Early Graft Loss after Deceased-Donor Kidney Transplantation: What Are the Consequences?

Abstract

BACKGROUND: Decreasing kidney discards continues to be of paramount importance for improving organ transplant access, but transplantation of nonideal deceased donor kidneys may have higher inherent risks of early graft loss (EGL). Patients with EGL (defined as graft failure within 90 days after transplant) are allowed reinstatement of waiting time according to United Network for Organ Sharing (UNOS) policy. The purpose of this study was to examine outcomes for patients experiencing EGL. STUDY DESIGN: We performed a single center retrospective review of adult deceased donor kidney transplant (DDKT)-alone recipients from 2001 to 2018, comparing those with EGL (including primary nonfunction [PNF]) to those without. RESULTS: EGL occurred in 103 (5.5%) of 1,868 patients, including 57 (55%) PNF, 25 (24%) deaths, 16 (16%) thrombosis, 3 (3%) rejection, and 2 (2%) disease recurrence. Kidney Donor Profile Index (KDPI) > 85% and donation after circulatory death (DCD) DDKTs did not increase risk of either EGL or PNF unless combined with prolonged cold ischemic time (CIT). For KDPI >85% with CIT >24 hours, the risk of EGL or PNF was tripled (EGL odds ratio [OR] 2.9, 95% CI 1.6–5.2; PNF OR3.6, 95% CI1.7–7.7). For DCD with CIT > 24 hours, increased risks were likewise seen for EGL (OR 2.4, 95% CI 1.3–4.3), and PNF (OR 3.2, 95% CI 1.5–7). One-year and 5-year patient survival rates were 60% and 50% after EGL, 80% and 73% after PNF, and 99% and 87% for controls, respectively. Only 24% of either EGL or PNF patients underwent retransplantation. CONCLUSIONS: EGL and PNF were associated with low retransplantation rates and inferior patient survival. Prolonged CIT compounds risks associated with KDPI > 85% and DCD donor kidneys. Therefore, policies promoting rapid allocation and increased local use of these kidneys should be considered.

Impact of preoperative ultrasonography for predicting the prognosis of deceased donor kidney transplantation

“…Careful kidney selection is essential since short term graft failure can be devastating both physically and psychologically for the patient and may also result in human leukocyte antigen sensitization or increased debility, limiting the possibility of re-transplantation in the future [31].…”

Renal Delivery of Pharmacologic Agents During Machine Perfusion to Prevent Ischaemia-Reperfusion Injury: From Murine Model to Clinical Trials

“…Regarding the classification of donation after circulatory death (DCD) donors, also referred to as nonheart-beating donors (NHBD) or death after cardiac death donors, it was regulated by the First International Workshop in Maastricht. First of all, DCD donation takes place after declaration of death based on cardiorespiratory criteria in contrast to DBD that required neurological criteria (16)(17)(18). In addition, while in DBD organs are perfused until the moment of preservation, with almost absent first warm ischemia time, organs from DCD donors underwent warm ischemia between circulatory arrest and the start of organ perfusion (Figure 1).…”

Primary non-function in a deceased donor kidney transplant even with a Kidney Donor Risk Index less than 1.0: a case report

“…According to several studies, identifying and transplanting deceased donor kidneys using the expanded criteria results in survival gains compared to outcomes for patients on the waiting list with hemodialysis [2]. It is important, however, to consider that some kidneys selected under the expanded criteria may turn out to be unacceptable [3]. To address this concern, preoperative biopsy and imaging of deceased donor kidneys are increasingly being used to assess candidate kidneys [4].…”

“…Due to increased knowledge about transplant immunology and the development of serologic tests, hyperacute rejection has become extremely rare. Nevertheless, cases of early graft loss (EGL) continue to occur [3].…”