Expanded Criteria Donor Kidneys Research Articles

Optimizing the clinical utility of sirolimus-based immunosuppression for kidney transplantation.

While calcineurin inhibitors (CNIs) are effective for preventing acute rejection in kidney transplant recipients, long-term use may cause chronic kidney injury and is associated with increased risks of cardiovascular events, cancer, and infection-associated death. Immunosuppression strategies are needed to balance risks of acute and subclinical rejection with long-term benefits of improved kidney function. Sirolimus, an inhibitor of mammalian target of rapamycin, is used for immunosuppression in kidney transplantation. Its clinical utility has evolved, over more than 15years, including de novo sirolimus with and without concomitant CNIs and conversion from CNI-based regimens to sirolimus. Sirolimus-containing regimens are associated with preservation of good renal function, with promising characteristics for improving long-term graft and patient survival, including antiviral and anticancer effects. Based on clinical evidence, use of low-dose sirolimus in a de novo approach with tacrolimus/steroids in the immediate posttransplantation period is appropriate. A feasible alternative is a long term, CNI-free combination with mycophenolate mofetil (following CNI-to-sirolimus conversion at 3-6months). These strategies are appropriate for a broad range of patients with various levels of immunologic risk, including those receiving expanded criteria donor kidneys or at increased risk of delayed graft function, particular challenges in Latin America and other global regions.

A Retrospective Cohort Study on Rehospitalization following Expanded Criteria Donor Kidney Transplantation.

Background Expanded criteria donor (ECD) kidneys are commonly used but are associated with increased graft failure. Graft failure is in turn related to rehospitalization within thirty days post transplant. Our goal was to determine whether ECD kidneys independently lead to rehospitalization within 30 days, 1 year, and 2 years after transplant. Methods All adult first-time recipients of deceased donor kidneys transplanted from 2003–2012 at our center were reviewed. Models included demographics, medical comorbidities, center for disease control high-risk kidney, ECD kidney, ischemia times, cause of renal failure, immunosuppressive regimen, positive psychiatric screening, alcoholism, surgeon, year the transplant was performed, years on dialysis before transplant, and the number of inpatient hospitalizations within 6 months prior to transplant. We conducted Andersen–Gill modeling and propensity score matching followed by logistic regression. We also used multivariable linear regression to predict average length of stay during rehospitalization. Results More ECD patients had a rehospitalization at 1 year (70.3% versus 59%, log-rank test p=0.014). Thirty-day and 2-year time marks were not significant. Andersen–Gill models predicting successive hospitalizations yielded HR of 1.42 (p=0.002) and 1.32 (p=0.015) for ECD patients at 1 and 2 years of after transplantation, respectively. Propensity score matching and logistic regression showed a significant relative risk of 1.630 at one year (p=0.033) and 1.313 at two years (p=0.268). There was no significant association between ECD and subsequent lengths of hospital stay. Conclusion Receiving an ECD kidney is independently associated with multiple readmissions within 2 years of transplant but unrelated to length of stay.

Has the Expansion in Extended Criteria Deceased Donors Led to a Different Type of Delayed Graft Function and Poorer Outcomes?

ObjectivesThere has been considerable change in the practice of deceased kidney transplantation in the past 15 years, with more extreme phenotypes implanted. The aim of this study was to determine whether increased use of expanded criteria donors (extended criteria donors and donors after circulatory death) affected clinical outcomes, including the incidence and pattern of delayed graft function. Methods and materialsA retrospective analysis of 1359 renal transplants was performed over 15 years. The first 10 years of data (group 1) were compared with the subsequent 5 years (group 2). Outcomes were analyzed at 6 months and 12 months in addition to serum creatinine and patterns of delayed graft function (posttransplant times: on hemodialysis, to peak creatinine, for creatinine to half, and for creatinine to fall within 10% of baseline). ResultsThere was a significant increase in the percentage of expanded criteria donor allografts used in group 2 with a significant increase in the incidence of delayed graft function. Despite this, serum creatinine and the incidence of biopsy-proven acute rejection had both improved in group 2. Group 2 expanded criteria donor kidneys had a significantly lower incidence of type 1 delayed graft function and a significantly higher incidence of types 3 and 4 delayed graft function. Time for creatinine to half in both groups was the best predictor of a serum creatinine <180 μmol/L at 1 year. ConclusionThe increased use of expanded criteria donor kidneys has led to a higher incidence of delayed graft function, but the pattern has shown that the requirement for hemodialysis has significantly reduced.

The effect on early renal function of various dynamic preservation strategies in a preclinical pig ischemia-reperfusion autotransplant model.

The aims of this study were to determine the most optimal timing to start machine perfusion during kidney preservation to improve early graft function and to evaluate the impact of temperature and oxygen supply during machine perfusion in a porcine ischemia-reperfusion autotransplant model. The left kidney of an approximately 40-kg female Belgian Landrace pig was exposed to 30 minutes of warm ischemia via vascular clamping and randomized to 1 of 6 study groups: (1) 22-hour static cold storage (SCS) (n = 6), (2) 22-hour hypothermic machine perfusion (HMP) (n = 6), (3) 22-hour oxygenated HMP (n = 7), (4) 20-hour HMP plus 2-hour normothermic perfusion (NP) (n = 6), (5) 20-hour SCS plus 2-hour oxygenated HMP (n = 7), and (6) 20-hour SCS plus 2-hour NP (n = 6). Graft recovery measured by serum creatinine level was significantly faster for continuous HMP preservation strategies compared with SCS alone and for all end-ischemic strategies. The active oxygenated 22-hour HMP group demonstrated a significantly faster recovery from early graft function compared with the 22-hour nonactive oxygenated HMP group. Active oxygenation was also found to be an important modulator of a faster increase in renal flow during HMP preservation. Continuous oxygenated HMP applied from the time of kidney procurement until transplant might be the best preservation strategy to improve early graft function.

Lymphocyte depletion and risk of acute rejection in renal transplant recipients at increased risk for delayed graft function.

Delayed graft function (DGF) is a risk factor for acute rejection (AR) in renal transplant recipients, and KDIGO guidelines suggest use of lymphocyte-depletion induction when DGF is anticipated. We analyzed the United Network for Organ Sharing/Organ Procurement and Transplantation Network (UNOS/OPTN) database to assess the impact of induction immunosuppression on the risk of AR in deceased kidney recipients based on pretransplant risk of DGF using a validated model. Recipients were categorized into 4 groups based upon the induction immunosuppression: (1) Rabbit anti-thymocyte globulin (rATG); (2) Alemtuzumab (C1H); (3) IL2-receptor antagonists (IL2-RA; basiliximab or daclizumab), and (4) No antibody induction. The primary endpoint for analysis was a composite endpoint of treated AR or graft failure by 1-year posttransplantation. Compared to no antibody induction, rATG and C1H had consistently lower adjusted odds of the composite endpoint across all risk strata for DGF risk, whereas IL2-Ra was associated with increased adjusted odds of the composite endpoint with increasing DGF risk. When the induction agents were compared, rATG and C1H were associated with decreasing adjusted odds for the composite endpoint with increasing risk of DGF, especially at the higher risk spectrum of DGF. Consideration must be given to use of lymphocyte-depletion induction when the anticipated risk of DGF is increased.

Utilization of Standard Criteria Donor and Expanded Criteria Donor Kidneys After Kidney Allocation System Implementation.

BackgroundImplementation of the Kidney Allocation System (KAS) changed how kidneys are allocated and the information on which organ utilization decisions are based. We aimed to evaluate how KAS implementation changed kidney utilization and recipient outcomes.Material/MethodsUsing the United Network for Organ Sharing database, we identified recipients of kidney transplants from donors with kidney donor profile index (KDPI) of 61–90% in the 5-years pre- and 18-months post-KAS implementation and examined patient and graft survival and donor kidney discard rates based on standard criteria donor (SCD) or expanded criteria donor (ECD) status.ResultsThe proportion of ECD kidneys was unchanged pre- versus post-KAS. Post-KAS, SCD kidneys were less likely to be transplanted into young recipients while ECD kidneys were more likely to be transplanted. SCD kidneys in the post-KAS period conferred a 1.42 (95% CI: 1.18–1.73) times higher adjusted mortality and 2% lower 1-year survival (94.2% vs. 96.2%, P<0.001) but had unchanged graft failure compared to pre-KAS. For ECD kidneys, there was no difference in mortality or graft survival. The discard rate increased after KAS for both SCD and ECD kidneys (P<0.05) but was not different between SCD and ECD kidneys for any KDPI group.ConclusionsAfter KAS implementation, patient survival for recipients of SCD kidneys was significantly worse.

Experience With Hypothermic Machine Perfusion in Expanded Criteria Donors: Functional Outcomes

Hypothermic machine perfusion (HMP) decreases delayed graft function (DGF) and improves 1-year graft survival in expanded criteria donors (ECDs). Time of HMP could be associated with incidence of DGF. ObjectiveTo analyze functional outcomes of ECD grafts preserved totally (local grafts) or partially (imported grafts) with HMP. Materials and MethodsWe analyzed prospectively collected data from a cohort of first ECD graft receptors, with a minimum follow-up of 6 months. A total of 119 imported and 74 local grafts were included. Local ECD kidneys were preserved with HMP after retrieval. Imported ECD kidneys were preserved with simple cold storage and HMP. Vascular thrombosis, acute rejection, DGF, 1-year glomerular filtration rate, and 1-year graft survival were assessed. Univariate and estimative multivariate logistic regression was applied for analysis of DGF. A Cox proportional hazards model was applied to estimate graft survival. ResultsDGF occurred in 14 recipients of local grafts and in 33 recipients of imported grafts (28.0 vs 18.1%, P = .13); 1-year graft survival was better in the group of local grafts (80.3 vs 91.9%, P = .03). No differences in vascular thrombosis (5.9 vs 5.4%, P = .88), acute rejection (12.3 vs 9.8%, P = .91), or 1-year glomerular filtration rate (41.2 vs 40.5 mL/m/1.73m2, P = .87) were observed. In multivariate analysis, adjusted odds ratio for DGF was 1.20 (P = .79) and adjusted hazard ratio for graft survival was 1.93 (P = .31). ConclusionsThere is a trend that complete HMP reduces the risk of DGF and improves 1-year graft survival in ECD kidneys.

Il trapianto renale da cadavere: valutazione di idoneità del donatore e del rene

Kidney transplantation is the optimal treatment for selected patients with end-stage kidney failure. However, the demand for kidney transplantation exceeds the supply of organs available. At the beginning of the twenty-first century, in an attempt to increase the pool of deceased donor organs and reduce organ discard rates, kidney transplant programs have been developed using Expanded Criteria Donor kidneys, for Single or Dual Kidney Transplantation, and kidneys from Donation after Circulatory Death. Moreover, for appropriately selected candidates, are now offered organs from donors with increased but “acceptable” risk profile for the transmission of infectious and neoplastic diseases. Based on this reality, to date, the assessment of eligibility for a deceased donor to kidney transplantation is complex and requires a multidisciplinary approach through each step of the donation process. In this review, we outline the various modalities of kidney transplantation from a deceased donor. We also report the eligibility criteria based on the donor profile for diseases transmissible to the recipient, and the scores based on donor characteristics and histology criteria from kidney biopsies that are currently used to refine the quality of organs used for transplantation.

Early Immunosuppressive Exposure of Enteric-Coated-Mycophenolate Sodium Plus Tacrolimus Associated with Acute Rejection in Expanded Criteria Donor Kidney Transplantation.

Background:Immunosuppressive agents are still inefficient in preventing biopsy-proven acute rejection (BPAR) after expanded criteria donor (ECD) kidney transplantation. The aim of this study was to investigate the relationships between early immunosuppressive exposure and the development of BPAR.Methods:We performed a retrospective study of 58 recipients of ECD kidney transplantation treated with enteric-coated-mycophenolate sodium, tacrolimus (Tac), and prednisone. The levels of mycophenolic acid-area under the curve (MPA-AUC)0-12h and Tac C0 were measured at the 1st week and the 1st month posttransplant, respectively. The correlation was assessed by multivariate logistic regression.Results:The occurrence rates of BPAR and antibody-mediated rejection were 24.1% and 10.3%, respectively. A low level of MPA-AUC0-12h at the 1st week posttransplant was found in BPAR recipients (38.42 ± 8.37 vs. 50.64 ± 13.22, P < 0.01). In addition, the incidence of BPAR was significantly high (P < 0.05) when the MPA-AUC0-12h level was <30 mg·h-1·L-1 at the 1st week (15.0% vs. 44.4%) or the Tac C0 was <4 ng/ml at the 1st month posttransplant (33.3% vs. 21.6%). Multivariable logistic regression analysis showed that the MPA-AUC0-12h at the 1st week (OR: 0.842, 95% CI: 0.784-0.903) and the Tac C0 at the 1st month (OR: 0.904, 95% CI: 0.822–0.986) had significant inverse correlation with BPAR (P < 0.05).Conclusions:Low-level exposure of MPA and Tac C0 in the early weeks posttransplant reflects an increased acute rejection risk, which suggested that MPA-AUC0-12h <30 mg·h-1·L-1 and Tac C0 <4 ng/ml should be avoided in the first few weeks after transplantation.

Dual kidney transplantation as a strategy to use expanded criteria donors: a systematic review

The objective of this review was to assess whether dual kidney transplantation (DKT) is better than single KT (SKT) for optimizing the use of expanded criteria donor kidneys. We did a systematic literature search and meta-analyses when possible, pooling data for calculating relative risks (RR) of major outcomes. Twenty-five studies met the inclusion criteria. One-year serum creatinine was better after DKT vs. SKT (mean difference -0.27 [-0.37, -0.17], P<0.001), with less incidence of acute rejection (RR 0.66 [0.52, 0.85], P<0.001) and without differences at five years. Less DGF was seen in DKT (RR 0.88 [0.76, 1.02], P=0.09). Mortality at 1 and 3years was similar after dual or SKT, but mortality at five years was lower after DKT (RR 0.71 [0.53, 0.94], P=0.02). One-year graft loss was similar between dual (n=4158) and SKT (n=51800) (RR 0.97 [0.87, 1.09], P=0.62). Three- and five-year graft loss was not considered because of high heterogeneity between studies. In conclusion, short-term graft function and long-term patient survival are better in recipients receiving DKT vs. SKT. However, these differences are based on few retrospective reports with a relatively low number of cases. Good quality randomized controlled trials are needed to assess whether the investment of two kidneys in one recipient is justified in face of the current organ shortage.

The Welsh Transplant Incident

Abstract Hughes and Stuart’s shocking and unexpected deaths from the transplant treatments they received at Cardiff’s University Hospital of Wales could, in Lord Denning’s terminology, be described as ‘a most extraordinary chapter of accidents’. As Hughes and Stuart’s transplant treatments were based on expanded criteria donor kidneys, their deaths underscore not only the perennial problem of organ shortage in England and Wales which necessitates the clinical use of ‘high risk’ organs; but also, their deaths invite a re-examination of some of the ethical and legal issues involved in transplantation with expanded criteria donor organs. Being incomparable in calamity and rarity, the Welsh transplant incident is bound to raise novel issues of first impression in negligence, issues that this essay attempts to identify and analyse.

Perfusion Parameters of Donation After Cardiac Death Kidneys Predict Early Transplant Outcomes Based on Expanded Criteria Donor Designation

BackgroundDonation after cardiac death is the only source of the deceased donor in China at present. Hypothermic machine perfusion has been used increasingly over the years. We determined the hypothermic machine perfusion parameters associated with early transplant outcomes based on the expanded criteria donor (ECD) designation. MethodsThere were 446 consecutive kidneys donated after cardiac death and preserved by hypothermic machine perfusion (LifePort) in our center that were included in this study. The database was divided into 2 groups: ECD and non-ECD groups. LifePort parameters and other pretransplant factors were analyzed. Logistic regression analysis was used to determine the significant factors for delayed graft function (DGF). Recovery time for renal function and 6-months serum creatinine were investigated. ResultsThe DGF rates were 20.25% and 11.72% in ECD and non-ECD group by our definition, respectively (P = .042). Higher pressures allowed comparable increases of flow in ECD kidneys despite still greater resistance. For non-ECD kidneys with an initial flow of ≤80 mL/min, the DGF rate of the subgroup with a terminal flow of ≥100 mL/min was significantly lower compared with that of other terminal flow subgroups (≤80 and 90–100 mL/min; P < .05), and showed a trend toward significance when compared with the terminal flow subgroup of 80 to 90 mL/min (P = .098). Terminal resistance was the most significant parameter predicting DGF (odds ratio 2.44; P < .001), and remained significant after adjusted for other relevant pretransplant variables. Logistic model for DGF (model: terminal resistance, hypotension in agonal phase, terminal serum creatinine, and cause of death) had good predictive ability (c-statistic 0.851; 95% confidence interval, 0.799–0.903). ConclusionsLifePort parameters provided a granular measurement easily accessible in evaluating the quality of kidneys donated after cardiac death that added information to ECD criterion.

Liver Transplant Recipients With End-Stage Renal Disease Largely Benefit From Kidney Transplantation

BackgroundThe incidence of end-stage renal disease (ESRD) after liver transplant (LT) has increased. The actual benefit of kidney transplantation (KT) is not completely understood in LT recipients with ESRD. MethodsWe analyzed Scientific Registry of Transplant Recipients data for all KT candidates with prior LT from 1998 to 2014; the benefits of KT relative to remaining on dialysis were compared by means of multivariate Cox proportional hazards regression analysis. ResultsThe number of these KT candidates with prior LT has tripled from 98 in 1998 to 323 in 2015; LT recipients with ESRD remaining on dialysis have a 2.5-times increase in the risk of liver graft failure and a 3.6-times increase in the risk of patient death compared with these patients receiving KT. The adjusted liver graft and patient survival rates after donors from donation after cardiac death or expanded-criteria donor kidney transplantation were significantly higher than in patients remaining on dialysis in LT recipients with ESRD. ConclusionsThe number of referrals to KT with prior LT is increasing at a rapid rate. Remaining on dialysis in LT recipients with ESRD has profound increased risks of liver graft failure and patient death in comparison to receiving a KT. LT recipients with ESRD can benefit from expanded-criteria donor and donation after cardiac death kidney transplantation.

Preimplantation Kidney Biopsies of Extended Criteria Donors Have a Heavier Inflammatory Burden Than Kidneys From Standard Criteria Donors.

BackgroundDonors after brain death develop a systemic proinflammatory state that may predispose the kidneys to injury after transplantation. Because it is not known whether this inflammatory environment similarly affects the kidneys from expanded criteria donor (ECD) and standard criteria donors (SCD), we sought to evaluate differences in the gene expression of inflammatory cytokines in preimplantation biopsies (PIBx) from ECD and SCD kidneys.MethodsCytokines gene expression was measured in 80 PIBx (SCD, 52; ECD, 28) and associated with donor variables.ResultsNormal histology and chronic histological lesions were not different between both types of kidneys. ECD kidneys showed significant increase in the transcripts of MCP-1, RANTES, TGF-β1, and IL-10 when compared with SCD. Kidneys presenting normal histology had similar inflammatory profile except by a higher expression of RANTES observed in ECD (P = 0.04). Interstitial fibrosis and tubular atrophy (interstitial fibrosis and tubular atrophy ≥ 1) were associated with higher expression of TGF-β1, RANTES, and IL-10 in ECD compared with SCD kidneys. Cold ischemia time of 24 hours or longer was significantly associated with upregulation of FOXP3, MCP-1, RANTES, and IL10, whereas longer duration of donor hospitalization significantly increased gene expression of all markers. High FOXP3 expression was also associated with lower level of serum creatinine at 1 year. Donor age was not associated with any of the transcripts studied.ConclusionsPIBx of ECD exhibit a higher gene expression of inflammatory cytokines when compared with SCD kidneys. This molecular profile may be a specific ECD kidney response to brain death and may help to predict the posttransplant outcomes of ECD recipients.

Long-Term Outcomes of Kidney Transplantation From Expanded-Criteria Deceased Donors: A Single-Center Experience

BackgroundOrgan shortage has prompted the use of expanded-criteria donors (ECDs). Our objective was to compare long-term outcomes of kidney transplants from ECDs with those from concurrent standard-criteria donors (SCDs). In addition, we evaluated variables associated with graft survival in both groups. MethodsWe retrospectively reviewed all 617 deceased-donor kidney transplantations performed from 2005 to 2009 in our department. The population was divided according to donor status into ECD or SCD. Patients were followed until 5 years after transplantation, death, graft failure, or loss to follow-up. ResultsWe transplanted 150 deceased-donor kidneys from ECDs and 467 from SCDs. ECD were older, more frequently women, had a lower pre-retrieval glomerular filtration rate, and more frequently died due to cerebrovascular accident. ECD recipients were older, presented a lower proportion of black race, more frequently were on hemodialysis, and presented a higher rate of first kidney transplants. Mean glomerular filtration rate was consistently lower in the ECD group. Patient and graft survivals were lower in the ECD group, but statistical significance was present only in graft survival censored for death with a functioning graft at 3 years and graft survival noncensored for death with a functioning graft at 5 years. Younger recipient ages, longer time on dialysis, acute rejection episodes, and glomerular filtration rate at 1 year after transplantation were independent risk factors for lower graft survival. ConclusionsTransplantation with the use of ECD kidneys provide quite satisfactory patient and graft survival rates despite their poorer long-term outcomes.

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.

Effect of Hypothermic Machine Perfusion on the Preservation of Kidneys Donated After Cardiac Death: A Single-Center, Randomized, Controlled Trial.

To assess the application of a hypothermic machine perfusion device (LifePort) in kidney transplantation from donation after cardiac death (DCD) donors, 24 pairs of DCD kidneys were randomly divided into two groups: one of the paired kidneys from the same donor was perfused with the LifePort machine (hypothermic machine perfusion [HMP]), and the contralateral kidney was prepared using common static cold preservation (CCP). The two groups were compared with respect to the incidence of delayed graft function (DGF), level of graft function, and pathological changes in time-zero biopsy specimens. The incidence of DGF was 16.7 and 37.5% in the HMP and CCP groups, respectively; the difference between the two groups was statistically significant (P < 0.05). The incidence of acute rejection was 4.1 (1/24) and 8.3% (2/24) in the HMP and CCP groups, respectively; this difference was not statistically significant (P > 0.05). Forty-eight kidney patients were followed up for 6 months, and the two groups of recipients all survived, yielding a survival rate of 100%. The mean 6-month serum creatinine levels were 98.7 ± 23.6 µmol/L in the HMP group and 105.3 ± 35.1 µmol/L in the CCP group; there was no significant difference between the two groups. HMP can reduce the incidence of DGF in DCD kidneys, and this effect is greater for expanded criteria donors kidneys. HMP can also improve early renal function.

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.

Long-Term Outcomes in Kidney Transplantation From Expanded-Criteria Donors After Circulatory Death

The number of recipients waiting for a transplant is increasing. In Japan, there is more frequent use of organs from expanded-criteria donors (ECDs) after circulatory death. We retrospectively analyzed long-term outcomes of kidney transplantation (KT) from expanded-criteria donation after circulatory death (DCD). From 1995 to 2013, 97 cases of KT from DCD donors were performed in our department. Death-censored graft survival rates of ECD kidneys (n = 50) versus standard-criteria deceased-donor (SCD) kidneys (n = 47) for 1, 5, and 10 years after transplantation were 84.0% vs 97.9%, 74.8% vs 95.6%, and 70.2% vs 81.8%, respectively. No significant difference was found between the 2 groups (P = .102). Kidneys from donors with a history of hypertension (HTN) and cerebrovascular events (CVE) and contribution from older donors had significantly lower 10-year graft survival rates (P values of .010, .036, and .050, respectively). Cox proportional hazard regression analyses showed donor age to be significantly associated with long-term graft survival independently from other factors. These results suggest that ECD kidneys remain an acceptable alternative to dialysis under certain conditions. Increased donor age was a significant risk factor determining long-term graft function. Moreover, comorbidities of HTN and CVE could become significant risk factors, especially in older donors.

Increased risk of graft failure and mortality in Dutch recipients receiving an expanded criteria donor kidney transplant

Survival of expanded criteria donor (ECD) kidneys and their recipients has not been thoroughly evaluated in Europe. Therefore, we compared the outcome of ECD and non-ECD kidney transplantations in a Dutch cohort, stratifying by age and diabetes. In all first Dutch kidney transplants in recipients ≥18years between 1995 and 2005, both relative risks (hazard ratios, HR) and adjusted absolute risk differences (RD) for ECD kidney transplantation were analysed. In 3062 transplantations [recipient age 49.0 (12.8)years; 20% ECD], ECD kidney transplantation was associated with graft failure including death [HR 1.62 (1.44-1.82)]. The adjusted HR was lower in recipients ≥60years of age [1.32 (1.07-1.63)] than in recipients 40-59years [1.71 (1.44-2.02) P=0.12 for comparison with ≥60years] and recipients 18-39years [1.92 (1.42-2.62) P=0.03 for comparison with ≥60years]. RDs showed a similar pattern. In diabetics, the risks for graft failure and death were higher than in the nondiabetics. ECD kidney grafts have a poorer prognosis than non-ECD grafts, especially in younger recipients (<60years), and diabetic recipients. Further studies and ethical discussions should reveal whether ECD kidneys should preferentially be allocated to specific subgroups, such as elderly and nondiabetic individuals.