Lower Kidney Donor Profile Index Research Articles

Vascularized composite allograft deceased donation in the United States.

Vascularized composite allograft (VCA) transplantation represents a significant advancement in reconstructive surgery and offers hope to individuals who experienced congenital disorders or severe tissue injuries to restore physical appearance, function, and enhance quality of life. VCA recovery introduces complexities to conventional solid organ recovery, and there remain concerns regarding the potential impact of VCA recovery on non-VCA organs for transplant. The current retrospective study examines deceased donor characteristics and observed-to-expected (O/E) organ yield ratios for 51 VCA donors recovered in the US between July 4, 2014 and March 31, 2024, compared with a contemporary cohort of non-VCA donors recovered in 2023. Among the VCA donors, 17 donated a uterus, 15 each donated head and neck and upper limbs, 4 were abdominal wall donors, and 2 donated external male genitalia. The findings indicate that VCA donors tended to be younger (18-34 years old), predominantly White, non-Hispanic, and had no history of diabetes, along with lower weight, lower kidney donor profile index, and lower ejection fraction. The analysis revealed that VCA donors had higher observed overall organ yield than expected (O/E: 1.24, 95% CI: 1.16-1.33), with better-than-expected organ yields across VCA types. The number of deceased VCA donors in the US is still relatively small compared to the overall donor population. As the field continues to evolve and more data becomes available, further analyses need to be conducted to understand the demographics of VCA donors and the potential impact of VCA donation within the donation and transplant system.

#2822 Can KDPI estimate long-term graft survival in a cohort of Portuguese patients?

Abstract Background and Aims The Kidney Donor Profile Index (KDPI) was introduced in the United States in 2014 to support clinicians' decision-making regarding the acceptance or decline of potential donors. In Portugal, there is no valid stratification score to assist physicians in accepting or declining an organ offer. Our study aims to characterize a cohort of Portuguese kidney transplant recipients and donors and evaluate the correlation between KDPI and long-term graft survival. The results are interpreted considering the nuances of the Portuguese allocation system, which favors an age-matched donor-recipient allocation. Method We conducted an observational single-center retrospective cohort study, which included patients who received a deceased donor kidney transplant at our unit between January 2013 and December 2015. We excluded patients for whom the donor KDPI index was unavailable for retrieval. Besides the KDPI index, we collected data regarding the receptor's demographic, clinical, and immunological characteristics, as well as graft and recipient survival. The primary outcome was death-censored survival, and follow-up ended on the 31st of December 2023. The secondary outcome was survival with a functioning graft. Survival estimates were obtained using Kaplan-Meier curves. We performed univariate and multivariate survival analysis with log-rank tests and Cox proportional-hazards regression models. Results We selected 364 deceased-donor kidney recipients and 212 kidney donors. The mean KDPI was 60% and 53.3% of donors were classified as expanded criteria. The kidney recipients were predominantly male (68.4%), with a mean age of 50.16 years and an average of 4 HLA mismatches. Median follow-up was 102 months. Considering recipient characteristics according to pre-defined KDPI strata (≤ 20%, 21-85%, > 85%), recipients from higher KDPI were significantly older, with a mean age of 40.6, 48.8, and 61.1 years, respectively (p < 0.001), and had a higher average body mass index (p = 0.041). There were no significant differences regarding the number of HLA mismatches (p = 0.624) or the proportion of hypersensitized patients (p = 0.253) between classes. During follow-up, 16.8% patients presented graft failure and 9.9% died with a functioning graft. Cumulative death-censored graft survival at 5, 8, and 10 years was 87.7%, 87.1%, and 84.4% respectively. The cumulative percentage of patients living with a functioning graft at 5, 8, and 10 years was 83.6%, 76.7%, and 68.6%. Death-censored graft survival was lower in recipients of donors with higher KDPI (Fig. 1), although it did not reach statistical significance (p-value = 0.166). The number of HLA mismatches (p = 0.592) or the recipient's age (p = 0.513) did not significantly impact death-censored graft survival, whereas delayed graft function (DGF) was the variable with the strongest association in univariate analysis (p < 0.001). In a multivariate Cox regression model, KDPI (HR 1.02, p = 0.005) and DGF (HR 3.2, p < 0.001) correlated with graft loss, while older recipients (HR 0.971, p = 0.019) seemed to have a protective effect over death-censored survival. Patient survival with a functioning graft was significantly associated with KDPI strata (p = 0.008; Fig. 2), the recipient's age (p = 0.006), and DGF (p < 0.001) in univariate analysis. Considering KDPI kidneys ≥ 90%, 10-year cumulative death-censored survival was 67.9%. Conclusion In our sample, despite not reaching statistical significance, there was a trend for improved death-censored graft survival in patients with lower KDPI, which further emulates the results of other European cohorts. Nevertheless, the 10-year cumulative death-censored survival of higher KDPI kidneys (≥ 90%) was remarkable, showing that long-term acceptable outcomes can be achieved. The impact of KDPI on patient survival with a functioning graft is probably overestimated, given the bias introduced by the Portuguese matching system, which rewards an “old-for-old” donor-recipient allocation.

Kidney Donation After Circulatory Death Using Thoracoabdominal Normothermic Regional Perfusion: The Largest Report of the United States Experience.

Thoracoabdominal normothermic regional perfusion (TA-NRP) has been increasingly used for donation after circulatory death (DCD) procurements in the United States. We present the largest report of outcomes of kidney transplants performed using DCD donor grafts perfused with TA-NRP. Adult DCD kidney transplants between 2020 and 2022 in the United Network for Organ Sharing database were included. Donors with ≥50 min between asystole and aortic cross-clamp time in which the heart was also transplanted were considered TA-NRP donors. All other donors were considered direct recovery donors. Multivariable regressions were used to assess delayed graft function, as well as posttransplant survival and all-cause graft failure at 30, 90, and 180 d. A propensity-matched analysis of cohorts matched on donor Kidney Donor Profile Index was performed. Of the 16 140 total DCD kidney transplants performed during the study period, 306 (1.9%) used TA-NRP. TA-NRP donors were younger ( P < 0.001) and had lower Kidney Donor Profile Index ( P < 0.001) compared with direct recovery donors. Recipients receiving grafts recovered using TA-NRP were younger ( P < 0.001) and more likely to be blood group O ( P < 0.001). Transplants using TA-NRP had lower likelihood of delayed graft function (adjusted odds ratio 0.22 [95% confidence interval, 0.15-0.31], P < 0.001) but similar 180-d survival ( P = 0.8) and all-cause graft failure ( P = 0.3) as transplants using direct recovery grafts. These inferences were unchanged on propensity-matched analysis. Our results demonstrate that kidney transplants using TA-NRP DCD allografts have positive short-term mortality and graft survival outcomes, with significantly decreased rates of delayed graft function compared with direct recovery DCD grafts.

Comparable kidney transplant outcomes in selected patients with a body mass index≥40: A personalized medicine approach to recipient selection.

Many kidney transplant (KT) centers decline patients with a body mass index (BMI) ≥40kg/m2 . This study's aim was to evaluate KT outcomes according to recipient BMI. We performed a single-center, retrospective review of adult KTs comparing BMI ≥40 patients (n=84, BMI=42±2kg/m2 ) to a matched BMI<40 cohort (n=84, BMI=28±5kg/m2 ). Patients were matched for age, gender, race, diabetes, and donor type. BMI ≥40 patients were on dialysis longer (5.2±3.2years vs. 4.1±3.5years, p=.03) and received lower kidney donor profile index (KDPI) kidneys (40±25%vs. 53±26%, p=.003). There were no significant differences in prevalence of delayed graft function, reoperations, readmissions, wound complications, patient survival, or renal function at 1year. Long-term graft survival was higher for BMI ≥40 patients, including after adjusting for KDPI (BMI ≥40: aHR=1.79, 95% CI=1.09-2.9). BMI ≥40 patients had similar BMI change in the first year post-transplant (delta BMI: BMI≥40 +.9±3.3 vs. BMI<40 +1.1±3.2, p=.59). Overall outcomes after KT were comparable in BMI ≥40 patients compared to a matched cohort with lower BMI with improved long-term graft survival in obese patients. BMI-based exclusion criteria for KT should be reexamined in favor of a more individualized approach.

342.1: Comparable Kidney Transplant Outcomes in Selected Patients With a BMI ≥40: A Personalized Medicine Approach To Recipient Selection

Introduction: Kidney transplantation confers a survival benefit compared with dialysis in most studies of obese patients. Yet, many transplant centers decline patients with a body mass index (BMI) ≥40 kg/m2. Our practice relies on computed tomography imaging to evaluate iliac depth and pelvic angle to assess candidacy (see Figure 1). Our aim was to evaluate post-transplant outcomes including survival in patients according to recipient BMI. Methods: We performed a single-center retrospective review of adult kidney transplant alone recipients comparing BMI ≥40 patients (n=84, BMI =42±2 kg/m2) to a matched BMI <40 cohort (n=84, BMI =28±5 kg/m2). Patients were matched for recipient age, gender, race, presence of diabetes, and donor type (living vs. deceased). Results: BMI ≥40 patients were on dialysis longer pre-transplant (5.2±3.2 years vs. 4.1±3.5 years, p=0.03) and received lower kidney donor profile index (KDPI) kidneys (40±25% vs. 53±26%, p=0.003) compared to lower BMI patients. There were no significant differences in prevalence of delayed graft function, reoperations, readmissions, wound complications, patient survival, or renal function at 1 year according to serum creatinine and eGFR. Long-term graft survival was higher for BMI ≥40 patients, including after adjusting for KDPI (BMI ≥40: aHR=1.79, 95% CI=1.09-2.9) (see Figure 2). BMI ≥40 patients had similar weight gain and BMI change in the first year post-transplant (delta weight: BMI ≥40 + 2.5±9.1 kg vs. BMI <40 + 3.0±8.0 kg, p=0.74; delta BMI: BMI ≥40 + 0.9±3.3 vs. BMI <40 + 1.1±3.2, p=0.59). BMI ≥40 patients had a higher mean HbA1c level (6.9±1.7% vs. 5.9±1.4%, p=0.003) at one year post-transplant. Conclusions: Overall patient survival and complications after kidney transplantation were comparable in BMI ≥40 patients compared to a matched cohort with lower BMI with improved long-term graft survival in the obese patients. BMI-based exclusion criteria for kidney transplantation should be reexamined in favor of a more individualized approach.

A tool for decision-making in kidney transplant candidates with poor prognosis to receive deceased donor transplantation in the United States

The primary outcomes for kidney transplant candidates are receipt of deceased or living donor transplant, death or removal from the waiting list. Here, we conducted a retrospective analysis of national Scientific Registry of Transplant Recipients data to evaluate outcomes for 208,717 adult kidney transplant candidates following the 2014 Kidney Allocation System in the United States. Competing risks models were utilized to evaluate Time to Equivalent Risk (TiTER) of deceased donor transplantation (DDTX) and death versus waitlist removal. We also evaluated TiTER based on kidney donor profile index (KDPI) and donor age. For all groups, the cumulative incidence of DDTX was initially higher from time of listing than death or waitlist removal. However, following accrued time on the waiting list, the cumulative incidence of death or waitlist removal exceeded DDTX for certain patient groups, particularly older, diabetic, blood type B and O and shorter pre-listing dialysis time. TiTER for all candidates aged 65-69 averaged 41 months and for 70 and older patients 28 months. Overall, 39.6% of candidates were in risk groups with TiTER under 72 months and 18.5% in groups with TiTER under 24 months. Particularly for older candidates, TiTER for kidneys was substantially shorter for younger donors or lower KDPI. Thus, our findings reveal that a large proportion of wait-listed patients in the United States have poor prognoses to ever undergo DDTX and our data may improve shared decision-making for candidates at time of waitlist placement. Hence, for specific patient groups, TiTER may be a useful tool to disseminate and quantify benefits of accepting relatively high risk donor organs.

Multiple-Organ Deceased Donation Is Associated With Superior Outcomes for Grafts and Transplant Recipients Compared With Kidney-Only Donation.

Since the development of Kidney Donor Profile Index, outcome differences based on number of donated organs per donor have not been evaluated. We retrospectively analyzed data from the United Network for Organ Sharing national database, which identified 176 311 adult renal transplant recipients from 2000 to 2019 with a deceased donor kidney from a kidney-only donor, from a donor of kidney and liver but no other organs, or from a multiorgan donor. Graft failure and transplant recipient survival were primary outcomes. A multivariate Cox proportional hazards model controlled for Kidney Donor Profile Index differences. Overall, multiorgan donors had a lower Kidney Donor Profile Index versus other donor types (odds ratio, 0.042; P < .001). Kidneys from donors with a higher Kidney Donor Profile Index were 95% less likely to be procured with other organs (P < .001). The recipient and graft survival rates for kidney transplants from kidney-only donors and from donors of kidney and liver but no other organs were 76% and 70%, respectively, whereas recipient and graft survival rates for kidney transplants from multiorgan donors were approximately 82% and 77%, respectively, at 5 years. After adjustment for the Kidney Donor Profile Index, the recipients of multiorgan donor grafts demonstrated superior outcomes for graft survival and mortality compared with kidney-only donors or kidney and liver only donors. The multiorgan donor status may be an additional consideration in future renal allocation calculators.

Risk factors and outcomes of BK viremia among deceased donor kidney transplant recipients based on donor characteristics.

BK polyomavirus (BKV) is a common infection among kidney transplant recipients (KTR). Risk factors and outcomes based on donor characteristics remain largely unknown. In this study, we aimed to analyze the impact of donor factors through a paired kidney analysis. We included 289 pairs of adult deceased donor transplants (578 KTRs total); each pair had received kidneys from the same donor. Recipient pairs were divided into three groups: "no BK group" if neither KTR developed BK viremia (n=336), "discordant" if the only one did (n=176), and "concordant" if both did (n=66). Acute rejection (AR), graft failure, and BK nephropathy (BKN) were outcomes of interest. Donors in the concordant group were younger, had lower kidney donor profile index (KDPI), and were less likely to be donor after circulatory death (DCD). In multivariate analyses, KTRs who had a donor with a higher body mass index (BMI) (hazard ratio (HR): 0.97; 95% confidence interval (CI): 0.95-0.99; p=.009) were less likely to develop BKV. Concordance was not associated with AR (HR: 0.83; 95% CI: 0.51-1.34; p=.45), graft failure (HR: 1.77; 95% CI: 0.42-7.50; p=.43), or BKN (HR: 1.02; 95% CI: 0.51-2.03; p=.96). Our study suggests lower donor BMI is associated with BKV infection, and concordance or discordance between paired kidney recipients is not associated with poor outcomes.

Successful Implementation of an Increased Viral Risk Donor Waiting List for Preconsented Kidney Transplant Candidates in Victoria, Australia.

We examined the characteristics and utilization of deceased donor IVRD kidneys and recipient outcomes within a 2-y period (July 31, 2018-July 31, 2020) postimplementation of a new opt-in allocation pathway for preconsented recipients in Victoria, Australia. Fifty-six kidneys from 31 IVRDs were utilized, comprising 13% of donors. Preconsent rate to accept IVRD kidneys increased to 41% of the waitlist in the 2 y postimplementation, and IVRDs having no kidneys utilized reduced to 0%. Compared with non-IVRD kidneys, kidney offer declines >10 per donor were less likely from IVRDs (3% vs 19%; P < 0.05). IVRDs were younger (median age 36 [IQR 30-44] vs 51 [35-60] y; P < 0.0001), with lower kidney donor profile index (25% [13-40%] vs 57% [29-75%]; P < 0.0001), and less hypertension (0% vs 22%; P < 0.01). Estimated glomerular filtration rate 3 mo post-transplant was superior (P < 0.01). Injecting drug use (61%) was the most common increased risk behavior. 29% of IVRDs were hepatitis C antibody positive but nucleic acid testing negative. No active infection was detected in any recipient post-transplant. The described opt-in system permits efficient allocation and utilization of kidneys from IVRDs, with superior quality and graft function. Education is crucial to facilitate informed consent and equity of access to this donor pool.

Impact of adjusted kidney volume measured in the bench surgery on one-year renal function in kidney transplantation.

BackgroundKidney transplantation is the treatment of choice in patient with end stage chronic kidney disease, offering the best long term survival and greater Quality of Life in this group of patients. Graft volume was correlated with improved renal function in living donor transplantations. The primary aim of this study was to correlate renal volume adjusted to body surface area with renal function one year (estimated glomerular filtration rate; eGFR) after kidney transplantation.MethodsThis single-center, prospective cohort study included 256 patients who underwent kidney transplantation from January 2011 through December 2015 at Hospital das Clínicas de Botucatu–UNESP. We evaluated three kidney measurements during the bench surgery; the final graft volume was calculated using the ellipsoid formula and adjusted to body surface area.ResultsIn the living donors there was positive correlation between adjusted graft volume and eGFR (r = 0.311, p = 0.008). Multivariate analysis revealed that low rejection rate and increased adjusted graft volume were independent factors correlated with eGFR. In deceased donors, there was no correlation between adjusted kidney volume and eGFR (r = 0.08, p = 0.279) in univariate analysis, but a multivariate analysis indicated that lower kidney donor profile index (KDPI), absence of rejection and high adjusted kidney volume were independent factors for better eGFR.ConclusionAdjusted kidney volume was positively correlated with a satisfactory eGFR at one year after living donor and deceased donor transplantations.

Utilizing increased risk for disease transmission (IRD) kidneys for pediatric renal transplant recipients.

Strategies to expand numbers of deceased donor kidneys suitable for pediatric recipients are urgently needed to prevent long-term dialysis-associated morbidity and mortality. Donors designated as increased risk of disease transmission (IRD) are infrequently used in pediatric recipients. We examined outcomes of these kidneys in pediatric patients and the potential to increase the donor pool. The United Network for Organ Sharing (UNOS) database records presence of IRD in all deceased donors since 2004. All pediatric kidney transplant recipients from 2004 to 2017 were identified and stratified by IRD status, and outcomes were examined. Four hundred seventy-three pediatric kidney transplant recipients received an IRD allograft. IRD donors had lower kidney donor profile index (KDPI); were more likely to be younger, male, and Caucasian; and were more likely to have used drugs. IRD kidneys were more likely to have been biopsied and placed on pulsatile perfusion. Other than an older recipient age, demographic data were not different between groups. Allograft and patient survivals were similar, as were rejection and delayed graft function rates. Compared with adult recipients and adult IRD recipients, pediatric recipients were more likely to have a younger donor, receive a kidney with a lower creatinine, and were less likely to have delayed graft function (p < 0.05). There were no recorded disease transmissions in IRD group. Patient and allograft survivals are similar in IRD and non-IRD kidneys. High-quality IRD organs used in adults represent a large number of donors with excellent outcomes. IRD allografts have a potential to increase transplant volume and should be considered for pediatric patients.

Allocation of the Highest Quality Kidneys and Transplant Outcomes Under the New Kidney Allocation System

Increased access to transplantation for highly sensitized candidates following implementation of the kidney allocation system (KAS) has been mostly due to higher use of organs with a lower kidney donor profile index (KDPI; a quality metric for donated kidneys), although changes in allocation of these organs was not intended. It is unclear whether clinical outcomes have changed in association with these changes. We investigated the use of kidneys with low and high KDPI scores over time and whether KDPI score affects patient and graft survival differently across varying levels of allosensitization. Observational cohort study. Adult (aged≥18 years) recipients of a deceased donor kidney transplant between October 1, 2009, and September 30, 2017 (Organ Procurement and Transplantation Network/United Network for Organ Sharing database; n= 84,451). Calculated panel-reactive antibody (cPRA) level (0%, 1%-79%, 80%-89%, 90%-98%, and 99%-100%) and KDPI score (≤20%, 21%-85%, and >85%). Death, graft loss. Time to event. Allocation of kidneys with KDPI scores≤ 20% and KDPI scores of 21% to 85% to recipients with cPRA levels≥ 99% increased 4-fold following implementation of the KAS withlittle change in allocation of kidneys with KDPI scores > 85%. Patient survival and graftloss were strongly associated with KDPI score, whereas the association with cPRA level was minimal. There was no evidence of a differential effect of KDPI scores across therange of cPRA levels on patient survival (Pfor interaction=0.06-0.9) or graft loss (Pfor interaction=0.5-0.9). Patient survival at 5 years among the 5 cPRA groups ranged from 87.2% to 89.8% for recipients of kidneys with KDPI scores≤ 20% (P=0.2), 82.8% to 85.5% for KDPI scores of 21% to 85% (P=0.04), and 70.2% to 79.2% for KDPI scores > 85% (P=0.2). Cumulative incidence of graft loss by cPRA level ranged from 7.7% to 10.6% for recipients of kidneys with KDPI scores≤ 20% (P=0.2), 11.8% to 15.0% forKDPI scores of 21% to 85% (P< 0.001), and 19.8% to 29.7% for KDPI scores > 85% (P= 0.4). Lack of data for crossmatches, donor-specific antibodies, and immunomodulation. Highly sensitized recipients received kidneys with lower KDPI scores following implementation of the KAS, reducing access to these kidneys by less-sensitized candidates. KDPI score has a stronger association with patient survival and graft loss than cPRA level. The association of KDPI score with these outcomes was not modified by the recipient's level of sensitization. The impact of the redistribution of kidneys with low KDPI scores on outcomes among less-sensitized recipients needs further evaluation.

Who can tolerate a marginal kidney? Predicting survival after deceased donor kidney transplant by donor-recipient combination.

The impact of donor quality on post-kidney transplant (KT) survival may vary by candidate condition. Characterizing this variation would increase access to KT without sacrificing outcomes. We developed a tool to estimate post-KT survival for combinations of donor quality and candidate condition. We studied deceased donor KT recipients (n=120818) and waitlisted candidates (n=376272) between 2005 and 2016 by using the Scientific Registry of Transplant Recipients. Donor quality and candidate condition were measured by using the Kidney Donor Profile Index (KDPI) and the Estimated Post Transplant Survival (EPTS) score. We estimated 5-year post-KT survival based on combinations of KDPI and EPTS score using random forest algorithms and waitlist survival by EPTS score using Weibull regressions. Survival benefit was defined as absolute reduction in mortality risk with KT. For candidates with an EPTSscore of80, 5-year waitlist survival was 47.6%, and 5-year post-KT survival was 78.9% after receiving kidneys with a KDPIof20 and was 70.7% after receiving kidneys with a KDPIof80. The impact of KDPI on survival benefit varied greatly by EPTS score. For candidates with low EPTS scores (eg, <40), the KDPI had limited impact on survival benefit. For candidates with middle or high EPTS scores (eg, >40), survival benefit decreased with higher KDPI but was still substantial even with a KDPIof100 (>16 percentage points). Our prediction tool (www.transplantmodels.com/kdpi-epts) can support individualized decision-making on kidney offers in clinical practice.

Kidney Donor Profile Index in the Case of Repeated Transplantation

Abstract Introduction. In 2014, new scoring system - Kidney Donor Profile Index (KDPI) was introduced. KDPI is a numerical measure that combines ten donor factors, including clinical parameters and demographics, to summarize into a single number the quality of deceased donor kidneys. There are some publications regarding usefulness of KDPI in the first kidney transplant recipients, however there are no data focusing on repeated transplantation patients. Aim of the Study. To determine the usefulness of kidney donor profile index as a risk marker of graft failure in repeated transplantation situations. Material and methods. A single-centre retrospective study was conducted. Patients who underwent a repeated transplantation from deceased donors between 2005. and 2013. were included in the study. Data about donor’s risk factors - age, height, weight, race, history of hypertension, history of diabetes, cause of death, serum creatinine, anti-HCV and if donor is after cardiac death - were collected and KDPI was calculated for all participants. Patients were divided into groups according to determined KDPI: Group 1 - KDPI &lt;35%; Group 2 - KDPI 36 - 69%; Group 3 - KDPI &gt;70%. For statistical analysis, IBM Statistical Package for the Social Sciences, version 21.0 was used. Results. A total of 72 patients were enrolled in the study. There were 17 patients (23.6%) in the 1. group, 38 patients (52.8%) in the 2. group and 17 patients (23.6%) in the 3. group. The most common cause of an end stage renal disease was chronic glomerulonephritis- 59.7% (n=43). Patients with higher KDPI developed acute rejection more often. In the group with KDPI &lt;35% it was observed in 35.3%, while in the groups with KDPI 36 - 69% and KDPI &gt;70% in 60.5% and 64.7% of patients, p = 0.02. Graft function differed significantly both, after one (p =0.01) and three years (p=0.04) with the highest eGFR results in the group with the lowest KDPI. The difference in graft survival rates was statistically significant, p = 0.027. After three- years it was 88.2% in the first group, 86.8% in the second group and 70.6% in the third group. Patient survival rates showed trend toward significance (p = 0.076) with only two patients lost during three- year follow up. Conclusions. KDPI presents relevance with repeated transplantation outcomes. Lower KDPI indicates better transplantation outcomes - superior graft function and better graft survival. However, there is only trend towards significance in patient survival rates.

The risk of allograft failure and the survival benefit of kidney transplantation are complicated by delayed graft function

Concern about the long-term impact of delayed graft function (DGF) may limit the use of high-risk organs for kidney transplantation. To understand this better, we analyzed 29,598 mate kidney transplants from the same deceased donor where only 1 transplant developed DGF. The DGF associated risk of graft failure was greatest in the first posttransplant year, and in patients with concomitant acute rejection (hazard ratio: 8.22, 95% confidence interval: 4.76-14.21). In contrast, the DGF-associated risk of graft failure after the first posttransplant year in patients without acute rejection was far lower (hazard ratio: 1.15, 95% confidence interval: 1.02-1.29). In subsequent analysis, recipients of transplants complicated by DGF still derived asurvival benefit when compared with patients who received treatment with dialysis irrespective of donor quality as measured by the Kidney Donor Profile Index (KDPI). The difference in the time required to derive a survival benefit was longer in transplants with DGF than in transplants without DGF, and this difference was greatest in recipients of lower quality kidneys (difference: 250-279 days for KDPI 20%-60% vs. 809 days for the KDPI over 80%). Thus, the association of DGF with graft failure isprimarily limited to the first posttransplant year. Transplants complicated by DGF provide a survival benefit compared to treatment with dialysis, but the survival benefit is lower in kidney transplants with lower KDPI. This information may increase acceptance of kidneys at high risk for DGF and inform strategies to minimize the risk of death in the setting of DGF.