Deciphering transplant outcomes of expanded kidney allografts donated after controlled circulatory death in the current transplant era. A call for caution

Abstract

Outcomes of kidney transplantation (KT) after controlled circulatory death (cDCD) with highly expanded criteria donors (ECD) and recipients have not been thoroughly evaluated. We analyzed in a multicenter cohort of 1161 consecutive KT, granular baseline donor and recipient factors predicting transplant outcomes, selected by bootstrapping and Cox proportional hazards, and were validated in a contemporaneous European KT cohort (n = 1585). 74.3% were DBD and 25.7% cDCD-KT. ECD-KT showed the poorest graft survival rates, irrespective of cDCD or DBD (log-rank < 0.001). Besides standard ECD classification, dialysis vintage, older age, and previous cardiovascular recipient events together with low class-II-HLA match, long cold ischemia time and combining a diabetic donor with a cDCD predicted graft loss (C-Index 0.715, 95% CI 0.675-0.755). External validation showed good prediction accuracy (C-Index 0.697, 95%CI 0.643-0.741). Recipient older age, male gender, dialysis vintage, previous cardiovascular events, and receiving a cDCD independently predicted patient death. Benefit/risk assessment of undergoing KT was compared with concurrent waitlisted candidates, and despite the fact that undergoing KT outperformed remaining waitlisted, remarkably high mortality rates were predicted if KT was undertaken under the worst risk-prediction model. Strategies to increase the donor pool, including cDCD transplants with highly expanded donor and recipient candidates, should be performed with caution.

Organ Utilization Rates from Non-Ideal Donors for Solid Organ Transplant in the United States

“…Successful utilization and transplantation of marginal organs relies on appropriate donor-recipient matching. Multiple studies have showed an overall survival benefit from transplantation with “marginal” donors compared to remaining waitlisted for nearly all candidates [ 32 , 33 , 34 ]. The results of the present study emphasize the need to maximize kidney utilization from NID, considering that the donor population is growing increasingly older, more obese, and has a higher prevalence of comorbid conditions [ 35 ].…”

Alloimmune Risk Stratification for Kidney Transplant Rejection

“…Kidney transplants from donors who are elderly, ECD, ECD/DCD, or kidneys with pre-existing lesions have poorer prognoses than transplants from standard-criteria donors. Recipients of organs from high-risk donors tend to have poor renal function, with reduced medium-term graft survival ( 12 , 13 ). Such patients are also at high risk of delayed graft function (DGF) ( 14 , 15 ).…”

Deceased Donor Characteristics and Kidney Transplant Outcomes

“…Across a number of studies, ECD-DCD kidneys report acceptable 3-year death-censored graft survival rates between 70%–90%, which are inferior to SCD-DCD kidneys but not ECD-DBD kidneys ( 26 - 32 ). However, Montero et al demonstrate how important selecting the most appropriate donor-recipient combination is in a recently published risk modelling study ( 33 ). In their multi-center cohort study, mortality risk for the highest risk-stratification group receiving ECD-DCD kidneys was significant.…”