplant Senior Program (ESP) donor kidneys in elderly recipients. This is a single‐center retrospective cohort study of elderly kidney transplant recipients transplanted between 2005 and 2017. Primary outcome measures were nondeath‐censored graft, death‐censored graft, and patient survival. In total, 348 patients were transplanted, 109 recipients (31.3%) received an LDK, 100 (28.7%) an ETKAS, and 139 (40%) an ESP kidney. 62.5% were male, and median age was 68 years. LDK recipients had significantly better 5‐year nondeath‐censored graft survival compared with ETKAS and ESP (resp. 71.0% vs. 66.1% vs. 55.6%, P = 0.047). Death‐censored graft survival after 1 year was significantly better in LDK recipients (99.1%) (ETKAS 90.8%; ESP 87.7%, P < 0.001). After 5 years, the difference remained significant (P < 0.001) with little additional graft loss (97.7% vs. 88.1% vs. 85.6). There was no significant difference in patient survival after 5 years (71.7% vs. 67.4% vs 61.9%, P = 0.480). In elderly recipients, the patient survival benefits of an LDK are limited, but there is decreased death‐censored graft loss for LDK recipients. Nevertheless, graft survival in ETKAS and ESP remains satisfactory.

Safety and feasibility of 2h of normothermic machine perfusion of donor kidneys in the Eurotransplant Senior Program.

BackgroundThe 5-year graft survival rate of donor kidneys transplanted in the Eurotransplant Senior Program (ESP) is only 47 per cent. Normothermic machine perfusion (NMP) may be a new preservation technique that improves graft outcome. This pilot study aimed to assess safety and feasibility of this technique within the ESP.MethodsRecipients were eligible for inclusion if they received a donor kidney within the ESP. Donor kidneys underwent 2 h of oxygenated NMP with a red cell-based solution at 37°C, additional to standard-of-care preservation (non-oxygenated hypothermic machine perfusion). The primary outcome was the safety and feasibility of NMP. As a secondary outcome, graft outcome was investigated and compared with that in a historical group of patients in the ESP and the contralateral kidneys.ResultsEleven patients were included in the NMP group; the function of eight kidneys could be compared with that of the contralateral kidney. Fifty-three patients in the ESP, transplanted consecutively between 2016 and 2018, were included as controls. No adverse events were noted, especially no arterial thrombosis or primary non-function of the transplants. After 120 min of oxygenated NMP, median flow increased from 117 (i.q.r. 80–126) to 215 (170–276) ml/min (P = 0.001). The incidence of immediate function was 64 per cent in the NMP group and 40 per cent in historical controls (P = 0.144). A significant difference in graft outcome was not observed.DiscussionThis pilot study showed NMP to be safe and feasible in kidneys transplanted in the ESP. A well powered study is warranted to confirm these results and investigate the potential advantages of NMP on graft outcome.

Comparison of kidney allograft survival in the Eurotransplant senior program after changing the allocation criteria in 2010-A single center experience.

The European Senior Program (ESP) aims to avoid waiting list competition between younger and elderly patients applying for renal transplantation. By listing patients ≥65 years on a separate waiting list and locally allocating of grafts ≥65 years exclusively to this cohort, waiting and cold ischemia times are predicted to be shortened, potentially resulting in improved kidney transplantation outcomes. This study compared a historic cohort of renal transplant recipients being simultaneously listed on the general and the ESP waiting lists with a collective exclusively listed on the ESP list in terms of surrogates of the transplantation outcome. Total 151 eligible patients ≥ 65 years from Münster transplant Center, Germany, between 1999 and 2014 were included. Graft function, graft and patient survival were compared using surrogate markers of short- and long-term graft function. Patients were grouped according to their time of transplantation. Recipients and donors in the newESP (nESP) cohort were significantly older (69.6 ± 3.5 years vs 67.1 ± 2 years, p<0.05; 72.0 ± 5.0 years vs 70.3 ± 5.0 years, p = 0.039), had significantly shorter dialysis vintage (19.6 ± 21.7 months vs 60.2 ± 28.1 months, p<0.001) and suffered from significantly more comorbidities (2.2 ± 0.9 vs 1.8 ± 0.8, p = 0.009) than the historic cohort (HC). Five-year death-censored graft survival was better than in the HC, but 5-year graft and patient survival were better in the ESP cohort. After 2005, cold ischemia time between groups was comparable. nESP grafts showed more primary function and significantly better long-term graft function 18 months after transplantation and onwards. nESP recipients received significantly older grafts, but experienced significantly shorter time on dialysis. Cold ischemia times were comparable, but graft function in the nESP cohort was significantly better in the long term.

A Retrospective Propensity Score Matched Analysis Reveals Superiority of Hypothermic Machine Perfusion over Static Cold Storage in Deceased Donor Kidney Transplantation.

Hypothermic machine perfusion (HMP) has been introduced as an alternative to static cold storage (SCS) in kidney transplantation, but its true benefit in the clinical routine remains incompletely understood. The aim of this study was to assess the effect of HMP vs. SCS in kidney transplantation. All kidney transplants performed between 08/2015 and 12/2019 (n = 347) were propensity score (PS) matched for cold ischemia time (CIT), extended criteria donor (ECD), gender mismatch, cytomegalovirus (CMV) mismatch, re-transplantation and Eurotransplant (ET) senior program. A total of 103 HMP and 103 SCS instances fitted the matching criteria. Prior to PS matching, the CIT was longer in the HMP group (17.5 h vs. 13.3 h; p < 0.001), while the delayed graft function (DGF) rates were 29.8% and 32.3% in HMP and SCS, respectively. In the PS matched groups, the DGF rate was 64.1% in SCS vs. 31.1% following HMP: equivalent to a 51.5% reduction of the DGF rate (OR 0.485, 95% CI 0.318–0.740). DGF was associated with decreased 1- and 3-year graft survival (100% and 96.3% vs. 90.8% and 86.7%, p = 0.001 and p = 0.008) or a 4.1-fold increased risk of graft failure (HR = 4.108; 95% CI: 1.336–12.631; p = 0.014). HMP significantly reduces DGF in kidney transplantation. DGF remains a strong predictor of graft survival.

Should We Perform Old-For-Old Kidney Transplantation during the COVID-19 Pandemic? The Risk for Post-Operative Intensive Stay

Health care systems worldwide have been facing major challenges since the outbreak of the SARS-CoV-2 pandemic. Kidney transplantation (KT) has been tremendously affected due to limited personal protective equipment (PPE) and intensive care unit (ICU) capacities. To provide valid information on risk factors for ICU admission in a high-risk cohort of old kidney recipients from old donors in the Eurotransplant Senior Program (ESP), we retrospectively conducted a bi-centric analysis. Overall, 17 (16.2%) patients out of 105 KTs were admitted to the ICU. They had a lower BMI, and both coronary artery disease (CAD) and hypertensive nephropathy were more frequent. A risk model combining BMI, CAD and hypertensive nephropathy gained a sensitivity of 94.1% and a negative predictive value of 97.8%, rendering it a valuable search test, but with low specificity (51.1%). ICU admission also proved to be an excellent parameter identifying patients at risk for short patient and graft survivals. Patients admitted to the ICU had shorter patient (1-year 57% vs. 90%) and graft (5-year 49% vs. 77%) survival. To conclude, potential kidney recipients with a low BMI, CAD and hypertensive nephropathy should only be transplanted in the ESP in times of SARS-CoV-2 pandemic if the local health situation can provide sufficient ICU capacities.

Should kidney allografts from old donors be allocated only to old recipients?

In several deceased donor kidney allocation systems, organs from elderly donors are allocated primarily to elderly recipients. The Eurotransplant Senior Program (ESP) was implemented in 1999, and since then, especially in Europe, the use of organs from elderly donors has steadily increased. The proportion of ≥60-year-old donors reported to the Collaborative Transplant Study (CTS) by European centers has doubled, from 21% in 2000-2001 to 42% in 2016-2017. Therefore, in the era of organ shortage it is a matter of debate whether kidney organs from elderly donors should only be allocated to elderly recipients or whether <65-year-old recipients can also benefit from these generally as "marginal" categorized organs. To discuss this issue, a European Consensus Meeting was organized by the CTS on April 12, 2018, in Heidelberg, in which 36 experts participated. Based on available evidence, it was unanimously concluded that kidney organs from 65- to 74-year-old donors can also be allocated to 55- to 64-year-old recipients, especially if these organs are from donors with no history of hypertension, no increased creatinine, no cerebrovascular death, and no other reasons for defining a marginal donor, such as diabetes or cancer.

Transplanting the Elderly: Mandatory Age- and Minimal Histocompatibility Matching.

Worldwide over 40% of patients receiving renal replacement therapy (RRT) are aged 65 years or older, a number that is still increasing. Renal transplantation is the preferred RRT, providing substantial survival benefit over those remaining on dialysis, including the elderly. Only 3% of patients aged 65 years or older accepted on the waiting list actually received a kidney transplant offer within the Eurotransplant allocation region. To increase the chance for elderly to receive a timely kidney transplant, the Eurotransplant Senior Program was introduced. The ESP supports local allocation of older kidneys to older donors in order to decrease cold ischemia time, while disregarding former exchange principles based on matching for HLA antigens. As a consequence, more elderly received a kidney transplant and a relative higher incidence of acute rejection resulted in additional courses of high steroids and/or depleting antibody therapy. Since death with a functioning graft due to infections is the dominant reason of graft loss in elderly, more intense clinical immunosuppression to prevent or treat acute rejection is not a very attractive option. Therefore in elderly kidney transplant candidates, we advocate reintroduction of minimal histocompatibility criteria (i.e., HLA-DR matching) followed by age-matching with mandatory local/regional allocation to also facilitate short cold ischemia.

Outcome of Kidney Transplantation Using Organs From Brain-dead Donors Older Than 75 Years

PurposeWe investigated whether older donor kidneys aged >75 years have acceptable long-term function and if recipients can benefit sufficiently from the transplantation. MethodsThis single-center study retrospectively analyzed patient data from 217 deceased donor kidney transplants performed between 1998 and 2014 as part of the Eurotransplant Senior Program, where the organ donors were ≥65 years old. Depending on donor age, the groups “older donors” (OD; n = 161) and “very old donors” (VOD; n = 56) received transplants from donors aged 65 to 75 years and >75 years, respectively. Donor and recipient clinical characteristics, delayed graft function, estimated glomerular filtration rate, 1-year rejection rate, patient and graft survival, and postoperative complications were investigated. ResultsComparing VOD group vs OD group, the 1-year, 3-year, and 5-year graft survival rates were 80.4% vs 76.4%, 62.5% vs 65.8%, and 42.6% vs 57.3%, respectively. Patient survival rates after 1, 3, and 5 years were 89.3% vs 88.2%, 71.4% vs 78.2%, and 57.5% vs 71.8%, respectively. There were no significant differences between the 2 groups (graft survival P = .107; patient survival P = .126). Kidney graft function after 1, 2, and 3 years was significantly better in the OD group than in the VOD group. No differences were found regarding postoperative complications, rejection rate, and delayed graft function. ConclusionThe utilization of selected kidney-grafts from donors >75 years resulted in acceptable outcomes after kidney transplantation and could expand the donor pool. In contrast to the high mortality rate during dialysis, recipients in both groups benefited from transplantation.