Expanded Criteria Donor Transplants Research Articles

Early Graft Loss Following Transplantation From Expanded Criteria Donors.

Expanded criteria donor (ECD) kidneys are associated with higher graft loss rates than standard criteria donor kidneys. We sought to determine factors associated with early graft loss and their discrimination ability for this outcome compared with kidney donor risk index. Data were extracted from the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) for ECD transplants between 1997 and 2014. The primary outcome was early graft loss (all-cause graft loss within 3 y of transplantation). Death-censored graft loss was substituted as a sensitivity analysis. Era-adjusted odds ratios were calculated by multivariable logistic regression for donor, recipient, and transplant factors available at transplantation. Discrimination was assessed by c-statistic, with 95% confidence intervals (CIs) calculated by bootstrapping. Of 2152 ECD kidney transplants, early graft loss occurred in 406 (19%) and was associated with recipient diabetes, smoking, First Nations recipients, and oliguria. Of factors defining ECD (age, elevated terminal creatinine, hypertension, death from cerebrovascular accident), all but mode of death were associated with early graft loss. The multivariable model, including known donor, recipient, and transplant factors, was moderately good at predicting early graft loss (c-statistic 0.65; 95% CI, 0.62-0.68). Recipient factors (c-statistic 0.62; 95% CI, 0.59-0.65) performed equally well compared with donor factors (c-statistic 0.60; 95% CI, 0.57-0.64) or the kidney donor risk index (c-statistic 0.60; 95% CI, 0.56-0.63). Early graft loss occurs in approximately one-fifth of ECD kidney transplants. The discriminatory value of commonly used recipient, donor, and transplant factors are approximately comparable and limited.

Influence of Cold Ischemia Time on the Outcome of Kidney Transplants from Donors Aged 70 Years and Above-A Collaborative Transplant Study Report.

The use of kidney allografts from ≥70-y-old donors has increased persistently over the last 20 y. Prolonged cold ischemia time (CIT) is well known to increase graft failure risk. However, despite their growing importance, no data are available on the impact of CIT, specifically on survival of allografts from ≥70-y-old donors. In total, 47 585 kidney transplantations from expanded criteria donors (ECDs) performed during 2000-2017 and reported to the Collaborative Transplant Study were analyzed. The impact of CIT on 5-y death-censored graft and patient survival was studied for transplantations from <70-y (n = 33 305) and ≥70-y-old ECDs (n = 14 280). Compared with the reference of ≤12 h CIT, a CIT of 13-18 h did not increase the risk of graft failure significantly, either for recipients of kidneys from <70-y or from ≥70-y-old ECDs. In contrast, graft failure risk increased significantly when CIT exceeded 18 h, both in recipients of kidneys from <70-y and, more pronounced, from ≥70-y-old ECDs (CIT 19-24 h: hazard ratio [HR] = 1.19 and 1.24; P < 0.001; CIT ≥24 h: HR = 1.28 and 1.32, P < 0.001 and P =0.003, respectively). Within the 18-h CIT interval, additional HLA matching further improved survival of ECD transplants significantly, whereas the negative impact of a prolonged CIT >18 h was stronger in ≥65-y-old recipients and for transplants with multiple HLA mismatches. The influence of CIT on patient survival was less pronounced. CIT, as long it is kept ≤18 h, has no significant impact on survival of kidney transplants, even from ≥70-y-old ECDs.

Does kidney transplantation with a standard or expanded criteria donor improve patient survival? Results from a Belgian cohort.

BackgroundChanges in recipient and donor factors have reopened the question of survival benefits of kidney transplantation versus dialysis.MethodsWe analysed survival among 3808 adult Belgian patients waitlisted for a first deceased donor kidney transplant from 2000 to 2012. The primary outcome was mortality during the median waiting time plus 3 years of follow-up after transplantation or with continued dialysis. Outcomes were analysed separately for standard criteria donor (SCD) and expanded criteria donor (ECD) kidney transplants. We adjusted survival analyses for recipient age (20–44, 45–64 and ≥65 years), sex and diabetes as the primary renal disease.ResultsAmong patients ≥65 years of age, only SCD transplantation provided a significant survival benefit compared with dialysis, with a mortality of 16.3% [95% confidence interval (CI) 13.2–19.9] with SCD transplantation, 20.5% (95% CI 16.1–24.6) with ECD transplantation and 24.6% (95% CI 19.4–29.5) with continued dialysis. Relative mortality risk was increased in the first months after transplantation compared with dialysis, with equivalent risk levels reached earlier with SCD than ECD transplantation in all age groups.ConclusionsThe results of this study suggest that older patients might gain a survival benefit with SCD transplantation versus dialysis, but any survival benefit with ECD transplantation versus dialysis may be small.

Impact of HLA compatibility in recipients of kidneys from expanded criteria donors: A Collaborative Transplant Study Report.

Due to a widespread organ shortage, the use of expanded criteria donors (ECDs) in kidney transplantation has increased persistently, reaching approximately 40% in recent years. Whether human leucocyte antigen (HLA) matching between donor and recipient should be part of allocation algorithms in transplantation of ECD kidneys, and especially of ECD kidneys from ≥70-year-old donors, is still in question. To this end, 135,529 kidney transplantations performed between 2000 and 2017 and reported to the Collaborative Transplant Study were analysed and the impact of HLA-A+B+DR mismatches on death-censored graft and patient survival as well as on rejection episodes was investigated. Results were stratified according to donor status (standard criteria donor (SCD) versus ECD) and age of ECD. HLA incompatibility increased the five-year death-censored graft failure risk similarly strong in recipients of ECD and SCD transplants (hazard ratio (HR) per HLA mismatch 1.078 and 1.075, respectively; p<.001 for both). Its impact on rejection treatments during the first post-transplant year was also significant but slightly weaker for recipients of ECD transplants (risk ratio (RR) per HLA mismatch 1.10 for ECD transplants and 1.13 for SCD transplants; p<.001 for both). Mortality increased gradually from zero to six HLA mismatches in recipients of SCD transplants, whereas for ECD transplants a significant increase was notable only from zero to more than zero mismatches. A significant but slightly less pronounced impact of HLA incompatibility on graft failure was observed in transplants from ≥70- compared with <70-year-old ECDs (HR per mismatch 1.047 and 1.093; p=.009 and<0.001, respectively). The influence of HLA mismatches on rejection treatments was the same for both ECD age groups (RR=1.10, p<.001 and p=.004, respectively). Our data indicate that HLA matching should be part of allocation algorithms not only in transplantation of kidneys from SCDs but also from ECDs.

Use of expanded-criteria donors and>85 KDPI kidneys for pediatric kidney transplantation in the United States.

Pediatric kidney transplant outcomes associated with expanded-criteria donors (ECD) and high Kidney Donor Profile Index (KDPI) kidneys are unknown. We reviewed the Scientific Registry of Transplant Recipients data from 1987-2017 to identify 96 ECD and 92>85 KDPI kidney recipients (<18years). Using propensity scores, we created comparison groups of 375 non-ECD and 357≤85 KDPI recipients for comparisons with ECD and>85 KDPI transplants, respectively. We used Cox regression for patient/graft survival and sequential Cox approach for survival benefit of ECD and>85 KDPI transplantationvs remaining on the waitlist. After adjustment, ECD recipients were at significantly increased risk of graft failure (adjusted hazard ratio [aHR]=1.6; P=.001) but not of mortality (aHR=1.33; P=.15) compared with non-ECD recipients. We observed no survival benefit of ECD transplants vs remaining on the waitlist (aHR=1.05; P=.83). We found no significant difference in graft failure (aHR=1.27; P=.12) and mortality (aHR=1.41; P=.13) risks between>85 KDPI and≤85 KDPI recipients. However, > 85 KDPI transplants were associated with a survival benefit vs remaining on the waitlist (aHR=0.41; P=.01). ECD transplantation in children is associated with a high graft loss risk and no survival benefit, whereas>85 KDPI transplantation is associated with a survival benefit for children vs remaining on the waitlist.

956 - Economic impact of pulsatile hypothermic perfusion in an expanded criteria donor transplant program. Long-term evaluation

956 - Economic impact of pulsatile hypothermic perfusion in an expanded criteria donor transplant program. Long-term evaluation

P1630IS THERE ALWAYS A SURVIVAL BENEFIT WITH KIDNEY TRANSPLANTATION? RESULTS FROM A BELGIAN COHORT

Abstract Background and Aims Older studies have shown a survival benefit with kidney transplantation compared to dialysis, even for patients older than 60 years. However, due to important evolutions such as older recipient age and the use of less-than-optimal quality donors, it is unclear if the survival benefit with transplantation still holds true nowadays. Method Patient survival was analyzed for 3808 Belgian patients waitlisted for a first deceased donor kidney transplant between 2000 to 2012. Patients were divided into age categories (20-44y, 45-64y, ≥65y). Primary outcome was the comparison of mortality during median waiting time plus 3 years follow-up, either after transplantation or when remaining on dialysis. Outcomes were analyzed separately for those receiving a standard criteria donor (SCD) or an expanded criteria donor (ECD) transplant. The survival analyses were adjusted for age, sex and primary renal disease. Results Among patients ≥ 65 years old, only SCD transplantation provided a significant survival benefit compared to dialysis: mortality was 16.3 % (95 % CI: 13.2–19.9 %) with SCD transplantation, 20.5 % (16.1–24.6 %) with ECD transplantation, and 24.6 % (19.5–29.5 %) when remaining on dialysis. Relative mortality risk was increased in the first months after transplantation compared to dialysis, with equal risk levels being reached earlier for SCD than ECD transplantations in all age groups. Conclusion This study suggests that older patients have a survival benefit with SCD transplantation versus dialysis, but the survival benefit with ECD transplantation versus dialysis may be small or non-existent.

The Need for New Donor Stratification to Predict Graft Survival in Deceased Donor Kidney Transplantation.

PurposeThe aim of this study was to determine whether stratification of deceased donors by the United Network for Organ Sharing (UNOS) criteria negatively impacts graft survival.Materials and MethodsWe retrospectively reviewed deceased donor and recipient pretransplant variables of kidney transplantations that occurred between February 1995 and December 2009. We compared clinical outcomes between standard criteria donors (SCDs) and expanded criteria donors (ECDs).ResultsThe deceased donors consisted of 369 patients. A total of 494 transplant recipients were enrolled in this study. Mean age was 41.7±11.4 year (range 18–69) and 273 patients (55.4%) were male. Mean duration of follow-up was 8.8±4.9 years. The recipients from ECD kidneys were 63 patients (12.8%). The overall mean cold ischemia time was 5.7±3.2 hours. Estimated glomerular filtration rate at 1, 2, and 3 years after transplantation were significantly lower in ECD transplants (1 year, 62.2±17.6 vs. 51.0±16.4, p<0.001; 2 year, 62.2±17.6 vs. 51.0±16.4, p=0.001; 3 year, 60.9±23.5 vs. 54.1±18.7, p=0.047). In multivariate analysis, donor age (≥40 years) was an independent risk factor for graft failure. In Kaplan-Meier analyses, there was no significant difference in death-censored graft survival (Log rank test, p>0.05), although patient survival was lower in ECDs than SCDs (Log rank test, p=0.011).ConclusionOur data demonstrate that stratification by the UNOS criteria does not predict graft survival. In order to expand the donor pool, new criteria for standard/expanded donors need to be modified by regional differences.

Trends in Usage and Outcomes for Expanded Criteria Donor Kidney Transplantation in the United States Characterized by Kidney Donor Profile Index.

There has been increasing concern in the kidney transplant community about the declining use of expanded criteria donors (ECD) despite improvement in survival and quality of life. The recent introduction of the Kidney Donor Profile Index (KDPI), which provides a more granular characterization of donor quality, was expected to increase utilization of marginal kidneys and decrease the discard rates. However, trends and practice patterns of ECD kidney utilization on a national level based on donor organ quality as per KDPI are not well known. We, therefore, performed a trend analysis of all ECD recipients in the United Network for Organ Sharing (UNOS) registry between 2002 and 2012, after calculating the corresponding KDPI, to enable understanding the trends of usage and outcomes based on the KDPI characterization. High-risk recipient characteristics (diabetes, body mass index ≥30 kg/m2, hypertension, and age ≥60 years) increased over the period of the study (trend test p<0.001 for all). The proportion of ECD transplants increased from 18% in 2003 to a peak of 20.4% in 2008 and then declined thereafter to 17.3% in 2012. Using the KDPI >85% definition, the proportion increased from 9.4% in 2003 to a peak of 12.1% in 2008 and declined to 9.7% in 2012. Overall, although this represents a significant utilization of kidneys with KDPI >85% over time (p<0.001), recent years have seen a decline in usage, probably related to regulations imposed by Centers for Medicare & Medicaid Services (CMS).When comparing the hazards of graft failure by KDPI, ECD kidneys with KDPI >85% have a slightly lower risk of graft failure compared to standard criteria donor (SCD) kidneys with KDPI >85%, with a hazard ratio (HR) of 0.95, a confidence interval (CI) of 0.94-0.96, and statistical significance of p<0.001. This indicates that some SCD kidneys may actually have a lower estimated quality, with a higher Kidney Donor Risk Index (KDRI), than some ECDs. The incidence of delayed graft function (DGF) in ECD recipients has significantly decreased over time from 35.2% in 2003 to 29.6% in 2011 (p=0.007), probably related to better understanding of the donor risk profile along with increased use of hypothermic machine perfusion and pretransplant biopsy to aid in optimal allograft selection.The recent decline in transplantation of KDPI >85% kidneys probably reflects risk-averse transplant center behavior. Whether discard of discordant SCD kidneys with KDPI >85% has contributed to this decline remains to be studied.

Comparison of survival outcomes between Expanded Criteria Donor and Standard Criteria Donor kidney transplant recipients: a systematic review and meta-analysis

In 2002, the United Network for Organ Sharing proposed increasing the pool of donor kidneys to include Expanded Criteria Donor (ECD). Outside the USA, the ECD definition remains the one used without questioning whether such a graft allocation criterion is valid worldwide. We performed a meta-analysis to quantify the differences between ECD and Standard Criteria Donor (SCD) transplants. We paid particular attention to select studies in which the methodology was appropriate and we took into consideration the geographical area. Thirty-two publications were included. Only five studies, all from the USA, reported confounder-adjusted hazard ratios comparing the survival outcomes between ECD and SCD kidney transplant recipients. These five studies confirmed that ECD recipients seemed to have poorer prognosis. From 29 studies reporting appropriate survival curves, we estimated the 5-year pooled nonadjusted survivals for ECD and SCD recipients. The relative differences between the two groups were lower in Europe than in North America, particularly for death-censored graft failure. It is of primary importance to propose appropriate studies for external validation of the ECD criteria in non-US kidney transplant recipients.

The Canadian experience using the expanded criteria donor classification for allocating deceased donor kidneys for transplantation.

BackgroundAlthough the outcomes of transplantation with expanded criteria donor (ECD) kidneys are inferior to non-ECD transplants in the USA, the impact of the ECD classification on Canadian kidney transplant recipients is not known.ObjectivesThe objective of the study was to assess the performance of the US-derived ECD classification among deceased donor kidney transplant recipients in a Canadian setting.DesignThis study was a population-based cohort study.SettingThe study was conducted in all adult kidney transplant centers in the province of Ontario.PatientsThe patients were incident-deceased donor kidney transplant recipients from January 1, 2005 to March 31, 2011.MeasurementsStudy subjects were identified through the Trillium Gift of Life Network and linked to healthcare databases in Ontario. ECD status was based on age, hypertension, kidney function, and stroke-related death. Outcomes of interest included graft loss, death, and delayed graft function.MethodsThe Kaplan-Meier product limit method was used to graphically assess time to graft loss or death. Multivariable Cox proportional hazards models were used to assess graft loss or death as a function of ECD status. Multivariable logistic regression models were fitted for the outcome of delayed graft function.ResultsOf 1422 deceased donor kidney transplants, 325 (23 %) were from ECDs. The median donor age was 63 vs. 42 years for ECD vs. non-ECD, respectively. The 5-year cumulative incidence of total graft loss was 29.2 % in ECD and 20.7 % in non-ECD kidney transplants. The relative hazards for total graft loss (HR 1.48 [95 % CI, 1.10; 2.00]) and death-censored graft loss (HR 1.80 [95 % CI, 1.19, 2.71]) were increased in ECD vs. non-ECD transplants. Increased relative risks were also observed for death and delayed graft function, albeit not statistically significant.LimitationsAlthough comprehensive in coverage and outcome ascertainment, the available details on covariate data may be limited in large healthcare databases.ConclusionsThe ECD classification identifies kidneys at increased risk for graft loss in Canadian patients. The performance of more granular measures of donor risk (e.g., Kidney Donor Risk Index) and its impact on organ allocation/utilization in Canadian patients requires further study.Electronic supplementary materialThe online version of this article (doi:10.1186/s40697-016-0106-9) contains supplementary material, which is available to authorized users.

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.

Organ quality metrics are a poor predictor of costs and resource utilization in deceased donor kidney transplantation

The desire to provide cost-effective care has lead to an investigation of the costs of therapy for end-stage renal disease. Organ quality metrics are one way to attempt to stratify kidney transplants, although the ability of these metrics to predict costs and resource use is undetermined. The Scientific Registry of Transplant Recipients database was linked to the University HealthSystem Consortium Database to identify adult deceased donor kidney transplant recipients from 2009 to 2012. Patients were divided into cohorts by kidney criteria (standard vs expanded) or kidney donor profile index (KDPI) score (<85 vs 85+). Length of stay, 30-day readmission, discharge disposition, and delayed graft function were used as indicators of resource use. Cost was defined as reimbursement based on Medicare cost/charge ratios and included the costs of readmission when applicable. More than 19,500 patients populated the final dataset. Lower-quality kidneys (expanded criteria donor or KDPI 85+) were more likely to be transplanted in older (both P < .001) and diabetic recipients (both P < .001). After multivariable analysis controlling for recipient characteristics, we found that expanded criteria donor transplants were not associated with increased costs compared with standard criteria donor transplants (risk ratio [RR] 0.97, 95% confidence interval [CI] 0.93-1.00, P = .07). KDPI 85+ was associated with slightly lower costs than KDPI <85 transplants (RR 0.95, 95% CI 0.91-0.99, P = .02). When KDPI was considered as a continuous variable, the association was maintained (RR 0.9993, 95% CI 0.999-0.9998, P = .01). Organ quality metrics are less influential predictors of short-term costs than recipient factors. Future studies should focus on recipient characteristics as a way to discern high versus low cost transplantation procedures.

Early Graft Loss After Kidney Transplantation: Risk Factors and Consequences

Early graft loss (EGL) after kidney transplantation is a catastrophic outcome that is assumed to be more likely after the use of kidneys from suboptimal donors. We therefore examined its incidence, risk factors and consequences in our center in relation to different donor types. Of 801 recipients who received a kidney-only transplant from deceased donors, 50 (6.2%) suffered EGL within 30 days of transplantation. Significant risks factors for EGL were donation after circulatory death (DCD) (odds ratio [OR] 2.88; p = 0.006), expanded criteria donor (ECD) transplantation (OR 4.22; p = 0.010), donor age (OR 1.03; p = 0.044) and recipient past history of thrombosis (OR 4.91; p = 0.001). Recipients with EGL had 12.28 times increased risk of death within the first year, but long-term survival was worse for patients remaining on the waiting list. In comparison with patients on the waiting list but not transplanted, and with all patients on the waiting list, the risk of death after EGL decreased to baseline 4 and 23 months after transplantation, respectively. Our findings suggest that DCD and ECD transplantation are significant risk factors for EGL, which is a major risk factor for recipient death. However, long-term mortality is even greater for those remaining on the waiting list.

A Lifetime of Allograft Function with Kidneys from Older Donors.

Strategies to increase expanded criteria donor (ECD) transplantation are needed. We quantified the extent to which ECD kidneys provide recipients with a lifetime of allograft function by determining the difference between patient survival and death-censored allograft survival (graft survival). Initial analyses compared 5-year outcomes in the Eurotransplant Senior Program (European) and the United States Renal Data System. Among European recipients ≥65 years, patient survival exceeded graft survival, and ECD recipients returned to dialysis for an average of 5.2 months after transplant failure. Among United States recipients ≥60 years, graft survival exceeded patient survival. Although patient survival in elderly recipients in the United States was low (49% at 5 years), the average difference in patient survival at 10 years in elderly recipients in the United States with an ECD versus non-ECD transplant was only 7 months. The probability of patient survival with a functioning allograft at 5 years was higher with ECD transplantation within 1 year after activation to the waiting list than with delayed non-ECD transplantation ≥3 years after activation to the waiting list. Subsequent analyses demonstrated that ECD transplants do not provide a lifetime of allograft function in recipients <50 years in the United States. These findings should encourage ECD transplantation in patients ≥60 years, demonstrate that rapid ECD transplantation is superior to delayed non-ECD transplantation, and challenge the policy in the United States of allowing patients <50 years to receive an ECD transplant.

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.

Outcomes Following Transplantation of ECD and SCD Kidneys After Circulatory Death With or Without Acute Kidney Injury.

Aim: Expanded criteria donors (ECDs) and acute kidney injury (AKI) result in high discard rates for kidneys from deceased donors. In contrast, we have consistently used kidneys from such marginal donors, especially in donation after cardiac death (DCD) donors. The aim of this study is to compare the outcomes in recipients of ECD vs. standard criteria donors (SCD) DCD kidney transplants (KTx) with/without AKI. Methods: One hundred and twenty adult recipients from DCD donors were enrolled in this study. The recipients were divided into four groups according to the type of donor and AKI status as follows: ECD with AKI (Group 1), ECD without AKI (Group 2), SCD with AKI (Group 3), and SCD without AKI (Group 4). The recipients were followed up for an average of 6.3 ± 3.4 years after KTx. Results: Of the 120 DCD grafts, primary non-function was noted in 10 (8%), and 13 (11%) functioned immediately after KTx. The incidence of delayed graft function was 97 (81%). The overall graft survival rates at 1, 5, and 10 years were 88%, 83% and 75%, respectively. The graft survival rate in Group 1 was significantly poorer than that of Groups 3 and 4 (Log-rank test, p < 0.05). The graft survival rate in Group 2 tended to be poorer than that of Groups 3 and 4, but was not significantly different.Figure: No Caption available.In Group 1, the graft survival rates at 1, 5, and 10 years were 77%, 69% and 69%, respectively. A multivariate Cox regression analysis showed that donor age was independently associated with graft outcome. Conclusion: Although the graft survival rate in recipients of ECD kidneys with AKI was inferior to SCD grafts, ECD DCD donors with AKI could be a valuable source of kidneys for KTx with promising long-term outcomes.

Patient selection and volume in the era surrounding implementation of Medicare conditions of participation for transplant programs.

To evaluate evidence of practice changes affecting kidney transplant program volumes, and donor, recipient and candidate selection in the era surrounding the introduction of Centers for Medicare and Medicaid Services (CMS) conditions of participation (CoPs) for organ transplant programs. Scientific Registry of Transplant Recipients; CMS ESRD and Medicare claims databases. Retrospective analysis of national registry data. A Cox proportional hazards model of 1-year graft survival was used to derive risks associated with deceased-donor kidney transplants performed from 2001 to 2010. Among programs with ongoing noncompliance with the CoPs, kidney transplant volumes declined by 38 percent (n = 766) from 2006 to 2011, including a 55 percent drop in expanded criteria donor transplants. Volume increased by 6 percent (n = 638) among programs remaining in compliance. Aggregate risk of 1-year graft failure increased over time due to increasing recipient age and obesity, and longer ESRD duration. Although trends in aggregate risk of 1-year kidney graft loss do not indicate that the introduction of the CoPs has systematically reduced opportunities for marginal candidates or that there has been a systematic shift away from utilization of higher risk deceased donor kidneys, total volume and expanded criteria donor utilization decreased overall among programs with ongoing noncompliance.

Racial and Socioeconomic Disparities in the Allocation of Expanded Criteria Donor Kidneys

In carefully selected individuals, receiving expanded criteria donor (ECD) kidneys confer a survival advantage over remaining on dialysis. However, wait lists for ECD kidneys often include a significant proportion of young patients, who have no predictable survival benefit from ECD kidneys. This study hypothesized that educational and socioeconomic factors might influence a younger patient's decision to accept an ECD kidney. This study was a retrospective analysis of all first single-kidney transplants in the Scientific Registry of Transplant Recipients database from 2000 to 2009 in patients aged 18-40 years and waitlisted <3 years. The primary outcome measured was the odds of receiving an ECD kidney compared with an standard criteria donor kidney in different demographic subgroups. Race, income, and education were analyzed in main-effect and two-way interaction models, corrected for candidate panel reactive antibodies and sex. Of 13,615 ECD transplants, 591 kidneys (4.3%) went to recipients aged between 18 and 40 years who were waitlisted <3 years. African Americans (odds ratio, 1.71; 95% confidence interval, 1.26 to 2.33) or those with low education (odds ratio, 2.32; 95% confidence interval, 1.38 to 3.89) were more likely to receive an ECD kidney than Caucasians or those with a college degree, respectively. However, African Americans with higher education levels did not have significantly higher odds of receiving an ECD kidney than Caucasians with a college degree. In patients aged <40 years and waitlisted <3 years, African Americans and those with lower educational status and low income are more likely to receive an ECD kidney than Caucasians or those with higher education. It is important that health care providers and patients understand such disparities to facilitate a more rational use of ECD kidneys.

379 Economic impact of pulsatile hypothermic perfusion in an expanded criteria donor transplant program. Analysis of the first year since its introduction

379 Economic impact of pulsatile hypothermic perfusion in an expanded criteria donor transplant program. Analysis of the first year since its introduction