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

Abstract

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 3 years 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 = 51 800) (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.

An international comparison of deceased donor kidney utilization: What can the United States and the United Kingdom learn from each other?

“…URs of older donors could theoretically be improved by the use of preimplant kidney biopsies, whose practice and utility vary greatly internationally and nationally . However, in the US biopsies are often cited as the primary reason for kidney discard .…”

Dual kidney transplants from adult marginal donors: Review and perspective

“…Five‐ and 10‐year graft survival rates for DKT are 69% and 50%, respectively, which are similar to outcomes in single kidney transplantation from SCDs and “translates” to a KDPI of 50–60% 106,110,120,129 . Moreover, DKT in older patients may be associated with a lower rate of acute rejection compared to single kidney transplantation, in part related to recipient selection bias (fewer retransplants, not highly sensitized) and immunosenescence 35–41,46–54,72,138,189–191 . However, DKT in patients < 50 years of age might be associated with inferior outcomes because of an increased risk of graft loss secondary to acute rejection 72,196 .…”

“…47,50,57,66 In the past 20 years, numerous centers in Italy and Spain have "pushed" the boundaries of DKT including the introduction of new techniques and liberalization of donor and recipient selection. 53,55,57,64,67,68,73,74,78,79,81,[87][88][89][90]93,95,[98][99][100]102,103,108,109,111,112,119,123,124,126,[131][132][133][134]138,145 "Old-for-old" transplants and the Eurotransplant Senior Program, which was originally implemented in 1999, have played a prominent role in conjunction with DKT, particularly from a recipient selection perspective. 158,172,[192][193][194] Centers in France, Germany, and the United Kingdom have likewise provided important contributions to the world experience in DKT including the use of alternative scoring systems and expansion with DCD donor kidneys.…”

“…DDs with marginal renal functional capacity represent a large proportion of potential kidneys doomed to discard or non‐recovery 7,10,11,33,110,148–175 . One approach to offset this dilemma has been the greater application of DKT from adult MDDs 35–145 . There have been several excellent recent reviews focusing on various aspects of DKT 72,118,127,129,130,138,142 .…”

“…Finally, there are no randomized controlled trials of DKT and no universally accepted standardized criteria in terms of defining DKT allocation and utilization, which remains largely clinician‐based and is often a default option when no one accepts either kidney from a DD. These concerns or “misperceptions” notwithstanding, the majority of data suggest that DKT is associated with a comparable or lower incidence of DGF and improved renal function compared to single kidney transplantation from adult MDDs (ECDs or high KDPI donors) 72,127,129,138 . For example, renal function following DKT was similar to single ECD kidney transplantation in six studies and better in four studies, the latter of which approached renal function in single SCD kidney transplantation 129 …”