Local Expansion of Donation After Circulatory Death Kidney Transplant Activity Improves Waitlisted Outcomes and Addresses Inequities of Access to Transplantation

Abstract

In the United Kingdom, donation after circulatory death (DCD) kidney transplant activity has increased rapidly, but marked regional variation persists. We report how increased DCD kidney transplant activity influenced waitlisted outcomes for a single center. Between 2002-2003 and 2011-2012, 430 (54%) DCD and 361 (46%) donation after brain death (DBD) kidney-only transplants were performed at the Cambridge Transplant Centre, with a higher proportion of DCD donors fulfilling expanded criteria status (41% DCD vs. 32% DBD; p = 0.01). Compared with U.K. outcomes, for which the proportion of DCD:DBD kidney transplants performed is lower (25%; p < 0.0001), listed patients at our center waited less time for transplantation (645 vs. 1045 days; p < 0.0001), and our center had higher transplantation rates and lower numbers of waiting list deaths. This was most apparent for older patients (aged >65 years; waiting time 730 vs. 1357 days nationally; p < 0.001), who received predominantly DCD kidneys from older donors (mean donor age 64 years), whereas younger recipients received equal proportions of living donor, DBD and DCD kidney transplants. Death-censored kidney graft survival was nevertheless comparable for younger and older recipients, although transplantation conferred a survival benefit from listing for only younger recipients. Local expansion in DCD kidney transplant activity improves survival outcomes for younger patients and addresses inequity of access to transplantation for older recipients.

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

“…However, a significant number of discarded ECD-DCD kidneys may be acceptable for KT [2]. In fact, as age of patients listed for KT is continuously rising [3, 4], DCD age criteria has also increased in recent years in many countries, especially in Europe [5–11], where policies are more open to expand donor pool criteria, in contrast to the US, where the potential poorer outcomes could lead to a higher discarded organ rate.…”

“…However, the increase in donor age is associated with reduced graft function as well as limited recipient and graft survival [18]. Moreover, it has been recently postulated that the use of aged DCD could be detrimental in elderly recipients [10, 11].…”

Outcomes of kidney transplantation from elderly deceased donors of a Korean registry

“…Longevity matching to provide kidneys of elderly DDs to elderly recipients is becoming commonplace. In the UK, particularly in the Cambridge group, the increased use of DCD and elderly DBD has reduced the waiting time in both, young and elderly recipients [21]. In the Korea registry, elderly recipients demonstrate shorter waiting times than young recipients; however, the difference is not statistically significant ( Table 2).…”

PreImplantation Trial of Histopathology In renal Allografts (PITHIA): a stepped-wedge cluster randomised controlled trial protocol

“…Comparison of Cambridge practice to UK transplant activity suggests that this approach resulted in greater numbers of kidney transplants being performed from older donors than would otherwise have been the case 7. Outcomes of the transplants were good, in that kidney graft survival from listing was similar to that achieved for all UK deceased kidney transplants—irrespective of donor age 11. However, Remuzzi’s approach has not been widely adopted across the UK.…”