Early outcomes of kidney transplantation from elderly donors after circulatory death (GEODAS study)

Abstract

Background Spain has dramatically increased the number of controlled circulatory death donors (cDCD). The initial selection criteria for considering cDCD for kidney transplantation (KT) have been expanded progressively, with practically no limits in donor age during the last years. We aimed to analyze the early clinical outcomes using expanded (> 65 years) cDCD in comparison with standard ones. Methods Observational multicenter study including 19 transplant centers in Spain. We performed a systematic inclusion in a central database of every KT from expanded cDCD at each participant unit from January-2012 to January-2017. Surgical procedures and immunosuppressive protocols were based on local practices. Data was analyzed in the central office using logistic and Cox regression or competitive-risk models for multivariate analysis. Median time of follow-up was 18.1 months. Results 561 KT were performed with kidneys from cDCD, 135 from donors older than 65 years. As expected, recipients from older cDCD were also older (65.8 (SD 8.8) vs 53.7 (SD 11.4) years; p < 0.001) and with higher comorbidity. At 1 year, no differences were found amongst older and younger cDCD KT recipients in terms of serum creatinine (1.6 (SD 0.7) vs 1.5 (SD 0.8) mg/dl; p = 0.29). Non-death censored graft survival was inferior, but death-censored graft survival was not different (95.5 vs 98.2% respectively; p = 0.481). They also presented a trend towards higher delayed graft function (55.4 vs 46.7%; p = 0.09) but a similar rate of primary non-function (3.7 vs 3.1%; p = 0.71), and acute rejection (3.0 vs 6.3%; p = 0.135). In the multivariate analysis, in short follow-up, donor age was not related with worse survival or poor kidney function (eGFR < 30 ml/min). Conclusions The use of kidneys from expanded cDCD is increasing for older and comorbid patients. Short-term graft outcomes are similar for expanded and standard cDCD, so they constitute a good-enough source of kidneys to improve the options of KT wait-listed patients.

Kidney transplantation outcomes from elderly donors after circulatory death: a comparison with elderly brain-dead donors

“…The first experiences were not very positive and described no benefit in terms of survival using kidneys from old DCDs (>65 years) compared with those who remained waitlisted on dialysis [ 15 , 16 ]. Since then, other studies have supported good death-censored graft survival and acceptable graft function in >65-year cDCD grafts, comparable to results from elderly DBDs [ 18 , 35 ]. Khalid et al [ 35 ] showed an overall death-censored graft survival of 90 and 80% at 3 and 5 y, respectively.…”

“…The increase in the availability of cDCD organs is mainly due to the use of older donors [ 9 , 18 , 25 ], which may result either from a better evaluation of potential donors in this age group or a greater utilization of these grafts. In fact, elderly donors constitute nearly 25% of cDCDs in Spain [ 18 , 26 ] and represented up to 52.9% of all cDCD-KTs in our cohort. So far, age-matching allocation policies have shown favourable results [ 10–13 ].…”

“…Donor age has been associated with inferior outcomes after KT due to lower kidney functional reserve and increased vasculopathy, which presumably reduce their capability to respond to injuries [ 36 , 37 ]. Nonetheless, only a few studies have focused on analysing results from elderly cDCDs [ 15 , 16 , 18 , 35 ]. The first experiences were not very positive and described no benefit in terms of survival using kidneys from old DCDs (>65 years) compared with those who remained waitlisted on dialysis [ 15 , 16 ].…”

“…However, the experience with cDCD elderly kidneys allocated to elderly recipients has not been that optimistic so far, and two cohorts have recently shown that survival in these recipients might be poorer than remaining on dialysis [ 15 , 16 ]. In this context, although some series have shown similar short-term patient and graft outcomes between cDCD-ECDs, cDCD standard criteria donors (SCDs) and DBD-ECDs [ 3 , 15 , 17 , 18 ], outcomes with KTs from elderly cDCDs need to be carefully studied in order to avoid poor patient and graft outcomes.…”

“…A study from the GEODAS working group including 19 transplant centres (including ours) in Spain recently found that 24% of cDCD kidneys transplanted between January 2012 and January 2017 were from donors >65 years of age. Recipients from cDCDs showed similar short-term outcomes regardless of donor age [ 18 ]. So far, there are no available data comparing graft and patient outcomes between elderly cDCDs and DBDs in Spain.…”