Recipients Of Expanded Criteria Donor Kidneys Research Articles

Impact of Donation After Circulatory Death on Outcomes of Expanded Criteria Donor Kidney Transplants

Expanded criteria donor (ECD) kidneys experience suboptimal outcomes compared with standard criteria donor kidneys. To examine the additional impact of deceased organ category, donation after circulatory death (DCD), and neurologic determination of death (NDD) on ECD outcomes, we examined 1- and 3-year patient and graft survival in all ECD kidney recipients in our institution between January 2008 and December 2017. Of 166 ECD recipients, 49 (29.5%) were DCD and 117 (70.5%) were NDD. Delayed graft function was higher in the DCD/ECD group 61.2 % vs 32.0 % among NDD/ECD recipients. Graft loss was significantly increased among DCD/ECD (hazard ratio for graft loss 4.81 [95% CI1.78-13.01], P = .002 at 1 year and 2.03 [95% CI 1.03-4.0], P = .042 at 3 years). Death-censored graft loss was higher among DCD/ECD (hazard ratio was 10.12 [95% CI, 2.14, 47.92], P = .004 at 1 year and 2.83 [95% CI, 1.24, 6.46], P = .014 at 3 years). There was no statistically significant difference in all-cause mortality. Our study demonstrated that DCD/ECD kidneys have lower graft survival compared with NDD/ECD kidneys. Time on dialysis, waiting time, and panel reactive antibody should be taken into account when offering these organs to patients.

Impact of pre-transplant biopsy on 5-year outcomes of expanded criteria donor kidney transplantation.

Compared to Standard Criteria Donors (SCD), Expanded Criteria Donor (ECD) kidneys are associated with poorer outcomes, although pre-transplant biopsy may mitigate risks. This study assessed 5-year outcomes of deceased-donor kidney transplant recipients, comparing recipients of ECD allografts evaluated histologically to recipients of SCD and ECD kidneys assessed clinically. This is a single-centre retrospective study. From November 2005 to December 2009 (Era 1), donors were assessed clinically for suitability for kidney donation. From December 2009 to October 2017 (Era 2), kidneys from ECDs and diabetics underwent pre-transplant biopsy and were allocated based on Remuzzi score. Outcomes of Era 1 and 2 recipients were compared. ECD kidney transplantation increased from 30.4% to 40.0% from Era 1 to 2. Univariable Cox regression, stratified by transplant era, found that 5-year graft loss was highest with Era 1 ECD (HR 2.5, 95% CI 1.1-5.5, P = .027) while graft loss for Era 2 ECD recipients was similar to SCD recipients. There was no difference in 5-year recipient survival. Amongst Era 1 ECD recipients, 51.2% experienced rejection compared to 30.8-41.5% for other subgroups. Five-year eGFR was higher with Era 2 ECD at 48.4 (33.3-60.7) ml/min/1.73 m2 compared to 42.2 (35.8-57.3) ml/min/1.73 m2 for Era 1 ECD. However, these differences were not statistically significant. Introduction of pre-transplant biopsy assessment may be associated with improved outcomes of ECD kidney recipients such that they are now comparable to SCD kidney recipients, with benefits persisting over 5 years.

Multicenter registry analysis comparing survival on home hemodialysis and kidney transplant recipients in Australia and New Zealand.

In the era of organ shortage, home hemodialysis (HHD) has been identified as the possible preferential bridge to kidney transplantation. Data are conflicting regarding the comparability of HHD and transplantation outcomes. This study aimed to compare patient and treatment survival between HHD patients and kidney transplant recipients. The Australia and New Zealand Dialysis and Transplant Registry was used to include incident HHD patients on Day 90 after initiation of kidney replacement therapy and first kidney-only transplant recipients in Australia and New Zealand from 1997 to 2017. Survival times were analyzed using the Kaplan-Meier product-limit method comparing HHD patients with subtypes of kidney transplant recipients using the log-rank test. Adjusted analyses were performed with multivariable Cox proportional hazards regression models for time to all-cause mortality. Time-to-treatment failure or death was assessed as a composite secondary outcome. The study compared 1411 HHD patients with 4960 living donor (LD) recipients, 6019 standard criteria donor (SCD) recipients and 2427 expanded criteria donor (ECD) recipients. While LD and SCD recipients had reduced risks of mortality compared with HHD patients [LD adjusted hazard ratio (HR) = 0.57, 95% confidence interval (CI) 0.46-0.71; SCD HR = 0.65 95% CI 0.52-0.79], the risk of mortality was comparable between ECD recipients and HHD patients (HR = 0.90, 95% CI 0.73-1.12). LD, SCD and ECD kidney recipients each experienced superior time-to-treatment failure or death compared with HHD patients. This large registry study showed that kidney transplant offers a survival benefit compared with HHD but that this advantage is not significant for ECD recipients.

P1431MULTI-CENTER REGISTRY ANALYSIS COMPARING SURVIVAL ON HOME HEMODIALYSIS AND KIDNEY TRANSPLANT RECIPIENTS IN AUSTRALIA AND NEW ZEALAND

Abstract Background and Aims In the era of organ shortage, home hemodialysis (HHD) has been identified as the possible preferential bridge to kidney transplantation. Data are conflicting regarding the comparability of HHD and transplantation outcomes. This study aimed to compare patient and treatment survival between HHD patients and kidney transplant recipients. Method The Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry was used to include incident HHD patients on day 90 after initiation of kidney replacement therapy and first kidney-only transplant recipients in Australia and New Zealand from 1997 to 2017. Survival times were analyzed using the Kaplan-Meier product limit method comparing HHD patients to subtypes of kidney transplant recipients using the log-rank test. Adjusted analyses were performed with multivariable Cox proportional hazards regression models for time to all-cause mortality. Time-to-treatment failure or death was assessed as a composite secondary outcome. Results The study compared 1411 HHD patients to 4960 living donor (LD) recipients, 6019 standard criteria donor (SCD) recipients and 2427 expanded criteria donor (ECD) recipients. While LD and SCD recipients had reduced risks of mortality compared to HHD patients (LD adjusted hazard ratio [HR] 0.57, 95%CI 0.46-0.71; SCD HR 0.65 95%CI 0.52-0.79), the risk of mortality was comparable between ECD recipients and HHD patients (HR 0.90, 95%CI 0.73-1.12). LD, SCD and ECD kidney recipients each experienced superior time-to-treatment failure or death compared to HHD patients. Conclusion This large registry study showed that kidney transplant offers a survival benefit compared to HHD but that this advantage is not significant for ECD recipients.

P1727DECEASED DONOR KIDNEY CHARACTERISTICS AND IMPACT ON 10-YEAR GRAFT SURVIVAL - A LONG-TERM OBSERVATIONAL STUDY

Abstract Background and Aims The long waiting list for deceased donor kidney transplantation has prompted the use of Expanded Criteria Donors (ECD) though it is possibly associated with worse graft function and outcomes than Standard Criteria Donors (SCD). Our centre had also implemented a protocol kidney biopsy at implantation from 2005 to 2009. The aim of this study was to evaluate the impact of donor factors and donor kidney histology on 10-year graft outcomes. Method A retrospective analysis was performed on 108 kidney transplant recipients who underwent a protocol biopsy at implantation from November 2005 to November 2009. The biopsy sample was evaluated for glomerulosclerosis, tubular atrophy, interstitial fibrosis and arteriolar narrowing and scored according to Remuzzi et al., N Engl J Med. 2006;354(4):343 (Remuzzi score). Donor factors evaluated were donor age, hypertension, diabetes mellitus, and terminal serum creatinine. The 10-year graft survival and estimated glomerular filtration rate (eGFR) was the main outcome of interest. Results The deceased donors included 58% males, 85% Chinese, with a median age of 49 (IQR 12) years. There were 13% diabetics, 51% hypertensive donors and the median terminal creatinine was 95 umol/L. The recipients were 51% male, 79% Chinese, with a median age of 47 (IQR 11) years at transplant. The time interval to transplant was 9.2 (IQR 3.0) years and the overall 10-year graft survival was 67.6%. Remuzzi score of ≤3 was associated with better 10-year graft survival compared with Remuzzi score of >3 (76.6% versus 45.2%, P =0.02). 10-year graft survival for SCD and ECD was not statistically different (71.6% versus 58.8%, P=0.187). A multivariate analysis was performed which included donor status (ECD vs SCD), Remuzzi score (>3 vs ≤3), donor age (≥60 or <60 years), donor hypertension, donor diabetes mellitus and terminal serum creatinine (≥133 umol/L versus <133 umol/L). Only Remuzzi score correlated with a better 10-year graft survival rate (P=0.020). All other factors did not correlate with 10-year graft survival. Amongst the 73 ten-year graft survivors, the median eGFR at year 10 was 47.5 (IQR 20.3) ml/min if the Remuzzi Score was ≤3 while the eGFR was 39.7 (IQR 33.0) ml/min if Remuzzi score was >3. However, this difference was not statistically significant (P=0.570). The 10-year eGFR was 45.8 (IQR 22.2) for SCD kidney recipients vs 49.5 (IQR 25.6) for ECD kidney recipients. Paradoxically, the median eGFR was higher with the ECD cohort but this was not statistically significant (P=0.443). Conclusion An implantation Remuzzi score of more than 3 is associated with poorer long-term graft survival as compared to other donor factors evaluated on 10-year graft survival or eGFR. Where possible, assessment of the kidney histology should be included as part of the kidney selection and allocation process in order to determine long term outcomes.

Delayed graft function is correlated with graft loss in recipients of expanded-criteria rather than standard-criteria donor kidneys: a retrospective, multicenter, observation cohort study.

Background:Although the use of expanded-criteria donors (ECDs) alleviates the problem of organ shortage, it significantly increases the incidence of delayed graft function (DGF). DGF is a common complication after kidney transplantation; however, the effect of DGF on graft loss is uncertain based on the published literature. Hence, the aim of this study was to determine the relationship between DGF and allograft survival.Methods:We conducted a retrospective, multicenter, observation cohort study. A total of 284 deceased donors and 541 recipients between February 2012 and March 2017 were included. We used logistic regression analysis to verify the association between clinical parameters and DGF, and Cox proportional hazards models were applied to quantify the hazard ratios of DGF for kidney graft loss.Results:Among the 284 deceased donors, 65 (22.8%) donors were ECD. Of the 541 recipients, 107 (19.8%) recipients developed DGF, and this rate was higher with ECD kidneys than with standard-criteria donor (SCD) kidneys (29.2% vs. 17.1%; P = 0.003). The 5-year graft survival rate was not significantly different between SCD kidney recipients with and without DGF (95.8% vs. 95.4%; P = 0.580). However, there was a significant difference between ECD kidney recipients with and without DGF (71.4% vs. 97.6%; P = 0.001), and the adjusted hazard ratio (HR) for graft loss for recipients with DGF was 1.885 (95% confidence interval [CI] = 1.305–7.630; P = 0.024). Results showed that induction therapy with anti-thymocyte globulin was protective against DGF (odds ratio = 0.359; 95% CI = 0.197–0.652; P = 0.001) with all donor kidneys and a protective factor for graft survival (HR = 0.308; 95% CI = 0.130–0.728; P = 0.007) with ECD kidneys.Conclusion:DGF is an independent risk factor for graft survival in recipients with ECD kidneys, but not SCD kidneys.

Dual Kidney Transplantation: Is It Worth It?

Use of expanded criteria donor (ECD) kidneys, which are associated with a reduced graft survival rate, has become widely adopted in elderly recipients in an old-to-old allocation system. However, the results are frequently unsatisfactory, and a high proportion of these ECD kidneys are discarded. Dual kidney transplantation (DKT) is an underused way to expand the pool of ECD kidneys and to rapidly transplant elderly patients with satisfactory results because of the transplantation of double the nephronic mass. In this overview, we summarize the results of the main studies on DKT. DKT suffers from a prejudice of heaviness and is considered to be useless by transplant centers that do not perform it. The literature is often biased by the heterogeneity of the criteria leading to a DKT and the common refusal of kidneys that are judged too marginal. In fact, we show that when strictly allocated according to reliable clinical or histological scores, dual and single ECD transplantations yield similar results in terms of patient and graft survival rates despite significant differences in donors' characteristics. DKTs are not associated with a higher proportion of surgical complications, except in some studies showing thrombosis of 1 of the 2 grafts. The benefits of dual transplantation are particularly evident for kidneys coming from most ECDs. There is still a need for more studies to find the best allocation criteria that would permit transplantation to the highest number of patients with similar outcomes in recipients of single and dual ECD kidneys.

Surveillance Registry of Sirolimus Use in Recipients of Kidney Allografts From Expanded Criteria Donors.

The use of expanded criteria donor (ECD) kidneys has increased the overall availability of renal transplants. This study assessed the use of sirolimus in patients receiving Argentina-ECD kidneys. This observational, open-label, 1-arm, prospective, longitudinal pilot study was conducted at 8 transplant centers in Argentina. Adults receiving kidney transplants (without pancreas) from ECDs were eligible if they were converted to sirolimus 1 to 36 months' posttransplantation, with sirolimus becoming base therapy within 1 month after conversion. Patients were followed up for 1 year. Outcomes included reasons for conversion, acute rejection, patient and graft survival, graft status, and safety. The intention-to-treat population included 52 patients (mean age, 48.7 years). Calcineurin inhibitor nephropathy (40%) and chronic allograft nephropathy (25%) were the most frequent reasons for conversion. Two acute rejections occurred during follow-up, but no patients experienced graft loss. One patient died during follow-up, and 3 patients died within 1 month of the last sirolimus dose. Levels of serum creatinine and creatinine clearance remained stable from baseline to week 52/53. Mean proteinuria measured in a subset of patients was 0.2 ± 0.2 g/24 hours before conversion and increased to 0.6 ± 1.2 g/24 hours at week 24/25 and 0.5 ± 0.6 g/24 hours at week 52/53. Adverse events were consistent with those in previous conversion trials; the most common were infections and infestations (54%). This pilot study illustrates the potential benefits of sirolimus in recipients of ECD kidneys in Argentina. Larger, randomized controlled trials are needed to confirm these findings and to clarify the long-term benefits of sirolimus in this patient population.

Does Thymoglobulin Induction Increase Susceptibility to Carbapenem-Resistant Acinetobacter baumannii Sepsis-related Death in Expanded Criteria Donors?

Solid organ transplant recipients are susceptible to antibiotic-resistant infections and carbapenem-resistant Acinetobacter baumannii (CRAB) has recently been recognized as a serious complication in solid organ recipients. High mortality rates have been described. We retrospectively analyzed 807 transplantations and detected 10 patients who died 24 hours after the diagnosis of septicemia, all with CRAB-positive blood cultures. Recipients were followed up for at least 1 year and were stratified into the following groups: Group 1, patients alive; Group 2, patients that died due to other causes except Acinetobacter infection; and Group 3, patients who died within 24 hours of CRAB diagnosis. CRAB-positive patients died a median of 3.17 (range, 1.81-18.7) months after transplantation. In these patients, expanded criteria donors (ECDs) were more frequent (P< .001), as were the use of anti-thymocyte globulin (ATG) induction (P= .02) and delayed graft function (P= .01). For ECD recipients, death rate from any cause, whether induced with ATG or not, was 25% and 20.6%, respectively (odds ratio [OR], 1.28; confidence interval [CI] 95%, 0.56-2.91; P= .68). The death rate from CRAB-related sepsis was 10.3% and 0% whether receiving ATG or not, respectively (OR, 15.49; CI 95%, 0.87-277.16; P= .014). There was a 25.75-fold increase in the death rate in ECD kidney recipients induced with thymoglobulin and with CRAB-related sepsis. Transplants from ECDs and induced with thymoglobulin may be at increased risk of CRAB death in 24 hours when compared with patients with standard donors and induced with thymoglobulin.

Renal transplantation with expanded criteria donors: Which is the optimal immunosuppression?

The growing gap between demand and supply for kidney transplants has led to renewed interest in the use of expanded criteria donor (ECD) kidneys in an effort to increase the donor pool. Although most studies of ECD kidney transplantation confirm lower allograft survival rates and, generally, worse outcomes than standard criteria donor kidneys, recipients of ECD kidneys generally have improved survival compared with wait-listed dialysis patients, thus encouraging the pursuit of this type of kidney transplantation. The relative benefits of transplantation using kidneys from ECDs are dependent on patient characteristics and the waiting time on dialysis. Because of the increased risk of poor graft function, calcineurin inhibitor (CNI)-induced nephrotoxicity, increased incidence of infections, cardiovascular risk, and malignancies, elderly recipients of an ECD kidney transplant are a special population that requires a tailored immunosuppressive regimen. Recipients of ECD kidneys often are excluded from transplant trials and, therefore, the optimal induction and maintenance immunosuppressive regimen for them is not known. Approaches are largely center specific and based upon expert opinion. Some data suggest that antithymocyte globulin might be the preferred induction agent for elderly recipients of ECD kidneys. Maintenance regimens that spare CNIs have been advocated, especially for older recipients of ECD kidneys. CNI-free regimens are not universally accepted due to occasionally high rejection rates. However, reduced CNI exposure and CNI-free regimens based on mammalian target of rapamycin inhibitors have shown acceptable outcomes in appropriately selected ECD transplant recipients.

Matching “Engine and Chassis” in ECD Kidney Transplantation Using a Novel Creatinine Clearance Match Ratio (CCMR) Is Associated With Improved Outcomes.

BACKGROUND: To improve outcomes of expanded criteria donor (ECD) kidneys, prior studies matched donors to recipients according to recipient weight or donor kidney size. This study hypothesizes that matching donors to recipients based on Cockcroft-Gault estimates of creatinine clearance can improve outcomes in ECD kidney transplants compared to predictions based on size matching or donor creatinine clearance alone. METHODS: Recipients of ECD kidneys in the Scientific Registry of Transplant Recipients (SRTR) who were transplanted from October 1, 1987 to August 31, 2011 were included. The estimated creatinine clearance ratio (CCMR) was calculated as the estimated recipient creatinine clearance based on manipulations of the Cockcroft-Gault equation utilizing donor creatinine clearance at the time of transplant. Univariate and multivariate analyses predicted the hazard ratio of graft failure and the odds ratio of requiring dialysis within the first week. The CCMR was compared to the kidney donor risk index (KDRI) and recipient-to-donor weight and age ratios using discrimination analyses. RESULTS: 25,640 ECD kidney transplants were analyzed. On multivariate analysis, higher CCMR was associated with increased graft failure and odds of requiring dialysis within the first week (comparing highest ratio quintile versus lowest ratio quintile: HR 1.53, p<0.001; OR 2.18, p<0.001). CCMR was found to be superior in prediction and discrimination ability as compared to donor creatinine clearance, recipient/donor age ratio, and recipient/donor weight ratio. CONCLUSION: ECD kidneys have improved outcomes when the donor/recipient creatinine clearance match ratio is optimal.

Recipients of ECD and SCD Kidney From the Donors Age 50-59 Have Comparable Outcomes: A Matched Pair Analysis.

Background: Both donor and recipient characteristics play a role in kidney transplant (tx) outcome. Using a large database to look at risks, the SRTR defined an expanded criteria donor (ECD) as one whose kidneys are associated with ≥ 1.7 risk of graft failure versus a standard criteria donor (SCD). Because of the worse results, use of kidneys from donors meeting ECD criteria has been limited. It is unclear whether worse outcomes are due to: a) worse kidney function at the time of tx, b) more rapid decline in renal function over time; and/or c) recipient characteristics. We compared outcomes of 49 recipients of ECD kidneys from donors 50-59 vs. 66 matched recipients of SCD kidneys (from donors 50-59). Recipients were matched on age at transplant, gender, date of transplant, type 1 diabetes prior the transplant, and primary versus retransplant. We compared eGFR levels at 1 and 12 months, slope of 1/Cr vs time in the first year, and separately, after the 1st year posttransplant. Results: There were no differences in demographics between the 2 groups except in race (ECD: 86% C, 0%AA, 4% other; SCD: 85%C, 0%AA, 14% other). Mean ECD recipient age was 50±14 years; SCD, 51±14 years (NS). Patient survival, graft survival, and death censored graft survival were not different between groups ( table 1).Table: No Caption available.Mean eGFR at 1 month was 41.3±19.6 for ECD and 37.2±14ml/min/1.73m2 for SCD; at 12 months was 43.1±17.9 for ECD and 36.4±15.8 ml/min/1.73 m2 for SCD (NS). Slope of 1/Cr vs time did not differ between ECD and SCD within first year; similarly, there was no difference after the 1st yr (table2).Table: No Caption available.Conclusion: ECD transplants from donors 50-59 (at least as selected at our institution), compared to recipient-matched SCD tx, have similar 1-yr intercept and similar post 1-yr slope of 1/Cr vs time. In matched recipients, ECD tx with 1 yr survival are associated with equivalent 60 month slopes of 1/Cr vs time as SCDs.

Use of Expanded Criteria Donors Gives Significantly Poorer Long-Term Graft Survival

Introduction: The use of expanded criteria donor (ECD) kidneys remains controversial as various groups have reported conflicting outcomes in terms of long-term graft outcomes. It is however well-known that ECD kidneys afford shorter graft survival as compared to kidneys from a standard criteria donor (SCD). In Singapore, patients with end stage renal failure (ESRF) must meet strict medical criteria before they are allowed to be placed on the National Transplant Registry to await a deceased donor kidney, including the absence of clinically overt cardiovascular and cerebrovascular disease. The aim of this study was to determine if there is a difference in long-term graft survival between recipients of SCD and ECD kidneys. Methods: A retrospective review was conducted on all deceased donor renal transplants (DDRT) performed at the Singapore General Hospital from 1st January 2000 to 31 December 2010. Results: During this period, 272 adults underwent a DDRT, with 226 (58.7%) receiving an SCD kidney (Group 1), and 46 (12.0%) receiving an ECD kidney (Group 2). The etiology of ESRF was predominantly chronic glomerulonephritis in both groups (83.1% Group 1 vs 73.9% Group 2, p = 0.75). The mean dialysis duration pretransplant was similar in both groups (45.3+8.7 vs. 46.7+9.0 months in Groups 1 and 2 respectively, p=0.28). While an increased incidence of early acute rejection (a rejection episode within 3 months post-transplant), and delayed graft function (a need for dialysis within a week post-transplant), are risk factors for decreased long-term graft function, the incidence of both events was similar in both groups (10.2% vs. 19.6%, p=0.07, and 42.5% vs. 54.4%, p=0.14, in Groups 1 and 2 respectively). Graft survival at 1 year was similar in both groups (96.0% Group 1 and 91.3% Group 2), but at 5 years there was a clear difference in graft survival (97.1% Group 1 and 68.4% Group 2). The 10-year graft survival was significantly reduced in recipients of ECD kidneys (p< 0.001) (Figure 1). Long term graft survival as described by half-lives was less than 6 years for ECD grafts and more than 10years for SCD grafts.[Figure 1]Conclusion: Patients receiving ECD kidneys, regardless of whether they have experienced an early acute rejection episode or delayed graft function, have a significantly reduced long-term graft survival. This is despite being in similar health as SCD recipients, with the absence of clinically overt cardiovascular and cerebrovascular disease pre-transplant. The use of ECD kidneys should be considered only in selected recipients.

Outcomes of Transplantation Using Kidneys From Donors Meeting Expanded Criteria in Australia and New Zealand, 1991 to 2005

Kidneys from expanded criteria donors (ECD) are reported to have inferior transplant outcomes. Using the Australia and New Zealand Dialysis and Transplant Registry, we reviewed deceased donor kidneys transplanted from 1991 to 2005 in Australia and New Zealand, followed until December 2006. ECD was defined using United Network for Organ Sharing criteria. Graft and patient outcomes, estimated glomerular filtration rates (eGFR), acute rejection, and delayed graft function were analyzed by donor-age and ECD status, with adjustment for important covariates. There were 3248 recipients of non-ECD kidneys and 781 recipients of ECD kidneys. Compared with donors aged less than 50 years, adjusted hazard ratios for graft failure (GF) at 0 to 1 and 1 to 5 years for ECD kidneys from donors aged 60 years or above were 1.92 (1.48-2.49; P<0.001) and 2.52 (1.97-3.23; P<0.001). The hazard ratios for GF were 1.87 (1.31-2.70; P<0.05) for ECD kidneys from donors aged 50 to 59 years in the first year but were not increased subsequently. Mean eGFR at 1 year decreased with increasing donor age and ECD status (56.4 [53.8-58.9] mL/min for kidneys from donors aged <50, 46.6 [45.0-48.3] and 43.5 [41.1-45.9] for non-ECD and ECD donors aged 50 to 59 years, respectively, and 38.6 [36.9-40.4] for donors > or =60; P<0.001) but subsequent eGFR loss was similar except for donors aged 60 years or above (P=0.021). Acute rejection and delayed graft function were more frequent in ECD kidney recipients, but the associations between GF and donor age/ECD status were independent of these factors. For recipients of ECD kidneys, donor age 60 years or above is the most significant determinant of poor outcome; donor age 50 to 59 years represents a category of intermediate risk.

Immunosuppression without calcineurin inhibition: optimization of renal function in expanded criteria donor renal transplantation

To assess the efficacy of calcineurin inhibitor (CNI)-free immunosuppression vs. calcineurin-based immunosuppression in patients receiving expanded criteria donor (ECD) kidneys. Thirteen recipients of ECD kidneys were enrolled in this pilot study and treated with induction therapy and maintained on sirolimus, mycophenolate mofetil (MMF) and prednisone. A contemporaneous control group was randomly selected comprised of 13 recipients of ECD kidneys who had been maintained on CNI plus MMF and prednisone. For the study group vs. the control group, two-yr graft survival was 92.3% vs. 84.6% (p = NS), two-yr patient survival was 100% vs. 92.3% (p = NS) and the acute rejection rates were 23% vs. 31% (p = NS), respectively. Renal function was significantly better in the study group compared with control up to the six-month mark, after which, it remained numerically but not statistically significant. Complications were more common in the study group, but serious adverse events requiring discontinuation were rare. This pilot study demonstrates that CNI-free regimens can be safely implemented in patients receiving ECD kidneys with excellent two-yr patient and graft survival and good renal allograft function. Longer follow-up in larger randomized controlled trials are necessary to establish these findings.

Impact of the Expanded Criteria Donor Allocation System on Candidates for and Recipients of Expanded Criteria Donor Kidneys

A national policy to allocate kidneys from expanded criteria donors (ECD) took effect October 31, 2002. To assess its impact, we analyzed data from the Scientific Registry of Transplant Recipients for ECD kidney candidates and recipients between November 1999 and October 2005. The likelihood of being listed for ECD transplant, of receiving any transplant, and of receiving an ECD transplant were assessed using logistic regression models. As of October 31, 2005, 42.6% of candidates were listed with an ECD designation (range by donation service area [DSA], 1.9% to 94.9%). ECD-listed candidates were likely to be older, diabetic, and sensitized. By October 31, 2005, candidates listed for ECD as of November 1, 2002 were 41% more likely to receive any kidney transplant than those not ECD-listed. Among ECD-listed recipients, 30.1% received an ECD transplant and 69.9% a non-ECD transplant. Recipients more likely to receive an ECD transplant were significantly older and in DSAs where a high percentage of ECD transplants were performed and/or a low percentage of candidates were ECD-listed. A large, regionally variable fraction of candidates are opting to receive ECD offers. Listing with an ECD designation increases the likelihood of transplantation in selected populations. Selective listing of ECD candidates is associated with a higher likelihood of receiving an ECD transplant.

Recent Trends and Results for Organ Donation and Transplantation in the United States, 2005

Recent Trends and Results for Organ Donation and Transplantation in the United States, 2005

Optimal use of older donors and recipients in kidney transplantation

The aging donor and recipient population have led to new challenges in kidney transplantation. The purpose of this study was to review retrospectively our single center experience in deceased-donor kidney transplantation, with respect to donor and recipient age. From October 1, 2001, through February 20, 2004, we performed 144 deceased-donor kidney transplantations, which included 37 procedures (26%) in recipients > or =60 years old and 107 procedures (74%) in recipients 19 to 59 years old. The deceased-donor pool included 57 expanded criteria donors (ECD) and 87 standard criteria donors (defined as not ECD). ECD kidneys were used by matching estimated renal functional mass to recipient size (body mass index, <25 kg/m(2)), which included the use of dual kidney transplantations (n = 9). ECD kidney recipients were further selected on the basis of age >40 years and low immunologic risk. Recipients received rabbit antithymocyte globulin or alemtuzumab induction in combination with tacrolimus, mycophenolate mofetil, and steroids. The mean age differed between recipient groups (65 vs 46 years; P < .001). In recipients > or =60 years old, 23 recipients (62%) received kidney transplants from ECDs compared with 34 kidney transplants from ECDs (32%; P < .001) in recipients who were <60 years old. Patient survival was 89% in recipients who were > or =60 years old, compared with 95% in recipients who were <60 years old (P = .11), with a mean follow-up time of 27 months. Kidney graft survival rates were 84% in both recipient groups. Initial and subsequent graft function, rejection, infection, reoperation, length of stay, readmission, and resource use were similar among groups. By the matching of nephron mass with recipient size and avoiding the use of ECD kidneys in recipients with a high immunologic risk, short-term outcomes that are comparable with standard criteria donor kidneys in younger patients can be achieved with either older donors or recipients, regardless of age.

Deceased-Donor Characteristics and the Survival Benefit of Kidney Transplantation

Transplantation using kidneys from deceased donors who meet the expanded criteria donor (ECD) definition (age > or =60 years or 50 to 59 years with at least 2 of the following: history of hypertension, serum creatinine level >1.5 mg/dL [132.6 micromol/L], and cerebrovascular cause of death) is associated with 70% higher risk of graft failure compared with non-ECD transplants. However, if ECD transplants offer improved overall patient survival, inferior graft outcome may represent an acceptable trade-off. To compare mortality after ECD kidney transplantation vs that in a combined standard-therapy group of non-ECD recipients and those still receiving dialysis. Retrospective cohort study using data from a US national registry of mortality and graft outcomes among kidney transplant candidates and recipients. The cohort included 109,127 patients receiving dialysis and added to the kidney waiting list between January 1, 1995, and December 31, 2002, and followed up through July 31, 2004. Long-term (3-year) relative risk of mortality for ECD kidney recipients vs those receiving standard therapy, estimated using time-dependent Cox regression models. By end of follow-up, 7790 ECD kidney transplants were performed. Because of excess ECD recipient mortality in the perioperative period, cumulative survival did not equal that of standard-therapy patients until 3.5 years posttransplantation. Long-term relative mortality risk was 17% lower for ECD recipients (relative risk, 0.83; 95% confidence interval, 0.77-0.90; P<.001). Subgroups with significant ECD survival benefit included patients older than 40 years, both sexes, non-Hispanics, all races, unsensitized patients, and those with diabetes or hypertension. In organ procurement organizations (OPOs) with long median waiting times (>1350 days), ECD recipients had a 27% lower risk of death (relative risk, 0.73; 95% confidence interval, 0.64-0.83; P<.001). In areas with shorter waiting times, only recipients with diabetes demonstrated an ECD survival benefit. ECD kidney transplants should be offered principally to candidates older than 40 years in OPOs with long waiting times. In OPOs with shorter waiting times, in which non-ECD kidney transplant availability is higher, candidates should be counseled that ECD survival benefit is observed only for patients with diabetes.

Expanded Criteria Donors: Process and Outcomes

Expanded criteria donor (ECD) kidneys are transplantable deceased donor (DD) kidneys for which the average patient, graft survival, and renal function are inferior when compared to standard criteria DD kidneys. Although the term ECD kidneys has been used since the early 1990s to describe kidneys with various characteristics associated with poorer outcomes, the concept has been formally implemented in U.S. organ allocation. A DD kidney is considered to be an ECD organ if the estimated adjusted risk of graft failure is > or = 70% (RR > or = 1.70) compared to DD kidneys with standard characteristics of transplant suitability. The donor characteristics that define an ECD kidney include age > or = 60 years, or age 50-59 years plus two of the following: cerebrovascular accident as the cause of death, preexisting hypertension, or terminal serum creatinine greater than 1.5 mg/dl. In the aggregate, recipients of ECD kidneys have improved survival compared to end-stage renal disease (ESRD) patients on the kidney transplant waiting list. Patient survival is 5% lower at 1 year and 8-12% lower at 3-5 years for ECD kidney recipients. Adjusted graft survival in ECD kidneys is 8% lower at 1 year and 15-20% lower at 3-5 years after transplantation compared to standard criteria donor kidneys. However, patients less than 40 years of age, African Americans, Asians for whom the median waiting time is less than 1350 days receive no survival benefit from ECD kidney transplantation. Informed choice by the potential recipient is a prominent feature of the allocation policy regarding ECD kidneys. Since there are recipient characteristics associated with no survival benefit following ECD transplantation, nephrologists who refer patients for kidney transplantation should be familiar with the combination of donor and recipient factors that are likely to yield detrimental results.